|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE [150993]
|
Facility
|
OP
|
$8,785.58
|
|
|
Service Code
|
HCPCS J0517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,840.85 |
| Max. Negotiated Rate |
$8,785.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,609.87
|
| Rate for Payer: Aetna of WY Medicare |
$5,798.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8,434.16
|
| Rate for Payer: Altius Commercial |
$8,434.16
|
| Rate for Payer: Beech Street Commercial |
$8,609.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7,212.96
|
| Rate for Payer: Cash Price |
$6,149.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,522.01
|
| Rate for Payer: Cigna of WY Commercial |
$8,609.87
|
| Rate for Payer: Entrust Commercial |
$8,346.30
|
| Rate for Payer: First Choice Health Commercial |
$8,346.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,346.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,095.64
|
| Rate for Payer: HealthUtah PPO |
$8,785.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,522.01
|
| Rate for Payer: Multiplan Medicare/VA |
$4,840.85
|
| Rate for Payer: One Health Plan of WY PPO |
$8,609.87
|
| Rate for Payer: PacificSource Commercial |
$7,907.02
|
| Rate for Payer: PHCS PPO |
$8,609.87
|
| Rate for Payer: Three Rivers PPO |
$6,589.18
|
| Rate for Payer: TriWest Veterans Administration |
$5,095.64
|
| Rate for Payer: United Healthcare Commercial |
$7,643.45
|
| Rate for Payer: United Healthcare Medicare |
$5,095.64
|
| Rate for Payer: WINHealth Partners Commercial |
$8,609.87
|
| Rate for Payer: Wise Provider Network Commercial |
$8,346.30
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE [150993]
|
Facility
|
IP
|
$8,785.58
|
|
|
Service Code
|
HCPCS J0517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,508.56 |
| Max. Negotiated Rate |
$8,785.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,609.87
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8,434.16
|
| Rate for Payer: Altius Commercial |
$8,434.16
|
| Rate for Payer: Beech Street Commercial |
$8,609.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7,212.96
|
| Rate for Payer: Cash Price |
$6,149.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,522.01
|
| Rate for Payer: Cigna of WY Commercial |
$8,609.87
|
| Rate for Payer: Entrust Commercial |
$8,346.30
|
| Rate for Payer: First Choice Health Commercial |
$8,346.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,346.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,798.48
|
| Rate for Payer: HealthUtah PPO |
$8,785.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,522.01
|
| Rate for Payer: Multiplan Medicare/VA |
$5,508.56
|
| Rate for Payer: One Health Plan of WY PPO |
$8,609.87
|
| Rate for Payer: PacificSource Commercial |
$7,907.02
|
| Rate for Payer: PHCS PPO |
$8,609.87
|
| Rate for Payer: Three Rivers PPO |
$6,589.18
|
| Rate for Payer: TriWest Veterans Administration |
$5,798.48
|
| Rate for Payer: United Healthcare Commercial |
$7,643.45
|
| Rate for Payer: United Healthcare Medicare |
$5,798.48
|
| Rate for Payer: WINHealth Partners Commercial |
$8,346.30
|
| Rate for Payer: Wise Provider Network Commercial |
$8,346.30
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES [93857]
|
Facility
|
IP
|
$0.64
|
|
|
Service Code
|
NDC 0904625549
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.61
|
| Rate for Payer: Altius Commercial |
$0.61
|
| Rate for Payer: Beech Street Commercial |
$0.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.53
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.62
|
| Rate for Payer: Cigna of WY Commercial |
$0.63
|
| Rate for Payer: Entrust Commercial |
$0.61
|
| Rate for Payer: First Choice Health Commercial |
$0.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.42
|
| Rate for Payer: HealthUtah PPO |
$0.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.62
|
| Rate for Payer: Multiplan Medicare/VA |
$0.40
|
| Rate for Payer: One Health Plan of WY PPO |
$0.63
|
| Rate for Payer: PacificSource Commercial |
$0.58
|
| Rate for Payer: PHCS PPO |
$0.63
|
| Rate for Payer: Three Rivers PPO |
$0.48
|
| Rate for Payer: TriWest Veterans Administration |
$0.42
|
| Rate for Payer: United Healthcare Commercial |
$0.56
|
| Rate for Payer: United Healthcare Medicare |
$0.42
|
| Rate for Payer: WINHealth Partners Commercial |
$0.61
|
| Rate for Payer: Wise Provider Network Commercial |
$0.61
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES [93857]
|
Facility
|
OP
|
$0.61
|
|
|
Service Code
|
NDC 6382471316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.60
|
| Rate for Payer: Aetna of WY Medicare |
$0.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.59
|
| Rate for Payer: Altius Commercial |
$0.59
|
| Rate for Payer: Beech Street Commercial |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.50
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.59
|
| Rate for Payer: Cigna of WY Commercial |
$0.60
|
| Rate for Payer: Entrust Commercial |
$0.58
|
| Rate for Payer: First Choice Health Commercial |
$0.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.35
|
| Rate for Payer: HealthUtah PPO |
$0.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.59
|
| Rate for Payer: Multiplan Medicare/VA |
$0.34
|
| Rate for Payer: One Health Plan of WY PPO |
$0.60
|
| Rate for Payer: PacificSource Commercial |
$0.55
|
| Rate for Payer: PHCS PPO |
$0.60
|
| Rate for Payer: Three Rivers PPO |
$0.46
|
| Rate for Payer: TriWest Veterans Administration |
$0.35
|
| Rate for Payer: United Healthcare Commercial |
$0.53
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
| Rate for Payer: WINHealth Partners Commercial |
$0.60
|
| Rate for Payer: Wise Provider Network Commercial |
$0.58
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES [93857]
|
Facility
|
IP
|
$0.61
|
|
|
Service Code
|
NDC 6382471316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.59
|
| Rate for Payer: Altius Commercial |
$0.59
|
| Rate for Payer: Beech Street Commercial |
$0.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.50
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.59
|
| Rate for Payer: Cigna of WY Commercial |
$0.60
|
| Rate for Payer: Entrust Commercial |
$0.58
|
| Rate for Payer: First Choice Health Commercial |
$0.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.40
|
| Rate for Payer: HealthUtah PPO |
$0.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.59
|
| Rate for Payer: Multiplan Medicare/VA |
$0.38
|
| Rate for Payer: One Health Plan of WY PPO |
$0.60
|
| Rate for Payer: PacificSource Commercial |
$0.55
|
| Rate for Payer: PHCS PPO |
$0.60
|
| Rate for Payer: Three Rivers PPO |
$0.46
|
| Rate for Payer: TriWest Veterans Administration |
$0.40
|
| Rate for Payer: United Healthcare Commercial |
$0.53
|
| Rate for Payer: United Healthcare Medicare |
$0.40
|
| Rate for Payer: WINHealth Partners Commercial |
$0.58
|
| Rate for Payer: Wise Provider Network Commercial |
$0.58
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES [93857]
|
Facility
|
OP
|
$0.64
|
|
|
Service Code
|
NDC 0904625549
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$0.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.63
|
| Rate for Payer: Aetna of WY Medicare |
$0.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.61
|
| Rate for Payer: Altius Commercial |
$0.61
|
| Rate for Payer: Beech Street Commercial |
$0.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.53
|
| Rate for Payer: Cash Price |
$0.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.62
|
| Rate for Payer: Cigna of WY Commercial |
$0.63
|
| Rate for Payer: Entrust Commercial |
$0.61
|
| Rate for Payer: First Choice Health Commercial |
$0.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.61
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.37
|
| Rate for Payer: HealthUtah PPO |
$0.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.62
|
| Rate for Payer: Multiplan Medicare/VA |
$0.35
|
| Rate for Payer: One Health Plan of WY PPO |
$0.63
|
| Rate for Payer: PacificSource Commercial |
$0.58
|
| Rate for Payer: PHCS PPO |
$0.63
|
| Rate for Payer: Three Rivers PPO |
$0.48
|
| Rate for Payer: TriWest Veterans Administration |
$0.37
|
| Rate for Payer: United Healthcare Commercial |
$0.56
|
| Rate for Payer: United Healthcare Medicare |
$0.37
|
| Rate for Payer: WINHealth Partners Commercial |
$0.63
|
| Rate for Payer: Wise Provider Network Commercial |
$0.61
|
|
|
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL [3150]
|
Facility
|
IP
|
$0.26
|
|
|
Service Code
|
NDC 1686468003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL [3150]
|
Facility
|
OP
|
$0.26
|
|
|
Service Code
|
NDC 1686468003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.25
|
| Rate for Payer: Aetna of WY Medicare |
$0.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.25
|
| Rate for Payer: Altius Commercial |
$0.25
|
| Rate for Payer: Beech Street Commercial |
$0.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.21
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.25
|
| Rate for Payer: Cigna of WY Commercial |
$0.25
|
| Rate for Payer: Entrust Commercial |
$0.25
|
| Rate for Payer: First Choice Health Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.15
|
| Rate for Payer: HealthUtah PPO |
$0.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.25
|
| Rate for Payer: Multiplan Medicare/VA |
$0.14
|
| Rate for Payer: One Health Plan of WY PPO |
$0.25
|
| Rate for Payer: PacificSource Commercial |
$0.23
|
| Rate for Payer: PHCS PPO |
$0.25
|
| Rate for Payer: Three Rivers PPO |
$0.20
|
| Rate for Payer: TriWest Veterans Administration |
$0.15
|
| Rate for Payer: United Healthcare Commercial |
$0.23
|
| Rate for Payer: United Healthcare Medicare |
$0.15
|
| Rate for Payer: WINHealth Partners Commercial |
$0.25
|
| Rate for Payer: Wise Provider Network Commercial |
$0.25
|
|
|
BENZOCAINE 20 % MUCOSAL GEL [18886]
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 5002443203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.47
|
| Rate for Payer: Aetna of WY Medicare |
$1.66
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.42
|
| Rate for Payer: Altius Commercial |
$2.42
|
| Rate for Payer: Beech Street Commercial |
$2.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.07
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.44
|
| Rate for Payer: Cigna of WY Commercial |
$2.47
|
| Rate for Payer: Entrust Commercial |
$2.39
|
| Rate for Payer: First Choice Health Commercial |
$2.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.46
|
| Rate for Payer: HealthUtah PPO |
$2.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.44
|
| Rate for Payer: Multiplan Medicare/VA |
$1.39
|
| Rate for Payer: One Health Plan of WY PPO |
$2.47
|
| Rate for Payer: PacificSource Commercial |
$2.27
|
| Rate for Payer: PHCS PPO |
$2.47
|
| Rate for Payer: Three Rivers PPO |
$1.89
|
| Rate for Payer: TriWest Veterans Administration |
$1.46
|
| Rate for Payer: United Healthcare Commercial |
$2.19
|
| Rate for Payer: United Healthcare Medicare |
$1.46
|
| Rate for Payer: WINHealth Partners Commercial |
$2.47
|
| Rate for Payer: Wise Provider Network Commercial |
$2.39
|
|
|
BENZOCAINE 20 % MUCOSAL GEL [18886]
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 5002443203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$2.52 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.42
|
| Rate for Payer: Altius Commercial |
$2.42
|
| Rate for Payer: Beech Street Commercial |
$2.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2.07
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.44
|
| Rate for Payer: Cigna of WY Commercial |
$2.47
|
| Rate for Payer: Entrust Commercial |
$2.39
|
| Rate for Payer: First Choice Health Commercial |
$2.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.66
|
| Rate for Payer: HealthUtah PPO |
$2.52
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.44
|
| Rate for Payer: Multiplan Medicare/VA |
$1.58
|
| Rate for Payer: One Health Plan of WY PPO |
$2.47
|
| Rate for Payer: PacificSource Commercial |
$2.27
|
| Rate for Payer: PHCS PPO |
$2.47
|
| Rate for Payer: Three Rivers PPO |
$1.89
|
| Rate for Payer: TriWest Veterans Administration |
$1.66
|
| Rate for Payer: United Healthcare Commercial |
$2.19
|
| Rate for Payer: United Healthcare Medicare |
$1.66
|
| Rate for Payer: WINHealth Partners Commercial |
$2.39
|
| Rate for Payer: Wise Provider Network Commercial |
$2.39
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY [37857]
|
Facility
|
OP
|
$30.39
|
|
|
Service Code
|
NDC 0283061026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.74 |
| Max. Negotiated Rate |
$30.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.78
|
| Rate for Payer: Aetna of WY Medicare |
$20.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$29.17
|
| Rate for Payer: Altius Commercial |
$29.17
|
| Rate for Payer: Beech Street Commercial |
$29.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.95
|
| Rate for Payer: Cash Price |
$21.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.48
|
| Rate for Payer: Cigna of WY Commercial |
$29.78
|
| Rate for Payer: Entrust Commercial |
$28.87
|
| Rate for Payer: First Choice Health Commercial |
$28.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.63
|
| Rate for Payer: HealthUtah PPO |
$30.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.48
|
| Rate for Payer: Multiplan Medicare/VA |
$16.74
|
| Rate for Payer: One Health Plan of WY PPO |
$29.78
|
| Rate for Payer: PacificSource Commercial |
$27.35
|
| Rate for Payer: PHCS PPO |
$29.78
|
| Rate for Payer: Three Rivers PPO |
$22.79
|
| Rate for Payer: TriWest Veterans Administration |
$17.63
|
| Rate for Payer: United Healthcare Commercial |
$26.44
|
| Rate for Payer: United Healthcare Medicare |
$17.63
|
| Rate for Payer: WINHealth Partners Commercial |
$29.78
|
| Rate for Payer: Wise Provider Network Commercial |
$28.87
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY [37857]
|
Facility
|
IP
|
$30.39
|
|
|
Service Code
|
NDC 0283061026
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.05 |
| Max. Negotiated Rate |
$30.39 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$29.17
|
| Rate for Payer: Altius Commercial |
$29.17
|
| Rate for Payer: Beech Street Commercial |
$29.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.95
|
| Rate for Payer: Cash Price |
$21.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$29.48
|
| Rate for Payer: Cigna of WY Commercial |
$29.78
|
| Rate for Payer: Entrust Commercial |
$28.87
|
| Rate for Payer: First Choice Health Commercial |
$28.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.87
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.06
|
| Rate for Payer: HealthUtah PPO |
$30.39
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$29.48
|
| Rate for Payer: Multiplan Medicare/VA |
$19.05
|
| Rate for Payer: One Health Plan of WY PPO |
$29.78
|
| Rate for Payer: PacificSource Commercial |
$27.35
|
| Rate for Payer: PHCS PPO |
$29.78
|
| Rate for Payer: Three Rivers PPO |
$22.79
|
| Rate for Payer: TriWest Veterans Administration |
$20.06
|
| Rate for Payer: United Healthcare Commercial |
$26.44
|
| Rate for Payer: United Healthcare Medicare |
$20.06
|
| Rate for Payer: WINHealth Partners Commercial |
$28.87
|
| Rate for Payer: Wise Provider Network Commercial |
$28.87
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY [37857]
|
Facility
|
OP
|
$32.42
|
|
|
Service Code
|
NDC 0283061043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.86 |
| Max. Negotiated Rate |
$32.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.77
|
| Rate for Payer: Aetna of WY Medicare |
$21.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.12
|
| Rate for Payer: Altius Commercial |
$31.12
|
| Rate for Payer: Beech Street Commercial |
$31.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.62
|
| Rate for Payer: Cash Price |
$22.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.45
|
| Rate for Payer: Cigna of WY Commercial |
$31.77
|
| Rate for Payer: Entrust Commercial |
$30.80
|
| Rate for Payer: First Choice Health Commercial |
$30.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.80
|
| Rate for Payer: HealthUtah PPO |
$32.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.45
|
| Rate for Payer: Multiplan Medicare/VA |
$17.86
|
| Rate for Payer: One Health Plan of WY PPO |
$31.77
|
| Rate for Payer: PacificSource Commercial |
$29.18
|
| Rate for Payer: PHCS PPO |
$31.77
|
| Rate for Payer: Three Rivers PPO |
$24.32
|
| Rate for Payer: TriWest Veterans Administration |
$18.80
|
| Rate for Payer: United Healthcare Commercial |
$28.21
|
| Rate for Payer: United Healthcare Medicare |
$18.80
|
| Rate for Payer: WINHealth Partners Commercial |
$31.77
|
| Rate for Payer: Wise Provider Network Commercial |
$30.80
|
|
|
BENZOCAINE 20 % MUCOSAL SPRAY [37857]
|
Facility
|
IP
|
$32.42
|
|
|
Service Code
|
NDC 0283061043
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.33 |
| Max. Negotiated Rate |
$32.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$31.12
|
| Rate for Payer: Altius Commercial |
$31.12
|
| Rate for Payer: Beech Street Commercial |
$31.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$26.62
|
| Rate for Payer: Cash Price |
$22.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.45
|
| Rate for Payer: Cigna of WY Commercial |
$31.77
|
| Rate for Payer: Entrust Commercial |
$30.80
|
| Rate for Payer: First Choice Health Commercial |
$30.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.40
|
| Rate for Payer: HealthUtah PPO |
$32.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.45
|
| Rate for Payer: Multiplan Medicare/VA |
$20.33
|
| Rate for Payer: One Health Plan of WY PPO |
$31.77
|
| Rate for Payer: PacificSource Commercial |
$29.18
|
| Rate for Payer: PHCS PPO |
$31.77
|
| Rate for Payer: Three Rivers PPO |
$24.32
|
| Rate for Payer: TriWest Veterans Administration |
$21.40
|
| Rate for Payer: United Healthcare Commercial |
$28.21
|
| Rate for Payer: United Healthcare Medicare |
$21.40
|
| Rate for Payer: WINHealth Partners Commercial |
$30.80
|
| Rate for Payer: Wise Provider Network Commercial |
$30.80
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
IP
|
$1.86
|
|
|
Service Code
|
NDC 6808421411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.79
|
| Rate for Payer: Altius Commercial |
$1.79
|
| Rate for Payer: Beech Street Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.80
|
| Rate for Payer: Cigna of WY Commercial |
$1.82
|
| Rate for Payer: Entrust Commercial |
$1.77
|
| Rate for Payer: First Choice Health Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.23
|
| Rate for Payer: HealthUtah PPO |
$1.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1.17
|
| Rate for Payer: One Health Plan of WY PPO |
$1.82
|
| Rate for Payer: PacificSource Commercial |
$1.67
|
| Rate for Payer: PHCS PPO |
$1.82
|
| Rate for Payer: Three Rivers PPO |
$1.40
|
| Rate for Payer: TriWest Veterans Administration |
$1.23
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$1.23
|
| Rate for Payer: WINHealth Partners Commercial |
$1.77
|
| Rate for Payer: Wise Provider Network Commercial |
$1.77
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
OP
|
$1.86
|
|
|
Service Code
|
NDC 6808421411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.82
|
| Rate for Payer: Aetna of WY Medicare |
$1.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.79
|
| Rate for Payer: Altius Commercial |
$1.79
|
| Rate for Payer: Beech Street Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.80
|
| Rate for Payer: Cigna of WY Commercial |
$1.82
|
| Rate for Payer: Entrust Commercial |
$1.77
|
| Rate for Payer: First Choice Health Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.08
|
| Rate for Payer: HealthUtah PPO |
$1.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1.02
|
| Rate for Payer: One Health Plan of WY PPO |
$1.82
|
| Rate for Payer: PacificSource Commercial |
$1.67
|
| Rate for Payer: PHCS PPO |
$1.82
|
| Rate for Payer: Three Rivers PPO |
$1.40
|
| Rate for Payer: TriWest Veterans Administration |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
| Rate for Payer: WINHealth Partners Commercial |
$1.82
|
| Rate for Payer: Wise Provider Network Commercial |
$1.77
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
OP
|
$1.86
|
|
|
Service Code
|
NDC 6808421401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.82
|
| Rate for Payer: Aetna of WY Medicare |
$1.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.79
|
| Rate for Payer: Altius Commercial |
$1.79
|
| Rate for Payer: Beech Street Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.80
|
| Rate for Payer: Cigna of WY Commercial |
$1.82
|
| Rate for Payer: Entrust Commercial |
$1.77
|
| Rate for Payer: First Choice Health Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.08
|
| Rate for Payer: HealthUtah PPO |
$1.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1.02
|
| Rate for Payer: One Health Plan of WY PPO |
$1.82
|
| Rate for Payer: PacificSource Commercial |
$1.67
|
| Rate for Payer: PHCS PPO |
$1.82
|
| Rate for Payer: Three Rivers PPO |
$1.40
|
| Rate for Payer: TriWest Veterans Administration |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
| Rate for Payer: WINHealth Partners Commercial |
$1.82
|
| Rate for Payer: Wise Provider Network Commercial |
$1.77
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 6945214320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.18
|
| Rate for Payer: Aetna of WY Medicare |
$0.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.15
|
| Rate for Payer: Altius Commercial |
$1.15
|
| Rate for Payer: Beech Street Commercial |
$1.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.99
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.16
|
| Rate for Payer: Cigna of WY Commercial |
$1.18
|
| Rate for Payer: Entrust Commercial |
$1.14
|
| Rate for Payer: First Choice Health Commercial |
$1.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.70
|
| Rate for Payer: HealthUtah PPO |
$1.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1.18
|
| Rate for Payer: PacificSource Commercial |
$1.08
|
| Rate for Payer: PHCS PPO |
$1.18
|
| Rate for Payer: Three Rivers PPO |
$0.90
|
| Rate for Payer: TriWest Veterans Administration |
$0.70
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Medicare |
$0.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1.18
|
| Rate for Payer: Wise Provider Network Commercial |
$1.14
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 6945214320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.15
|
| Rate for Payer: Altius Commercial |
$1.15
|
| Rate for Payer: Beech Street Commercial |
$1.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.99
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.16
|
| Rate for Payer: Cigna of WY Commercial |
$1.18
|
| Rate for Payer: Entrust Commercial |
$1.14
|
| Rate for Payer: First Choice Health Commercial |
$1.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.79
|
| Rate for Payer: HealthUtah PPO |
$1.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.75
|
| Rate for Payer: One Health Plan of WY PPO |
$1.18
|
| Rate for Payer: PacificSource Commercial |
$1.08
|
| Rate for Payer: PHCS PPO |
$1.18
|
| Rate for Payer: Three Rivers PPO |
$0.90
|
| Rate for Payer: TriWest Veterans Administration |
$0.79
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Medicare |
$0.79
|
| Rate for Payer: WINHealth Partners Commercial |
$1.14
|
| Rate for Payer: Wise Provider Network Commercial |
$1.14
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 0904715361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.90
|
| Rate for Payer: Altius Commercial |
$1.90
|
| Rate for Payer: Beech Street Commercial |
$1.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.63
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.92
|
| Rate for Payer: Cigna of WY Commercial |
$1.94
|
| Rate for Payer: Entrust Commercial |
$1.88
|
| Rate for Payer: First Choice Health Commercial |
$1.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.31
|
| Rate for Payer: HealthUtah PPO |
$1.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.92
|
| Rate for Payer: Multiplan Medicare/VA |
$1.24
|
| Rate for Payer: One Health Plan of WY PPO |
$1.94
|
| Rate for Payer: PacificSource Commercial |
$1.78
|
| Rate for Payer: PHCS PPO |
$1.94
|
| Rate for Payer: Three Rivers PPO |
$1.48
|
| Rate for Payer: TriWest Veterans Administration |
$1.31
|
| Rate for Payer: United Healthcare Commercial |
$1.72
|
| Rate for Payer: United Healthcare Medicare |
$1.31
|
| Rate for Payer: WINHealth Partners Commercial |
$1.88
|
| Rate for Payer: Wise Provider Network Commercial |
$1.88
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
OP
|
$1.98
|
|
|
Service Code
|
NDC 0904715361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.94
|
| Rate for Payer: Aetna of WY Medicare |
$1.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.90
|
| Rate for Payer: Altius Commercial |
$1.90
|
| Rate for Payer: Beech Street Commercial |
$1.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.63
|
| Rate for Payer: Cash Price |
$1.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.92
|
| Rate for Payer: Cigna of WY Commercial |
$1.94
|
| Rate for Payer: Entrust Commercial |
$1.88
|
| Rate for Payer: First Choice Health Commercial |
$1.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.15
|
| Rate for Payer: HealthUtah PPO |
$1.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.92
|
| Rate for Payer: Multiplan Medicare/VA |
$1.09
|
| Rate for Payer: One Health Plan of WY PPO |
$1.94
|
| Rate for Payer: PacificSource Commercial |
$1.78
|
| Rate for Payer: PHCS PPO |
$1.94
|
| Rate for Payer: Three Rivers PPO |
$1.48
|
| Rate for Payer: TriWest Veterans Administration |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.72
|
| Rate for Payer: United Healthcare Medicare |
$1.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1.94
|
| Rate for Payer: Wise Provider Network Commercial |
$1.88
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
IP
|
$1.86
|
|
|
Service Code
|
NDC 6808421401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$1.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.79
|
| Rate for Payer: Altius Commercial |
$1.79
|
| Rate for Payer: Beech Street Commercial |
$1.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.53
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.80
|
| Rate for Payer: Cigna of WY Commercial |
$1.82
|
| Rate for Payer: Entrust Commercial |
$1.77
|
| Rate for Payer: First Choice Health Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.23
|
| Rate for Payer: HealthUtah PPO |
$1.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1.17
|
| Rate for Payer: One Health Plan of WY PPO |
$1.82
|
| Rate for Payer: PacificSource Commercial |
$1.67
|
| Rate for Payer: PHCS PPO |
$1.82
|
| Rate for Payer: Three Rivers PPO |
$1.40
|
| Rate for Payer: TriWest Veterans Administration |
$1.23
|
| Rate for Payer: United Healthcare Commercial |
$1.62
|
| Rate for Payer: United Healthcare Medicare |
$1.23
|
| Rate for Payer: WINHealth Partners Commercial |
$1.77
|
| Rate for Payer: Wise Provider Network Commercial |
$1.77
|
|
|
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9472]
|
Facility
|
IP
|
$48.02
|
|
|
Service Code
|
HCPCS J0702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.11 |
| Max. Negotiated Rate |
$48.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.06
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$46.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$41.64
|
| Rate for Payer: Altius Commercial |
$41.64
|
| Rate for Payer: Altius Commercial |
$46.10
|
| Rate for Payer: Beech Street Commercial |
$47.06
|
| Rate for Payer: Beech Street Commercial |
$42.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.42
|
| Rate for Payer: Cash Price |
$33.61
|
| Rate for Payer: Cash Price |
$30.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$42.08
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.58
|
| Rate for Payer: Cigna of WY Commercial |
$47.06
|
| Rate for Payer: Cigna of WY Commercial |
$42.51
|
| Rate for Payer: Entrust Commercial |
$41.21
|
| Rate for Payer: Entrust Commercial |
$45.62
|
| Rate for Payer: First Choice Health Commercial |
$41.21
|
| Rate for Payer: First Choice Health Commercial |
$45.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.63
|
| Rate for Payer: HealthUtah PPO |
$48.02
|
| Rate for Payer: HealthUtah PPO |
$43.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.58
|
| Rate for Payer: Multiplan Medicare/VA |
$30.11
|
| Rate for Payer: Multiplan Medicare/VA |
$27.20
|
| Rate for Payer: One Health Plan of WY PPO |
$47.06
|
| Rate for Payer: One Health Plan of WY PPO |
$42.51
|
| Rate for Payer: PacificSource Commercial |
$43.22
|
| Rate for Payer: PacificSource Commercial |
$39.04
|
| Rate for Payer: PHCS PPO |
$42.51
|
| Rate for Payer: PHCS PPO |
$47.06
|
| Rate for Payer: Three Rivers PPO |
$32.54
|
| Rate for Payer: Three Rivers PPO |
$36.02
|
| Rate for Payer: TriWest Veterans Administration |
$31.69
|
| Rate for Payer: TriWest Veterans Administration |
$28.63
|
| Rate for Payer: United Healthcare Commercial |
$37.74
|
| Rate for Payer: United Healthcare Commercial |
$41.78
|
| Rate for Payer: United Healthcare Medicare |
$31.69
|
| Rate for Payer: United Healthcare Medicare |
$28.63
|
| Rate for Payer: WINHealth Partners Commercial |
$41.21
|
| Rate for Payer: WINHealth Partners Commercial |
$45.62
|
| Rate for Payer: Wise Provider Network Commercial |
$41.21
|
| Rate for Payer: Wise Provider Network Commercial |
$45.62
|
|
|
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9472]
|
Facility
|
OP
|
$48.02
|
|
|
Service Code
|
HCPCS J0702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.46 |
| Max. Negotiated Rate |
$48.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.06
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.51
|
| Rate for Payer: Aetna of WY Medicare |
$31.69
|
| Rate for Payer: Aetna of WY Medicare |
$28.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$41.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$46.10
|
| Rate for Payer: Altius Commercial |
$46.10
|
| Rate for Payer: Altius Commercial |
$41.64
|
| Rate for Payer: Beech Street Commercial |
$42.51
|
| Rate for Payer: Beech Street Commercial |
$47.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$39.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.61
|
| Rate for Payer: Cash Price |
$30.37
|
| Rate for Payer: Cash Price |
$33.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$42.08
|
| Rate for Payer: Cigna of WY Commercial |
$42.51
|
| Rate for Payer: Cigna of WY Commercial |
$47.06
|
| Rate for Payer: Entrust Commercial |
$45.62
|
| Rate for Payer: Entrust Commercial |
$41.21
|
| Rate for Payer: First Choice Health Commercial |
$41.21
|
| Rate for Payer: First Choice Health Commercial |
$45.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.16
|
| Rate for Payer: HealthUtah PPO |
$43.38
|
| Rate for Payer: HealthUtah PPO |
$48.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.58
|
| Rate for Payer: Multiplan Medicare/VA |
$26.46
|
| Rate for Payer: Multiplan Medicare/VA |
$23.90
|
| Rate for Payer: One Health Plan of WY PPO |
$42.51
|
| Rate for Payer: One Health Plan of WY PPO |
$47.06
|
| Rate for Payer: PacificSource Commercial |
$43.22
|
| Rate for Payer: PacificSource Commercial |
$39.04
|
| Rate for Payer: PHCS PPO |
$42.51
|
| Rate for Payer: PHCS PPO |
$47.06
|
| Rate for Payer: Three Rivers PPO |
$32.54
|
| Rate for Payer: Three Rivers PPO |
$36.02
|
| Rate for Payer: TriWest Veterans Administration |
$27.85
|
| Rate for Payer: TriWest Veterans Administration |
$25.16
|
| Rate for Payer: United Healthcare Commercial |
$37.74
|
| Rate for Payer: United Healthcare Commercial |
$41.78
|
| Rate for Payer: United Healthcare Medicare |
$27.85
|
| Rate for Payer: United Healthcare Medicare |
$25.16
|
| Rate for Payer: WINHealth Partners Commercial |
$42.51
|
| Rate for Payer: WINHealth Partners Commercial |
$47.06
|
| Rate for Payer: Wise Provider Network Commercial |
$41.21
|
| Rate for Payer: Wise Provider Network Commercial |
$45.62
|
|
|
BETAMETHASONE ACET&SOD PHOSP
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
HCPCS J0702
|
| Hospital Charge Code |
J0702
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.64
|
| Rate for Payer: Aetna of WY Medicare |
$6.88
|
| Rate for Payer: Beech Street Commercial |
$17.10
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.46
|
| Rate for Payer: Cigna of WY Commercial |
$17.64
|
| Rate for Payer: First Choice Health Commercial |
$16.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.88
|
| Rate for Payer: HealthUtah PPO |
$18.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.46
|
| Rate for Payer: Multiplan Medicare/VA |
$5.85
|
| Rate for Payer: One Health Plan of WY PPO |
$17.64
|
| Rate for Payer: PacificSource Commercial |
$16.20
|
| Rate for Payer: PHCS PPO |
$17.10
|
| Rate for Payer: Three Rivers PPO |
$13.50
|
| Rate for Payer: TriWest Veterans Administration |
$6.88
|
| Rate for Payer: United Healthcare Commercial |
$15.66
|
| Rate for Payer: United Healthcare Medicare |
$6.88
|
| Rate for Payer: WINHealth Partners Commercial |
$17.10
|
|
