|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
IP
|
$15.40
|
|
|
Service Code
|
NDC 0143933401
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.66 |
| Max. Negotiated Rate |
$15.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.78
|
| Rate for Payer: Altius Commercial |
$14.78
|
| Rate for Payer: Beech Street Commercial |
$15.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.64
|
| Rate for Payer: Cash Price |
$10.78
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.94
|
| Rate for Payer: Cigna of WY Commercial |
$15.09
|
| Rate for Payer: Entrust Commercial |
$14.63
|
| Rate for Payer: First Choice Health Commercial |
$14.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.16
|
| Rate for Payer: HealthUtah PPO |
$15.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.94
|
| Rate for Payer: Multiplan Medicare/VA |
$9.66
|
| Rate for Payer: One Health Plan of WY PPO |
$15.09
|
| Rate for Payer: PacificSource Commercial |
$13.86
|
| Rate for Payer: PHCS PPO |
$15.09
|
| Rate for Payer: Three Rivers PPO |
$11.55
|
| Rate for Payer: TriWest Veterans Administration |
$10.16
|
| Rate for Payer: United Healthcare Commercial |
$13.40
|
| Rate for Payer: United Healthcare Medicare |
$10.16
|
| Rate for Payer: WINHealth Partners Commercial |
$14.63
|
| Rate for Payer: Wise Provider Network Commercial |
$14.63
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
OP
|
$17.08
|
|
|
Service Code
|
NDC 0409156018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.41 |
| Max. Negotiated Rate |
$17.08 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.74
|
| Rate for Payer: Aetna of WY Medicare |
$11.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$16.40
|
| Rate for Payer: Altius Commercial |
$16.40
|
| Rate for Payer: Beech Street Commercial |
$16.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.02
|
| Rate for Payer: Cash Price |
$11.95
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.57
|
| Rate for Payer: Cigna of WY Commercial |
$16.74
|
| Rate for Payer: Entrust Commercial |
$16.23
|
| Rate for Payer: First Choice Health Commercial |
$16.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.23
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.91
|
| Rate for Payer: HealthUtah PPO |
$17.08
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.57
|
| Rate for Payer: Multiplan Medicare/VA |
$9.41
|
| Rate for Payer: One Health Plan of WY PPO |
$16.74
|
| Rate for Payer: PacificSource Commercial |
$15.37
|
| Rate for Payer: PHCS PPO |
$16.74
|
| Rate for Payer: Three Rivers PPO |
$12.81
|
| Rate for Payer: TriWest Veterans Administration |
$9.91
|
| Rate for Payer: United Healthcare Commercial |
$14.86
|
| Rate for Payer: United Healthcare Medicare |
$9.91
|
| Rate for Payer: WINHealth Partners Commercial |
$16.74
|
| Rate for Payer: Wise Provider Network Commercial |
$16.23
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 0143933101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.68
|
| Rate for Payer: Aetna of WY Medicare |
$10.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.36
|
| Rate for Payer: Altius Commercial |
$15.36
|
| Rate for Payer: Beech Street Commercial |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.14
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.52
|
| Rate for Payer: Cigna of WY Commercial |
$15.68
|
| Rate for Payer: Entrust Commercial |
$15.20
|
| Rate for Payer: First Choice Health Commercial |
$15.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.28
|
| Rate for Payer: HealthUtah PPO |
$16.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.52
|
| Rate for Payer: Multiplan Medicare/VA |
$8.82
|
| Rate for Payer: One Health Plan of WY PPO |
$15.68
|
| Rate for Payer: PacificSource Commercial |
$14.40
|
| Rate for Payer: PHCS PPO |
$15.68
|
| Rate for Payer: Three Rivers PPO |
$12.00
|
| Rate for Payer: TriWest Veterans Administration |
$9.28
|
| Rate for Payer: United Healthcare Commercial |
$13.92
|
| Rate for Payer: United Healthcare Medicare |
$9.28
|
| Rate for Payer: WINHealth Partners Commercial |
$15.68
|
| Rate for Payer: Wise Provider Network Commercial |
$15.20
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
IP
|
$16.05
|
|
|
Service Code
|
NDC 5515016910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.06 |
| Max. Negotiated Rate |
$16.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.73
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.41
|
| Rate for Payer: Altius Commercial |
$15.41
|
| Rate for Payer: Beech Street Commercial |
$15.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.18
|
| Rate for Payer: Cash Price |
$11.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.57
|
| Rate for Payer: Cigna of WY Commercial |
$15.73
|
| Rate for Payer: Entrust Commercial |
$15.25
|
| Rate for Payer: First Choice Health Commercial |
$15.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.59
|
| Rate for Payer: HealthUtah PPO |
$16.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.57
|
| Rate for Payer: Multiplan Medicare/VA |
$10.06
|
| Rate for Payer: One Health Plan of WY PPO |
$15.73
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.73
|
| Rate for Payer: Three Rivers PPO |
$12.04
|
| Rate for Payer: TriWest Veterans Administration |
$10.59
|
| Rate for Payer: United Healthcare Commercial |
$13.96
|
| Rate for Payer: United Healthcare Medicare |
$10.59
|
| Rate for Payer: WINHealth Partners Commercial |
$15.25
|
| Rate for Payer: Wise Provider Network Commercial |
$15.25
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
OP
|
$16.05
|
|
|
Service Code
|
NDC 5515016910
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.84 |
| Max. Negotiated Rate |
$16.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.73
|
| Rate for Payer: Aetna of WY Medicare |
$10.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.41
|
| Rate for Payer: Altius Commercial |
$15.41
|
| Rate for Payer: Beech Street Commercial |
$15.73
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.18
|
| Rate for Payer: Cash Price |
$11.24
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.57
|
| Rate for Payer: Cigna of WY Commercial |
$15.73
|
| Rate for Payer: Entrust Commercial |
$15.25
|
| Rate for Payer: First Choice Health Commercial |
$15.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.31
|
| Rate for Payer: HealthUtah PPO |
$16.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.57
|
| Rate for Payer: Multiplan Medicare/VA |
$8.84
|
| Rate for Payer: One Health Plan of WY PPO |
$15.73
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.73
|
| Rate for Payer: Three Rivers PPO |
$12.04
|
| Rate for Payer: TriWest Veterans Administration |
$9.31
|
| Rate for Payer: United Healthcare Commercial |
$13.96
|
| Rate for Payer: United Healthcare Medicare |
$9.31
|
| Rate for Payer: WINHealth Partners Commercial |
$15.73
|
| Rate for Payer: Wise Provider Network Commercial |
$15.25
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
IP
|
$16.01
|
|
|
Service Code
|
NDC 0409116218
|
|
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
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [28413]
|
Facility
|
OP
|
$26.25
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.46 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.72
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Aetna of WY Medicare |
$17.32
|
| Rate for Payer: Aetna of WY Medicare |
$16.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.20
|
| Rate for Payer: Altius Commercial |
$25.20
|
| Rate for Payer: Altius Commercial |
$24.00
|
| Rate for Payer: Beech Street Commercial |
$24.50
|
| Rate for Payer: Beech Street Commercial |
$25.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.52
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$18.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: Cigna of WY Commercial |
$25.72
|
| Rate for Payer: Entrust Commercial |
$24.94
|
| Rate for Payer: Entrust Commercial |
$23.75
|
| Rate for Payer: First Choice Health Commercial |
$23.75
|
| Rate for Payer: First Choice Health Commercial |
$24.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.50
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: HealthUtah PPO |
$26.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.46
|
| Rate for Payer: Multiplan Medicare/VA |
$14.46
|
| Rate for Payer: Multiplan Medicare/VA |
$13.78
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: One Health Plan of WY PPO |
$25.72
|
| Rate for Payer: PacificSource Commercial |
$23.62
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PHCS PPO |
$24.50
|
| Rate for Payer: PHCS PPO |
$25.72
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: Three Rivers PPO |
$19.69
|
| Rate for Payer: TriWest Veterans Administration |
$15.22
|
| Rate for Payer: TriWest Veterans Administration |
$14.50
|
| Rate for Payer: United Healthcare Commercial |
$21.75
|
| Rate for Payer: United Healthcare Commercial |
$22.84
|
| Rate for Payer: United Healthcare Medicare |
$15.22
|
| Rate for Payer: United Healthcare Medicare |
$14.50
|
| Rate for Payer: WINHealth Partners Commercial |
$24.50
|
| Rate for Payer: WINHealth Partners Commercial |
$25.72
|
| Rate for Payer: Wise Provider Network Commercial |
$23.75
|
| Rate for Payer: Wise Provider Network Commercial |
$24.94
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [28413]
|
Facility
|
IP
|
$26.25
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.46 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.72
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$25.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.00
|
| Rate for Payer: Altius Commercial |
$24.00
|
| Rate for Payer: Altius Commercial |
$25.20
|
| Rate for Payer: Beech Street Commercial |
$25.72
|
| Rate for Payer: Beech Street Commercial |
$24.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.55
|
| Rate for Payer: Cash Price |
$18.38
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.46
|
| Rate for Payer: Cigna of WY Commercial |
$25.72
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: Entrust Commercial |
$23.75
|
| Rate for Payer: Entrust Commercial |
$24.94
|
| Rate for Payer: First Choice Health Commercial |
$23.75
|
| Rate for Payer: First Choice Health Commercial |
$24.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.32
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.50
|
| Rate for Payer: HealthUtah PPO |
$26.25
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.46
|
| Rate for Payer: Multiplan Medicare/VA |
$16.46
|
| Rate for Payer: Multiplan Medicare/VA |
$15.68
|
| Rate for Payer: One Health Plan of WY PPO |
$25.72
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: PacificSource Commercial |
$23.62
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PHCS PPO |
$24.50
|
| Rate for Payer: PHCS PPO |
$25.72
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: Three Rivers PPO |
$19.69
|
| Rate for Payer: TriWest Veterans Administration |
$17.32
|
| Rate for Payer: TriWest Veterans Administration |
$16.50
|
| Rate for Payer: United Healthcare Commercial |
$21.75
|
| Rate for Payer: United Healthcare Commercial |
$22.84
|
| Rate for Payer: United Healthcare Medicare |
$17.32
|
| Rate for Payer: United Healthcare Medicare |
$16.50
|
| Rate for Payer: WINHealth Partners Commercial |
$23.75
|
| Rate for Payer: WINHealth Partners Commercial |
$24.94
|
| Rate for Payer: Wise Provider Network Commercial |
$23.75
|
| Rate for Payer: Wise Provider Network Commercial |
$24.94
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [28408]
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.03 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.36
|
| Rate for Payer: Altius Commercial |
$15.36
|
| Rate for Payer: Beech Street Commercial |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.14
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.52
|
| Rate for Payer: Cigna of WY Commercial |
$15.68
|
| Rate for Payer: Entrust Commercial |
$15.20
|
| Rate for Payer: First Choice Health Commercial |
$15.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.56
|
| Rate for Payer: HealthUtah PPO |
$16.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.52
|
| Rate for Payer: Multiplan Medicare/VA |
$10.03
|
| Rate for Payer: One Health Plan of WY PPO |
$15.68
|
| Rate for Payer: PacificSource Commercial |
$14.40
|
| Rate for Payer: PHCS PPO |
$15.68
|
| Rate for Payer: Three Rivers PPO |
$12.00
|
| Rate for Payer: TriWest Veterans Administration |
$10.56
|
| Rate for Payer: United Healthcare Commercial |
$13.92
|
| Rate for Payer: United Healthcare Medicare |
$10.56
|
| Rate for Payer: WINHealth Partners Commercial |
$15.20
|
| Rate for Payer: Wise Provider Network Commercial |
$15.20
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) INJECTION SOLUTION [28408]
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
HCPCS J0665
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.82 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.68
|
| Rate for Payer: Aetna of WY Medicare |
$10.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$15.36
|
| Rate for Payer: Altius Commercial |
$15.36
|
| Rate for Payer: Beech Street Commercial |
$15.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$13.14
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.52
|
| Rate for Payer: Cigna of WY Commercial |
$15.68
|
| Rate for Payer: Entrust Commercial |
$15.20
|
| Rate for Payer: First Choice Health Commercial |
$15.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.28
|
| Rate for Payer: HealthUtah PPO |
$16.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.52
|
| Rate for Payer: Multiplan Medicare/VA |
$8.82
|
| Rate for Payer: One Health Plan of WY PPO |
$15.68
|
| Rate for Payer: PacificSource Commercial |
$14.40
|
| Rate for Payer: PHCS PPO |
$15.68
|
| Rate for Payer: Three Rivers PPO |
$12.00
|
| Rate for Payer: TriWest Veterans Administration |
$9.28
|
| Rate for Payer: United Healthcare Commercial |
$13.92
|
| Rate for Payer: United Healthcare Medicare |
$9.28
|
| Rate for Payer: WINHealth Partners Commercial |
$15.68
|
| Rate for Payer: Wise Provider Network Commercial |
$15.20
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [27426]
|
Facility
|
OP
|
$8.17
|
|
|
Service Code
|
NDC 6068748111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$8.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.01
|
| Rate for Payer: Aetna of WY Medicare |
$5.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.84
|
| Rate for Payer: Altius Commercial |
$7.84
|
| Rate for Payer: Beech Street Commercial |
$8.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.71
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.92
|
| Rate for Payer: Cigna of WY Commercial |
$8.01
|
| Rate for Payer: Entrust Commercial |
$7.76
|
| Rate for Payer: First Choice Health Commercial |
$7.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.74
|
| Rate for Payer: HealthUtah PPO |
$8.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.92
|
| Rate for Payer: Multiplan Medicare/VA |
$4.50
|
| Rate for Payer: One Health Plan of WY PPO |
$8.01
|
| Rate for Payer: PacificSource Commercial |
$7.35
|
| Rate for Payer: PHCS PPO |
$8.01
|
| Rate for Payer: Three Rivers PPO |
$6.13
|
| Rate for Payer: TriWest Veterans Administration |
$4.74
|
| Rate for Payer: United Healthcare Commercial |
$7.11
|
| Rate for Payer: United Healthcare Medicare |
$4.74
|
| Rate for Payer: WINHealth Partners Commercial |
$8.01
|
| Rate for Payer: Wise Provider Network Commercial |
$7.76
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [27426]
|
Facility
|
IP
|
$8.17
|
|
|
Service Code
|
NDC 6068748111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$8.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.84
|
| Rate for Payer: Altius Commercial |
$7.84
|
| Rate for Payer: Beech Street Commercial |
$8.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.71
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.92
|
| Rate for Payer: Cigna of WY Commercial |
$8.01
|
| Rate for Payer: Entrust Commercial |
$7.76
|
| Rate for Payer: First Choice Health Commercial |
$7.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.39
|
| Rate for Payer: HealthUtah PPO |
$8.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.92
|
| Rate for Payer: Multiplan Medicare/VA |
$5.12
|
| Rate for Payer: One Health Plan of WY PPO |
$8.01
|
| Rate for Payer: PacificSource Commercial |
$7.35
|
| Rate for Payer: PHCS PPO |
$8.01
|
| Rate for Payer: Three Rivers PPO |
$6.13
|
| Rate for Payer: TriWest Veterans Administration |
$5.39
|
| Rate for Payer: United Healthcare Commercial |
$7.11
|
| Rate for Payer: United Healthcare Medicare |
$5.39
|
| Rate for Payer: WINHealth Partners Commercial |
$7.76
|
| Rate for Payer: Wise Provider Network Commercial |
$7.76
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [27426]
|
Facility
|
OP
|
$8.17
|
|
|
Service Code
|
NDC 6068748121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.50 |
| Max. Negotiated Rate |
$8.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.01
|
| Rate for Payer: Aetna of WY Medicare |
$5.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.84
|
| Rate for Payer: Altius Commercial |
$7.84
|
| Rate for Payer: Beech Street Commercial |
$8.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.71
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.92
|
| Rate for Payer: Cigna of WY Commercial |
$8.01
|
| Rate for Payer: Entrust Commercial |
$7.76
|
| Rate for Payer: First Choice Health Commercial |
$7.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.74
|
| Rate for Payer: HealthUtah PPO |
$8.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.92
|
| Rate for Payer: Multiplan Medicare/VA |
$4.50
|
| Rate for Payer: One Health Plan of WY PPO |
$8.01
|
| Rate for Payer: PacificSource Commercial |
$7.35
|
| Rate for Payer: PHCS PPO |
$8.01
|
| Rate for Payer: Three Rivers PPO |
$6.13
|
| Rate for Payer: TriWest Veterans Administration |
$4.74
|
| Rate for Payer: United Healthcare Commercial |
$7.11
|
| Rate for Payer: United Healthcare Medicare |
$4.74
|
| Rate for Payer: WINHealth Partners Commercial |
$8.01
|
| Rate for Payer: Wise Provider Network Commercial |
$7.76
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [27426]
|
Facility
|
IP
|
$8.17
|
|
|
Service Code
|
NDC 6068748121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.12 |
| Max. Negotiated Rate |
$8.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8.01
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.84
|
| Rate for Payer: Altius Commercial |
$7.84
|
| Rate for Payer: Beech Street Commercial |
$8.01
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.71
|
| Rate for Payer: Cash Price |
$5.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.92
|
| Rate for Payer: Cigna of WY Commercial |
$8.01
|
| Rate for Payer: Entrust Commercial |
$7.76
|
| Rate for Payer: First Choice Health Commercial |
$7.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.76
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.39
|
| Rate for Payer: HealthUtah PPO |
$8.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.92
|
| Rate for Payer: Multiplan Medicare/VA |
$5.12
|
| Rate for Payer: One Health Plan of WY PPO |
$8.01
|
| Rate for Payer: PacificSource Commercial |
$7.35
|
| Rate for Payer: PHCS PPO |
$8.01
|
| Rate for Payer: Three Rivers PPO |
$6.13
|
| Rate for Payer: TriWest Veterans Administration |
$5.39
|
| Rate for Payer: United Healthcare Commercial |
$7.11
|
| Rate for Payer: United Healthcare Medicare |
$5.39
|
| Rate for Payer: WINHealth Partners Commercial |
$7.76
|
| Rate for Payer: Wise Provider Network Commercial |
$7.76
|
|
|
BUPROPION HCL 75 MG TABLET [14008]
|
Facility
|
OP
|
$3.71
|
|
|
Service Code
|
NDC 5026814215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.64
|
| Rate for Payer: Aetna of WY Medicare |
$2.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.56
|
| Rate for Payer: Altius Commercial |
$3.56
|
| Rate for Payer: Beech Street Commercial |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.60
|
| Rate for Payer: Cigna of WY Commercial |
$3.64
|
| Rate for Payer: Entrust Commercial |
$3.52
|
| Rate for Payer: First Choice Health Commercial |
$3.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.15
|
| Rate for Payer: HealthUtah PPO |
$3.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.60
|
| Rate for Payer: Multiplan Medicare/VA |
$2.04
|
| Rate for Payer: One Health Plan of WY PPO |
$3.64
|
| Rate for Payer: PacificSource Commercial |
$3.34
|
| Rate for Payer: PHCS PPO |
$3.64
|
| Rate for Payer: Three Rivers PPO |
$2.78
|
| Rate for Payer: TriWest Veterans Administration |
$2.15
|
| Rate for Payer: United Healthcare Commercial |
$3.23
|
| Rate for Payer: United Healthcare Medicare |
$2.15
|
| Rate for Payer: WINHealth Partners Commercial |
$3.64
|
| Rate for Payer: Wise Provider Network Commercial |
$3.52
|
|
|
BUPROPION HCL 75 MG TABLET [14008]
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
NDC 5026814215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.56
|
| Rate for Payer: Altius Commercial |
$3.56
|
| Rate for Payer: Beech Street Commercial |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.60
|
| Rate for Payer: Cigna of WY Commercial |
$3.64
|
| Rate for Payer: Entrust Commercial |
$3.52
|
| Rate for Payer: First Choice Health Commercial |
$3.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.45
|
| Rate for Payer: HealthUtah PPO |
$3.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.60
|
| Rate for Payer: Multiplan Medicare/VA |
$2.33
|
| Rate for Payer: One Health Plan of WY PPO |
$3.64
|
| Rate for Payer: PacificSource Commercial |
$3.34
|
| Rate for Payer: PHCS PPO |
$3.64
|
| Rate for Payer: Three Rivers PPO |
$2.78
|
| Rate for Payer: TriWest Veterans Administration |
$2.45
|
| Rate for Payer: United Healthcare Commercial |
$3.23
|
| Rate for Payer: United Healthcare Medicare |
$2.45
|
| Rate for Payer: WINHealth Partners Commercial |
$3.52
|
| Rate for Payer: Wise Provider Network Commercial |
$3.52
|
|
|
BUPROPION HCL 75 MG TABLET [14008]
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
NDC 5026814211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.56
|
| Rate for Payer: Altius Commercial |
$3.56
|
| Rate for Payer: Beech Street Commercial |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.60
|
| Rate for Payer: Cigna of WY Commercial |
$3.64
|
| Rate for Payer: Entrust Commercial |
$3.52
|
| Rate for Payer: First Choice Health Commercial |
$3.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.45
|
| Rate for Payer: HealthUtah PPO |
$3.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.60
|
| Rate for Payer: Multiplan Medicare/VA |
$2.33
|
| Rate for Payer: One Health Plan of WY PPO |
$3.64
|
| Rate for Payer: PacificSource Commercial |
$3.34
|
| Rate for Payer: PHCS PPO |
$3.64
|
| Rate for Payer: Three Rivers PPO |
$2.78
|
| Rate for Payer: TriWest Veterans Administration |
$2.45
|
| Rate for Payer: United Healthcare Commercial |
$3.23
|
| Rate for Payer: United Healthcare Medicare |
$2.45
|
| Rate for Payer: WINHealth Partners Commercial |
$3.52
|
| Rate for Payer: Wise Provider Network Commercial |
$3.52
|
|
|
BUPROPION HCL 75 MG TABLET [14008]
|
Facility
|
OP
|
$3.71
|
|
|
Service Code
|
NDC 5026814211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.04 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3.64
|
| Rate for Payer: Aetna of WY Medicare |
$2.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3.56
|
| Rate for Payer: Altius Commercial |
$3.56
|
| Rate for Payer: Beech Street Commercial |
$3.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3.05
|
| Rate for Payer: Cash Price |
$2.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3.60
|
| Rate for Payer: Cigna of WY Commercial |
$3.64
|
| Rate for Payer: Entrust Commercial |
$3.52
|
| Rate for Payer: First Choice Health Commercial |
$3.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.15
|
| Rate for Payer: HealthUtah PPO |
$3.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3.60
|
| Rate for Payer: Multiplan Medicare/VA |
$2.04
|
| Rate for Payer: One Health Plan of WY PPO |
$3.64
|
| Rate for Payer: PacificSource Commercial |
$3.34
|
| Rate for Payer: PHCS PPO |
$3.64
|
| Rate for Payer: Three Rivers PPO |
$2.78
|
| Rate for Payer: TriWest Veterans Administration |
$2.15
|
| Rate for Payer: United Healthcare Commercial |
$3.23
|
| Rate for Payer: United Healthcare Medicare |
$2.15
|
| Rate for Payer: WINHealth Partners Commercial |
$3.64
|
| Rate for Payer: Wise Provider Network Commercial |
$3.52
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [29684]
|
Facility
|
OP
|
$7.40
|
|
|
Service Code
|
NDC 6068731201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.25
|
| Rate for Payer: Aetna of WY Medicare |
$4.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.10
|
| Rate for Payer: Altius Commercial |
$7.10
|
| Rate for Payer: Beech Street Commercial |
$7.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.08
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.18
|
| Rate for Payer: Cigna of WY Commercial |
$7.25
|
| Rate for Payer: Entrust Commercial |
$7.03
|
| Rate for Payer: First Choice Health Commercial |
$7.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.29
|
| Rate for Payer: HealthUtah PPO |
$7.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.18
|
| Rate for Payer: Multiplan Medicare/VA |
$4.08
|
| Rate for Payer: One Health Plan of WY PPO |
$7.25
|
| Rate for Payer: PacificSource Commercial |
$6.66
|
| Rate for Payer: PHCS PPO |
$7.25
|
| Rate for Payer: Three Rivers PPO |
$5.55
|
| Rate for Payer: TriWest Veterans Administration |
$4.29
|
| Rate for Payer: United Healthcare Commercial |
$6.44
|
| Rate for Payer: United Healthcare Medicare |
$4.29
|
| Rate for Payer: WINHealth Partners Commercial |
$7.25
|
| Rate for Payer: Wise Provider Network Commercial |
$7.03
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [29684]
|
Facility
|
IP
|
$5.27
|
|
|
Service Code
|
NDC 0904708404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$5.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.06
|
| Rate for Payer: Altius Commercial |
$5.06
|
| Rate for Payer: Beech Street Commercial |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.33
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.11
|
| Rate for Payer: Cigna of WY Commercial |
$5.16
|
| Rate for Payer: Entrust Commercial |
$5.01
|
| Rate for Payer: First Choice Health Commercial |
$5.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.48
|
| Rate for Payer: HealthUtah PPO |
$5.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.11
|
| Rate for Payer: Multiplan Medicare/VA |
$3.30
|
| Rate for Payer: One Health Plan of WY PPO |
$5.16
|
| Rate for Payer: PacificSource Commercial |
$4.74
|
| Rate for Payer: PHCS PPO |
$5.16
|
| Rate for Payer: Three Rivers PPO |
$3.95
|
| Rate for Payer: TriWest Veterans Administration |
$3.48
|
| Rate for Payer: United Healthcare Commercial |
$4.58
|
| Rate for Payer: United Healthcare Medicare |
$3.48
|
| Rate for Payer: WINHealth Partners Commercial |
$5.01
|
| Rate for Payer: Wise Provider Network Commercial |
$5.01
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [29684]
|
Facility
|
OP
|
$5.27
|
|
|
Service Code
|
NDC 0904708404
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.90 |
| Max. Negotiated Rate |
$5.27 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.16
|
| Rate for Payer: Aetna of WY Medicare |
$3.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.06
|
| Rate for Payer: Altius Commercial |
$5.06
|
| Rate for Payer: Beech Street Commercial |
$5.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.33
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.11
|
| Rate for Payer: Cigna of WY Commercial |
$5.16
|
| Rate for Payer: Entrust Commercial |
$5.01
|
| Rate for Payer: First Choice Health Commercial |
$5.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.06
|
| Rate for Payer: HealthUtah PPO |
$5.27
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.11
|
| Rate for Payer: Multiplan Medicare/VA |
$2.90
|
| Rate for Payer: One Health Plan of WY PPO |
$5.16
|
| Rate for Payer: PacificSource Commercial |
$4.74
|
| Rate for Payer: PHCS PPO |
$5.16
|
| Rate for Payer: Three Rivers PPO |
$3.95
|
| Rate for Payer: TriWest Veterans Administration |
$3.06
|
| Rate for Payer: United Healthcare Commercial |
$4.58
|
| Rate for Payer: United Healthcare Medicare |
$3.06
|
| Rate for Payer: WINHealth Partners Commercial |
$5.16
|
| Rate for Payer: Wise Provider Network Commercial |
$5.01
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [29684]
|
Facility
|
IP
|
$7.40
|
|
|
Service Code
|
NDC 6068731211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.10
|
| Rate for Payer: Altius Commercial |
$7.10
|
| Rate for Payer: Beech Street Commercial |
$7.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.08
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.18
|
| Rate for Payer: Cigna of WY Commercial |
$7.25
|
| Rate for Payer: Entrust Commercial |
$7.03
|
| Rate for Payer: First Choice Health Commercial |
$7.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.88
|
| Rate for Payer: HealthUtah PPO |
$7.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.18
|
| Rate for Payer: Multiplan Medicare/VA |
$4.64
|
| Rate for Payer: One Health Plan of WY PPO |
$7.25
|
| Rate for Payer: PacificSource Commercial |
$6.66
|
| Rate for Payer: PHCS PPO |
$7.25
|
| Rate for Payer: Three Rivers PPO |
$5.55
|
| Rate for Payer: TriWest Veterans Administration |
$4.88
|
| Rate for Payer: United Healthcare Commercial |
$6.44
|
| Rate for Payer: United Healthcare Medicare |
$4.88
|
| Rate for Payer: WINHealth Partners Commercial |
$7.03
|
| Rate for Payer: Wise Provider Network Commercial |
$7.03
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [29684]
|
Facility
|
OP
|
$7.40
|
|
|
Service Code
|
NDC 6068731211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.25
|
| Rate for Payer: Aetna of WY Medicare |
$4.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.10
|
| Rate for Payer: Altius Commercial |
$7.10
|
| Rate for Payer: Beech Street Commercial |
$7.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.08
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.18
|
| Rate for Payer: Cigna of WY Commercial |
$7.25
|
| Rate for Payer: Entrust Commercial |
$7.03
|
| Rate for Payer: First Choice Health Commercial |
$7.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.29
|
| Rate for Payer: HealthUtah PPO |
$7.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.18
|
| Rate for Payer: Multiplan Medicare/VA |
$4.08
|
| Rate for Payer: One Health Plan of WY PPO |
$7.25
|
| Rate for Payer: PacificSource Commercial |
$6.66
|
| Rate for Payer: PHCS PPO |
$7.25
|
| Rate for Payer: Three Rivers PPO |
$5.55
|
| Rate for Payer: TriWest Veterans Administration |
$4.29
|
| Rate for Payer: United Healthcare Commercial |
$6.44
|
| Rate for Payer: United Healthcare Medicare |
$4.29
|
| Rate for Payer: WINHealth Partners Commercial |
$7.25
|
| Rate for Payer: Wise Provider Network Commercial |
$7.03
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [29684]
|
Facility
|
IP
|
$7.40
|
|
|
Service Code
|
NDC 6068731201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.10
|
| Rate for Payer: Altius Commercial |
$7.10
|
| Rate for Payer: Beech Street Commercial |
$7.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.08
|
| Rate for Payer: Cash Price |
$5.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.18
|
| Rate for Payer: Cigna of WY Commercial |
$7.25
|
| Rate for Payer: Entrust Commercial |
$7.03
|
| Rate for Payer: First Choice Health Commercial |
$7.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.03
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.88
|
| Rate for Payer: HealthUtah PPO |
$7.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.18
|
| Rate for Payer: Multiplan Medicare/VA |
$4.64
|
| Rate for Payer: One Health Plan of WY PPO |
$7.25
|
| Rate for Payer: PacificSource Commercial |
$6.66
|
| Rate for Payer: PHCS PPO |
$7.25
|
| Rate for Payer: Three Rivers PPO |
$5.55
|
| Rate for Payer: TriWest Veterans Administration |
$4.88
|
| Rate for Payer: United Healthcare Commercial |
$6.44
|
| Rate for Payer: United Healthcare Medicare |
$4.88
|
| Rate for Payer: WINHealth Partners Commercial |
$7.03
|
| Rate for Payer: Wise Provider Network Commercial |
$7.03
|
|
|
BUR 6.0 EGG 14 FLU 1607-2-3
|
Facility
|
OP
|
$111.30
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$61.33 |
| Max. Negotiated Rate |
$111.30 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$109.07
|
| Rate for Payer: Aetna of WY Medicare |
$73.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$106.85
|
| Rate for Payer: Altius Commercial |
$106.85
|
| Rate for Payer: Beech Street Commercial |
$109.07
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$91.38
|
| Rate for Payer: Cash Price |
$77.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$107.96
|
| Rate for Payer: Cigna of WY Commercial |
$109.07
|
| Rate for Payer: Entrust Commercial |
$105.74
|
| Rate for Payer: First Choice Health Commercial |
$105.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$105.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.55
|
| Rate for Payer: HealthUtah PPO |
$111.30
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$107.96
|
| Rate for Payer: Multiplan Medicare/VA |
$61.33
|
| Rate for Payer: One Health Plan of WY PPO |
$109.07
|
| Rate for Payer: PacificSource Commercial |
$100.17
|
| Rate for Payer: PHCS PPO |
$109.07
|
| Rate for Payer: Three Rivers PPO |
$83.48
|
| Rate for Payer: TriWest Veterans Administration |
$64.55
|
| Rate for Payer: United Healthcare Commercial |
$96.83
|
| Rate for Payer: United Healthcare Medicare |
$64.55
|
| Rate for Payer: WINHealth Partners Commercial |
$109.07
|
| Rate for Payer: Wise Provider Network Commercial |
$105.74
|
|
