|
GASTROSTOMY BALLOON SLG 18X2.0
|
Facility
|
OP
|
$288.19
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$158.79 |
| Max. Negotiated Rate |
$288.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$282.43
|
| Rate for Payer: Aetna of WY Medicare |
$190.21
|
| Rate for Payer: Altius Auto/Workers Compensation |
$276.66
|
| Rate for Payer: Altius Commercial |
$276.66
|
| Rate for Payer: Beech Street Commercial |
$282.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$236.60
|
| Rate for Payer: Cash Price |
$201.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$279.54
|
| Rate for Payer: Cigna of WY Commercial |
$282.43
|
| Rate for Payer: Entrust Commercial |
$273.78
|
| Rate for Payer: First Choice Health Commercial |
$273.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$273.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$167.15
|
| Rate for Payer: HealthUtah PPO |
$288.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$279.54
|
| Rate for Payer: Multiplan Medicare/VA |
$158.79
|
| Rate for Payer: One Health Plan of WY PPO |
$282.43
|
| Rate for Payer: PacificSource Commercial |
$259.37
|
| Rate for Payer: PHCS PPO |
$282.43
|
| Rate for Payer: Three Rivers PPO |
$216.14
|
| Rate for Payer: TriWest Veterans Administration |
$167.15
|
| Rate for Payer: United Healthcare Commercial |
$250.73
|
| Rate for Payer: United Healthcare Medicare |
$167.15
|
| Rate for Payer: WINHealth Partners Commercial |
$282.43
|
| Rate for Payer: Wise Provider Network Commercial |
$273.78
|
|
|
GASTROSTOMY BALLOON SLG 18X2.0
|
Facility
|
IP
|
$288.19
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$180.70 |
| Max. Negotiated Rate |
$288.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$282.43
|
| Rate for Payer: Altius Auto/Workers Compensation |
$276.66
|
| Rate for Payer: Altius Commercial |
$276.66
|
| Rate for Payer: Beech Street Commercial |
$282.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$236.60
|
| Rate for Payer: Cash Price |
$201.73
|
| Rate for Payer: ChoiceCare Network Commercial |
$279.54
|
| Rate for Payer: Cigna of WY Commercial |
$282.43
|
| Rate for Payer: Entrust Commercial |
$273.78
|
| Rate for Payer: First Choice Health Commercial |
$273.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$273.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$190.21
|
| Rate for Payer: HealthUtah PPO |
$288.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$279.54
|
| Rate for Payer: Multiplan Medicare/VA |
$180.70
|
| Rate for Payer: One Health Plan of WY PPO |
$282.43
|
| Rate for Payer: PacificSource Commercial |
$259.37
|
| Rate for Payer: PHCS PPO |
$282.43
|
| Rate for Payer: Three Rivers PPO |
$216.14
|
| Rate for Payer: TriWest Veterans Administration |
$190.21
|
| Rate for Payer: United Healthcare Commercial |
$250.73
|
| Rate for Payer: United Healthcare Medicare |
$190.21
|
| Rate for Payer: WINHealth Partners Commercial |
$273.78
|
| Rate for Payer: Wise Provider Network Commercial |
$273.78
|
|
|
GASTROTOMY W/EXPLORATION/FOREIGN BODY REMOVAL
|
Professional
|
Both
|
$2,670.00
|
|
|
Service Code
|
HCPCS 43500 80
|
| Hospital Charge Code |
43500
|
| Min. Negotiated Rate |
$635.90 |
| Max. Negotiated Rate |
$2,670.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,616.60
|
| Rate for Payer: Aetna of WY Medicare |
$748.12
|
| Rate for Payer: Beech Street Commercial |
$2,536.50
|
| Rate for Payer: Cash Price |
$1,869.00
|
| Rate for Payer: Cash Price |
$1,869.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,589.90
|
| Rate for Payer: Cigna of WY Commercial |
$2,616.60
|
| Rate for Payer: First Choice Health Commercial |
$2,403.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,536.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$748.12
|
| Rate for Payer: HealthUtah PPO |
$2,670.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,589.90
|
| Rate for Payer: Multiplan Medicare/VA |
$635.90
|
| Rate for Payer: One Health Plan of WY PPO |
$2,616.60
|
| Rate for Payer: PacificSource Commercial |
$2,403.00
|
| Rate for Payer: PHCS PPO |
$2,536.50
|
| Rate for Payer: Three Rivers PPO |
$2,002.50
|
| Rate for Payer: TriWest Veterans Administration |
$748.12
|
| Rate for Payer: United Healthcare Commercial |
$2,322.90
|
| Rate for Payer: United Healthcare Medicare |
$748.12
|
| Rate for Payer: WINHealth Partners Commercial |
$2,269.50
|
|
|
GASTROTOMY W/EXPLORATION/FOREIGN BODY REMOVAL
|
Professional
|
Both
|
$2,670.00
|
|
|
Service Code
|
HCPCS 43500
|
| Hospital Charge Code |
43500
|
| Min. Negotiated Rate |
$635.90 |
| Max. Negotiated Rate |
$2,670.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,616.60
|
| Rate for Payer: Aetna of WY Medicare |
$748.12
|
| Rate for Payer: Beech Street Commercial |
$2,536.50
|
| Rate for Payer: Cash Price |
$1,869.00
|
| Rate for Payer: Cash Price |
$1,869.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,589.90
|
| Rate for Payer: Cigna of WY Commercial |
$2,616.60
|
| Rate for Payer: First Choice Health Commercial |
$2,403.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,536.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$748.12
|
| Rate for Payer: HealthUtah PPO |
$2,670.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,589.90
|
| Rate for Payer: Multiplan Medicare/VA |
$635.90
|
| Rate for Payer: One Health Plan of WY PPO |
$2,616.60
|
| Rate for Payer: PacificSource Commercial |
$2,403.00
|
| Rate for Payer: PHCS PPO |
$2,536.50
|
| Rate for Payer: Three Rivers PPO |
$2,002.50
|
| Rate for Payer: TriWest Veterans Administration |
$748.12
|
| Rate for Payer: United Healthcare Commercial |
$2,322.90
|
| Rate for Payer: United Healthcare Medicare |
$748.12
|
| Rate for Payer: WINHealth Partners Commercial |
$2,269.50
|
|
|
GAUZE <=16 IN NO W/SAL W/O B
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
HCPCS A6222
|
| Hospital Charge Code |
A6222
|
| Min. Negotiated Rate |
$17.25 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.54
|
| Rate for Payer: Beech Street Commercial |
$21.85
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.31
|
| Rate for Payer: Cigna of WY Commercial |
$22.54
|
| Rate for Payer: First Choice Health Commercial |
$20.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.85
|
| Rate for Payer: HealthUtah PPO |
$23.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.31
|
| Rate for Payer: One Health Plan of WY PPO |
$22.54
|
| Rate for Payer: PacificSource Commercial |
$20.70
|
| Rate for Payer: PHCS PPO |
$21.85
|
| Rate for Payer: Three Rivers PPO |
$17.25
|
| Rate for Payer: United Healthcare Commercial |
$20.01
|
| Rate for Payer: WINHealth Partners Commercial |
$21.85
|
|
|
GAUZE PACKING PLAIN STRIP 1"
|
Facility
|
IP
|
$6.01
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.77 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.89
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.77
|
| 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 |
$4.93
|
| 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 |
$3.97
|
| Rate for Payer: HealthUtah PPO |
$6.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.83
|
| Rate for Payer: Multiplan Medicare/VA |
$3.77
|
| 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 |
$3.97
|
| Rate for Payer: United Healthcare Commercial |
$5.23
|
| Rate for Payer: United Healthcare Medicare |
$3.97
|
| Rate for Payer: WINHealth Partners Commercial |
$5.71
|
| Rate for Payer: Wise Provider Network Commercial |
$5.71
|
|
|
GAUZE PACKING PLAIN STRIP 1"
|
Facility
|
OP
|
$6.01
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.31 |
| 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 Auto/Workers Compensation |
$5.77
|
| 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 |
$4.93
|
| 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 |
$3.49
|
| Rate for Payer: HealthUtah PPO |
$6.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.83
|
| Rate for Payer: Multiplan Medicare/VA |
$3.31
|
| 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 |
$3.49
|
| Rate for Payer: United Healthcare Commercial |
$5.23
|
| Rate for Payer: United Healthcare Medicare |
$3.49
|
| Rate for Payer: WINHealth Partners Commercial |
$5.89
|
| Rate for Payer: Wise Provider Network Commercial |
$5.71
|
|
|
GAUZE PACKING PLAIN STRIP 1/2"
|
Facility
|
IP
|
$5.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.45 |
| Max. Negotiated Rate |
$5.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.39
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.28
|
| Rate for Payer: Altius Commercial |
$5.28
|
| Rate for Payer: Beech Street Commercial |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.52
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.34
|
| Rate for Payer: Cigna of WY Commercial |
$5.39
|
| Rate for Payer: Entrust Commercial |
$5.22
|
| Rate for Payer: First Choice Health Commercial |
$5.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.63
|
| Rate for Payer: HealthUtah PPO |
$5.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.34
|
| Rate for Payer: Multiplan Medicare/VA |
$3.45
|
| Rate for Payer: One Health Plan of WY PPO |
$5.39
|
| Rate for Payer: PacificSource Commercial |
$4.95
|
| Rate for Payer: PHCS PPO |
$5.39
|
| Rate for Payer: Three Rivers PPO |
$4.12
|
| Rate for Payer: TriWest Veterans Administration |
$3.63
|
| Rate for Payer: United Healthcare Commercial |
$4.78
|
| Rate for Payer: United Healthcare Medicare |
$3.63
|
| Rate for Payer: WINHealth Partners Commercial |
$5.22
|
| Rate for Payer: Wise Provider Network Commercial |
$5.22
|
|
|
GAUZE PACKING PLAIN STRIP 1/2"
|
Facility
|
OP
|
$5.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.03 |
| Max. Negotiated Rate |
$5.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.39
|
| Rate for Payer: Aetna of WY Medicare |
$3.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.28
|
| Rate for Payer: Altius Commercial |
$5.28
|
| Rate for Payer: Beech Street Commercial |
$5.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.52
|
| Rate for Payer: Cash Price |
$3.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.34
|
| Rate for Payer: Cigna of WY Commercial |
$5.39
|
| Rate for Payer: Entrust Commercial |
$5.22
|
| Rate for Payer: First Choice Health Commercial |
$5.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.19
|
| Rate for Payer: HealthUtah PPO |
$5.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.34
|
| Rate for Payer: Multiplan Medicare/VA |
$3.03
|
| Rate for Payer: One Health Plan of WY PPO |
$5.39
|
| Rate for Payer: PacificSource Commercial |
$4.95
|
| Rate for Payer: PHCS PPO |
$5.39
|
| Rate for Payer: Three Rivers PPO |
$4.12
|
| Rate for Payer: TriWest Veterans Administration |
$3.19
|
| Rate for Payer: United Healthcare Commercial |
$4.78
|
| Rate for Payer: United Healthcare Medicare |
$3.19
|
| Rate for Payer: WINHealth Partners Commercial |
$5.39
|
| Rate for Payer: Wise Provider Network Commercial |
$5.22
|
|
|
GAUZE PACKING PLAIN STRIP 1/4"
|
Facility
|
OP
|
$5.58
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.07 |
| Max. Negotiated Rate |
$5.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.47
|
| Rate for Payer: Aetna of WY Medicare |
$3.68
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.36
|
| Rate for Payer: Altius Commercial |
$5.36
|
| Rate for Payer: Beech Street Commercial |
$5.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.58
|
| Rate for Payer: Cash Price |
$3.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.41
|
| Rate for Payer: Cigna of WY Commercial |
$5.47
|
| Rate for Payer: Entrust Commercial |
$5.30
|
| Rate for Payer: First Choice Health Commercial |
$5.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.24
|
| Rate for Payer: HealthUtah PPO |
$5.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.41
|
| Rate for Payer: Multiplan Medicare/VA |
$3.07
|
| Rate for Payer: One Health Plan of WY PPO |
$5.47
|
| Rate for Payer: PacificSource Commercial |
$5.02
|
| Rate for Payer: PHCS PPO |
$5.47
|
| Rate for Payer: Three Rivers PPO |
$4.18
|
| Rate for Payer: TriWest Veterans Administration |
$3.24
|
| Rate for Payer: United Healthcare Commercial |
$4.85
|
| Rate for Payer: United Healthcare Medicare |
$3.24
|
| Rate for Payer: WINHealth Partners Commercial |
$5.47
|
| Rate for Payer: Wise Provider Network Commercial |
$5.30
|
|
|
GAUZE PACKING PLAIN STRIP 1/4"
|
Facility
|
IP
|
$5.58
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.50 |
| Max. Negotiated Rate |
$5.58 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5.36
|
| Rate for Payer: Altius Commercial |
$5.36
|
| Rate for Payer: Beech Street Commercial |
$5.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.58
|
| Rate for Payer: Cash Price |
$3.91
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.41
|
| Rate for Payer: Cigna of WY Commercial |
$5.47
|
| Rate for Payer: Entrust Commercial |
$5.30
|
| Rate for Payer: First Choice Health Commercial |
$5.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.68
|
| Rate for Payer: HealthUtah PPO |
$5.58
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.41
|
| Rate for Payer: Multiplan Medicare/VA |
$3.50
|
| Rate for Payer: One Health Plan of WY PPO |
$5.47
|
| Rate for Payer: PacificSource Commercial |
$5.02
|
| Rate for Payer: PHCS PPO |
$5.47
|
| Rate for Payer: Three Rivers PPO |
$4.18
|
| Rate for Payer: TriWest Veterans Administration |
$3.68
|
| Rate for Payer: United Healthcare Commercial |
$4.85
|
| Rate for Payer: United Healthcare Medicare |
$3.68
|
| Rate for Payer: WINHealth Partners Commercial |
$5.30
|
| Rate for Payer: Wise Provider Network Commercial |
$5.30
|
|
|
GC STOCKING FULL LNGTH 40+
|
Professional
|
Both
|
$756.00
|
|
|
Service Code
|
HCPCS A6538
|
| Hospital Charge Code |
A6538
|
| Min. Negotiated Rate |
$82.48 |
| Max. Negotiated Rate |
$756.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$740.88
|
| Rate for Payer: Aetna of WY Medicare |
$97.04
|
| Rate for Payer: Beech Street Commercial |
$718.20
|
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: Cash Price |
$529.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$733.32
|
| Rate for Payer: Cigna of WY Commercial |
$740.88
|
| Rate for Payer: First Choice Health Commercial |
$680.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$718.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$97.04
|
| Rate for Payer: HealthUtah PPO |
$756.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$733.32
|
| Rate for Payer: Multiplan Medicare/VA |
$82.48
|
| Rate for Payer: One Health Plan of WY PPO |
$740.88
|
| Rate for Payer: PacificSource Commercial |
$680.40
|
| Rate for Payer: PHCS PPO |
$718.20
|
| Rate for Payer: Three Rivers PPO |
$567.00
|
| Rate for Payer: TriWest Veterans Administration |
$97.04
|
| Rate for Payer: United Healthcare Commercial |
$657.72
|
| Rate for Payer: United Healthcare Medicare |
$97.04
|
| Rate for Payer: WINHealth Partners Commercial |
$718.20
|
|
|
GC STOCKING THIGHLNGTH 18-30
|
Professional
|
Both
|
$47.00
|
|
|
Service Code
|
HCPCS A6533
|
| Hospital Charge Code |
A6533
|
| Min. Negotiated Rate |
$35.25 |
| Max. Negotiated Rate |
$51.86 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$46.06
|
| Rate for Payer: Aetna of WY Medicare |
$51.86
|
| Rate for Payer: Beech Street Commercial |
$44.65
|
| Rate for Payer: Cash Price |
$32.90
|
| Rate for Payer: Cash Price |
$32.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$45.59
|
| Rate for Payer: Cigna of WY Commercial |
$46.06
|
| Rate for Payer: First Choice Health Commercial |
$42.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$44.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$51.86
|
| Rate for Payer: HealthUtah PPO |
$47.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$45.59
|
| Rate for Payer: Multiplan Medicare/VA |
$44.08
|
| Rate for Payer: One Health Plan of WY PPO |
$46.06
|
| Rate for Payer: PacificSource Commercial |
$42.30
|
| Rate for Payer: PHCS PPO |
$44.65
|
| Rate for Payer: Three Rivers PPO |
$35.25
|
| Rate for Payer: TriWest Veterans Administration |
$51.86
|
| Rate for Payer: United Healthcare Commercial |
$40.89
|
| Rate for Payer: United Healthcare Medicare |
$51.86
|
| Rate for Payer: WINHealth Partners Commercial |
$44.65
|
|
|
GC STOCKING THIGHLNGTH 30-40
|
Professional
|
Both
|
$278.00
|
|
|
Service Code
|
HCPCS A6534
|
| Hospital Charge Code |
A6534
|
| Min. Negotiated Rate |
$50.34 |
| Max. Negotiated Rate |
$278.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$272.44
|
| Rate for Payer: Aetna of WY Medicare |
$59.22
|
| Rate for Payer: Beech Street Commercial |
$264.10
|
| Rate for Payer: Cash Price |
$194.60
|
| Rate for Payer: Cash Price |
$194.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$269.66
|
| Rate for Payer: Cigna of WY Commercial |
$272.44
|
| Rate for Payer: First Choice Health Commercial |
$250.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$264.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$59.22
|
| Rate for Payer: HealthUtah PPO |
$278.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$269.66
|
| Rate for Payer: Multiplan Medicare/VA |
$50.34
|
| Rate for Payer: One Health Plan of WY PPO |
$272.44
|
| Rate for Payer: PacificSource Commercial |
$250.20
|
| Rate for Payer: PHCS PPO |
$264.10
|
| Rate for Payer: Three Rivers PPO |
$208.50
|
| Rate for Payer: TriWest Veterans Administration |
$59.22
|
| Rate for Payer: United Healthcare Commercial |
$241.86
|
| Rate for Payer: United Healthcare Medicare |
$59.22
|
| Rate for Payer: WINHealth Partners Commercial |
$264.10
|
|
|
GC STOCKING THIGHLNGTH 40+
|
Professional
|
Both
|
$74.00
|
|
|
Service Code
|
HCPCS A6535
|
| Hospital Charge Code |
A6535
|
| Min. Negotiated Rate |
$55.50 |
| Max. Negotiated Rate |
$74.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$72.52
|
| Rate for Payer: Beech Street Commercial |
$70.30
|
| Rate for Payer: Cash Price |
$51.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$71.78
|
| Rate for Payer: Cigna of WY Commercial |
$72.52
|
| Rate for Payer: First Choice Health Commercial |
$66.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$70.30
|
| Rate for Payer: HealthUtah PPO |
$74.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$71.78
|
| Rate for Payer: One Health Plan of WY PPO |
$72.52
|
| Rate for Payer: PacificSource Commercial |
$66.60
|
| Rate for Payer: PHCS PPO |
$70.30
|
| Rate for Payer: Three Rivers PPO |
$55.50
|
| Rate for Payer: United Healthcare Commercial |
$64.38
|
| Rate for Payer: WINHealth Partners Commercial |
$70.30
|
|
|
GC STOCKING WAISTLNGTH 30-40
|
Professional
|
Both
|
$278.00
|
|
|
Service Code
|
HCPCS A6540
|
| Hospital Charge Code |
A6540
|
| Min. Negotiated Rate |
$208.50 |
| Max. Negotiated Rate |
$278.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$272.44
|
| Rate for Payer: Beech Street Commercial |
$264.10
|
| Rate for Payer: Cash Price |
$194.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$269.66
|
| Rate for Payer: Cigna of WY Commercial |
$272.44
|
| Rate for Payer: First Choice Health Commercial |
$250.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$264.10
|
| Rate for Payer: HealthUtah PPO |
$278.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$269.66
|
| Rate for Payer: One Health Plan of WY PPO |
$272.44
|
| Rate for Payer: PacificSource Commercial |
$250.20
|
| Rate for Payer: PHCS PPO |
$264.10
|
| Rate for Payer: Three Rivers PPO |
$208.50
|
| Rate for Payer: United Healthcare Commercial |
$241.86
|
| Rate for Payer: WINHealth Partners Commercial |
$264.10
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE [16878]
|
Facility
|
OP
|
$19.66
|
|
|
Service Code
|
NDC 6371301972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.83 |
| Max. Negotiated Rate |
$19.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.27
|
| Rate for Payer: Aetna of WY Medicare |
$12.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.87
|
| Rate for Payer: Altius Commercial |
$18.87
|
| Rate for Payer: Beech Street Commercial |
$19.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.14
|
| Rate for Payer: Cash Price |
$13.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.07
|
| Rate for Payer: Cigna of WY Commercial |
$19.27
|
| Rate for Payer: Entrust Commercial |
$18.68
|
| Rate for Payer: First Choice Health Commercial |
$18.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.40
|
| Rate for Payer: HealthUtah PPO |
$19.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.07
|
| Rate for Payer: Multiplan Medicare/VA |
$10.83
|
| Rate for Payer: One Health Plan of WY PPO |
$19.27
|
| Rate for Payer: PacificSource Commercial |
$17.69
|
| Rate for Payer: PHCS PPO |
$19.27
|
| Rate for Payer: Three Rivers PPO |
$14.74
|
| Rate for Payer: TriWest Veterans Administration |
$11.40
|
| Rate for Payer: United Healthcare Commercial |
$17.10
|
| Rate for Payer: United Healthcare Medicare |
$11.40
|
| Rate for Payer: WINHealth Partners Commercial |
$19.27
|
| Rate for Payer: Wise Provider Network Commercial |
$18.68
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE [16878]
|
Facility
|
IP
|
$19.66
|
|
|
Service Code
|
NDC 6371301972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.33 |
| Max. Negotiated Rate |
$19.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.87
|
| Rate for Payer: Altius Commercial |
$18.87
|
| Rate for Payer: Beech Street Commercial |
$19.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.14
|
| Rate for Payer: Cash Price |
$13.76
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.07
|
| Rate for Payer: Cigna of WY Commercial |
$19.27
|
| Rate for Payer: Entrust Commercial |
$18.68
|
| Rate for Payer: First Choice Health Commercial |
$18.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.98
|
| Rate for Payer: HealthUtah PPO |
$19.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.07
|
| Rate for Payer: Multiplan Medicare/VA |
$12.33
|
| Rate for Payer: One Health Plan of WY PPO |
$19.27
|
| Rate for Payer: PacificSource Commercial |
$17.69
|
| Rate for Payer: PHCS PPO |
$19.27
|
| Rate for Payer: Three Rivers PPO |
$14.74
|
| Rate for Payer: TriWest Veterans Administration |
$12.98
|
| Rate for Payer: United Healthcare Commercial |
$17.10
|
| Rate for Payer: United Healthcare Medicare |
$12.98
|
| Rate for Payer: WINHealth Partners Commercial |
$18.68
|
| Rate for Payer: Wise Provider Network Commercial |
$18.68
|
|
|
GEL-ONE
|
Professional
|
Both
|
$2,597.00
|
|
|
Service Code
|
HCPCS J7326
|
| Hospital Charge Code |
J7326
|
| Min. Negotiated Rate |
$444.02 |
| Max. Negotiated Rate |
$2,597.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,545.06
|
| Rate for Payer: Aetna of WY Medicare |
$522.37
|
| Rate for Payer: Beech Street Commercial |
$2,467.15
|
| Rate for Payer: Cash Price |
$1,817.90
|
| Rate for Payer: Cash Price |
$1,817.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,519.09
|
| Rate for Payer: Cigna of WY Commercial |
$2,545.06
|
| Rate for Payer: First Choice Health Commercial |
$2,337.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,467.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$522.37
|
| Rate for Payer: HealthUtah PPO |
$2,597.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,519.09
|
| Rate for Payer: Multiplan Medicare/VA |
$444.02
|
| Rate for Payer: One Health Plan of WY PPO |
$2,545.06
|
| Rate for Payer: PacificSource Commercial |
$2,337.30
|
| Rate for Payer: PHCS PPO |
$2,467.15
|
| Rate for Payer: Three Rivers PPO |
$1,947.75
|
| Rate for Payer: TriWest Veterans Administration |
$522.37
|
| Rate for Payer: United Healthcare Commercial |
$2,259.39
|
| Rate for Payer: United Healthcare Medicare |
$522.37
|
| Rate for Payer: WINHealth Partners Commercial |
$2,467.15
|
|
|
GELPORT 120 MM SYSTEM C8XX2
|
Facility
|
IP
|
$2,012.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,261.84 |
| Max. Negotiated Rate |
$2,012.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,972.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,932.00
|
| Rate for Payer: Altius Commercial |
$1,932.00
|
| Rate for Payer: Beech Street Commercial |
$1,972.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,652.26
|
| Rate for Payer: Cash Price |
$1,408.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,952.12
|
| Rate for Payer: Cigna of WY Commercial |
$1,972.25
|
| Rate for Payer: Entrust Commercial |
$1,911.88
|
| Rate for Payer: First Choice Health Commercial |
$1,911.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,911.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,328.25
|
| Rate for Payer: HealthUtah PPO |
$2,012.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,952.12
|
| Rate for Payer: Multiplan Medicare/VA |
$1,261.84
|
| Rate for Payer: One Health Plan of WY PPO |
$1,972.25
|
| Rate for Payer: PacificSource Commercial |
$1,811.25
|
| Rate for Payer: PHCS PPO |
$1,972.25
|
| Rate for Payer: Three Rivers PPO |
$1,509.38
|
| Rate for Payer: TriWest Veterans Administration |
$1,328.25
|
| Rate for Payer: United Healthcare Commercial |
$1,750.88
|
| Rate for Payer: United Healthcare Medicare |
$1,328.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,911.88
|
| Rate for Payer: Wise Provider Network Commercial |
$1,911.88
|
|
|
GELPORT 120 MM SYSTEM C8XX2
|
Facility
|
OP
|
$2,012.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,108.89 |
| Max. Negotiated Rate |
$2,012.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,972.25
|
| Rate for Payer: Aetna of WY Medicare |
$1,328.25
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,932.00
|
| Rate for Payer: Altius Commercial |
$1,932.00
|
| Rate for Payer: Beech Street Commercial |
$1,972.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,652.26
|
| Rate for Payer: Cash Price |
$1,408.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,952.12
|
| Rate for Payer: Cigna of WY Commercial |
$1,972.25
|
| Rate for Payer: Entrust Commercial |
$1,911.88
|
| Rate for Payer: First Choice Health Commercial |
$1,911.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,911.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,167.25
|
| Rate for Payer: HealthUtah PPO |
$2,012.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,952.12
|
| Rate for Payer: Multiplan Medicare/VA |
$1,108.89
|
| Rate for Payer: One Health Plan of WY PPO |
$1,972.25
|
| Rate for Payer: PacificSource Commercial |
$1,811.25
|
| Rate for Payer: PHCS PPO |
$1,972.25
|
| Rate for Payer: Three Rivers PPO |
$1,509.38
|
| Rate for Payer: TriWest Veterans Administration |
$1,167.25
|
| Rate for Payer: United Healthcare Commercial |
$1,750.88
|
| Rate for Payer: United Healthcare Medicare |
$1,167.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,972.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,911.88
|
|
|
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [94528]
|
Facility
|
OP
|
$21.89
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.06 |
| Max. Negotiated Rate |
$21.89 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.45
|
| Rate for Payer: Aetna of WY Medicare |
$14.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$21.01
|
| Rate for Payer: Altius Commercial |
$21.01
|
| Rate for Payer: Beech Street Commercial |
$21.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.97
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.23
|
| Rate for Payer: Cigna of WY Commercial |
$21.45
|
| Rate for Payer: Entrust Commercial |
$20.80
|
| Rate for Payer: First Choice Health Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.70
|
| Rate for Payer: HealthUtah PPO |
$21.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.23
|
| Rate for Payer: Multiplan Medicare/VA |
$12.06
|
| Rate for Payer: One Health Plan of WY PPO |
$21.45
|
| Rate for Payer: PacificSource Commercial |
$19.70
|
| Rate for Payer: PHCS PPO |
$21.45
|
| Rate for Payer: Three Rivers PPO |
$16.42
|
| Rate for Payer: TriWest Veterans Administration |
$12.70
|
| Rate for Payer: United Healthcare Commercial |
$19.04
|
| Rate for Payer: United Healthcare Medicare |
$12.70
|
| Rate for Payer: WINHealth Partners Commercial |
$21.45
|
| Rate for Payer: Wise Provider Network Commercial |
$20.80
|
|
|
GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [94528]
|
Facility
|
IP
|
$21.89
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$21.89 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$21.01
|
| Rate for Payer: Altius Commercial |
$21.01
|
| Rate for Payer: Beech Street Commercial |
$21.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.97
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.23
|
| Rate for Payer: Cigna of WY Commercial |
$21.45
|
| Rate for Payer: Entrust Commercial |
$20.80
|
| Rate for Payer: First Choice Health Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.45
|
| Rate for Payer: HealthUtah PPO |
$21.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.23
|
| Rate for Payer: Multiplan Medicare/VA |
$13.73
|
| Rate for Payer: One Health Plan of WY PPO |
$21.45
|
| Rate for Payer: PacificSource Commercial |
$19.70
|
| Rate for Payer: PHCS PPO |
$21.45
|
| Rate for Payer: Three Rivers PPO |
$16.42
|
| Rate for Payer: TriWest Veterans Administration |
$14.45
|
| Rate for Payer: United Healthcare Commercial |
$19.04
|
| Rate for Payer: United Healthcare Medicare |
$14.45
|
| Rate for Payer: WINHealth Partners Commercial |
$20.80
|
| Rate for Payer: Wise Provider Network Commercial |
$20.80
|
|
|
GEMCITABINE 38 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000726]
|
Facility
|
OP
|
$21.89
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.06 |
| Max. Negotiated Rate |
$21.89 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.45
|
| Rate for Payer: Aetna of WY Medicare |
$14.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$21.01
|
| Rate for Payer: Altius Commercial |
$21.01
|
| Rate for Payer: Beech Street Commercial |
$21.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.97
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.23
|
| Rate for Payer: Cigna of WY Commercial |
$21.45
|
| Rate for Payer: Entrust Commercial |
$20.80
|
| Rate for Payer: First Choice Health Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.70
|
| Rate for Payer: HealthUtah PPO |
$21.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.23
|
| Rate for Payer: Multiplan Medicare/VA |
$12.06
|
| Rate for Payer: One Health Plan of WY PPO |
$21.45
|
| Rate for Payer: PacificSource Commercial |
$19.70
|
| Rate for Payer: PHCS PPO |
$21.45
|
| Rate for Payer: Three Rivers PPO |
$16.42
|
| Rate for Payer: TriWest Veterans Administration |
$12.70
|
| Rate for Payer: United Healthcare Commercial |
$19.04
|
| Rate for Payer: United Healthcare Medicare |
$12.70
|
| Rate for Payer: WINHealth Partners Commercial |
$21.45
|
| Rate for Payer: Wise Provider Network Commercial |
$20.80
|
|
|
GEMCITABINE 38 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000726]
|
Facility
|
IP
|
$21.89
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.73 |
| Max. Negotiated Rate |
$21.89 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.45
|
| Rate for Payer: Altius Auto/Workers Compensation |
$21.01
|
| Rate for Payer: Altius Commercial |
$21.01
|
| Rate for Payer: Beech Street Commercial |
$21.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.97
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.23
|
| Rate for Payer: Cigna of WY Commercial |
$21.45
|
| Rate for Payer: Entrust Commercial |
$20.80
|
| Rate for Payer: First Choice Health Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.45
|
| Rate for Payer: HealthUtah PPO |
$21.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.23
|
| Rate for Payer: Multiplan Medicare/VA |
$13.73
|
| Rate for Payer: One Health Plan of WY PPO |
$21.45
|
| Rate for Payer: PacificSource Commercial |
$19.70
|
| Rate for Payer: PHCS PPO |
$21.45
|
| Rate for Payer: Three Rivers PPO |
$16.42
|
| Rate for Payer: TriWest Veterans Administration |
$14.45
|
| Rate for Payer: United Healthcare Commercial |
$19.04
|
| Rate for Payer: United Healthcare Medicare |
$14.45
|
| Rate for Payer: WINHealth Partners Commercial |
$20.80
|
| Rate for Payer: Wise Provider Network Commercial |
$20.80
|
|
