Washakie Medical Center

, Worland

Procedure	Code	Cash Price
FAMOTIDINE 20MG 20MG 2ML SNIJ	S0028	< $1
FINASTERIDE 5MG 5MG TB	S0138	< $1
BUPROPION SR 150MG 150MG TBER	S0106	< $1
METRONIDAZOLE IN NS IV SYRINGE 5 MG/ML (NICU/PEDS)	J1836	< $1
Chloroprocaine hcl injection	J2401	< $1
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION	J0665	< $1
ATROPINE 1 MG/ML INTRAVENOUS SOLUTION	J0461	< $1
IOTHALAMATE MEGLUMINE 17.2 % URETHRAL SOLUTION	Q9958	< $1
PROPOFOL 10 MG/ML INTRAVENOUS EMULSION	J2704	< $1
ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION	J2795	< $1
DAPTOMYCIN 350 MG INTRAVENOUS SOLUTION	J0878	< $1
METHYLPREDNISOLONE ACETATE 40 MG/ML SUSPENSION FOR INJECTION	J1010	< $1
DAPTOMYCIN 1MG 350MG 7ML PWIJ	J0873	< $1
FOSAPREPITANT 150 MG INTRAVENOUS POWDER FOR SOLUTION	J1453	< $1
IOTHALAMT 60 PERC 1ML 50ML SNIJ	Q9961	< $1
Calcium glucon (wg critical)	J0613	< $1
GADOTERATE MEGLUMINE 0.5 MMOL/ML 20ML VI	A9575	$1.13
IRON SUCROSE IV INJECTION 100 MG/5 ML	J1756	$1.14
Inj, calcium gluconate, nos	J0612	$1.14
METHYLPREDNISOLONE SODIUM SUCCINATE 500 MG INTRAVENOUS SOLUTION	J2919	$1.18
BIVALIRUDIN 1MG 250MG 5ML PWIJ	J0583	$1.23
NICARDIPINE 25 MG/10 ML INTRAVENOUS SOLUTION	J2404	$1.23
LIDOCAINE IN D5W 4 MG/ML INFUSION PREMIX (FOR PAIN)	J2001	$1.24
GADOBUTRL 0.1ML 30MMOL 30ML SN MDV	A9585	$1.27
INJ METHYLPREDNISOLONE ACETATE	J1050	$1.29
GLYCOPYRROL MPI 0.1MG 0.2MG 1MLSNIJ	J1596	$1.29
PREDNISONE 5 MG TABLET	J7512	$1.32
ESMOLOL 2 000 MG/100 ML (20 MG/ML) IN SODIUM CHLORIDE (ISO-OSMOTIC) IV	J1805	$1.54
IOPAMIDOL 370 MG IODINE/ML (76 %) INTRAVENOUS SOLUTION	Q9967	$1.58
OXALIPLATIN 100 MG/20 ML INTRAVENOUS SOLUTION	J9263	$1.59
FILGRASTIM-SNDZ 300 MCG/0.5 ML INJECTION SYRINGE	Q5101	$1.64
Nivestym	Q5110	$1.73
Ferumoxytol, esrd use	Q0139	$1.73
MIDAZOL WCC 1MG 50MG 50ML SNIV	J2251	$1.74
DIATRIZOATE MEGLUMINE-DIATRIZOATE SODIUM 66 %-10 % ORAL SOLUTION	Q9963	$1.76
INJ DEXAMETHASONE SOD PHOSPH	J1100	$1.91
MIDAZOLAM (PF) 5 MG/ML NASAL	J2250	$1.97
Ferumoxytol, non-esrd	Q0138	$2.19
Argatroban esrd dialysis 1mg	J0884	$2.19
Inj esmolol hcl wg crit care	J1806	$2.20
PACLITAXEL 1MG 30MG 5ML CN MDV	J9267	$2.32
PHENYLEPH 20MCG 100MCG 1ML SNIJ	J2371	$2.41
DEXAMETHASONE 1 MG/ML DROPS (CONCENTRATE)	J8540	$2.50
Dexmedetomidine film, 1 mcg	J1105	$2.55
SODIUM THIOSULFATE 12.5 GRAM/50 ML (250 MG/ML) INTRAVENOUS SOLUTION	J0209	$2.70
INJ ONDANSETRON HYDROCHLORIDE	J2405	$2.72
PHENYTOIN SODIUM IV SOLUTION 50 MG/ML	J1165	$2.80
Wilate injection	J7183	$2.88
Inj filgrastim excl biosimil	J1442	$3.02
Factor viii	J7190	$3.06
Factor ix recombinant nos	J7195	$3.06
ANTIHEMOPHILIC FACTOR-VWF 1 000 UNIT-2 400 UNIT INTRAVENOUS SOLUTION	J7187	$3.12
Argatroban nonesrd use 1mg	J0883	$3.19
Inj ferric carboxymaltos 1mg	J1439	$3.28
IOPAMIDOL 200 MG IODINE/ML (41 %) INJECTION SOLUTION	Q9966	$3.29
ACETYLCYSTEINE 200 MG/ML (20 %) INTRAVENOUS SOLUTION	J0132	$3.41
INJ KETOROLAC TROMETHAMINE	J1885	$3.48
COCAINE 4 % NASAL SOLUTION	C9046	$3.56
ENOXAPARIN 100 MG/ML SUBCUTANEOUS SYRINGE	J1650	$3.57
ADENOSINE 3MG/ML IV	J0153	$3.66
Inj, afstyla, 1 i.u.	J7210	$3.67
Inj retacrit esrd on dialysi	Q5105	$3.79
Factor ix complex	J7194	$3.80
Inj, lecanemab-irmb, 1 mg	J0174	$3.82
Inj, cyclophosphamide, nos	J9075	$3.85
METHYLPREDNISOLONE 4 MG TABLET	J7509	$3.92
Methylnaltrexone injection	J2212	$3.94
Inj, epinephrine (belcher)	J0173	$4.05
Factor viii recombinant NOS	J7192	$4.15
NEOSTIGMINE 3MG SIMP	J2710	$4.16
VASOPRESSIN 20 UNIT	J2599	$4.16
GADOTERIDOL 1ML 25MMOL 50ML SNIVMDV	A9576	$4.16
D5W-NS IV BOLUS	J7042	$4.54
BUPRENORPHINE 2 MG	J0571	$4.78
COCAINE NUMBRINO 1MG 160MG 4ML SNNS	C9143	$4.92
NITROGLYCERIN 50 MG/250 ML (200 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS	J2305	$4.93
LABETALOL 20 MG/4 ML (5 MG/ML) INTRAVENOUS SYRINGE	J1920	$5.05
INJECTION DIPHENHYDRAMINE HCL	J1200	$5.22
FENTANYL INFUSION 2500 MCG/50 ML	J3010	$5.37
TOPOTECAN 4 MG/4 ML (1 MG/ML) INTRAVENOUS SOLUTION	J9351	$5.45
PALONOSETRON 0.25 MG/5 ML INTRAVENOUS SOLUTION	J2469	$5.52
Prothrombin complex Kcentra	J7168	$5.64
DOCETAXEL 80 MG/8 ML (10 MG/ML) INTRAVENOUS SOLUTION	J9171	$5.65
Gel-syn injection 0.1 mg	J7328	$5.73
GADOB DIME 1ML 52.9GM 100ML SNIJMDV	A9578	$5.75
OLANZAPINE 10 MG INTRAMUSCULAR SOLUTION	J2359	$5.81
PROTAMINE 10 MG/ML INTRAVENOUS SOLUTION	J2720	$5.83
CYCLOSPORINE MODIFIED 25 MG CAPSULE	J7515	$5.98
NAFCILLIN 2GM 2GM PWIJ	S0032	$6.03
EPIRUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION	J9178	$6.20
Factor viia recomb novoseven	J7189	$6.22
IOHEXOL 180MG 1ML 3.6GM 20ML SNIJ	Q9965	$6.24
BORTEZOMIB 2.5 MG/ML SUBCUT INJECTION	J9041	$6.55
SODIUM CHLORIDE 3% BOLUS	J7131	$6.56
GADOTERIDOL 1ML 5MMOL 10ML SNIJ	A9579	$6.76
BUMETANIDE 0.25 MG/ML INJECTION SOLUTION	J1939	$6.81
METHACHOLINE 1MG 63.94MG 18ML SNIH	J7674	$6.81
aripirazole lauroxil 1 mg	J1944	$6.86
INSULIN LIS DME LESS THAN1M 50U 300U 3ML MDV	J1817	$6.87
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK	J1956	$6.91