|
LIDOCAINE 5 % TOPICAL PATCH [13275]
|
Facility
|
OP
|
$11.23
|
|
|
Service Code
|
NDC 0603188010
|
|
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 0591352511
|
|
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 6516279108
|
|
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
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [13275]
|
Facility
|
OP
|
$9.42
|
|
|
Service Code
|
NDC 6516279108
|
|
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
|
OP
|
$11.23
|
|
|
Service Code
|
NDC 0591352511
|
|
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
|
OP
|
$26.72
|
|
|
Service Code
|
NDC 0378905516
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.72 |
| Max. Negotiated Rate |
$26.72 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$26.19
|
| Rate for Payer: Aetna of WY Medicare |
$17.64
|
| 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 |
$15.50
|
| Rate for Payer: HealthUtah PPO |
$26.72
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.92
|
| Rate for Payer: Multiplan Medicare/VA |
$14.72
|
| 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 |
$15.50
|
| Rate for Payer: United Healthcare Commercial |
$23.25
|
| Rate for Payer: United Healthcare Medicare |
$15.50
|
| Rate for Payer: WINHealth Partners Commercial |
$26.19
|
| Rate for Payer: Wise Provider Network Commercial |
$25.38
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [13275]
|
Facility
|
IP
|
$11.23
|
|
|
Service Code
|
NDC 0591352530
|
|
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-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [2281]
|
Facility
|
IP
|
$16.01
|
|
|
Service Code
|
NDC 0409318311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$16.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.37
|
| Rate for Payer: Altius Commercial |
$15.37
|
| Rate for Payer: Beech Street Commercial |
$15.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.14
|
| Rate for Payer: Cash Price |
$11.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.53
|
| Rate for Payer: Cigna of WY Commercial |
$15.69
|
| Rate for Payer: Entrust Commercial |
$15.21
|
| Rate for Payer: First Choice Health Commercial |
$15.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.57
|
| Rate for Payer: HealthUtah PPO |
$16.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.53
|
| Rate for Payer: Multiplan Medicare/VA |
$10.04
|
| Rate for Payer: One Health Plan of WY PPO |
$15.69
|
| Rate for Payer: PacificSource Commercial |
$14.41
|
| Rate for Payer: PHCS PPO |
$15.69
|
| Rate for Payer: Three Rivers PPO |
$12.01
|
| Rate for Payer: TriWest Veterans Administration |
$10.57
|
| Rate for Payer: United Healthcare Commercial |
$13.93
|
| Rate for Payer: United Healthcare Medicare |
$10.57
|
| Rate for Payer: WINHealth Partners Commercial |
$15.21
|
| Rate for Payer: Wise Provider Network Commercial |
$15.21
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [2281]
|
Facility
|
IP
|
$16.01
|
|
|
Service Code
|
NDC 0409318301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.04 |
| Max. Negotiated Rate |
$16.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.37
|
| Rate for Payer: Altius Commercial |
$15.37
|
| Rate for Payer: Beech Street Commercial |
$15.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.14
|
| Rate for Payer: Cash Price |
$11.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.53
|
| Rate for Payer: Cigna of WY Commercial |
$15.69
|
| Rate for Payer: Entrust Commercial |
$15.21
|
| Rate for Payer: First Choice Health Commercial |
$15.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.57
|
| Rate for Payer: HealthUtah PPO |
$16.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.53
|
| Rate for Payer: Multiplan Medicare/VA |
$10.04
|
| Rate for Payer: One Health Plan of WY PPO |
$15.69
|
| Rate for Payer: PacificSource Commercial |
$14.41
|
| Rate for Payer: PHCS PPO |
$15.69
|
| Rate for Payer: Three Rivers PPO |
$12.01
|
| Rate for Payer: TriWest Veterans Administration |
$10.57
|
| Rate for Payer: United Healthcare Commercial |
$13.93
|
| Rate for Payer: United Healthcare Medicare |
$10.57
|
| Rate for Payer: WINHealth Partners Commercial |
$15.21
|
| Rate for Payer: Wise Provider Network Commercial |
$15.21
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [2281]
|
Facility
|
OP
|
$16.01
|
|
|
Service Code
|
NDC 0409318311
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$16.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.69
|
| Rate for Payer: Aetna of WY Medicare |
$10.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.37
|
| Rate for Payer: Altius Commercial |
$15.37
|
| Rate for Payer: Beech Street Commercial |
$15.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.14
|
| Rate for Payer: Cash Price |
$11.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.53
|
| Rate for Payer: Cigna of WY Commercial |
$15.69
|
| Rate for Payer: Entrust Commercial |
$15.21
|
| Rate for Payer: First Choice Health Commercial |
$15.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.29
|
| Rate for Payer: HealthUtah PPO |
$16.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.53
|
| Rate for Payer: Multiplan Medicare/VA |
$8.82
|
| Rate for Payer: One Health Plan of WY PPO |
$15.69
|
| Rate for Payer: PacificSource Commercial |
$14.41
|
| Rate for Payer: PHCS PPO |
$15.69
|
| Rate for Payer: Three Rivers PPO |
$12.01
|
| Rate for Payer: TriWest Veterans Administration |
$9.29
|
| Rate for Payer: United Healthcare Commercial |
$13.93
|
| Rate for Payer: United Healthcare Medicare |
$9.29
|
| Rate for Payer: WINHealth Partners Commercial |
$15.69
|
| Rate for Payer: Wise Provider Network Commercial |
$15.21
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [2281]
|
Facility
|
OP
|
$16.01
|
|
|
Service Code
|
NDC 0409318301
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$16.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.69
|
| Rate for Payer: Aetna of WY Medicare |
$10.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.37
|
| Rate for Payer: Altius Commercial |
$15.37
|
| Rate for Payer: Beech Street Commercial |
$15.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.14
|
| Rate for Payer: Cash Price |
$11.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.53
|
| Rate for Payer: Cigna of WY Commercial |
$15.69
|
| Rate for Payer: Entrust Commercial |
$15.21
|
| Rate for Payer: First Choice Health Commercial |
$15.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.21
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.29
|
| Rate for Payer: HealthUtah PPO |
$16.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.53
|
| Rate for Payer: Multiplan Medicare/VA |
$8.82
|
| Rate for Payer: One Health Plan of WY PPO |
$15.69
|
| Rate for Payer: PacificSource Commercial |
$14.41
|
| Rate for Payer: PHCS PPO |
$15.69
|
| Rate for Payer: Three Rivers PPO |
$12.01
|
| Rate for Payer: TriWest Veterans Administration |
$9.29
|
| Rate for Payer: United Healthcare Commercial |
$13.93
|
| Rate for Payer: United Healthcare Medicare |
$9.29
|
| Rate for Payer: WINHealth Partners Commercial |
$15.69
|
| Rate for Payer: Wise Provider Network Commercial |
$15.21
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [1061]
|
Facility
|
OP
|
$15.71
|
|
|
Service Code
|
HCPCS J2003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.66 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.40
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.15
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.01
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.74
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.37
|
| Rate for Payer: Aetna of WY Medicare |
$10.37
|
| Rate for Payer: Aetna of WY Medicare |
$10.60
|
| Rate for Payer: Aetna of WY Medicare |
$10.35
|
| Rate for Payer: Aetna of WY Medicare |
$10.20
|
| Rate for Payer: Aetna of WY Medicare |
$10.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.42
|
| Rate for Payer: Altius Commercial |
$15.42
|
| Rate for Payer: Altius Commercial |
$14.84
|
| Rate for Payer: Altius Commercial |
$15.05
|
| Rate for Payer: Altius Commercial |
$14.71
|
| Rate for Payer: Altius Commercial |
$15.08
|
| Rate for Payer: Beech Street Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.01
|
| Rate for Payer: Beech Street Commercial |
$15.37
|
| Rate for Payer: Beech Street Commercial |
$15.15
|
| Rate for Payer: Beech Street Commercial |
$15.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.19
|
| Rate for Payer: Cash Price |
$11.24
|
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Cash Price |
$10.97
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.86
|
| Rate for Payer: Cigna of WY Commercial |
$15.01
|
| Rate for Payer: Cigna of WY Commercial |
$15.15
|
| Rate for Payer: Cigna of WY Commercial |
$15.37
|
| Rate for Payer: Cigna of WY Commercial |
$15.40
|
| Rate for Payer: Cigna of WY Commercial |
$15.74
|
| Rate for Payer: Entrust Commercial |
$14.55
|
| Rate for Payer: Entrust Commercial |
$14.69
|
| Rate for Payer: Entrust Commercial |
$14.90
|
| Rate for Payer: Entrust Commercial |
$15.26
|
| Rate for Payer: Entrust Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.55
|
| Rate for Payer: First Choice Health Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$15.26
|
| Rate for Payer: First Choice Health Commercial |
$14.90
|
| Rate for Payer: First Choice Health Commercial |
$14.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.31
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.09
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.97
|
| Rate for Payer: HealthUtah PPO |
$15.32
|
| Rate for Payer: HealthUtah PPO |
$15.68
|
| Rate for Payer: HealthUtah PPO |
$15.46
|
| Rate for Payer: HealthUtah PPO |
$16.06
|
| Rate for Payer: HealthUtah PPO |
$15.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.21
|
| Rate for Payer: Multiplan Medicare/VA |
$8.85
|
| Rate for Payer: Multiplan Medicare/VA |
$8.44
|
| Rate for Payer: Multiplan Medicare/VA |
$8.64
|
| Rate for Payer: Multiplan Medicare/VA |
$8.66
|
| Rate for Payer: Multiplan Medicare/VA |
$8.52
|
| Rate for Payer: One Health Plan of WY PPO |
$15.15
|
| Rate for Payer: One Health Plan of WY PPO |
$15.01
|
| Rate for Payer: One Health Plan of WY PPO |
$15.37
|
| Rate for Payer: One Health Plan of WY PPO |
$15.40
|
| Rate for Payer: One Health Plan of WY PPO |
$15.74
|
| Rate for Payer: PacificSource Commercial |
$14.11
|
| Rate for Payer: PacificSource Commercial |
$13.79
|
| Rate for Payer: PacificSource Commercial |
$14.14
|
| Rate for Payer: PacificSource Commercial |
$14.45
|
| Rate for Payer: PacificSource Commercial |
$13.91
|
| Rate for Payer: PHCS PPO |
$15.74
|
| Rate for Payer: PHCS PPO |
$15.15
|
| Rate for Payer: PHCS PPO |
$15.37
|
| Rate for Payer: PHCS PPO |
$15.40
|
| Rate for Payer: PHCS PPO |
$15.01
|
| Rate for Payer: Three Rivers PPO |
$11.60
|
| Rate for Payer: Three Rivers PPO |
$11.76
|
| Rate for Payer: Three Rivers PPO |
$11.49
|
| Rate for Payer: Three Rivers PPO |
$12.04
|
| Rate for Payer: Three Rivers PPO |
$11.78
|
| Rate for Payer: TriWest Veterans Administration |
$8.97
|
| Rate for Payer: TriWest Veterans Administration |
$9.11
|
| Rate for Payer: TriWest Veterans Administration |
$9.31
|
| Rate for Payer: TriWest Veterans Administration |
$9.09
|
| Rate for Payer: TriWest Veterans Administration |
$8.89
|
| Rate for Payer: United Healthcare Commercial |
$13.67
|
| Rate for Payer: United Healthcare Commercial |
$13.45
|
| Rate for Payer: United Healthcare Commercial |
$13.33
|
| Rate for Payer: United Healthcare Commercial |
$13.64
|
| Rate for Payer: United Healthcare Commercial |
$13.97
|
| Rate for Payer: United Healthcare Medicare |
$9.09
|
| Rate for Payer: United Healthcare Medicare |
$9.11
|
| Rate for Payer: United Healthcare Medicare |
$8.89
|
| Rate for Payer: United Healthcare Medicare |
$8.97
|
| Rate for Payer: United Healthcare Medicare |
$9.31
|
| Rate for Payer: WINHealth Partners Commercial |
$15.01
|
| Rate for Payer: WINHealth Partners Commercial |
$15.40
|
| Rate for Payer: WINHealth Partners Commercial |
$15.74
|
| Rate for Payer: WINHealth Partners Commercial |
$15.37
|
| Rate for Payer: WINHealth Partners Commercial |
$15.15
|
| Rate for Payer: Wise Provider Network Commercial |
$14.90
|
| Rate for Payer: Wise Provider Network Commercial |
$15.26
|
| Rate for Payer: Wise Provider Network Commercial |
$14.69
|
| Rate for Payer: Wise Provider Network Commercial |
$14.55
|
| Rate for Payer: Wise Provider Network Commercial |
$14.92
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [1061]
|
Facility
|
IP
|
$16.06
|
|
|
Service Code
|
HCPCS J2003
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.07 |
| Max. Negotiated Rate |
$16.06 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.74
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.37
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.40
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.01
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.05
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.71
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.08
|
| Rate for Payer: Altius Commercial |
$14.84
|
| Rate for Payer: Altius Commercial |
$15.05
|
| Rate for Payer: Altius Commercial |
$15.42
|
| Rate for Payer: Altius Commercial |
$14.71
|
| Rate for Payer: Altius Commercial |
$15.08
|
| Rate for Payer: Beech Street Commercial |
$15.15
|
| Rate for Payer: Beech Street Commercial |
$15.01
|
| Rate for Payer: Beech Street Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.74
|
| Rate for Payer: Beech Street Commercial |
$15.37
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.87
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.19
|
| Rate for Payer: Cash Price |
$11.24
|
| Rate for Payer: Cash Price |
$10.82
|
| Rate for Payer: Cash Price |
$10.72
|
| Rate for Payer: Cash Price |
$10.97
|
| Rate for Payer: Cash Price |
$11.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.58
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.86
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.24
|
| Rate for Payer: Cigna of WY Commercial |
$15.74
|
| Rate for Payer: Cigna of WY Commercial |
$15.15
|
| Rate for Payer: Cigna of WY Commercial |
$15.40
|
| Rate for Payer: Cigna of WY Commercial |
$15.37
|
| Rate for Payer: Cigna of WY Commercial |
$15.01
|
| Rate for Payer: Entrust Commercial |
$14.55
|
| Rate for Payer: Entrust Commercial |
$15.26
|
| Rate for Payer: Entrust Commercial |
$14.90
|
| Rate for Payer: Entrust Commercial |
$14.69
|
| Rate for Payer: Entrust Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.69
|
| Rate for Payer: First Choice Health Commercial |
$14.55
|
| Rate for Payer: First Choice Health Commercial |
$15.26
|
| Rate for Payer: First Choice Health Commercial |
$14.92
|
| Rate for Payer: First Choice Health Commercial |
$14.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.26
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.69
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.37
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.35
|
| Rate for Payer: HealthUtah PPO |
$15.71
|
| Rate for Payer: HealthUtah PPO |
$15.32
|
| Rate for Payer: HealthUtah PPO |
$15.46
|
| Rate for Payer: HealthUtah PPO |
$16.06
|
| Rate for Payer: HealthUtah PPO |
$15.68
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.24
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.86
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.21
|
| Rate for Payer: Multiplan Medicare/VA |
$9.83
|
| Rate for Payer: Multiplan Medicare/VA |
$9.69
|
| Rate for Payer: Multiplan Medicare/VA |
$9.61
|
| Rate for Payer: Multiplan Medicare/VA |
$9.85
|
| Rate for Payer: Multiplan Medicare/VA |
$10.07
|
| Rate for Payer: One Health Plan of WY PPO |
$15.01
|
| Rate for Payer: One Health Plan of WY PPO |
$15.15
|
| Rate for Payer: One Health Plan of WY PPO |
$15.37
|
| Rate for Payer: One Health Plan of WY PPO |
$15.40
|
| Rate for Payer: One Health Plan of WY PPO |
$15.74
|
| Rate for Payer: PacificSource Commercial |
$13.79
|
| Rate for Payer: PacificSource Commercial |
$14.11
|
| Rate for Payer: PacificSource Commercial |
$13.91
|
| Rate for Payer: PacificSource Commercial |
$14.14
|
| Rate for Payer: PacificSource Commercial |
$14.45
|
| Rate for Payer: PHCS PPO |
$15.40
|
| Rate for Payer: PHCS PPO |
$15.74
|
| Rate for Payer: PHCS PPO |
$15.37
|
| Rate for Payer: PHCS PPO |
$15.01
|
| Rate for Payer: PHCS PPO |
$15.15
|
| Rate for Payer: Three Rivers PPO |
$11.60
|
| Rate for Payer: Three Rivers PPO |
$12.04
|
| Rate for Payer: Three Rivers PPO |
$11.78
|
| Rate for Payer: Three Rivers PPO |
$11.76
|
| Rate for Payer: Three Rivers PPO |
$11.49
|
| Rate for Payer: TriWest Veterans Administration |
$10.60
|
| Rate for Payer: TriWest Veterans Administration |
$10.35
|
| Rate for Payer: TriWest Veterans Administration |
$10.11
|
| Rate for Payer: TriWest Veterans Administration |
$10.20
|
| Rate for Payer: TriWest Veterans Administration |
$10.37
|
| Rate for Payer: United Healthcare Commercial |
$13.67
|
| Rate for Payer: United Healthcare Commercial |
$13.97
|
| Rate for Payer: United Healthcare Commercial |
$13.33
|
| Rate for Payer: United Healthcare Commercial |
$13.45
|
| Rate for Payer: United Healthcare Commercial |
$13.64
|
| Rate for Payer: United Healthcare Medicare |
$10.35
|
| Rate for Payer: United Healthcare Medicare |
$10.37
|
| Rate for Payer: United Healthcare Medicare |
$10.20
|
| Rate for Payer: United Healthcare Medicare |
$10.11
|
| Rate for Payer: United Healthcare Medicare |
$10.60
|
| Rate for Payer: WINHealth Partners Commercial |
$14.69
|
| Rate for Payer: WINHealth Partners Commercial |
$14.92
|
| Rate for Payer: WINHealth Partners Commercial |
$15.26
|
| Rate for Payer: WINHealth Partners Commercial |
$14.90
|
| Rate for Payer: WINHealth Partners Commercial |
$14.55
|
| Rate for Payer: Wise Provider Network Commercial |
$14.69
|
| Rate for Payer: Wise Provider Network Commercial |
$15.26
|
| Rate for Payer: Wise Provider Network Commercial |
$14.92
|
| Rate for Payer: Wise Provider Network Commercial |
$14.55
|
| Rate for Payer: Wise Provider Network Commercial |
$14.90
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [16627]
|
Facility
|
IP
|
$15.77
|
|
|
Service Code
|
NDC 6332348602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$15.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.14
|
| Rate for Payer: Altius Commercial |
$15.14
|
| Rate for Payer: Beech Street Commercial |
$15.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.95
|
| Rate for Payer: Cash Price |
$11.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.30
|
| Rate for Payer: Cigna of WY Commercial |
$15.45
|
| Rate for Payer: Entrust Commercial |
$14.98
|
| Rate for Payer: First Choice Health Commercial |
$14.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.41
|
| Rate for Payer: HealthUtah PPO |
$15.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.30
|
| Rate for Payer: Multiplan Medicare/VA |
$9.89
|
| Rate for Payer: One Health Plan of WY PPO |
$15.45
|
| Rate for Payer: PacificSource Commercial |
$14.19
|
| Rate for Payer: PHCS PPO |
$15.45
|
| Rate for Payer: Three Rivers PPO |
$11.83
|
| Rate for Payer: TriWest Veterans Administration |
$10.41
|
| Rate for Payer: United Healthcare Commercial |
$13.72
|
| Rate for Payer: United Healthcare Medicare |
$10.41
|
| Rate for Payer: WINHealth Partners Commercial |
$14.98
|
| Rate for Payer: Wise Provider Network Commercial |
$14.98
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [16627]
|
Facility
|
OP
|
$15.81
|
|
|
Service Code
|
NDC 5515025520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.71 |
| Max. Negotiated Rate |
$15.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.49
|
| Rate for Payer: Aetna of WY Medicare |
$10.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.18
|
| Rate for Payer: Altius Commercial |
$15.18
|
| Rate for Payer: Beech Street Commercial |
$15.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.98
|
| Rate for Payer: Cash Price |
$11.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.34
|
| Rate for Payer: Cigna of WY Commercial |
$15.49
|
| Rate for Payer: Entrust Commercial |
$15.02
|
| Rate for Payer: First Choice Health Commercial |
$15.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.17
|
| Rate for Payer: HealthUtah PPO |
$15.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.34
|
| Rate for Payer: Multiplan Medicare/VA |
$8.71
|
| Rate for Payer: One Health Plan of WY PPO |
$15.49
|
| Rate for Payer: PacificSource Commercial |
$14.23
|
| Rate for Payer: PHCS PPO |
$15.49
|
| Rate for Payer: Three Rivers PPO |
$11.86
|
| Rate for Payer: TriWest Veterans Administration |
$9.17
|
| Rate for Payer: United Healthcare Commercial |
$13.75
|
| Rate for Payer: United Healthcare Medicare |
$9.17
|
| Rate for Payer: WINHealth Partners Commercial |
$15.49
|
| Rate for Payer: Wise Provider Network Commercial |
$15.02
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [16627]
|
Facility
|
IP
|
$15.81
|
|
|
Service Code
|
NDC 5515025520
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.91 |
| Max. Negotiated Rate |
$15.81 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.18
|
| Rate for Payer: Altius Commercial |
$15.18
|
| Rate for Payer: Beech Street Commercial |
$15.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.98
|
| Rate for Payer: Cash Price |
$11.07
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.34
|
| Rate for Payer: Cigna of WY Commercial |
$15.49
|
| Rate for Payer: Entrust Commercial |
$15.02
|
| Rate for Payer: First Choice Health Commercial |
$15.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.43
|
| Rate for Payer: HealthUtah PPO |
$15.81
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.34
|
| Rate for Payer: Multiplan Medicare/VA |
$9.91
|
| Rate for Payer: One Health Plan of WY PPO |
$15.49
|
| Rate for Payer: PacificSource Commercial |
$14.23
|
| Rate for Payer: PHCS PPO |
$15.49
|
| Rate for Payer: Three Rivers PPO |
$11.86
|
| Rate for Payer: TriWest Veterans Administration |
$10.43
|
| Rate for Payer: United Healthcare Commercial |
$13.75
|
| Rate for Payer: United Healthcare Medicare |
$10.43
|
| Rate for Payer: WINHealth Partners Commercial |
$15.02
|
| Rate for Payer: Wise Provider Network Commercial |
$15.02
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [16627]
|
Facility
|
OP
|
$15.77
|
|
|
Service Code
|
NDC 6332348602
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$15.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.45
|
| Rate for Payer: Aetna of WY Medicare |
$10.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.14
|
| Rate for Payer: Altius Commercial |
$15.14
|
| Rate for Payer: Beech Street Commercial |
$15.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.95
|
| Rate for Payer: Cash Price |
$11.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.30
|
| Rate for Payer: Cigna of WY Commercial |
$15.45
|
| Rate for Payer: Entrust Commercial |
$14.98
|
| Rate for Payer: First Choice Health Commercial |
$14.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.15
|
| Rate for Payer: HealthUtah PPO |
$15.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.30
|
| Rate for Payer: Multiplan Medicare/VA |
$8.69
|
| Rate for Payer: One Health Plan of WY PPO |
$15.45
|
| Rate for Payer: PacificSource Commercial |
$14.19
|
| Rate for Payer: PHCS PPO |
$15.45
|
| Rate for Payer: Three Rivers PPO |
$11.83
|
| Rate for Payer: TriWest Veterans Administration |
$9.15
|
| Rate for Payer: United Healthcare Commercial |
$13.72
|
| Rate for Payer: United Healthcare Medicare |
$9.15
|
| Rate for Payer: WINHealth Partners Commercial |
$15.45
|
| Rate for Payer: Wise Provider Network Commercial |
$14.98
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [16627]
|
Facility
|
IP
|
$15.77
|
|
|
Service Code
|
NDC 6332348627
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$15.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.14
|
| Rate for Payer: Altius Commercial |
$15.14
|
| Rate for Payer: Beech Street Commercial |
$15.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.95
|
| Rate for Payer: Cash Price |
$11.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.30
|
| Rate for Payer: Cigna of WY Commercial |
$15.45
|
| Rate for Payer: Entrust Commercial |
$14.98
|
| Rate for Payer: First Choice Health Commercial |
$14.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.41
|
| Rate for Payer: HealthUtah PPO |
$15.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.30
|
| Rate for Payer: Multiplan Medicare/VA |
$9.89
|
| Rate for Payer: One Health Plan of WY PPO |
$15.45
|
| Rate for Payer: PacificSource Commercial |
$14.19
|
| Rate for Payer: PHCS PPO |
$15.45
|
| Rate for Payer: Three Rivers PPO |
$11.83
|
| Rate for Payer: TriWest Veterans Administration |
$10.41
|
| Rate for Payer: United Healthcare Commercial |
$13.72
|
| Rate for Payer: United Healthcare Medicare |
$10.41
|
| Rate for Payer: WINHealth Partners Commercial |
$14.98
|
| Rate for Payer: Wise Provider Network Commercial |
$14.98
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [16627]
|
Facility
|
OP
|
$15.77
|
|
|
Service Code
|
NDC 6332348627
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$15.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.45
|
| Rate for Payer: Aetna of WY Medicare |
$10.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.14
|
| Rate for Payer: Altius Commercial |
$15.14
|
| Rate for Payer: Beech Street Commercial |
$15.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.95
|
| Rate for Payer: Cash Price |
$11.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.30
|
| Rate for Payer: Cigna of WY Commercial |
$15.45
|
| Rate for Payer: Entrust Commercial |
$14.98
|
| Rate for Payer: First Choice Health Commercial |
$14.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.15
|
| Rate for Payer: HealthUtah PPO |
$15.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.30
|
| Rate for Payer: Multiplan Medicare/VA |
$8.69
|
| Rate for Payer: One Health Plan of WY PPO |
$15.45
|
| Rate for Payer: PacificSource Commercial |
$14.19
|
| Rate for Payer: PHCS PPO |
$15.45
|
| Rate for Payer: Three Rivers PPO |
$11.83
|
| Rate for Payer: TriWest Veterans Administration |
$9.15
|
| Rate for Payer: United Healthcare Commercial |
$13.72
|
| Rate for Payer: United Healthcare Medicare |
$9.15
|
| Rate for Payer: WINHealth Partners Commercial |
$15.45
|
| Rate for Payer: Wise Provider Network Commercial |
$14.98
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [15092]
|
Facility
|
IP
|
$0.29
|
|
|
Service Code
|
NDC 5038336315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.28
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.28
|
| Rate for Payer: Altius Commercial |
$0.28
|
| Rate for Payer: Beech Street Commercial |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.28
|
| Rate for Payer: Cigna of WY Commercial |
$0.28
|
| Rate for Payer: Entrust Commercial |
$0.28
|
| Rate for Payer: First Choice Health Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.19
|
| Rate for Payer: HealthUtah PPO |
$0.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.28
|
| Rate for Payer: Multiplan Medicare/VA |
$0.18
|
| Rate for Payer: One Health Plan of WY PPO |
$0.28
|
| Rate for Payer: PacificSource Commercial |
$0.26
|
| Rate for Payer: PHCS PPO |
$0.28
|
| Rate for Payer: Three Rivers PPO |
$0.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.19
|
| Rate for Payer: United Healthcare Commercial |
$0.25
|
| Rate for Payer: United Healthcare Medicare |
$0.19
|
| Rate for Payer: WINHealth Partners Commercial |
$0.28
|
| Rate for Payer: Wise Provider Network Commercial |
$0.28
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [15092]
|
Facility
|
OP
|
$1.64
|
|
|
Service Code
|
NDC 0121495015
|
|
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 HCL 2 % MUCOSAL SOLUTION [15092]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 7288812526
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.24 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.43
|
| Rate for Payer: Aetna of WY Medicare |
$0.29
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.42
|
| Rate for Payer: Altius Commercial |
$0.42
|
| Rate for Payer: Beech Street Commercial |
$0.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.36
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.43
|
| Rate for Payer: Cigna of WY Commercial |
$0.43
|
| Rate for Payer: Entrust Commercial |
$0.42
|
| Rate for Payer: First Choice Health Commercial |
$0.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.26
|
| Rate for Payer: HealthUtah PPO |
$0.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.43
|
| Rate for Payer: Multiplan Medicare/VA |
$0.24
|
| Rate for Payer: One Health Plan of WY PPO |
$0.43
|
| Rate for Payer: PacificSource Commercial |
$0.40
|
| Rate for Payer: PHCS PPO |
$0.43
|
| Rate for Payer: Three Rivers PPO |
$0.33
|
| Rate for Payer: TriWest Veterans Administration |
$0.26
|
| Rate for Payer: United Healthcare Commercial |
$0.38
|
| Rate for Payer: United Healthcare Medicare |
$0.26
|
| Rate for Payer: WINHealth Partners Commercial |
$0.43
|
| Rate for Payer: Wise Provider Network Commercial |
$0.42
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [15092]
|
Facility
|
OP
|
$0.29
|
|
|
Service Code
|
NDC 5038336315
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.28
|
| Rate for Payer: Aetna of WY Medicare |
$0.19
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.28
|
| Rate for Payer: Altius Commercial |
$0.28
|
| Rate for Payer: Beech Street Commercial |
$0.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.24
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.28
|
| Rate for Payer: Cigna of WY Commercial |
$0.28
|
| Rate for Payer: Entrust Commercial |
$0.28
|
| Rate for Payer: First Choice Health Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.17
|
| Rate for Payer: HealthUtah PPO |
$0.29
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.28
|
| Rate for Payer: Multiplan Medicare/VA |
$0.16
|
| Rate for Payer: One Health Plan of WY PPO |
$0.28
|
| Rate for Payer: PacificSource Commercial |
$0.26
|
| Rate for Payer: PHCS PPO |
$0.28
|
| Rate for Payer: Three Rivers PPO |
$0.22
|
| Rate for Payer: TriWest Veterans Administration |
$0.17
|
| Rate for Payer: United Healthcare Commercial |
$0.25
|
| Rate for Payer: United Healthcare Medicare |
$0.17
|
| Rate for Payer: WINHealth Partners Commercial |
$0.28
|
| Rate for Payer: Wise Provider Network Commercial |
$0.28
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [15092]
|
Facility
|
OP
|
$3.92
|
|
|
Service Code
|
NDC 6213571242
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.84
|
| Rate for Payer: Aetna of WY Medicare |
$2.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.76
|
| Rate for Payer: Altius Commercial |
$3.76
|
| Rate for Payer: Beech Street Commercial |
$3.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.22
|
| Rate for Payer: Cash Price |
$2.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.80
|
| Rate for Payer: Cigna of WY Commercial |
$3.84
|
| Rate for Payer: Entrust Commercial |
$3.72
|
| Rate for Payer: First Choice Health Commercial |
$3.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.27
|
| Rate for Payer: HealthUtah PPO |
$3.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.80
|
| Rate for Payer: Multiplan Medicare/VA |
$2.16
|
| Rate for Payer: One Health Plan of WY PPO |
$3.84
|
| Rate for Payer: PacificSource Commercial |
$3.53
|
| Rate for Payer: PHCS PPO |
$3.84
|
| Rate for Payer: Three Rivers PPO |
$2.94
|
| Rate for Payer: TriWest Veterans Administration |
$2.27
|
| Rate for Payer: United Healthcare Commercial |
$3.41
|
| Rate for Payer: United Healthcare Medicare |
$2.27
|
| Rate for Payer: WINHealth Partners Commercial |
$3.84
|
| Rate for Payer: Wise Provider Network Commercial |
$3.72
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [15092]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 0054350049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.44 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.42
|
| Rate for Payer: Altius Commercial |
$0.42
|
| Rate for Payer: Beech Street Commercial |
$0.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.36
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.43
|
| Rate for Payer: Cigna of WY Commercial |
$0.43
|
| Rate for Payer: Entrust Commercial |
$0.42
|
| Rate for Payer: First Choice Health Commercial |
$0.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.42
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.29
|
| Rate for Payer: HealthUtah PPO |
$0.44
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.43
|
| Rate for Payer: Multiplan Medicare/VA |
$0.28
|
| Rate for Payer: One Health Plan of WY PPO |
$0.43
|
| Rate for Payer: PacificSource Commercial |
$0.40
|
| Rate for Payer: PHCS PPO |
$0.43
|
| Rate for Payer: Three Rivers PPO |
$0.33
|
| Rate for Payer: TriWest Veterans Administration |
$0.29
|
| Rate for Payer: United Healthcare Commercial |
$0.38
|
| Rate for Payer: United Healthcare Medicare |
$0.29
|
| Rate for Payer: WINHealth Partners Commercial |
$0.42
|
| Rate for Payer: Wise Provider Network Commercial |
$0.42
|
|
