|
BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [17231]
|
Facility
|
OP
|
$8.90
|
|
|
Service Code
|
NDC 6838272001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.90 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.72
|
| Rate for Payer: Aetna of WY Medicare |
$5.87
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.54
|
| Rate for Payer: Altius Commercial |
$8.54
|
| Rate for Payer: Beech Street Commercial |
$8.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.31
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.63
|
| Rate for Payer: Cigna of WY Commercial |
$8.72
|
| Rate for Payer: Entrust Commercial |
$8.46
|
| Rate for Payer: First Choice Health Commercial |
$8.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.16
|
| Rate for Payer: HealthUtah PPO |
$8.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.63
|
| Rate for Payer: Multiplan Medicare/VA |
$4.90
|
| Rate for Payer: One Health Plan of WY PPO |
$8.72
|
| Rate for Payer: PacificSource Commercial |
$8.01
|
| Rate for Payer: PHCS PPO |
$8.72
|
| Rate for Payer: Three Rivers PPO |
$6.68
|
| Rate for Payer: TriWest Veterans Administration |
$5.16
|
| Rate for Payer: United Healthcare Commercial |
$7.74
|
| Rate for Payer: United Healthcare Medicare |
$5.16
|
| Rate for Payer: WINHealth Partners Commercial |
$8.72
|
| Rate for Payer: Wise Provider Network Commercial |
$8.46
|
|
|
BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [17231]
|
Facility
|
IP
|
$8.90
|
|
|
Service Code
|
NDC 6838272001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$8.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$8.54
|
| Rate for Payer: Altius Commercial |
$8.54
|
| Rate for Payer: Beech Street Commercial |
$8.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.31
|
| Rate for Payer: Cash Price |
$6.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$8.63
|
| Rate for Payer: Cigna of WY Commercial |
$8.72
|
| Rate for Payer: Entrust Commercial |
$8.46
|
| Rate for Payer: First Choice Health Commercial |
$8.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.46
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.87
|
| Rate for Payer: HealthUtah PPO |
$8.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8.63
|
| Rate for Payer: Multiplan Medicare/VA |
$5.58
|
| Rate for Payer: One Health Plan of WY PPO |
$8.72
|
| Rate for Payer: PacificSource Commercial |
$8.01
|
| Rate for Payer: PHCS PPO |
$8.72
|
| Rate for Payer: Three Rivers PPO |
$6.68
|
| Rate for Payer: TriWest Veterans Administration |
$5.87
|
| Rate for Payer: United Healthcare Commercial |
$7.74
|
| Rate for Payer: United Healthcare Medicare |
$5.87
|
| Rate for Payer: WINHealth Partners Commercial |
$8.46
|
| Rate for Payer: Wise Provider Network Commercial |
$8.46
|
|
|
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [43651]
|
Facility
|
OP
|
$45.94
|
|
|
Service Code
|
NDC 0186037020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.31 |
| Max. Negotiated Rate |
$45.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$45.02
|
| Rate for Payer: Aetna of WY Medicare |
$30.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$44.10
|
| Rate for Payer: Altius Commercial |
$44.10
|
| Rate for Payer: Beech Street Commercial |
$45.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37.72
|
| Rate for Payer: Cash Price |
$32.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$44.56
|
| Rate for Payer: Cigna of WY Commercial |
$45.02
|
| Rate for Payer: Entrust Commercial |
$43.64
|
| Rate for Payer: First Choice Health Commercial |
$43.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$43.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.65
|
| Rate for Payer: HealthUtah PPO |
$45.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$44.56
|
| Rate for Payer: Multiplan Medicare/VA |
$25.31
|
| Rate for Payer: One Health Plan of WY PPO |
$45.02
|
| Rate for Payer: PacificSource Commercial |
$41.35
|
| Rate for Payer: PHCS PPO |
$45.02
|
| Rate for Payer: Three Rivers PPO |
$34.46
|
| Rate for Payer: TriWest Veterans Administration |
$26.65
|
| Rate for Payer: United Healthcare Commercial |
$39.97
|
| Rate for Payer: United Healthcare Medicare |
$26.65
|
| Rate for Payer: WINHealth Partners Commercial |
$45.02
|
| Rate for Payer: Wise Provider Network Commercial |
$43.64
|
|
|
BUDESONIDE-FORMOTEROL HFA 160 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [43651]
|
Facility
|
IP
|
$45.94
|
|
|
Service Code
|
NDC 0186037020
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.80 |
| Max. Negotiated Rate |
$45.94 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$45.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$44.10
|
| Rate for Payer: Altius Commercial |
$44.10
|
| Rate for Payer: Beech Street Commercial |
$45.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37.72
|
| Rate for Payer: Cash Price |
$32.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$44.56
|
| Rate for Payer: Cigna of WY Commercial |
$45.02
|
| Rate for Payer: Entrust Commercial |
$43.64
|
| Rate for Payer: First Choice Health Commercial |
$43.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$43.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.32
|
| Rate for Payer: HealthUtah PPO |
$45.94
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$44.56
|
| Rate for Payer: Multiplan Medicare/VA |
$28.80
|
| Rate for Payer: One Health Plan of WY PPO |
$45.02
|
| Rate for Payer: PacificSource Commercial |
$41.35
|
| Rate for Payer: PHCS PPO |
$45.02
|
| Rate for Payer: Three Rivers PPO |
$34.46
|
| Rate for Payer: TriWest Veterans Administration |
$30.32
|
| Rate for Payer: United Healthcare Commercial |
$39.97
|
| Rate for Payer: United Healthcare Medicare |
$30.32
|
| Rate for Payer: WINHealth Partners Commercial |
$43.64
|
| Rate for Payer: Wise Provider Network Commercial |
$43.64
|
|
|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [43650]
|
Facility
|
IP
|
$40.19
|
|
|
Service Code
|
NDC 0186037220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$25.20 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.58
|
| Rate for Payer: Altius Commercial |
$38.58
|
| Rate for Payer: Beech Street Commercial |
$39.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.00
|
| Rate for Payer: Cash Price |
$28.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.98
|
| Rate for Payer: Cigna of WY Commercial |
$39.39
|
| Rate for Payer: Entrust Commercial |
$38.18
|
| Rate for Payer: First Choice Health Commercial |
$38.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.53
|
| Rate for Payer: HealthUtah PPO |
$40.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.98
|
| Rate for Payer: Multiplan Medicare/VA |
$25.20
|
| Rate for Payer: One Health Plan of WY PPO |
$39.39
|
| Rate for Payer: PacificSource Commercial |
$36.17
|
| Rate for Payer: PHCS PPO |
$39.39
|
| Rate for Payer: Three Rivers PPO |
$30.14
|
| Rate for Payer: TriWest Veterans Administration |
$26.53
|
| Rate for Payer: United Healthcare Commercial |
$34.97
|
| Rate for Payer: United Healthcare Medicare |
$26.53
|
| Rate for Payer: WINHealth Partners Commercial |
$38.18
|
| Rate for Payer: Wise Provider Network Commercial |
$38.18
|
|
|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [43650]
|
Facility
|
OP
|
$40.19
|
|
|
Service Code
|
NDC 0186037220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.14 |
| Max. Negotiated Rate |
$40.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.39
|
| Rate for Payer: Aetna of WY Medicare |
$26.53
|
| Rate for Payer: Altius Auto/Workers Compensation |
$38.58
|
| Rate for Payer: Altius Commercial |
$38.58
|
| Rate for Payer: Beech Street Commercial |
$39.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.00
|
| Rate for Payer: Cash Price |
$28.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.98
|
| Rate for Payer: Cigna of WY Commercial |
$39.39
|
| Rate for Payer: Entrust Commercial |
$38.18
|
| Rate for Payer: First Choice Health Commercial |
$38.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.31
|
| Rate for Payer: HealthUtah PPO |
$40.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.98
|
| Rate for Payer: Multiplan Medicare/VA |
$22.14
|
| Rate for Payer: One Health Plan of WY PPO |
$39.39
|
| Rate for Payer: PacificSource Commercial |
$36.17
|
| Rate for Payer: PHCS PPO |
$39.39
|
| Rate for Payer: Three Rivers PPO |
$30.14
|
| Rate for Payer: TriWest Veterans Administration |
$23.31
|
| Rate for Payer: United Healthcare Commercial |
$34.97
|
| Rate for Payer: United Healthcare Medicare |
$23.31
|
| Rate for Payer: WINHealth Partners Commercial |
$39.39
|
| Rate for Payer: Wise Provider Network Commercial |
$38.18
|
|
|
BUDESONIDE NON-COMP UNIT
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
HCPCS J7626
|
| Hospital Charge Code |
J7626
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.54
|
| Rate for Payer: Aetna of WY Medicare |
$1.20
|
| Rate for Payer: Beech Street Commercial |
$21.85
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.31
|
| Rate for Payer: Cigna of WY Commercial |
$22.54
|
| Rate for Payer: First Choice Health Commercial |
$20.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.20
|
| Rate for Payer: HealthUtah PPO |
$23.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.31
|
| Rate for Payer: Multiplan Medicare/VA |
$1.02
|
| Rate for Payer: One Health Plan of WY PPO |
$22.54
|
| Rate for Payer: PacificSource Commercial |
$20.70
|
| Rate for Payer: PHCS PPO |
$21.85
|
| Rate for Payer: Three Rivers PPO |
$17.25
|
| Rate for Payer: TriWest Veterans Administration |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$20.01
|
| Rate for Payer: United Healthcare Medicare |
$1.20
|
| Rate for Payer: WINHealth Partners Commercial |
$21.85
|
|
|
BULKAMID URETHRAL BULKING SYSTEM
|
Facility
|
OP
|
$4,025.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,217.78 |
| Max. Negotiated Rate |
$4,025.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,944.50
|
| Rate for Payer: Aetna of WY Medicare |
$2,656.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,864.00
|
| Rate for Payer: Altius Commercial |
$3,864.00
|
| Rate for Payer: Beech Street Commercial |
$3,944.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,304.52
|
| Rate for Payer: Cash Price |
$2,817.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,904.25
|
| Rate for Payer: Cigna of WY Commercial |
$3,944.50
|
| Rate for Payer: Entrust Commercial |
$3,823.75
|
| Rate for Payer: First Choice Health Commercial |
$3,823.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,823.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,334.50
|
| Rate for Payer: HealthUtah PPO |
$4,025.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,904.25
|
| Rate for Payer: Multiplan Medicare/VA |
$2,217.78
|
| Rate for Payer: One Health Plan of WY PPO |
$3,944.50
|
| Rate for Payer: PacificSource Commercial |
$3,622.50
|
| Rate for Payer: PHCS PPO |
$3,944.50
|
| Rate for Payer: Three Rivers PPO |
$3,018.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,334.50
|
| Rate for Payer: United Healthcare Commercial |
$3,501.75
|
| Rate for Payer: United Healthcare Medicare |
$2,334.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,944.50
|
| Rate for Payer: Wise Provider Network Commercial |
$3,823.75
|
|
|
BULKAMID URETHRAL BULKING SYSTEM
|
Facility
|
IP
|
$4,025.00
|
|
| Hospital Charge Code |
27800000S1
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,523.68 |
| Max. Negotiated Rate |
$4,025.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,944.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,864.00
|
| Rate for Payer: Altius Commercial |
$3,864.00
|
| Rate for Payer: Beech Street Commercial |
$3,944.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,304.52
|
| Rate for Payer: Cash Price |
$2,817.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,904.25
|
| Rate for Payer: Cigna of WY Commercial |
$3,944.50
|
| Rate for Payer: Entrust Commercial |
$3,823.75
|
| Rate for Payer: First Choice Health Commercial |
$3,823.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,823.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,656.50
|
| Rate for Payer: HealthUtah PPO |
$4,025.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,904.25
|
| Rate for Payer: Multiplan Medicare/VA |
$2,523.68
|
| Rate for Payer: One Health Plan of WY PPO |
$3,944.50
|
| Rate for Payer: PacificSource Commercial |
$3,622.50
|
| Rate for Payer: PHCS PPO |
$3,944.50
|
| Rate for Payer: Three Rivers PPO |
$3,018.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,656.50
|
| Rate for Payer: United Healthcare Commercial |
$3,501.75
|
| Rate for Payer: United Healthcare Medicare |
$2,656.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,823.75
|
| Rate for Payer: Wise Provider Network Commercial |
$3,823.75
|
|
|
BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [417]
|
Facility
|
OP
|
$16.36
|
|
|
Service Code
|
NDC 0409175250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.01 |
| Max. Negotiated Rate |
$16.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.03
|
| Rate for Payer: Aetna of WY Medicare |
$10.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.71
|
| Rate for Payer: Altius Commercial |
$15.71
|
| Rate for Payer: Beech Street Commercial |
$16.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.43
|
| Rate for Payer: Cash Price |
$11.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.87
|
| Rate for Payer: Cigna of WY Commercial |
$16.03
|
| Rate for Payer: Entrust Commercial |
$15.54
|
| Rate for Payer: First Choice Health Commercial |
$15.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.49
|
| Rate for Payer: HealthUtah PPO |
$16.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.87
|
| Rate for Payer: Multiplan Medicare/VA |
$9.01
|
| Rate for Payer: One Health Plan of WY PPO |
$16.03
|
| Rate for Payer: PacificSource Commercial |
$14.72
|
| Rate for Payer: PHCS PPO |
$16.03
|
| Rate for Payer: Three Rivers PPO |
$12.27
|
| Rate for Payer: TriWest Veterans Administration |
$9.49
|
| Rate for Payer: United Healthcare Commercial |
$14.23
|
| Rate for Payer: United Healthcare Medicare |
$9.49
|
| Rate for Payer: WINHealth Partners Commercial |
$16.03
|
| Rate for Payer: Wise Provider Network Commercial |
$15.54
|
|
|
BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [417]
|
Facility
|
IP
|
$16.55
|
|
|
Service Code
|
NDC 6332346101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.89
|
| Rate for Payer: Altius Commercial |
$15.89
|
| Rate for Payer: Beech Street Commercial |
$16.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.59
|
| Rate for Payer: Cash Price |
$11.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.05
|
| Rate for Payer: Cigna of WY Commercial |
$16.22
|
| Rate for Payer: Entrust Commercial |
$15.72
|
| Rate for Payer: First Choice Health Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.92
|
| Rate for Payer: HealthUtah PPO |
$16.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.05
|
| Rate for Payer: Multiplan Medicare/VA |
$10.38
|
| Rate for Payer: One Health Plan of WY PPO |
$16.22
|
| Rate for Payer: PacificSource Commercial |
$14.90
|
| Rate for Payer: PHCS PPO |
$16.22
|
| Rate for Payer: Three Rivers PPO |
$12.41
|
| Rate for Payer: TriWest Veterans Administration |
$10.92
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$10.92
|
| Rate for Payer: WINHealth Partners Commercial |
$15.72
|
| Rate for Payer: Wise Provider Network Commercial |
$15.72
|
|
|
BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [417]
|
Facility
|
IP
|
$16.36
|
|
|
Service Code
|
NDC 0409175250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$16.36 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.71
|
| Rate for Payer: Altius Commercial |
$15.71
|
| Rate for Payer: Beech Street Commercial |
$16.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.43
|
| Rate for Payer: Cash Price |
$11.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.87
|
| Rate for Payer: Cigna of WY Commercial |
$16.03
|
| Rate for Payer: Entrust Commercial |
$15.54
|
| Rate for Payer: First Choice Health Commercial |
$15.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.80
|
| Rate for Payer: HealthUtah PPO |
$16.36
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.87
|
| Rate for Payer: Multiplan Medicare/VA |
$10.26
|
| Rate for Payer: One Health Plan of WY PPO |
$16.03
|
| Rate for Payer: PacificSource Commercial |
$14.72
|
| Rate for Payer: PHCS PPO |
$16.03
|
| Rate for Payer: Three Rivers PPO |
$12.27
|
| Rate for Payer: TriWest Veterans Administration |
$10.80
|
| Rate for Payer: United Healthcare Commercial |
$14.23
|
| Rate for Payer: United Healthcare Medicare |
$10.80
|
| Rate for Payer: WINHealth Partners Commercial |
$15.54
|
| Rate for Payer: Wise Provider Network Commercial |
$15.54
|
|
|
BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [417]
|
Facility
|
OP
|
$16.55
|
|
|
Service Code
|
NDC 6332346101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.22
|
| Rate for Payer: Aetna of WY Medicare |
$10.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.89
|
| Rate for Payer: Altius Commercial |
$15.89
|
| Rate for Payer: Beech Street Commercial |
$16.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.59
|
| Rate for Payer: Cash Price |
$11.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.05
|
| Rate for Payer: Cigna of WY Commercial |
$16.22
|
| Rate for Payer: Entrust Commercial |
$15.72
|
| Rate for Payer: First Choice Health Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.60
|
| Rate for Payer: HealthUtah PPO |
$16.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.05
|
| Rate for Payer: Multiplan Medicare/VA |
$9.12
|
| Rate for Payer: One Health Plan of WY PPO |
$16.22
|
| Rate for Payer: PacificSource Commercial |
$14.90
|
| Rate for Payer: PHCS PPO |
$16.22
|
| Rate for Payer: Three Rivers PPO |
$12.41
|
| Rate for Payer: TriWest Veterans Administration |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$9.60
|
| Rate for Payer: WINHealth Partners Commercial |
$16.22
|
| Rate for Payer: Wise Provider Network Commercial |
$15.72
|
|
|
BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [2607]
|
Facility
|
IP
|
$16.66
|
|
|
Service Code
|
NDC 6332346301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$16.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.33
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.99
|
| Rate for Payer: Altius Commercial |
$15.99
|
| Rate for Payer: Beech Street Commercial |
$16.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.68
|
| Rate for Payer: Cash Price |
$11.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.16
|
| Rate for Payer: Cigna of WY Commercial |
$16.33
|
| Rate for Payer: Entrust Commercial |
$15.83
|
| Rate for Payer: First Choice Health Commercial |
$15.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.00
|
| Rate for Payer: HealthUtah PPO |
$16.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.16
|
| Rate for Payer: Multiplan Medicare/VA |
$10.45
|
| Rate for Payer: One Health Plan of WY PPO |
$16.33
|
| Rate for Payer: PacificSource Commercial |
$14.99
|
| Rate for Payer: PHCS PPO |
$16.33
|
| Rate for Payer: Three Rivers PPO |
$12.50
|
| Rate for Payer: TriWest Veterans Administration |
$11.00
|
| Rate for Payer: United Healthcare Commercial |
$14.49
|
| Rate for Payer: United Healthcare Medicare |
$11.00
|
| Rate for Payer: WINHealth Partners Commercial |
$15.83
|
| Rate for Payer: Wise Provider Network Commercial |
$15.83
|
|
|
BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [2607]
|
Facility
|
OP
|
$16.66
|
|
|
Service Code
|
NDC 6332346301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.18 |
| Max. Negotiated Rate |
$16.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.33
|
| Rate for Payer: Aetna of WY Medicare |
$11.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.99
|
| Rate for Payer: Altius Commercial |
$15.99
|
| Rate for Payer: Beech Street Commercial |
$16.33
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.68
|
| Rate for Payer: Cash Price |
$11.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.16
|
| Rate for Payer: Cigna of WY Commercial |
$16.33
|
| Rate for Payer: Entrust Commercial |
$15.83
|
| Rate for Payer: First Choice Health Commercial |
$15.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.66
|
| Rate for Payer: HealthUtah PPO |
$16.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.16
|
| Rate for Payer: Multiplan Medicare/VA |
$9.18
|
| Rate for Payer: One Health Plan of WY PPO |
$16.33
|
| Rate for Payer: PacificSource Commercial |
$14.99
|
| Rate for Payer: PHCS PPO |
$16.33
|
| Rate for Payer: Three Rivers PPO |
$12.50
|
| Rate for Payer: TriWest Veterans Administration |
$9.66
|
| Rate for Payer: United Healthcare Commercial |
$14.49
|
| Rate for Payer: United Healthcare Medicare |
$9.66
|
| Rate for Payer: WINHealth Partners Commercial |
$16.33
|
| Rate for Payer: Wise Provider Network Commercial |
$15.83
|
|
|
BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [2607]
|
Facility
|
IP
|
$16.46
|
|
|
Service Code
|
NDC 0409175550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$16.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.80
|
| Rate for Payer: Altius Commercial |
$15.80
|
| Rate for Payer: Beech Street Commercial |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.51
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.97
|
| Rate for Payer: Cigna of WY Commercial |
$16.13
|
| Rate for Payer: Entrust Commercial |
$15.64
|
| Rate for Payer: First Choice Health Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.86
|
| Rate for Payer: HealthUtah PPO |
$16.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.97
|
| Rate for Payer: Multiplan Medicare/VA |
$10.32
|
| Rate for Payer: One Health Plan of WY PPO |
$16.13
|
| Rate for Payer: PacificSource Commercial |
$14.81
|
| Rate for Payer: PHCS PPO |
$16.13
|
| Rate for Payer: Three Rivers PPO |
$12.34
|
| Rate for Payer: TriWest Veterans Administration |
$10.86
|
| Rate for Payer: United Healthcare Commercial |
$14.32
|
| Rate for Payer: United Healthcare Medicare |
$10.86
|
| Rate for Payer: WINHealth Partners Commercial |
$15.64
|
| Rate for Payer: Wise Provider Network Commercial |
$15.64
|
|
|
BUPIVACAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [2607]
|
Facility
|
OP
|
$16.46
|
|
|
Service Code
|
NDC 0409175550
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.07 |
| Max. Negotiated Rate |
$16.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.13
|
| Rate for Payer: Aetna of WY Medicare |
$10.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.80
|
| Rate for Payer: Altius Commercial |
$15.80
|
| Rate for Payer: Beech Street Commercial |
$16.13
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.51
|
| Rate for Payer: Cash Price |
$11.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.97
|
| Rate for Payer: Cigna of WY Commercial |
$16.13
|
| Rate for Payer: Entrust Commercial |
$15.64
|
| Rate for Payer: First Choice Health Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.64
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.55
|
| Rate for Payer: HealthUtah PPO |
$16.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.97
|
| Rate for Payer: Multiplan Medicare/VA |
$9.07
|
| Rate for Payer: One Health Plan of WY PPO |
$16.13
|
| Rate for Payer: PacificSource Commercial |
$14.81
|
| Rate for Payer: PHCS PPO |
$16.13
|
| Rate for Payer: Three Rivers PPO |
$12.34
|
| Rate for Payer: TriWest Veterans Administration |
$9.55
|
| Rate for Payer: United Healthcare Commercial |
$14.32
|
| Rate for Payer: United Healthcare Medicare |
$9.55
|
| Rate for Payer: WINHealth Partners Commercial |
$16.13
|
| Rate for Payer: Wise Provider Network Commercial |
$15.64
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [28405]
|
Facility
|
OP
|
$17.69
|
|
|
Service Code
|
NDC 0409174610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$17.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.34
|
| Rate for Payer: Aetna of WY Medicare |
$11.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.98
|
| Rate for Payer: Altius Commercial |
$16.98
|
| Rate for Payer: Beech Street Commercial |
$17.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.52
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.16
|
| Rate for Payer: Cigna of WY Commercial |
$17.34
|
| Rate for Payer: Entrust Commercial |
$16.81
|
| Rate for Payer: First Choice Health Commercial |
$16.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.26
|
| Rate for Payer: HealthUtah PPO |
$17.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.16
|
| Rate for Payer: Multiplan Medicare/VA |
$9.75
|
| Rate for Payer: One Health Plan of WY PPO |
$17.34
|
| Rate for Payer: PacificSource Commercial |
$15.92
|
| Rate for Payer: PHCS PPO |
$17.34
|
| Rate for Payer: Three Rivers PPO |
$13.27
|
| Rate for Payer: TriWest Veterans Administration |
$10.26
|
| Rate for Payer: United Healthcare Commercial |
$15.39
|
| Rate for Payer: United Healthcare Medicare |
$10.26
|
| Rate for Payer: WINHealth Partners Commercial |
$17.34
|
| Rate for Payer: Wise Provider Network Commercial |
$16.81
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [28405]
|
Facility
|
IP
|
$16.55
|
|
|
Service Code
|
NDC 0409174630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.89
|
| Rate for Payer: Altius Commercial |
$15.89
|
| Rate for Payer: Beech Street Commercial |
$16.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.59
|
| Rate for Payer: Cash Price |
$11.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.05
|
| Rate for Payer: Cigna of WY Commercial |
$16.22
|
| Rate for Payer: Entrust Commercial |
$15.72
|
| Rate for Payer: First Choice Health Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.92
|
| Rate for Payer: HealthUtah PPO |
$16.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.05
|
| Rate for Payer: Multiplan Medicare/VA |
$10.38
|
| Rate for Payer: One Health Plan of WY PPO |
$16.22
|
| Rate for Payer: PacificSource Commercial |
$14.90
|
| Rate for Payer: PHCS PPO |
$16.22
|
| Rate for Payer: Three Rivers PPO |
$12.41
|
| Rate for Payer: TriWest Veterans Administration |
$10.92
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$10.92
|
| Rate for Payer: WINHealth Partners Commercial |
$15.72
|
| Rate for Payer: Wise Provider Network Commercial |
$15.72
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [28405]
|
Facility
|
IP
|
$17.69
|
|
|
Service Code
|
NDC 0409174610
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$17.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.98
|
| Rate for Payer: Altius Commercial |
$16.98
|
| Rate for Payer: Beech Street Commercial |
$17.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.52
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.16
|
| Rate for Payer: Cigna of WY Commercial |
$17.34
|
| Rate for Payer: Entrust Commercial |
$16.81
|
| Rate for Payer: First Choice Health Commercial |
$16.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.68
|
| Rate for Payer: HealthUtah PPO |
$17.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.16
|
| Rate for Payer: Multiplan Medicare/VA |
$11.09
|
| Rate for Payer: One Health Plan of WY PPO |
$17.34
|
| Rate for Payer: PacificSource Commercial |
$15.92
|
| Rate for Payer: PHCS PPO |
$17.34
|
| Rate for Payer: Three Rivers PPO |
$13.27
|
| Rate for Payer: TriWest Veterans Administration |
$11.68
|
| Rate for Payer: United Healthcare Commercial |
$15.39
|
| Rate for Payer: United Healthcare Medicare |
$11.68
|
| Rate for Payer: WINHealth Partners Commercial |
$16.81
|
| Rate for Payer: Wise Provider Network Commercial |
$16.81
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [28405]
|
Facility
|
OP
|
$16.55
|
|
|
Service Code
|
NDC 0409174630
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.22
|
| Rate for Payer: Aetna of WY Medicare |
$10.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.89
|
| Rate for Payer: Altius Commercial |
$15.89
|
| Rate for Payer: Beech Street Commercial |
$16.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.59
|
| Rate for Payer: Cash Price |
$11.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.05
|
| Rate for Payer: Cigna of WY Commercial |
$16.22
|
| Rate for Payer: Entrust Commercial |
$15.72
|
| Rate for Payer: First Choice Health Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.60
|
| Rate for Payer: HealthUtah PPO |
$16.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.05
|
| Rate for Payer: Multiplan Medicare/VA |
$9.12
|
| Rate for Payer: One Health Plan of WY PPO |
$16.22
|
| Rate for Payer: PacificSource Commercial |
$14.90
|
| Rate for Payer: PHCS PPO |
$16.22
|
| Rate for Payer: Three Rivers PPO |
$12.41
|
| Rate for Payer: TriWest Veterans Administration |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$9.60
|
| Rate for Payer: WINHealth Partners Commercial |
$16.22
|
| Rate for Payer: Wise Provider Network Commercial |
$15.72
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [28405]
|
Facility
|
OP
|
$16.55
|
|
|
Service Code
|
NDC 0409174671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.12 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.22
|
| Rate for Payer: Aetna of WY Medicare |
$10.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.89
|
| Rate for Payer: Altius Commercial |
$15.89
|
| Rate for Payer: Beech Street Commercial |
$16.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.59
|
| Rate for Payer: Cash Price |
$11.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.05
|
| Rate for Payer: Cigna of WY Commercial |
$16.22
|
| Rate for Payer: Entrust Commercial |
$15.72
|
| Rate for Payer: First Choice Health Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.60
|
| Rate for Payer: HealthUtah PPO |
$16.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.05
|
| Rate for Payer: Multiplan Medicare/VA |
$9.12
|
| Rate for Payer: One Health Plan of WY PPO |
$16.22
|
| Rate for Payer: PacificSource Commercial |
$14.90
|
| Rate for Payer: PHCS PPO |
$16.22
|
| Rate for Payer: Three Rivers PPO |
$12.41
|
| Rate for Payer: TriWest Veterans Administration |
$9.60
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$9.60
|
| Rate for Payer: WINHealth Partners Commercial |
$16.22
|
| Rate for Payer: Wise Provider Network Commercial |
$15.72
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [28405]
|
Facility
|
OP
|
$17.69
|
|
|
Service Code
|
NDC 0409174670
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.75 |
| Max. Negotiated Rate |
$17.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.34
|
| Rate for Payer: Aetna of WY Medicare |
$11.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.98
|
| Rate for Payer: Altius Commercial |
$16.98
|
| Rate for Payer: Beech Street Commercial |
$17.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.52
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.16
|
| Rate for Payer: Cigna of WY Commercial |
$17.34
|
| Rate for Payer: Entrust Commercial |
$16.81
|
| Rate for Payer: First Choice Health Commercial |
$16.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.26
|
| Rate for Payer: HealthUtah PPO |
$17.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.16
|
| Rate for Payer: Multiplan Medicare/VA |
$9.75
|
| Rate for Payer: One Health Plan of WY PPO |
$17.34
|
| Rate for Payer: PacificSource Commercial |
$15.92
|
| Rate for Payer: PHCS PPO |
$17.34
|
| Rate for Payer: Three Rivers PPO |
$13.27
|
| Rate for Payer: TriWest Veterans Administration |
$10.26
|
| Rate for Payer: United Healthcare Commercial |
$15.39
|
| Rate for Payer: United Healthcare Medicare |
$10.26
|
| Rate for Payer: WINHealth Partners Commercial |
$17.34
|
| Rate for Payer: Wise Provider Network Commercial |
$16.81
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [28405]
|
Facility
|
IP
|
$16.55
|
|
|
Service Code
|
NDC 0409174671
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$16.55 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.89
|
| Rate for Payer: Altius Commercial |
$15.89
|
| Rate for Payer: Beech Street Commercial |
$16.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.59
|
| Rate for Payer: Cash Price |
$11.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.05
|
| Rate for Payer: Cigna of WY Commercial |
$16.22
|
| Rate for Payer: Entrust Commercial |
$15.72
|
| Rate for Payer: First Choice Health Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.92
|
| Rate for Payer: HealthUtah PPO |
$16.55
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.05
|
| Rate for Payer: Multiplan Medicare/VA |
$10.38
|
| Rate for Payer: One Health Plan of WY PPO |
$16.22
|
| Rate for Payer: PacificSource Commercial |
$14.90
|
| Rate for Payer: PHCS PPO |
$16.22
|
| Rate for Payer: Three Rivers PPO |
$12.41
|
| Rate for Payer: TriWest Veterans Administration |
$10.92
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$10.92
|
| Rate for Payer: WINHealth Partners Commercial |
$15.72
|
| Rate for Payer: Wise Provider Network Commercial |
$15.72
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.25 %-1:200,000 INJECTION SOLUTION [28405]
|
Facility
|
IP
|
$17.69
|
|
|
Service Code
|
NDC 0409174670
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.09 |
| Max. Negotiated Rate |
$17.69 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.98
|
| Rate for Payer: Altius Commercial |
$16.98
|
| Rate for Payer: Beech Street Commercial |
$17.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.52
|
| Rate for Payer: Cash Price |
$12.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.16
|
| Rate for Payer: Cigna of WY Commercial |
$17.34
|
| Rate for Payer: Entrust Commercial |
$16.81
|
| Rate for Payer: First Choice Health Commercial |
$16.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.81
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.68
|
| Rate for Payer: HealthUtah PPO |
$17.69
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.16
|
| Rate for Payer: Multiplan Medicare/VA |
$11.09
|
| Rate for Payer: One Health Plan of WY PPO |
$17.34
|
| Rate for Payer: PacificSource Commercial |
$15.92
|
| Rate for Payer: PHCS PPO |
$17.34
|
| Rate for Payer: Three Rivers PPO |
$13.27
|
| Rate for Payer: TriWest Veterans Administration |
$11.68
|
| Rate for Payer: United Healthcare Commercial |
$15.39
|
| Rate for Payer: United Healthcare Medicare |
$11.68
|
| Rate for Payer: WINHealth Partners Commercial |
$16.81
|
| Rate for Payer: Wise Provider Network Commercial |
$16.81
|
|
