|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [15092]
|
Facility
|
IP
|
$1.64
|
|
|
Service Code
|
NDC 0121495015
|
|
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 HCL 2 % MUCOSAL SOLUTION [15092]
|
Facility
|
IP
|
$3.92
|
|
|
Service Code
|
NDC 6213571242
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.46 |
| Max. Negotiated Rate |
$3.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.84
|
| 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 |
$2.59
|
| Rate for Payer: HealthUtah PPO |
$3.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.80
|
| Rate for Payer: Multiplan Medicare/VA |
$2.46
|
| 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 |
$2.59
|
| Rate for Payer: United Healthcare Commercial |
$3.41
|
| Rate for Payer: United Healthcare Medicare |
$2.59
|
| Rate for Payer: WINHealth Partners Commercial |
$3.72
|
| Rate for Payer: Wise Provider Network Commercial |
$3.72
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [15092]
|
Facility
|
IP
|
$0.44
|
|
|
Service Code
|
NDC 7288812526
|
|
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
|
|
|
LIDOCAINE HCL 2 % MUCOSAL SOLUTION [15092]
|
Facility
|
OP
|
$0.44
|
|
|
Service Code
|
NDC 0054350049
|
|
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 4 % (40 MG/ML) MUCOSAL SOLUTION [10785]
|
Facility
|
OP
|
$2.13
|
|
|
Service Code
|
NDC 7095451810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.09
|
| Rate for Payer: Aetna of WY Medicare |
$1.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.04
|
| Rate for Payer: Altius Commercial |
$2.04
|
| Rate for Payer: Beech Street Commercial |
$2.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.75
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.07
|
| Rate for Payer: Cigna of WY Commercial |
$2.09
|
| Rate for Payer: Entrust Commercial |
$2.02
|
| Rate for Payer: First Choice Health Commercial |
$2.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.24
|
| Rate for Payer: HealthUtah PPO |
$2.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.07
|
| Rate for Payer: Multiplan Medicare/VA |
$1.17
|
| Rate for Payer: One Health Plan of WY PPO |
$2.09
|
| Rate for Payer: PacificSource Commercial |
$1.92
|
| Rate for Payer: PHCS PPO |
$2.09
|
| Rate for Payer: Three Rivers PPO |
$1.60
|
| Rate for Payer: TriWest Veterans Administration |
$1.24
|
| Rate for Payer: United Healthcare Commercial |
$1.85
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
| Rate for Payer: WINHealth Partners Commercial |
$2.09
|
| Rate for Payer: Wise Provider Network Commercial |
$2.02
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [10785]
|
Facility
|
IP
|
$2.13
|
|
|
Service Code
|
NDC 7095451810
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$2.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2.04
|
| Rate for Payer: Altius Commercial |
$2.04
|
| Rate for Payer: Beech Street Commercial |
$2.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1.75
|
| Rate for Payer: Cash Price |
$1.49
|
| Rate for Payer: ChoiceCare Network Commercial |
$2.07
|
| Rate for Payer: Cigna of WY Commercial |
$2.09
|
| Rate for Payer: Entrust Commercial |
$2.02
|
| Rate for Payer: First Choice Health Commercial |
$2.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.41
|
| Rate for Payer: HealthUtah PPO |
$2.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2.07
|
| Rate for Payer: Multiplan Medicare/VA |
$1.34
|
| Rate for Payer: One Health Plan of WY PPO |
$2.09
|
| Rate for Payer: PacificSource Commercial |
$1.92
|
| Rate for Payer: PHCS PPO |
$2.09
|
| Rate for Payer: Three Rivers PPO |
$1.60
|
| Rate for Payer: TriWest Veterans Administration |
$1.41
|
| Rate for Payer: United Healthcare Commercial |
$1.85
|
| Rate for Payer: United Healthcare Medicare |
$1.41
|
| Rate for Payer: WINHealth Partners Commercial |
$2.02
|
| Rate for Payer: Wise Provider Network Commercial |
$2.02
|
|
|
LIDOCAINE INJECTION
|
Professional
|
Both
|
$1.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
J2001
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.98
|
| Rate for Payer: Aetna of WY Medicare |
$0.03
|
| Rate for Payer: Beech Street Commercial |
$0.95
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.97
|
| Rate for Payer: Cigna of WY Commercial |
$0.98
|
| Rate for Payer: First Choice Health Commercial |
$0.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.03
|
| Rate for Payer: HealthUtah PPO |
$1.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.97
|
| Rate for Payer: Multiplan Medicare/VA |
$0.02
|
| Rate for Payer: One Health Plan of WY PPO |
$0.98
|
| Rate for Payer: PacificSource Commercial |
$0.90
|
| Rate for Payer: PHCS PPO |
$0.95
|
| Rate for Payer: Three Rivers PPO |
$0.75
|
| Rate for Payer: TriWest Veterans Administration |
$0.03
|
| Rate for Payer: United Healthcare Commercial |
$0.87
|
| Rate for Payer: United Healthcare Medicare |
$0.03
|
| Rate for Payer: WINHealth Partners Commercial |
$0.95
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [41210]
|
Facility
|
IP
|
$16.57
|
|
|
Service Code
|
NDC 6332349207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.39 |
| Max. Negotiated Rate |
$16.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.91
|
| Rate for Payer: Altius Commercial |
$15.91
|
| Rate for Payer: Beech Street Commercial |
$16.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.60
|
| Rate for Payer: Cash Price |
$11.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.07
|
| Rate for Payer: Cigna of WY Commercial |
$16.24
|
| Rate for Payer: Entrust Commercial |
$15.74
|
| Rate for Payer: First Choice Health Commercial |
$15.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.94
|
| Rate for Payer: HealthUtah PPO |
$16.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.07
|
| Rate for Payer: Multiplan Medicare/VA |
$10.39
|
| Rate for Payer: One Health Plan of WY PPO |
$16.24
|
| Rate for Payer: PacificSource Commercial |
$14.91
|
| Rate for Payer: PHCS PPO |
$16.24
|
| Rate for Payer: Three Rivers PPO |
$12.43
|
| Rate for Payer: TriWest Veterans Administration |
$10.94
|
| Rate for Payer: United Healthcare Commercial |
$14.42
|
| Rate for Payer: United Healthcare Medicare |
$10.94
|
| Rate for Payer: WINHealth Partners Commercial |
$15.74
|
| Rate for Payer: Wise Provider Network Commercial |
$15.74
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [41210]
|
Facility
|
OP
|
$16.97
|
|
|
Service Code
|
NDC 0143959501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.35 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.63
|
| Rate for Payer: Aetna of WY Medicare |
$11.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.29
|
| Rate for Payer: Altius Commercial |
$16.29
|
| Rate for Payer: Beech Street Commercial |
$16.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.93
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.46
|
| Rate for Payer: Cigna of WY Commercial |
$16.63
|
| Rate for Payer: Entrust Commercial |
$16.12
|
| Rate for Payer: First Choice Health Commercial |
$16.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.84
|
| Rate for Payer: HealthUtah PPO |
$16.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.46
|
| Rate for Payer: Multiplan Medicare/VA |
$9.35
|
| Rate for Payer: One Health Plan of WY PPO |
$16.63
|
| Rate for Payer: PacificSource Commercial |
$15.27
|
| Rate for Payer: PHCS PPO |
$16.63
|
| Rate for Payer: Three Rivers PPO |
$12.73
|
| Rate for Payer: TriWest Veterans Administration |
$9.84
|
| Rate for Payer: United Healthcare Commercial |
$14.76
|
| Rate for Payer: United Healthcare Medicare |
$9.84
|
| Rate for Payer: WINHealth Partners Commercial |
$16.63
|
| Rate for Payer: Wise Provider Network Commercial |
$16.12
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [41210]
|
Facility
|
IP
|
$17.37
|
|
|
Service Code
|
NDC 5515016205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.89 |
| Max. Negotiated Rate |
$17.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.02
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.68
|
| Rate for Payer: Altius Commercial |
$16.68
|
| Rate for Payer: Beech Street Commercial |
$17.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.26
|
| Rate for Payer: Cash Price |
$12.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.85
|
| Rate for Payer: Cigna of WY Commercial |
$17.02
|
| Rate for Payer: Entrust Commercial |
$16.50
|
| Rate for Payer: First Choice Health Commercial |
$16.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.46
|
| Rate for Payer: HealthUtah PPO |
$17.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.85
|
| Rate for Payer: Multiplan Medicare/VA |
$10.89
|
| Rate for Payer: One Health Plan of WY PPO |
$17.02
|
| Rate for Payer: PacificSource Commercial |
$15.63
|
| Rate for Payer: PHCS PPO |
$17.02
|
| Rate for Payer: Three Rivers PPO |
$13.03
|
| Rate for Payer: TriWest Veterans Administration |
$11.46
|
| Rate for Payer: United Healthcare Commercial |
$15.11
|
| Rate for Payer: United Healthcare Medicare |
$11.46
|
| Rate for Payer: WINHealth Partners Commercial |
$16.50
|
| Rate for Payer: Wise Provider Network Commercial |
$16.50
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [41210]
|
Facility
|
OP
|
$17.37
|
|
|
Service Code
|
NDC 5515016205
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.57 |
| Max. Negotiated Rate |
$17.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.02
|
| Rate for Payer: Aetna of WY Medicare |
$11.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.68
|
| Rate for Payer: Altius Commercial |
$16.68
|
| Rate for Payer: Beech Street Commercial |
$17.02
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.26
|
| Rate for Payer: Cash Price |
$12.16
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.85
|
| Rate for Payer: Cigna of WY Commercial |
$17.02
|
| Rate for Payer: Entrust Commercial |
$16.50
|
| Rate for Payer: First Choice Health Commercial |
$16.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.07
|
| Rate for Payer: HealthUtah PPO |
$17.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.85
|
| Rate for Payer: Multiplan Medicare/VA |
$9.57
|
| Rate for Payer: One Health Plan of WY PPO |
$17.02
|
| Rate for Payer: PacificSource Commercial |
$15.63
|
| Rate for Payer: PHCS PPO |
$17.02
|
| Rate for Payer: Three Rivers PPO |
$13.03
|
| Rate for Payer: TriWest Veterans Administration |
$10.07
|
| Rate for Payer: United Healthcare Commercial |
$15.11
|
| Rate for Payer: United Healthcare Medicare |
$10.07
|
| Rate for Payer: WINHealth Partners Commercial |
$17.02
|
| Rate for Payer: Wise Provider Network Commercial |
$16.50
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [41210]
|
Facility
|
OP
|
$16.54
|
|
|
Service Code
|
NDC 7135102105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.11 |
| Max. Negotiated Rate |
$16.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.21
|
| Rate for Payer: Aetna of WY Medicare |
$10.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.88
|
| Rate for Payer: Altius Commercial |
$15.88
|
| Rate for Payer: Beech Street Commercial |
$16.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.58
|
| Rate for Payer: Cash Price |
$11.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.04
|
| Rate for Payer: Cigna of WY Commercial |
$16.21
|
| Rate for Payer: Entrust Commercial |
$15.71
|
| Rate for Payer: First Choice Health Commercial |
$15.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.59
|
| Rate for Payer: HealthUtah PPO |
$16.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.04
|
| Rate for Payer: Multiplan Medicare/VA |
$9.11
|
| Rate for Payer: One Health Plan of WY PPO |
$16.21
|
| Rate for Payer: PacificSource Commercial |
$14.89
|
| Rate for Payer: PHCS PPO |
$16.21
|
| Rate for Payer: Three Rivers PPO |
$12.40
|
| Rate for Payer: TriWest Veterans Administration |
$9.59
|
| Rate for Payer: United Healthcare Commercial |
$14.39
|
| Rate for Payer: United Healthcare Medicare |
$9.59
|
| Rate for Payer: WINHealth Partners Commercial |
$16.21
|
| Rate for Payer: Wise Provider Network Commercial |
$15.71
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [41210]
|
Facility
|
IP
|
$18.14
|
|
|
Service Code
|
NDC 6332349209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.37 |
| Max. Negotiated Rate |
$18.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.41
|
| Rate for Payer: Altius Commercial |
$17.41
|
| Rate for Payer: Beech Street Commercial |
$17.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$12.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.60
|
| Rate for Payer: Cigna of WY Commercial |
$17.78
|
| Rate for Payer: Entrust Commercial |
$17.23
|
| Rate for Payer: First Choice Health Commercial |
$17.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.97
|
| Rate for Payer: HealthUtah PPO |
$18.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.60
|
| Rate for Payer: Multiplan Medicare/VA |
$11.37
|
| Rate for Payer: One Health Plan of WY PPO |
$17.78
|
| Rate for Payer: PacificSource Commercial |
$16.33
|
| Rate for Payer: PHCS PPO |
$17.78
|
| Rate for Payer: Three Rivers PPO |
$13.60
|
| Rate for Payer: TriWest Veterans Administration |
$11.97
|
| Rate for Payer: United Healthcare Commercial |
$15.78
|
| Rate for Payer: United Healthcare Medicare |
$11.97
|
| Rate for Payer: WINHealth Partners Commercial |
$17.23
|
| Rate for Payer: Wise Provider Network Commercial |
$17.23
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [41210]
|
Facility
|
OP
|
$16.57
|
|
|
Service Code
|
NDC 6332349207
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.13 |
| Max. Negotiated Rate |
$16.57 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.24
|
| Rate for Payer: Aetna of WY Medicare |
$10.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.91
|
| Rate for Payer: Altius Commercial |
$15.91
|
| Rate for Payer: Beech Street Commercial |
$16.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.60
|
| Rate for Payer: Cash Price |
$11.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.07
|
| Rate for Payer: Cigna of WY Commercial |
$16.24
|
| Rate for Payer: Entrust Commercial |
$15.74
|
| Rate for Payer: First Choice Health Commercial |
$15.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.61
|
| Rate for Payer: HealthUtah PPO |
$16.57
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.07
|
| Rate for Payer: Multiplan Medicare/VA |
$9.13
|
| Rate for Payer: One Health Plan of WY PPO |
$16.24
|
| Rate for Payer: PacificSource Commercial |
$14.91
|
| Rate for Payer: PHCS PPO |
$16.24
|
| Rate for Payer: Three Rivers PPO |
$12.43
|
| Rate for Payer: TriWest Veterans Administration |
$9.61
|
| Rate for Payer: United Healthcare Commercial |
$14.42
|
| Rate for Payer: United Healthcare Medicare |
$9.61
|
| Rate for Payer: WINHealth Partners Commercial |
$16.24
|
| Rate for Payer: Wise Provider Network Commercial |
$15.74
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [41210]
|
Facility
|
IP
|
$16.97
|
|
|
Service Code
|
NDC 0143959501
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.64 |
| Max. Negotiated Rate |
$16.97 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.29
|
| Rate for Payer: Altius Commercial |
$16.29
|
| Rate for Payer: Beech Street Commercial |
$16.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.93
|
| Rate for Payer: Cash Price |
$11.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.46
|
| Rate for Payer: Cigna of WY Commercial |
$16.63
|
| Rate for Payer: Entrust Commercial |
$16.12
|
| Rate for Payer: First Choice Health Commercial |
$16.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.20
|
| Rate for Payer: HealthUtah PPO |
$16.97
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.46
|
| Rate for Payer: Multiplan Medicare/VA |
$10.64
|
| Rate for Payer: One Health Plan of WY PPO |
$16.63
|
| Rate for Payer: PacificSource Commercial |
$15.27
|
| Rate for Payer: PHCS PPO |
$16.63
|
| Rate for Payer: Three Rivers PPO |
$12.73
|
| Rate for Payer: TriWest Veterans Administration |
$11.20
|
| Rate for Payer: United Healthcare Commercial |
$14.76
|
| Rate for Payer: United Healthcare Medicare |
$11.20
|
| Rate for Payer: WINHealth Partners Commercial |
$16.12
|
| Rate for Payer: Wise Provider Network Commercial |
$16.12
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [41210]
|
Facility
|
OP
|
$18.14
|
|
|
Service Code
|
NDC 6332349209
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.00 |
| Max. Negotiated Rate |
$18.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.78
|
| Rate for Payer: Aetna of WY Medicare |
$11.97
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.41
|
| Rate for Payer: Altius Commercial |
$17.41
|
| Rate for Payer: Beech Street Commercial |
$17.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$12.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.60
|
| Rate for Payer: Cigna of WY Commercial |
$17.78
|
| Rate for Payer: Entrust Commercial |
$17.23
|
| Rate for Payer: First Choice Health Commercial |
$17.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.52
|
| Rate for Payer: HealthUtah PPO |
$18.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.60
|
| Rate for Payer: Multiplan Medicare/VA |
$10.00
|
| Rate for Payer: One Health Plan of WY PPO |
$17.78
|
| Rate for Payer: PacificSource Commercial |
$16.33
|
| Rate for Payer: PHCS PPO |
$17.78
|
| Rate for Payer: Three Rivers PPO |
$13.60
|
| Rate for Payer: TriWest Veterans Administration |
$10.52
|
| Rate for Payer: United Healthcare Commercial |
$15.78
|
| Rate for Payer: United Healthcare Medicare |
$10.52
|
| Rate for Payer: WINHealth Partners Commercial |
$17.78
|
| Rate for Payer: Wise Provider Network Commercial |
$17.23
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [41210]
|
Facility
|
IP
|
$16.54
|
|
|
Service Code
|
NDC 7135102105
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.37 |
| Max. Negotiated Rate |
$16.54 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.21
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.88
|
| Rate for Payer: Altius Commercial |
$15.88
|
| Rate for Payer: Beech Street Commercial |
$16.21
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.58
|
| Rate for Payer: Cash Price |
$11.57
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.04
|
| Rate for Payer: Cigna of WY Commercial |
$16.21
|
| Rate for Payer: Entrust Commercial |
$15.71
|
| Rate for Payer: First Choice Health Commercial |
$15.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.92
|
| Rate for Payer: HealthUtah PPO |
$16.54
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.04
|
| Rate for Payer: Multiplan Medicare/VA |
$10.37
|
| Rate for Payer: One Health Plan of WY PPO |
$16.21
|
| Rate for Payer: PacificSource Commercial |
$14.89
|
| Rate for Payer: PHCS PPO |
$16.21
|
| Rate for Payer: Three Rivers PPO |
$12.40
|
| Rate for Payer: TriWest Veterans Administration |
$10.92
|
| Rate for Payer: United Healthcare Commercial |
$14.39
|
| Rate for Payer: United Healthcare Medicare |
$10.92
|
| Rate for Payer: WINHealth Partners Commercial |
$15.71
|
| Rate for Payer: Wise Provider Network Commercial |
$15.71
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [41211]
|
Facility
|
IP
|
$17.13
|
|
|
Service Code
|
NDC 5515016505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.74 |
| Max. Negotiated Rate |
$17.13 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.44
|
| Rate for Payer: Altius Commercial |
$16.44
|
| Rate for Payer: Beech Street Commercial |
$16.79
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.06
|
| Rate for Payer: Cash Price |
$11.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.62
|
| Rate for Payer: Cigna of WY Commercial |
$16.79
|
| Rate for Payer: Entrust Commercial |
$16.27
|
| Rate for Payer: First Choice Health Commercial |
$16.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.27
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.31
|
| Rate for Payer: HealthUtah PPO |
$17.13
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.62
|
| Rate for Payer: Multiplan Medicare/VA |
$10.74
|
| Rate for Payer: One Health Plan of WY PPO |
$16.79
|
| Rate for Payer: PacificSource Commercial |
$15.42
|
| Rate for Payer: PHCS PPO |
$16.79
|
| Rate for Payer: Three Rivers PPO |
$12.85
|
| Rate for Payer: TriWest Veterans Administration |
$11.31
|
| Rate for Payer: United Healthcare Commercial |
$14.90
|
| Rate for Payer: United Healthcare Medicare |
$11.31
|
| Rate for Payer: WINHealth Partners Commercial |
$16.27
|
| Rate for Payer: Wise Provider Network Commercial |
$16.27
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [41211]
|
Facility
|
IP
|
$21.67
|
|
|
Service Code
|
NDC 5515016402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.59 |
| Max. Negotiated Rate |
$21.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.24
|
| Rate for Payer: Altius Auto/Workers Compensation |
$20.80
|
| Rate for Payer: Altius Commercial |
$20.80
|
| Rate for Payer: Beech Street Commercial |
$21.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.79
|
| Rate for Payer: Cash Price |
$15.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.02
|
| Rate for Payer: Cigna of WY Commercial |
$21.24
|
| Rate for Payer: Entrust Commercial |
$20.59
|
| Rate for Payer: First Choice Health Commercial |
$20.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.30
|
| Rate for Payer: HealthUtah PPO |
$21.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.02
|
| Rate for Payer: Multiplan Medicare/VA |
$13.59
|
| Rate for Payer: One Health Plan of WY PPO |
$21.24
|
| Rate for Payer: PacificSource Commercial |
$19.50
|
| Rate for Payer: PHCS PPO |
$21.24
|
| Rate for Payer: Three Rivers PPO |
$16.25
|
| Rate for Payer: TriWest Veterans Administration |
$14.30
|
| Rate for Payer: United Healthcare Commercial |
$18.85
|
| Rate for Payer: United Healthcare Medicare |
$14.30
|
| Rate for Payer: WINHealth Partners Commercial |
$20.59
|
| Rate for Payer: Wise Provider Network Commercial |
$20.59
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [41211]
|
Facility
|
OP
|
$21.67
|
|
|
Service Code
|
NDC 5515016402
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.94 |
| Max. Negotiated Rate |
$21.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.24
|
| Rate for Payer: Aetna of WY Medicare |
$14.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$20.80
|
| Rate for Payer: Altius Commercial |
$20.80
|
| Rate for Payer: Beech Street Commercial |
$21.24
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.79
|
| Rate for Payer: Cash Price |
$15.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.02
|
| Rate for Payer: Cigna of WY Commercial |
$21.24
|
| Rate for Payer: Entrust Commercial |
$20.59
|
| Rate for Payer: First Choice Health Commercial |
$20.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.57
|
| Rate for Payer: HealthUtah PPO |
$21.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.02
|
| Rate for Payer: Multiplan Medicare/VA |
$11.94
|
| Rate for Payer: One Health Plan of WY PPO |
$21.24
|
| Rate for Payer: PacificSource Commercial |
$19.50
|
| Rate for Payer: PHCS PPO |
$21.24
|
| Rate for Payer: Three Rivers PPO |
$16.25
|
| Rate for Payer: TriWest Veterans Administration |
$12.57
|
| Rate for Payer: United Healthcare Commercial |
$18.85
|
| Rate for Payer: United Healthcare Medicare |
$12.57
|
| Rate for Payer: WINHealth Partners Commercial |
$21.24
|
| Rate for Payer: Wise Provider Network Commercial |
$20.59
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [41211]
|
Facility
|
OP
|
$16.77
|
|
|
Service Code
|
NDC 0143959425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$16.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.43
|
| Rate for Payer: Aetna of WY Medicare |
$11.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.10
|
| Rate for Payer: Altius Commercial |
$16.10
|
| Rate for Payer: Beech Street Commercial |
$16.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.77
|
| Rate for Payer: Cash Price |
$11.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.27
|
| Rate for Payer: Cigna of WY Commercial |
$16.43
|
| Rate for Payer: Entrust Commercial |
$15.93
|
| Rate for Payer: First Choice Health Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.73
|
| Rate for Payer: HealthUtah PPO |
$16.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.27
|
| Rate for Payer: Multiplan Medicare/VA |
$9.24
|
| Rate for Payer: One Health Plan of WY PPO |
$16.43
|
| Rate for Payer: PacificSource Commercial |
$15.09
|
| Rate for Payer: PHCS PPO |
$16.43
|
| Rate for Payer: Three Rivers PPO |
$12.58
|
| Rate for Payer: TriWest Veterans Administration |
$9.73
|
| Rate for Payer: United Healthcare Commercial |
$14.59
|
| Rate for Payer: United Healthcare Medicare |
$9.73
|
| Rate for Payer: WINHealth Partners Commercial |
$16.43
|
| Rate for Payer: Wise Provider Network Commercial |
$15.93
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [41211]
|
Facility
|
OP
|
$17.87
|
|
|
Service Code
|
NDC 6332349504
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.85 |
| Max. Negotiated Rate |
$17.87 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.51
|
| Rate for Payer: Aetna of WY Medicare |
$11.79
|
| Rate for Payer: Altius Auto/Workers Compensation |
$17.16
|
| Rate for Payer: Altius Commercial |
$17.16
|
| Rate for Payer: Beech Street Commercial |
$17.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.67
|
| Rate for Payer: Cash Price |
$12.51
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.33
|
| Rate for Payer: Cigna of WY Commercial |
$17.51
|
| Rate for Payer: Entrust Commercial |
$16.98
|
| Rate for Payer: First Choice Health Commercial |
$16.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.98
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.36
|
| Rate for Payer: HealthUtah PPO |
$17.87
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.33
|
| Rate for Payer: Multiplan Medicare/VA |
$9.85
|
| Rate for Payer: One Health Plan of WY PPO |
$17.51
|
| Rate for Payer: PacificSource Commercial |
$16.08
|
| Rate for Payer: PHCS PPO |
$17.51
|
| Rate for Payer: Three Rivers PPO |
$13.40
|
| Rate for Payer: TriWest Veterans Administration |
$10.36
|
| Rate for Payer: United Healthcare Commercial |
$15.55
|
| Rate for Payer: United Healthcare Medicare |
$10.36
|
| Rate for Payer: WINHealth Partners Commercial |
$17.51
|
| Rate for Payer: Wise Provider Network Commercial |
$16.98
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [41211]
|
Facility
|
OP
|
$16.77
|
|
|
Service Code
|
NDC 0143959401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$16.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.43
|
| Rate for Payer: Aetna of WY Medicare |
$11.07
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.10
|
| Rate for Payer: Altius Commercial |
$16.10
|
| Rate for Payer: Beech Street Commercial |
$16.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.77
|
| Rate for Payer: Cash Price |
$11.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.27
|
| Rate for Payer: Cigna of WY Commercial |
$16.43
|
| Rate for Payer: Entrust Commercial |
$15.93
|
| Rate for Payer: First Choice Health Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.73
|
| Rate for Payer: HealthUtah PPO |
$16.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.27
|
| Rate for Payer: Multiplan Medicare/VA |
$9.24
|
| Rate for Payer: One Health Plan of WY PPO |
$16.43
|
| Rate for Payer: PacificSource Commercial |
$15.09
|
| Rate for Payer: PHCS PPO |
$16.43
|
| Rate for Payer: Three Rivers PPO |
$12.58
|
| Rate for Payer: TriWest Veterans Administration |
$9.73
|
| Rate for Payer: United Healthcare Commercial |
$14.59
|
| Rate for Payer: United Healthcare Medicare |
$9.73
|
| Rate for Payer: WINHealth Partners Commercial |
$16.43
|
| Rate for Payer: Wise Provider Network Commercial |
$15.93
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [41211]
|
Facility
|
IP
|
$16.77
|
|
|
Service Code
|
NDC 0143959401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$16.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.10
|
| Rate for Payer: Altius Commercial |
$16.10
|
| Rate for Payer: Beech Street Commercial |
$16.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.77
|
| Rate for Payer: Cash Price |
$11.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.27
|
| Rate for Payer: Cigna of WY Commercial |
$16.43
|
| Rate for Payer: Entrust Commercial |
$15.93
|
| Rate for Payer: First Choice Health Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.07
|
| Rate for Payer: HealthUtah PPO |
$16.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.27
|
| Rate for Payer: Multiplan Medicare/VA |
$10.51
|
| Rate for Payer: One Health Plan of WY PPO |
$16.43
|
| Rate for Payer: PacificSource Commercial |
$15.09
|
| Rate for Payer: PHCS PPO |
$16.43
|
| Rate for Payer: Three Rivers PPO |
$12.58
|
| Rate for Payer: TriWest Veterans Administration |
$11.07
|
| Rate for Payer: United Healthcare Commercial |
$14.59
|
| Rate for Payer: United Healthcare Medicare |
$11.07
|
| Rate for Payer: WINHealth Partners Commercial |
$15.93
|
| Rate for Payer: Wise Provider Network Commercial |
$15.93
|
|
|
LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [41211]
|
Facility
|
IP
|
$16.77
|
|
|
Service Code
|
NDC 0143959425
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.51 |
| Max. Negotiated Rate |
$16.77 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.10
|
| Rate for Payer: Altius Commercial |
$16.10
|
| Rate for Payer: Beech Street Commercial |
$16.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.77
|
| Rate for Payer: Cash Price |
$11.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.27
|
| Rate for Payer: Cigna of WY Commercial |
$16.43
|
| Rate for Payer: Entrust Commercial |
$15.93
|
| Rate for Payer: First Choice Health Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.07
|
| Rate for Payer: HealthUtah PPO |
$16.77
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.27
|
| Rate for Payer: Multiplan Medicare/VA |
$10.51
|
| Rate for Payer: One Health Plan of WY PPO |
$16.43
|
| Rate for Payer: PacificSource Commercial |
$15.09
|
| Rate for Payer: PHCS PPO |
$16.43
|
| Rate for Payer: Three Rivers PPO |
$12.58
|
| Rate for Payer: TriWest Veterans Administration |
$11.07
|
| Rate for Payer: United Healthcare Commercial |
$14.59
|
| Rate for Payer: United Healthcare Medicare |
$11.07
|
| Rate for Payer: WINHealth Partners Commercial |
$15.93
|
| Rate for Payer: Wise Provider Network Commercial |
$15.93
|
|
