|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [28403]
|
Facility
|
IP
|
$16.31
|
|
|
Service Code
|
NDC 0409174971
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.23 |
| Max. Negotiated Rate |
$16.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.66
|
| Rate for Payer: Altius Commercial |
$15.66
|
| Rate for Payer: Beech Street Commercial |
$15.98
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.39
|
| Rate for Payer: Cash Price |
$11.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.82
|
| Rate for Payer: Cigna of WY Commercial |
$15.98
|
| Rate for Payer: Entrust Commercial |
$15.49
|
| Rate for Payer: First Choice Health Commercial |
$15.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.76
|
| Rate for Payer: HealthUtah PPO |
$16.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.82
|
| Rate for Payer: Multiplan Medicare/VA |
$10.23
|
| Rate for Payer: One Health Plan of WY PPO |
$15.98
|
| Rate for Payer: PacificSource Commercial |
$14.68
|
| Rate for Payer: PHCS PPO |
$15.98
|
| Rate for Payer: Three Rivers PPO |
$12.23
|
| Rate for Payer: TriWest Veterans Administration |
$10.76
|
| Rate for Payer: United Healthcare Commercial |
$14.19
|
| Rate for Payer: United Healthcare Medicare |
$10.76
|
| Rate for Payer: WINHealth Partners Commercial |
$15.49
|
| Rate for Payer: Wise Provider Network Commercial |
$15.49
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [28403]
|
Facility
|
OP
|
$17.73
|
|
|
Service Code
|
NDC 0409174970
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$17.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.38
|
| Rate for Payer: Aetna of WY Medicare |
$11.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.02
|
| Rate for Payer: Altius Commercial |
$17.02
|
| Rate for Payer: Beech Street Commercial |
$17.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.56
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.20
|
| Rate for Payer: Cigna of WY Commercial |
$17.38
|
| Rate for Payer: Entrust Commercial |
$16.84
|
| Rate for Payer: First Choice Health Commercial |
$16.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.28
|
| Rate for Payer: HealthUtah PPO |
$17.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.20
|
| Rate for Payer: Multiplan Medicare/VA |
$9.77
|
| Rate for Payer: One Health Plan of WY PPO |
$17.38
|
| Rate for Payer: PacificSource Commercial |
$15.96
|
| Rate for Payer: PHCS PPO |
$17.38
|
| Rate for Payer: Three Rivers PPO |
$13.30
|
| Rate for Payer: TriWest Veterans Administration |
$10.28
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$10.28
|
| Rate for Payer: WINHealth Partners Commercial |
$17.38
|
| Rate for Payer: Wise Provider Network Commercial |
$16.84
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [28403]
|
Facility
|
IP
|
$17.73
|
|
|
Service Code
|
NDC 0409174970
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$17.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.02
|
| Rate for Payer: Altius Commercial |
$17.02
|
| Rate for Payer: Beech Street Commercial |
$17.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.56
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.20
|
| Rate for Payer: Cigna of WY Commercial |
$17.38
|
| Rate for Payer: Entrust Commercial |
$16.84
|
| Rate for Payer: First Choice Health Commercial |
$16.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.70
|
| Rate for Payer: HealthUtah PPO |
$17.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.20
|
| Rate for Payer: Multiplan Medicare/VA |
$11.12
|
| Rate for Payer: One Health Plan of WY PPO |
$17.38
|
| Rate for Payer: PacificSource Commercial |
$15.96
|
| Rate for Payer: PHCS PPO |
$17.38
|
| Rate for Payer: Three Rivers PPO |
$13.30
|
| Rate for Payer: TriWest Veterans Administration |
$11.70
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$11.70
|
| Rate for Payer: WINHealth Partners Commercial |
$16.84
|
| Rate for Payer: Wise Provider Network Commercial |
$16.84
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [28403]
|
Facility
|
IP
|
$17.73
|
|
|
Service Code
|
NDC 0409174910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$17.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.02
|
| Rate for Payer: Altius Commercial |
$17.02
|
| Rate for Payer: Beech Street Commercial |
$17.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.56
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.20
|
| Rate for Payer: Cigna of WY Commercial |
$17.38
|
| Rate for Payer: Entrust Commercial |
$16.84
|
| Rate for Payer: First Choice Health Commercial |
$16.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.70
|
| Rate for Payer: HealthUtah PPO |
$17.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.20
|
| Rate for Payer: Multiplan Medicare/VA |
$11.12
|
| Rate for Payer: One Health Plan of WY PPO |
$17.38
|
| Rate for Payer: PacificSource Commercial |
$15.96
|
| Rate for Payer: PHCS PPO |
$17.38
|
| Rate for Payer: Three Rivers PPO |
$13.30
|
| Rate for Payer: TriWest Veterans Administration |
$11.70
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$11.70
|
| Rate for Payer: WINHealth Partners Commercial |
$16.84
|
| Rate for Payer: Wise Provider Network Commercial |
$16.84
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [28403]
|
Facility
|
OP
|
$17.73
|
|
|
Service Code
|
NDC 0409174910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$17.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.38
|
| Rate for Payer: Aetna of WY Medicare |
$11.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.02
|
| Rate for Payer: Altius Commercial |
$17.02
|
| Rate for Payer: Beech Street Commercial |
$17.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.56
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.20
|
| Rate for Payer: Cigna of WY Commercial |
$17.38
|
| Rate for Payer: Entrust Commercial |
$16.84
|
| Rate for Payer: First Choice Health Commercial |
$16.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.28
|
| Rate for Payer: HealthUtah PPO |
$17.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.20
|
| Rate for Payer: Multiplan Medicare/VA |
$9.77
|
| Rate for Payer: One Health Plan of WY PPO |
$17.38
|
| Rate for Payer: PacificSource Commercial |
$15.96
|
| Rate for Payer: PHCS PPO |
$17.38
|
| Rate for Payer: Three Rivers PPO |
$13.30
|
| Rate for Payer: TriWest Veterans Administration |
$10.28
|
| Rate for Payer: United Healthcare Commercial |
$15.43
|
| Rate for Payer: United Healthcare Medicare |
$10.28
|
| Rate for Payer: WINHealth Partners Commercial |
$17.38
|
| Rate for Payer: Wise Provider Network Commercial |
$16.84
|
|
|
BUPIVACAINE-EPINEPHRINE (PF) 0.5 %-1:200,000 INJECTION SOLUTION [28403]
|
Facility
|
OP
|
$16.31
|
|
|
Service Code
|
NDC 0409174971
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.99 |
| Max. Negotiated Rate |
$16.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.98
|
| Rate for Payer: Aetna of WY Medicare |
$10.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.66
|
| Rate for Payer: Altius Commercial |
$15.66
|
| Rate for Payer: Beech Street Commercial |
$15.98
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.39
|
| Rate for Payer: Cash Price |
$11.42
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.82
|
| Rate for Payer: Cigna of WY Commercial |
$15.98
|
| Rate for Payer: Entrust Commercial |
$15.49
|
| Rate for Payer: First Choice Health Commercial |
$15.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.49
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.46
|
| Rate for Payer: HealthUtah PPO |
$16.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.82
|
| Rate for Payer: Multiplan Medicare/VA |
$8.99
|
| Rate for Payer: One Health Plan of WY PPO |
$15.98
|
| Rate for Payer: PacificSource Commercial |
$14.68
|
| Rate for Payer: PHCS PPO |
$15.98
|
| Rate for Payer: Three Rivers PPO |
$12.23
|
| Rate for Payer: TriWest Veterans Administration |
$9.46
|
| Rate for Payer: United Healthcare Commercial |
$14.19
|
| Rate for Payer: United Healthcare Medicare |
$9.46
|
| Rate for Payer: WINHealth Partners Commercial |
$15.98
|
| Rate for Payer: Wise Provider Network Commercial |
$15.49
|
|
|
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [3872]
|
Facility
|
OP
|
$15.90
|
|
|
Service Code
|
NDC 7006975201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.76 |
| Max. Negotiated Rate |
$15.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.58
|
| Rate for Payer: Aetna of WY Medicare |
$10.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.26
|
| Rate for Payer: Altius Commercial |
$15.26
|
| Rate for Payer: Beech Street Commercial |
$15.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.05
|
| Rate for Payer: Cash Price |
$11.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.42
|
| Rate for Payer: Cigna of WY Commercial |
$15.58
|
| Rate for Payer: Entrust Commercial |
$15.10
|
| Rate for Payer: First Choice Health Commercial |
$15.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.22
|
| Rate for Payer: HealthUtah PPO |
$15.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.42
|
| Rate for Payer: Multiplan Medicare/VA |
$8.76
|
| Rate for Payer: One Health Plan of WY PPO |
$15.58
|
| Rate for Payer: PacificSource Commercial |
$14.31
|
| Rate for Payer: PHCS PPO |
$15.58
|
| Rate for Payer: Three Rivers PPO |
$11.92
|
| Rate for Payer: TriWest Veterans Administration |
$9.22
|
| Rate for Payer: United Healthcare Commercial |
$13.83
|
| Rate for Payer: United Healthcare Medicare |
$9.22
|
| Rate for Payer: WINHealth Partners Commercial |
$15.58
|
| Rate for Payer: Wise Provider Network Commercial |
$15.10
|
|
|
BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [3872]
|
Facility
|
IP
|
$15.90
|
|
|
Service Code
|
NDC 7006975201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.97 |
| Max. Negotiated Rate |
$15.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.26
|
| Rate for Payer: Altius Commercial |
$15.26
|
| Rate for Payer: Beech Street Commercial |
$15.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.05
|
| Rate for Payer: Cash Price |
$11.13
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.42
|
| Rate for Payer: Cigna of WY Commercial |
$15.58
|
| Rate for Payer: Entrust Commercial |
$15.10
|
| Rate for Payer: First Choice Health Commercial |
$15.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.49
|
| Rate for Payer: HealthUtah PPO |
$15.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.42
|
| Rate for Payer: Multiplan Medicare/VA |
$9.97
|
| Rate for Payer: One Health Plan of WY PPO |
$15.58
|
| Rate for Payer: PacificSource Commercial |
$14.31
|
| Rate for Payer: PHCS PPO |
$15.58
|
| Rate for Payer: Three Rivers PPO |
$11.92
|
| Rate for Payer: TriWest Veterans Administration |
$10.49
|
| Rate for Payer: United Healthcare Commercial |
$13.83
|
| Rate for Payer: United Healthcare Medicare |
$10.49
|
| Rate for Payer: WINHealth Partners Commercial |
$15.10
|
| Rate for Payer: Wise Provider Network Commercial |
$15.10
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [4728]
|
Facility
|
OP
|
$15.88
|
|
|
Service Code
|
NDC 0143932901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.75 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.56
|
| Rate for Payer: Aetna of WY Medicare |
$10.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.24
|
| Rate for Payer: Altius Commercial |
$15.24
|
| Rate for Payer: Beech Street Commercial |
$15.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.04
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.40
|
| Rate for Payer: Cigna of WY Commercial |
$15.56
|
| Rate for Payer: Entrust Commercial |
$15.09
|
| Rate for Payer: First Choice Health Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.21
|
| Rate for Payer: HealthUtah PPO |
$15.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.40
|
| Rate for Payer: Multiplan Medicare/VA |
$8.75
|
| Rate for Payer: One Health Plan of WY PPO |
$15.56
|
| Rate for Payer: PacificSource Commercial |
$14.29
|
| Rate for Payer: PHCS PPO |
$15.56
|
| Rate for Payer: Three Rivers PPO |
$11.91
|
| Rate for Payer: TriWest Veterans Administration |
$9.21
|
| Rate for Payer: United Healthcare Commercial |
$13.82
|
| Rate for Payer: United Healthcare Medicare |
$9.21
|
| Rate for Payer: WINHealth Partners Commercial |
$15.56
|
| Rate for Payer: Wise Provider Network Commercial |
$15.09
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [4728]
|
Facility
|
OP
|
$15.24
|
|
|
Service Code
|
NDC 0409116318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.40 |
| Max. Negotiated Rate |
$15.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.94
|
| Rate for Payer: Aetna of WY Medicare |
$10.06
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.63
|
| Rate for Payer: Altius Commercial |
$14.63
|
| Rate for Payer: Beech Street Commercial |
$14.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.51
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.78
|
| Rate for Payer: Cigna of WY Commercial |
$14.94
|
| Rate for Payer: Entrust Commercial |
$14.48
|
| Rate for Payer: First Choice Health Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.84
|
| Rate for Payer: HealthUtah PPO |
$15.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.78
|
| Rate for Payer: Multiplan Medicare/VA |
$8.40
|
| Rate for Payer: One Health Plan of WY PPO |
$14.94
|
| Rate for Payer: PacificSource Commercial |
$13.72
|
| Rate for Payer: PHCS PPO |
$14.94
|
| Rate for Payer: Three Rivers PPO |
$11.43
|
| Rate for Payer: TriWest Veterans Administration |
$8.84
|
| Rate for Payer: United Healthcare Commercial |
$13.26
|
| Rate for Payer: United Healthcare Medicare |
$8.84
|
| Rate for Payer: WINHealth Partners Commercial |
$14.94
|
| Rate for Payer: Wise Provider Network Commercial |
$14.48
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [4728]
|
Facility
|
OP
|
$15.26
|
|
|
Service Code
|
NDC 5515025050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| 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 Auto/Workers Compensation |
$14.65
|
| 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 |
$12.53
|
| 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 |
$8.85
|
| Rate for Payer: HealthUtah PPO |
$15.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.80
|
| Rate for Payer: Multiplan Medicare/VA |
$8.41
|
| 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 |
$8.85
|
| Rate for Payer: United Healthcare Commercial |
$13.28
|
| Rate for Payer: United Healthcare Medicare |
$8.85
|
| Rate for Payer: WINHealth Partners Commercial |
$14.95
|
| Rate for Payer: Wise Provider Network Commercial |
$14.50
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [4728]
|
Facility
|
IP
|
$15.26
|
|
|
Service Code
|
NDC 5515025050
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.57 |
| Max. Negotiated Rate |
$15.26 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.95
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.65
|
| 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 |
$12.53
|
| 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 |
$10.07
|
| Rate for Payer: HealthUtah PPO |
$15.26
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.80
|
| Rate for Payer: Multiplan Medicare/VA |
$9.57
|
| 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 |
$10.07
|
| Rate for Payer: United Healthcare Commercial |
$13.28
|
| Rate for Payer: United Healthcare Medicare |
$10.07
|
| Rate for Payer: WINHealth Partners Commercial |
$14.50
|
| Rate for Payer: Wise Provider Network Commercial |
$14.50
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [4728]
|
Facility
|
IP
|
$15.24
|
|
|
Service Code
|
NDC 0409116318
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$15.24 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.63
|
| Rate for Payer: Altius Commercial |
$14.63
|
| Rate for Payer: Beech Street Commercial |
$14.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.51
|
| Rate for Payer: Cash Price |
$10.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.78
|
| Rate for Payer: Cigna of WY Commercial |
$14.94
|
| Rate for Payer: Entrust Commercial |
$14.48
|
| Rate for Payer: First Choice Health Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.48
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.06
|
| Rate for Payer: HealthUtah PPO |
$15.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.78
|
| Rate for Payer: Multiplan Medicare/VA |
$9.56
|
| Rate for Payer: One Health Plan of WY PPO |
$14.94
|
| Rate for Payer: PacificSource Commercial |
$13.72
|
| Rate for Payer: PHCS PPO |
$14.94
|
| Rate for Payer: Three Rivers PPO |
$11.43
|
| Rate for Payer: TriWest Veterans Administration |
$10.06
|
| Rate for Payer: United Healthcare Commercial |
$13.26
|
| Rate for Payer: United Healthcare Medicare |
$10.06
|
| Rate for Payer: WINHealth Partners Commercial |
$14.48
|
| Rate for Payer: Wise Provider Network Commercial |
$14.48
|
|
|
BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [4728]
|
Facility
|
IP
|
$15.88
|
|
|
Service Code
|
NDC 0143932901
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$15.88 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.24
|
| Rate for Payer: Altius Commercial |
$15.24
|
| Rate for Payer: Beech Street Commercial |
$15.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.04
|
| Rate for Payer: Cash Price |
$11.12
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.40
|
| Rate for Payer: Cigna of WY Commercial |
$15.56
|
| Rate for Payer: Entrust Commercial |
$15.09
|
| Rate for Payer: First Choice Health Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.48
|
| Rate for Payer: HealthUtah PPO |
$15.88
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.40
|
| Rate for Payer: Multiplan Medicare/VA |
$9.96
|
| Rate for Payer: One Health Plan of WY PPO |
$15.56
|
| Rate for Payer: PacificSource Commercial |
$14.29
|
| Rate for Payer: PHCS PPO |
$15.56
|
| Rate for Payer: Three Rivers PPO |
$11.91
|
| Rate for Payer: TriWest Veterans Administration |
$10.48
|
| Rate for Payer: United Healthcare Commercial |
$13.82
|
| Rate for Payer: United Healthcare Medicare |
$10.48
|
| Rate for Payer: WINHealth Partners Commercial |
$15.09
|
| Rate for Payer: Wise Provider Network Commercial |
$15.09
|
|
|
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION [94701]
|
Facility
|
OP
|
$41.08
|
|
|
Service Code
|
HCPCS J0666
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.64 |
| Max. Negotiated Rate |
$41.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.26
|
| Rate for Payer: Aetna of WY Medicare |
$27.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$39.44
|
| Rate for Payer: Altius Commercial |
$39.44
|
| Rate for Payer: Beech Street Commercial |
$40.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.73
|
| Rate for Payer: Cash Price |
$28.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.85
|
| Rate for Payer: Cigna of WY Commercial |
$40.26
|
| Rate for Payer: Entrust Commercial |
$39.03
|
| Rate for Payer: First Choice Health Commercial |
$39.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.83
|
| Rate for Payer: HealthUtah PPO |
$41.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.85
|
| Rate for Payer: Multiplan Medicare/VA |
$22.64
|
| Rate for Payer: One Health Plan of WY PPO |
$40.26
|
| Rate for Payer: PacificSource Commercial |
$36.97
|
| Rate for Payer: PHCS PPO |
$40.26
|
| Rate for Payer: Three Rivers PPO |
$30.81
|
| Rate for Payer: TriWest Veterans Administration |
$23.83
|
| Rate for Payer: United Healthcare Commercial |
$35.74
|
| Rate for Payer: United Healthcare Medicare |
$23.83
|
| Rate for Payer: WINHealth Partners Commercial |
$40.26
|
| Rate for Payer: Wise Provider Network Commercial |
$39.03
|
|
|
BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION [94701]
|
Facility
|
IP
|
$41.08
|
|
|
Service Code
|
HCPCS J0666
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.76 |
| Max. Negotiated Rate |
$41.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$40.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$39.44
|
| Rate for Payer: Altius Commercial |
$39.44
|
| Rate for Payer: Beech Street Commercial |
$40.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.73
|
| Rate for Payer: Cash Price |
$28.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$39.85
|
| Rate for Payer: Cigna of WY Commercial |
$40.26
|
| Rate for Payer: Entrust Commercial |
$39.03
|
| Rate for Payer: First Choice Health Commercial |
$39.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.11
|
| Rate for Payer: HealthUtah PPO |
$41.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$39.85
|
| Rate for Payer: Multiplan Medicare/VA |
$25.76
|
| Rate for Payer: One Health Plan of WY PPO |
$40.26
|
| Rate for Payer: PacificSource Commercial |
$36.97
|
| Rate for Payer: PHCS PPO |
$40.26
|
| Rate for Payer: Three Rivers PPO |
$30.81
|
| Rate for Payer: TriWest Veterans Administration |
$27.11
|
| Rate for Payer: United Healthcare Commercial |
$35.74
|
| Rate for Payer: United Healthcare Medicare |
$27.11
|
| Rate for Payer: WINHealth Partners Commercial |
$39.03
|
| Rate for Payer: Wise Provider Network Commercial |
$39.03
|
|
|
BUPIVACAINE-MELOXICAM ER 200 MG-6 MG/7 ML SURGICAL SITE INSTILL SOLN [162344]
|
Facility
|
IP
|
$43.75
|
|
|
Service Code
|
NDC 4742630303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$43.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$42.00
|
| Rate for Payer: Altius Commercial |
$42.00
|
| Rate for Payer: Beech Street Commercial |
$42.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.92
|
| Rate for Payer: Cash Price |
$30.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$42.44
|
| Rate for Payer: Cigna of WY Commercial |
$42.88
|
| Rate for Payer: Entrust Commercial |
$41.56
|
| Rate for Payer: First Choice Health Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.88
|
| Rate for Payer: HealthUtah PPO |
$43.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.44
|
| Rate for Payer: Multiplan Medicare/VA |
$27.43
|
| Rate for Payer: One Health Plan of WY PPO |
$42.88
|
| Rate for Payer: PacificSource Commercial |
$39.38
|
| Rate for Payer: PHCS PPO |
$42.88
|
| Rate for Payer: Three Rivers PPO |
$32.81
|
| Rate for Payer: TriWest Veterans Administration |
$28.88
|
| Rate for Payer: United Healthcare Commercial |
$38.06
|
| Rate for Payer: United Healthcare Medicare |
$28.88
|
| Rate for Payer: WINHealth Partners Commercial |
$41.56
|
| Rate for Payer: Wise Provider Network Commercial |
$41.56
|
|
|
BUPIVACAINE-MELOXICAM ER 200 MG-6 MG/7 ML SURGICAL SITE INSTILL SOLN [162344]
|
Facility
|
OP
|
$43.75
|
|
|
Service Code
|
NDC 4742630303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.11 |
| Max. Negotiated Rate |
$43.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.88
|
| Rate for Payer: Aetna of WY Medicare |
$28.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$42.00
|
| Rate for Payer: Altius Commercial |
$42.00
|
| Rate for Payer: Beech Street Commercial |
$42.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.92
|
| Rate for Payer: Cash Price |
$30.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$42.44
|
| Rate for Payer: Cigna of WY Commercial |
$42.88
|
| Rate for Payer: Entrust Commercial |
$41.56
|
| Rate for Payer: First Choice Health Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.38
|
| Rate for Payer: HealthUtah PPO |
$43.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.44
|
| Rate for Payer: Multiplan Medicare/VA |
$24.11
|
| Rate for Payer: One Health Plan of WY PPO |
$42.88
|
| Rate for Payer: PacificSource Commercial |
$39.38
|
| Rate for Payer: PHCS PPO |
$42.88
|
| Rate for Payer: Three Rivers PPO |
$32.81
|
| Rate for Payer: TriWest Veterans Administration |
$25.38
|
| Rate for Payer: United Healthcare Commercial |
$38.06
|
| Rate for Payer: United Healthcare Medicare |
$25.38
|
| Rate for Payer: WINHealth Partners Commercial |
$42.88
|
| Rate for Payer: Wise Provider Network Commercial |
$41.56
|
|
|
BUPIVACAINE-MELOXICAM ER 200 MG-6 MG/7 ML SURGICAL SITE INSTILL SOLN [162344]
|
Facility
|
OP
|
$43.75
|
|
|
Service Code
|
NDC 4742630301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.11 |
| Max. Negotiated Rate |
$43.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.88
|
| Rate for Payer: Aetna of WY Medicare |
$28.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$42.00
|
| Rate for Payer: Altius Commercial |
$42.00
|
| Rate for Payer: Beech Street Commercial |
$42.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.92
|
| Rate for Payer: Cash Price |
$30.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$42.44
|
| Rate for Payer: Cigna of WY Commercial |
$42.88
|
| Rate for Payer: Entrust Commercial |
$41.56
|
| Rate for Payer: First Choice Health Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.38
|
| Rate for Payer: HealthUtah PPO |
$43.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.44
|
| Rate for Payer: Multiplan Medicare/VA |
$24.11
|
| Rate for Payer: One Health Plan of WY PPO |
$42.88
|
| Rate for Payer: PacificSource Commercial |
$39.38
|
| Rate for Payer: PHCS PPO |
$42.88
|
| Rate for Payer: Three Rivers PPO |
$32.81
|
| Rate for Payer: TriWest Veterans Administration |
$25.38
|
| Rate for Payer: United Healthcare Commercial |
$38.06
|
| Rate for Payer: United Healthcare Medicare |
$25.38
|
| Rate for Payer: WINHealth Partners Commercial |
$42.88
|
| Rate for Payer: Wise Provider Network Commercial |
$41.56
|
|
|
BUPIVACAINE-MELOXICAM ER 200 MG-6 MG/7 ML SURGICAL SITE INSTILL SOLN [162344]
|
Facility
|
IP
|
$43.75
|
|
|
Service Code
|
NDC 4742630301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.43 |
| Max. Negotiated Rate |
$43.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$42.00
|
| Rate for Payer: Altius Commercial |
$42.00
|
| Rate for Payer: Beech Street Commercial |
$42.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.92
|
| Rate for Payer: Cash Price |
$30.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$42.44
|
| Rate for Payer: Cigna of WY Commercial |
$42.88
|
| Rate for Payer: Entrust Commercial |
$41.56
|
| Rate for Payer: First Choice Health Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.88
|
| Rate for Payer: HealthUtah PPO |
$43.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$42.44
|
| Rate for Payer: Multiplan Medicare/VA |
$27.43
|
| Rate for Payer: One Health Plan of WY PPO |
$42.88
|
| Rate for Payer: PacificSource Commercial |
$39.38
|
| Rate for Payer: PHCS PPO |
$42.88
|
| Rate for Payer: Three Rivers PPO |
$32.81
|
| Rate for Payer: TriWest Veterans Administration |
$28.88
|
| Rate for Payer: United Healthcare Commercial |
$38.06
|
| Rate for Payer: United Healthcare Medicare |
$28.88
|
| Rate for Payer: WINHealth Partners Commercial |
$41.56
|
| Rate for Payer: Wise Provider Network Commercial |
$41.56
|
|
|
BUPIVACAINE-MELOXICAM ER 400 MG-12 MG/14 ML SURGICAL SITE INSTILL SOLN [162341]
|
Facility
|
OP
|
$43.18
|
|
|
Service Code
|
NDC 4742630104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.79 |
| Max. Negotiated Rate |
$43.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.32
|
| Rate for Payer: Aetna of WY Medicare |
$28.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$41.45
|
| Rate for Payer: Altius Commercial |
$41.45
|
| Rate for Payer: Beech Street Commercial |
$42.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.45
|
| Rate for Payer: Cash Price |
$30.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.88
|
| Rate for Payer: Cigna of WY Commercial |
$42.32
|
| Rate for Payer: Entrust Commercial |
$41.02
|
| Rate for Payer: First Choice Health Commercial |
$41.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.04
|
| Rate for Payer: HealthUtah PPO |
$43.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.88
|
| Rate for Payer: Multiplan Medicare/VA |
$23.79
|
| Rate for Payer: One Health Plan of WY PPO |
$42.32
|
| Rate for Payer: PacificSource Commercial |
$38.86
|
| Rate for Payer: PHCS PPO |
$42.32
|
| Rate for Payer: Three Rivers PPO |
$32.38
|
| Rate for Payer: TriWest Veterans Administration |
$25.04
|
| Rate for Payer: United Healthcare Commercial |
$37.57
|
| Rate for Payer: United Healthcare Medicare |
$25.04
|
| Rate for Payer: WINHealth Partners Commercial |
$42.32
|
| Rate for Payer: Wise Provider Network Commercial |
$41.02
|
|
|
BUPIVACAINE-MELOXICAM ER 400 MG-12 MG/14 ML SURGICAL SITE INSTILL SOLN [162341]
|
Facility
|
IP
|
$43.18
|
|
|
Service Code
|
NDC 4742630104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.07 |
| Max. Negotiated Rate |
$43.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$41.45
|
| Rate for Payer: Altius Commercial |
$41.45
|
| Rate for Payer: Beech Street Commercial |
$42.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.45
|
| Rate for Payer: Cash Price |
$30.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.88
|
| Rate for Payer: Cigna of WY Commercial |
$42.32
|
| Rate for Payer: Entrust Commercial |
$41.02
|
| Rate for Payer: First Choice Health Commercial |
$41.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.50
|
| Rate for Payer: HealthUtah PPO |
$43.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.88
|
| Rate for Payer: Multiplan Medicare/VA |
$27.07
|
| Rate for Payer: One Health Plan of WY PPO |
$42.32
|
| Rate for Payer: PacificSource Commercial |
$38.86
|
| Rate for Payer: PHCS PPO |
$42.32
|
| Rate for Payer: Three Rivers PPO |
$32.38
|
| Rate for Payer: TriWest Veterans Administration |
$28.50
|
| Rate for Payer: United Healthcare Commercial |
$37.57
|
| Rate for Payer: United Healthcare Medicare |
$28.50
|
| Rate for Payer: WINHealth Partners Commercial |
$41.02
|
| Rate for Payer: Wise Provider Network Commercial |
$41.02
|
|
|
BUPIVACAINE-MELOXICAM ER 400 MG-12 MG/14 ML SURGICAL SITE INSTILL SOLN [162341]
|
Facility
|
OP
|
$43.18
|
|
|
Service Code
|
NDC 4742630102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$23.79 |
| Max. Negotiated Rate |
$43.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.32
|
| Rate for Payer: Aetna of WY Medicare |
$28.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$41.45
|
| Rate for Payer: Altius Commercial |
$41.45
|
| Rate for Payer: Beech Street Commercial |
$42.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.45
|
| Rate for Payer: Cash Price |
$30.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.88
|
| Rate for Payer: Cigna of WY Commercial |
$42.32
|
| Rate for Payer: Entrust Commercial |
$41.02
|
| Rate for Payer: First Choice Health Commercial |
$41.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.04
|
| Rate for Payer: HealthUtah PPO |
$43.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.88
|
| Rate for Payer: Multiplan Medicare/VA |
$23.79
|
| Rate for Payer: One Health Plan of WY PPO |
$42.32
|
| Rate for Payer: PacificSource Commercial |
$38.86
|
| Rate for Payer: PHCS PPO |
$42.32
|
| Rate for Payer: Three Rivers PPO |
$32.38
|
| Rate for Payer: TriWest Veterans Administration |
$25.04
|
| Rate for Payer: United Healthcare Commercial |
$37.57
|
| Rate for Payer: United Healthcare Medicare |
$25.04
|
| Rate for Payer: WINHealth Partners Commercial |
$42.32
|
| Rate for Payer: Wise Provider Network Commercial |
$41.02
|
|
|
BUPIVACAINE-MELOXICAM ER 400 MG-12 MG/14 ML SURGICAL SITE INSTILL SOLN [162341]
|
Facility
|
IP
|
$43.18
|
|
|
Service Code
|
NDC 4742630102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.07 |
| Max. Negotiated Rate |
$43.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$41.45
|
| Rate for Payer: Altius Commercial |
$41.45
|
| Rate for Payer: Beech Street Commercial |
$42.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$35.45
|
| Rate for Payer: Cash Price |
$30.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.88
|
| Rate for Payer: Cigna of WY Commercial |
$42.32
|
| Rate for Payer: Entrust Commercial |
$41.02
|
| Rate for Payer: First Choice Health Commercial |
$41.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$41.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.50
|
| Rate for Payer: HealthUtah PPO |
$43.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.88
|
| Rate for Payer: Multiplan Medicare/VA |
$27.07
|
| Rate for Payer: One Health Plan of WY PPO |
$42.32
|
| Rate for Payer: PacificSource Commercial |
$38.86
|
| Rate for Payer: PHCS PPO |
$42.32
|
| Rate for Payer: Three Rivers PPO |
$32.38
|
| Rate for Payer: TriWest Veterans Administration |
$28.50
|
| Rate for Payer: United Healthcare Commercial |
$37.57
|
| Rate for Payer: United Healthcare Medicare |
$28.50
|
| Rate for Payer: WINHealth Partners Commercial |
$41.02
|
| Rate for Payer: Wise Provider Network Commercial |
$41.02
|
|
|
BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [28406]
|
Facility
|
IP
|
$15.30
|
|
|
Service Code
|
NDC 0409115919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.59 |
| Max. Negotiated Rate |
$15.30 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$14.99
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.69
|
| Rate for Payer: Altius Commercial |
$14.69
|
| Rate for Payer: Beech Street Commercial |
$14.99
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.56
|
| Rate for Payer: Cash Price |
$10.71
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.84
|
| Rate for Payer: Cigna of WY Commercial |
$14.99
|
| Rate for Payer: Entrust Commercial |
$14.54
|
| Rate for Payer: First Choice Health Commercial |
$14.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.54
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.10
|
| Rate for Payer: HealthUtah PPO |
$15.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.84
|
| Rate for Payer: Multiplan Medicare/VA |
$9.59
|
| Rate for Payer: One Health Plan of WY PPO |
$14.99
|
| Rate for Payer: PacificSource Commercial |
$13.77
|
| Rate for Payer: PHCS PPO |
$14.99
|
| Rate for Payer: Three Rivers PPO |
$11.48
|
| Rate for Payer: TriWest Veterans Administration |
$10.10
|
| Rate for Payer: United Healthcare Commercial |
$13.31
|
| Rate for Payer: United Healthcare Medicare |
$10.10
|
| Rate for Payer: WINHealth Partners Commercial |
$14.54
|
| Rate for Payer: Wise Provider Network Commercial |
$14.54
|
|
