|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
OP
|
$15.92
|
|
|
Service Code
|
NDC 0409156018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$15.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.60
|
| Rate for Payer: Aetna of WY Medicare |
$10.51
|
| Rate for Payer: Altius Commercial |
$15.28
|
| Rate for Payer: Beech Street Commercial |
$15.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.44
|
| Rate for Payer: Cash Price |
$11.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.44
|
| Rate for Payer: Cigna of WY Commercial |
$15.60
|
| Rate for Payer: Entrust Commercial |
$15.12
|
| Rate for Payer: First Choice Health Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.07
|
| Rate for Payer: HealthUtah PPO |
$15.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.44
|
| Rate for Payer: Multiplan Medicare/VA |
$8.62
|
| Rate for Payer: One Health Plan of WY PPO |
$15.60
|
| Rate for Payer: PacificSource Commercial |
$14.33
|
| Rate for Payer: PHCS PPO |
$15.60
|
| Rate for Payer: Three Rivers PPO |
$11.94
|
| Rate for Payer: TriWest Veterans Administration |
$9.07
|
| Rate for Payer: United Healthcare Commercial |
$15.20
|
| Rate for Payer: United Healthcare Medicare |
$9.07
|
| Rate for Payer: WINHealth Partners Commercial |
$15.60
|
| Rate for Payer: Wise Provider Network Commercial |
$15.12
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
IP
|
$15.92
|
|
|
Service Code
|
NDC 0409116218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.23 |
| Max. Negotiated Rate |
$15.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.60
|
| Rate for Payer: Aetna of WY Medicare |
$10.19
|
| Rate for Payer: Altius Commercial |
$15.28
|
| Rate for Payer: Beech Street Commercial |
$15.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.44
|
| Rate for Payer: Cash Price |
$11.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.44
|
| Rate for Payer: Cigna of WY Commercial |
$15.60
|
| Rate for Payer: Entrust Commercial |
$15.12
|
| Rate for Payer: First Choice Health Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.71
|
| Rate for Payer: HealthUtah PPO |
$15.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.44
|
| Rate for Payer: Multiplan Medicare/VA |
$9.23
|
| Rate for Payer: One Health Plan of WY PPO |
$15.60
|
| Rate for Payer: PacificSource Commercial |
$14.33
|
| Rate for Payer: PHCS PPO |
$15.60
|
| Rate for Payer: Three Rivers PPO |
$11.94
|
| Rate for Payer: TriWest Veterans Administration |
$9.71
|
| Rate for Payer: United Healthcare Commercial |
$15.20
|
| Rate for Payer: United Healthcare Medicare |
$9.71
|
| Rate for Payer: WINHealth Partners Commercial |
$15.12
|
| Rate for Payer: Wise Provider Network Commercial |
$15.12
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
OP
|
$15.35
|
|
|
Service Code
|
NDC 0409116201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.31 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Aetna of WY Medicare |
$10.13
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.75
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$8.31
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$14.66
|
| Rate for Payer: United Healthcare Medicare |
$8.75
|
| Rate for Payer: WINHealth Partners Commercial |
$15.04
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
OP
|
$16.90
|
|
|
Service Code
|
NDC 5515017030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.15 |
| Max. Negotiated Rate |
$16.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.56
|
| Rate for Payer: Aetna of WY Medicare |
$11.15
|
| Rate for Payer: Altius Commercial |
$16.22
|
| Rate for Payer: Beech Street Commercial |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.39
|
| Rate for Payer: Cash Price |
$11.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.39
|
| Rate for Payer: Cigna of WY Commercial |
$16.56
|
| Rate for Payer: Entrust Commercial |
$16.06
|
| Rate for Payer: First Choice Health Commercial |
$16.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.63
|
| Rate for Payer: HealthUtah PPO |
$16.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.39
|
| Rate for Payer: Multiplan Medicare/VA |
$9.15
|
| Rate for Payer: One Health Plan of WY PPO |
$16.56
|
| Rate for Payer: PacificSource Commercial |
$15.21
|
| Rate for Payer: PHCS PPO |
$16.56
|
| Rate for Payer: Three Rivers PPO |
$12.68
|
| Rate for Payer: TriWest Veterans Administration |
$9.63
|
| Rate for Payer: United Healthcare Commercial |
$16.14
|
| Rate for Payer: United Healthcare Medicare |
$9.63
|
| Rate for Payer: WINHealth Partners Commercial |
$16.56
|
| Rate for Payer: Wise Provider Network Commercial |
$16.06
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
OP
|
$15.92
|
|
|
Service Code
|
NDC 0409116218
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$15.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.60
|
| Rate for Payer: Aetna of WY Medicare |
$10.51
|
| Rate for Payer: Altius Commercial |
$15.28
|
| Rate for Payer: Beech Street Commercial |
$15.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.44
|
| Rate for Payer: Cash Price |
$11.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.44
|
| Rate for Payer: Cigna of WY Commercial |
$15.60
|
| Rate for Payer: Entrust Commercial |
$15.12
|
| Rate for Payer: First Choice Health Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.07
|
| Rate for Payer: HealthUtah PPO |
$15.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.44
|
| Rate for Payer: Multiplan Medicare/VA |
$8.62
|
| Rate for Payer: One Health Plan of WY PPO |
$15.60
|
| Rate for Payer: PacificSource Commercial |
$14.33
|
| Rate for Payer: PHCS PPO |
$15.60
|
| Rate for Payer: Three Rivers PPO |
$11.94
|
| Rate for Payer: TriWest Veterans Administration |
$9.07
|
| Rate for Payer: United Healthcare Commercial |
$15.20
|
| Rate for Payer: United Healthcare Medicare |
$9.07
|
| Rate for Payer: WINHealth Partners Commercial |
$15.60
|
| Rate for Payer: Wise Provider Network Commercial |
$15.12
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
IP
|
$16.90
|
|
|
Service Code
|
NDC 5515017030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.79 |
| Max. Negotiated Rate |
$16.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.56
|
| Rate for Payer: Aetna of WY Medicare |
$10.82
|
| Rate for Payer: Altius Commercial |
$16.22
|
| Rate for Payer: Beech Street Commercial |
$16.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.39
|
| Rate for Payer: Cash Price |
$11.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.39
|
| Rate for Payer: Cigna of WY Commercial |
$16.56
|
| Rate for Payer: Entrust Commercial |
$16.06
|
| Rate for Payer: First Choice Health Commercial |
$16.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.31
|
| Rate for Payer: HealthUtah PPO |
$16.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.39
|
| Rate for Payer: Multiplan Medicare/VA |
$9.79
|
| Rate for Payer: One Health Plan of WY PPO |
$16.56
|
| Rate for Payer: PacificSource Commercial |
$15.21
|
| Rate for Payer: PHCS PPO |
$16.56
|
| Rate for Payer: Three Rivers PPO |
$12.68
|
| Rate for Payer: TriWest Veterans Administration |
$10.31
|
| Rate for Payer: United Healthcare Commercial |
$16.14
|
| Rate for Payer: United Healthcare Medicare |
$10.31
|
| Rate for Payer: WINHealth Partners Commercial |
$16.06
|
| Rate for Payer: Wise Provider Network Commercial |
$16.06
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
IP
|
$15.92
|
|
|
Service Code
|
NDC 0409156018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.23 |
| Max. Negotiated Rate |
$15.92 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.60
|
| Rate for Payer: Aetna of WY Medicare |
$10.19
|
| Rate for Payer: Altius Commercial |
$15.28
|
| Rate for Payer: Beech Street Commercial |
$15.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.44
|
| Rate for Payer: Cash Price |
$11.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.44
|
| Rate for Payer: Cigna of WY Commercial |
$15.60
|
| Rate for Payer: Entrust Commercial |
$15.12
|
| Rate for Payer: First Choice Health Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.71
|
| Rate for Payer: HealthUtah PPO |
$15.92
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.44
|
| Rate for Payer: Multiplan Medicare/VA |
$9.23
|
| Rate for Payer: One Health Plan of WY PPO |
$15.60
|
| Rate for Payer: PacificSource Commercial |
$14.33
|
| Rate for Payer: PHCS PPO |
$15.60
|
| Rate for Payer: Three Rivers PPO |
$11.94
|
| Rate for Payer: TriWest Veterans Administration |
$9.71
|
| Rate for Payer: United Healthcare Commercial |
$15.20
|
| Rate for Payer: United Healthcare Medicare |
$9.71
|
| Rate for Payer: WINHealth Partners Commercial |
$15.12
|
| Rate for Payer: Wise Provider Network Commercial |
$15.12
|
|
|
BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [28407]
|
Facility
|
IP
|
$15.35
|
|
|
Service Code
|
NDC 0409116201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$15.35 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.04
|
| Rate for Payer: Aetna of WY Medicare |
$9.82
|
| Rate for Payer: Altius Commercial |
$14.74
|
| Rate for Payer: Beech Street Commercial |
$15.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$14.89
|
| Rate for Payer: Cash Price |
$10.74
|
| Rate for Payer: ChoiceCare Network Commercial |
$14.89
|
| Rate for Payer: Cigna of WY Commercial |
$15.04
|
| Rate for Payer: Entrust Commercial |
$14.58
|
| Rate for Payer: First Choice Health Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.58
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.36
|
| Rate for Payer: HealthUtah PPO |
$15.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$14.89
|
| Rate for Payer: Multiplan Medicare/VA |
$8.90
|
| Rate for Payer: One Health Plan of WY PPO |
$15.04
|
| Rate for Payer: PacificSource Commercial |
$13.82
|
| Rate for Payer: PHCS PPO |
$15.04
|
| Rate for Payer: Three Rivers PPO |
$11.51
|
| Rate for Payer: TriWest Veterans Administration |
$9.36
|
| Rate for Payer: United Healthcare Commercial |
$14.66
|
| Rate for Payer: United Healthcare Medicare |
$9.36
|
| Rate for Payer: WINHealth Partners Commercial |
$14.58
|
| Rate for Payer: Wise Provider Network Commercial |
$14.58
|
|
|
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 |
$9.30 |
| Max. Negotiated Rate |
$16.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.73
|
| Rate for Payer: Aetna of WY Medicare |
$10.27
|
| 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 |
$15.57
|
| 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 |
$9.79
|
| Rate for Payer: HealthUtah PPO |
$16.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.57
|
| Rate for Payer: Multiplan Medicare/VA |
$9.30
|
| 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 |
$9.79
|
| Rate for Payer: United Healthcare Commercial |
$15.33
|
| Rate for Payer: United Healthcare Medicare |
$9.79
|
| Rate for Payer: WINHealth Partners Commercial |
$15.25
|
| Rate for Payer: Wise Provider Network Commercial |
$15.25
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [28413]
|
Facility
|
IP
|
$25.28
|
|
|
Service Code
|
NDC 0409176110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.65 |
| Max. Negotiated Rate |
$25.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.77
|
| Rate for Payer: Aetna of WY Medicare |
$16.18
|
| Rate for Payer: Altius Commercial |
$24.27
|
| Rate for Payer: Beech Street Commercial |
$24.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.52
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.52
|
| Rate for Payer: Cigna of WY Commercial |
$24.77
|
| Rate for Payer: Entrust Commercial |
$24.02
|
| Rate for Payer: First Choice Health Commercial |
$24.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.42
|
| Rate for Payer: HealthUtah PPO |
$25.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.52
|
| Rate for Payer: Multiplan Medicare/VA |
$14.65
|
| Rate for Payer: One Health Plan of WY PPO |
$24.77
|
| Rate for Payer: PacificSource Commercial |
$22.75
|
| Rate for Payer: PHCS PPO |
$24.77
|
| Rate for Payer: Three Rivers PPO |
$18.96
|
| Rate for Payer: TriWest Veterans Administration |
$15.42
|
| Rate for Payer: United Healthcare Commercial |
$24.14
|
| Rate for Payer: United Healthcare Medicare |
$15.42
|
| Rate for Payer: WINHealth Partners Commercial |
$24.02
|
| Rate for Payer: Wise Provider Network Commercial |
$24.02
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [28413]
|
Facility
|
IP
|
$17.91
|
|
|
Service Code
|
NDC 0264937988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$17.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.55
|
| Rate for Payer: Aetna of WY Medicare |
$11.46
|
| Rate for Payer: Altius Commercial |
$17.19
|
| Rate for Payer: Beech Street Commercial |
$17.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.37
|
| Rate for Payer: Cash Price |
$12.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.37
|
| Rate for Payer: Cigna of WY Commercial |
$17.55
|
| Rate for Payer: Entrust Commercial |
$17.01
|
| Rate for Payer: First Choice Health Commercial |
$17.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.93
|
| Rate for Payer: HealthUtah PPO |
$17.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.37
|
| Rate for Payer: Multiplan Medicare/VA |
$10.38
|
| Rate for Payer: One Health Plan of WY PPO |
$17.55
|
| Rate for Payer: PacificSource Commercial |
$16.12
|
| Rate for Payer: PHCS PPO |
$17.55
|
| Rate for Payer: Three Rivers PPO |
$13.43
|
| Rate for Payer: TriWest Veterans Administration |
$10.93
|
| Rate for Payer: United Healthcare Commercial |
$17.10
|
| Rate for Payer: United Healthcare Medicare |
$10.93
|
| Rate for Payer: WINHealth Partners Commercial |
$17.01
|
| Rate for Payer: Wise Provider Network Commercial |
$17.01
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [28413]
|
Facility
|
OP
|
$25.28
|
|
|
Service Code
|
NDC 0409176110
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.69 |
| Max. Negotiated Rate |
$25.28 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.77
|
| Rate for Payer: Aetna of WY Medicare |
$16.68
|
| Rate for Payer: Altius Commercial |
$24.27
|
| Rate for Payer: Beech Street Commercial |
$24.77
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.52
|
| Rate for Payer: Cash Price |
$17.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.52
|
| Rate for Payer: Cigna of WY Commercial |
$24.77
|
| Rate for Payer: Entrust Commercial |
$24.02
|
| Rate for Payer: First Choice Health Commercial |
$24.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.02
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.41
|
| Rate for Payer: HealthUtah PPO |
$25.28
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.52
|
| Rate for Payer: Multiplan Medicare/VA |
$13.69
|
| Rate for Payer: One Health Plan of WY PPO |
$24.77
|
| Rate for Payer: PacificSource Commercial |
$22.75
|
| Rate for Payer: PHCS PPO |
$24.77
|
| Rate for Payer: Three Rivers PPO |
$18.96
|
| Rate for Payer: TriWest Veterans Administration |
$14.41
|
| Rate for Payer: United Healthcare Commercial |
$24.14
|
| Rate for Payer: United Healthcare Medicare |
$14.41
|
| Rate for Payer: WINHealth Partners Commercial |
$24.77
|
| Rate for Payer: Wise Provider Network Commercial |
$24.02
|
|
|
BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [28413]
|
Facility
|
OP
|
$17.91
|
|
|
Service Code
|
NDC 0264937988
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.70 |
| Max. Negotiated Rate |
$17.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.55
|
| Rate for Payer: Aetna of WY Medicare |
$11.82
|
| Rate for Payer: Altius Commercial |
$17.19
|
| Rate for Payer: Beech Street Commercial |
$17.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.37
|
| Rate for Payer: Cash Price |
$12.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.37
|
| Rate for Payer: Cigna of WY Commercial |
$17.55
|
| Rate for Payer: Entrust Commercial |
$17.01
|
| Rate for Payer: First Choice Health Commercial |
$17.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.21
|
| Rate for Payer: HealthUtah PPO |
$17.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.37
|
| Rate for Payer: Multiplan Medicare/VA |
$9.70
|
| Rate for Payer: One Health Plan of WY PPO |
$17.55
|
| Rate for Payer: PacificSource Commercial |
$16.12
|
| Rate for Payer: PHCS PPO |
$17.55
|
| Rate for Payer: Three Rivers PPO |
$13.43
|
| Rate for Payer: TriWest Veterans Administration |
$10.21
|
| Rate for Payer: United Healthcare Commercial |
$17.10
|
| Rate for Payer: United Healthcare Medicare |
$10.21
|
| Rate for Payer: WINHealth Partners Commercial |
$17.55
|
| Rate for Payer: Wise Provider Network Commercial |
$17.01
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [27426]
|
Facility
|
IP
|
$23.17
|
|
|
Service Code
|
NDC 6068748121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.43 |
| Max. Negotiated Rate |
$23.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.71
|
| Rate for Payer: Aetna of WY Medicare |
$14.83
|
| Rate for Payer: Altius Commercial |
$22.24
|
| Rate for Payer: Beech Street Commercial |
$22.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.47
|
| Rate for Payer: Cash Price |
$16.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.47
|
| Rate for Payer: Cigna of WY Commercial |
$22.71
|
| Rate for Payer: Entrust Commercial |
$22.01
|
| Rate for Payer: First Choice Health Commercial |
$22.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.13
|
| Rate for Payer: HealthUtah PPO |
$23.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.47
|
| Rate for Payer: Multiplan Medicare/VA |
$13.43
|
| Rate for Payer: One Health Plan of WY PPO |
$22.71
|
| Rate for Payer: PacificSource Commercial |
$20.85
|
| Rate for Payer: PHCS PPO |
$22.71
|
| Rate for Payer: Three Rivers PPO |
$17.38
|
| Rate for Payer: TriWest Veterans Administration |
$14.13
|
| Rate for Payer: United Healthcare Commercial |
$22.13
|
| Rate for Payer: United Healthcare Medicare |
$14.13
|
| Rate for Payer: WINHealth Partners Commercial |
$22.01
|
| Rate for Payer: Wise Provider Network Commercial |
$22.01
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [27426]
|
Facility
|
OP
|
$23.17
|
|
|
Service Code
|
NDC 6068748121
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.55 |
| Max. Negotiated Rate |
$23.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.71
|
| Rate for Payer: Aetna of WY Medicare |
$15.29
|
| Rate for Payer: Altius Commercial |
$22.24
|
| Rate for Payer: Beech Street Commercial |
$22.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.47
|
| Rate for Payer: Cash Price |
$16.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.47
|
| Rate for Payer: Cigna of WY Commercial |
$22.71
|
| Rate for Payer: Entrust Commercial |
$22.01
|
| Rate for Payer: First Choice Health Commercial |
$22.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.21
|
| Rate for Payer: HealthUtah PPO |
$23.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.47
|
| Rate for Payer: Multiplan Medicare/VA |
$12.55
|
| Rate for Payer: One Health Plan of WY PPO |
$22.71
|
| Rate for Payer: PacificSource Commercial |
$20.85
|
| Rate for Payer: PHCS PPO |
$22.71
|
| Rate for Payer: Three Rivers PPO |
$17.38
|
| Rate for Payer: TriWest Veterans Administration |
$13.21
|
| Rate for Payer: United Healthcare Commercial |
$22.13
|
| Rate for Payer: United Healthcare Medicare |
$13.21
|
| Rate for Payer: WINHealth Partners Commercial |
$22.71
|
| Rate for Payer: Wise Provider Network Commercial |
$22.01
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [27426]
|
Facility
|
OP
|
$23.17
|
|
|
Service Code
|
NDC 6068748111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.55 |
| Max. Negotiated Rate |
$23.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.71
|
| Rate for Payer: Aetna of WY Medicare |
$15.29
|
| Rate for Payer: Altius Commercial |
$22.24
|
| Rate for Payer: Beech Street Commercial |
$22.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.47
|
| Rate for Payer: Cash Price |
$16.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.47
|
| Rate for Payer: Cigna of WY Commercial |
$22.71
|
| Rate for Payer: Entrust Commercial |
$22.01
|
| Rate for Payer: First Choice Health Commercial |
$22.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.21
|
| Rate for Payer: HealthUtah PPO |
$23.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.47
|
| Rate for Payer: Multiplan Medicare/VA |
$12.55
|
| Rate for Payer: One Health Plan of WY PPO |
$22.71
|
| Rate for Payer: PacificSource Commercial |
$20.85
|
| Rate for Payer: PHCS PPO |
$22.71
|
| Rate for Payer: Three Rivers PPO |
$17.38
|
| Rate for Payer: TriWest Veterans Administration |
$13.21
|
| Rate for Payer: United Healthcare Commercial |
$22.13
|
| Rate for Payer: United Healthcare Medicare |
$13.21
|
| Rate for Payer: WINHealth Partners Commercial |
$22.71
|
| Rate for Payer: Wise Provider Network Commercial |
$22.01
|
|
|
BUPRENORPHINE HCL 2 MG SUBLINGUAL TABLET [27426]
|
Facility
|
IP
|
$23.17
|
|
|
Service Code
|
NDC 6068748111
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.43 |
| Max. Negotiated Rate |
$23.17 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.71
|
| Rate for Payer: Aetna of WY Medicare |
$14.83
|
| Rate for Payer: Altius Commercial |
$22.24
|
| Rate for Payer: Beech Street Commercial |
$22.71
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.47
|
| Rate for Payer: Cash Price |
$16.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.47
|
| Rate for Payer: Cigna of WY Commercial |
$22.71
|
| Rate for Payer: Entrust Commercial |
$22.01
|
| Rate for Payer: First Choice Health Commercial |
$22.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.01
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.13
|
| Rate for Payer: HealthUtah PPO |
$23.17
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.47
|
| Rate for Payer: Multiplan Medicare/VA |
$13.43
|
| Rate for Payer: One Health Plan of WY PPO |
$22.71
|
| Rate for Payer: PacificSource Commercial |
$20.85
|
| Rate for Payer: PHCS PPO |
$22.71
|
| Rate for Payer: Three Rivers PPO |
$17.38
|
| Rate for Payer: TriWest Veterans Administration |
$14.13
|
| Rate for Payer: United Healthcare Commercial |
$22.13
|
| Rate for Payer: United Healthcare Medicare |
$14.13
|
| Rate for Payer: WINHealth Partners Commercial |
$22.01
|
| Rate for Payer: Wise Provider Network Commercial |
$22.01
|
|
|
BUPROPION HCL 75 MG TABLET [14008]
|
Facility
|
OP
|
$18.71
|
|
|
Service Code
|
NDC 5026814211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.13 |
| Max. Negotiated Rate |
$18.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.34
|
| Rate for Payer: Aetna of WY Medicare |
$12.35
|
| Rate for Payer: Altius Commercial |
$17.96
|
| Rate for Payer: Beech Street Commercial |
$18.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.15
|
| Rate for Payer: Cash Price |
$13.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.15
|
| Rate for Payer: Cigna of WY Commercial |
$18.34
|
| Rate for Payer: Entrust Commercial |
$17.77
|
| Rate for Payer: First Choice Health Commercial |
$17.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.66
|
| Rate for Payer: HealthUtah PPO |
$18.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.15
|
| Rate for Payer: Multiplan Medicare/VA |
$10.13
|
| Rate for Payer: One Health Plan of WY PPO |
$18.34
|
| Rate for Payer: PacificSource Commercial |
$16.84
|
| Rate for Payer: PHCS PPO |
$18.34
|
| Rate for Payer: Three Rivers PPO |
$14.03
|
| Rate for Payer: TriWest Veterans Administration |
$10.66
|
| Rate for Payer: United Healthcare Commercial |
$17.87
|
| Rate for Payer: United Healthcare Medicare |
$10.66
|
| Rate for Payer: WINHealth Partners Commercial |
$18.34
|
| Rate for Payer: Wise Provider Network Commercial |
$17.77
|
|
|
BUPROPION HCL 75 MG TABLET [14008]
|
Facility
|
OP
|
$18.71
|
|
|
Service Code
|
NDC 5026814215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.13 |
| Max. Negotiated Rate |
$18.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.34
|
| Rate for Payer: Aetna of WY Medicare |
$12.35
|
| Rate for Payer: Altius Commercial |
$17.96
|
| Rate for Payer: Beech Street Commercial |
$18.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.15
|
| Rate for Payer: Cash Price |
$13.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.15
|
| Rate for Payer: Cigna of WY Commercial |
$18.34
|
| Rate for Payer: Entrust Commercial |
$17.77
|
| Rate for Payer: First Choice Health Commercial |
$17.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.66
|
| Rate for Payer: HealthUtah PPO |
$18.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.15
|
| Rate for Payer: Multiplan Medicare/VA |
$10.13
|
| Rate for Payer: One Health Plan of WY PPO |
$18.34
|
| Rate for Payer: PacificSource Commercial |
$16.84
|
| Rate for Payer: PHCS PPO |
$18.34
|
| Rate for Payer: Three Rivers PPO |
$14.03
|
| Rate for Payer: TriWest Veterans Administration |
$10.66
|
| Rate for Payer: United Healthcare Commercial |
$17.87
|
| Rate for Payer: United Healthcare Medicare |
$10.66
|
| Rate for Payer: WINHealth Partners Commercial |
$18.34
|
| Rate for Payer: Wise Provider Network Commercial |
$17.77
|
|
|
BUPROPION HCL 75 MG TABLET [14008]
|
Facility
|
IP
|
$18.71
|
|
|
Service Code
|
NDC 5026814211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$18.71 |
| Rate for Payer: United Healthcare Commercial |
$17.87
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.34
|
| Rate for Payer: Aetna of WY Medicare |
$11.97
|
| Rate for Payer: Altius Commercial |
$17.96
|
| Rate for Payer: Beech Street Commercial |
$18.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.15
|
| Rate for Payer: Cash Price |
$13.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.15
|
| Rate for Payer: Cigna of WY Commercial |
$18.34
|
| Rate for Payer: Entrust Commercial |
$17.77
|
| Rate for Payer: First Choice Health Commercial |
$17.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.41
|
| Rate for Payer: HealthUtah PPO |
$18.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.15
|
| Rate for Payer: Multiplan Medicare/VA |
$10.84
|
| Rate for Payer: One Health Plan of WY PPO |
$18.34
|
| Rate for Payer: PacificSource Commercial |
$16.84
|
| Rate for Payer: PHCS PPO |
$18.34
|
| Rate for Payer: Three Rivers PPO |
$14.03
|
| Rate for Payer: TriWest Veterans Administration |
$11.41
|
| Rate for Payer: United Healthcare Medicare |
$11.41
|
| Rate for Payer: WINHealth Partners Commercial |
$17.77
|
| Rate for Payer: Wise Provider Network Commercial |
$17.77
|
|
|
BUPROPION HCL 75 MG TABLET [14008]
|
Facility
|
IP
|
$18.71
|
|
|
Service Code
|
NDC 5026814215
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.84 |
| Max. Negotiated Rate |
$18.71 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.34
|
| Rate for Payer: Aetna of WY Medicare |
$11.97
|
| Rate for Payer: Altius Commercial |
$17.96
|
| Rate for Payer: Beech Street Commercial |
$18.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.15
|
| Rate for Payer: Cash Price |
$13.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.15
|
| Rate for Payer: Cigna of WY Commercial |
$18.34
|
| Rate for Payer: Entrust Commercial |
$17.77
|
| Rate for Payer: First Choice Health Commercial |
$17.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.77
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.41
|
| Rate for Payer: HealthUtah PPO |
$18.71
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.15
|
| Rate for Payer: Multiplan Medicare/VA |
$10.84
|
| Rate for Payer: One Health Plan of WY PPO |
$18.34
|
| Rate for Payer: PacificSource Commercial |
$16.84
|
| Rate for Payer: PHCS PPO |
$18.34
|
| Rate for Payer: Three Rivers PPO |
$14.03
|
| Rate for Payer: TriWest Veterans Administration |
$11.41
|
| Rate for Payer: United Healthcare Commercial |
$17.87
|
| Rate for Payer: United Healthcare Medicare |
$11.41
|
| Rate for Payer: WINHealth Partners Commercial |
$17.77
|
| Rate for Payer: Wise Provider Network Commercial |
$17.77
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [29684]
|
Facility
|
OP
|
$22.40
|
|
|
Service Code
|
NDC 6068731201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.13 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.95
|
| Rate for Payer: Aetna of WY Medicare |
$14.78
|
| Rate for Payer: Altius Commercial |
$21.50
|
| Rate for Payer: Beech Street Commercial |
$21.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.73
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.73
|
| Rate for Payer: Cigna of WY Commercial |
$21.95
|
| Rate for Payer: Entrust Commercial |
$21.28
|
| Rate for Payer: First Choice Health Commercial |
$21.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.77
|
| Rate for Payer: HealthUtah PPO |
$22.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.73
|
| Rate for Payer: Multiplan Medicare/VA |
$12.13
|
| Rate for Payer: One Health Plan of WY PPO |
$21.95
|
| Rate for Payer: PacificSource Commercial |
$20.16
|
| Rate for Payer: PHCS PPO |
$21.95
|
| Rate for Payer: Three Rivers PPO |
$16.80
|
| Rate for Payer: TriWest Veterans Administration |
$12.77
|
| Rate for Payer: United Healthcare Commercial |
$21.39
|
| Rate for Payer: United Healthcare Medicare |
$12.77
|
| Rate for Payer: WINHealth Partners Commercial |
$21.95
|
| Rate for Payer: Wise Provider Network Commercial |
$21.28
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [29684]
|
Facility
|
IP
|
$22.40
|
|
|
Service Code
|
NDC 6068731211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.98 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.95
|
| Rate for Payer: Aetna of WY Medicare |
$14.34
|
| Rate for Payer: Altius Commercial |
$21.50
|
| Rate for Payer: Beech Street Commercial |
$21.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.73
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.73
|
| Rate for Payer: Cigna of WY Commercial |
$21.95
|
| Rate for Payer: Entrust Commercial |
$21.28
|
| Rate for Payer: First Choice Health Commercial |
$21.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.66
|
| Rate for Payer: HealthUtah PPO |
$22.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.73
|
| Rate for Payer: Multiplan Medicare/VA |
$12.98
|
| Rate for Payer: One Health Plan of WY PPO |
$21.95
|
| Rate for Payer: PacificSource Commercial |
$20.16
|
| Rate for Payer: PHCS PPO |
$21.95
|
| Rate for Payer: Three Rivers PPO |
$16.80
|
| Rate for Payer: TriWest Veterans Administration |
$13.66
|
| Rate for Payer: United Healthcare Commercial |
$21.39
|
| Rate for Payer: United Healthcare Medicare |
$13.66
|
| Rate for Payer: WINHealth Partners Commercial |
$21.28
|
| Rate for Payer: Wise Provider Network Commercial |
$21.28
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [29684]
|
Facility
|
OP
|
$22.40
|
|
|
Service Code
|
NDC 6068731211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.13 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.95
|
| Rate for Payer: Aetna of WY Medicare |
$14.78
|
| Rate for Payer: Altius Commercial |
$21.50
|
| Rate for Payer: Beech Street Commercial |
$21.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.73
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.73
|
| Rate for Payer: Cigna of WY Commercial |
$21.95
|
| Rate for Payer: Entrust Commercial |
$21.28
|
| Rate for Payer: First Choice Health Commercial |
$21.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.77
|
| Rate for Payer: HealthUtah PPO |
$22.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.73
|
| Rate for Payer: Multiplan Medicare/VA |
$12.13
|
| Rate for Payer: One Health Plan of WY PPO |
$21.95
|
| Rate for Payer: PacificSource Commercial |
$20.16
|
| Rate for Payer: PHCS PPO |
$21.95
|
| Rate for Payer: Three Rivers PPO |
$16.80
|
| Rate for Payer: TriWest Veterans Administration |
$12.77
|
| Rate for Payer: United Healthcare Commercial |
$21.39
|
| Rate for Payer: United Healthcare Medicare |
$12.77
|
| Rate for Payer: WINHealth Partners Commercial |
$21.95
|
| Rate for Payer: Wise Provider Network Commercial |
$21.28
|
|
|
BUPROPION HCL XL 150 MG 24 HR TABLET, EXTENDED RELEASE [29684]
|
Facility
|
IP
|
$22.40
|
|
|
Service Code
|
NDC 6068731201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.98 |
| Max. Negotiated Rate |
$22.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.95
|
| Rate for Payer: Aetna of WY Medicare |
$14.34
|
| Rate for Payer: Altius Commercial |
$21.50
|
| Rate for Payer: Beech Street Commercial |
$21.95
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.73
|
| Rate for Payer: Cash Price |
$15.68
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.73
|
| Rate for Payer: Cigna of WY Commercial |
$21.95
|
| Rate for Payer: Entrust Commercial |
$21.28
|
| Rate for Payer: First Choice Health Commercial |
$21.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.28
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.66
|
| Rate for Payer: HealthUtah PPO |
$22.40
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.73
|
| Rate for Payer: Multiplan Medicare/VA |
$12.98
|
| Rate for Payer: One Health Plan of WY PPO |
$21.95
|
| Rate for Payer: PacificSource Commercial |
$20.16
|
| Rate for Payer: PHCS PPO |
$21.95
|
| Rate for Payer: Three Rivers PPO |
$16.80
|
| Rate for Payer: TriWest Veterans Administration |
$13.66
|
| Rate for Payer: United Healthcare Commercial |
$21.39
|
| Rate for Payer: United Healthcare Medicare |
$13.66
|
| Rate for Payer: WINHealth Partners Commercial |
$21.28
|
| Rate for Payer: Wise Provider Network Commercial |
$21.28
|
|
