|
BASIC METABOLIC PANEL CALCIUM TOTAL
|
Professional
|
Both
|
$116.00
|
|
|
Service Code
|
HCPCS 80048
|
| Hospital Charge Code |
80048
|
| Min. Negotiated Rate |
$7.19 |
| Max. Negotiated Rate |
$116.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$113.68
|
| Rate for Payer: Aetna of WY Medicare |
$8.46
|
| Rate for Payer: Beech Street Commercial |
$110.20
|
| Rate for Payer: Cash Price |
$81.20
|
| Rate for Payer: Cash Price |
$81.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$112.52
|
| Rate for Payer: Cigna of WY Commercial |
$113.68
|
| Rate for Payer: First Choice Health Commercial |
$104.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$110.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.46
|
| Rate for Payer: HealthUtah PPO |
$116.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$112.52
|
| Rate for Payer: Multiplan Medicare/VA |
$7.19
|
| Rate for Payer: One Health Plan of WY PPO |
$113.68
|
| Rate for Payer: PacificSource Commercial |
$104.40
|
| Rate for Payer: PHCS PPO |
$110.20
|
| Rate for Payer: Three Rivers PPO |
$87.00
|
| Rate for Payer: TriWest Veterans Administration |
$8.46
|
| Rate for Payer: United Healthcare Commercial |
$100.92
|
| Rate for Payer: United Healthcare Medicare |
$8.46
|
| Rate for Payer: WINHealth Partners Commercial |
$110.20
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION [12210]
|
Facility
|
OP
|
$254.82
|
|
|
Service Code
|
HCPCS J9030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$140.41 |
| Max. Negotiated Rate |
$254.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$249.72
|
| Rate for Payer: Aetna of WY Medicare |
$168.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$244.63
|
| Rate for Payer: Altius Commercial |
$244.63
|
| Rate for Payer: Beech Street Commercial |
$249.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$209.21
|
| Rate for Payer: Cash Price |
$178.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$247.18
|
| Rate for Payer: Cigna of WY Commercial |
$249.72
|
| Rate for Payer: Entrust Commercial |
$242.08
|
| Rate for Payer: First Choice Health Commercial |
$242.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$242.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$147.80
|
| Rate for Payer: HealthUtah PPO |
$254.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$247.18
|
| Rate for Payer: Multiplan Medicare/VA |
$140.41
|
| Rate for Payer: One Health Plan of WY PPO |
$249.72
|
| Rate for Payer: PacificSource Commercial |
$229.34
|
| Rate for Payer: PHCS PPO |
$249.72
|
| Rate for Payer: Three Rivers PPO |
$191.12
|
| Rate for Payer: TriWest Veterans Administration |
$147.80
|
| Rate for Payer: United Healthcare Commercial |
$221.69
|
| Rate for Payer: United Healthcare Medicare |
$147.80
|
| Rate for Payer: WINHealth Partners Commercial |
$249.72
|
| Rate for Payer: Wise Provider Network Commercial |
$242.08
|
|
|
BCG LIVE 50 MG INTRAVESICAL SUSPENSION [12210]
|
Facility
|
IP
|
$254.82
|
|
|
Service Code
|
HCPCS J9030
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$159.77 |
| Max. Negotiated Rate |
$254.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$249.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$244.63
|
| Rate for Payer: Altius Commercial |
$244.63
|
| Rate for Payer: Beech Street Commercial |
$249.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$209.21
|
| Rate for Payer: Cash Price |
$178.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$247.18
|
| Rate for Payer: Cigna of WY Commercial |
$249.72
|
| Rate for Payer: Entrust Commercial |
$242.08
|
| Rate for Payer: First Choice Health Commercial |
$242.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$242.08
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$168.18
|
| Rate for Payer: HealthUtah PPO |
$254.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$247.18
|
| Rate for Payer: Multiplan Medicare/VA |
$159.77
|
| Rate for Payer: One Health Plan of WY PPO |
$249.72
|
| Rate for Payer: PacificSource Commercial |
$229.34
|
| Rate for Payer: PHCS PPO |
$249.72
|
| Rate for Payer: Three Rivers PPO |
$191.12
|
| Rate for Payer: TriWest Veterans Administration |
$168.18
|
| Rate for Payer: United Healthcare Commercial |
$221.69
|
| Rate for Payer: United Healthcare Medicare |
$168.18
|
| Rate for Payer: WINHealth Partners Commercial |
$242.08
|
| Rate for Payer: Wise Provider Network Commercial |
$242.08
|
|
|
BELATACEPT 250 MG INTRAVENOUS SOLUTION [92727]
|
Facility
|
IP
|
$984.88
|
|
|
Service Code
|
HCPCS J0485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$617.52 |
| Max. Negotiated Rate |
$984.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$965.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$945.48
|
| Rate for Payer: Altius Commercial |
$945.48
|
| Rate for Payer: Beech Street Commercial |
$965.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$808.59
|
| Rate for Payer: Cash Price |
$689.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$955.33
|
| Rate for Payer: Cigna of WY Commercial |
$965.18
|
| Rate for Payer: Entrust Commercial |
$935.64
|
| Rate for Payer: First Choice Health Commercial |
$935.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$935.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$650.02
|
| Rate for Payer: HealthUtah PPO |
$984.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$955.33
|
| Rate for Payer: Multiplan Medicare/VA |
$617.52
|
| Rate for Payer: One Health Plan of WY PPO |
$965.18
|
| Rate for Payer: PacificSource Commercial |
$886.39
|
| Rate for Payer: PHCS PPO |
$965.18
|
| Rate for Payer: Three Rivers PPO |
$738.66
|
| Rate for Payer: TriWest Veterans Administration |
$650.02
|
| Rate for Payer: United Healthcare Commercial |
$856.85
|
| Rate for Payer: United Healthcare Medicare |
$650.02
|
| Rate for Payer: WINHealth Partners Commercial |
$935.64
|
| Rate for Payer: Wise Provider Network Commercial |
$935.64
|
|
|
BELATACEPT 250 MG INTRAVENOUS SOLUTION [92727]
|
Facility
|
OP
|
$984.88
|
|
|
Service Code
|
HCPCS J0485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$542.67 |
| Max. Negotiated Rate |
$984.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$965.18
|
| Rate for Payer: Aetna of WY Medicare |
$650.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$945.48
|
| Rate for Payer: Altius Commercial |
$945.48
|
| Rate for Payer: Beech Street Commercial |
$965.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$808.59
|
| Rate for Payer: Cash Price |
$689.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$955.33
|
| Rate for Payer: Cigna of WY Commercial |
$965.18
|
| Rate for Payer: Entrust Commercial |
$935.64
|
| Rate for Payer: First Choice Health Commercial |
$935.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$935.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$571.23
|
| Rate for Payer: HealthUtah PPO |
$984.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$955.33
|
| Rate for Payer: Multiplan Medicare/VA |
$542.67
|
| Rate for Payer: One Health Plan of WY PPO |
$965.18
|
| Rate for Payer: PacificSource Commercial |
$886.39
|
| Rate for Payer: PHCS PPO |
$965.18
|
| Rate for Payer: Three Rivers PPO |
$738.66
|
| Rate for Payer: TriWest Veterans Administration |
$571.23
|
| Rate for Payer: United Healthcare Commercial |
$856.85
|
| Rate for Payer: United Healthcare Medicare |
$571.23
|
| Rate for Payer: WINHealth Partners Commercial |
$965.18
|
| Rate for Payer: Wise Provider Network Commercial |
$935.64
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION [91846]
|
Facility
|
OP
|
$649.75
|
|
|
Service Code
|
HCPCS J0490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$358.01 |
| Max. Negotiated Rate |
$649.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$636.76
|
| Rate for Payer: Aetna of WY Medicare |
$428.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$623.76
|
| Rate for Payer: Altius Commercial |
$623.76
|
| Rate for Payer: Beech Street Commercial |
$636.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$533.44
|
| Rate for Payer: Cash Price |
$454.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$630.26
|
| Rate for Payer: Cigna of WY Commercial |
$636.76
|
| Rate for Payer: Entrust Commercial |
$617.26
|
| Rate for Payer: First Choice Health Commercial |
$617.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$617.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$376.86
|
| Rate for Payer: HealthUtah PPO |
$649.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$630.26
|
| Rate for Payer: Multiplan Medicare/VA |
$358.01
|
| Rate for Payer: One Health Plan of WY PPO |
$636.76
|
| Rate for Payer: PacificSource Commercial |
$584.78
|
| Rate for Payer: PHCS PPO |
$636.76
|
| Rate for Payer: Three Rivers PPO |
$487.31
|
| Rate for Payer: TriWest Veterans Administration |
$376.86
|
| Rate for Payer: United Healthcare Commercial |
$565.28
|
| Rate for Payer: United Healthcare Medicare |
$376.86
|
| Rate for Payer: WINHealth Partners Commercial |
$636.76
|
| Rate for Payer: Wise Provider Network Commercial |
$617.26
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION [91846]
|
Facility
|
IP
|
$649.75
|
|
|
Service Code
|
HCPCS J0490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$407.39 |
| Max. Negotiated Rate |
$649.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$636.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$623.76
|
| Rate for Payer: Altius Commercial |
$623.76
|
| Rate for Payer: Beech Street Commercial |
$636.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$533.44
|
| Rate for Payer: Cash Price |
$454.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$630.26
|
| Rate for Payer: Cigna of WY Commercial |
$636.76
|
| Rate for Payer: Entrust Commercial |
$617.26
|
| Rate for Payer: First Choice Health Commercial |
$617.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$617.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$428.84
|
| Rate for Payer: HealthUtah PPO |
$649.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$630.26
|
| Rate for Payer: Multiplan Medicare/VA |
$407.39
|
| Rate for Payer: One Health Plan of WY PPO |
$636.76
|
| Rate for Payer: PacificSource Commercial |
$584.78
|
| Rate for Payer: PHCS PPO |
$636.76
|
| Rate for Payer: Three Rivers PPO |
$487.31
|
| Rate for Payer: TriWest Veterans Administration |
$428.84
|
| Rate for Payer: United Healthcare Commercial |
$565.28
|
| Rate for Payer: United Healthcare Medicare |
$428.84
|
| Rate for Payer: WINHealth Partners Commercial |
$617.26
|
| Rate for Payer: Wise Provider Network Commercial |
$617.26
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION [91847]
|
Facility
|
OP
|
$2,130.70
|
|
|
Service Code
|
HCPCS J0490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,174.02 |
| Max. Negotiated Rate |
$2,130.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,088.09
|
| Rate for Payer: Aetna of WY Medicare |
$1,406.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,045.47
|
| Rate for Payer: Altius Commercial |
$2,045.47
|
| Rate for Payer: Beech Street Commercial |
$2,088.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,749.30
|
| Rate for Payer: Cash Price |
$1,491.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,066.78
|
| Rate for Payer: Cigna of WY Commercial |
$2,088.09
|
| Rate for Payer: Entrust Commercial |
$2,024.16
|
| Rate for Payer: First Choice Health Commercial |
$2,024.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,024.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,235.81
|
| Rate for Payer: HealthUtah PPO |
$2,130.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,066.78
|
| Rate for Payer: Multiplan Medicare/VA |
$1,174.02
|
| Rate for Payer: One Health Plan of WY PPO |
$2,088.09
|
| Rate for Payer: PacificSource Commercial |
$1,917.63
|
| Rate for Payer: PHCS PPO |
$2,088.09
|
| Rate for Payer: Three Rivers PPO |
$1,598.02
|
| Rate for Payer: TriWest Veterans Administration |
$1,235.81
|
| Rate for Payer: United Healthcare Commercial |
$1,853.71
|
| Rate for Payer: United Healthcare Medicare |
$1,235.81
|
| Rate for Payer: WINHealth Partners Commercial |
$2,088.09
|
| Rate for Payer: Wise Provider Network Commercial |
$2,024.16
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION [91847]
|
Facility
|
IP
|
$2,130.70
|
|
|
Service Code
|
HCPCS J0490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,335.95 |
| Max. Negotiated Rate |
$2,130.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,088.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,045.47
|
| Rate for Payer: Altius Commercial |
$2,045.47
|
| Rate for Payer: Beech Street Commercial |
$2,088.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,749.30
|
| Rate for Payer: Cash Price |
$1,491.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,066.78
|
| Rate for Payer: Cigna of WY Commercial |
$2,088.09
|
| Rate for Payer: Entrust Commercial |
$2,024.16
|
| Rate for Payer: First Choice Health Commercial |
$2,024.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,024.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,406.26
|
| Rate for Payer: HealthUtah PPO |
$2,130.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,066.78
|
| Rate for Payer: Multiplan Medicare/VA |
$1,335.95
|
| Rate for Payer: One Health Plan of WY PPO |
$2,088.09
|
| Rate for Payer: PacificSource Commercial |
$1,917.63
|
| Rate for Payer: PHCS PPO |
$2,088.09
|
| Rate for Payer: Three Rivers PPO |
$1,598.02
|
| Rate for Payer: TriWest Veterans Administration |
$1,406.26
|
| Rate for Payer: United Healthcare Commercial |
$1,853.71
|
| Rate for Payer: United Healthcare Medicare |
$1,406.26
|
| Rate for Payer: WINHealth Partners Commercial |
$2,024.16
|
| Rate for Payer: Wise Provider Network Commercial |
$2,024.16
|
|
|
BELMONT RAPID INFUSE 3 BAG SPIKE SET
|
Facility
|
IP
|
$637.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$399.40 |
| Max. Negotiated Rate |
$637.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$624.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$611.52
|
| Rate for Payer: Altius Commercial |
$611.52
|
| Rate for Payer: Beech Street Commercial |
$624.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$522.98
|
| Rate for Payer: Cash Price |
$445.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$617.89
|
| Rate for Payer: Cigna of WY Commercial |
$624.26
|
| Rate for Payer: Entrust Commercial |
$605.15
|
| Rate for Payer: First Choice Health Commercial |
$605.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$605.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$420.42
|
| Rate for Payer: HealthUtah PPO |
$637.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$617.89
|
| Rate for Payer: Multiplan Medicare/VA |
$399.40
|
| Rate for Payer: One Health Plan of WY PPO |
$624.26
|
| Rate for Payer: PacificSource Commercial |
$573.30
|
| Rate for Payer: PHCS PPO |
$624.26
|
| Rate for Payer: Three Rivers PPO |
$477.75
|
| Rate for Payer: TriWest Veterans Administration |
$420.42
|
| Rate for Payer: United Healthcare Commercial |
$554.19
|
| Rate for Payer: United Healthcare Medicare |
$420.42
|
| Rate for Payer: WINHealth Partners Commercial |
$605.15
|
| Rate for Payer: Wise Provider Network Commercial |
$605.15
|
|
|
BELMONT RAPID INFUSE 3 BAG SPIKE SET
|
Facility
|
OP
|
$637.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$350.99 |
| Max. Negotiated Rate |
$637.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$624.26
|
| Rate for Payer: Aetna of WY Medicare |
$420.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$611.52
|
| Rate for Payer: Altius Commercial |
$611.52
|
| Rate for Payer: Beech Street Commercial |
$624.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$522.98
|
| Rate for Payer: Cash Price |
$445.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$617.89
|
| Rate for Payer: Cigna of WY Commercial |
$624.26
|
| Rate for Payer: Entrust Commercial |
$605.15
|
| Rate for Payer: First Choice Health Commercial |
$605.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$605.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$369.46
|
| Rate for Payer: HealthUtah PPO |
$637.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$617.89
|
| Rate for Payer: Multiplan Medicare/VA |
$350.99
|
| Rate for Payer: One Health Plan of WY PPO |
$624.26
|
| Rate for Payer: PacificSource Commercial |
$573.30
|
| Rate for Payer: PHCS PPO |
$624.26
|
| Rate for Payer: Three Rivers PPO |
$477.75
|
| Rate for Payer: TriWest Veterans Administration |
$369.46
|
| Rate for Payer: United Healthcare Commercial |
$554.19
|
| Rate for Payer: United Healthcare Medicare |
$369.46
|
| Rate for Payer: WINHealth Partners Commercial |
$624.26
|
| Rate for Payer: Wise Provider Network Commercial |
$605.15
|
|
|
BENAZEPRIL 20 MG TABLET [15779]
|
Facility
|
IP
|
$2.88
|
|
|
Service Code
|
NDC 5026811111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.76
|
| Rate for Payer: Altius Commercial |
$2.76
|
| Rate for Payer: Beech Street Commercial |
$2.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.79
|
| Rate for Payer: Cigna of WY Commercial |
$2.82
|
| Rate for Payer: Entrust Commercial |
$2.74
|
| Rate for Payer: First Choice Health Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.90
|
| Rate for Payer: HealthUtah PPO |
$2.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.79
|
| Rate for Payer: Multiplan Medicare/VA |
$1.81
|
| Rate for Payer: One Health Plan of WY PPO |
$2.82
|
| Rate for Payer: PacificSource Commercial |
$2.59
|
| Rate for Payer: PHCS PPO |
$2.82
|
| Rate for Payer: Three Rivers PPO |
$2.16
|
| Rate for Payer: TriWest Veterans Administration |
$1.90
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
| Rate for Payer: United Healthcare Medicare |
$1.90
|
| Rate for Payer: WINHealth Partners Commercial |
$2.74
|
| Rate for Payer: Wise Provider Network Commercial |
$2.74
|
|
|
BENAZEPRIL 20 MG TABLET [15779]
|
Facility
|
OP
|
$2.88
|
|
|
Service Code
|
NDC 5026811111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.82
|
| Rate for Payer: Aetna of WY Medicare |
$1.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.76
|
| Rate for Payer: Altius Commercial |
$2.76
|
| Rate for Payer: Beech Street Commercial |
$2.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.79
|
| Rate for Payer: Cigna of WY Commercial |
$2.82
|
| Rate for Payer: Entrust Commercial |
$2.74
|
| Rate for Payer: First Choice Health Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.67
|
| Rate for Payer: HealthUtah PPO |
$2.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.79
|
| Rate for Payer: Multiplan Medicare/VA |
$1.59
|
| Rate for Payer: One Health Plan of WY PPO |
$2.82
|
| Rate for Payer: PacificSource Commercial |
$2.59
|
| Rate for Payer: PHCS PPO |
$2.82
|
| Rate for Payer: Three Rivers PPO |
$2.16
|
| Rate for Payer: TriWest Veterans Administration |
$1.67
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
| Rate for Payer: United Healthcare Medicare |
$1.67
|
| Rate for Payer: WINHealth Partners Commercial |
$2.82
|
| Rate for Payer: Wise Provider Network Commercial |
$2.74
|
|
|
BENAZEPRIL 20 MG TABLET [15779]
|
Facility
|
IP
|
$2.88
|
|
|
Service Code
|
NDC 5026811115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.76
|
| Rate for Payer: Altius Commercial |
$2.76
|
| Rate for Payer: Beech Street Commercial |
$2.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.79
|
| Rate for Payer: Cigna of WY Commercial |
$2.82
|
| Rate for Payer: Entrust Commercial |
$2.74
|
| Rate for Payer: First Choice Health Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.90
|
| Rate for Payer: HealthUtah PPO |
$2.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.79
|
| Rate for Payer: Multiplan Medicare/VA |
$1.81
|
| Rate for Payer: One Health Plan of WY PPO |
$2.82
|
| Rate for Payer: PacificSource Commercial |
$2.59
|
| Rate for Payer: PHCS PPO |
$2.82
|
| Rate for Payer: Three Rivers PPO |
$2.16
|
| Rate for Payer: TriWest Veterans Administration |
$1.90
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
| Rate for Payer: United Healthcare Medicare |
$1.90
|
| Rate for Payer: WINHealth Partners Commercial |
$2.74
|
| Rate for Payer: Wise Provider Network Commercial |
$2.74
|
|
|
BENAZEPRIL 20 MG TABLET [15779]
|
Facility
|
OP
|
$2.88
|
|
|
Service Code
|
NDC 5026811115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.82
|
| Rate for Payer: Aetna of WY Medicare |
$1.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.76
|
| Rate for Payer: Altius Commercial |
$2.76
|
| Rate for Payer: Beech Street Commercial |
$2.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.79
|
| Rate for Payer: Cigna of WY Commercial |
$2.82
|
| Rate for Payer: Entrust Commercial |
$2.74
|
| Rate for Payer: First Choice Health Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.67
|
| Rate for Payer: HealthUtah PPO |
$2.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.79
|
| Rate for Payer: Multiplan Medicare/VA |
$1.59
|
| Rate for Payer: One Health Plan of WY PPO |
$2.82
|
| Rate for Payer: PacificSource Commercial |
$2.59
|
| Rate for Payer: PHCS PPO |
$2.82
|
| Rate for Payer: Three Rivers PPO |
$2.16
|
| Rate for Payer: TriWest Veterans Administration |
$1.67
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
| Rate for Payer: United Healthcare Medicare |
$1.67
|
| Rate for Payer: WINHealth Partners Commercial |
$2.82
|
| Rate for Payer: Wise Provider Network Commercial |
$2.74
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
OP
|
$3.17
|
|
|
Service Code
|
NDC 5026811211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.11
|
| Rate for Payer: Aetna of WY Medicare |
$2.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.04
|
| Rate for Payer: Altius Commercial |
$3.04
|
| Rate for Payer: Beech Street Commercial |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.60
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.07
|
| Rate for Payer: Cigna of WY Commercial |
$3.11
|
| Rate for Payer: Entrust Commercial |
$3.01
|
| Rate for Payer: First Choice Health Commercial |
$3.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.84
|
| Rate for Payer: HealthUtah PPO |
$3.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.07
|
| Rate for Payer: Multiplan Medicare/VA |
$1.75
|
| Rate for Payer: One Health Plan of WY PPO |
$3.11
|
| Rate for Payer: PacificSource Commercial |
$2.85
|
| Rate for Payer: PHCS PPO |
$3.11
|
| Rate for Payer: Three Rivers PPO |
$2.38
|
| Rate for Payer: TriWest Veterans Administration |
$1.84
|
| Rate for Payer: United Healthcare Commercial |
$2.76
|
| Rate for Payer: United Healthcare Medicare |
$1.84
|
| Rate for Payer: WINHealth Partners Commercial |
$3.11
|
| Rate for Payer: Wise Provider Network Commercial |
$3.01
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 6586211801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.33
|
| Rate for Payer: Altius Commercial |
$0.33
|
| Rate for Payer: Beech Street Commercial |
$0.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.33
|
| Rate for Payer: Cigna of WY Commercial |
$0.33
|
| Rate for Payer: Entrust Commercial |
$0.32
|
| Rate for Payer: First Choice Health Commercial |
$0.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.22
|
| Rate for Payer: HealthUtah PPO |
$0.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.33
|
| Rate for Payer: Multiplan Medicare/VA |
$0.21
|
| Rate for Payer: One Health Plan of WY PPO |
$0.33
|
| Rate for Payer: PacificSource Commercial |
$0.31
|
| Rate for Payer: PHCS PPO |
$0.33
|
| Rate for Payer: Three Rivers PPO |
$0.26
|
| Rate for Payer: TriWest Veterans Administration |
$0.22
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
| Rate for Payer: United Healthcare Medicare |
$0.22
|
| Rate for Payer: WINHealth Partners Commercial |
$0.32
|
| Rate for Payer: Wise Provider Network Commercial |
$0.32
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
OP
|
$3.17
|
|
|
Service Code
|
NDC 5026811215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.75 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.11
|
| Rate for Payer: Aetna of WY Medicare |
$2.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.04
|
| Rate for Payer: Altius Commercial |
$3.04
|
| Rate for Payer: Beech Street Commercial |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.60
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.07
|
| Rate for Payer: Cigna of WY Commercial |
$3.11
|
| Rate for Payer: Entrust Commercial |
$3.01
|
| Rate for Payer: First Choice Health Commercial |
$3.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.84
|
| Rate for Payer: HealthUtah PPO |
$3.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.07
|
| Rate for Payer: Multiplan Medicare/VA |
$1.75
|
| Rate for Payer: One Health Plan of WY PPO |
$3.11
|
| Rate for Payer: PacificSource Commercial |
$2.85
|
| Rate for Payer: PHCS PPO |
$3.11
|
| Rate for Payer: Three Rivers PPO |
$2.38
|
| Rate for Payer: TriWest Veterans Administration |
$1.84
|
| Rate for Payer: United Healthcare Commercial |
$2.76
|
| Rate for Payer: United Healthcare Medicare |
$1.84
|
| Rate for Payer: WINHealth Partners Commercial |
$3.11
|
| Rate for Payer: Wise Provider Network Commercial |
$3.01
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
IP
|
$3.17
|
|
|
Service Code
|
NDC 5026811211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.04
|
| Rate for Payer: Altius Commercial |
$3.04
|
| Rate for Payer: Beech Street Commercial |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.60
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.07
|
| Rate for Payer: Cigna of WY Commercial |
$3.11
|
| Rate for Payer: Entrust Commercial |
$3.01
|
| Rate for Payer: First Choice Health Commercial |
$3.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.09
|
| Rate for Payer: HealthUtah PPO |
$3.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.07
|
| Rate for Payer: Multiplan Medicare/VA |
$1.99
|
| Rate for Payer: One Health Plan of WY PPO |
$3.11
|
| Rate for Payer: PacificSource Commercial |
$2.85
|
| Rate for Payer: PHCS PPO |
$3.11
|
| Rate for Payer: Three Rivers PPO |
$2.38
|
| Rate for Payer: TriWest Veterans Administration |
$2.09
|
| Rate for Payer: United Healthcare Commercial |
$2.76
|
| Rate for Payer: United Healthcare Medicare |
$2.09
|
| Rate for Payer: WINHealth Partners Commercial |
$3.01
|
| Rate for Payer: Wise Provider Network Commercial |
$3.01
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
IP
|
$3.17
|
|
|
Service Code
|
NDC 5026811215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$3.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.04
|
| Rate for Payer: Altius Commercial |
$3.04
|
| Rate for Payer: Beech Street Commercial |
$3.11
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.60
|
| Rate for Payer: Cash Price |
$2.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.07
|
| Rate for Payer: Cigna of WY Commercial |
$3.11
|
| Rate for Payer: Entrust Commercial |
$3.01
|
| Rate for Payer: First Choice Health Commercial |
$3.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.09
|
| Rate for Payer: HealthUtah PPO |
$3.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.07
|
| Rate for Payer: Multiplan Medicare/VA |
$1.99
|
| Rate for Payer: One Health Plan of WY PPO |
$3.11
|
| Rate for Payer: PacificSource Commercial |
$2.85
|
| Rate for Payer: PHCS PPO |
$3.11
|
| Rate for Payer: Three Rivers PPO |
$2.38
|
| Rate for Payer: TriWest Veterans Administration |
$2.09
|
| Rate for Payer: United Healthcare Commercial |
$2.76
|
| Rate for Payer: United Healthcare Medicare |
$2.09
|
| Rate for Payer: WINHealth Partners Commercial |
$3.01
|
| Rate for Payer: Wise Provider Network Commercial |
$3.01
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 6586211801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.33
|
| Rate for Payer: Aetna of WY Medicare |
$0.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.33
|
| Rate for Payer: Altius Commercial |
$0.33
|
| Rate for Payer: Beech Street Commercial |
$0.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.33
|
| Rate for Payer: Cigna of WY Commercial |
$0.33
|
| Rate for Payer: Entrust Commercial |
$0.32
|
| Rate for Payer: First Choice Health Commercial |
$0.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.20
|
| Rate for Payer: HealthUtah PPO |
$0.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.33
|
| Rate for Payer: Multiplan Medicare/VA |
$0.19
|
| Rate for Payer: One Health Plan of WY PPO |
$0.33
|
| Rate for Payer: PacificSource Commercial |
$0.31
|
| Rate for Payer: PHCS PPO |
$0.33
|
| Rate for Payer: Three Rivers PPO |
$0.26
|
| Rate for Payer: TriWest Veterans Administration |
$0.20
|
| Rate for Payer: United Healthcare Commercial |
$0.30
|
| Rate for Payer: United Healthcare Medicare |
$0.20
|
| Rate for Payer: WINHealth Partners Commercial |
$0.33
|
| Rate for Payer: Wise Provider Network Commercial |
$0.32
|
|
|
BENDAMUSTINE 100 MG INTRAVENOUS POWDER FOR SOLUTION [52831]
|
Facility
|
OP
|
$1,615.00
|
|
|
Service Code
|
HCPCS J9033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$889.86 |
| Max. Negotiated Rate |
$1,615.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,582.70
|
| Rate for Payer: Aetna of WY Medicare |
$1,065.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,550.40
|
| Rate for Payer: Altius Commercial |
$1,550.40
|
| Rate for Payer: Beech Street Commercial |
$1,582.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,325.92
|
| Rate for Payer: Cash Price |
$1,130.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,566.55
|
| Rate for Payer: Cigna of WY Commercial |
$1,582.70
|
| Rate for Payer: Entrust Commercial |
$1,534.25
|
| Rate for Payer: First Choice Health Commercial |
$1,534.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,534.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$936.70
|
| Rate for Payer: HealthUtah PPO |
$1,615.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,566.55
|
| Rate for Payer: Multiplan Medicare/VA |
$889.86
|
| Rate for Payer: One Health Plan of WY PPO |
$1,582.70
|
| Rate for Payer: PacificSource Commercial |
$1,453.50
|
| Rate for Payer: PHCS PPO |
$1,582.70
|
| Rate for Payer: Three Rivers PPO |
$1,211.25
|
| Rate for Payer: TriWest Veterans Administration |
$936.70
|
| Rate for Payer: United Healthcare Commercial |
$1,405.05
|
| Rate for Payer: United Healthcare Medicare |
$936.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,582.70
|
| Rate for Payer: Wise Provider Network Commercial |
$1,534.25
|
|
|
BENDAMUSTINE 100 MG INTRAVENOUS POWDER FOR SOLUTION [52831]
|
Facility
|
IP
|
$1,615.00
|
|
|
Service Code
|
HCPCS J9033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,012.60 |
| Max. Negotiated Rate |
$1,615.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,582.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,550.40
|
| Rate for Payer: Altius Commercial |
$1,550.40
|
| Rate for Payer: Beech Street Commercial |
$1,582.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,325.92
|
| Rate for Payer: Cash Price |
$1,130.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,566.55
|
| Rate for Payer: Cigna of WY Commercial |
$1,582.70
|
| Rate for Payer: Entrust Commercial |
$1,534.25
|
| Rate for Payer: First Choice Health Commercial |
$1,534.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,534.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,065.90
|
| Rate for Payer: HealthUtah PPO |
$1,615.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,566.55
|
| Rate for Payer: Multiplan Medicare/VA |
$1,012.60
|
| Rate for Payer: One Health Plan of WY PPO |
$1,582.70
|
| Rate for Payer: PacificSource Commercial |
$1,453.50
|
| Rate for Payer: PHCS PPO |
$1,582.70
|
| Rate for Payer: Three Rivers PPO |
$1,211.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,065.90
|
| Rate for Payer: United Healthcare Commercial |
$1,405.05
|
| Rate for Payer: United Healthcare Medicare |
$1,065.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,534.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,534.25
|
|
|
BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION [143245]
|
Facility
|
OP
|
$633.45
|
|
|
Service Code
|
HCPCS J9036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$349.03 |
| Max. Negotiated Rate |
$633.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$620.78
|
| Rate for Payer: Aetna of WY Medicare |
$418.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$608.11
|
| Rate for Payer: Altius Commercial |
$608.11
|
| Rate for Payer: Beech Street Commercial |
$620.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$520.06
|
| Rate for Payer: Cash Price |
$443.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$614.45
|
| Rate for Payer: Cigna of WY Commercial |
$620.78
|
| Rate for Payer: Entrust Commercial |
$601.78
|
| Rate for Payer: First Choice Health Commercial |
$601.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$601.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$367.40
|
| Rate for Payer: HealthUtah PPO |
$633.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$614.45
|
| Rate for Payer: Multiplan Medicare/VA |
$349.03
|
| Rate for Payer: One Health Plan of WY PPO |
$620.78
|
| Rate for Payer: PacificSource Commercial |
$570.10
|
| Rate for Payer: PHCS PPO |
$620.78
|
| Rate for Payer: Three Rivers PPO |
$475.09
|
| Rate for Payer: TriWest Veterans Administration |
$367.40
|
| Rate for Payer: United Healthcare Commercial |
$551.10
|
| Rate for Payer: United Healthcare Medicare |
$367.40
|
| Rate for Payer: WINHealth Partners Commercial |
$620.78
|
| Rate for Payer: Wise Provider Network Commercial |
$601.78
|
|
|
BENDAMUSTINE 25 MG/ML INTRAVENOUS SOLUTION [143245]
|
Facility
|
IP
|
$633.45
|
|
|
Service Code
|
HCPCS J9036
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$397.17 |
| Max. Negotiated Rate |
$633.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$620.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$608.11
|
| Rate for Payer: Altius Commercial |
$608.11
|
| Rate for Payer: Beech Street Commercial |
$620.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$520.06
|
| Rate for Payer: Cash Price |
$443.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$614.45
|
| Rate for Payer: Cigna of WY Commercial |
$620.78
|
| Rate for Payer: Entrust Commercial |
$601.78
|
| Rate for Payer: First Choice Health Commercial |
$601.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$601.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$418.08
|
| Rate for Payer: HealthUtah PPO |
$633.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$614.45
|
| Rate for Payer: Multiplan Medicare/VA |
$397.17
|
| Rate for Payer: One Health Plan of WY PPO |
$620.78
|
| Rate for Payer: PacificSource Commercial |
$570.10
|
| Rate for Payer: PHCS PPO |
$620.78
|
| Rate for Payer: Three Rivers PPO |
$475.09
|
| Rate for Payer: TriWest Veterans Administration |
$418.08
|
| Rate for Payer: United Healthcare Commercial |
$551.10
|
| Rate for Payer: United Healthcare Medicare |
$418.08
|
| Rate for Payer: WINHealth Partners Commercial |
$601.78
|
| Rate for Payer: Wise Provider Network Commercial |
$601.78
|
|
