|
LEVOTHYROXINE 50 MCG TABLET [12043]
|
Facility
|
IP
|
$0.40
|
|
|
Service Code
|
NDC 1672944817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.38
|
| Rate for Payer: Altius Commercial |
$0.38
|
| Rate for Payer: Beech Street Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.39
|
| Rate for Payer: Cigna of WY Commercial |
$0.39
|
| Rate for Payer: Entrust Commercial |
$0.38
|
| Rate for Payer: First Choice Health Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.26
|
| Rate for Payer: HealthUtah PPO |
$0.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.25
|
| Rate for Payer: One Health Plan of WY PPO |
$0.39
|
| Rate for Payer: PacificSource Commercial |
$0.36
|
| Rate for Payer: PHCS PPO |
$0.39
|
| Rate for Payer: Three Rivers PPO |
$0.30
|
| Rate for Payer: TriWest Veterans Administration |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.35
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: WINHealth Partners Commercial |
$0.38
|
| Rate for Payer: Wise Provider Network Commercial |
$0.38
|
|
|
LEVOTHYROXINE 50 MCG TABLET [12043]
|
Facility
|
OP
|
$1.88
|
|
|
Service Code
|
NDC 6068746401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.84
|
| Rate for Payer: Aetna of WY Medicare |
$1.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.80
|
| Rate for Payer: Altius Commercial |
$1.80
|
| Rate for Payer: Beech Street Commercial |
$1.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.82
|
| Rate for Payer: Cigna of WY Commercial |
$1.84
|
| Rate for Payer: Entrust Commercial |
$1.79
|
| Rate for Payer: First Choice Health Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.09
|
| Rate for Payer: HealthUtah PPO |
$1.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.82
|
| Rate for Payer: Multiplan Medicare/VA |
$1.04
|
| Rate for Payer: One Health Plan of WY PPO |
$1.84
|
| Rate for Payer: PacificSource Commercial |
$1.69
|
| Rate for Payer: PHCS PPO |
$1.84
|
| Rate for Payer: Three Rivers PPO |
$1.41
|
| Rate for Payer: TriWest Veterans Administration |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
| Rate for Payer: United Healthcare Medicare |
$1.09
|
| Rate for Payer: WINHealth Partners Commercial |
$1.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1.79
|
|
|
LEVOTHYROXINE 50 MCG TABLET [12043]
|
Facility
|
OP
|
$0.40
|
|
|
Service Code
|
NDC 1672944817
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.39
|
| Rate for Payer: Aetna of WY Medicare |
$0.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.38
|
| Rate for Payer: Altius Commercial |
$0.38
|
| Rate for Payer: Beech Street Commercial |
$0.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.33
|
| Rate for Payer: Cash Price |
$0.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.39
|
| Rate for Payer: Cigna of WY Commercial |
$0.39
|
| Rate for Payer: Entrust Commercial |
$0.38
|
| Rate for Payer: First Choice Health Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.23
|
| Rate for Payer: HealthUtah PPO |
$0.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.39
|
| Rate for Payer: Multiplan Medicare/VA |
$0.22
|
| Rate for Payer: One Health Plan of WY PPO |
$0.39
|
| Rate for Payer: PacificSource Commercial |
$0.36
|
| Rate for Payer: PHCS PPO |
$0.39
|
| Rate for Payer: Three Rivers PPO |
$0.30
|
| Rate for Payer: TriWest Veterans Administration |
$0.23
|
| Rate for Payer: United Healthcare Commercial |
$0.35
|
| Rate for Payer: United Healthcare Medicare |
$0.23
|
| Rate for Payer: WINHealth Partners Commercial |
$0.39
|
| Rate for Payer: Wise Provider Network Commercial |
$0.38
|
|
|
LEVOTHYROXINE 50 MCG TABLET [12043]
|
Facility
|
IP
|
$1.88
|
|
|
Service Code
|
NDC 6068746411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.80
|
| Rate for Payer: Altius Commercial |
$1.80
|
| Rate for Payer: Beech Street Commercial |
$1.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.82
|
| Rate for Payer: Cigna of WY Commercial |
$1.84
|
| Rate for Payer: Entrust Commercial |
$1.79
|
| Rate for Payer: First Choice Health Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.24
|
| Rate for Payer: HealthUtah PPO |
$1.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.82
|
| Rate for Payer: Multiplan Medicare/VA |
$1.18
|
| Rate for Payer: One Health Plan of WY PPO |
$1.84
|
| Rate for Payer: PacificSource Commercial |
$1.69
|
| Rate for Payer: PHCS PPO |
$1.84
|
| Rate for Payer: Three Rivers PPO |
$1.41
|
| Rate for Payer: TriWest Veterans Administration |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
| Rate for Payer: WINHealth Partners Commercial |
$1.79
|
| Rate for Payer: Wise Provider Network Commercial |
$1.79
|
|
|
LEVOTHYROXINE 50 MCG TABLET [12043]
|
Facility
|
OP
|
$1.88
|
|
|
Service Code
|
NDC 6068746411
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.84
|
| Rate for Payer: Aetna of WY Medicare |
$1.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.80
|
| Rate for Payer: Altius Commercial |
$1.80
|
| Rate for Payer: Beech Street Commercial |
$1.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.54
|
| Rate for Payer: Cash Price |
$1.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.82
|
| Rate for Payer: Cigna of WY Commercial |
$1.84
|
| Rate for Payer: Entrust Commercial |
$1.79
|
| Rate for Payer: First Choice Health Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.79
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.09
|
| Rate for Payer: HealthUtah PPO |
$1.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.82
|
| Rate for Payer: Multiplan Medicare/VA |
$1.04
|
| Rate for Payer: One Health Plan of WY PPO |
$1.84
|
| Rate for Payer: PacificSource Commercial |
$1.69
|
| Rate for Payer: PHCS PPO |
$1.84
|
| Rate for Payer: Three Rivers PPO |
$1.41
|
| Rate for Payer: TriWest Veterans Administration |
$1.09
|
| Rate for Payer: United Healthcare Commercial |
$1.64
|
| Rate for Payer: United Healthcare Medicare |
$1.09
|
| Rate for Payer: WINHealth Partners Commercial |
$1.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1.79
|
|
|
LEVOTHYROXINE 75 MCG TABLET [8793]
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
NDC 6068747511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.26
|
| Rate for Payer: Altius Commercial |
$2.26
|
| Rate for Payer: Beech Street Commercial |
$2.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.93
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.28
|
| Rate for Payer: Cigna of WY Commercial |
$2.30
|
| Rate for Payer: Entrust Commercial |
$2.23
|
| Rate for Payer: First Choice Health Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.55
|
| Rate for Payer: HealthUtah PPO |
$2.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.28
|
| Rate for Payer: Multiplan Medicare/VA |
$1.47
|
| Rate for Payer: One Health Plan of WY PPO |
$2.30
|
| Rate for Payer: PacificSource Commercial |
$2.12
|
| Rate for Payer: PHCS PPO |
$2.30
|
| Rate for Payer: Three Rivers PPO |
$1.76
|
| Rate for Payer: TriWest Veterans Administration |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$2.04
|
| Rate for Payer: United Healthcare Medicare |
$1.55
|
| Rate for Payer: WINHealth Partners Commercial |
$2.23
|
| Rate for Payer: Wise Provider Network Commercial |
$2.23
|
|
|
LEVOTHYROXINE 75 MCG TABLET [8793]
|
Facility
|
OP
|
$2.35
|
|
|
Service Code
|
NDC 6068747511
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.30
|
| Rate for Payer: Aetna of WY Medicare |
$1.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.26
|
| Rate for Payer: Altius Commercial |
$2.26
|
| Rate for Payer: Beech Street Commercial |
$2.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.93
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.28
|
| Rate for Payer: Cigna of WY Commercial |
$2.30
|
| Rate for Payer: Entrust Commercial |
$2.23
|
| Rate for Payer: First Choice Health Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.36
|
| Rate for Payer: HealthUtah PPO |
$2.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.28
|
| Rate for Payer: Multiplan Medicare/VA |
$1.29
|
| Rate for Payer: One Health Plan of WY PPO |
$2.30
|
| Rate for Payer: PacificSource Commercial |
$2.12
|
| Rate for Payer: PHCS PPO |
$2.30
|
| Rate for Payer: Three Rivers PPO |
$1.76
|
| Rate for Payer: TriWest Veterans Administration |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$2.04
|
| Rate for Payer: United Healthcare Medicare |
$1.36
|
| Rate for Payer: WINHealth Partners Commercial |
$2.30
|
| Rate for Payer: Wise Provider Network Commercial |
$2.23
|
|
|
LEVOTHYROXINE 75 MCG TABLET [8793]
|
Facility
|
OP
|
$2.35
|
|
|
Service Code
|
NDC 6068747501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.30
|
| Rate for Payer: Aetna of WY Medicare |
$1.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.26
|
| Rate for Payer: Altius Commercial |
$2.26
|
| Rate for Payer: Beech Street Commercial |
$2.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.93
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.28
|
| Rate for Payer: Cigna of WY Commercial |
$2.30
|
| Rate for Payer: Entrust Commercial |
$2.23
|
| Rate for Payer: First Choice Health Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.36
|
| Rate for Payer: HealthUtah PPO |
$2.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.28
|
| Rate for Payer: Multiplan Medicare/VA |
$1.29
|
| Rate for Payer: One Health Plan of WY PPO |
$2.30
|
| Rate for Payer: PacificSource Commercial |
$2.12
|
| Rate for Payer: PHCS PPO |
$2.30
|
| Rate for Payer: Three Rivers PPO |
$1.76
|
| Rate for Payer: TriWest Veterans Administration |
$1.36
|
| Rate for Payer: United Healthcare Commercial |
$2.04
|
| Rate for Payer: United Healthcare Medicare |
$1.36
|
| Rate for Payer: WINHealth Partners Commercial |
$2.30
|
| Rate for Payer: Wise Provider Network Commercial |
$2.23
|
|
|
LEVOTHYROXINE 75 MCG TABLET [8793]
|
Facility
|
IP
|
$2.35
|
|
|
Service Code
|
NDC 6068747501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.26
|
| Rate for Payer: Altius Commercial |
$2.26
|
| Rate for Payer: Beech Street Commercial |
$2.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.93
|
| Rate for Payer: Cash Price |
$1.64
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.28
|
| Rate for Payer: Cigna of WY Commercial |
$2.30
|
| Rate for Payer: Entrust Commercial |
$2.23
|
| Rate for Payer: First Choice Health Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.55
|
| Rate for Payer: HealthUtah PPO |
$2.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.28
|
| Rate for Payer: Multiplan Medicare/VA |
$1.47
|
| Rate for Payer: One Health Plan of WY PPO |
$2.30
|
| Rate for Payer: PacificSource Commercial |
$2.12
|
| Rate for Payer: PHCS PPO |
$2.30
|
| Rate for Payer: Three Rivers PPO |
$1.76
|
| Rate for Payer: TriWest Veterans Administration |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$2.04
|
| Rate for Payer: United Healthcare Medicare |
$1.55
|
| Rate for Payer: WINHealth Partners Commercial |
$2.23
|
| Rate for Payer: Wise Provider Network Commercial |
$2.23
|
|
|
LEVOTHYROXINE 88 MCG TABLET [9698]
|
Facility
|
OP
|
$2.33
|
|
|
Service Code
|
NDC 6068748611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.28
|
| Rate for Payer: Aetna of WY Medicare |
$1.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.24
|
| Rate for Payer: Altius Commercial |
$2.24
|
| Rate for Payer: Beech Street Commercial |
$2.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.91
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.26
|
| Rate for Payer: Cigna of WY Commercial |
$2.28
|
| Rate for Payer: Entrust Commercial |
$2.21
|
| Rate for Payer: First Choice Health Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.35
|
| Rate for Payer: HealthUtah PPO |
$2.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1.28
|
| Rate for Payer: One Health Plan of WY PPO |
$2.28
|
| Rate for Payer: PacificSource Commercial |
$2.10
|
| Rate for Payer: PHCS PPO |
$2.28
|
| Rate for Payer: Three Rivers PPO |
$1.75
|
| Rate for Payer: TriWest Veterans Administration |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$2.03
|
| Rate for Payer: United Healthcare Medicare |
$1.35
|
| Rate for Payer: WINHealth Partners Commercial |
$2.28
|
| Rate for Payer: Wise Provider Network Commercial |
$2.21
|
|
|
LEVOTHYROXINE 88 MCG TABLET [9698]
|
Facility
|
IP
|
$2.33
|
|
|
Service Code
|
NDC 6068748611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.24
|
| Rate for Payer: Altius Commercial |
$2.24
|
| Rate for Payer: Beech Street Commercial |
$2.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.91
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.26
|
| Rate for Payer: Cigna of WY Commercial |
$2.28
|
| Rate for Payer: Entrust Commercial |
$2.21
|
| Rate for Payer: First Choice Health Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.54
|
| Rate for Payer: HealthUtah PPO |
$2.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1.46
|
| Rate for Payer: One Health Plan of WY PPO |
$2.28
|
| Rate for Payer: PacificSource Commercial |
$2.10
|
| Rate for Payer: PHCS PPO |
$2.28
|
| Rate for Payer: Three Rivers PPO |
$1.75
|
| Rate for Payer: TriWest Veterans Administration |
$1.54
|
| Rate for Payer: United Healthcare Commercial |
$2.03
|
| Rate for Payer: United Healthcare Medicare |
$1.54
|
| Rate for Payer: WINHealth Partners Commercial |
$2.21
|
| Rate for Payer: Wise Provider Network Commercial |
$2.21
|
|
|
LEVOTHYROXINE 88 MCG TABLET [9698]
|
Facility
|
IP
|
$2.33
|
|
|
Service Code
|
NDC 6068748601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.24
|
| Rate for Payer: Altius Commercial |
$2.24
|
| Rate for Payer: Beech Street Commercial |
$2.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.91
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.26
|
| Rate for Payer: Cigna of WY Commercial |
$2.28
|
| Rate for Payer: Entrust Commercial |
$2.21
|
| Rate for Payer: First Choice Health Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.54
|
| Rate for Payer: HealthUtah PPO |
$2.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1.46
|
| Rate for Payer: One Health Plan of WY PPO |
$2.28
|
| Rate for Payer: PacificSource Commercial |
$2.10
|
| Rate for Payer: PHCS PPO |
$2.28
|
| Rate for Payer: Three Rivers PPO |
$1.75
|
| Rate for Payer: TriWest Veterans Administration |
$1.54
|
| Rate for Payer: United Healthcare Commercial |
$2.03
|
| Rate for Payer: United Healthcare Medicare |
$1.54
|
| Rate for Payer: WINHealth Partners Commercial |
$2.21
|
| Rate for Payer: Wise Provider Network Commercial |
$2.21
|
|
|
LEVOTHYROXINE 88 MCG TABLET [9698]
|
Facility
|
OP
|
$2.33
|
|
|
Service Code
|
NDC 6068748601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.28
|
| Rate for Payer: Aetna of WY Medicare |
$1.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.24
|
| Rate for Payer: Altius Commercial |
$2.24
|
| Rate for Payer: Beech Street Commercial |
$2.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.91
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.26
|
| Rate for Payer: Cigna of WY Commercial |
$2.28
|
| Rate for Payer: Entrust Commercial |
$2.21
|
| Rate for Payer: First Choice Health Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.35
|
| Rate for Payer: HealthUtah PPO |
$2.33
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1.28
|
| Rate for Payer: One Health Plan of WY PPO |
$2.28
|
| Rate for Payer: PacificSource Commercial |
$2.10
|
| Rate for Payer: PHCS PPO |
$2.28
|
| Rate for Payer: Three Rivers PPO |
$1.75
|
| Rate for Payer: TriWest Veterans Administration |
$1.35
|
| Rate for Payer: United Healthcare Commercial |
$2.03
|
| Rate for Payer: United Healthcare Medicare |
$1.35
|
| Rate for Payer: WINHealth Partners Commercial |
$2.28
|
| Rate for Payer: Wise Provider Network Commercial |
$2.21
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [9623]
|
Facility
|
IP
|
$16.12
|
|
|
Service Code
|
NDC 6332348227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.48
|
| Rate for Payer: Altius Commercial |
$15.48
|
| Rate for Payer: Beech Street Commercial |
$15.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.23
|
| Rate for Payer: Cash Price |
$11.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.64
|
| Rate for Payer: Cigna of WY Commercial |
$15.80
|
| Rate for Payer: Entrust Commercial |
$15.31
|
| Rate for Payer: First Choice Health Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.64
|
| Rate for Payer: HealthUtah PPO |
$16.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.64
|
| Rate for Payer: Multiplan Medicare/VA |
$10.11
|
| Rate for Payer: One Health Plan of WY PPO |
$15.80
|
| Rate for Payer: PacificSource Commercial |
$14.51
|
| Rate for Payer: PHCS PPO |
$15.80
|
| Rate for Payer: Three Rivers PPO |
$12.09
|
| Rate for Payer: TriWest Veterans Administration |
$10.64
|
| Rate for Payer: United Healthcare Commercial |
$14.02
|
| Rate for Payer: United Healthcare Medicare |
$10.64
|
| Rate for Payer: WINHealth Partners Commercial |
$15.31
|
| Rate for Payer: Wise Provider Network Commercial |
$15.31
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [9623]
|
Facility
|
IP
|
$16.04
|
|
|
Service Code
|
NDC 6332348205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.40
|
| Rate for Payer: Altius Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.17
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.56
|
| Rate for Payer: Cigna of WY Commercial |
$15.72
|
| Rate for Payer: Entrust Commercial |
$15.24
|
| Rate for Payer: First Choice Health Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.59
|
| Rate for Payer: HealthUtah PPO |
$16.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.56
|
| Rate for Payer: Multiplan Medicare/VA |
$10.06
|
| Rate for Payer: One Health Plan of WY PPO |
$15.72
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.72
|
| Rate for Payer: Three Rivers PPO |
$12.03
|
| Rate for Payer: TriWest Veterans Administration |
$10.59
|
| Rate for Payer: United Healthcare Commercial |
$13.95
|
| Rate for Payer: United Healthcare Medicare |
$10.59
|
| Rate for Payer: WINHealth Partners Commercial |
$15.24
|
| Rate for Payer: Wise Provider Network Commercial |
$15.24
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [9623]
|
Facility
|
IP
|
$16.58
|
|
|
Service Code
|
NDC 6332348217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.40 |
| Max. Negotiated Rate |
$16.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.92
|
| Rate for Payer: Altius Commercial |
$15.92
|
| Rate for Payer: Beech Street Commercial |
$16.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.61
|
| Rate for Payer: Cash Price |
$11.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.08
|
| Rate for Payer: Cigna of WY Commercial |
$16.25
|
| Rate for Payer: Entrust Commercial |
$15.75
|
| Rate for Payer: First Choice Health Commercial |
$15.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.94
|
| Rate for Payer: HealthUtah PPO |
$16.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.08
|
| Rate for Payer: Multiplan Medicare/VA |
$10.40
|
| Rate for Payer: One Health Plan of WY PPO |
$16.25
|
| Rate for Payer: PacificSource Commercial |
$14.92
|
| Rate for Payer: PHCS PPO |
$16.25
|
| Rate for Payer: Three Rivers PPO |
$12.44
|
| Rate for Payer: TriWest Veterans Administration |
$10.94
|
| Rate for Payer: United Healthcare Commercial |
$14.42
|
| Rate for Payer: United Healthcare Medicare |
$10.94
|
| Rate for Payer: WINHealth Partners Commercial |
$15.75
|
| Rate for Payer: Wise Provider Network Commercial |
$15.75
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [9623]
|
Facility
|
OP
|
$16.12
|
|
|
Service Code
|
NDC 6332348227
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.80
|
| Rate for Payer: Aetna of WY Medicare |
$10.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.48
|
| Rate for Payer: Altius Commercial |
$15.48
|
| Rate for Payer: Beech Street Commercial |
$15.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.23
|
| Rate for Payer: Cash Price |
$11.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.64
|
| Rate for Payer: Cigna of WY Commercial |
$15.80
|
| Rate for Payer: Entrust Commercial |
$15.31
|
| Rate for Payer: First Choice Health Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.35
|
| Rate for Payer: HealthUtah PPO |
$16.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.88
|
| Rate for Payer: One Health Plan of WY PPO |
$15.80
|
| Rate for Payer: PacificSource Commercial |
$14.51
|
| Rate for Payer: PHCS PPO |
$15.80
|
| Rate for Payer: Three Rivers PPO |
$12.09
|
| Rate for Payer: TriWest Veterans Administration |
$9.35
|
| Rate for Payer: United Healthcare Commercial |
$14.02
|
| Rate for Payer: United Healthcare Medicare |
$9.35
|
| Rate for Payer: WINHealth Partners Commercial |
$15.80
|
| Rate for Payer: Wise Provider Network Commercial |
$15.31
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [9623]
|
Facility
|
OP
|
$16.04
|
|
|
Service Code
|
NDC 6332348205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.72
|
| Rate for Payer: Aetna of WY Medicare |
$10.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.40
|
| Rate for Payer: Altius Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.17
|
| Rate for Payer: Cash Price |
$11.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.56
|
| Rate for Payer: Cigna of WY Commercial |
$15.72
|
| Rate for Payer: Entrust Commercial |
$15.24
|
| Rate for Payer: First Choice Health Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.30
|
| Rate for Payer: HealthUtah PPO |
$16.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.84
|
| Rate for Payer: One Health Plan of WY PPO |
$15.72
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.72
|
| Rate for Payer: Three Rivers PPO |
$12.03
|
| Rate for Payer: TriWest Veterans Administration |
$9.30
|
| Rate for Payer: United Healthcare Commercial |
$13.95
|
| Rate for Payer: United Healthcare Medicare |
$9.30
|
| Rate for Payer: WINHealth Partners Commercial |
$15.72
|
| Rate for Payer: Wise Provider Network Commercial |
$15.24
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [9623]
|
Facility
|
OP
|
$16.12
|
|
|
Service Code
|
NDC 6332348203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.80
|
| Rate for Payer: Aetna of WY Medicare |
$10.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.48
|
| Rate for Payer: Altius Commercial |
$15.48
|
| Rate for Payer: Beech Street Commercial |
$15.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.23
|
| Rate for Payer: Cash Price |
$11.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.64
|
| Rate for Payer: Cigna of WY Commercial |
$15.80
|
| Rate for Payer: Entrust Commercial |
$15.31
|
| Rate for Payer: First Choice Health Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.35
|
| Rate for Payer: HealthUtah PPO |
$16.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.88
|
| Rate for Payer: One Health Plan of WY PPO |
$15.80
|
| Rate for Payer: PacificSource Commercial |
$14.51
|
| Rate for Payer: PHCS PPO |
$15.80
|
| Rate for Payer: Three Rivers PPO |
$12.09
|
| Rate for Payer: TriWest Veterans Administration |
$9.35
|
| Rate for Payer: United Healthcare Commercial |
$14.02
|
| Rate for Payer: United Healthcare Medicare |
$9.35
|
| Rate for Payer: WINHealth Partners Commercial |
$15.80
|
| Rate for Payer: Wise Provider Network Commercial |
$15.31
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [9623]
|
Facility
|
OP
|
$16.58
|
|
|
Service Code
|
NDC 6332348217
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.14 |
| Max. Negotiated Rate |
$16.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.25
|
| Rate for Payer: Aetna of WY Medicare |
$10.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.92
|
| Rate for Payer: Altius Commercial |
$15.92
|
| Rate for Payer: Beech Street Commercial |
$16.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.61
|
| Rate for Payer: Cash Price |
$11.61
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.08
|
| Rate for Payer: Cigna of WY Commercial |
$16.25
|
| Rate for Payer: Entrust Commercial |
$15.75
|
| Rate for Payer: First Choice Health Commercial |
$15.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.62
|
| Rate for Payer: HealthUtah PPO |
$16.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.08
|
| Rate for Payer: Multiplan Medicare/VA |
$9.14
|
| Rate for Payer: One Health Plan of WY PPO |
$16.25
|
| Rate for Payer: PacificSource Commercial |
$14.92
|
| Rate for Payer: PHCS PPO |
$16.25
|
| Rate for Payer: Three Rivers PPO |
$12.44
|
| Rate for Payer: TriWest Veterans Administration |
$9.62
|
| Rate for Payer: United Healthcare Commercial |
$14.42
|
| Rate for Payer: United Healthcare Medicare |
$9.62
|
| Rate for Payer: WINHealth Partners Commercial |
$16.25
|
| Rate for Payer: Wise Provider Network Commercial |
$15.75
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [9623]
|
Facility
|
IP
|
$16.12
|
|
|
Service Code
|
NDC 6332348203
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.11 |
| Max. Negotiated Rate |
$16.12 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.48
|
| Rate for Payer: Altius Commercial |
$15.48
|
| Rate for Payer: Beech Street Commercial |
$15.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.23
|
| Rate for Payer: Cash Price |
$11.28
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.64
|
| Rate for Payer: Cigna of WY Commercial |
$15.80
|
| Rate for Payer: Entrust Commercial |
$15.31
|
| Rate for Payer: First Choice Health Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.64
|
| Rate for Payer: HealthUtah PPO |
$16.12
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.64
|
| Rate for Payer: Multiplan Medicare/VA |
$10.11
|
| Rate for Payer: One Health Plan of WY PPO |
$15.80
|
| Rate for Payer: PacificSource Commercial |
$14.51
|
| Rate for Payer: PHCS PPO |
$15.80
|
| Rate for Payer: Three Rivers PPO |
$12.09
|
| Rate for Payer: TriWest Veterans Administration |
$10.64
|
| Rate for Payer: United Healthcare Commercial |
$14.02
|
| Rate for Payer: United Healthcare Medicare |
$10.64
|
| Rate for Payer: WINHealth Partners Commercial |
$15.31
|
| Rate for Payer: Wise Provider Network Commercial |
$15.31
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [9623]
|
Facility
|
IP
|
$15.48
|
|
|
Service Code
|
NDC 0409000701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.71 |
| Max. Negotiated Rate |
$15.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.86
|
| Rate for Payer: Altius Commercial |
$14.86
|
| Rate for Payer: Beech Street Commercial |
$15.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.71
|
| Rate for Payer: Cash Price |
$10.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.02
|
| Rate for Payer: Cigna of WY Commercial |
$15.17
|
| Rate for Payer: Entrust Commercial |
$14.71
|
| Rate for Payer: First Choice Health Commercial |
$14.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.22
|
| Rate for Payer: HealthUtah PPO |
$15.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.02
|
| Rate for Payer: Multiplan Medicare/VA |
$9.71
|
| Rate for Payer: One Health Plan of WY PPO |
$15.17
|
| Rate for Payer: PacificSource Commercial |
$13.93
|
| Rate for Payer: PHCS PPO |
$15.17
|
| Rate for Payer: Three Rivers PPO |
$11.61
|
| Rate for Payer: TriWest Veterans Administration |
$10.22
|
| Rate for Payer: United Healthcare Commercial |
$13.47
|
| Rate for Payer: United Healthcare Medicare |
$10.22
|
| Rate for Payer: WINHealth Partners Commercial |
$14.71
|
| Rate for Payer: Wise Provider Network Commercial |
$14.71
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [9623]
|
Facility
|
OP
|
$15.48
|
|
|
Service Code
|
NDC 0409000701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.53 |
| Max. Negotiated Rate |
$15.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.17
|
| Rate for Payer: Aetna of WY Medicare |
$10.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.86
|
| Rate for Payer: Altius Commercial |
$14.86
|
| Rate for Payer: Beech Street Commercial |
$15.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.71
|
| Rate for Payer: Cash Price |
$10.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.02
|
| Rate for Payer: Cigna of WY Commercial |
$15.17
|
| Rate for Payer: Entrust Commercial |
$14.71
|
| Rate for Payer: First Choice Health Commercial |
$14.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.98
|
| Rate for Payer: HealthUtah PPO |
$15.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.02
|
| Rate for Payer: Multiplan Medicare/VA |
$8.53
|
| Rate for Payer: One Health Plan of WY PPO |
$15.17
|
| Rate for Payer: PacificSource Commercial |
$13.93
|
| Rate for Payer: PHCS PPO |
$15.17
|
| Rate for Payer: Three Rivers PPO |
$11.61
|
| Rate for Payer: TriWest Veterans Administration |
$8.98
|
| Rate for Payer: United Healthcare Commercial |
$13.47
|
| Rate for Payer: United Healthcare Medicare |
$8.98
|
| Rate for Payer: WINHealth Partners Commercial |
$15.17
|
| Rate for Payer: Wise Provider Network Commercial |
$14.71
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [18567]
|
Facility
|
OP
|
$15.67
|
|
|
Service Code
|
NDC 0409318201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.36
|
| Rate for Payer: Aetna of WY Medicare |
$10.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.04
|
| Rate for Payer: Altius Commercial |
$15.04
|
| Rate for Payer: Beech Street Commercial |
$15.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.87
|
| Rate for Payer: Cash Price |
$10.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.20
|
| Rate for Payer: Cigna of WY Commercial |
$15.36
|
| Rate for Payer: Entrust Commercial |
$14.89
|
| Rate for Payer: First Choice Health Commercial |
$14.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.09
|
| Rate for Payer: HealthUtah PPO |
$15.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.20
|
| Rate for Payer: Multiplan Medicare/VA |
$8.63
|
| Rate for Payer: One Health Plan of WY PPO |
$15.36
|
| Rate for Payer: PacificSource Commercial |
$14.10
|
| Rate for Payer: PHCS PPO |
$15.36
|
| Rate for Payer: Three Rivers PPO |
$11.75
|
| Rate for Payer: TriWest Veterans Administration |
$9.09
|
| Rate for Payer: United Healthcare Commercial |
$13.63
|
| Rate for Payer: United Healthcare Medicare |
$9.09
|
| Rate for Payer: WINHealth Partners Commercial |
$15.36
|
| Rate for Payer: Wise Provider Network Commercial |
$14.89
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [18567]
|
Facility
|
OP
|
$15.67
|
|
|
Service Code
|
NDC 0409318211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.36
|
| Rate for Payer: Aetna of WY Medicare |
$10.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.04
|
| Rate for Payer: Altius Commercial |
$15.04
|
| Rate for Payer: Beech Street Commercial |
$15.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.87
|
| Rate for Payer: Cash Price |
$10.97
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.20
|
| Rate for Payer: Cigna of WY Commercial |
$15.36
|
| Rate for Payer: Entrust Commercial |
$14.89
|
| Rate for Payer: First Choice Health Commercial |
$14.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.09
|
| Rate for Payer: HealthUtah PPO |
$15.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.20
|
| Rate for Payer: Multiplan Medicare/VA |
$8.63
|
| Rate for Payer: One Health Plan of WY PPO |
$15.36
|
| Rate for Payer: PacificSource Commercial |
$14.10
|
| Rate for Payer: PHCS PPO |
$15.36
|
| Rate for Payer: Three Rivers PPO |
$11.75
|
| Rate for Payer: TriWest Veterans Administration |
$9.09
|
| Rate for Payer: United Healthcare Commercial |
$13.63
|
| Rate for Payer: United Healthcare Medicare |
$9.09
|
| Rate for Payer: WINHealth Partners Commercial |
$15.36
|
| Rate for Payer: Wise Provider Network Commercial |
$14.89
|
|
