|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [18567]
|
Facility
|
OP
|
$15.67
|
|
|
Service Code
|
NDC 0409014701
|
|
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
|
IP
|
$15.67
|
|
|
Service Code
|
NDC 0409318201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.36
|
| 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 |
$10.34
|
| Rate for Payer: HealthUtah PPO |
$15.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.20
|
| Rate for Payer: Multiplan Medicare/VA |
$9.83
|
| 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 |
$10.34
|
| Rate for Payer: United Healthcare Commercial |
$13.63
|
| Rate for Payer: United Healthcare Medicare |
$10.34
|
| Rate for Payer: WINHealth Partners Commercial |
$14.89
|
| Rate for Payer: Wise Provider Network Commercial |
$14.89
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [18567]
|
Facility
|
IP
|
$15.67
|
|
|
Service Code
|
NDC 0409014701
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.36
|
| 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 |
$10.34
|
| Rate for Payer: HealthUtah PPO |
$15.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.20
|
| Rate for Payer: Multiplan Medicare/VA |
$9.83
|
| 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 |
$10.34
|
| Rate for Payer: United Healthcare Commercial |
$13.63
|
| Rate for Payer: United Healthcare Medicare |
$10.34
|
| Rate for Payer: WINHealth Partners Commercial |
$14.89
|
| Rate for Payer: Wise Provider Network Commercial |
$14.89
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [18567]
|
Facility
|
IP
|
$15.67
|
|
|
Service Code
|
NDC 0409318211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.83 |
| Max. Negotiated Rate |
$15.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.36
|
| 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 |
$10.34
|
| Rate for Payer: HealthUtah PPO |
$15.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.20
|
| Rate for Payer: Multiplan Medicare/VA |
$9.83
|
| 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 |
$10.34
|
| Rate for Payer: United Healthcare Commercial |
$13.63
|
| Rate for Payer: United Healthcare Medicare |
$10.34
|
| Rate for Payer: WINHealth Partners Commercial |
$14.89
|
| Rate for Payer: Wise Provider Network Commercial |
$14.89
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [18567]
|
Facility
|
OP
|
$16.14
|
|
|
Service Code
|
NDC 6332348303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$16.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.82
|
| Rate for Payer: Aetna of WY Medicare |
$10.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.49
|
| Rate for Payer: Altius Commercial |
$15.49
|
| Rate for Payer: Beech Street Commercial |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.25
|
| Rate for Payer: Cash Price |
$11.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.66
|
| Rate for Payer: Cigna of WY Commercial |
$15.82
|
| Rate for Payer: Entrust Commercial |
$15.33
|
| Rate for Payer: First Choice Health Commercial |
$15.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.36
|
| Rate for Payer: HealthUtah PPO |
$16.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.66
|
| Rate for Payer: Multiplan Medicare/VA |
$8.89
|
| Rate for Payer: One Health Plan of WY PPO |
$15.82
|
| Rate for Payer: PacificSource Commercial |
$14.53
|
| Rate for Payer: PHCS PPO |
$15.82
|
| Rate for Payer: Three Rivers PPO |
$12.10
|
| Rate for Payer: TriWest Veterans Administration |
$9.36
|
| Rate for Payer: United Healthcare Commercial |
$14.04
|
| Rate for Payer: United Healthcare Medicare |
$9.36
|
| Rate for Payer: WINHealth Partners Commercial |
$15.82
|
| Rate for Payer: Wise Provider Network Commercial |
$15.33
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [18567]
|
Facility
|
IP
|
$16.14
|
|
|
Service Code
|
NDC 6332348303
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$16.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.49
|
| Rate for Payer: Altius Commercial |
$15.49
|
| Rate for Payer: Beech Street Commercial |
$15.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.25
|
| Rate for Payer: Cash Price |
$11.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.66
|
| Rate for Payer: Cigna of WY Commercial |
$15.82
|
| Rate for Payer: Entrust Commercial |
$15.33
|
| Rate for Payer: First Choice Health Commercial |
$15.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.65
|
| Rate for Payer: HealthUtah PPO |
$16.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.66
|
| Rate for Payer: Multiplan Medicare/VA |
$10.12
|
| Rate for Payer: One Health Plan of WY PPO |
$15.82
|
| Rate for Payer: PacificSource Commercial |
$14.53
|
| Rate for Payer: PHCS PPO |
$15.82
|
| Rate for Payer: Three Rivers PPO |
$12.10
|
| Rate for Payer: TriWest Veterans Administration |
$10.65
|
| Rate for Payer: United Healthcare Commercial |
$14.04
|
| Rate for Payer: United Healthcare Medicare |
$10.65
|
| Rate for Payer: WINHealth Partners Commercial |
$15.33
|
| Rate for Payer: Wise Provider Network Commercial |
$15.33
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [54095]
|
Facility
|
OP
|
$3.97
|
|
|
Service Code
|
NDC 2502167376
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.89
|
| Rate for Payer: Aetna of WY Medicare |
$2.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.81
|
| Rate for Payer: Altius Commercial |
$3.81
|
| Rate for Payer: Beech Street Commercial |
$3.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.26
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.85
|
| Rate for Payer: Cigna of WY Commercial |
$3.89
|
| Rate for Payer: Entrust Commercial |
$3.77
|
| Rate for Payer: First Choice Health Commercial |
$3.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.30
|
| Rate for Payer: HealthUtah PPO |
$3.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.85
|
| Rate for Payer: Multiplan Medicare/VA |
$2.19
|
| Rate for Payer: One Health Plan of WY PPO |
$3.89
|
| Rate for Payer: PacificSource Commercial |
$3.57
|
| Rate for Payer: PHCS PPO |
$3.89
|
| Rate for Payer: Three Rivers PPO |
$2.98
|
| Rate for Payer: TriWest Veterans Administration |
$2.30
|
| Rate for Payer: United Healthcare Commercial |
$3.45
|
| Rate for Payer: United Healthcare Medicare |
$2.30
|
| Rate for Payer: WINHealth Partners Commercial |
$3.89
|
| Rate for Payer: Wise Provider Network Commercial |
$3.77
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [54095]
|
Facility
|
OP
|
$2.31
|
|
|
Service Code
|
NDC 2502167377
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.27 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.26
|
| Rate for Payer: Aetna of WY Medicare |
$1.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.22
|
| Rate for Payer: Altius Commercial |
$2.22
|
| Rate for Payer: Beech Street Commercial |
$2.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.90
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.24
|
| Rate for Payer: Cigna of WY Commercial |
$2.26
|
| Rate for Payer: Entrust Commercial |
$2.19
|
| Rate for Payer: First Choice Health Commercial |
$2.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.34
|
| Rate for Payer: HealthUtah PPO |
$2.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.24
|
| Rate for Payer: Multiplan Medicare/VA |
$1.27
|
| Rate for Payer: One Health Plan of WY PPO |
$2.26
|
| Rate for Payer: PacificSource Commercial |
$2.08
|
| Rate for Payer: PHCS PPO |
$2.26
|
| Rate for Payer: Three Rivers PPO |
$1.73
|
| Rate for Payer: TriWest Veterans Administration |
$1.34
|
| Rate for Payer: United Healthcare Commercial |
$2.01
|
| Rate for Payer: United Healthcare Medicare |
$1.34
|
| Rate for Payer: WINHealth Partners Commercial |
$2.26
|
| Rate for Payer: Wise Provider Network Commercial |
$2.19
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [54095]
|
Facility
|
IP
|
$2.31
|
|
|
Service Code
|
NDC 2502167377
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.22
|
| Rate for Payer: Altius Commercial |
$2.22
|
| Rate for Payer: Beech Street Commercial |
$2.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.90
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.24
|
| Rate for Payer: Cigna of WY Commercial |
$2.26
|
| Rate for Payer: Entrust Commercial |
$2.19
|
| Rate for Payer: First Choice Health Commercial |
$2.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.52
|
| Rate for Payer: HealthUtah PPO |
$2.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.24
|
| Rate for Payer: Multiplan Medicare/VA |
$1.45
|
| Rate for Payer: One Health Plan of WY PPO |
$2.26
|
| Rate for Payer: PacificSource Commercial |
$2.08
|
| Rate for Payer: PHCS PPO |
$2.26
|
| Rate for Payer: Three Rivers PPO |
$1.73
|
| Rate for Payer: TriWest Veterans Administration |
$1.52
|
| Rate for Payer: United Healthcare Commercial |
$2.01
|
| Rate for Payer: United Healthcare Medicare |
$1.52
|
| Rate for Payer: WINHealth Partners Commercial |
$2.19
|
| Rate for Payer: Wise Provider Network Commercial |
$2.19
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [54095]
|
Facility
|
IP
|
$3.97
|
|
|
Service Code
|
NDC 2502167376
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.49 |
| Max. Negotiated Rate |
$3.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.81
|
| Rate for Payer: Altius Commercial |
$3.81
|
| Rate for Payer: Beech Street Commercial |
$3.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.26
|
| Rate for Payer: Cash Price |
$2.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.85
|
| Rate for Payer: Cigna of WY Commercial |
$3.89
|
| Rate for Payer: Entrust Commercial |
$3.77
|
| Rate for Payer: First Choice Health Commercial |
$3.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.62
|
| Rate for Payer: HealthUtah PPO |
$3.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.85
|
| Rate for Payer: Multiplan Medicare/VA |
$2.49
|
| Rate for Payer: One Health Plan of WY PPO |
$3.89
|
| Rate for Payer: PacificSource Commercial |
$3.57
|
| Rate for Payer: PHCS PPO |
$3.89
|
| Rate for Payer: Three Rivers PPO |
$2.98
|
| Rate for Payer: TriWest Veterans Administration |
$2.62
|
| Rate for Payer: United Healthcare Commercial |
$3.45
|
| Rate for Payer: United Healthcare Medicare |
$2.62
|
| Rate for Payer: WINHealth Partners Commercial |
$3.77
|
| Rate for Payer: Wise Provider Network Commercial |
$3.77
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [97430]
|
Facility
|
IP
|
$1.20
|
|
|
Service Code
|
NDC 6438078933
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.18
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.15
|
| Rate for Payer: Altius Commercial |
$1.15
|
| Rate for Payer: Beech Street Commercial |
$1.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.99
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.16
|
| Rate for Payer: Cigna of WY Commercial |
$1.18
|
| Rate for Payer: Entrust Commercial |
$1.14
|
| Rate for Payer: First Choice Health Commercial |
$1.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.79
|
| Rate for Payer: HealthUtah PPO |
$1.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.75
|
| Rate for Payer: One Health Plan of WY PPO |
$1.18
|
| Rate for Payer: PacificSource Commercial |
$1.08
|
| Rate for Payer: PHCS PPO |
$1.18
|
| Rate for Payer: Three Rivers PPO |
$0.90
|
| Rate for Payer: TriWest Veterans Administration |
$0.79
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Medicare |
$0.79
|
| Rate for Payer: WINHealth Partners Commercial |
$1.14
|
| Rate for Payer: Wise Provider Network Commercial |
$1.14
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [97430]
|
Facility
|
IP
|
$4.48
|
|
|
Service Code
|
NDC 6846241827
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.30
|
| Rate for Payer: Altius Commercial |
$4.30
|
| Rate for Payer: Beech Street Commercial |
$4.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.35
|
| Rate for Payer: Cigna of WY Commercial |
$4.39
|
| Rate for Payer: Entrust Commercial |
$4.26
|
| Rate for Payer: First Choice Health Commercial |
$4.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.96
|
| Rate for Payer: HealthUtah PPO |
$4.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.35
|
| Rate for Payer: Multiplan Medicare/VA |
$2.81
|
| Rate for Payer: One Health Plan of WY PPO |
$4.39
|
| Rate for Payer: PacificSource Commercial |
$4.03
|
| Rate for Payer: PHCS PPO |
$4.39
|
| Rate for Payer: Three Rivers PPO |
$3.36
|
| Rate for Payer: TriWest Veterans Administration |
$2.96
|
| Rate for Payer: United Healthcare Commercial |
$3.90
|
| Rate for Payer: United Healthcare Medicare |
$2.96
|
| Rate for Payer: WINHealth Partners Commercial |
$4.26
|
| Rate for Payer: Wise Provider Network Commercial |
$4.26
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [97430]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 6516291853
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.61
|
| Rate for Payer: Aetna of WY Medicare |
$1.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.57
|
| Rate for Payer: Altius Commercial |
$1.57
|
| Rate for Payer: Beech Street Commercial |
$1.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.59
|
| Rate for Payer: Cigna of WY Commercial |
$1.61
|
| Rate for Payer: Entrust Commercial |
$1.56
|
| Rate for Payer: First Choice Health Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.95
|
| Rate for Payer: HealthUtah PPO |
$1.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.59
|
| Rate for Payer: Multiplan Medicare/VA |
$0.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1.61
|
| Rate for Payer: PacificSource Commercial |
$1.48
|
| Rate for Payer: PHCS PPO |
$1.61
|
| Rate for Payer: Three Rivers PPO |
$1.23
|
| Rate for Payer: TriWest Veterans Administration |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$0.95
|
| Rate for Payer: WINHealth Partners Commercial |
$1.61
|
| Rate for Payer: Wise Provider Network Commercial |
$1.56
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [97430]
|
Facility
|
OP
|
$4.00
|
|
|
Service Code
|
NDC 5167230085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.92
|
| Rate for Payer: Aetna of WY Medicare |
$2.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.84
|
| Rate for Payer: Altius Commercial |
$3.84
|
| Rate for Payer: Beech Street Commercial |
$3.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.28
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.88
|
| Rate for Payer: Cigna of WY Commercial |
$3.92
|
| Rate for Payer: Entrust Commercial |
$3.80
|
| Rate for Payer: First Choice Health Commercial |
$3.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.32
|
| Rate for Payer: HealthUtah PPO |
$4.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.88
|
| Rate for Payer: Multiplan Medicare/VA |
$2.20
|
| Rate for Payer: One Health Plan of WY PPO |
$3.92
|
| Rate for Payer: PacificSource Commercial |
$3.60
|
| Rate for Payer: PHCS PPO |
$3.92
|
| Rate for Payer: Three Rivers PPO |
$3.00
|
| Rate for Payer: TriWest Veterans Administration |
$2.32
|
| Rate for Payer: United Healthcare Commercial |
$3.48
|
| Rate for Payer: United Healthcare Medicare |
$2.32
|
| Rate for Payer: WINHealth Partners Commercial |
$3.92
|
| Rate for Payer: Wise Provider Network Commercial |
$3.80
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [97430]
|
Facility
|
OP
|
$4.48
|
|
|
Service Code
|
NDC 6846241827
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.47 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.39
|
| Rate for Payer: Aetna of WY Medicare |
$2.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4.30
|
| Rate for Payer: Altius Commercial |
$4.30
|
| Rate for Payer: Beech Street Commercial |
$4.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.68
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.35
|
| Rate for Payer: Cigna of WY Commercial |
$4.39
|
| Rate for Payer: Entrust Commercial |
$4.26
|
| Rate for Payer: First Choice Health Commercial |
$4.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.60
|
| Rate for Payer: HealthUtah PPO |
$4.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.35
|
| Rate for Payer: Multiplan Medicare/VA |
$2.47
|
| Rate for Payer: One Health Plan of WY PPO |
$4.39
|
| Rate for Payer: PacificSource Commercial |
$4.03
|
| Rate for Payer: PHCS PPO |
$4.39
|
| Rate for Payer: Three Rivers PPO |
$3.36
|
| Rate for Payer: TriWest Veterans Administration |
$2.60
|
| Rate for Payer: United Healthcare Commercial |
$3.90
|
| Rate for Payer: United Healthcare Medicare |
$2.60
|
| Rate for Payer: WINHealth Partners Commercial |
$4.39
|
| Rate for Payer: Wise Provider Network Commercial |
$4.26
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [97430]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 6516291853
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$1.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.57
|
| Rate for Payer: Altius Commercial |
$1.57
|
| Rate for Payer: Beech Street Commercial |
$1.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.35
|
| Rate for Payer: Cash Price |
$1.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.59
|
| Rate for Payer: Cigna of WY Commercial |
$1.61
|
| Rate for Payer: Entrust Commercial |
$1.56
|
| Rate for Payer: First Choice Health Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.56
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.08
|
| Rate for Payer: HealthUtah PPO |
$1.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.59
|
| Rate for Payer: Multiplan Medicare/VA |
$1.03
|
| Rate for Payer: One Health Plan of WY PPO |
$1.61
|
| Rate for Payer: PacificSource Commercial |
$1.48
|
| Rate for Payer: PHCS PPO |
$1.61
|
| Rate for Payer: Three Rivers PPO |
$1.23
|
| Rate for Payer: TriWest Veterans Administration |
$1.08
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$1.08
|
| Rate for Payer: WINHealth Partners Commercial |
$1.56
|
| Rate for Payer: Wise Provider Network Commercial |
$1.56
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [97430]
|
Facility
|
IP
|
$4.00
|
|
|
Service Code
|
NDC 5167230085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.84
|
| Rate for Payer: Altius Commercial |
$3.84
|
| Rate for Payer: Beech Street Commercial |
$3.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.28
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.88
|
| Rate for Payer: Cigna of WY Commercial |
$3.92
|
| Rate for Payer: Entrust Commercial |
$3.80
|
| Rate for Payer: First Choice Health Commercial |
$3.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.64
|
| Rate for Payer: HealthUtah PPO |
$4.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.88
|
| Rate for Payer: Multiplan Medicare/VA |
$2.51
|
| Rate for Payer: One Health Plan of WY PPO |
$3.92
|
| Rate for Payer: PacificSource Commercial |
$3.60
|
| Rate for Payer: PHCS PPO |
$3.92
|
| Rate for Payer: Three Rivers PPO |
$3.00
|
| Rate for Payer: TriWest Veterans Administration |
$2.64
|
| Rate for Payer: United Healthcare Commercial |
$3.48
|
| Rate for Payer: United Healthcare Medicare |
$2.64
|
| Rate for Payer: WINHealth Partners Commercial |
$3.80
|
| Rate for Payer: Wise Provider Network Commercial |
$3.80
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [97430]
|
Facility
|
OP
|
$1.20
|
|
|
Service Code
|
NDC 6438078933
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.66 |
| Max. Negotiated Rate |
$1.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1.18
|
| Rate for Payer: Aetna of WY Medicare |
$0.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1.15
|
| Rate for Payer: Altius Commercial |
$1.15
|
| Rate for Payer: Beech Street Commercial |
$1.18
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.99
|
| Rate for Payer: Cash Price |
$0.84
|
| Rate for Payer: ChoiceCare Network Commercial |
$1.16
|
| Rate for Payer: Cigna of WY Commercial |
$1.18
|
| Rate for Payer: Entrust Commercial |
$1.14
|
| Rate for Payer: First Choice Health Commercial |
$1.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.70
|
| Rate for Payer: HealthUtah PPO |
$1.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1.16
|
| Rate for Payer: Multiplan Medicare/VA |
$0.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1.18
|
| Rate for Payer: PacificSource Commercial |
$1.08
|
| Rate for Payer: PHCS PPO |
$1.18
|
| Rate for Payer: Three Rivers PPO |
$0.90
|
| Rate for Payer: TriWest Veterans Administration |
$0.70
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Medicare |
$0.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1.18
|
| Rate for Payer: Wise Provider Network Commercial |
$1.14
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [13275]
|
Facility
|
OP
|
$9.42
|
|
|
Service Code
|
NDC 6516279104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.19 |
| Max. Negotiated Rate |
$9.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.23
|
| Rate for Payer: Aetna of WY Medicare |
$6.22
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.04
|
| Rate for Payer: Altius Commercial |
$9.04
|
| Rate for Payer: Beech Street Commercial |
$9.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.73
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.14
|
| Rate for Payer: Cigna of WY Commercial |
$9.23
|
| Rate for Payer: Entrust Commercial |
$8.95
|
| Rate for Payer: First Choice Health Commercial |
$8.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.46
|
| Rate for Payer: HealthUtah PPO |
$9.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.14
|
| Rate for Payer: Multiplan Medicare/VA |
$5.19
|
| Rate for Payer: One Health Plan of WY PPO |
$9.23
|
| Rate for Payer: PacificSource Commercial |
$8.48
|
| Rate for Payer: PHCS PPO |
$9.23
|
| Rate for Payer: Three Rivers PPO |
$7.06
|
| Rate for Payer: TriWest Veterans Administration |
$5.46
|
| Rate for Payer: United Healthcare Commercial |
$8.20
|
| Rate for Payer: United Healthcare Medicare |
$5.46
|
| Rate for Payer: WINHealth Partners Commercial |
$9.23
|
| Rate for Payer: Wise Provider Network Commercial |
$8.95
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [13275]
|
Facility
|
IP
|
$55.61
|
|
|
Service Code
|
NDC 6195900101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.87 |
| Max. Negotiated Rate |
$55.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.39
|
| Rate for Payer: Altius Commercial |
$53.39
|
| Rate for Payer: Beech Street Commercial |
$54.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.66
|
| Rate for Payer: Cash Price |
$38.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.94
|
| Rate for Payer: Cigna of WY Commercial |
$54.50
|
| Rate for Payer: Entrust Commercial |
$52.83
|
| Rate for Payer: First Choice Health Commercial |
$52.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.70
|
| Rate for Payer: HealthUtah PPO |
$55.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.94
|
| Rate for Payer: Multiplan Medicare/VA |
$34.87
|
| Rate for Payer: One Health Plan of WY PPO |
$54.50
|
| Rate for Payer: PacificSource Commercial |
$50.05
|
| Rate for Payer: PHCS PPO |
$54.50
|
| Rate for Payer: Three Rivers PPO |
$41.71
|
| Rate for Payer: TriWest Veterans Administration |
$36.70
|
| Rate for Payer: United Healthcare Commercial |
$48.38
|
| Rate for Payer: United Healthcare Medicare |
$36.70
|
| Rate for Payer: WINHealth Partners Commercial |
$52.83
|
| Rate for Payer: Wise Provider Network Commercial |
$52.83
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [13275]
|
Facility
|
OP
|
$55.61
|
|
|
Service Code
|
NDC 6195900101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$30.64 |
| Max. Negotiated Rate |
$55.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.50
|
| Rate for Payer: Aetna of WY Medicare |
$36.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.39
|
| Rate for Payer: Altius Commercial |
$53.39
|
| Rate for Payer: Beech Street Commercial |
$54.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.66
|
| Rate for Payer: Cash Price |
$38.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.94
|
| Rate for Payer: Cigna of WY Commercial |
$54.50
|
| Rate for Payer: Entrust Commercial |
$52.83
|
| Rate for Payer: First Choice Health Commercial |
$52.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.25
|
| Rate for Payer: HealthUtah PPO |
$55.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.94
|
| Rate for Payer: Multiplan Medicare/VA |
$30.64
|
| Rate for Payer: One Health Plan of WY PPO |
$54.50
|
| Rate for Payer: PacificSource Commercial |
$50.05
|
| Rate for Payer: PHCS PPO |
$54.50
|
| Rate for Payer: Three Rivers PPO |
$41.71
|
| Rate for Payer: TriWest Veterans Administration |
$32.25
|
| Rate for Payer: United Healthcare Commercial |
$48.38
|
| Rate for Payer: United Healthcare Medicare |
$32.25
|
| Rate for Payer: WINHealth Partners Commercial |
$54.50
|
| Rate for Payer: Wise Provider Network Commercial |
$52.83
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [13275]
|
Facility
|
IP
|
$26.72
|
|
|
Service Code
|
NDC 0378905516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.75 |
| Max. Negotiated Rate |
$26.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.65
|
| Rate for Payer: Altius Commercial |
$25.65
|
| Rate for Payer: Beech Street Commercial |
$26.19
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.94
|
| Rate for Payer: Cash Price |
$18.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.92
|
| Rate for Payer: Cigna of WY Commercial |
$26.19
|
| Rate for Payer: Entrust Commercial |
$25.38
|
| Rate for Payer: First Choice Health Commercial |
$25.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$25.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.64
|
| Rate for Payer: HealthUtah PPO |
$26.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.92
|
| Rate for Payer: Multiplan Medicare/VA |
$16.75
|
| Rate for Payer: One Health Plan of WY PPO |
$26.19
|
| Rate for Payer: PacificSource Commercial |
$24.05
|
| Rate for Payer: PHCS PPO |
$26.19
|
| Rate for Payer: Three Rivers PPO |
$20.04
|
| Rate for Payer: TriWest Veterans Administration |
$17.64
|
| Rate for Payer: United Healthcare Commercial |
$23.25
|
| Rate for Payer: United Healthcare Medicare |
$17.64
|
| Rate for Payer: WINHealth Partners Commercial |
$25.38
|
| Rate for Payer: Wise Provider Network Commercial |
$25.38
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [13275]
|
Facility
|
OP
|
$11.23
|
|
|
Service Code
|
NDC 0591352530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.19 |
| Max. Negotiated Rate |
$11.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11.01
|
| Rate for Payer: Aetna of WY Medicare |
$7.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.78
|
| Rate for Payer: Altius Commercial |
$10.78
|
| Rate for Payer: Beech Street Commercial |
$11.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.22
|
| Rate for Payer: Cash Price |
$7.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.89
|
| Rate for Payer: Cigna of WY Commercial |
$11.01
|
| Rate for Payer: Entrust Commercial |
$10.67
|
| Rate for Payer: First Choice Health Commercial |
$10.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.51
|
| Rate for Payer: HealthUtah PPO |
$11.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.89
|
| Rate for Payer: Multiplan Medicare/VA |
$6.19
|
| Rate for Payer: One Health Plan of WY PPO |
$11.01
|
| Rate for Payer: PacificSource Commercial |
$10.11
|
| Rate for Payer: PHCS PPO |
$11.01
|
| Rate for Payer: Three Rivers PPO |
$8.42
|
| Rate for Payer: TriWest Veterans Administration |
$6.51
|
| Rate for Payer: United Healthcare Commercial |
$9.77
|
| Rate for Payer: United Healthcare Medicare |
$6.51
|
| Rate for Payer: WINHealth Partners Commercial |
$11.01
|
| Rate for Payer: Wise Provider Network Commercial |
$10.67
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [13275]
|
Facility
|
IP
|
$11.23
|
|
|
Service Code
|
NDC 0603188010
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.04 |
| Max. Negotiated Rate |
$11.23 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$11.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.78
|
| Rate for Payer: Altius Commercial |
$10.78
|
| Rate for Payer: Beech Street Commercial |
$11.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.22
|
| Rate for Payer: Cash Price |
$7.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.89
|
| Rate for Payer: Cigna of WY Commercial |
$11.01
|
| Rate for Payer: Entrust Commercial |
$10.67
|
| Rate for Payer: First Choice Health Commercial |
$10.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.67
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.41
|
| Rate for Payer: HealthUtah PPO |
$11.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.89
|
| Rate for Payer: Multiplan Medicare/VA |
$7.04
|
| Rate for Payer: One Health Plan of WY PPO |
$11.01
|
| Rate for Payer: PacificSource Commercial |
$10.11
|
| Rate for Payer: PHCS PPO |
$11.01
|
| Rate for Payer: Three Rivers PPO |
$8.42
|
| Rate for Payer: TriWest Veterans Administration |
$7.41
|
| Rate for Payer: United Healthcare Commercial |
$9.77
|
| Rate for Payer: United Healthcare Medicare |
$7.41
|
| Rate for Payer: WINHealth Partners Commercial |
$10.67
|
| Rate for Payer: Wise Provider Network Commercial |
$10.67
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [13275]
|
Facility
|
IP
|
$9.42
|
|
|
Service Code
|
NDC 6516279104
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.91 |
| Max. Negotiated Rate |
$9.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$9.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$9.04
|
| Rate for Payer: Altius Commercial |
$9.04
|
| Rate for Payer: Beech Street Commercial |
$9.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$7.73
|
| Rate for Payer: Cash Price |
$6.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$9.14
|
| Rate for Payer: Cigna of WY Commercial |
$9.23
|
| Rate for Payer: Entrust Commercial |
$8.95
|
| Rate for Payer: First Choice Health Commercial |
$8.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.22
|
| Rate for Payer: HealthUtah PPO |
$9.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$9.14
|
| Rate for Payer: Multiplan Medicare/VA |
$5.91
|
| Rate for Payer: One Health Plan of WY PPO |
$9.23
|
| Rate for Payer: PacificSource Commercial |
$8.48
|
| Rate for Payer: PHCS PPO |
$9.23
|
| Rate for Payer: Three Rivers PPO |
$7.06
|
| Rate for Payer: TriWest Veterans Administration |
$6.22
|
| Rate for Payer: United Healthcare Commercial |
$8.20
|
| Rate for Payer: United Healthcare Medicare |
$6.22
|
| Rate for Payer: WINHealth Partners Commercial |
$8.95
|
| Rate for Payer: Wise Provider Network Commercial |
$8.95
|
|
