|
CARBAMAZEPINE 200 MG TABLET [9411]
|
Facility
|
IP
|
$17.26
|
|
|
Service Code
|
NDC 0904617261
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$17.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.91
|
| Rate for Payer: Aetna of WY Medicare |
$11.05
|
| Rate for Payer: Altius Commercial |
$16.57
|
| Rate for Payer: Beech Street Commercial |
$16.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.74
|
| Rate for Payer: Cash Price |
$12.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.74
|
| Rate for Payer: Cigna of WY Commercial |
$16.91
|
| Rate for Payer: Entrust Commercial |
$16.40
|
| Rate for Payer: First Choice Health Commercial |
$16.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.53
|
| Rate for Payer: HealthUtah PPO |
$17.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.74
|
| Rate for Payer: Multiplan Medicare/VA |
$10.00
|
| Rate for Payer: One Health Plan of WY PPO |
$16.91
|
| Rate for Payer: PacificSource Commercial |
$15.53
|
| Rate for Payer: PHCS PPO |
$16.91
|
| Rate for Payer: Three Rivers PPO |
$12.94
|
| Rate for Payer: TriWest Veterans Administration |
$10.53
|
| Rate for Payer: United Healthcare Commercial |
$16.48
|
| Rate for Payer: United Healthcare Medicare |
$10.53
|
| Rate for Payer: WINHealth Partners Commercial |
$16.40
|
| Rate for Payer: Wise Provider Network Commercial |
$16.40
|
|
|
CARBAMAZEPINE 200 MG TABLET [9411]
|
Facility
|
OP
|
$18.58
|
|
|
Service Code
|
NDC 6808444411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$18.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.21
|
| Rate for Payer: Aetna of WY Medicare |
$12.26
|
| Rate for Payer: Altius Commercial |
$17.84
|
| Rate for Payer: Beech Street Commercial |
$18.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.02
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.02
|
| Rate for Payer: Cigna of WY Commercial |
$18.21
|
| Rate for Payer: Entrust Commercial |
$17.65
|
| Rate for Payer: First Choice Health Commercial |
$17.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.59
|
| Rate for Payer: HealthUtah PPO |
$18.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.02
|
| Rate for Payer: Multiplan Medicare/VA |
$10.06
|
| Rate for Payer: One Health Plan of WY PPO |
$18.21
|
| Rate for Payer: PacificSource Commercial |
$16.72
|
| Rate for Payer: PHCS PPO |
$18.21
|
| Rate for Payer: Three Rivers PPO |
$13.94
|
| Rate for Payer: TriWest Veterans Administration |
$10.59
|
| Rate for Payer: United Healthcare Commercial |
$17.74
|
| Rate for Payer: United Healthcare Medicare |
$10.59
|
| Rate for Payer: WINHealth Partners Commercial |
$18.21
|
| Rate for Payer: Wise Provider Network Commercial |
$17.65
|
|
|
CARBAMAZEPINE 200 MG TABLET [9411]
|
Facility
|
IP
|
$18.58
|
|
|
Service Code
|
NDC 6808444411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$18.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.21
|
| Rate for Payer: Aetna of WY Medicare |
$11.89
|
| Rate for Payer: Altius Commercial |
$17.84
|
| Rate for Payer: Beech Street Commercial |
$18.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.02
|
| Rate for Payer: Cash Price |
$13.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.02
|
| Rate for Payer: Cigna of WY Commercial |
$18.21
|
| Rate for Payer: Entrust Commercial |
$17.65
|
| Rate for Payer: First Choice Health Commercial |
$17.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.33
|
| Rate for Payer: HealthUtah PPO |
$18.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.02
|
| Rate for Payer: Multiplan Medicare/VA |
$10.77
|
| Rate for Payer: One Health Plan of WY PPO |
$18.21
|
| Rate for Payer: PacificSource Commercial |
$16.72
|
| Rate for Payer: PHCS PPO |
$18.21
|
| Rate for Payer: Three Rivers PPO |
$13.94
|
| Rate for Payer: TriWest Veterans Administration |
$11.33
|
| Rate for Payer: United Healthcare Commercial |
$17.74
|
| Rate for Payer: United Healthcare Medicare |
$11.33
|
| Rate for Payer: WINHealth Partners Commercial |
$17.65
|
| Rate for Payer: Wise Provider Network Commercial |
$17.65
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [14733]
|
Facility
|
IP
|
$15.59
|
|
|
Service Code
|
NDC 4612255705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.28
|
| Rate for Payer: Aetna of WY Medicare |
$9.98
|
| Rate for Payer: Altius Commercial |
$14.97
|
| Rate for Payer: Beech Street Commercial |
$15.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.12
|
| Rate for Payer: Cash Price |
$10.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.12
|
| Rate for Payer: Cigna of WY Commercial |
$15.28
|
| Rate for Payer: Entrust Commercial |
$14.81
|
| Rate for Payer: First Choice Health Commercial |
$14.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.51
|
| Rate for Payer: HealthUtah PPO |
$15.59
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.12
|
| Rate for Payer: Multiplan Medicare/VA |
$9.03
|
| Rate for Payer: One Health Plan of WY PPO |
$15.28
|
| Rate for Payer: PacificSource Commercial |
$14.03
|
| Rate for Payer: PHCS PPO |
$15.28
|
| Rate for Payer: Three Rivers PPO |
$11.69
|
| Rate for Payer: TriWest Veterans Administration |
$9.51
|
| Rate for Payer: United Healthcare Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare |
$9.51
|
| Rate for Payer: WINHealth Partners Commercial |
$14.81
|
| Rate for Payer: Wise Provider Network Commercial |
$14.81
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [14733]
|
Facility
|
OP
|
$15.50
|
|
|
Service Code
|
NDC 0904662735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.39 |
| Max. Negotiated Rate |
$15.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.19
|
| Rate for Payer: Aetna of WY Medicare |
$10.23
|
| Rate for Payer: Altius Commercial |
$14.88
|
| Rate for Payer: Beech Street Commercial |
$15.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.04
|
| Rate for Payer: Cash Price |
$10.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.04
|
| Rate for Payer: Cigna of WY Commercial |
$15.19
|
| Rate for Payer: Entrust Commercial |
$14.72
|
| Rate for Payer: First Choice Health Commercial |
$14.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.84
|
| Rate for Payer: HealthUtah PPO |
$15.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.04
|
| Rate for Payer: Multiplan Medicare/VA |
$8.39
|
| Rate for Payer: One Health Plan of WY PPO |
$15.19
|
| Rate for Payer: PacificSource Commercial |
$13.95
|
| Rate for Payer: PHCS PPO |
$15.19
|
| Rate for Payer: Three Rivers PPO |
$11.62
|
| Rate for Payer: TriWest Veterans Administration |
$8.84
|
| Rate for Payer: United Healthcare Commercial |
$14.80
|
| Rate for Payer: United Healthcare Medicare |
$8.84
|
| Rate for Payer: WINHealth Partners Commercial |
$15.19
|
| Rate for Payer: Wise Provider Network Commercial |
$14.72
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [14733]
|
Facility
|
OP
|
$15.59
|
|
|
Service Code
|
NDC 4612255705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.44 |
| Max. Negotiated Rate |
$15.59 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.28
|
| Rate for Payer: Aetna of WY Medicare |
$10.29
|
| Rate for Payer: Altius Commercial |
$14.97
|
| Rate for Payer: Beech Street Commercial |
$15.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.12
|
| Rate for Payer: Cash Price |
$10.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.12
|
| Rate for Payer: Cigna of WY Commercial |
$15.28
|
| Rate for Payer: Entrust Commercial |
$14.81
|
| Rate for Payer: First Choice Health Commercial |
$14.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.89
|
| Rate for Payer: HealthUtah PPO |
$15.59
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.12
|
| Rate for Payer: Multiplan Medicare/VA |
$8.44
|
| Rate for Payer: One Health Plan of WY PPO |
$15.28
|
| Rate for Payer: PacificSource Commercial |
$14.03
|
| Rate for Payer: PHCS PPO |
$15.28
|
| Rate for Payer: Three Rivers PPO |
$11.69
|
| Rate for Payer: TriWest Veterans Administration |
$8.89
|
| Rate for Payer: United Healthcare Commercial |
$14.89
|
| Rate for Payer: United Healthcare Medicare |
$8.89
|
| Rate for Payer: WINHealth Partners Commercial |
$15.28
|
| Rate for Payer: Wise Provider Network Commercial |
$14.81
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS [14733]
|
Facility
|
IP
|
$15.50
|
|
|
Service Code
|
NDC 0904662735
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.98 |
| Max. Negotiated Rate |
$15.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.19
|
| Rate for Payer: Aetna of WY Medicare |
$9.92
|
| Rate for Payer: Altius Commercial |
$14.88
|
| Rate for Payer: Beech Street Commercial |
$15.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.04
|
| Rate for Payer: Cash Price |
$10.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.04
|
| Rate for Payer: Cigna of WY Commercial |
$15.19
|
| Rate for Payer: Entrust Commercial |
$14.72
|
| Rate for Payer: First Choice Health Commercial |
$14.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.46
|
| Rate for Payer: HealthUtah PPO |
$15.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.04
|
| Rate for Payer: Multiplan Medicare/VA |
$8.98
|
| Rate for Payer: One Health Plan of WY PPO |
$15.19
|
| Rate for Payer: PacificSource Commercial |
$13.95
|
| Rate for Payer: PHCS PPO |
$15.19
|
| Rate for Payer: Three Rivers PPO |
$11.62
|
| Rate for Payer: TriWest Veterans Administration |
$9.46
|
| Rate for Payer: United Healthcare Commercial |
$14.80
|
| Rate for Payer: United Healthcare Medicare |
$9.46
|
| Rate for Payer: WINHealth Partners Commercial |
$14.72
|
| Rate for Payer: Wise Provider Network Commercial |
$14.72
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [18223]
|
Facility
|
OP
|
$16.46
|
|
|
Service Code
|
NDC 6068766111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.91 |
| Max. Negotiated Rate |
$16.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.13
|
| Rate for Payer: Aetna of WY Medicare |
$10.86
|
| Rate for Payer: Altius Commercial |
$15.80
|
| Rate for Payer: Beech Street Commercial |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.97
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.97
|
| Rate for Payer: Cigna of WY Commercial |
$16.13
|
| Rate for Payer: Entrust Commercial |
$15.64
|
| Rate for Payer: First Choice Health Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.38
|
| Rate for Payer: HealthUtah PPO |
$16.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.97
|
| Rate for Payer: Multiplan Medicare/VA |
$8.91
|
| Rate for Payer: One Health Plan of WY PPO |
$16.13
|
| Rate for Payer: PacificSource Commercial |
$14.81
|
| Rate for Payer: PHCS PPO |
$16.13
|
| Rate for Payer: Three Rivers PPO |
$12.34
|
| Rate for Payer: TriWest Veterans Administration |
$9.38
|
| Rate for Payer: United Healthcare Commercial |
$15.72
|
| Rate for Payer: United Healthcare Medicare |
$9.38
|
| Rate for Payer: WINHealth Partners Commercial |
$16.13
|
| Rate for Payer: Wise Provider Network Commercial |
$15.64
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [18223]
|
Facility
|
IP
|
$16.46
|
|
|
Service Code
|
NDC 6068766111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.54 |
| Max. Negotiated Rate |
$16.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.13
|
| Rate for Payer: Aetna of WY Medicare |
$10.53
|
| Rate for Payer: Altius Commercial |
$15.80
|
| Rate for Payer: Beech Street Commercial |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.97
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.97
|
| Rate for Payer: Cigna of WY Commercial |
$16.13
|
| Rate for Payer: Entrust Commercial |
$15.64
|
| Rate for Payer: First Choice Health Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.04
|
| Rate for Payer: HealthUtah PPO |
$16.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.97
|
| Rate for Payer: Multiplan Medicare/VA |
$9.54
|
| Rate for Payer: One Health Plan of WY PPO |
$16.13
|
| Rate for Payer: PacificSource Commercial |
$14.81
|
| Rate for Payer: PHCS PPO |
$16.13
|
| Rate for Payer: Three Rivers PPO |
$12.34
|
| Rate for Payer: TriWest Veterans Administration |
$10.04
|
| Rate for Payer: United Healthcare Commercial |
$15.72
|
| Rate for Payer: United Healthcare Medicare |
$10.04
|
| Rate for Payer: WINHealth Partners Commercial |
$15.64
|
| Rate for Payer: Wise Provider Network Commercial |
$15.64
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [18223]
|
Facility
|
OP
|
$15.23
|
|
|
Service Code
|
NDC 5965145705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.25 |
| Max. Negotiated Rate |
$15.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.93
|
| Rate for Payer: Aetna of WY Medicare |
$10.05
|
| Rate for Payer: Altius Commercial |
$14.62
|
| Rate for Payer: Beech Street Commercial |
$14.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.77
|
| Rate for Payer: Cash Price |
$10.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.77
|
| Rate for Payer: Cigna of WY Commercial |
$14.93
|
| Rate for Payer: Entrust Commercial |
$14.47
|
| Rate for Payer: First Choice Health Commercial |
$14.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.68
|
| Rate for Payer: HealthUtah PPO |
$15.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.77
|
| Rate for Payer: Multiplan Medicare/VA |
$8.25
|
| Rate for Payer: One Health Plan of WY PPO |
$14.93
|
| Rate for Payer: PacificSource Commercial |
$13.71
|
| Rate for Payer: PHCS PPO |
$14.93
|
| 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 |
$14.93
|
| Rate for Payer: Wise Provider Network Commercial |
$14.47
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET [18223]
|
Facility
|
IP
|
$15.23
|
|
|
Service Code
|
NDC 5965145705
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.83 |
| Max. Negotiated Rate |
$15.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.93
|
| Rate for Payer: Aetna of WY Medicare |
$9.75
|
| Rate for Payer: Altius Commercial |
$14.62
|
| Rate for Payer: Beech Street Commercial |
$14.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.77
|
| Rate for Payer: Cash Price |
$10.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.77
|
| Rate for Payer: Cigna of WY Commercial |
$14.93
|
| Rate for Payer: Entrust Commercial |
$14.47
|
| Rate for Payer: First Choice Health Commercial |
$14.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.47
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.29
|
| Rate for Payer: HealthUtah PPO |
$15.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.77
|
| Rate for Payer: Multiplan Medicare/VA |
$8.83
|
| Rate for Payer: One Health Plan of WY PPO |
$14.93
|
| Rate for Payer: PacificSource Commercial |
$13.71
|
| Rate for Payer: PHCS PPO |
$14.93
|
| Rate for Payer: Three Rivers PPO |
$11.42
|
| Rate for Payer: TriWest Veterans Administration |
$9.29
|
| Rate for Payer: United Healthcare Commercial |
$14.54
|
| Rate for Payer: United Healthcare Medicare |
$9.29
|
| Rate for Payer: WINHealth Partners Commercial |
$14.47
|
| Rate for Payer: Wise Provider Network Commercial |
$14.47
|
|
|
CARBOJET CO2 TUBE SET
|
Facility
|
IP
|
$647.50
|
|
| Hospital Charge Code |
2650738
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$375.23 |
| Max. Negotiated Rate |
$647.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$634.55
|
| Rate for Payer: Aetna of WY Medicare |
$414.40
|
| Rate for Payer: Altius Commercial |
$621.60
|
| Rate for Payer: Beech Street Commercial |
$634.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$628.08
|
| Rate for Payer: Cash Price |
$453.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$628.08
|
| Rate for Payer: Cigna of WY Commercial |
$634.55
|
| Rate for Payer: Entrust Commercial |
$615.12
|
| Rate for Payer: First Choice Health Commercial |
$615.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$615.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$394.98
|
| Rate for Payer: HealthUtah PPO |
$647.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$628.08
|
| Rate for Payer: Multiplan Medicare/VA |
$375.23
|
| Rate for Payer: One Health Plan of WY PPO |
$634.55
|
| Rate for Payer: PacificSource Commercial |
$582.75
|
| Rate for Payer: PHCS PPO |
$634.55
|
| Rate for Payer: Three Rivers PPO |
$485.62
|
| Rate for Payer: TriWest Veterans Administration |
$394.98
|
| Rate for Payer: United Healthcare Commercial |
$618.36
|
| Rate for Payer: United Healthcare Medicare |
$394.98
|
| Rate for Payer: WINHealth Partners Commercial |
$615.12
|
| Rate for Payer: Wise Provider Network Commercial |
$615.12
|
|
|
CARBOJET CO2 TUBE SET
|
Facility
|
OP
|
$647.50
|
|
| Hospital Charge Code |
2650738
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$350.62 |
| Max. Negotiated Rate |
$647.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$634.55
|
| Rate for Payer: Aetna of WY Medicare |
$427.35
|
| Rate for Payer: Altius Commercial |
$621.60
|
| Rate for Payer: Beech Street Commercial |
$634.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$628.08
|
| Rate for Payer: Cash Price |
$453.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$628.08
|
| Rate for Payer: Cigna of WY Commercial |
$634.55
|
| Rate for Payer: Entrust Commercial |
$615.12
|
| Rate for Payer: First Choice Health Commercial |
$615.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$615.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$369.08
|
| Rate for Payer: HealthUtah PPO |
$647.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$628.08
|
| Rate for Payer: Multiplan Medicare/VA |
$350.62
|
| Rate for Payer: One Health Plan of WY PPO |
$634.55
|
| Rate for Payer: PacificSource Commercial |
$582.75
|
| Rate for Payer: PHCS PPO |
$634.55
|
| Rate for Payer: Three Rivers PPO |
$485.62
|
| Rate for Payer: TriWest Veterans Administration |
$369.08
|
| Rate for Payer: United Healthcare Commercial |
$618.36
|
| Rate for Payer: United Healthcare Medicare |
$369.08
|
| Rate for Payer: WINHealth Partners Commercial |
$634.55
|
| Rate for Payer: Wise Provider Network Commercial |
$615.12
|
|
|
CARBON MONOXIDE DIFFUSING CAPACITY
|
Professional
|
Both
|
$52.00
|
|
|
Service Code
|
HCPCS 94720 26
|
| Min. Negotiated Rate |
$39.00 |
| Max. Negotiated Rate |
$52.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$50.96
|
| Rate for Payer: Beech Street Commercial |
$49.40
|
| Rate for Payer: Cash Price |
$36.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$50.44
|
| Rate for Payer: Cigna of WY Commercial |
$50.96
|
| Rate for Payer: First Choice Health Commercial |
$46.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$49.40
|
| Rate for Payer: HealthUtah PPO |
$52.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$50.44
|
| Rate for Payer: One Health Plan of WY PPO |
$50.96
|
| Rate for Payer: PacificSource Commercial |
$46.80
|
| Rate for Payer: PHCS PPO |
$49.40
|
| Rate for Payer: Three Rivers PPO |
$39.00
|
| Rate for Payer: United Healthcare Commercial |
$49.40
|
| Rate for Payer: WINHealth Partners Commercial |
$49.40
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [29603]
|
Facility
|
IP
|
$19.41
|
|
|
Service Code
|
HCPCS J9045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.25 |
| Max. Negotiated Rate |
$19.41 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.02
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.98
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.42
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.56
|
| Rate for Payer: Aetna of WY Medicare |
$12.12
|
| Rate for Payer: Aetna of WY Medicare |
$11.74
|
| Rate for Payer: Aetna of WY Medicare |
$12.42
|
| Rate for Payer: Aetna of WY Medicare |
$12.03
|
| Rate for Payer: Altius Commercial |
$18.63
|
| Rate for Payer: Altius Commercial |
$18.18
|
| Rate for Payer: Altius Commercial |
$17.62
|
| Rate for Payer: Altius Commercial |
$18.05
|
| Rate for Payer: Beech Street Commercial |
$17.98
|
| Rate for Payer: Beech Street Commercial |
$19.02
|
| Rate for Payer: Beech Street Commercial |
$18.42
|
| Rate for Payer: Beech Street Commercial |
$18.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.83
|
| Rate for Payer: Cash Price |
$13.26
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cash Price |
$13.58
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.80
|
| Rate for Payer: Cigna of WY Commercial |
$18.56
|
| Rate for Payer: Cigna of WY Commercial |
$17.98
|
| Rate for Payer: Cigna of WY Commercial |
$19.02
|
| Rate for Payer: Cigna of WY Commercial |
$18.42
|
| Rate for Payer: Entrust Commercial |
$17.86
|
| Rate for Payer: Entrust Commercial |
$18.44
|
| Rate for Payer: Entrust Commercial |
$17.43
|
| Rate for Payer: Entrust Commercial |
$17.99
|
| Rate for Payer: First Choice Health Commercial |
$17.99
|
| Rate for Payer: First Choice Health Commercial |
$18.44
|
| Rate for Payer: First Choice Health Commercial |
$17.43
|
| Rate for Payer: First Choice Health Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.47
|
| Rate for Payer: HealthUtah PPO |
$18.94
|
| Rate for Payer: HealthUtah PPO |
$19.41
|
| Rate for Payer: HealthUtah PPO |
$18.80
|
| Rate for Payer: HealthUtah PPO |
$18.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.24
|
| Rate for Payer: Multiplan Medicare/VA |
$10.98
|
| Rate for Payer: Multiplan Medicare/VA |
$10.63
|
| Rate for Payer: Multiplan Medicare/VA |
$10.89
|
| Rate for Payer: Multiplan Medicare/VA |
$11.25
|
| Rate for Payer: One Health Plan of WY PPO |
$19.02
|
| Rate for Payer: One Health Plan of WY PPO |
$18.42
|
| Rate for Payer: One Health Plan of WY PPO |
$17.98
|
| Rate for Payer: One Health Plan of WY PPO |
$18.56
|
| Rate for Payer: PacificSource Commercial |
$17.47
|
| Rate for Payer: PacificSource Commercial |
$17.05
|
| Rate for Payer: PacificSource Commercial |
$16.92
|
| Rate for Payer: PacificSource Commercial |
$16.52
|
| Rate for Payer: PHCS PPO |
$19.02
|
| Rate for Payer: PHCS PPO |
$17.98
|
| Rate for Payer: PHCS PPO |
$18.42
|
| Rate for Payer: PHCS PPO |
$18.56
|
| Rate for Payer: Three Rivers PPO |
$14.56
|
| Rate for Payer: Three Rivers PPO |
$14.20
|
| Rate for Payer: Three Rivers PPO |
$13.76
|
| Rate for Payer: Three Rivers PPO |
$14.10
|
| Rate for Payer: TriWest Veterans Administration |
$11.55
|
| Rate for Payer: TriWest Veterans Administration |
$11.84
|
| Rate for Payer: TriWest Veterans Administration |
$11.19
|
| Rate for Payer: TriWest Veterans Administration |
$11.47
|
| Rate for Payer: United Healthcare Commercial |
$17.95
|
| Rate for Payer: United Healthcare Commercial |
$18.54
|
| Rate for Payer: United Healthcare Commercial |
$18.09
|
| Rate for Payer: United Healthcare Commercial |
$17.52
|
| Rate for Payer: United Healthcare Medicare |
$11.19
|
| Rate for Payer: United Healthcare Medicare |
$11.84
|
| Rate for Payer: United Healthcare Medicare |
$11.47
|
| Rate for Payer: United Healthcare Medicare |
$11.55
|
| Rate for Payer: WINHealth Partners Commercial |
$17.86
|
| Rate for Payer: WINHealth Partners Commercial |
$17.99
|
| Rate for Payer: WINHealth Partners Commercial |
$17.43
|
| Rate for Payer: WINHealth Partners Commercial |
$18.44
|
| Rate for Payer: Wise Provider Network Commercial |
$17.43
|
| Rate for Payer: Wise Provider Network Commercial |
$17.99
|
| Rate for Payer: Wise Provider Network Commercial |
$18.44
|
| Rate for Payer: Wise Provider Network Commercial |
$17.86
|
|
|
CARBOPLATIN 10 MG/ML INTRAVENOUS SOLUTION [29603]
|
Facility
|
OP
|
$18.35
|
|
|
Service Code
|
HCPCS J9045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.94 |
| Max. Negotiated Rate |
$18.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.98
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.02
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.42
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.56
|
| Rate for Payer: Aetna of WY Medicare |
$12.81
|
| Rate for Payer: Aetna of WY Medicare |
$12.11
|
| Rate for Payer: Aetna of WY Medicare |
$12.41
|
| Rate for Payer: Aetna of WY Medicare |
$12.50
|
| Rate for Payer: Altius Commercial |
$18.05
|
| Rate for Payer: Altius Commercial |
$17.62
|
| Rate for Payer: Altius Commercial |
$18.18
|
| Rate for Payer: Altius Commercial |
$18.63
|
| Rate for Payer: Beech Street Commercial |
$18.42
|
| Rate for Payer: Beech Street Commercial |
$19.02
|
| Rate for Payer: Beech Street Commercial |
$17.98
|
| Rate for Payer: Beech Street Commercial |
$18.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.83
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.80
|
| Rate for Payer: Cash Price |
$13.26
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: Cash Price |
$13.58
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.80
|
| Rate for Payer: Cigna of WY Commercial |
$18.42
|
| Rate for Payer: Cigna of WY Commercial |
$18.56
|
| Rate for Payer: Cigna of WY Commercial |
$19.02
|
| Rate for Payer: Cigna of WY Commercial |
$17.98
|
| Rate for Payer: Entrust Commercial |
$18.44
|
| Rate for Payer: Entrust Commercial |
$17.86
|
| Rate for Payer: Entrust Commercial |
$17.43
|
| Rate for Payer: Entrust Commercial |
$17.99
|
| Rate for Payer: First Choice Health Commercial |
$18.44
|
| Rate for Payer: First Choice Health Commercial |
$17.86
|
| Rate for Payer: First Choice Health Commercial |
$17.43
|
| Rate for Payer: First Choice Health Commercial |
$17.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.72
|
| Rate for Payer: HealthUtah PPO |
$18.80
|
| Rate for Payer: HealthUtah PPO |
$19.41
|
| Rate for Payer: HealthUtah PPO |
$18.35
|
| Rate for Payer: HealthUtah PPO |
$18.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.83
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.24
|
| Rate for Payer: Multiplan Medicare/VA |
$10.26
|
| Rate for Payer: Multiplan Medicare/VA |
$10.18
|
| Rate for Payer: Multiplan Medicare/VA |
$9.94
|
| Rate for Payer: Multiplan Medicare/VA |
$10.51
|
| Rate for Payer: One Health Plan of WY PPO |
$17.98
|
| Rate for Payer: One Health Plan of WY PPO |
$19.02
|
| Rate for Payer: One Health Plan of WY PPO |
$18.56
|
| Rate for Payer: One Health Plan of WY PPO |
$18.42
|
| Rate for Payer: PacificSource Commercial |
$17.05
|
| Rate for Payer: PacificSource Commercial |
$16.52
|
| Rate for Payer: PacificSource Commercial |
$16.92
|
| Rate for Payer: PacificSource Commercial |
$17.47
|
| Rate for Payer: PHCS PPO |
$19.02
|
| Rate for Payer: PHCS PPO |
$17.98
|
| Rate for Payer: PHCS PPO |
$18.42
|
| Rate for Payer: PHCS PPO |
$18.56
|
| Rate for Payer: Three Rivers PPO |
$14.56
|
| Rate for Payer: Three Rivers PPO |
$14.20
|
| Rate for Payer: Three Rivers PPO |
$13.76
|
| Rate for Payer: Three Rivers PPO |
$14.10
|
| Rate for Payer: TriWest Veterans Administration |
$11.06
|
| Rate for Payer: TriWest Veterans Administration |
$10.80
|
| Rate for Payer: TriWest Veterans Administration |
$10.72
|
| Rate for Payer: TriWest Veterans Administration |
$10.46
|
| Rate for Payer: United Healthcare Commercial |
$17.95
|
| Rate for Payer: United Healthcare Commercial |
$18.54
|
| Rate for Payer: United Healthcare Commercial |
$18.09
|
| Rate for Payer: United Healthcare Commercial |
$17.52
|
| Rate for Payer: United Healthcare Medicare |
$10.72
|
| Rate for Payer: United Healthcare Medicare |
$11.06
|
| Rate for Payer: United Healthcare Medicare |
$10.80
|
| Rate for Payer: United Healthcare Medicare |
$10.46
|
| Rate for Payer: WINHealth Partners Commercial |
$17.98
|
| Rate for Payer: WINHealth Partners Commercial |
$19.02
|
| Rate for Payer: WINHealth Partners Commercial |
$18.56
|
| Rate for Payer: WINHealth Partners Commercial |
$18.42
|
| Rate for Payer: Wise Provider Network Commercial |
$17.99
|
| Rate for Payer: Wise Provider Network Commercial |
$17.86
|
| Rate for Payer: Wise Provider Network Commercial |
$17.43
|
| Rate for Payer: Wise Provider Network Commercial |
$18.44
|
|
|
CARBOPROST TROMETHAMINE 250 MCG/ML INTRAMUSCULAR SOLUTION [20456]
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
NDC 0009085608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$121.84 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Beech Street Commercial |
$220.50
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$220.50
|
| Rate for Payer: Aetna of WY Medicare |
$148.50
|
| Rate for Payer: Altius Commercial |
$216.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$218.25
|
| 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 |
$128.25
|
| Rate for Payer: HealthUtah PPO |
$225.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$218.25
|
| Rate for Payer: Multiplan Medicare/VA |
$121.84
|
| 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 |
$128.25
|
| Rate for Payer: United Healthcare Commercial |
$214.88
|
| Rate for Payer: United Healthcare Medicare |
$128.25
|
| 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 0009085608
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$130.39 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$220.50
|
| Rate for Payer: Aetna of WY Medicare |
$144.00
|
| 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 |
$218.25
|
| 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 |
$137.25
|
| Rate for Payer: HealthUtah PPO |
$225.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$218.25
|
| Rate for Payer: Multiplan Medicare/VA |
$130.39
|
| 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 |
$137.25
|
| Rate for Payer: United Healthcare Commercial |
$214.88
|
| Rate for Payer: United Healthcare Medicare |
$137.25
|
| Rate for Payer: WINHealth Partners Commercial |
$213.75
|
| Rate for Payer: Wise Provider Network Commercial |
$213.75
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [11519]
|
Facility
|
IP
|
$17.24
|
|
|
Service Code
|
NDC 0023079815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.99 |
| Max. Negotiated Rate |
$17.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.90
|
| Rate for Payer: Aetna of WY Medicare |
$11.03
|
| Rate for Payer: Altius Commercial |
$16.55
|
| Rate for Payer: Beech Street Commercial |
$16.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.72
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.72
|
| Rate for Payer: Cigna of WY Commercial |
$16.90
|
| Rate for Payer: Entrust Commercial |
$16.38
|
| Rate for Payer: First Choice Health Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.52
|
| Rate for Payer: HealthUtah PPO |
$17.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.72
|
| Rate for Payer: Multiplan Medicare/VA |
$9.99
|
| Rate for Payer: One Health Plan of WY PPO |
$16.90
|
| Rate for Payer: PacificSource Commercial |
$15.52
|
| Rate for Payer: PHCS PPO |
$16.90
|
| Rate for Payer: Three Rivers PPO |
$12.93
|
| Rate for Payer: TriWest Veterans Administration |
$10.52
|
| Rate for Payer: United Healthcare Commercial |
$16.46
|
| Rate for Payer: United Healthcare Medicare |
$10.52
|
| Rate for Payer: WINHealth Partners Commercial |
$16.38
|
| Rate for Payer: Wise Provider Network Commercial |
$16.38
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS [11519]
|
Facility
|
OP
|
$17.24
|
|
|
Service Code
|
NDC 0023079815
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.34 |
| Max. Negotiated Rate |
$17.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.90
|
| Rate for Payer: Aetna of WY Medicare |
$11.38
|
| Rate for Payer: Altius Commercial |
$16.55
|
| Rate for Payer: Beech Street Commercial |
$16.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.72
|
| Rate for Payer: Cash Price |
$12.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.72
|
| Rate for Payer: Cigna of WY Commercial |
$16.90
|
| Rate for Payer: Entrust Commercial |
$16.38
|
| Rate for Payer: First Choice Health Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.83
|
| Rate for Payer: HealthUtah PPO |
$17.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.72
|
| Rate for Payer: Multiplan Medicare/VA |
$9.34
|
| Rate for Payer: One Health Plan of WY PPO |
$16.90
|
| Rate for Payer: PacificSource Commercial |
$15.52
|
| Rate for Payer: PHCS PPO |
$16.90
|
| Rate for Payer: Three Rivers PPO |
$12.93
|
| Rate for Payer: TriWest Veterans Administration |
$9.83
|
| Rate for Payer: United Healthcare Commercial |
$16.46
|
| Rate for Payer: United Healthcare Medicare |
$9.83
|
| Rate for Payer: WINHealth Partners Commercial |
$16.90
|
| Rate for Payer: Wise Provider Network Commercial |
$16.38
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$15.94
|
|
|
Service Code
|
NDC 0536138792
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$15.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.62
|
| Rate for Payer: Aetna of WY Medicare |
$10.20
|
| Rate for Payer: Altius Commercial |
$15.30
|
| Rate for Payer: Beech Street Commercial |
$15.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.46
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.46
|
| Rate for Payer: Cigna of WY Commercial |
$15.62
|
| Rate for Payer: Entrust Commercial |
$15.14
|
| Rate for Payer: First Choice Health Commercial |
$15.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.72
|
| Rate for Payer: HealthUtah PPO |
$15.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.46
|
| Rate for Payer: Multiplan Medicare/VA |
$9.24
|
| Rate for Payer: One Health Plan of WY PPO |
$15.62
|
| Rate for Payer: PacificSource Commercial |
$14.35
|
| Rate for Payer: PHCS PPO |
$15.62
|
| Rate for Payer: Three Rivers PPO |
$11.96
|
| Rate for Payer: TriWest Veterans Administration |
$9.72
|
| Rate for Payer: United Healthcare Commercial |
$15.22
|
| Rate for Payer: United Healthcare Medicare |
$9.72
|
| Rate for Payer: WINHealth Partners Commercial |
$15.14
|
| Rate for Payer: Wise Provider Network Commercial |
$15.14
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$15.94
|
|
|
Service Code
|
NDC 8770141319
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$15.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.62
|
| Rate for Payer: Aetna of WY Medicare |
$10.52
|
| Rate for Payer: Altius Commercial |
$15.30
|
| Rate for Payer: Beech Street Commercial |
$15.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.46
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.46
|
| Rate for Payer: Cigna of WY Commercial |
$15.62
|
| Rate for Payer: Entrust Commercial |
$15.14
|
| Rate for Payer: First Choice Health Commercial |
$15.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.09
|
| Rate for Payer: HealthUtah PPO |
$15.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.46
|
| Rate for Payer: Multiplan Medicare/VA |
$8.63
|
| Rate for Payer: One Health Plan of WY PPO |
$15.62
|
| Rate for Payer: PacificSource Commercial |
$14.35
|
| Rate for Payer: PHCS PPO |
$15.62
|
| Rate for Payer: Three Rivers PPO |
$11.96
|
| Rate for Payer: TriWest Veterans Administration |
$9.09
|
| Rate for Payer: United Healthcare Commercial |
$15.22
|
| Rate for Payer: United Healthcare Medicare |
$9.09
|
| Rate for Payer: WINHealth Partners Commercial |
$15.62
|
| Rate for Payer: Wise Provider Network Commercial |
$15.14
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$16.09
|
|
|
Service Code
|
NDC 4612219565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$16.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.77
|
| Rate for Payer: Aetna of WY Medicare |
$10.62
|
| Rate for Payer: Altius Commercial |
$15.45
|
| Rate for Payer: Beech Street Commercial |
$15.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.61
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.61
|
| Rate for Payer: Cigna of WY Commercial |
$15.77
|
| Rate for Payer: Entrust Commercial |
$15.29
|
| Rate for Payer: First Choice Health Commercial |
$15.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.17
|
| Rate for Payer: HealthUtah PPO |
$16.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.61
|
| Rate for Payer: Multiplan Medicare/VA |
$8.71
|
| Rate for Payer: One Health Plan of WY PPO |
$15.77
|
| Rate for Payer: PacificSource Commercial |
$14.48
|
| Rate for Payer: PHCS PPO |
$15.77
|
| Rate for Payer: Three Rivers PPO |
$12.07
|
| Rate for Payer: TriWest Veterans Administration |
$9.17
|
| Rate for Payer: United Healthcare Commercial |
$15.37
|
| Rate for Payer: United Healthcare Medicare |
$9.17
|
| Rate for Payer: WINHealth Partners Commercial |
$15.77
|
| Rate for Payer: Wise Provider Network Commercial |
$15.29
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
IP
|
$16.09
|
|
|
Service Code
|
NDC 4612219565
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.32 |
| Max. Negotiated Rate |
$16.09 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.77
|
| Rate for Payer: Aetna of WY Medicare |
$10.30
|
| Rate for Payer: Altius Commercial |
$15.45
|
| Rate for Payer: Beech Street Commercial |
$15.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.61
|
| Rate for Payer: Cash Price |
$11.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.61
|
| Rate for Payer: Cigna of WY Commercial |
$15.77
|
| Rate for Payer: Entrust Commercial |
$15.29
|
| Rate for Payer: First Choice Health Commercial |
$15.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.81
|
| Rate for Payer: HealthUtah PPO |
$16.09
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.61
|
| Rate for Payer: Multiplan Medicare/VA |
$9.32
|
| Rate for Payer: One Health Plan of WY PPO |
$15.77
|
| Rate for Payer: PacificSource Commercial |
$14.48
|
| Rate for Payer: PHCS PPO |
$15.77
|
| Rate for Payer: Three Rivers PPO |
$12.07
|
| Rate for Payer: TriWest Veterans Administration |
$9.81
|
| Rate for Payer: United Healthcare Commercial |
$15.37
|
| Rate for Payer: United Healthcare Medicare |
$9.81
|
| Rate for Payer: WINHealth Partners Commercial |
$15.29
|
| Rate for Payer: Wise Provider Network Commercial |
$15.29
|
|
|
CARBOXYMETHYLCELLULOSE SODIUM 0.5 % EYE DROPS IN A DROPPERETTE [26541]
|
Facility
|
OP
|
$15.94
|
|
|
Service Code
|
NDC 0536138792
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$15.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.62
|
| Rate for Payer: Aetna of WY Medicare |
$10.52
|
| Rate for Payer: Altius Commercial |
$15.30
|
| Rate for Payer: Beech Street Commercial |
$15.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.46
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.46
|
| Rate for Payer: Cigna of WY Commercial |
$15.62
|
| Rate for Payer: Entrust Commercial |
$15.14
|
| Rate for Payer: First Choice Health Commercial |
$15.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.09
|
| Rate for Payer: HealthUtah PPO |
$15.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.46
|
| Rate for Payer: Multiplan Medicare/VA |
$8.63
|
| Rate for Payer: One Health Plan of WY PPO |
$15.62
|
| Rate for Payer: PacificSource Commercial |
$14.35
|
| Rate for Payer: PHCS PPO |
$15.62
|
| Rate for Payer: Three Rivers PPO |
$11.96
|
| Rate for Payer: TriWest Veterans Administration |
$9.09
|
| Rate for Payer: United Healthcare Commercial |
$15.22
|
| Rate for Payer: United Healthcare Medicare |
$9.09
|
| Rate for Payer: WINHealth Partners Commercial |
$15.62
|
| Rate for Payer: Wise Provider Network Commercial |
$15.14
|
|
