|
GLYCERIN 99.5 % TOPICAL SOLUTION [40601]
|
Facility
|
OP
|
$0.20
|
|
|
Service Code
|
NDC 3172213747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.20
|
| Rate for Payer: Aetna of WY Medicare |
$0.13
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.19
|
| Rate for Payer: Altius Commercial |
$0.19
|
| Rate for Payer: Beech Street Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.19
|
| Rate for Payer: Cigna of WY Commercial |
$0.20
|
| Rate for Payer: Entrust Commercial |
$0.19
|
| Rate for Payer: First Choice Health Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.12
|
| Rate for Payer: HealthUtah PPO |
$0.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.19
|
| Rate for Payer: Multiplan Medicare/VA |
$0.11
|
| Rate for Payer: One Health Plan of WY PPO |
$0.20
|
| Rate for Payer: PacificSource Commercial |
$0.18
|
| Rate for Payer: PHCS PPO |
$0.20
|
| Rate for Payer: Three Rivers PPO |
$0.15
|
| Rate for Payer: TriWest Veterans Administration |
$0.12
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.12
|
| Rate for Payer: WINHealth Partners Commercial |
$0.20
|
| Rate for Payer: Wise Provider Network Commercial |
$0.19
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION [40601]
|
Facility
|
OP
|
$0.14
|
|
|
Service Code
|
NDC 8770140072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.14
|
| Rate for Payer: Aetna of WY Medicare |
$0.09
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.13
|
| Rate for Payer: Altius Commercial |
$0.13
|
| Rate for Payer: Beech Street Commercial |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.14
|
| Rate for Payer: Cigna of WY Commercial |
$0.14
|
| Rate for Payer: Entrust Commercial |
$0.13
|
| Rate for Payer: First Choice Health Commercial |
$0.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.08
|
| Rate for Payer: HealthUtah PPO |
$0.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.14
|
| Rate for Payer: Multiplan Medicare/VA |
$0.08
|
| Rate for Payer: One Health Plan of WY PPO |
$0.14
|
| Rate for Payer: PacificSource Commercial |
$0.13
|
| Rate for Payer: PHCS PPO |
$0.14
|
| Rate for Payer: Three Rivers PPO |
$0.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.08
|
| Rate for Payer: United Healthcare Commercial |
$0.12
|
| Rate for Payer: United Healthcare Medicare |
$0.08
|
| Rate for Payer: WINHealth Partners Commercial |
$0.14
|
| Rate for Payer: Wise Provider Network Commercial |
$0.13
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION [40601]
|
Facility
|
IP
|
$0.14
|
|
|
Service Code
|
NDC 8770140072
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.13
|
| Rate for Payer: Altius Commercial |
$0.13
|
| Rate for Payer: Beech Street Commercial |
$0.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.11
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.14
|
| Rate for Payer: Cigna of WY Commercial |
$0.14
|
| Rate for Payer: Entrust Commercial |
$0.13
|
| Rate for Payer: First Choice Health Commercial |
$0.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.09
|
| Rate for Payer: HealthUtah PPO |
$0.14
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.14
|
| Rate for Payer: Multiplan Medicare/VA |
$0.09
|
| Rate for Payer: One Health Plan of WY PPO |
$0.14
|
| Rate for Payer: PacificSource Commercial |
$0.13
|
| Rate for Payer: PHCS PPO |
$0.14
|
| Rate for Payer: Three Rivers PPO |
$0.11
|
| Rate for Payer: TriWest Veterans Administration |
$0.09
|
| Rate for Payer: United Healthcare Commercial |
$0.12
|
| Rate for Payer: United Healthcare Medicare |
$0.09
|
| Rate for Payer: WINHealth Partners Commercial |
$0.13
|
| Rate for Payer: Wise Provider Network Commercial |
$0.13
|
|
|
GLYCERIN 99.5 % TOPICAL SOLUTION [40601]
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 3172213747
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.19
|
| Rate for Payer: Altius Commercial |
$0.19
|
| Rate for Payer: Beech Street Commercial |
$0.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.19
|
| Rate for Payer: Cigna of WY Commercial |
$0.20
|
| Rate for Payer: Entrust Commercial |
$0.19
|
| Rate for Payer: First Choice Health Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.13
|
| Rate for Payer: HealthUtah PPO |
$0.20
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.19
|
| Rate for Payer: Multiplan Medicare/VA |
$0.13
|
| Rate for Payer: One Health Plan of WY PPO |
$0.20
|
| Rate for Payer: PacificSource Commercial |
$0.18
|
| Rate for Payer: PHCS PPO |
$0.20
|
| Rate for Payer: Three Rivers PPO |
$0.15
|
| Rate for Payer: TriWest Veterans Administration |
$0.13
|
| Rate for Payer: United Healthcare Commercial |
$0.17
|
| Rate for Payer: United Healthcare Medicare |
$0.13
|
| Rate for Payer: WINHealth Partners Commercial |
$0.19
|
| Rate for Payer: Wise Provider Network Commercial |
$0.19
|
|
|
GLYCERIN (LAXATIVE) 2.8 GRAM/2.7 ML RECTAL SOLUTION [88720]
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 0132019012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.82
|
| Rate for Payer: Aetna of WY Medicare |
$0.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.81
|
| Rate for Payer: Altius Commercial |
$0.81
|
| Rate for Payer: Beech Street Commercial |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.69
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.82
|
| Rate for Payer: Entrust Commercial |
$0.80
|
| Rate for Payer: First Choice Health Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.49
|
| Rate for Payer: HealthUtah PPO |
$0.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.46
|
| Rate for Payer: One Health Plan of WY PPO |
$0.82
|
| Rate for Payer: PacificSource Commercial |
$0.76
|
| Rate for Payer: PHCS PPO |
$0.82
|
| Rate for Payer: Three Rivers PPO |
$0.63
|
| Rate for Payer: TriWest Veterans Administration |
$0.49
|
| Rate for Payer: United Healthcare Commercial |
$0.73
|
| Rate for Payer: United Healthcare Medicare |
$0.49
|
| Rate for Payer: WINHealth Partners Commercial |
$0.82
|
| Rate for Payer: Wise Provider Network Commercial |
$0.80
|
|
|
GLYCERIN (LAXATIVE) 2.8 GRAM/2.7 ML RECTAL SOLUTION [88720]
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 0132019012
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$0.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$0.81
|
| Rate for Payer: Altius Commercial |
$0.81
|
| Rate for Payer: Beech Street Commercial |
$0.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$0.69
|
| Rate for Payer: Cash Price |
$0.59
|
| Rate for Payer: ChoiceCare Network Commercial |
$0.81
|
| Rate for Payer: Cigna of WY Commercial |
$0.82
|
| Rate for Payer: Entrust Commercial |
$0.80
|
| Rate for Payer: First Choice Health Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$0.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$0.55
|
| Rate for Payer: HealthUtah PPO |
$0.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$0.81
|
| Rate for Payer: Multiplan Medicare/VA |
$0.53
|
| Rate for Payer: One Health Plan of WY PPO |
$0.82
|
| Rate for Payer: PacificSource Commercial |
$0.76
|
| Rate for Payer: PHCS PPO |
$0.82
|
| Rate for Payer: Three Rivers PPO |
$0.63
|
| Rate for Payer: TriWest Veterans Administration |
$0.55
|
| Rate for Payer: United Healthcare Commercial |
$0.73
|
| Rate for Payer: United Healthcare Medicare |
$0.55
|
| Rate for Payer: WINHealth Partners Commercial |
$0.80
|
| Rate for Payer: Wise Provider Network Commercial |
$0.80
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [2820]
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
HCPCS J1596
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.78 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.26
|
| Rate for Payer: Aetna of WY Medicare |
$16.50
|
| Rate for Payer: Aetna of WY Medicare |
$16.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.76
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.00
|
| Rate for Payer: Altius Commercial |
$24.00
|
| Rate for Payer: Altius Commercial |
$23.76
|
| Rate for Payer: Beech Street Commercial |
$24.26
|
| Rate for Payer: Beech Street Commercial |
$24.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.32
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.01
|
| Rate for Payer: Cigna of WY Commercial |
$24.26
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: Entrust Commercial |
$23.75
|
| Rate for Payer: Entrust Commercial |
$23.51
|
| Rate for Payer: First Choice Health Commercial |
$23.51
|
| Rate for Payer: First Choice Health Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.36
|
| Rate for Payer: HealthUtah PPO |
$24.75
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Multiplan Medicare/VA |
$13.78
|
| Rate for Payer: Multiplan Medicare/VA |
$13.64
|
| Rate for Payer: One Health Plan of WY PPO |
$24.26
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PacificSource Commercial |
$22.28
|
| Rate for Payer: PHCS PPO |
$24.26
|
| Rate for Payer: PHCS PPO |
$24.50
|
| Rate for Payer: Three Rivers PPO |
$18.56
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: TriWest Veterans Administration |
$14.50
|
| Rate for Payer: TriWest Veterans Administration |
$14.36
|
| Rate for Payer: United Healthcare Commercial |
$21.53
|
| Rate for Payer: United Healthcare Commercial |
$21.75
|
| Rate for Payer: United Healthcare Medicare |
$14.50
|
| Rate for Payer: United Healthcare Medicare |
$14.36
|
| Rate for Payer: WINHealth Partners Commercial |
$24.26
|
| Rate for Payer: WINHealth Partners Commercial |
$24.50
|
| Rate for Payer: Wise Provider Network Commercial |
$23.51
|
| Rate for Payer: Wise Provider Network Commercial |
$23.75
|
|
|
GLYCOPYRROLATE 0.2 MG/ML INJECTION SOLUTION [2820]
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
HCPCS J1596
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.68 |
| Max. Negotiated Rate |
$25.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.50
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$24.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$24.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.76
|
| Rate for Payer: Altius Commercial |
$23.76
|
| Rate for Payer: Altius Commercial |
$24.00
|
| Rate for Payer: Beech Street Commercial |
$24.50
|
| Rate for Payer: Beech Street Commercial |
$24.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$20.52
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.25
|
| Rate for Payer: Cigna of WY Commercial |
$24.50
|
| Rate for Payer: Cigna of WY Commercial |
$24.26
|
| Rate for Payer: Entrust Commercial |
$23.51
|
| Rate for Payer: Entrust Commercial |
$23.75
|
| Rate for Payer: First Choice Health Commercial |
$23.51
|
| Rate for Payer: First Choice Health Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$23.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.34
|
| Rate for Payer: HealthUtah PPO |
$25.00
|
| Rate for Payer: HealthUtah PPO |
$24.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.25
|
| Rate for Payer: Multiplan Medicare/VA |
$15.68
|
| Rate for Payer: Multiplan Medicare/VA |
$15.52
|
| Rate for Payer: One Health Plan of WY PPO |
$24.50
|
| Rate for Payer: One Health Plan of WY PPO |
$24.26
|
| Rate for Payer: PacificSource Commercial |
$22.50
|
| Rate for Payer: PacificSource Commercial |
$22.28
|
| Rate for Payer: PHCS PPO |
$24.26
|
| Rate for Payer: PHCS PPO |
$24.50
|
| Rate for Payer: Three Rivers PPO |
$18.56
|
| Rate for Payer: Three Rivers PPO |
$18.75
|
| Rate for Payer: TriWest Veterans Administration |
$16.50
|
| Rate for Payer: TriWest Veterans Administration |
$16.34
|
| Rate for Payer: United Healthcare Commercial |
$21.53
|
| Rate for Payer: United Healthcare Commercial |
$21.75
|
| Rate for Payer: United Healthcare Medicare |
$16.50
|
| Rate for Payer: United Healthcare Medicare |
$16.34
|
| Rate for Payer: WINHealth Partners Commercial |
$23.51
|
| Rate for Payer: WINHealth Partners Commercial |
$23.75
|
| Rate for Payer: Wise Provider Network Commercial |
$23.51
|
| Rate for Payer: Wise Provider Network Commercial |
$23.75
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [128996]
|
Facility
|
IP
|
$514.80
|
|
|
Service Code
|
HCPCS J1602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$322.78 |
| Max. Negotiated Rate |
$514.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$504.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$494.21
|
| Rate for Payer: Altius Commercial |
$494.21
|
| Rate for Payer: Beech Street Commercial |
$504.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$422.65
|
| Rate for Payer: Cash Price |
$360.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$499.36
|
| Rate for Payer: Cigna of WY Commercial |
$504.50
|
| Rate for Payer: Entrust Commercial |
$489.06
|
| Rate for Payer: First Choice Health Commercial |
$489.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$489.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$339.77
|
| Rate for Payer: HealthUtah PPO |
$514.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$499.36
|
| Rate for Payer: Multiplan Medicare/VA |
$322.78
|
| Rate for Payer: One Health Plan of WY PPO |
$504.50
|
| Rate for Payer: PacificSource Commercial |
$463.32
|
| Rate for Payer: PHCS PPO |
$504.50
|
| Rate for Payer: Three Rivers PPO |
$386.10
|
| Rate for Payer: TriWest Veterans Administration |
$339.77
|
| Rate for Payer: United Healthcare Commercial |
$447.88
|
| Rate for Payer: United Healthcare Medicare |
$339.77
|
| Rate for Payer: WINHealth Partners Commercial |
$489.06
|
| Rate for Payer: Wise Provider Network Commercial |
$489.06
|
|
|
GOLIMUMAB 12.5 MG/ML INTRAVENOUS SOLUTION [128996]
|
Facility
|
OP
|
$514.80
|
|
|
Service Code
|
HCPCS J1602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$283.65 |
| Max. Negotiated Rate |
$514.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$504.50
|
| Rate for Payer: Aetna of WY Medicare |
$339.77
|
| Rate for Payer: Altius Auto/Workers Compensation |
$494.21
|
| Rate for Payer: Altius Commercial |
$494.21
|
| Rate for Payer: Beech Street Commercial |
$504.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$422.65
|
| Rate for Payer: Cash Price |
$360.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$499.36
|
| Rate for Payer: Cigna of WY Commercial |
$504.50
|
| Rate for Payer: Entrust Commercial |
$489.06
|
| Rate for Payer: First Choice Health Commercial |
$489.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$489.06
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$298.58
|
| Rate for Payer: HealthUtah PPO |
$514.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$499.36
|
| Rate for Payer: Multiplan Medicare/VA |
$283.65
|
| Rate for Payer: One Health Plan of WY PPO |
$504.50
|
| Rate for Payer: PacificSource Commercial |
$463.32
|
| Rate for Payer: PHCS PPO |
$504.50
|
| Rate for Payer: Three Rivers PPO |
$386.10
|
| Rate for Payer: TriWest Veterans Administration |
$298.58
|
| Rate for Payer: United Healthcare Commercial |
$447.88
|
| Rate for Payer: United Healthcare Medicare |
$298.58
|
| Rate for Payer: WINHealth Partners Commercial |
$504.50
|
| Rate for Payer: Wise Provider Network Commercial |
$489.06
|
|
|
GOWN ENDO X-LARGE
|
Facility
|
IP
|
$7.79
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.88 |
| Max. Negotiated Rate |
$7.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.63
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.48
|
| Rate for Payer: Altius Commercial |
$7.48
|
| Rate for Payer: Beech Street Commercial |
$7.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.40
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.56
|
| Rate for Payer: Cigna of WY Commercial |
$7.63
|
| Rate for Payer: Entrust Commercial |
$7.40
|
| Rate for Payer: First Choice Health Commercial |
$7.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.14
|
| Rate for Payer: HealthUtah PPO |
$7.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.56
|
| Rate for Payer: Multiplan Medicare/VA |
$4.88
|
| Rate for Payer: One Health Plan of WY PPO |
$7.63
|
| Rate for Payer: PacificSource Commercial |
$7.01
|
| Rate for Payer: PHCS PPO |
$7.63
|
| Rate for Payer: Three Rivers PPO |
$5.84
|
| Rate for Payer: TriWest Veterans Administration |
$5.14
|
| Rate for Payer: United Healthcare Commercial |
$6.78
|
| Rate for Payer: United Healthcare Medicare |
$5.14
|
| Rate for Payer: WINHealth Partners Commercial |
$7.40
|
| Rate for Payer: Wise Provider Network Commercial |
$7.40
|
|
|
GOWN ENDO X-LARGE
|
Facility
|
OP
|
$7.79
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.29 |
| Max. Negotiated Rate |
$7.79 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.63
|
| Rate for Payer: Aetna of WY Medicare |
$5.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$7.48
|
| Rate for Payer: Altius Commercial |
$7.48
|
| Rate for Payer: Beech Street Commercial |
$7.63
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$6.40
|
| Rate for Payer: Cash Price |
$5.46
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.56
|
| Rate for Payer: Cigna of WY Commercial |
$7.63
|
| Rate for Payer: Entrust Commercial |
$7.40
|
| Rate for Payer: First Choice Health Commercial |
$7.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4.52
|
| Rate for Payer: HealthUtah PPO |
$7.79
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.56
|
| Rate for Payer: Multiplan Medicare/VA |
$4.29
|
| Rate for Payer: One Health Plan of WY PPO |
$7.63
|
| Rate for Payer: PacificSource Commercial |
$7.01
|
| Rate for Payer: PHCS PPO |
$7.63
|
| Rate for Payer: Three Rivers PPO |
$5.84
|
| Rate for Payer: TriWest Veterans Administration |
$4.52
|
| Rate for Payer: United Healthcare Commercial |
$6.78
|
| Rate for Payer: United Healthcare Medicare |
$4.52
|
| Rate for Payer: WINHealth Partners Commercial |
$7.63
|
| Rate for Payer: Wise Provider Network Commercial |
$7.40
|
|
|
GOWN SURGERY LARGE
|
Facility
|
OP
|
$10.67
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.46
|
| Rate for Payer: Aetna of WY Medicare |
$7.04
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.24
|
| Rate for Payer: Altius Commercial |
$10.24
|
| Rate for Payer: Beech Street Commercial |
$10.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.76
|
| Rate for Payer: Cash Price |
$7.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.35
|
| Rate for Payer: Cigna of WY Commercial |
$10.46
|
| Rate for Payer: Entrust Commercial |
$10.14
|
| Rate for Payer: First Choice Health Commercial |
$10.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.19
|
| Rate for Payer: HealthUtah PPO |
$10.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.35
|
| Rate for Payer: Multiplan Medicare/VA |
$5.88
|
| Rate for Payer: One Health Plan of WY PPO |
$10.46
|
| Rate for Payer: PacificSource Commercial |
$9.60
|
| Rate for Payer: PHCS PPO |
$10.46
|
| Rate for Payer: Three Rivers PPO |
$8.00
|
| Rate for Payer: TriWest Veterans Administration |
$6.19
|
| Rate for Payer: United Healthcare Commercial |
$9.28
|
| Rate for Payer: United Healthcare Medicare |
$6.19
|
| Rate for Payer: WINHealth Partners Commercial |
$10.46
|
| Rate for Payer: Wise Provider Network Commercial |
$10.14
|
|
|
GOWN SURGERY LARGE
|
Facility
|
IP
|
$10.67
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.69 |
| Max. Negotiated Rate |
$10.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.24
|
| Rate for Payer: Altius Commercial |
$10.24
|
| Rate for Payer: Beech Street Commercial |
$10.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8.76
|
| Rate for Payer: Cash Price |
$7.47
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.35
|
| Rate for Payer: Cigna of WY Commercial |
$10.46
|
| Rate for Payer: Entrust Commercial |
$10.14
|
| Rate for Payer: First Choice Health Commercial |
$10.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.14
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.04
|
| Rate for Payer: HealthUtah PPO |
$10.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.35
|
| Rate for Payer: Multiplan Medicare/VA |
$6.69
|
| Rate for Payer: One Health Plan of WY PPO |
$10.46
|
| Rate for Payer: PacificSource Commercial |
$9.60
|
| Rate for Payer: PHCS PPO |
$10.46
|
| Rate for Payer: Three Rivers PPO |
$8.00
|
| Rate for Payer: TriWest Veterans Administration |
$7.04
|
| Rate for Payer: United Healthcare Commercial |
$9.28
|
| Rate for Payer: United Healthcare Medicare |
$7.04
|
| Rate for Payer: WINHealth Partners Commercial |
$10.14
|
| Rate for Payer: Wise Provider Network Commercial |
$10.14
|
|
|
GOWN SURGERY LARGE LONG
|
Facility
|
OP
|
$12.42
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$12.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.17
|
| Rate for Payer: Aetna of WY Medicare |
$8.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$11.92
|
| Rate for Payer: Altius Commercial |
$11.92
|
| Rate for Payer: Beech Street Commercial |
$12.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.20
|
| Rate for Payer: Cash Price |
$8.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.05
|
| Rate for Payer: Cigna of WY Commercial |
$12.17
|
| Rate for Payer: Entrust Commercial |
$11.80
|
| Rate for Payer: First Choice Health Commercial |
$11.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.20
|
| Rate for Payer: HealthUtah PPO |
$12.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.05
|
| Rate for Payer: Multiplan Medicare/VA |
$6.84
|
| Rate for Payer: One Health Plan of WY PPO |
$12.17
|
| Rate for Payer: PacificSource Commercial |
$11.18
|
| Rate for Payer: PHCS PPO |
$12.17
|
| Rate for Payer: Three Rivers PPO |
$9.32
|
| Rate for Payer: TriWest Veterans Administration |
$7.20
|
| Rate for Payer: United Healthcare Commercial |
$10.81
|
| Rate for Payer: United Healthcare Medicare |
$7.20
|
| Rate for Payer: WINHealth Partners Commercial |
$12.17
|
| Rate for Payer: Wise Provider Network Commercial |
$11.80
|
|
|
GOWN SURGERY LARGE LONG
|
Facility
|
IP
|
$12.42
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.79 |
| Max. Negotiated Rate |
$12.42 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.17
|
| Rate for Payer: Altius Auto/Workers Compensation |
$11.92
|
| Rate for Payer: Altius Commercial |
$11.92
|
| Rate for Payer: Beech Street Commercial |
$12.17
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.20
|
| Rate for Payer: Cash Price |
$8.69
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.05
|
| Rate for Payer: Cigna of WY Commercial |
$12.17
|
| Rate for Payer: Entrust Commercial |
$11.80
|
| Rate for Payer: First Choice Health Commercial |
$11.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$11.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.20
|
| Rate for Payer: HealthUtah PPO |
$12.42
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.05
|
| Rate for Payer: Multiplan Medicare/VA |
$7.79
|
| Rate for Payer: One Health Plan of WY PPO |
$12.17
|
| Rate for Payer: PacificSource Commercial |
$11.18
|
| Rate for Payer: PHCS PPO |
$12.17
|
| Rate for Payer: Three Rivers PPO |
$9.32
|
| Rate for Payer: TriWest Veterans Administration |
$8.20
|
| Rate for Payer: United Healthcare Commercial |
$10.81
|
| Rate for Payer: United Healthcare Medicare |
$8.20
|
| Rate for Payer: WINHealth Partners Commercial |
$11.80
|
| Rate for Payer: Wise Provider Network Commercial |
$11.80
|
|
|
GOWN SURGERY X-LARGE
|
Facility
|
IP
|
$10.96
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.87 |
| Max. Negotiated Rate |
$10.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.74
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.52
|
| Rate for Payer: Altius Commercial |
$10.52
|
| Rate for Payer: Beech Street Commercial |
$10.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.00
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.63
|
| Rate for Payer: Cigna of WY Commercial |
$10.74
|
| Rate for Payer: Entrust Commercial |
$10.41
|
| Rate for Payer: First Choice Health Commercial |
$10.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.23
|
| Rate for Payer: HealthUtah PPO |
$10.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.63
|
| Rate for Payer: Multiplan Medicare/VA |
$6.87
|
| Rate for Payer: One Health Plan of WY PPO |
$10.74
|
| Rate for Payer: PacificSource Commercial |
$9.86
|
| Rate for Payer: PHCS PPO |
$10.74
|
| Rate for Payer: Three Rivers PPO |
$8.22
|
| Rate for Payer: TriWest Veterans Administration |
$7.23
|
| Rate for Payer: United Healthcare Commercial |
$9.54
|
| Rate for Payer: United Healthcare Medicare |
$7.23
|
| Rate for Payer: WINHealth Partners Commercial |
$10.41
|
| Rate for Payer: Wise Provider Network Commercial |
$10.41
|
|
|
GOWN SURGERY X-LARGE
|
Facility
|
OP
|
$10.96
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.04 |
| Max. Negotiated Rate |
$10.96 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.74
|
| Rate for Payer: Aetna of WY Medicare |
$7.23
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.52
|
| Rate for Payer: Altius Commercial |
$10.52
|
| Rate for Payer: Beech Street Commercial |
$10.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.00
|
| Rate for Payer: Cash Price |
$7.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.63
|
| Rate for Payer: Cigna of WY Commercial |
$10.74
|
| Rate for Payer: Entrust Commercial |
$10.41
|
| Rate for Payer: First Choice Health Commercial |
$10.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.41
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.36
|
| Rate for Payer: HealthUtah PPO |
$10.96
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.63
|
| Rate for Payer: Multiplan Medicare/VA |
$6.04
|
| Rate for Payer: One Health Plan of WY PPO |
$10.74
|
| Rate for Payer: PacificSource Commercial |
$9.86
|
| Rate for Payer: PHCS PPO |
$10.74
|
| Rate for Payer: Three Rivers PPO |
$8.22
|
| Rate for Payer: TriWest Veterans Administration |
$6.36
|
| Rate for Payer: United Healthcare Commercial |
$9.54
|
| Rate for Payer: United Healthcare Medicare |
$6.36
|
| Rate for Payer: WINHealth Partners Commercial |
$10.74
|
| Rate for Payer: Wise Provider Network Commercial |
$10.41
|
|
|
GOWN SURGERY X-LARGE LONG
|
Facility
|
OP
|
$13.80
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.60 |
| Max. Negotiated Rate |
$13.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13.52
|
| Rate for Payer: Aetna of WY Medicare |
$9.11
|
| Rate for Payer: Altius Auto/Workers Compensation |
$13.25
|
| Rate for Payer: Altius Commercial |
$13.25
|
| Rate for Payer: Beech Street Commercial |
$13.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.33
|
| Rate for Payer: Cash Price |
$9.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$13.39
|
| Rate for Payer: Cigna of WY Commercial |
$13.52
|
| Rate for Payer: Entrust Commercial |
$13.11
|
| Rate for Payer: First Choice Health Commercial |
$13.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.00
|
| Rate for Payer: HealthUtah PPO |
$13.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13.39
|
| Rate for Payer: Multiplan Medicare/VA |
$7.60
|
| Rate for Payer: One Health Plan of WY PPO |
$13.52
|
| Rate for Payer: PacificSource Commercial |
$12.42
|
| Rate for Payer: PHCS PPO |
$13.52
|
| Rate for Payer: Three Rivers PPO |
$10.35
|
| Rate for Payer: TriWest Veterans Administration |
$8.00
|
| Rate for Payer: United Healthcare Commercial |
$12.01
|
| Rate for Payer: United Healthcare Medicare |
$8.00
|
| Rate for Payer: WINHealth Partners Commercial |
$13.52
|
| Rate for Payer: Wise Provider Network Commercial |
$13.11
|
|
|
GOWN SURGERY X-LARGE LONG
|
Facility
|
IP
|
$13.80
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$13.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$13.25
|
| Rate for Payer: Altius Commercial |
$13.25
|
| Rate for Payer: Beech Street Commercial |
$13.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$11.33
|
| Rate for Payer: Cash Price |
$9.66
|
| Rate for Payer: ChoiceCare Network Commercial |
$13.39
|
| Rate for Payer: Cigna of WY Commercial |
$13.52
|
| Rate for Payer: Entrust Commercial |
$13.11
|
| Rate for Payer: First Choice Health Commercial |
$13.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$13.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.11
|
| Rate for Payer: HealthUtah PPO |
$13.80
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13.39
|
| Rate for Payer: Multiplan Medicare/VA |
$8.65
|
| Rate for Payer: One Health Plan of WY PPO |
$13.52
|
| Rate for Payer: PacificSource Commercial |
$12.42
|
| Rate for Payer: PHCS PPO |
$13.52
|
| Rate for Payer: Three Rivers PPO |
$10.35
|
| Rate for Payer: TriWest Veterans Administration |
$9.11
|
| Rate for Payer: United Healthcare Commercial |
$12.01
|
| Rate for Payer: United Healthcare Medicare |
$9.11
|
| Rate for Payer: WINHealth Partners Commercial |
$13.11
|
| Rate for Payer: Wise Provider Network Commercial |
$13.11
|
|
|
GOWN SURGERY XX-LARGE
|
Facility
|
OP
|
$15.61
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.60 |
| Max. Negotiated Rate |
$15.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.30
|
| Rate for Payer: Aetna of WY Medicare |
$10.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.99
|
| Rate for Payer: Altius Commercial |
$14.99
|
| Rate for Payer: Beech Street Commercial |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.82
|
| Rate for Payer: Cash Price |
$10.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.14
|
| Rate for Payer: Cigna of WY Commercial |
$15.30
|
| Rate for Payer: Entrust Commercial |
$14.83
|
| Rate for Payer: First Choice Health Commercial |
$14.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.05
|
| Rate for Payer: HealthUtah PPO |
$15.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.14
|
| Rate for Payer: Multiplan Medicare/VA |
$8.60
|
| Rate for Payer: One Health Plan of WY PPO |
$15.30
|
| Rate for Payer: PacificSource Commercial |
$14.05
|
| Rate for Payer: PHCS PPO |
$15.30
|
| Rate for Payer: Three Rivers PPO |
$11.71
|
| Rate for Payer: TriWest Veterans Administration |
$9.05
|
| Rate for Payer: United Healthcare Commercial |
$13.58
|
| Rate for Payer: United Healthcare Medicare |
$9.05
|
| Rate for Payer: WINHealth Partners Commercial |
$15.30
|
| Rate for Payer: Wise Provider Network Commercial |
$14.83
|
|
|
GOWN SURGERY XX-LARGE
|
Facility
|
IP
|
$15.61
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.79 |
| Max. Negotiated Rate |
$15.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$14.99
|
| Rate for Payer: Altius Commercial |
$14.99
|
| Rate for Payer: Beech Street Commercial |
$15.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$12.82
|
| Rate for Payer: Cash Price |
$10.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.14
|
| Rate for Payer: Cigna of WY Commercial |
$15.30
|
| Rate for Payer: Entrust Commercial |
$14.83
|
| Rate for Payer: First Choice Health Commercial |
$14.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$14.83
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.30
|
| Rate for Payer: HealthUtah PPO |
$15.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.14
|
| Rate for Payer: Multiplan Medicare/VA |
$9.79
|
| Rate for Payer: One Health Plan of WY PPO |
$15.30
|
| Rate for Payer: PacificSource Commercial |
$14.05
|
| Rate for Payer: PHCS PPO |
$15.30
|
| Rate for Payer: Three Rivers PPO |
$11.71
|
| Rate for Payer: TriWest Veterans Administration |
$10.30
|
| Rate for Payer: United Healthcare Commercial |
$13.58
|
| Rate for Payer: United Healthcare Medicare |
$10.30
|
| Rate for Payer: WINHealth Partners Commercial |
$14.83
|
| Rate for Payer: Wise Provider Network Commercial |
$14.83
|
|
|
GOWN SURGERY XX-LARGE LONG
|
Facility
|
IP
|
$12.74
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.99 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.49
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.23
|
| Rate for Payer: Altius Commercial |
$12.23
|
| Rate for Payer: Beech Street Commercial |
$12.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.46
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.36
|
| Rate for Payer: Cigna of WY Commercial |
$12.49
|
| Rate for Payer: Entrust Commercial |
$12.10
|
| Rate for Payer: First Choice Health Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$8.41
|
| Rate for Payer: HealthUtah PPO |
$12.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.36
|
| Rate for Payer: Multiplan Medicare/VA |
$7.99
|
| Rate for Payer: One Health Plan of WY PPO |
$12.49
|
| Rate for Payer: PacificSource Commercial |
$11.47
|
| Rate for Payer: PHCS PPO |
$12.49
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$8.41
|
| Rate for Payer: United Healthcare Commercial |
$11.08
|
| Rate for Payer: United Healthcare Medicare |
$8.41
|
| Rate for Payer: WINHealth Partners Commercial |
$12.10
|
| Rate for Payer: Wise Provider Network Commercial |
$12.10
|
|
|
GOWN SURGERY XX-LARGE LONG
|
Facility
|
OP
|
$12.74
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.02 |
| Max. Negotiated Rate |
$12.74 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$12.49
|
| Rate for Payer: Aetna of WY Medicare |
$8.41
|
| Rate for Payer: Altius Auto/Workers Compensation |
$12.23
|
| Rate for Payer: Altius Commercial |
$12.23
|
| Rate for Payer: Beech Street Commercial |
$12.49
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.46
|
| Rate for Payer: Cash Price |
$8.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$12.36
|
| Rate for Payer: Cigna of WY Commercial |
$12.49
|
| Rate for Payer: Entrust Commercial |
$12.10
|
| Rate for Payer: First Choice Health Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.39
|
| Rate for Payer: HealthUtah PPO |
$12.74
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$12.36
|
| Rate for Payer: Multiplan Medicare/VA |
$7.02
|
| Rate for Payer: One Health Plan of WY PPO |
$12.49
|
| Rate for Payer: PacificSource Commercial |
$11.47
|
| Rate for Payer: PHCS PPO |
$12.49
|
| Rate for Payer: Three Rivers PPO |
$9.56
|
| Rate for Payer: TriWest Veterans Administration |
$7.39
|
| Rate for Payer: United Healthcare Commercial |
$11.08
|
| Rate for Payer: United Healthcare Medicare |
$7.39
|
| Rate for Payer: WINHealth Partners Commercial |
$12.49
|
| Rate for Payer: Wise Provider Network Commercial |
$12.10
|
|
|
GRAFT EAR CRTLG AUTOGENOUS NOSE/EAR
|
Professional
|
Both
|
$3,448.00
|
|
|
Service Code
|
HCPCS 21235
|
| Hospital Charge Code |
21235
|
| Min. Negotiated Rate |
$472.13 |
| Max. Negotiated Rate |
$3,448.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,379.04
|
| Rate for Payer: Aetna of WY Medicare |
$555.45
|
| Rate for Payer: Beech Street Commercial |
$3,275.60
|
| Rate for Payer: Cash Price |
$2,413.60
|
| Rate for Payer: Cash Price |
$2,413.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,344.56
|
| Rate for Payer: Cigna of WY Commercial |
$3,379.04
|
| Rate for Payer: First Choice Health Commercial |
$3,103.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,275.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$555.45
|
| Rate for Payer: HealthUtah PPO |
$3,448.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,344.56
|
| Rate for Payer: Multiplan Medicare/VA |
$472.13
|
| Rate for Payer: One Health Plan of WY PPO |
$3,379.04
|
| Rate for Payer: PacificSource Commercial |
$3,103.20
|
| Rate for Payer: PHCS PPO |
$3,275.60
|
| Rate for Payer: Three Rivers PPO |
$2,586.00
|
| Rate for Payer: TriWest Veterans Administration |
$555.45
|
| Rate for Payer: United Healthcare Commercial |
$2,999.76
|
| Rate for Payer: United Healthcare Medicare |
$555.45
|
| Rate for Payer: WINHealth Partners Commercial |
$2,930.80
|
|
