|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES [93857]
|
Facility
|
IP
|
$15.64
|
|
|
Service Code
|
NDC 6382471316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$15.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.33
|
| Rate for Payer: Aetna of WY Medicare |
$10.01
|
| Rate for Payer: Altius Commercial |
$15.01
|
| Rate for Payer: Beech Street Commercial |
$15.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.17
|
| Rate for Payer: Cash Price |
$10.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.17
|
| Rate for Payer: Cigna of WY Commercial |
$15.33
|
| Rate for Payer: Entrust Commercial |
$14.86
|
| Rate for Payer: First Choice Health Commercial |
$14.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.54
|
| Rate for Payer: HealthUtah PPO |
$15.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.17
|
| Rate for Payer: Multiplan Medicare/VA |
$9.06
|
| Rate for Payer: One Health Plan of WY PPO |
$15.33
|
| Rate for Payer: PacificSource Commercial |
$14.08
|
| Rate for Payer: PHCS PPO |
$15.33
|
| Rate for Payer: Three Rivers PPO |
$11.73
|
| Rate for Payer: TriWest Veterans Administration |
$9.54
|
| Rate for Payer: United Healthcare Commercial |
$14.94
|
| Rate for Payer: United Healthcare Medicare |
$9.54
|
| Rate for Payer: WINHealth Partners Commercial |
$14.86
|
| Rate for Payer: Wise Provider Network Commercial |
$14.86
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES [93857]
|
Facility
|
IP
|
$15.60
|
|
|
Service Code
|
NDC 0904625549
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.04 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.29
|
| Rate for Payer: Aetna of WY Medicare |
$9.98
|
| Rate for Payer: Altius Commercial |
$14.98
|
| Rate for Payer: Beech Street Commercial |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.13
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.13
|
| Rate for Payer: Cigna of WY Commercial |
$15.29
|
| Rate for Payer: Entrust Commercial |
$14.82
|
| Rate for Payer: First Choice Health Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.52
|
| Rate for Payer: HealthUtah PPO |
$15.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.13
|
| Rate for Payer: Multiplan Medicare/VA |
$9.04
|
| Rate for Payer: One Health Plan of WY PPO |
$15.29
|
| Rate for Payer: PacificSource Commercial |
$14.04
|
| Rate for Payer: PHCS PPO |
$15.29
|
| Rate for Payer: Three Rivers PPO |
$11.70
|
| Rate for Payer: TriWest Veterans Administration |
$9.52
|
| Rate for Payer: United Healthcare Commercial |
$14.90
|
| Rate for Payer: United Healthcare Medicare |
$9.52
|
| Rate for Payer: WINHealth Partners Commercial |
$14.82
|
| Rate for Payer: Wise Provider Network Commercial |
$14.82
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES [93857]
|
Facility
|
OP
|
$15.64
|
|
|
Service Code
|
NDC 6382471316
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.47 |
| Max. Negotiated Rate |
$15.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.33
|
| Rate for Payer: Aetna of WY Medicare |
$10.32
|
| Rate for Payer: Altius Commercial |
$15.01
|
| Rate for Payer: Beech Street Commercial |
$15.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.17
|
| Rate for Payer: Cash Price |
$10.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.17
|
| Rate for Payer: Cigna of WY Commercial |
$15.33
|
| Rate for Payer: Entrust Commercial |
$14.86
|
| Rate for Payer: First Choice Health Commercial |
$14.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.91
|
| Rate for Payer: HealthUtah PPO |
$15.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.17
|
| Rate for Payer: Multiplan Medicare/VA |
$8.47
|
| Rate for Payer: One Health Plan of WY PPO |
$15.33
|
| Rate for Payer: PacificSource Commercial |
$14.08
|
| Rate for Payer: PHCS PPO |
$15.33
|
| Rate for Payer: Three Rivers PPO |
$11.73
|
| Rate for Payer: TriWest Veterans Administration |
$8.91
|
| Rate for Payer: United Healthcare Commercial |
$14.94
|
| Rate for Payer: United Healthcare Medicare |
$8.91
|
| Rate for Payer: WINHealth Partners Commercial |
$15.33
|
| Rate for Payer: Wise Provider Network Commercial |
$14.86
|
|
|
BENZOCAINE 15 MG-MENTHOL 3.6 MG LOZENGES [93857]
|
Facility
|
OP
|
$15.60
|
|
|
Service Code
|
NDC 0904625549
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.45 |
| Max. Negotiated Rate |
$15.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.29
|
| Rate for Payer: Aetna of WY Medicare |
$10.30
|
| Rate for Payer: Altius Commercial |
$14.98
|
| Rate for Payer: Beech Street Commercial |
$15.29
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.13
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.13
|
| Rate for Payer: Cigna of WY Commercial |
$15.29
|
| Rate for Payer: Entrust Commercial |
$14.82
|
| Rate for Payer: First Choice Health Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.89
|
| Rate for Payer: HealthUtah PPO |
$15.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.13
|
| Rate for Payer: Multiplan Medicare/VA |
$8.45
|
| Rate for Payer: One Health Plan of WY PPO |
$15.29
|
| Rate for Payer: PacificSource Commercial |
$14.04
|
| Rate for Payer: PHCS PPO |
$15.29
|
| Rate for Payer: Three Rivers PPO |
$11.70
|
| Rate for Payer: TriWest Veterans Administration |
$8.89
|
| Rate for Payer: United Healthcare Commercial |
$14.90
|
| Rate for Payer: United Healthcare Medicare |
$8.89
|
| Rate for Payer: WINHealth Partners Commercial |
$15.29
|
| Rate for Payer: Wise Provider Network Commercial |
$14.82
|
|
|
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL [3150]
|
Facility
|
OP
|
$15.26
|
|
|
Service Code
|
NDC 1686468003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.26 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.95
|
| Rate for Payer: Aetna of WY Medicare |
$10.07
|
| Rate for Payer: Altius Commercial |
$14.65
|
| Rate for Payer: Beech Street Commercial |
$14.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.80
|
| Rate for Payer: Cash Price |
$10.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.80
|
| Rate for Payer: Cigna of WY Commercial |
$14.95
|
| Rate for Payer: Entrust Commercial |
$14.50
|
| Rate for Payer: First Choice Health Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.70
|
| Rate for Payer: HealthUtah PPO |
$15.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.80
|
| Rate for Payer: Multiplan Medicare/VA |
$8.26
|
| Rate for Payer: One Health Plan of WY PPO |
$14.95
|
| Rate for Payer: PacificSource Commercial |
$13.73
|
| Rate for Payer: PHCS PPO |
$14.95
|
| Rate for Payer: Three Rivers PPO |
$11.44
|
| Rate for Payer: TriWest Veterans Administration |
$8.70
|
| Rate for Payer: United Healthcare Commercial |
$14.57
|
| Rate for Payer: United Healthcare Medicare |
$8.70
|
| Rate for Payer: WINHealth Partners Commercial |
$14.95
|
| Rate for Payer: Wise Provider Network Commercial |
$14.50
|
|
|
BENZOCAINE 20 %-MENTHOL 0.5 % TOPICAL AEROSOL [3150]
|
Facility
|
IP
|
$15.26
|
|
|
Service Code
|
NDC 1686468003
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.95
|
| Rate for Payer: Aetna of WY Medicare |
$9.77
|
| Rate for Payer: Altius Commercial |
$14.65
|
| Rate for Payer: Beech Street Commercial |
$14.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.80
|
| Rate for Payer: Cash Price |
$10.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.80
|
| Rate for Payer: Cigna of WY Commercial |
$14.95
|
| Rate for Payer: Entrust Commercial |
$14.50
|
| Rate for Payer: First Choice Health Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.31
|
| Rate for Payer: HealthUtah PPO |
$15.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.80
|
| Rate for Payer: Multiplan Medicare/VA |
$8.84
|
| Rate for Payer: One Health Plan of WY PPO |
$14.95
|
| Rate for Payer: PacificSource Commercial |
$13.73
|
| Rate for Payer: PHCS PPO |
$14.95
|
| Rate for Payer: Three Rivers PPO |
$11.44
|
| Rate for Payer: TriWest Veterans Administration |
$9.31
|
| Rate for Payer: United Healthcare Commercial |
$14.57
|
| Rate for Payer: United Healthcare Medicare |
$9.31
|
| Rate for Payer: WINHealth Partners Commercial |
$14.50
|
| Rate for Payer: Wise Provider Network Commercial |
$14.50
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
IP
|
$16.98
|
|
|
Service Code
|
NDC 6945214320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.84 |
| Max. Negotiated Rate |
$16.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.64
|
| Rate for Payer: Aetna of WY Medicare |
$10.87
|
| Rate for Payer: Altius Commercial |
$16.30
|
| Rate for Payer: Beech Street Commercial |
$16.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.47
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.47
|
| Rate for Payer: Cigna of WY Commercial |
$16.64
|
| Rate for Payer: Entrust Commercial |
$16.13
|
| Rate for Payer: First Choice Health Commercial |
$16.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.36
|
| Rate for Payer: HealthUtah PPO |
$16.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.47
|
| Rate for Payer: Multiplan Medicare/VA |
$9.84
|
| Rate for Payer: One Health Plan of WY PPO |
$16.64
|
| Rate for Payer: PacificSource Commercial |
$15.28
|
| Rate for Payer: PHCS PPO |
$16.64
|
| Rate for Payer: Three Rivers PPO |
$12.74
|
| Rate for Payer: TriWest Veterans Administration |
$10.36
|
| Rate for Payer: United Healthcare Commercial |
$16.22
|
| Rate for Payer: United Healthcare Medicare |
$10.36
|
| Rate for Payer: WINHealth Partners Commercial |
$16.13
|
| Rate for Payer: Wise Provider Network Commercial |
$16.13
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
OP
|
$16.86
|
|
|
Service Code
|
NDC 6808421411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.13 |
| Max. Negotiated Rate |
$16.86 |
| Rate for Payer: United Healthcare Commercial |
$16.10
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.52
|
| Rate for Payer: Aetna of WY Medicare |
$11.13
|
| Rate for Payer: Altius Commercial |
$16.19
|
| Rate for Payer: Beech Street Commercial |
$16.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.35
|
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.35
|
| Rate for Payer: Cigna of WY Commercial |
$16.52
|
| Rate for Payer: Entrust Commercial |
$16.02
|
| Rate for Payer: First Choice Health Commercial |
$16.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.61
|
| Rate for Payer: HealthUtah PPO |
$16.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.35
|
| Rate for Payer: Multiplan Medicare/VA |
$9.13
|
| Rate for Payer: One Health Plan of WY PPO |
$16.52
|
| Rate for Payer: PacificSource Commercial |
$15.17
|
| Rate for Payer: PHCS PPO |
$16.52
|
| Rate for Payer: Three Rivers PPO |
$12.64
|
| Rate for Payer: TriWest Veterans Administration |
$9.61
|
| Rate for Payer: United Healthcare Medicare |
$9.61
|
| Rate for Payer: WINHealth Partners Commercial |
$16.52
|
| Rate for Payer: Wise Provider Network Commercial |
$16.02
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
IP
|
$16.86
|
|
|
Service Code
|
NDC 6808421401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$16.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.52
|
| Rate for Payer: Aetna of WY Medicare |
$10.79
|
| Rate for Payer: Altius Commercial |
$16.19
|
| Rate for Payer: Beech Street Commercial |
$16.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.35
|
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.35
|
| Rate for Payer: Cigna of WY Commercial |
$16.52
|
| Rate for Payer: Entrust Commercial |
$16.02
|
| Rate for Payer: First Choice Health Commercial |
$16.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.28
|
| Rate for Payer: HealthUtah PPO |
$16.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.35
|
| Rate for Payer: Multiplan Medicare/VA |
$9.77
|
| Rate for Payer: One Health Plan of WY PPO |
$16.52
|
| Rate for Payer: PacificSource Commercial |
$15.17
|
| Rate for Payer: PHCS PPO |
$16.52
|
| Rate for Payer: Three Rivers PPO |
$12.64
|
| Rate for Payer: TriWest Veterans Administration |
$10.28
|
| Rate for Payer: United Healthcare Commercial |
$16.10
|
| Rate for Payer: United Healthcare Medicare |
$10.28
|
| Rate for Payer: WINHealth Partners Commercial |
$16.02
|
| Rate for Payer: Wise Provider Network Commercial |
$16.02
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
IP
|
$16.20
|
|
|
Service Code
|
NDC 0904715361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.88
|
| Rate for Payer: Aetna of WY Medicare |
$10.37
|
| Rate for Payer: Altius Commercial |
$15.55
|
| Rate for Payer: Beech Street Commercial |
$15.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.71
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.71
|
| Rate for Payer: Cigna of WY Commercial |
$15.88
|
| Rate for Payer: Entrust Commercial |
$15.39
|
| Rate for Payer: First Choice Health Commercial |
$15.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.88
|
| Rate for Payer: HealthUtah PPO |
$16.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.71
|
| Rate for Payer: Multiplan Medicare/VA |
$9.39
|
| Rate for Payer: One Health Plan of WY PPO |
$15.88
|
| Rate for Payer: PacificSource Commercial |
$14.58
|
| Rate for Payer: PHCS PPO |
$15.88
|
| Rate for Payer: Three Rivers PPO |
$12.15
|
| Rate for Payer: TriWest Veterans Administration |
$9.88
|
| Rate for Payer: United Healthcare Commercial |
$15.47
|
| Rate for Payer: United Healthcare Medicare |
$9.88
|
| Rate for Payer: WINHealth Partners Commercial |
$15.39
|
| Rate for Payer: Wise Provider Network Commercial |
$15.39
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
IP
|
$16.86
|
|
|
Service Code
|
NDC 6808421411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$16.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.52
|
| Rate for Payer: Aetna of WY Medicare |
$10.79
|
| Rate for Payer: Altius Commercial |
$16.19
|
| Rate for Payer: Beech Street Commercial |
$16.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.35
|
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.35
|
| Rate for Payer: Cigna of WY Commercial |
$16.52
|
| Rate for Payer: Entrust Commercial |
$16.02
|
| Rate for Payer: First Choice Health Commercial |
$16.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.28
|
| Rate for Payer: HealthUtah PPO |
$16.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.35
|
| Rate for Payer: Multiplan Medicare/VA |
$9.77
|
| Rate for Payer: One Health Plan of WY PPO |
$16.52
|
| Rate for Payer: PacificSource Commercial |
$15.17
|
| Rate for Payer: PHCS PPO |
$16.52
|
| Rate for Payer: Three Rivers PPO |
$12.64
|
| Rate for Payer: TriWest Veterans Administration |
$10.28
|
| Rate for Payer: United Healthcare Commercial |
$16.10
|
| Rate for Payer: United Healthcare Medicare |
$10.28
|
| Rate for Payer: WINHealth Partners Commercial |
$16.02
|
| Rate for Payer: Wise Provider Network Commercial |
$16.02
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
OP
|
$16.98
|
|
|
Service Code
|
NDC 6945214320
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.19 |
| Max. Negotiated Rate |
$16.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.64
|
| Rate for Payer: Aetna of WY Medicare |
$11.21
|
| Rate for Payer: Altius Commercial |
$16.30
|
| Rate for Payer: Beech Street Commercial |
$16.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.47
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.47
|
| Rate for Payer: Cigna of WY Commercial |
$16.64
|
| Rate for Payer: Entrust Commercial |
$16.13
|
| Rate for Payer: First Choice Health Commercial |
$16.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.68
|
| Rate for Payer: HealthUtah PPO |
$16.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.47
|
| Rate for Payer: Multiplan Medicare/VA |
$9.19
|
| Rate for Payer: One Health Plan of WY PPO |
$16.64
|
| Rate for Payer: PacificSource Commercial |
$15.28
|
| Rate for Payer: PHCS PPO |
$16.64
|
| Rate for Payer: Three Rivers PPO |
$12.74
|
| Rate for Payer: TriWest Veterans Administration |
$9.68
|
| Rate for Payer: United Healthcare Commercial |
$16.22
|
| Rate for Payer: United Healthcare Medicare |
$9.68
|
| Rate for Payer: WINHealth Partners Commercial |
$16.64
|
| Rate for Payer: Wise Provider Network Commercial |
$16.13
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
OP
|
$16.20
|
|
|
Service Code
|
NDC 0904715361
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.77 |
| Max. Negotiated Rate |
$16.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.88
|
| Rate for Payer: Aetna of WY Medicare |
$10.69
|
| Rate for Payer: Altius Commercial |
$15.55
|
| Rate for Payer: Beech Street Commercial |
$15.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.71
|
| Rate for Payer: Cash Price |
$11.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.71
|
| Rate for Payer: Cigna of WY Commercial |
$15.88
|
| Rate for Payer: Entrust Commercial |
$15.39
|
| Rate for Payer: First Choice Health Commercial |
$15.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.39
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.23
|
| Rate for Payer: HealthUtah PPO |
$16.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.71
|
| Rate for Payer: Multiplan Medicare/VA |
$8.77
|
| Rate for Payer: One Health Plan of WY PPO |
$15.88
|
| Rate for Payer: PacificSource Commercial |
$14.58
|
| Rate for Payer: PHCS PPO |
$15.88
|
| Rate for Payer: Three Rivers PPO |
$12.15
|
| Rate for Payer: TriWest Veterans Administration |
$9.23
|
| Rate for Payer: United Healthcare Commercial |
$15.47
|
| Rate for Payer: United Healthcare Medicare |
$9.23
|
| Rate for Payer: WINHealth Partners Commercial |
$15.88
|
| Rate for Payer: Wise Provider Network Commercial |
$15.39
|
|
|
BENZONATATE 100 MG CAPSULE [11768]
|
Facility
|
OP
|
$16.86
|
|
|
Service Code
|
NDC 6808421401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.13 |
| Max. Negotiated Rate |
$16.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.52
|
| Rate for Payer: Aetna of WY Medicare |
$11.13
|
| Rate for Payer: Altius Commercial |
$16.19
|
| Rate for Payer: Beech Street Commercial |
$16.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.35
|
| Rate for Payer: Cash Price |
$11.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.35
|
| Rate for Payer: Cigna of WY Commercial |
$16.52
|
| Rate for Payer: Entrust Commercial |
$16.02
|
| Rate for Payer: First Choice Health Commercial |
$16.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.61
|
| Rate for Payer: HealthUtah PPO |
$16.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.35
|
| Rate for Payer: Multiplan Medicare/VA |
$9.13
|
| Rate for Payer: One Health Plan of WY PPO |
$16.52
|
| Rate for Payer: PacificSource Commercial |
$15.17
|
| Rate for Payer: PHCS PPO |
$16.52
|
| Rate for Payer: Three Rivers PPO |
$12.64
|
| Rate for Payer: TriWest Veterans Administration |
$9.61
|
| Rate for Payer: United Healthcare Commercial |
$16.10
|
| Rate for Payer: United Healthcare Medicare |
$9.61
|
| Rate for Payer: WINHealth Partners Commercial |
$16.52
|
| Rate for Payer: Wise Provider Network Commercial |
$16.02
|
|
|
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 |
$26.00 |
| 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 |
$41.19
|
| Rate for Payer: Aetna of WY Medicare |
$31.69
|
| Rate for Payer: Aetna of WY Medicare |
$27.74
|
| Rate for Payer: Altius Commercial |
$46.10
|
| Rate for Payer: Altius Commercial |
$40.35
|
| Rate for Payer: Beech Street Commercial |
$41.19
|
| Rate for Payer: Beech Street Commercial |
$47.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.58
|
| Rate for Payer: Cash Price |
$33.61
|
| Rate for Payer: Cash Price |
$29.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.77
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.58
|
| Rate for Payer: Cigna of WY Commercial |
$47.06
|
| Rate for Payer: Cigna of WY Commercial |
$41.19
|
| Rate for Payer: Entrust Commercial |
$39.93
|
| Rate for Payer: Entrust Commercial |
$45.62
|
| Rate for Payer: First Choice Health Commercial |
$45.62
|
| Rate for Payer: First Choice Health Commercial |
$39.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.96
|
| Rate for Payer: HealthUtah PPO |
$48.02
|
| Rate for Payer: HealthUtah PPO |
$42.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.58
|
| Rate for Payer: Multiplan Medicare/VA |
$22.76
|
| Rate for Payer: Multiplan Medicare/VA |
$26.00
|
| Rate for Payer: One Health Plan of WY PPO |
$47.06
|
| Rate for Payer: One Health Plan of WY PPO |
$41.19
|
| Rate for Payer: PacificSource Commercial |
$43.22
|
| Rate for Payer: PacificSource Commercial |
$37.83
|
| Rate for Payer: PHCS PPO |
$47.06
|
| Rate for Payer: PHCS PPO |
$41.19
|
| Rate for Payer: Three Rivers PPO |
$31.52
|
| Rate for Payer: Three Rivers PPO |
$36.02
|
| Rate for Payer: TriWest Veterans Administration |
$23.96
|
| Rate for Payer: TriWest Veterans Administration |
$27.37
|
| Rate for Payer: United Healthcare Commercial |
$40.14
|
| Rate for Payer: United Healthcare Commercial |
$45.86
|
| Rate for Payer: United Healthcare Medicare |
$27.37
|
| Rate for Payer: United Healthcare Medicare |
$23.96
|
| Rate for Payer: WINHealth Partners Commercial |
$41.19
|
| Rate for Payer: WINHealth Partners Commercial |
$47.06
|
| Rate for Payer: Wise Provider Network Commercial |
$45.62
|
| Rate for Payer: Wise Provider Network Commercial |
$39.93
|
|
|
BETAMETHASONE ACETATE AND SODIUM PHOS 6 MG/ML SUSPENSION FOR INJECTION [9472]
|
Facility
|
IP
|
$42.03
|
|
|
Service Code
|
HCPCS J0702
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.36 |
| Max. Negotiated Rate |
$42.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$41.19
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$47.06
|
| Rate for Payer: Aetna of WY Medicare |
$26.90
|
| Rate for Payer: Aetna of WY Medicare |
$30.73
|
| Rate for Payer: Altius Commercial |
$46.10
|
| Rate for Payer: Altius Commercial |
$40.35
|
| Rate for Payer: Beech Street Commercial |
$41.19
|
| Rate for Payer: Beech Street Commercial |
$47.06
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$46.58
|
| Rate for Payer: Cash Price |
$33.61
|
| Rate for Payer: Cash Price |
$29.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$46.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.77
|
| Rate for Payer: Cigna of WY Commercial |
$47.06
|
| Rate for Payer: Cigna of WY Commercial |
$41.19
|
| Rate for Payer: Entrust Commercial |
$39.93
|
| Rate for Payer: Entrust Commercial |
$45.62
|
| Rate for Payer: First Choice Health Commercial |
$39.93
|
| Rate for Payer: First Choice Health Commercial |
$45.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$45.62
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$29.29
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.64
|
| Rate for Payer: HealthUtah PPO |
$48.02
|
| Rate for Payer: HealthUtah PPO |
$42.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$46.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.77
|
| Rate for Payer: Multiplan Medicare/VA |
$27.83
|
| Rate for Payer: Multiplan Medicare/VA |
$24.36
|
| Rate for Payer: One Health Plan of WY PPO |
$41.19
|
| Rate for Payer: One Health Plan of WY PPO |
$47.06
|
| Rate for Payer: PacificSource Commercial |
$37.83
|
| Rate for Payer: PacificSource Commercial |
$43.22
|
| Rate for Payer: PHCS PPO |
$41.19
|
| Rate for Payer: PHCS PPO |
$47.06
|
| Rate for Payer: Three Rivers PPO |
$31.52
|
| Rate for Payer: Three Rivers PPO |
$36.02
|
| Rate for Payer: TriWest Veterans Administration |
$29.29
|
| Rate for Payer: TriWest Veterans Administration |
$25.64
|
| Rate for Payer: United Healthcare Commercial |
$40.14
|
| Rate for Payer: United Healthcare Commercial |
$45.86
|
| Rate for Payer: United Healthcare Medicare |
$29.29
|
| Rate for Payer: United Healthcare Medicare |
$25.64
|
| Rate for Payer: WINHealth Partners Commercial |
$39.93
|
| Rate for Payer: WINHealth Partners Commercial |
$45.62
|
| Rate for Payer: Wise Provider Network Commercial |
$45.62
|
| Rate for Payer: Wise Provider Network Commercial |
$39.93
|
|
|
BETAMETHASONE ACET&SOD PHOSP
|
Professional
|
Both
|
$15.00
|
|
|
Service Code
|
HCPCS J0702
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.70
|
| Rate for Payer: Aetna of WY Medicare |
$6.88
|
| Rate for Payer: Beech Street Commercial |
$14.25
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.55
|
| Rate for Payer: Cigna of WY Commercial |
$14.70
|
| Rate for Payer: First Choice Health Commercial |
$13.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.88
|
| Rate for Payer: HealthUtah PPO |
$15.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.55
|
| Rate for Payer: Multiplan Medicare/VA |
$5.85
|
| Rate for Payer: One Health Plan of WY PPO |
$14.70
|
| Rate for Payer: PacificSource Commercial |
$13.50
|
| Rate for Payer: PHCS PPO |
$14.25
|
| Rate for Payer: Three Rivers PPO |
$11.25
|
| Rate for Payer: TriWest Veterans Administration |
$6.88
|
| Rate for Payer: United Healthcare Commercial |
$14.25
|
| Rate for Payer: WINHealth Partners Commercial |
$14.25
|
|
|
BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM [5025]
|
Facility
|
IP
|
$18.80
|
|
|
Service Code
|
NDC 5167213103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$18.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.42
|
| Rate for Payer: Aetna of WY Medicare |
$12.03
|
| Rate for Payer: Altius Commercial |
$18.05
|
| Rate for Payer: Beech Street Commercial |
$18.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.24
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.24
|
| Rate for Payer: Cigna of WY Commercial |
$18.42
|
| Rate for Payer: Entrust Commercial |
$17.86
|
| Rate for Payer: First Choice Health Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.47
|
| Rate for Payer: HealthUtah PPO |
$18.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.24
|
| Rate for Payer: Multiplan Medicare/VA |
$10.89
|
| Rate for Payer: One Health Plan of WY PPO |
$18.42
|
| Rate for Payer: PacificSource Commercial |
$16.92
|
| Rate for Payer: PHCS PPO |
$18.42
|
| Rate for Payer: Three Rivers PPO |
$14.10
|
| Rate for Payer: TriWest Veterans Administration |
$11.47
|
| Rate for Payer: United Healthcare Commercial |
$17.95
|
| Rate for Payer: United Healthcare Medicare |
$11.47
|
| Rate for Payer: WINHealth Partners Commercial |
$17.86
|
| Rate for Payer: Wise Provider Network Commercial |
$17.86
|
|
|
BETAMETHASONE, AUGMENTED 0.05 % TOPICAL CREAM [5025]
|
Facility
|
OP
|
$18.80
|
|
|
Service Code
|
NDC 5167213103
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.18 |
| Max. Negotiated Rate |
$18.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.42
|
| Rate for Payer: Aetna of WY Medicare |
$12.41
|
| Rate for Payer: Altius Commercial |
$18.05
|
| Rate for Payer: Beech Street Commercial |
$18.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.24
|
| Rate for Payer: Cash Price |
$13.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.24
|
| Rate for Payer: Cigna of WY Commercial |
$18.42
|
| Rate for Payer: Entrust Commercial |
$17.86
|
| Rate for Payer: First Choice Health Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.72
|
| Rate for Payer: HealthUtah PPO |
$18.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.24
|
| Rate for Payer: Multiplan Medicare/VA |
$10.18
|
| Rate for Payer: One Health Plan of WY PPO |
$18.42
|
| Rate for Payer: PacificSource Commercial |
$16.92
|
| Rate for Payer: PHCS PPO |
$18.42
|
| Rate for Payer: Three Rivers PPO |
$14.10
|
| Rate for Payer: TriWest Veterans Administration |
$10.72
|
| Rate for Payer: United Healthcare Commercial |
$17.95
|
| Rate for Payer: United Healthcare Medicare |
$10.72
|
| Rate for Payer: WINHealth Partners Commercial |
$18.42
|
| Rate for Payer: Wise Provider Network Commercial |
$17.86
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [18420]
|
Facility
|
OP
|
$22.03
|
|
|
Service Code
|
NDC 0472038145
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.93 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.59
|
| Rate for Payer: Aetna of WY Medicare |
$14.54
|
| Rate for Payer: Altius Commercial |
$21.15
|
| Rate for Payer: Beech Street Commercial |
$21.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.37
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.37
|
| Rate for Payer: Cigna of WY Commercial |
$21.59
|
| Rate for Payer: Entrust Commercial |
$20.93
|
| Rate for Payer: First Choice Health Commercial |
$20.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.56
|
| Rate for Payer: HealthUtah PPO |
$22.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.37
|
| Rate for Payer: Multiplan Medicare/VA |
$11.93
|
| Rate for Payer: One Health Plan of WY PPO |
$21.59
|
| Rate for Payer: PacificSource Commercial |
$19.83
|
| Rate for Payer: PHCS PPO |
$21.59
|
| Rate for Payer: Three Rivers PPO |
$16.52
|
| Rate for Payer: TriWest Veterans Administration |
$12.56
|
| Rate for Payer: United Healthcare Commercial |
$21.04
|
| Rate for Payer: United Healthcare Medicare |
$12.56
|
| Rate for Payer: WINHealth Partners Commercial |
$21.59
|
| Rate for Payer: Wise Provider Network Commercial |
$20.93
|
|
|
BETAMETHASONE DIPROPIONATE 0.05 % TOPICAL OINTMENT [18420]
|
Facility
|
IP
|
$22.03
|
|
|
Service Code
|
NDC 0472038145
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.77 |
| Max. Negotiated Rate |
$22.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.59
|
| Rate for Payer: Aetna of WY Medicare |
$14.10
|
| Rate for Payer: Altius Commercial |
$21.15
|
| Rate for Payer: Beech Street Commercial |
$21.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.37
|
| Rate for Payer: Cash Price |
$15.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.37
|
| Rate for Payer: Cigna of WY Commercial |
$21.59
|
| Rate for Payer: Entrust Commercial |
$20.93
|
| Rate for Payer: First Choice Health Commercial |
$20.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.44
|
| Rate for Payer: HealthUtah PPO |
$22.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.37
|
| Rate for Payer: Multiplan Medicare/VA |
$12.77
|
| Rate for Payer: One Health Plan of WY PPO |
$21.59
|
| Rate for Payer: PacificSource Commercial |
$19.83
|
| Rate for Payer: PHCS PPO |
$21.59
|
| Rate for Payer: Three Rivers PPO |
$16.52
|
| Rate for Payer: TriWest Veterans Administration |
$13.44
|
| Rate for Payer: United Healthcare Commercial |
$21.04
|
| Rate for Payer: United Healthcare Medicare |
$13.44
|
| Rate for Payer: WINHealth Partners Commercial |
$20.93
|
| Rate for Payer: Wise Provider Network Commercial |
$20.93
|
|
|
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION [156345]
|
Facility
|
IP
|
$245.02
|
|
|
Service Code
|
HCPCS Q5118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$141.99 |
| Max. Negotiated Rate |
$245.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$240.12
|
| Rate for Payer: Aetna of WY Medicare |
$156.81
|
| Rate for Payer: Altius Commercial |
$235.22
|
| Rate for Payer: Beech Street Commercial |
$240.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$237.67
|
| Rate for Payer: Cash Price |
$171.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$237.67
|
| Rate for Payer: Cigna of WY Commercial |
$240.12
|
| Rate for Payer: Entrust Commercial |
$232.77
|
| Rate for Payer: First Choice Health Commercial |
$232.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$232.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$149.46
|
| Rate for Payer: HealthUtah PPO |
$245.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$237.67
|
| Rate for Payer: Multiplan Medicare/VA |
$141.99
|
| Rate for Payer: One Health Plan of WY PPO |
$240.12
|
| Rate for Payer: PacificSource Commercial |
$220.52
|
| Rate for Payer: PHCS PPO |
$240.12
|
| Rate for Payer: Three Rivers PPO |
$183.76
|
| Rate for Payer: TriWest Veterans Administration |
$149.46
|
| Rate for Payer: United Healthcare Commercial |
$233.99
|
| Rate for Payer: United Healthcare Medicare |
$149.46
|
| Rate for Payer: WINHealth Partners Commercial |
$232.77
|
| Rate for Payer: Wise Provider Network Commercial |
$232.77
|
|
|
BEVACIZUMAB-BVZR 25 MG/ML INTRAVENOUS SOLUTION [156345]
|
Facility
|
OP
|
$245.02
|
|
|
Service Code
|
HCPCS Q5118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$132.68 |
| Max. Negotiated Rate |
$245.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$240.12
|
| Rate for Payer: Aetna of WY Medicare |
$161.71
|
| Rate for Payer: Altius Commercial |
$235.22
|
| Rate for Payer: Beech Street Commercial |
$240.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$237.67
|
| Rate for Payer: Cash Price |
$171.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$237.67
|
| Rate for Payer: Cigna of WY Commercial |
$240.12
|
| Rate for Payer: Entrust Commercial |
$232.77
|
| Rate for Payer: First Choice Health Commercial |
$232.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$232.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$139.66
|
| Rate for Payer: HealthUtah PPO |
$245.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$237.67
|
| Rate for Payer: Multiplan Medicare/VA |
$132.68
|
| Rate for Payer: One Health Plan of WY PPO |
$240.12
|
| Rate for Payer: PacificSource Commercial |
$220.52
|
| Rate for Payer: PHCS PPO |
$240.12
|
| Rate for Payer: Three Rivers PPO |
$183.76
|
| Rate for Payer: TriWest Veterans Administration |
$139.66
|
| Rate for Payer: United Healthcare Commercial |
$233.99
|
| Rate for Payer: United Healthcare Medicare |
$139.66
|
| Rate for Payer: WINHealth Partners Commercial |
$240.12
|
| Rate for Payer: Wise Provider Network Commercial |
$232.77
|
|
|
BICEP BUTTON DRILL PIN AR-2263
|
Facility
|
IP
|
$94.02
|
|
| Hospital Charge Code |
2650687
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.48 |
| Max. Negotiated Rate |
$94.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.14
|
| Rate for Payer: Aetna of WY Medicare |
$60.17
|
| Rate for Payer: Altius Commercial |
$90.26
|
| Rate for Payer: Beech Street Commercial |
$92.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$91.20
|
| Rate for Payer: Cash Price |
$65.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.20
|
| Rate for Payer: Cigna of WY Commercial |
$92.14
|
| Rate for Payer: Entrust Commercial |
$89.32
|
| Rate for Payer: First Choice Health Commercial |
$89.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.35
|
| Rate for Payer: HealthUtah PPO |
$94.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.20
|
| Rate for Payer: Multiplan Medicare/VA |
$54.48
|
| Rate for Payer: One Health Plan of WY PPO |
$92.14
|
| Rate for Payer: PacificSource Commercial |
$84.62
|
| Rate for Payer: PHCS PPO |
$92.14
|
| Rate for Payer: Three Rivers PPO |
$70.52
|
| Rate for Payer: TriWest Veterans Administration |
$57.35
|
| Rate for Payer: United Healthcare Commercial |
$89.79
|
| Rate for Payer: United Healthcare Medicare |
$57.35
|
| Rate for Payer: WINHealth Partners Commercial |
$89.32
|
| Rate for Payer: Wise Provider Network Commercial |
$89.32
|
|
|
BICEP BUTTON DRILL PIN AR-2263
|
Facility
|
OP
|
$94.02
|
|
| Hospital Charge Code |
2650687
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$50.91 |
| Max. Negotiated Rate |
$94.02 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.14
|
| Rate for Payer: Aetna of WY Medicare |
$62.05
|
| Rate for Payer: Altius Commercial |
$90.26
|
| Rate for Payer: Beech Street Commercial |
$92.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$91.20
|
| Rate for Payer: Cash Price |
$65.82
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.20
|
| Rate for Payer: Cigna of WY Commercial |
$92.14
|
| Rate for Payer: Entrust Commercial |
$89.32
|
| Rate for Payer: First Choice Health Commercial |
$89.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.59
|
| Rate for Payer: HealthUtah PPO |
$94.02
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.20
|
| Rate for Payer: Multiplan Medicare/VA |
$50.91
|
| Rate for Payer: One Health Plan of WY PPO |
$92.14
|
| Rate for Payer: PacificSource Commercial |
$84.62
|
| Rate for Payer: PHCS PPO |
$92.14
|
| Rate for Payer: Three Rivers PPO |
$70.52
|
| Rate for Payer: TriWest Veterans Administration |
$53.59
|
| Rate for Payer: United Healthcare Commercial |
$89.79
|
| Rate for Payer: United Healthcare Medicare |
$53.59
|
| Rate for Payer: WINHealth Partners Commercial |
$92.14
|
| Rate for Payer: Wise Provider Network Commercial |
$89.32
|
|
