|
BATTERY FLYTE HOOD STRYKER
|
Facility
|
OP
|
$933.62
|
|
| Hospital Charge Code |
2650906
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$505.56 |
| Max. Negotiated Rate |
$933.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$914.95
|
| Rate for Payer: Aetna of WY Medicare |
$616.19
|
| Rate for Payer: Altius Commercial |
$896.28
|
| Rate for Payer: Beech Street Commercial |
$914.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$905.61
|
| Rate for Payer: Cash Price |
$653.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$905.61
|
| Rate for Payer: Cigna of WY Commercial |
$914.95
|
| Rate for Payer: Entrust Commercial |
$886.94
|
| Rate for Payer: First Choice Health Commercial |
$886.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$886.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$532.16
|
| Rate for Payer: HealthUtah PPO |
$933.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$905.61
|
| Rate for Payer: Multiplan Medicare/VA |
$505.56
|
| Rate for Payer: One Health Plan of WY PPO |
$914.95
|
| Rate for Payer: PacificSource Commercial |
$840.26
|
| Rate for Payer: PHCS PPO |
$914.95
|
| Rate for Payer: Three Rivers PPO |
$700.22
|
| Rate for Payer: TriWest Veterans Administration |
$532.16
|
| Rate for Payer: United Healthcare Commercial |
$891.61
|
| Rate for Payer: United Healthcare Medicare |
$532.16
|
| Rate for Payer: WINHealth Partners Commercial |
$914.95
|
| Rate for Payer: Wise Provider Network Commercial |
$886.94
|
|
|
BB-TAK THREADED AR-13226T
|
Facility
|
OP
|
$297.50
|
|
| Hospital Charge Code |
3002836
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$161.10 |
| Max. Negotiated Rate |
$297.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$291.55
|
| Rate for Payer: Aetna of WY Medicare |
$196.35
|
| Rate for Payer: Altius Commercial |
$285.60
|
| Rate for Payer: Beech Street Commercial |
$291.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$288.58
|
| Rate for Payer: Cash Price |
$208.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$288.58
|
| Rate for Payer: Cigna of WY Commercial |
$291.55
|
| Rate for Payer: Entrust Commercial |
$282.62
|
| Rate for Payer: First Choice Health Commercial |
$282.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$282.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$169.58
|
| Rate for Payer: HealthUtah PPO |
$297.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$288.58
|
| Rate for Payer: Multiplan Medicare/VA |
$161.10
|
| Rate for Payer: One Health Plan of WY PPO |
$291.55
|
| Rate for Payer: PacificSource Commercial |
$267.75
|
| Rate for Payer: PHCS PPO |
$291.55
|
| Rate for Payer: Three Rivers PPO |
$223.12
|
| Rate for Payer: TriWest Veterans Administration |
$169.58
|
| Rate for Payer: United Healthcare Commercial |
$284.11
|
| Rate for Payer: United Healthcare Medicare |
$169.58
|
| Rate for Payer: WINHealth Partners Commercial |
$291.55
|
| Rate for Payer: Wise Provider Network Commercial |
$282.62
|
|
|
BB-TAK THREADED AR-13226T
|
Facility
|
IP
|
$297.50
|
|
| Hospital Charge Code |
3002836
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$172.40 |
| Max. Negotiated Rate |
$297.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$291.55
|
| Rate for Payer: Aetna of WY Medicare |
$190.40
|
| Rate for Payer: Altius Commercial |
$285.60
|
| Rate for Payer: Beech Street Commercial |
$291.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$288.58
|
| Rate for Payer: Cash Price |
$208.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$288.58
|
| Rate for Payer: Cigna of WY Commercial |
$291.55
|
| Rate for Payer: Entrust Commercial |
$282.62
|
| Rate for Payer: First Choice Health Commercial |
$282.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$282.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$181.48
|
| Rate for Payer: HealthUtah PPO |
$297.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$288.58
|
| Rate for Payer: Multiplan Medicare/VA |
$172.40
|
| Rate for Payer: One Health Plan of WY PPO |
$291.55
|
| Rate for Payer: PacificSource Commercial |
$267.75
|
| Rate for Payer: PHCS PPO |
$291.55
|
| Rate for Payer: Three Rivers PPO |
$223.12
|
| Rate for Payer: TriWest Veterans Administration |
$181.48
|
| Rate for Payer: United Healthcare Commercial |
$284.11
|
| Rate for Payer: United Healthcare Medicare |
$181.48
|
| Rate for Payer: WINHealth Partners Commercial |
$282.62
|
| Rate for Payer: Wise Provider Network Commercial |
$282.62
|
|
|
BELATACEPT 250 MG INTRAVENOUS SOLUTION [92727]
|
Facility
|
IP
|
$984.88
|
|
|
Service Code
|
HCPCS J0485
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$570.74 |
| Max. Negotiated Rate |
$984.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$965.18
|
| Rate for Payer: Aetna of WY Medicare |
$630.32
|
| 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 |
$955.33
|
| 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 |
$600.78
|
| Rate for Payer: HealthUtah PPO |
$984.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$955.33
|
| Rate for Payer: Multiplan Medicare/VA |
$570.74
|
| 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 |
$600.78
|
| Rate for Payer: United Healthcare Commercial |
$940.56
|
| Rate for Payer: United Healthcare Medicare |
$600.78
|
| 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 |
$533.31 |
| 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 Commercial |
$945.48
|
| Rate for Payer: Beech Street Commercial |
$965.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$955.33
|
| 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 |
$561.38
|
| Rate for Payer: HealthUtah PPO |
$984.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$955.33
|
| Rate for Payer: Multiplan Medicare/VA |
$533.31
|
| 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 |
$561.38
|
| Rate for Payer: United Healthcare Commercial |
$940.56
|
| Rate for Payer: United Healthcare Medicare |
$561.38
|
| 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
|
$628.10
|
|
|
Service Code
|
HCPCS J0490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$340.12 |
| Max. Negotiated Rate |
$628.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$615.54
|
| Rate for Payer: Aetna of WY Medicare |
$414.55
|
| Rate for Payer: Altius Commercial |
$602.98
|
| Rate for Payer: Beech Street Commercial |
$615.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$609.26
|
| Rate for Payer: Cash Price |
$439.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$609.26
|
| Rate for Payer: Cigna of WY Commercial |
$615.54
|
| Rate for Payer: Entrust Commercial |
$596.70
|
| Rate for Payer: First Choice Health Commercial |
$596.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$596.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$358.02
|
| Rate for Payer: HealthUtah PPO |
$628.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$609.26
|
| Rate for Payer: Multiplan Medicare/VA |
$340.12
|
| Rate for Payer: One Health Plan of WY PPO |
$615.54
|
| Rate for Payer: PacificSource Commercial |
$565.29
|
| Rate for Payer: PHCS PPO |
$615.54
|
| Rate for Payer: Three Rivers PPO |
$471.08
|
| Rate for Payer: TriWest Veterans Administration |
$358.02
|
| Rate for Payer: United Healthcare Commercial |
$599.84
|
| Rate for Payer: United Healthcare Medicare |
$358.02
|
| Rate for Payer: WINHealth Partners Commercial |
$615.54
|
| Rate for Payer: Wise Provider Network Commercial |
$596.70
|
|
|
BELIMUMAB 120 MG INTRAVENOUS SOLUTION [91846]
|
Facility
|
IP
|
$628.10
|
|
|
Service Code
|
HCPCS J0490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$363.98 |
| Max. Negotiated Rate |
$628.10 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$615.54
|
| Rate for Payer: Aetna of WY Medicare |
$401.98
|
| Rate for Payer: Altius Commercial |
$602.98
|
| Rate for Payer: Beech Street Commercial |
$615.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$609.26
|
| Rate for Payer: Cash Price |
$439.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$609.26
|
| Rate for Payer: Cigna of WY Commercial |
$615.54
|
| Rate for Payer: Entrust Commercial |
$596.70
|
| Rate for Payer: First Choice Health Commercial |
$596.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$596.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$383.14
|
| Rate for Payer: HealthUtah PPO |
$628.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$609.26
|
| Rate for Payer: Multiplan Medicare/VA |
$363.98
|
| Rate for Payer: One Health Plan of WY PPO |
$615.54
|
| Rate for Payer: PacificSource Commercial |
$565.29
|
| Rate for Payer: PHCS PPO |
$615.54
|
| Rate for Payer: Three Rivers PPO |
$471.08
|
| Rate for Payer: TriWest Veterans Administration |
$383.14
|
| Rate for Payer: United Healthcare Commercial |
$599.84
|
| Rate for Payer: United Healthcare Medicare |
$383.14
|
| Rate for Payer: WINHealth Partners Commercial |
$596.70
|
| Rate for Payer: Wise Provider Network Commercial |
$596.70
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION [91847]
|
Facility
|
OP
|
$2,058.57
|
|
|
Service Code
|
HCPCS J0490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,114.72 |
| Max. Negotiated Rate |
$2,058.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,017.40
|
| Rate for Payer: Aetna of WY Medicare |
$1,358.66
|
| Rate for Payer: Altius Commercial |
$1,976.23
|
| Rate for Payer: Beech Street Commercial |
$2,017.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,996.81
|
| Rate for Payer: Cash Price |
$1,441.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,996.81
|
| Rate for Payer: Cigna of WY Commercial |
$2,017.40
|
| Rate for Payer: Entrust Commercial |
$1,955.64
|
| Rate for Payer: First Choice Health Commercial |
$1,955.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,955.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,173.38
|
| Rate for Payer: HealthUtah PPO |
$2,058.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,996.81
|
| Rate for Payer: Multiplan Medicare/VA |
$1,114.72
|
| Rate for Payer: One Health Plan of WY PPO |
$2,017.40
|
| Rate for Payer: PacificSource Commercial |
$1,852.71
|
| Rate for Payer: PHCS PPO |
$2,017.40
|
| Rate for Payer: Three Rivers PPO |
$1,543.93
|
| Rate for Payer: TriWest Veterans Administration |
$1,173.38
|
| Rate for Payer: United Healthcare Commercial |
$1,965.93
|
| Rate for Payer: United Healthcare Medicare |
$1,173.38
|
| Rate for Payer: WINHealth Partners Commercial |
$2,017.40
|
| Rate for Payer: Wise Provider Network Commercial |
$1,955.64
|
|
|
BELIMUMAB 400 MG INTRAVENOUS SOLUTION [91847]
|
Facility
|
IP
|
$2,058.57
|
|
|
Service Code
|
HCPCS J0490
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,192.94 |
| Max. Negotiated Rate |
$2,058.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,017.40
|
| Rate for Payer: Aetna of WY Medicare |
$1,317.48
|
| Rate for Payer: Altius Commercial |
$1,976.23
|
| Rate for Payer: Beech Street Commercial |
$2,017.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,996.81
|
| Rate for Payer: Cash Price |
$1,441.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,996.81
|
| Rate for Payer: Cigna of WY Commercial |
$2,017.40
|
| Rate for Payer: Entrust Commercial |
$1,955.64
|
| Rate for Payer: First Choice Health Commercial |
$1,955.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,955.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,255.73
|
| Rate for Payer: HealthUtah PPO |
$2,058.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,996.81
|
| Rate for Payer: Multiplan Medicare/VA |
$1,192.94
|
| Rate for Payer: One Health Plan of WY PPO |
$2,017.40
|
| Rate for Payer: PacificSource Commercial |
$1,852.71
|
| Rate for Payer: PHCS PPO |
$2,017.40
|
| Rate for Payer: Three Rivers PPO |
$1,543.93
|
| Rate for Payer: TriWest Veterans Administration |
$1,255.73
|
| Rate for Payer: United Healthcare Commercial |
$1,965.93
|
| Rate for Payer: United Healthcare Medicare |
$1,255.73
|
| Rate for Payer: WINHealth Partners Commercial |
$1,955.64
|
| Rate for Payer: Wise Provider Network Commercial |
$1,955.64
|
|
|
BENAZEPRIL 20 MG TABLET [15779]
|
Facility
|
OP
|
$17.88
|
|
|
Service Code
|
NDC 5026811111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$17.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.52
|
| Rate for Payer: Aetna of WY Medicare |
$11.80
|
| Rate for Payer: Altius Commercial |
$17.16
|
| Rate for Payer: Beech Street Commercial |
$17.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.34
|
| Rate for Payer: Cash Price |
$12.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.34
|
| Rate for Payer: Cigna of WY Commercial |
$17.52
|
| Rate for Payer: Entrust Commercial |
$16.99
|
| Rate for Payer: First Choice Health Commercial |
$16.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.19
|
| Rate for Payer: HealthUtah PPO |
$17.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.34
|
| Rate for Payer: Multiplan Medicare/VA |
$9.68
|
| Rate for Payer: One Health Plan of WY PPO |
$17.52
|
| Rate for Payer: PacificSource Commercial |
$16.09
|
| Rate for Payer: PHCS PPO |
$17.52
|
| Rate for Payer: Three Rivers PPO |
$13.41
|
| Rate for Payer: TriWest Veterans Administration |
$10.19
|
| Rate for Payer: United Healthcare Commercial |
$17.08
|
| Rate for Payer: United Healthcare Medicare |
$10.19
|
| Rate for Payer: WINHealth Partners Commercial |
$17.52
|
| Rate for Payer: Wise Provider Network Commercial |
$16.99
|
|
|
BENAZEPRIL 20 MG TABLET [15779]
|
Facility
|
OP
|
$17.88
|
|
|
Service Code
|
NDC 5026811115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.68 |
| Max. Negotiated Rate |
$17.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.52
|
| Rate for Payer: Aetna of WY Medicare |
$11.80
|
| Rate for Payer: Altius Commercial |
$17.16
|
| Rate for Payer: Beech Street Commercial |
$17.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.34
|
| Rate for Payer: Cash Price |
$12.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.34
|
| Rate for Payer: Cigna of WY Commercial |
$17.52
|
| Rate for Payer: Entrust Commercial |
$16.99
|
| Rate for Payer: First Choice Health Commercial |
$16.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.19
|
| Rate for Payer: HealthUtah PPO |
$17.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.34
|
| Rate for Payer: Multiplan Medicare/VA |
$9.68
|
| Rate for Payer: One Health Plan of WY PPO |
$17.52
|
| Rate for Payer: PacificSource Commercial |
$16.09
|
| Rate for Payer: PHCS PPO |
$17.52
|
| Rate for Payer: Three Rivers PPO |
$13.41
|
| Rate for Payer: TriWest Veterans Administration |
$10.19
|
| Rate for Payer: United Healthcare Commercial |
$17.08
|
| Rate for Payer: United Healthcare Medicare |
$10.19
|
| Rate for Payer: WINHealth Partners Commercial |
$17.52
|
| Rate for Payer: Wise Provider Network Commercial |
$16.99
|
|
|
BENAZEPRIL 20 MG TABLET [15779]
|
Facility
|
IP
|
$17.88
|
|
|
Service Code
|
NDC 5026811111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$17.88 |
| Rate for Payer: WINHealth Partners Commercial |
$16.99
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.52
|
| Rate for Payer: Aetna of WY Medicare |
$11.44
|
| Rate for Payer: Altius Commercial |
$17.16
|
| Rate for Payer: Beech Street Commercial |
$17.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.34
|
| Rate for Payer: Cash Price |
$12.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.34
|
| Rate for Payer: Cigna of WY Commercial |
$17.52
|
| Rate for Payer: Entrust Commercial |
$16.99
|
| Rate for Payer: First Choice Health Commercial |
$16.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.91
|
| Rate for Payer: HealthUtah PPO |
$17.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.34
|
| Rate for Payer: Multiplan Medicare/VA |
$10.36
|
| Rate for Payer: One Health Plan of WY PPO |
$17.52
|
| Rate for Payer: PacificSource Commercial |
$16.09
|
| Rate for Payer: PHCS PPO |
$17.52
|
| Rate for Payer: Three Rivers PPO |
$13.41
|
| Rate for Payer: TriWest Veterans Administration |
$10.91
|
| Rate for Payer: United Healthcare Commercial |
$17.08
|
| Rate for Payer: United Healthcare Medicare |
$10.91
|
| Rate for Payer: Wise Provider Network Commercial |
$16.99
|
|
|
BENAZEPRIL 20 MG TABLET [15779]
|
Facility
|
IP
|
$17.88
|
|
|
Service Code
|
NDC 5026811115
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.36 |
| Max. Negotiated Rate |
$17.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.52
|
| Rate for Payer: Aetna of WY Medicare |
$11.44
|
| Rate for Payer: Altius Commercial |
$17.16
|
| Rate for Payer: Beech Street Commercial |
$17.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.34
|
| Rate for Payer: Cash Price |
$12.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.34
|
| Rate for Payer: Cigna of WY Commercial |
$17.52
|
| Rate for Payer: Entrust Commercial |
$16.99
|
| Rate for Payer: First Choice Health Commercial |
$16.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.91
|
| Rate for Payer: HealthUtah PPO |
$17.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.34
|
| Rate for Payer: Multiplan Medicare/VA |
$10.36
|
| Rate for Payer: One Health Plan of WY PPO |
$17.52
|
| Rate for Payer: PacificSource Commercial |
$16.09
|
| Rate for Payer: PHCS PPO |
$17.52
|
| Rate for Payer: Three Rivers PPO |
$13.41
|
| Rate for Payer: TriWest Veterans Administration |
$10.91
|
| Rate for Payer: United Healthcare Commercial |
$17.08
|
| Rate for Payer: United Healthcare Medicare |
$10.91
|
| Rate for Payer: WINHealth Partners Commercial |
$16.99
|
| Rate for Payer: Wise Provider Network Commercial |
$16.99
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
OP
|
$18.17
|
|
|
Service Code
|
NDC 5026811215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.84 |
| Max. Negotiated Rate |
$18.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.81
|
| Rate for Payer: Aetna of WY Medicare |
$11.99
|
| Rate for Payer: Altius Commercial |
$17.44
|
| Rate for Payer: Beech Street Commercial |
$17.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.62
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.62
|
| Rate for Payer: Cigna of WY Commercial |
$17.81
|
| Rate for Payer: Entrust Commercial |
$17.26
|
| Rate for Payer: First Choice Health Commercial |
$17.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.36
|
| Rate for Payer: HealthUtah PPO |
$18.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.62
|
| Rate for Payer: Multiplan Medicare/VA |
$9.84
|
| Rate for Payer: One Health Plan of WY PPO |
$17.81
|
| Rate for Payer: PacificSource Commercial |
$16.35
|
| Rate for Payer: PHCS PPO |
$17.81
|
| Rate for Payer: Three Rivers PPO |
$13.63
|
| Rate for Payer: TriWest Veterans Administration |
$10.36
|
| Rate for Payer: United Healthcare Commercial |
$17.35
|
| Rate for Payer: United Healthcare Medicare |
$10.36
|
| Rate for Payer: WINHealth Partners Commercial |
$17.81
|
| Rate for Payer: Wise Provider Network Commercial |
$17.26
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
IP
|
$18.17
|
|
|
Service Code
|
NDC 6586211801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$18.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.81
|
| Rate for Payer: Aetna of WY Medicare |
$11.63
|
| Rate for Payer: Altius Commercial |
$17.44
|
| Rate for Payer: Beech Street Commercial |
$17.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.62
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.62
|
| Rate for Payer: Cigna of WY Commercial |
$17.81
|
| Rate for Payer: Entrust Commercial |
$17.26
|
| Rate for Payer: First Choice Health Commercial |
$17.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.08
|
| Rate for Payer: HealthUtah PPO |
$18.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.62
|
| Rate for Payer: Multiplan Medicare/VA |
$10.53
|
| Rate for Payer: One Health Plan of WY PPO |
$17.81
|
| Rate for Payer: PacificSource Commercial |
$16.35
|
| Rate for Payer: PHCS PPO |
$17.81
|
| Rate for Payer: Three Rivers PPO |
$13.63
|
| Rate for Payer: TriWest Veterans Administration |
$11.08
|
| Rate for Payer: United Healthcare Commercial |
$17.35
|
| Rate for Payer: United Healthcare Medicare |
$11.08
|
| Rate for Payer: WINHealth Partners Commercial |
$17.26
|
| Rate for Payer: Wise Provider Network Commercial |
$17.26
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
OP
|
$15.34
|
|
|
Service Code
|
NDC 5026811211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$15.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.03
|
| Rate for Payer: Aetna of WY Medicare |
$10.12
|
| Rate for Payer: Altius Commercial |
$14.73
|
| Rate for Payer: Beech Street Commercial |
$15.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.88
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.88
|
| Rate for Payer: Cigna of WY Commercial |
$15.03
|
| Rate for Payer: Entrust Commercial |
$14.57
|
| Rate for Payer: First Choice Health Commercial |
$14.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.74
|
| Rate for Payer: HealthUtah PPO |
$15.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.88
|
| Rate for Payer: Multiplan Medicare/VA |
$8.31
|
| Rate for Payer: One Health Plan of WY PPO |
$15.03
|
| Rate for Payer: PacificSource Commercial |
$13.81
|
| Rate for Payer: PHCS PPO |
$15.03
|
| Rate for Payer: Three Rivers PPO |
$11.50
|
| Rate for Payer: TriWest Veterans Administration |
$8.74
|
| Rate for Payer: United Healthcare Commercial |
$14.65
|
| Rate for Payer: United Healthcare Medicare |
$8.74
|
| Rate for Payer: WINHealth Partners Commercial |
$15.03
|
| Rate for Payer: Wise Provider Network Commercial |
$14.57
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
IP
|
$15.34
|
|
|
Service Code
|
NDC 5026811211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$15.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.03
|
| Rate for Payer: Aetna of WY Medicare |
$9.82
|
| Rate for Payer: Altius Commercial |
$14.73
|
| Rate for Payer: Beech Street Commercial |
$15.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.88
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.88
|
| Rate for Payer: Cigna of WY Commercial |
$15.03
|
| Rate for Payer: Entrust Commercial |
$14.57
|
| Rate for Payer: First Choice Health Commercial |
$14.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.57
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.36
|
| Rate for Payer: HealthUtah PPO |
$15.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.88
|
| Rate for Payer: Multiplan Medicare/VA |
$8.89
|
| Rate for Payer: One Health Plan of WY PPO |
$15.03
|
| Rate for Payer: PacificSource Commercial |
$13.81
|
| Rate for Payer: PHCS PPO |
$15.03
|
| Rate for Payer: Three Rivers PPO |
$11.50
|
| Rate for Payer: TriWest Veterans Administration |
$9.36
|
| Rate for Payer: United Healthcare Commercial |
$14.65
|
| Rate for Payer: United Healthcare Medicare |
$9.36
|
| Rate for Payer: WINHealth Partners Commercial |
$14.57
|
| Rate for Payer: Wise Provider Network Commercial |
$14.57
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
IP
|
$18.17
|
|
|
Service Code
|
NDC 5026811215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.53 |
| Max. Negotiated Rate |
$18.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.81
|
| Rate for Payer: Aetna of WY Medicare |
$11.63
|
| Rate for Payer: Altius Commercial |
$17.44
|
| Rate for Payer: Beech Street Commercial |
$17.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.62
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.62
|
| Rate for Payer: Cigna of WY Commercial |
$17.81
|
| Rate for Payer: Entrust Commercial |
$17.26
|
| Rate for Payer: First Choice Health Commercial |
$17.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.08
|
| Rate for Payer: HealthUtah PPO |
$18.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.62
|
| Rate for Payer: Multiplan Medicare/VA |
$10.53
|
| Rate for Payer: One Health Plan of WY PPO |
$17.81
|
| Rate for Payer: PacificSource Commercial |
$16.35
|
| Rate for Payer: PHCS PPO |
$17.81
|
| Rate for Payer: Three Rivers PPO |
$13.63
|
| Rate for Payer: TriWest Veterans Administration |
$11.08
|
| Rate for Payer: United Healthcare Commercial |
$17.35
|
| Rate for Payer: United Healthcare Medicare |
$11.08
|
| Rate for Payer: WINHealth Partners Commercial |
$17.26
|
| Rate for Payer: Wise Provider Network Commercial |
$17.26
|
|
|
BENAZEPRIL 40 MG TABLET [17780]
|
Facility
|
OP
|
$18.17
|
|
|
Service Code
|
NDC 6586211801
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.84 |
| Max. Negotiated Rate |
$18.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.81
|
| Rate for Payer: Aetna of WY Medicare |
$11.99
|
| Rate for Payer: Altius Commercial |
$17.44
|
| Rate for Payer: Beech Street Commercial |
$17.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.62
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.62
|
| Rate for Payer: Cigna of WY Commercial |
$17.81
|
| Rate for Payer: Entrust Commercial |
$17.26
|
| Rate for Payer: First Choice Health Commercial |
$17.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.36
|
| Rate for Payer: HealthUtah PPO |
$18.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.62
|
| Rate for Payer: Multiplan Medicare/VA |
$9.84
|
| Rate for Payer: One Health Plan of WY PPO |
$17.81
|
| Rate for Payer: PacificSource Commercial |
$16.35
|
| Rate for Payer: PHCS PPO |
$17.81
|
| Rate for Payer: Three Rivers PPO |
$13.63
|
| Rate for Payer: TriWest Veterans Administration |
$10.36
|
| Rate for Payer: United Healthcare Commercial |
$17.35
|
| Rate for Payer: United Healthcare Medicare |
$10.36
|
| Rate for Payer: WINHealth Partners Commercial |
$17.81
|
| Rate for Payer: Wise Provider Network Commercial |
$17.26
|
|
|
BENDAMUSTINE 100 MG INTRAVENOUS POWDER FOR SOLUTION [52831]
|
Facility
|
IP
|
$1,615.00
|
|
|
Service Code
|
HCPCS J9033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$935.89 |
| 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 |
$1,033.60
|
| 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 |
$1,566.55
|
| 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 |
$985.15
|
| Rate for Payer: HealthUtah PPO |
$1,615.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,566.55
|
| Rate for Payer: Multiplan Medicare/VA |
$935.89
|
| 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 |
$985.15
|
| Rate for Payer: United Healthcare Commercial |
$1,542.32
|
| Rate for Payer: United Healthcare Medicare |
$985.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1,534.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,534.25
|
|
|
BENDAMUSTINE 100 MG INTRAVENOUS POWDER FOR SOLUTION [52831]
|
Facility
|
OP
|
$1,615.00
|
|
|
Service Code
|
HCPCS J9033
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$874.52 |
| 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 Commercial |
$1,550.40
|
| Rate for Payer: Beech Street Commercial |
$1,582.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,566.55
|
| 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 |
$920.55
|
| Rate for Payer: HealthUtah PPO |
$1,615.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,566.55
|
| Rate for Payer: Multiplan Medicare/VA |
$874.52
|
| 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 |
$920.55
|
| Rate for Payer: United Healthcare Commercial |
$1,542.32
|
| Rate for Payer: United Healthcare Medicare |
$920.55
|
| Rate for Payer: WINHealth Partners Commercial |
$1,582.70
|
| 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 |
$343.01 |
| 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 Commercial |
$608.11
|
| Rate for Payer: Beech Street Commercial |
$620.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$614.45
|
| 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 |
$361.07
|
| Rate for Payer: HealthUtah PPO |
$633.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$614.45
|
| Rate for Payer: Multiplan Medicare/VA |
$343.01
|
| 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 |
$361.07
|
| Rate for Payer: United Healthcare Commercial |
$604.94
|
| Rate for Payer: United Healthcare Medicare |
$361.07
|
| 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 |
$367.08 |
| Max. Negotiated Rate |
$633.45 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$620.78
|
| Rate for Payer: Aetna of WY Medicare |
$405.41
|
| 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 |
$614.45
|
| 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 |
$386.40
|
| Rate for Payer: HealthUtah PPO |
$633.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$614.45
|
| Rate for Payer: Multiplan Medicare/VA |
$367.08
|
| 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 |
$386.40
|
| Rate for Payer: United Healthcare Commercial |
$604.94
|
| Rate for Payer: United Healthcare Medicare |
$386.40
|
| Rate for Payer: WINHealth Partners Commercial |
$601.78
|
| Rate for Payer: Wise Provider Network Commercial |
$601.78
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE [150993]
|
Facility
|
OP
|
$5,691.75
|
|
|
Service Code
|
HCPCS J0517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,082.08 |
| Max. Negotiated Rate |
$5,691.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,577.92
|
| Rate for Payer: Aetna of WY Medicare |
$3,756.56
|
| Rate for Payer: Altius Commercial |
$5,464.08
|
| Rate for Payer: Beech Street Commercial |
$5,577.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,521.00
|
| Rate for Payer: Cash Price |
$3,984.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,521.00
|
| Rate for Payer: Cigna of WY Commercial |
$5,577.92
|
| Rate for Payer: Entrust Commercial |
$5,407.16
|
| Rate for Payer: First Choice Health Commercial |
$5,407.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,407.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,244.30
|
| Rate for Payer: HealthUtah PPO |
$5,691.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,521.00
|
| Rate for Payer: Multiplan Medicare/VA |
$3,082.08
|
| Rate for Payer: One Health Plan of WY PPO |
$5,577.92
|
| Rate for Payer: PacificSource Commercial |
$5,122.58
|
| Rate for Payer: PHCS PPO |
$5,577.92
|
| Rate for Payer: Three Rivers PPO |
$4,268.81
|
| Rate for Payer: TriWest Veterans Administration |
$3,244.30
|
| Rate for Payer: United Healthcare Commercial |
$5,435.62
|
| Rate for Payer: United Healthcare Medicare |
$3,244.30
|
| Rate for Payer: WINHealth Partners Commercial |
$5,577.92
|
| Rate for Payer: Wise Provider Network Commercial |
$5,407.16
|
|
|
BENRALIZUMAB 30 MG/ML SUBCUTANEOUS SYRINGE [150993]
|
Facility
|
IP
|
$5,691.75
|
|
|
Service Code
|
HCPCS J0517
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,298.37 |
| Max. Negotiated Rate |
$5,691.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,577.92
|
| Rate for Payer: Aetna of WY Medicare |
$3,642.72
|
| Rate for Payer: Altius Commercial |
$5,464.08
|
| Rate for Payer: Beech Street Commercial |
$5,577.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,521.00
|
| Rate for Payer: Cash Price |
$3,984.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,521.00
|
| Rate for Payer: Cigna of WY Commercial |
$5,577.92
|
| Rate for Payer: Entrust Commercial |
$5,407.16
|
| Rate for Payer: First Choice Health Commercial |
$5,407.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,407.16
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,471.97
|
| Rate for Payer: HealthUtah PPO |
$5,691.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,521.00
|
| Rate for Payer: Multiplan Medicare/VA |
$3,298.37
|
| Rate for Payer: One Health Plan of WY PPO |
$5,577.92
|
| Rate for Payer: PacificSource Commercial |
$5,122.58
|
| Rate for Payer: PHCS PPO |
$5,577.92
|
| Rate for Payer: Three Rivers PPO |
$4,268.81
|
| Rate for Payer: TriWest Veterans Administration |
$3,471.97
|
| Rate for Payer: United Healthcare Commercial |
$5,435.62
|
| Rate for Payer: United Healthcare Medicare |
$3,471.97
|
| Rate for Payer: WINHealth Partners Commercial |
$5,407.16
|
| Rate for Payer: Wise Provider Network Commercial |
$5,407.16
|
|
