|
BUDDY LOOP 1/2" WIDE BLACK
|
Facility
|
IP
|
$6.01
|
|
| Hospital Charge Code |
2200405
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.89
|
| Rate for Payer: Aetna of WY Medicare |
$3.85
|
| Rate for Payer: Altius Commercial |
$5.77
|
| Rate for Payer: Beech Street Commercial |
$5.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.83
|
| Rate for Payer: Cash Price |
$4.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.83
|
| Rate for Payer: Cigna of WY Commercial |
$5.89
|
| Rate for Payer: Entrust Commercial |
$5.71
|
| Rate for Payer: First Choice Health Commercial |
$5.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.67
|
| Rate for Payer: HealthUtah PPO |
$6.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.83
|
| Rate for Payer: Multiplan Medicare/VA |
$3.48
|
| Rate for Payer: One Health Plan of WY PPO |
$5.89
|
| Rate for Payer: PacificSource Commercial |
$5.41
|
| Rate for Payer: PHCS PPO |
$5.89
|
| Rate for Payer: Three Rivers PPO |
$4.51
|
| Rate for Payer: TriWest Veterans Administration |
$3.67
|
| Rate for Payer: United Healthcare Commercial |
$5.74
|
| Rate for Payer: United Healthcare Medicare |
$3.67
|
| Rate for Payer: WINHealth Partners Commercial |
$5.71
|
| Rate for Payer: Wise Provider Network Commercial |
$5.71
|
|
|
BUDDY LOOP 1/2" WIDE BLACK
|
Facility
|
OP
|
$6.01
|
|
| Hospital Charge Code |
2200405
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.89
|
| Rate for Payer: Aetna of WY Medicare |
$3.97
|
| Rate for Payer: Altius Commercial |
$5.77
|
| Rate for Payer: Beech Street Commercial |
$5.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.83
|
| Rate for Payer: Cash Price |
$4.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.83
|
| Rate for Payer: Cigna of WY Commercial |
$5.89
|
| Rate for Payer: Entrust Commercial |
$5.71
|
| Rate for Payer: First Choice Health Commercial |
$5.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.43
|
| Rate for Payer: HealthUtah PPO |
$6.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.83
|
| Rate for Payer: Multiplan Medicare/VA |
$3.25
|
| Rate for Payer: One Health Plan of WY PPO |
$5.89
|
| Rate for Payer: PacificSource Commercial |
$5.41
|
| Rate for Payer: PHCS PPO |
$5.89
|
| Rate for Payer: Three Rivers PPO |
$4.51
|
| Rate for Payer: TriWest Veterans Administration |
$3.43
|
| Rate for Payer: United Healthcare Commercial |
$5.74
|
| Rate for Payer: United Healthcare Medicare |
$3.43
|
| Rate for Payer: WINHealth Partners Commercial |
$5.89
|
| Rate for Payer: Wise Provider Network Commercial |
$5.71
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [15049]
|
Facility
|
OP
|
$24.50
|
|
|
Service Code
|
HCPCS J7626
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.27 |
| Max. Negotiated Rate |
$24.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.01
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.22
|
| Rate for Payer: Aetna of WY Medicare |
$16.17
|
| Rate for Payer: Aetna of WY Medicare |
$19.68
|
| Rate for Payer: Altius Commercial |
$23.52
|
| Rate for Payer: Altius Commercial |
$28.63
|
| Rate for Payer: Beech Street Commercial |
$24.01
|
| Rate for Payer: Beech Street Commercial |
$29.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.76
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: Cash Price |
$20.88
|
| Rate for Payer: ChoiceCare Network Commercial |
$28.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.76
|
| Rate for Payer: Cigna of WY Commercial |
$24.01
|
| Rate for Payer: Cigna of WY Commercial |
$29.22
|
| Rate for Payer: Entrust Commercial |
$28.33
|
| Rate for Payer: Entrust Commercial |
$23.28
|
| Rate for Payer: First Choice Health Commercial |
$23.28
|
| Rate for Payer: First Choice Health Commercial |
$28.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.00
|
| Rate for Payer: HealthUtah PPO |
$29.82
|
| Rate for Payer: HealthUtah PPO |
$24.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$28.93
|
| Rate for Payer: Multiplan Medicare/VA |
$13.27
|
| Rate for Payer: Multiplan Medicare/VA |
$16.15
|
| Rate for Payer: One Health Plan of WY PPO |
$24.01
|
| Rate for Payer: One Health Plan of WY PPO |
$29.22
|
| Rate for Payer: PacificSource Commercial |
$26.84
|
| Rate for Payer: PacificSource Commercial |
$22.05
|
| Rate for Payer: PHCS PPO |
$24.01
|
| Rate for Payer: PHCS PPO |
$29.22
|
| Rate for Payer: Three Rivers PPO |
$18.38
|
| Rate for Payer: Three Rivers PPO |
$22.36
|
| Rate for Payer: TriWest Veterans Administration |
$17.00
|
| Rate for Payer: TriWest Veterans Administration |
$13.96
|
| Rate for Payer: United Healthcare Commercial |
$23.40
|
| Rate for Payer: United Healthcare Commercial |
$28.48
|
| Rate for Payer: United Healthcare Medicare |
$17.00
|
| Rate for Payer: United Healthcare Medicare |
$13.96
|
| Rate for Payer: WINHealth Partners Commercial |
$24.01
|
| Rate for Payer: WINHealth Partners Commercial |
$29.22
|
| Rate for Payer: Wise Provider Network Commercial |
$23.28
|
| Rate for Payer: Wise Provider Network Commercial |
$28.33
|
|
|
BUDESONIDE 0.25 MG/2 ML SUSPENSION FOR NEBULIZATION [15049]
|
Facility
|
IP
|
$24.50
|
|
|
Service Code
|
HCPCS J7626
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.20 |
| Max. Negotiated Rate |
$24.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.01
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$29.22
|
| Rate for Payer: Aetna of WY Medicare |
$19.08
|
| Rate for Payer: Aetna of WY Medicare |
$15.68
|
| Rate for Payer: Altius Commercial |
$28.63
|
| Rate for Payer: Altius Commercial |
$23.52
|
| Rate for Payer: Beech Street Commercial |
$24.01
|
| Rate for Payer: Beech Street Commercial |
$29.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$28.93
|
| Rate for Payer: Cash Price |
$20.88
|
| Rate for Payer: Cash Price |
$17.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$28.93
|
| Rate for Payer: Cigna of WY Commercial |
$24.01
|
| Rate for Payer: Cigna of WY Commercial |
$29.22
|
| Rate for Payer: Entrust Commercial |
$28.33
|
| Rate for Payer: Entrust Commercial |
$23.28
|
| Rate for Payer: First Choice Health Commercial |
$28.33
|
| Rate for Payer: First Choice Health Commercial |
$23.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$28.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.19
|
| Rate for Payer: HealthUtah PPO |
$24.50
|
| Rate for Payer: HealthUtah PPO |
$29.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.76
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$28.93
|
| Rate for Payer: Multiplan Medicare/VA |
$17.28
|
| Rate for Payer: Multiplan Medicare/VA |
$14.20
|
| Rate for Payer: One Health Plan of WY PPO |
$29.22
|
| Rate for Payer: One Health Plan of WY PPO |
$24.01
|
| Rate for Payer: PacificSource Commercial |
$22.05
|
| Rate for Payer: PacificSource Commercial |
$26.84
|
| Rate for Payer: PHCS PPO |
$29.22
|
| Rate for Payer: PHCS PPO |
$24.01
|
| Rate for Payer: Three Rivers PPO |
$18.38
|
| Rate for Payer: Three Rivers PPO |
$22.36
|
| Rate for Payer: TriWest Veterans Administration |
$14.94
|
| Rate for Payer: TriWest Veterans Administration |
$18.19
|
| Rate for Payer: United Healthcare Commercial |
$23.40
|
| Rate for Payer: United Healthcare Commercial |
$28.48
|
| Rate for Payer: United Healthcare Medicare |
$14.94
|
| Rate for Payer: United Healthcare Medicare |
$18.19
|
| Rate for Payer: WINHealth Partners Commercial |
$28.33
|
| Rate for Payer: WINHealth Partners Commercial |
$23.28
|
| Rate for Payer: Wise Provider Network Commercial |
$23.28
|
| Rate for Payer: Wise Provider Network Commercial |
$28.33
|
|
|
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [15228]
|
Facility
|
IP
|
$32.50
|
|
|
Service Code
|
NDC 6818098405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.83 |
| Max. Negotiated Rate |
$32.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.85
|
| Rate for Payer: Aetna of WY Medicare |
$20.80
|
| Rate for Payer: Altius Commercial |
$31.20
|
| Rate for Payer: Beech Street Commercial |
$31.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.52
|
| Rate for Payer: Cash Price |
$22.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.52
|
| Rate for Payer: Cigna of WY Commercial |
$31.85
|
| Rate for Payer: Entrust Commercial |
$30.88
|
| Rate for Payer: First Choice Health Commercial |
$30.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.82
|
| Rate for Payer: HealthUtah PPO |
$32.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.52
|
| Rate for Payer: Multiplan Medicare/VA |
$18.83
|
| Rate for Payer: One Health Plan of WY PPO |
$31.85
|
| Rate for Payer: PacificSource Commercial |
$29.25
|
| Rate for Payer: PHCS PPO |
$31.85
|
| Rate for Payer: Three Rivers PPO |
$24.38
|
| Rate for Payer: TriWest Veterans Administration |
$19.82
|
| Rate for Payer: United Healthcare Commercial |
$31.04
|
| Rate for Payer: United Healthcare Medicare |
$19.82
|
| Rate for Payer: WINHealth Partners Commercial |
$30.88
|
| Rate for Payer: Wise Provider Network Commercial |
$30.88
|
|
|
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [15228]
|
Facility
|
IP
|
$17.00
|
|
|
Service Code
|
NDC 6068752479
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.85 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.66
|
| Rate for Payer: Aetna of WY Medicare |
$10.88
|
| Rate for Payer: Altius Commercial |
$16.32
|
| Rate for Payer: Beech Street Commercial |
$16.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.49
|
| Rate for Payer: Cash Price |
$11.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.49
|
| Rate for Payer: Cigna of WY Commercial |
$16.66
|
| Rate for Payer: Entrust Commercial |
$16.15
|
| Rate for Payer: First Choice Health Commercial |
$16.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.37
|
| Rate for Payer: HealthUtah PPO |
$17.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.49
|
| Rate for Payer: Multiplan Medicare/VA |
$9.85
|
| Rate for Payer: One Health Plan of WY PPO |
$16.66
|
| Rate for Payer: PacificSource Commercial |
$15.30
|
| Rate for Payer: PHCS PPO |
$16.66
|
| Rate for Payer: Three Rivers PPO |
$12.75
|
| Rate for Payer: TriWest Veterans Administration |
$10.37
|
| Rate for Payer: United Healthcare Commercial |
$16.24
|
| Rate for Payer: United Healthcare Medicare |
$10.37
|
| Rate for Payer: WINHealth Partners Commercial |
$16.15
|
| Rate for Payer: Wise Provider Network Commercial |
$16.15
|
|
|
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [15228]
|
Facility
|
OP
|
$17.00
|
|
|
Service Code
|
NDC 6068752479
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.21 |
| Max. Negotiated Rate |
$17.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.66
|
| Rate for Payer: Aetna of WY Medicare |
$11.22
|
| Rate for Payer: Altius Commercial |
$16.32
|
| Rate for Payer: Beech Street Commercial |
$16.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.49
|
| Rate for Payer: Cash Price |
$11.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.49
|
| Rate for Payer: Cigna of WY Commercial |
$16.66
|
| Rate for Payer: Entrust Commercial |
$16.15
|
| Rate for Payer: First Choice Health Commercial |
$16.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.69
|
| Rate for Payer: HealthUtah PPO |
$17.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.49
|
| Rate for Payer: Multiplan Medicare/VA |
$9.21
|
| Rate for Payer: One Health Plan of WY PPO |
$16.66
|
| Rate for Payer: PacificSource Commercial |
$15.30
|
| Rate for Payer: PHCS PPO |
$16.66
|
| Rate for Payer: Three Rivers PPO |
$12.75
|
| Rate for Payer: TriWest Veterans Administration |
$9.69
|
| Rate for Payer: United Healthcare Commercial |
$16.24
|
| Rate for Payer: United Healthcare Medicare |
$9.69
|
| Rate for Payer: WINHealth Partners Commercial |
$16.66
|
| Rate for Payer: Wise Provider Network Commercial |
$16.15
|
|
|
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [15228]
|
Facility
|
IP
|
$32.50
|
|
|
Service Code
|
NDC 6068752483
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.83 |
| Max. Negotiated Rate |
$32.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.85
|
| Rate for Payer: Aetna of WY Medicare |
$20.80
|
| Rate for Payer: Altius Commercial |
$31.20
|
| Rate for Payer: Beech Street Commercial |
$31.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.52
|
| Rate for Payer: Cash Price |
$22.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.52
|
| Rate for Payer: Cigna of WY Commercial |
$31.85
|
| Rate for Payer: Entrust Commercial |
$30.88
|
| Rate for Payer: First Choice Health Commercial |
$30.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.82
|
| Rate for Payer: HealthUtah PPO |
$32.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.52
|
| Rate for Payer: Multiplan Medicare/VA |
$18.83
|
| Rate for Payer: One Health Plan of WY PPO |
$31.85
|
| Rate for Payer: PacificSource Commercial |
$29.25
|
| Rate for Payer: PHCS PPO |
$31.85
|
| Rate for Payer: Three Rivers PPO |
$24.38
|
| Rate for Payer: TriWest Veterans Administration |
$19.82
|
| Rate for Payer: United Healthcare Commercial |
$31.04
|
| Rate for Payer: United Healthcare Medicare |
$19.82
|
| Rate for Payer: WINHealth Partners Commercial |
$30.88
|
| Rate for Payer: Wise Provider Network Commercial |
$30.88
|
|
|
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [15228]
|
Facility
|
OP
|
$32.50
|
|
|
Service Code
|
NDC 6818098405
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$32.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.85
|
| Rate for Payer: Aetna of WY Medicare |
$21.45
|
| Rate for Payer: Altius Commercial |
$31.20
|
| Rate for Payer: Beech Street Commercial |
$31.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.52
|
| Rate for Payer: Cash Price |
$22.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.52
|
| Rate for Payer: Cigna of WY Commercial |
$31.85
|
| Rate for Payer: Entrust Commercial |
$30.88
|
| Rate for Payer: First Choice Health Commercial |
$30.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.52
|
| Rate for Payer: HealthUtah PPO |
$32.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.52
|
| Rate for Payer: Multiplan Medicare/VA |
$17.60
|
| Rate for Payer: One Health Plan of WY PPO |
$31.85
|
| Rate for Payer: PacificSource Commercial |
$29.25
|
| Rate for Payer: PHCS PPO |
$31.85
|
| Rate for Payer: Three Rivers PPO |
$24.38
|
| Rate for Payer: TriWest Veterans Administration |
$18.52
|
| Rate for Payer: United Healthcare Commercial |
$31.04
|
| Rate for Payer: United Healthcare Medicare |
$18.52
|
| Rate for Payer: WINHealth Partners Commercial |
$31.85
|
| Rate for Payer: Wise Provider Network Commercial |
$30.88
|
|
|
BUDESONIDE 0.5 MG/2 ML SUSPENSION FOR NEBULIZATION [15228]
|
Facility
|
OP
|
$32.50
|
|
|
Service Code
|
NDC 6068752483
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.60 |
| Max. Negotiated Rate |
$32.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.85
|
| Rate for Payer: Aetna of WY Medicare |
$21.45
|
| Rate for Payer: Altius Commercial |
$31.20
|
| Rate for Payer: Beech Street Commercial |
$31.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.52
|
| Rate for Payer: Cash Price |
$22.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.52
|
| Rate for Payer: Cigna of WY Commercial |
$31.85
|
| Rate for Payer: Entrust Commercial |
$30.88
|
| Rate for Payer: First Choice Health Commercial |
$30.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.52
|
| Rate for Payer: HealthUtah PPO |
$32.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.52
|
| Rate for Payer: Multiplan Medicare/VA |
$17.60
|
| Rate for Payer: One Health Plan of WY PPO |
$31.85
|
| Rate for Payer: PacificSource Commercial |
$29.25
|
| Rate for Payer: PHCS PPO |
$31.85
|
| Rate for Payer: Three Rivers PPO |
$24.38
|
| Rate for Payer: TriWest Veterans Administration |
$18.52
|
| Rate for Payer: United Healthcare Commercial |
$31.04
|
| Rate for Payer: United Healthcare Medicare |
$18.52
|
| Rate for Payer: WINHealth Partners Commercial |
$31.85
|
| Rate for Payer: Wise Provider Network Commercial |
$30.88
|
|
|
BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [17231]
|
Facility
|
OP
|
$23.90
|
|
|
Service Code
|
NDC 6838272001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.94 |
| Max. Negotiated Rate |
$23.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.42
|
| Rate for Payer: Aetna of WY Medicare |
$15.77
|
| Rate for Payer: Altius Commercial |
$22.94
|
| Rate for Payer: Beech Street Commercial |
$23.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.18
|
| Rate for Payer: Cash Price |
$16.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.18
|
| Rate for Payer: Cigna of WY Commercial |
$23.42
|
| Rate for Payer: Entrust Commercial |
$22.70
|
| Rate for Payer: First Choice Health Commercial |
$22.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.62
|
| Rate for Payer: HealthUtah PPO |
$23.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.18
|
| Rate for Payer: Multiplan Medicare/VA |
$12.94
|
| Rate for Payer: One Health Plan of WY PPO |
$23.42
|
| Rate for Payer: PacificSource Commercial |
$21.51
|
| Rate for Payer: PHCS PPO |
$23.42
|
| Rate for Payer: Three Rivers PPO |
$17.92
|
| Rate for Payer: TriWest Veterans Administration |
$13.62
|
| Rate for Payer: United Healthcare Commercial |
$22.82
|
| Rate for Payer: United Healthcare Medicare |
$13.62
|
| Rate for Payer: WINHealth Partners Commercial |
$23.42
|
| Rate for Payer: Wise Provider Network Commercial |
$22.70
|
|
|
BUDESONIDE DR - ER 3 MG CAPSULE,DELAYED,EXTENDED RELEASE [17231]
|
Facility
|
IP
|
$23.90
|
|
|
Service Code
|
NDC 6838272001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.85 |
| Max. Negotiated Rate |
$23.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.42
|
| Rate for Payer: Aetna of WY Medicare |
$15.30
|
| Rate for Payer: Altius Commercial |
$22.94
|
| Rate for Payer: Beech Street Commercial |
$23.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$23.18
|
| Rate for Payer: Cash Price |
$16.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.18
|
| Rate for Payer: Cigna of WY Commercial |
$23.42
|
| Rate for Payer: Entrust Commercial |
$22.70
|
| Rate for Payer: First Choice Health Commercial |
$22.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.58
|
| Rate for Payer: HealthUtah PPO |
$23.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.18
|
| Rate for Payer: Multiplan Medicare/VA |
$13.85
|
| Rate for Payer: One Health Plan of WY PPO |
$23.42
|
| Rate for Payer: PacificSource Commercial |
$21.51
|
| Rate for Payer: PHCS PPO |
$23.42
|
| Rate for Payer: Three Rivers PPO |
$17.92
|
| Rate for Payer: TriWest Veterans Administration |
$14.58
|
| Rate for Payer: United Healthcare Commercial |
$22.82
|
| Rate for Payer: United Healthcare Medicare |
$14.58
|
| Rate for Payer: WINHealth Partners Commercial |
$22.70
|
| Rate for Payer: Wise Provider Network Commercial |
$22.70
|
|
|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [43650]
|
Facility
|
OP
|
$55.19
|
|
|
Service Code
|
NDC 0186037220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.89 |
| Max. Negotiated Rate |
$55.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.09
|
| Rate for Payer: Aetna of WY Medicare |
$36.43
|
| Rate for Payer: Altius Commercial |
$52.98
|
| Rate for Payer: Beech Street Commercial |
$54.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.53
|
| Rate for Payer: Cash Price |
$38.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.53
|
| Rate for Payer: Cigna of WY Commercial |
$54.09
|
| Rate for Payer: Entrust Commercial |
$52.43
|
| Rate for Payer: First Choice Health Commercial |
$52.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.46
|
| Rate for Payer: HealthUtah PPO |
$55.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.53
|
| Rate for Payer: Multiplan Medicare/VA |
$29.89
|
| Rate for Payer: One Health Plan of WY PPO |
$54.09
|
| Rate for Payer: PacificSource Commercial |
$49.67
|
| Rate for Payer: PHCS PPO |
$54.09
|
| Rate for Payer: Three Rivers PPO |
$41.39
|
| Rate for Payer: TriWest Veterans Administration |
$31.46
|
| Rate for Payer: United Healthcare Commercial |
$52.71
|
| Rate for Payer: United Healthcare Medicare |
$31.46
|
| Rate for Payer: WINHealth Partners Commercial |
$54.09
|
| Rate for Payer: Wise Provider Network Commercial |
$52.43
|
|
|
BUDESONIDE-FORMOTEROL HFA 80 MCG-4.5 MCG/ACTUATION AEROSOL INHALER [43650]
|
Facility
|
IP
|
$55.19
|
|
|
Service Code
|
NDC 0186037220
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$55.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.09
|
| Rate for Payer: Aetna of WY Medicare |
$35.32
|
| Rate for Payer: Altius Commercial |
$52.98
|
| Rate for Payer: Beech Street Commercial |
$54.09
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.53
|
| Rate for Payer: Cash Price |
$38.63
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.53
|
| Rate for Payer: Cigna of WY Commercial |
$54.09
|
| Rate for Payer: Entrust Commercial |
$52.43
|
| Rate for Payer: First Choice Health Commercial |
$52.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.43
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.67
|
| Rate for Payer: HealthUtah PPO |
$55.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.53
|
| Rate for Payer: Multiplan Medicare/VA |
$31.98
|
| Rate for Payer: One Health Plan of WY PPO |
$54.09
|
| Rate for Payer: PacificSource Commercial |
$49.67
|
| Rate for Payer: PHCS PPO |
$54.09
|
| Rate for Payer: Three Rivers PPO |
$41.39
|
| Rate for Payer: TriWest Veterans Administration |
$33.67
|
| Rate for Payer: United Healthcare Commercial |
$52.71
|
| Rate for Payer: United Healthcare Medicare |
$33.67
|
| Rate for Payer: WINHealth Partners Commercial |
$52.43
|
| Rate for Payer: Wise Provider Network Commercial |
$52.43
|
|
|
BUDESONIDE NON-COMP UNIT
|
Professional
|
Both
|
$20.00
|
|
|
Service Code
|
HCPCS J7626
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.60
|
| Rate for Payer: Aetna of WY Medicare |
$1.20
|
| Rate for Payer: Beech Street Commercial |
$19.00
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.40
|
| Rate for Payer: Cigna of WY Commercial |
$19.60
|
| Rate for Payer: First Choice Health Commercial |
$18.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1.20
|
| Rate for Payer: HealthUtah PPO |
$20.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.40
|
| Rate for Payer: Multiplan Medicare/VA |
$1.02
|
| Rate for Payer: One Health Plan of WY PPO |
$19.60
|
| Rate for Payer: PacificSource Commercial |
$18.00
|
| Rate for Payer: PHCS PPO |
$19.00
|
| Rate for Payer: Three Rivers PPO |
$15.00
|
| Rate for Payer: TriWest Veterans Administration |
$1.20
|
| Rate for Payer: United Healthcare Commercial |
$19.00
|
| Rate for Payer: WINHealth Partners Commercial |
$19.00
|
|
|
BUGBEE 3FRX105CM ELECTRODE
|
Facility
|
IP
|
$228.48
|
|
| Hospital Charge Code |
2750133
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$132.40 |
| Max. Negotiated Rate |
$228.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$223.91
|
| Rate for Payer: Aetna of WY Medicare |
$146.23
|
| Rate for Payer: Altius Commercial |
$219.34
|
| Rate for Payer: Beech Street Commercial |
$223.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.63
|
| Rate for Payer: Cash Price |
$159.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$221.63
|
| Rate for Payer: Cigna of WY Commercial |
$223.91
|
| Rate for Payer: Entrust Commercial |
$217.06
|
| Rate for Payer: First Choice Health Commercial |
$217.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$217.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$139.37
|
| Rate for Payer: HealthUtah PPO |
$228.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$221.63
|
| Rate for Payer: Multiplan Medicare/VA |
$132.40
|
| Rate for Payer: One Health Plan of WY PPO |
$223.91
|
| Rate for Payer: PacificSource Commercial |
$205.63
|
| Rate for Payer: PHCS PPO |
$223.91
|
| Rate for Payer: Three Rivers PPO |
$171.36
|
| Rate for Payer: TriWest Veterans Administration |
$139.37
|
| Rate for Payer: United Healthcare Commercial |
$218.20
|
| Rate for Payer: United Healthcare Medicare |
$139.37
|
| Rate for Payer: WINHealth Partners Commercial |
$217.06
|
| Rate for Payer: Wise Provider Network Commercial |
$217.06
|
|
|
BUGBEE 3FRX105CM ELECTRODE
|
Facility
|
OP
|
$228.48
|
|
| Hospital Charge Code |
2750133
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$123.72 |
| Max. Negotiated Rate |
$228.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$223.91
|
| Rate for Payer: Aetna of WY Medicare |
$150.80
|
| Rate for Payer: Altius Commercial |
$219.34
|
| Rate for Payer: Beech Street Commercial |
$223.91
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$221.63
|
| Rate for Payer: Cash Price |
$159.94
|
| Rate for Payer: ChoiceCare Network Commercial |
$221.63
|
| Rate for Payer: Cigna of WY Commercial |
$223.91
|
| Rate for Payer: Entrust Commercial |
$217.06
|
| Rate for Payer: First Choice Health Commercial |
$217.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$217.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$130.23
|
| Rate for Payer: HealthUtah PPO |
$228.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$221.63
|
| Rate for Payer: Multiplan Medicare/VA |
$123.72
|
| Rate for Payer: One Health Plan of WY PPO |
$223.91
|
| Rate for Payer: PacificSource Commercial |
$205.63
|
| Rate for Payer: PHCS PPO |
$223.91
|
| Rate for Payer: Three Rivers PPO |
$171.36
|
| Rate for Payer: TriWest Veterans Administration |
$130.23
|
| Rate for Payer: United Healthcare Commercial |
$218.20
|
| Rate for Payer: United Healthcare Medicare |
$130.23
|
| Rate for Payer: WINHealth Partners Commercial |
$223.91
|
| Rate for Payer: Wise Provider Network Commercial |
$217.06
|
|
|
BUGBEE BLUE 8 FR 37CM REUSABLE
|
Facility
|
OP
|
$294.00
|
|
| Hospital Charge Code |
2650031
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$159.20 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$288.12
|
| Rate for Payer: Aetna of WY Medicare |
$194.04
|
| Rate for Payer: Altius Commercial |
$282.24
|
| Rate for Payer: Beech Street Commercial |
$288.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$285.18
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$285.18
|
| Rate for Payer: Cigna of WY Commercial |
$288.12
|
| Rate for Payer: Entrust Commercial |
$279.30
|
| Rate for Payer: First Choice Health Commercial |
$279.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$279.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$167.58
|
| Rate for Payer: HealthUtah PPO |
$294.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$285.18
|
| Rate for Payer: Multiplan Medicare/VA |
$159.20
|
| Rate for Payer: One Health Plan of WY PPO |
$288.12
|
| Rate for Payer: PacificSource Commercial |
$264.60
|
| Rate for Payer: PHCS PPO |
$288.12
|
| Rate for Payer: Three Rivers PPO |
$220.50
|
| Rate for Payer: TriWest Veterans Administration |
$167.58
|
| Rate for Payer: United Healthcare Commercial |
$280.77
|
| Rate for Payer: United Healthcare Medicare |
$167.58
|
| Rate for Payer: WINHealth Partners Commercial |
$288.12
|
| Rate for Payer: Wise Provider Network Commercial |
$279.30
|
|
|
BUGBEE BLUE 8 FR 37CM REUSABLE
|
Facility
|
IP
|
$294.00
|
|
| Hospital Charge Code |
2650031
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$170.37 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$288.12
|
| Rate for Payer: Aetna of WY Medicare |
$188.16
|
| Rate for Payer: Altius Commercial |
$282.24
|
| Rate for Payer: Beech Street Commercial |
$288.12
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$285.18
|
| Rate for Payer: Cash Price |
$205.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$285.18
|
| Rate for Payer: Cigna of WY Commercial |
$288.12
|
| Rate for Payer: Entrust Commercial |
$279.30
|
| Rate for Payer: First Choice Health Commercial |
$279.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$279.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$179.34
|
| Rate for Payer: HealthUtah PPO |
$294.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$285.18
|
| Rate for Payer: Multiplan Medicare/VA |
$170.37
|
| Rate for Payer: One Health Plan of WY PPO |
$288.12
|
| Rate for Payer: PacificSource Commercial |
$264.60
|
| Rate for Payer: PHCS PPO |
$288.12
|
| Rate for Payer: Three Rivers PPO |
$220.50
|
| Rate for Payer: TriWest Veterans Administration |
$179.34
|
| Rate for Payer: United Healthcare Commercial |
$280.77
|
| Rate for Payer: United Healthcare Medicare |
$179.34
|
| Rate for Payer: WINHealth Partners Commercial |
$279.30
|
| Rate for Payer: Wise Provider Network Commercial |
$279.30
|
|
|
BULKAMID URETHRAL BULKING SYSTEM
|
Facility
|
OP
|
$4,025.00
|
|
| Hospital Charge Code |
2650970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,179.54 |
| Max. Negotiated Rate |
$4,025.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,944.50
|
| Rate for Payer: Aetna of WY Medicare |
$2,656.50
|
| Rate for Payer: Altius Commercial |
$3,864.00
|
| Rate for Payer: Beech Street Commercial |
$3,944.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,904.25
|
| Rate for Payer: Cash Price |
$2,817.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,904.25
|
| Rate for Payer: Cigna of WY Commercial |
$3,944.50
|
| Rate for Payer: Entrust Commercial |
$3,823.75
|
| Rate for Payer: First Choice Health Commercial |
$3,823.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,823.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,294.25
|
| Rate for Payer: HealthUtah PPO |
$4,025.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,904.25
|
| Rate for Payer: Multiplan Medicare/VA |
$2,179.54
|
| Rate for Payer: One Health Plan of WY PPO |
$3,944.50
|
| Rate for Payer: PacificSource Commercial |
$3,622.50
|
| Rate for Payer: PHCS PPO |
$3,944.50
|
| Rate for Payer: Three Rivers PPO |
$3,018.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,294.25
|
| Rate for Payer: United Healthcare Commercial |
$3,843.88
|
| Rate for Payer: United Healthcare Medicare |
$2,294.25
|
| Rate for Payer: WINHealth Partners Commercial |
$3,944.50
|
| Rate for Payer: Wise Provider Network Commercial |
$3,823.75
|
|
|
BULKAMID URETHRAL BULKING SYSTEM
|
Facility
|
IP
|
$4,025.00
|
|
| Hospital Charge Code |
2650970
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,332.49 |
| Max. Negotiated Rate |
$4,025.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,944.50
|
| Rate for Payer: Aetna of WY Medicare |
$2,576.00
|
| Rate for Payer: Altius Commercial |
$3,864.00
|
| Rate for Payer: Beech Street Commercial |
$3,944.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,904.25
|
| Rate for Payer: Cash Price |
$2,817.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,904.25
|
| Rate for Payer: Cigna of WY Commercial |
$3,944.50
|
| Rate for Payer: Entrust Commercial |
$3,823.75
|
| Rate for Payer: First Choice Health Commercial |
$3,823.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,823.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,455.25
|
| Rate for Payer: HealthUtah PPO |
$4,025.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,904.25
|
| Rate for Payer: Multiplan Medicare/VA |
$2,332.49
|
| Rate for Payer: One Health Plan of WY PPO |
$3,944.50
|
| Rate for Payer: PacificSource Commercial |
$3,622.50
|
| Rate for Payer: PHCS PPO |
$3,944.50
|
| Rate for Payer: Three Rivers PPO |
$3,018.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,455.25
|
| Rate for Payer: United Healthcare Commercial |
$3,843.88
|
| Rate for Payer: United Healthcare Medicare |
$2,455.25
|
| Rate for Payer: WINHealth Partners Commercial |
$3,823.75
|
| Rate for Payer: Wise Provider Network Commercial |
$3,823.75
|
|
|
BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [417]
|
Facility
|
OP
|
$16.25
|
|
|
Service Code
|
NDC 6332346101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$16.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.92
|
| Rate for Payer: Aetna of WY Medicare |
$10.72
|
| Rate for Payer: Altius Commercial |
$15.60
|
| Rate for Payer: Beech Street Commercial |
$15.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.76
|
| Rate for Payer: Cash Price |
$11.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.76
|
| Rate for Payer: Cigna of WY Commercial |
$15.92
|
| Rate for Payer: Entrust Commercial |
$15.44
|
| Rate for Payer: First Choice Health Commercial |
$15.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.26
|
| Rate for Payer: HealthUtah PPO |
$16.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.76
|
| Rate for Payer: Multiplan Medicare/VA |
$8.80
|
| Rate for Payer: One Health Plan of WY PPO |
$15.92
|
| Rate for Payer: PacificSource Commercial |
$14.62
|
| Rate for Payer: PHCS PPO |
$15.92
|
| Rate for Payer: Three Rivers PPO |
$12.19
|
| Rate for Payer: TriWest Veterans Administration |
$9.26
|
| Rate for Payer: United Healthcare Commercial |
$15.52
|
| Rate for Payer: United Healthcare Medicare |
$9.26
|
| Rate for Payer: WINHealth Partners Commercial |
$15.92
|
| Rate for Payer: Wise Provider Network Commercial |
$15.44
|
|
|
BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [417]
|
Facility
|
IP
|
$15.98
|
|
|
Service Code
|
NDC 0409175250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.26 |
| Max. Negotiated Rate |
$15.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.66
|
| Rate for Payer: Aetna of WY Medicare |
$10.23
|
| Rate for Payer: Altius Commercial |
$15.34
|
| Rate for Payer: Beech Street Commercial |
$15.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.50
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.50
|
| Rate for Payer: Cigna of WY Commercial |
$15.66
|
| Rate for Payer: Entrust Commercial |
$15.18
|
| Rate for Payer: First Choice Health Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.75
|
| Rate for Payer: HealthUtah PPO |
$15.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.50
|
| Rate for Payer: Multiplan Medicare/VA |
$9.26
|
| Rate for Payer: One Health Plan of WY PPO |
$15.66
|
| Rate for Payer: PacificSource Commercial |
$14.38
|
| Rate for Payer: PHCS PPO |
$15.66
|
| Rate for Payer: Three Rivers PPO |
$11.98
|
| Rate for Payer: TriWest Veterans Administration |
$9.75
|
| Rate for Payer: United Healthcare Commercial |
$15.26
|
| Rate for Payer: United Healthcare Medicare |
$9.75
|
| Rate for Payer: WINHealth Partners Commercial |
$15.18
|
| Rate for Payer: Wise Provider Network Commercial |
$15.18
|
|
|
BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [417]
|
Facility
|
IP
|
$16.25
|
|
|
Service Code
|
NDC 6332346101
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.42 |
| Max. Negotiated Rate |
$16.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.92
|
| Rate for Payer: Aetna of WY Medicare |
$10.40
|
| Rate for Payer: Altius Commercial |
$15.60
|
| Rate for Payer: Beech Street Commercial |
$15.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.76
|
| Rate for Payer: Cash Price |
$11.37
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.76
|
| Rate for Payer: Cigna of WY Commercial |
$15.92
|
| Rate for Payer: Entrust Commercial |
$15.44
|
| Rate for Payer: First Choice Health Commercial |
$15.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.91
|
| Rate for Payer: HealthUtah PPO |
$16.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.76
|
| Rate for Payer: Multiplan Medicare/VA |
$9.42
|
| Rate for Payer: One Health Plan of WY PPO |
$15.92
|
| Rate for Payer: PacificSource Commercial |
$14.62
|
| Rate for Payer: PHCS PPO |
$15.92
|
| Rate for Payer: Three Rivers PPO |
$12.19
|
| Rate for Payer: TriWest Veterans Administration |
$9.91
|
| Rate for Payer: United Healthcare Commercial |
$15.52
|
| Rate for Payer: United Healthcare Medicare |
$9.91
|
| Rate for Payer: WINHealth Partners Commercial |
$15.44
|
| Rate for Payer: Wise Provider Network Commercial |
$15.44
|
|
|
BUPIVACAINE-EPINEPHRINE 0.25 %-1:200,000 INJECTION SOLUTION [417]
|
Facility
|
OP
|
$15.98
|
|
|
Service Code
|
NDC 0409175250
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$15.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.66
|
| Rate for Payer: Aetna of WY Medicare |
$10.55
|
| Rate for Payer: Altius Commercial |
$15.34
|
| Rate for Payer: Beech Street Commercial |
$15.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.50
|
| Rate for Payer: Cash Price |
$11.18
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.50
|
| Rate for Payer: Cigna of WY Commercial |
$15.66
|
| Rate for Payer: Entrust Commercial |
$15.18
|
| Rate for Payer: First Choice Health Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.11
|
| Rate for Payer: HealthUtah PPO |
$15.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.50
|
| Rate for Payer: Multiplan Medicare/VA |
$8.65
|
| Rate for Payer: One Health Plan of WY PPO |
$15.66
|
| Rate for Payer: PacificSource Commercial |
$14.38
|
| Rate for Payer: PHCS PPO |
$15.66
|
| Rate for Payer: Three Rivers PPO |
$11.98
|
| Rate for Payer: TriWest Veterans Administration |
$9.11
|
| Rate for Payer: United Healthcare Commercial |
$15.26
|
| Rate for Payer: United Healthcare Medicare |
$9.11
|
| Rate for Payer: WINHealth Partners Commercial |
$15.66
|
| Rate for Payer: Wise Provider Network Commercial |
$15.18
|
|
