|
ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [91361]
|
Facility
|
OP
|
$15.32
|
|
|
Service Code
|
HCPCS J0136
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.30 |
| Max. Negotiated Rate |
$15.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.01
|
| Rate for Payer: Aetna of WY Medicare |
$10.11
|
| Rate for Payer: Altius Commercial |
$14.71
|
| Rate for Payer: Beech Street Commercial |
$15.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.86
|
| Rate for Payer: Cash Price |
$10.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.86
|
| Rate for Payer: Cigna of WY Commercial |
$15.01
|
| Rate for Payer: Entrust Commercial |
$14.55
|
| Rate for Payer: First Choice Health Commercial |
$14.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.73
|
| Rate for Payer: HealthUtah PPO |
$15.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.86
|
| Rate for Payer: Multiplan Medicare/VA |
$8.30
|
| Rate for Payer: One Health Plan of WY PPO |
$15.01
|
| Rate for Payer: PacificSource Commercial |
$13.79
|
| Rate for Payer: PHCS PPO |
$15.01
|
| Rate for Payer: Three Rivers PPO |
$11.49
|
| Rate for Payer: TriWest Veterans Administration |
$8.73
|
| Rate for Payer: United Healthcare Commercial |
$14.63
|
| Rate for Payer: United Healthcare Medicare |
$8.73
|
| Rate for Payer: WINHealth Partners Commercial |
$15.01
|
| Rate for Payer: Wise Provider Network Commercial |
$14.55
|
|
|
ACETAMINOPHEN 1,000 MG/100 ML (10 MG/ML) INTRAVENOUS SOLUTION [91361]
|
Facility
|
IP
|
$15.38
|
|
|
Service Code
|
HCPCS J0134
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.91 |
| Max. Negotiated Rate |
$15.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.07
|
| Rate for Payer: Aetna of WY Medicare |
$9.84
|
| Rate for Payer: Altius Commercial |
$14.76
|
| Rate for Payer: Beech Street Commercial |
$15.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.92
|
| Rate for Payer: Cash Price |
$10.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.92
|
| Rate for Payer: Cigna of WY Commercial |
$15.07
|
| Rate for Payer: Entrust Commercial |
$14.61
|
| Rate for Payer: First Choice Health Commercial |
$14.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.38
|
| Rate for Payer: HealthUtah PPO |
$15.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.92
|
| Rate for Payer: Multiplan Medicare/VA |
$8.91
|
| Rate for Payer: One Health Plan of WY PPO |
$15.07
|
| Rate for Payer: PacificSource Commercial |
$13.84
|
| Rate for Payer: PHCS PPO |
$15.07
|
| Rate for Payer: Three Rivers PPO |
$11.54
|
| Rate for Payer: TriWest Veterans Administration |
$9.38
|
| Rate for Payer: United Healthcare Commercial |
$14.69
|
| Rate for Payer: United Healthcare Medicare |
$9.38
|
| Rate for Payer: WINHealth Partners Commercial |
$14.61
|
| Rate for Payer: Wise Provider Network Commercial |
$14.61
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [10410]
|
Facility
|
IP
|
$16.23
|
|
|
Service Code
|
NDC 4580273200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$16.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.91
|
| Rate for Payer: Aetna of WY Medicare |
$10.39
|
| Rate for Payer: Altius Commercial |
$15.58
|
| Rate for Payer: Beech Street Commercial |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$11.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.74
|
| Rate for Payer: Cigna of WY Commercial |
$15.91
|
| Rate for Payer: Entrust Commercial |
$15.42
|
| Rate for Payer: First Choice Health Commercial |
$15.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.90
|
| Rate for Payer: HealthUtah PPO |
$16.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.74
|
| Rate for Payer: Multiplan Medicare/VA |
$9.41
|
| Rate for Payer: One Health Plan of WY PPO |
$15.91
|
| Rate for Payer: PacificSource Commercial |
$14.61
|
| Rate for Payer: PHCS PPO |
$15.91
|
| Rate for Payer: Three Rivers PPO |
$12.17
|
| Rate for Payer: TriWest Veterans Administration |
$9.90
|
| Rate for Payer: United Healthcare Commercial |
$15.50
|
| Rate for Payer: United Healthcare Medicare |
$9.90
|
| Rate for Payer: WINHealth Partners Commercial |
$15.42
|
| Rate for Payer: Wise Provider Network Commercial |
$15.42
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [10410]
|
Facility
|
OP
|
$16.23
|
|
|
Service Code
|
NDC 4580273230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.79 |
| Max. Negotiated Rate |
$16.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.91
|
| Rate for Payer: Aetna of WY Medicare |
$10.71
|
| Rate for Payer: Altius Commercial |
$15.58
|
| Rate for Payer: Beech Street Commercial |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$11.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.74
|
| Rate for Payer: Cigna of WY Commercial |
$15.91
|
| Rate for Payer: Entrust Commercial |
$15.42
|
| Rate for Payer: First Choice Health Commercial |
$15.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.25
|
| Rate for Payer: HealthUtah PPO |
$16.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.74
|
| Rate for Payer: Multiplan Medicare/VA |
$8.79
|
| Rate for Payer: One Health Plan of WY PPO |
$15.91
|
| Rate for Payer: PacificSource Commercial |
$14.61
|
| Rate for Payer: PHCS PPO |
$15.91
|
| Rate for Payer: Three Rivers PPO |
$12.17
|
| Rate for Payer: TriWest Veterans Administration |
$9.25
|
| Rate for Payer: United Healthcare Commercial |
$15.50
|
| Rate for Payer: United Healthcare Medicare |
$9.25
|
| Rate for Payer: WINHealth Partners Commercial |
$15.91
|
| Rate for Payer: Wise Provider Network Commercial |
$15.42
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [10410]
|
Facility
|
OP
|
$16.23
|
|
|
Service Code
|
NDC 4580273200
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.79 |
| Max. Negotiated Rate |
$16.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.91
|
| Rate for Payer: Aetna of WY Medicare |
$10.71
|
| Rate for Payer: Altius Commercial |
$15.58
|
| Rate for Payer: Beech Street Commercial |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$11.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.74
|
| Rate for Payer: Cigna of WY Commercial |
$15.91
|
| Rate for Payer: Entrust Commercial |
$15.42
|
| Rate for Payer: First Choice Health Commercial |
$15.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.25
|
| Rate for Payer: HealthUtah PPO |
$16.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.74
|
| Rate for Payer: Multiplan Medicare/VA |
$8.79
|
| Rate for Payer: One Health Plan of WY PPO |
$15.91
|
| Rate for Payer: PacificSource Commercial |
$14.61
|
| Rate for Payer: PHCS PPO |
$15.91
|
| Rate for Payer: Three Rivers PPO |
$12.17
|
| Rate for Payer: TriWest Veterans Administration |
$9.25
|
| Rate for Payer: United Healthcare Commercial |
$15.50
|
| Rate for Payer: United Healthcare Medicare |
$9.25
|
| Rate for Payer: WINHealth Partners Commercial |
$15.91
|
| Rate for Payer: Wise Provider Network Commercial |
$15.42
|
|
|
ACETAMINOPHEN 120 MG RECTAL SUPPOSITORY [10410]
|
Facility
|
IP
|
$16.23
|
|
|
Service Code
|
NDC 4580273230
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$16.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.91
|
| Rate for Payer: Aetna of WY Medicare |
$10.39
|
| Rate for Payer: Altius Commercial |
$15.58
|
| Rate for Payer: Beech Street Commercial |
$15.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.74
|
| Rate for Payer: Cash Price |
$11.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.74
|
| Rate for Payer: Cigna of WY Commercial |
$15.91
|
| Rate for Payer: Entrust Commercial |
$15.42
|
| Rate for Payer: First Choice Health Commercial |
$15.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.90
|
| Rate for Payer: HealthUtah PPO |
$16.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.74
|
| Rate for Payer: Multiplan Medicare/VA |
$9.41
|
| Rate for Payer: One Health Plan of WY PPO |
$15.91
|
| Rate for Payer: PacificSource Commercial |
$14.61
|
| Rate for Payer: PHCS PPO |
$15.91
|
| Rate for Payer: Three Rivers PPO |
$12.17
|
| Rate for Payer: TriWest Veterans Administration |
$9.90
|
| Rate for Payer: United Healthcare Commercial |
$15.50
|
| Rate for Payer: United Healthcare Medicare |
$9.90
|
| Rate for Payer: WINHealth Partners Commercial |
$15.42
|
| Rate for Payer: Wise Provider Network Commercial |
$15.42
|
|
|
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [88532]
|
Facility
|
IP
|
$15.72
|
|
|
Service Code
|
NDC 6809423159
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.41
|
| Rate for Payer: Aetna of WY Medicare |
$10.06
|
| Rate for Payer: Altius Commercial |
$15.09
|
| Rate for Payer: Beech Street Commercial |
$15.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.25
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.25
|
| Rate for Payer: Cigna of WY Commercial |
$15.41
|
| Rate for Payer: Entrust Commercial |
$14.93
|
| Rate for Payer: First Choice Health Commercial |
$14.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.59
|
| Rate for Payer: HealthUtah PPO |
$15.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.25
|
| Rate for Payer: Multiplan Medicare/VA |
$9.11
|
| Rate for Payer: One Health Plan of WY PPO |
$15.41
|
| Rate for Payer: PacificSource Commercial |
$14.15
|
| Rate for Payer: PHCS PPO |
$15.41
|
| Rate for Payer: Three Rivers PPO |
$11.79
|
| Rate for Payer: TriWest Veterans Administration |
$9.59
|
| Rate for Payer: United Healthcare Commercial |
$15.01
|
| Rate for Payer: United Healthcare Medicare |
$9.59
|
| Rate for Payer: WINHealth Partners Commercial |
$14.93
|
| Rate for Payer: Wise Provider Network Commercial |
$14.93
|
|
|
ACETAMINOPHEN 160 MG/5 ML (5 ML) ORAL SUSPENSION [88532]
|
Facility
|
OP
|
$15.72
|
|
|
Service Code
|
NDC 6809423159
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.51 |
| Max. Negotiated Rate |
$15.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.41
|
| Rate for Payer: Aetna of WY Medicare |
$10.38
|
| Rate for Payer: Altius Commercial |
$15.09
|
| Rate for Payer: Beech Street Commercial |
$15.41
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.25
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.25
|
| Rate for Payer: Cigna of WY Commercial |
$15.41
|
| Rate for Payer: Entrust Commercial |
$14.93
|
| Rate for Payer: First Choice Health Commercial |
$14.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.96
|
| Rate for Payer: HealthUtah PPO |
$15.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.25
|
| Rate for Payer: Multiplan Medicare/VA |
$8.51
|
| Rate for Payer: One Health Plan of WY PPO |
$15.41
|
| Rate for Payer: PacificSource Commercial |
$14.15
|
| Rate for Payer: PHCS PPO |
$15.41
|
| Rate for Payer: Three Rivers PPO |
$11.79
|
| Rate for Payer: TriWest Veterans Administration |
$8.96
|
| Rate for Payer: United Healthcare Commercial |
$15.01
|
| Rate for Payer: United Healthcare Medicare |
$8.96
|
| Rate for Payer: WINHealth Partners Commercial |
$15.41
|
| Rate for Payer: Wise Provider Network Commercial |
$14.93
|
|
|
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION [1179]
|
Facility
|
OP
|
$15.22
|
|
|
Service Code
|
NDC 5058061201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.92
|
| Rate for Payer: Aetna of WY Medicare |
$10.05
|
| Rate for Payer: Altius Commercial |
$14.61
|
| Rate for Payer: Beech Street Commercial |
$14.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.76
|
| Rate for Payer: Cash Price |
$10.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.76
|
| Rate for Payer: Cigna of WY Commercial |
$14.92
|
| Rate for Payer: Entrust Commercial |
$14.46
|
| Rate for Payer: First Choice Health Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.68
|
| Rate for Payer: HealthUtah PPO |
$15.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.76
|
| Rate for Payer: Multiplan Medicare/VA |
$8.24
|
| Rate for Payer: One Health Plan of WY PPO |
$14.92
|
| Rate for Payer: PacificSource Commercial |
$13.70
|
| Rate for Payer: PHCS PPO |
$14.92
|
| Rate for Payer: Three Rivers PPO |
$11.42
|
| Rate for Payer: TriWest Veterans Administration |
$8.68
|
| Rate for Payer: United Healthcare Commercial |
$14.54
|
| Rate for Payer: United Healthcare Medicare |
$8.68
|
| Rate for Payer: WINHealth Partners Commercial |
$14.92
|
| Rate for Payer: Wise Provider Network Commercial |
$14.46
|
|
|
ACETAMINOPHEN 160 MG/5 ML ORAL SUSPENSION [1179]
|
Facility
|
IP
|
$15.22
|
|
|
Service Code
|
NDC 5058061201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.92
|
| Rate for Payer: Aetna of WY Medicare |
$9.74
|
| Rate for Payer: Altius Commercial |
$14.61
|
| Rate for Payer: Beech Street Commercial |
$14.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.76
|
| Rate for Payer: Cash Price |
$10.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.76
|
| Rate for Payer: Cigna of WY Commercial |
$14.92
|
| Rate for Payer: Entrust Commercial |
$14.46
|
| Rate for Payer: First Choice Health Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.28
|
| Rate for Payer: HealthUtah PPO |
$15.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.76
|
| Rate for Payer: Multiplan Medicare/VA |
$8.82
|
| Rate for Payer: One Health Plan of WY PPO |
$14.92
|
| Rate for Payer: PacificSource Commercial |
$13.70
|
| Rate for Payer: PHCS PPO |
$14.92
|
| Rate for Payer: Three Rivers PPO |
$11.42
|
| Rate for Payer: TriWest Veterans Administration |
$9.28
|
| Rate for Payer: United Healthcare Commercial |
$14.54
|
| Rate for Payer: United Healthcare Medicare |
$9.28
|
| Rate for Payer: WINHealth Partners Commercial |
$14.46
|
| Rate for Payer: Wise Provider Network Commercial |
$14.46
|
|
|
ACETAMINOPHEN 325 MG TABLET [1446]
|
Facility
|
IP
|
$15.04
|
|
|
Service Code
|
NDC 0904677361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.72 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.63
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.59
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.17
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.72
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$9.17
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$9.17
|
| Rate for Payer: WINHealth Partners Commercial |
$14.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
ACETAMINOPHEN 325 MG TABLET [1446]
|
Facility
|
IP
|
$15.18
|
|
|
Service Code
|
NDC 5058045811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.88
|
| Rate for Payer: Aetna of WY Medicare |
$9.72
|
| Rate for Payer: Altius Commercial |
$14.57
|
| Rate for Payer: Beech Street Commercial |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.72
|
| Rate for Payer: Cash Price |
$10.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.72
|
| Rate for Payer: Cigna of WY Commercial |
$14.88
|
| Rate for Payer: Entrust Commercial |
$14.42
|
| Rate for Payer: First Choice Health Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.26
|
| Rate for Payer: HealthUtah PPO |
$15.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.72
|
| Rate for Payer: Multiplan Medicare/VA |
$8.80
|
| Rate for Payer: One Health Plan of WY PPO |
$14.88
|
| Rate for Payer: PacificSource Commercial |
$13.66
|
| Rate for Payer: PHCS PPO |
$14.88
|
| Rate for Payer: Three Rivers PPO |
$11.38
|
| Rate for Payer: TriWest Veterans Administration |
$9.26
|
| Rate for Payer: United Healthcare Commercial |
$14.50
|
| Rate for Payer: United Healthcare Medicare |
$9.26
|
| Rate for Payer: WINHealth Partners Commercial |
$14.42
|
| Rate for Payer: Wise Provider Network Commercial |
$14.42
|
|
|
ACETAMINOPHEN 325 MG TABLET [1446]
|
Facility
|
OP
|
$15.04
|
|
|
Service Code
|
NDC 0904677361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.74
|
| Rate for Payer: Aetna of WY Medicare |
$9.93
|
| Rate for Payer: Altius Commercial |
$14.44
|
| Rate for Payer: Beech Street Commercial |
$14.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.59
|
| Rate for Payer: Cash Price |
$10.53
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.59
|
| Rate for Payer: Cigna of WY Commercial |
$14.74
|
| Rate for Payer: Entrust Commercial |
$14.29
|
| Rate for Payer: First Choice Health Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.57
|
| Rate for Payer: HealthUtah PPO |
$15.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.59
|
| Rate for Payer: Multiplan Medicare/VA |
$8.14
|
| Rate for Payer: One Health Plan of WY PPO |
$14.74
|
| Rate for Payer: PacificSource Commercial |
$13.54
|
| Rate for Payer: PHCS PPO |
$14.74
|
| Rate for Payer: Three Rivers PPO |
$11.28
|
| Rate for Payer: TriWest Veterans Administration |
$8.57
|
| Rate for Payer: United Healthcare Commercial |
$14.36
|
| Rate for Payer: United Healthcare Medicare |
$8.57
|
| Rate for Payer: WINHealth Partners Commercial |
$14.74
|
| Rate for Payer: Wise Provider Network Commercial |
$14.29
|
|
|
ACETAMINOPHEN 325 MG TABLET [1446]
|
Facility
|
OP
|
$15.18
|
|
|
Service Code
|
NDC 5058045811
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.22 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.88
|
| Rate for Payer: Aetna of WY Medicare |
$10.02
|
| Rate for Payer: Altius Commercial |
$14.57
|
| Rate for Payer: Beech Street Commercial |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.72
|
| Rate for Payer: Cash Price |
$10.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.72
|
| Rate for Payer: Cigna of WY Commercial |
$14.88
|
| Rate for Payer: Entrust Commercial |
$14.42
|
| Rate for Payer: First Choice Health Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.65
|
| Rate for Payer: HealthUtah PPO |
$15.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.72
|
| Rate for Payer: Multiplan Medicare/VA |
$8.22
|
| Rate for Payer: One Health Plan of WY PPO |
$14.88
|
| Rate for Payer: PacificSource Commercial |
$13.66
|
| Rate for Payer: PHCS PPO |
$14.88
|
| Rate for Payer: Three Rivers PPO |
$11.38
|
| Rate for Payer: TriWest Veterans Administration |
$8.65
|
| Rate for Payer: United Healthcare Commercial |
$14.50
|
| Rate for Payer: United Healthcare Medicare |
$8.65
|
| Rate for Payer: WINHealth Partners Commercial |
$14.88
|
| Rate for Payer: Wise Provider Network Commercial |
$14.42
|
|
|
ACETAMINOPHEN 325 MG TABLET [1446]
|
Facility
|
OP
|
$15.21
|
|
|
Service Code
|
NDC 5789610410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$15.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.91
|
| Rate for Payer: Aetna of WY Medicare |
$10.04
|
| Rate for Payer: Altius Commercial |
$14.60
|
| Rate for Payer: Beech Street Commercial |
$14.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.75
|
| Rate for Payer: Cash Price |
$10.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.75
|
| Rate for Payer: Cigna of WY Commercial |
$14.91
|
| Rate for Payer: Entrust Commercial |
$14.45
|
| Rate for Payer: First Choice Health Commercial |
$14.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.67
|
| Rate for Payer: HealthUtah PPO |
$15.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.75
|
| Rate for Payer: Multiplan Medicare/VA |
$8.24
|
| Rate for Payer: One Health Plan of WY PPO |
$14.91
|
| Rate for Payer: PacificSource Commercial |
$13.69
|
| Rate for Payer: PHCS PPO |
$14.91
|
| Rate for Payer: Three Rivers PPO |
$11.41
|
| Rate for Payer: TriWest Veterans Administration |
$8.67
|
| Rate for Payer: United Healthcare Commercial |
$14.53
|
| Rate for Payer: United Healthcare Medicare |
$8.67
|
| Rate for Payer: WINHealth Partners Commercial |
$14.91
|
| Rate for Payer: Wise Provider Network Commercial |
$14.45
|
|
|
ACETAMINOPHEN 325 MG TABLET [1446]
|
Facility
|
IP
|
$15.21
|
|
|
Service Code
|
NDC 5789610410
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.81 |
| Max. Negotiated Rate |
$15.21 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.91
|
| Rate for Payer: Aetna of WY Medicare |
$9.73
|
| Rate for Payer: Altius Commercial |
$14.60
|
| Rate for Payer: Beech Street Commercial |
$14.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.75
|
| Rate for Payer: Cash Price |
$10.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.75
|
| Rate for Payer: Cigna of WY Commercial |
$14.91
|
| Rate for Payer: Entrust Commercial |
$14.45
|
| Rate for Payer: First Choice Health Commercial |
$14.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.28
|
| Rate for Payer: HealthUtah PPO |
$15.21
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.75
|
| Rate for Payer: Multiplan Medicare/VA |
$8.81
|
| Rate for Payer: One Health Plan of WY PPO |
$14.91
|
| Rate for Payer: PacificSource Commercial |
$13.69
|
| Rate for Payer: PHCS PPO |
$14.91
|
| Rate for Payer: Three Rivers PPO |
$11.41
|
| Rate for Payer: TriWest Veterans Administration |
$9.28
|
| Rate for Payer: United Healthcare Commercial |
$14.53
|
| Rate for Payer: United Healthcare Medicare |
$9.28
|
| Rate for Payer: WINHealth Partners Commercial |
$14.45
|
| Rate for Payer: Wise Provider Network Commercial |
$14.45
|
|
|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
IP
|
$15.18
|
|
|
Service Code
|
NDC 5058045711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.88
|
| Rate for Payer: Aetna of WY Medicare |
$9.72
|
| Rate for Payer: Altius Commercial |
$14.57
|
| Rate for Payer: Beech Street Commercial |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.72
|
| Rate for Payer: Cash Price |
$10.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.72
|
| Rate for Payer: Cigna of WY Commercial |
$14.88
|
| Rate for Payer: Entrust Commercial |
$14.42
|
| Rate for Payer: First Choice Health Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.26
|
| Rate for Payer: HealthUtah PPO |
$15.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.72
|
| Rate for Payer: Multiplan Medicare/VA |
$8.80
|
| Rate for Payer: One Health Plan of WY PPO |
$14.88
|
| Rate for Payer: PacificSource Commercial |
$13.66
|
| Rate for Payer: PHCS PPO |
$14.88
|
| Rate for Payer: Three Rivers PPO |
$11.38
|
| Rate for Payer: TriWest Veterans Administration |
$9.26
|
| Rate for Payer: United Healthcare Commercial |
$14.50
|
| Rate for Payer: United Healthcare Medicare |
$9.26
|
| Rate for Payer: WINHealth Partners Commercial |
$14.42
|
| Rate for Payer: Wise Provider Network Commercial |
$14.42
|
|
|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
OP
|
$15.22
|
|
|
Service Code
|
NDC 5058045770
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.92
|
| Rate for Payer: Aetna of WY Medicare |
$10.05
|
| Rate for Payer: Altius Commercial |
$14.61
|
| Rate for Payer: Beech Street Commercial |
$14.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.76
|
| Rate for Payer: Cash Price |
$10.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.76
|
| Rate for Payer: Cigna of WY Commercial |
$14.92
|
| Rate for Payer: Entrust Commercial |
$14.46
|
| Rate for Payer: First Choice Health Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.68
|
| Rate for Payer: HealthUtah PPO |
$15.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.76
|
| Rate for Payer: Multiplan Medicare/VA |
$8.24
|
| Rate for Payer: One Health Plan of WY PPO |
$14.92
|
| Rate for Payer: PacificSource Commercial |
$13.70
|
| Rate for Payer: PHCS PPO |
$14.92
|
| Rate for Payer: Three Rivers PPO |
$11.42
|
| Rate for Payer: TriWest Veterans Administration |
$8.68
|
| Rate for Payer: United Healthcare Commercial |
$14.54
|
| Rate for Payer: United Healthcare Medicare |
$8.68
|
| Rate for Payer: WINHealth Partners Commercial |
$14.92
|
| Rate for Payer: Wise Provider Network Commercial |
$14.46
|
|
|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
OP
|
$15.18
|
|
|
Service Code
|
NDC 5058045711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.22 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.88
|
| Rate for Payer: Aetna of WY Medicare |
$10.02
|
| Rate for Payer: Altius Commercial |
$14.57
|
| Rate for Payer: Beech Street Commercial |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.72
|
| Rate for Payer: Cash Price |
$10.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.72
|
| Rate for Payer: Cigna of WY Commercial |
$14.88
|
| Rate for Payer: Entrust Commercial |
$14.42
|
| Rate for Payer: First Choice Health Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.65
|
| Rate for Payer: HealthUtah PPO |
$15.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.72
|
| Rate for Payer: Multiplan Medicare/VA |
$8.22
|
| Rate for Payer: One Health Plan of WY PPO |
$14.88
|
| Rate for Payer: PacificSource Commercial |
$13.66
|
| Rate for Payer: PHCS PPO |
$14.88
|
| Rate for Payer: Three Rivers PPO |
$11.38
|
| Rate for Payer: TriWest Veterans Administration |
$8.65
|
| Rate for Payer: United Healthcare Commercial |
$14.50
|
| Rate for Payer: United Healthcare Medicare |
$8.65
|
| Rate for Payer: WINHealth Partners Commercial |
$14.88
|
| Rate for Payer: Wise Provider Network Commercial |
$14.42
|
|
|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
OP
|
$15.08
|
|
|
Service Code
|
NDC 0904673061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Aetna of WY Medicare |
$9.95
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.63
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.60
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Multiplan Medicare/VA |
$8.17
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: TriWest Veterans Administration |
$8.60
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$8.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.78
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
|
|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
IP
|
$15.22
|
|
|
Service Code
|
NDC 5058045770
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$15.22 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.92
|
| Rate for Payer: Aetna of WY Medicare |
$9.74
|
| Rate for Payer: Altius Commercial |
$14.61
|
| Rate for Payer: Beech Street Commercial |
$14.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.76
|
| Rate for Payer: Cash Price |
$10.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.76
|
| Rate for Payer: Cigna of WY Commercial |
$14.92
|
| Rate for Payer: Entrust Commercial |
$14.46
|
| Rate for Payer: First Choice Health Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.28
|
| Rate for Payer: HealthUtah PPO |
$15.22
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.76
|
| Rate for Payer: Multiplan Medicare/VA |
$8.82
|
| Rate for Payer: One Health Plan of WY PPO |
$14.92
|
| Rate for Payer: PacificSource Commercial |
$13.70
|
| Rate for Payer: PHCS PPO |
$14.92
|
| Rate for Payer: Three Rivers PPO |
$11.42
|
| Rate for Payer: TriWest Veterans Administration |
$9.28
|
| Rate for Payer: United Healthcare Commercial |
$14.54
|
| Rate for Payer: United Healthcare Medicare |
$9.28
|
| Rate for Payer: WINHealth Partners Commercial |
$14.46
|
| Rate for Payer: Wise Provider Network Commercial |
$14.46
|
|
|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
IP
|
$15.08
|
|
|
Service Code
|
NDC 0904673061
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.78
|
| Rate for Payer: Aetna of WY Medicare |
$9.65
|
| Rate for Payer: Altius Commercial |
$14.48
|
| Rate for Payer: Beech Street Commercial |
$14.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.63
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.63
|
| Rate for Payer: Cigna of WY Commercial |
$14.78
|
| Rate for Payer: Entrust Commercial |
$14.33
|
| Rate for Payer: First Choice Health Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.20
|
| Rate for Payer: HealthUtah PPO |
$15.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.63
|
| Rate for Payer: Multiplan Medicare/VA |
$8.74
|
| Rate for Payer: One Health Plan of WY PPO |
$14.78
|
| Rate for Payer: PacificSource Commercial |
$13.57
|
| Rate for Payer: PHCS PPO |
$14.78
|
| Rate for Payer: Three Rivers PPO |
$11.31
|
| Rate for Payer: TriWest Veterans Administration |
$9.20
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$9.20
|
| Rate for Payer: WINHealth Partners Commercial |
$14.33
|
| Rate for Payer: Wise Provider Network Commercial |
$14.33
|
|
|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
IP
|
$15.18
|
|
|
Service Code
|
NDC 0904673080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.88
|
| Rate for Payer: Aetna of WY Medicare |
$9.72
|
| Rate for Payer: Altius Commercial |
$14.57
|
| Rate for Payer: Beech Street Commercial |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.72
|
| Rate for Payer: Cash Price |
$10.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.72
|
| Rate for Payer: Cigna of WY Commercial |
$14.88
|
| Rate for Payer: Entrust Commercial |
$14.42
|
| Rate for Payer: First Choice Health Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.26
|
| Rate for Payer: HealthUtah PPO |
$15.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.72
|
| Rate for Payer: Multiplan Medicare/VA |
$8.80
|
| Rate for Payer: One Health Plan of WY PPO |
$14.88
|
| Rate for Payer: PacificSource Commercial |
$13.66
|
| Rate for Payer: PHCS PPO |
$14.88
|
| Rate for Payer: Three Rivers PPO |
$11.38
|
| Rate for Payer: TriWest Veterans Administration |
$9.26
|
| Rate for Payer: United Healthcare Commercial |
$14.50
|
| Rate for Payer: United Healthcare Medicare |
$9.26
|
| Rate for Payer: WINHealth Partners Commercial |
$14.42
|
| Rate for Payer: Wise Provider Network Commercial |
$14.42
|
|
|
ACETAMINOPHEN 500 MG TABLET [7875]
|
Facility
|
OP
|
$15.18
|
|
|
Service Code
|
NDC 0904673080
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.22 |
| Max. Negotiated Rate |
$15.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.88
|
| Rate for Payer: Aetna of WY Medicare |
$10.02
|
| Rate for Payer: Altius Commercial |
$14.57
|
| Rate for Payer: Beech Street Commercial |
$14.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.72
|
| Rate for Payer: Cash Price |
$10.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.72
|
| Rate for Payer: Cigna of WY Commercial |
$14.88
|
| Rate for Payer: Entrust Commercial |
$14.42
|
| Rate for Payer: First Choice Health Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.65
|
| Rate for Payer: HealthUtah PPO |
$15.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.72
|
| Rate for Payer: Multiplan Medicare/VA |
$8.22
|
| Rate for Payer: One Health Plan of WY PPO |
$14.88
|
| Rate for Payer: PacificSource Commercial |
$13.66
|
| Rate for Payer: PHCS PPO |
$14.88
|
| Rate for Payer: Three Rivers PPO |
$11.38
|
| Rate for Payer: TriWest Veterans Administration |
$8.65
|
| Rate for Payer: United Healthcare Commercial |
$14.50
|
| Rate for Payer: United Healthcare Medicare |
$8.65
|
| Rate for Payer: WINHealth Partners Commercial |
$14.88
|
| Rate for Payer: Wise Provider Network Commercial |
$14.42
|
|
|
ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [1510]
|
Facility
|
IP
|
$16.42
|
|
|
Service Code
|
NDC 4580273030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.52 |
| Max. Negotiated Rate |
$16.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.09
|
| Rate for Payer: Aetna of WY Medicare |
$10.51
|
| Rate for Payer: Altius Commercial |
$15.76
|
| Rate for Payer: Beech Street Commercial |
$16.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.93
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.93
|
| Rate for Payer: Cigna of WY Commercial |
$16.09
|
| Rate for Payer: Entrust Commercial |
$15.60
|
| Rate for Payer: First Choice Health Commercial |
$15.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.02
|
| Rate for Payer: HealthUtah PPO |
$16.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.93
|
| Rate for Payer: Multiplan Medicare/VA |
$9.52
|
| Rate for Payer: One Health Plan of WY PPO |
$16.09
|
| Rate for Payer: PacificSource Commercial |
$14.78
|
| Rate for Payer: PHCS PPO |
$16.09
|
| Rate for Payer: Three Rivers PPO |
$12.32
|
| Rate for Payer: TriWest Veterans Administration |
$10.02
|
| Rate for Payer: United Healthcare Commercial |
$15.68
|
| Rate for Payer: United Healthcare Medicare |
$10.02
|
| Rate for Payer: WINHealth Partners Commercial |
$15.60
|
| Rate for Payer: Wise Provider Network Commercial |
$15.60
|
|
