|
GABAPENTIN 600 MG TABLET [1692]
|
Facility
|
OP
|
$17.62
|
|
|
Service Code
|
NDC 6068750711
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.54 |
| Max. Negotiated Rate |
$17.62 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.27
|
| Rate for Payer: Aetna of WY Medicare |
$11.63
|
| Rate for Payer: Altius Commercial |
$16.92
|
| Rate for Payer: Beech Street Commercial |
$17.27
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$17.09
|
| Rate for Payer: Cash Price |
$12.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.09
|
| Rate for Payer: Cigna of WY Commercial |
$17.27
|
| Rate for Payer: Entrust Commercial |
$16.74
|
| Rate for Payer: First Choice Health Commercial |
$16.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$16.74
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.04
|
| Rate for Payer: HealthUtah PPO |
$17.62
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.09
|
| Rate for Payer: Multiplan Medicare/VA |
$9.54
|
| Rate for Payer: One Health Plan of WY PPO |
$17.27
|
| Rate for Payer: PacificSource Commercial |
$15.86
|
| Rate for Payer: PHCS PPO |
$17.27
|
| Rate for Payer: Three Rivers PPO |
$13.22
|
| Rate for Payer: TriWest Veterans Administration |
$10.04
|
| Rate for Payer: United Healthcare Commercial |
$16.83
|
| Rate for Payer: United Healthcare Medicare |
$10.04
|
| Rate for Payer: WINHealth Partners Commercial |
$17.27
|
| Rate for Payer: Wise Provider Network Commercial |
$16.74
|
|
|
GADAVIST 2 ML VIAL INJ-MRI
|
Facility
|
OP
|
$581.98
|
|
| Hospital Charge Code |
6550200
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$315.14 |
| Max. Negotiated Rate |
$581.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$570.34
|
| Rate for Payer: Aetna of WY Medicare |
$384.11
|
| Rate for Payer: Altius Commercial |
$558.70
|
| Rate for Payer: Beech Street Commercial |
$570.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$564.52
|
| Rate for Payer: Cash Price |
$407.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$564.52
|
| Rate for Payer: Cigna of WY Commercial |
$570.34
|
| Rate for Payer: Entrust Commercial |
$552.88
|
| Rate for Payer: First Choice Health Commercial |
$552.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$552.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$331.73
|
| Rate for Payer: HealthUtah PPO |
$581.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$564.52
|
| Rate for Payer: Multiplan Medicare/VA |
$315.14
|
| Rate for Payer: One Health Plan of WY PPO |
$570.34
|
| Rate for Payer: PacificSource Commercial |
$523.78
|
| Rate for Payer: PHCS PPO |
$570.34
|
| Rate for Payer: Three Rivers PPO |
$436.48
|
| Rate for Payer: TriWest Veterans Administration |
$331.73
|
| Rate for Payer: United Healthcare Commercial |
$555.79
|
| Rate for Payer: United Healthcare Medicare |
$331.73
|
| Rate for Payer: WINHealth Partners Commercial |
$570.34
|
| Rate for Payer: Wise Provider Network Commercial |
$552.88
|
|
|
GADAVIST 2 ML VIAL INJ-MRI
|
Facility
|
IP
|
$581.98
|
|
| Hospital Charge Code |
6550200
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$337.26 |
| Max. Negotiated Rate |
$581.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$570.34
|
| Rate for Payer: Aetna of WY Medicare |
$372.47
|
| Rate for Payer: Altius Commercial |
$558.70
|
| Rate for Payer: Beech Street Commercial |
$570.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$564.52
|
| Rate for Payer: Cash Price |
$407.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$564.52
|
| Rate for Payer: Cigna of WY Commercial |
$570.34
|
| Rate for Payer: Entrust Commercial |
$552.88
|
| Rate for Payer: First Choice Health Commercial |
$552.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$552.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$355.01
|
| Rate for Payer: HealthUtah PPO |
$581.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$564.52
|
| Rate for Payer: Multiplan Medicare/VA |
$337.26
|
| Rate for Payer: One Health Plan of WY PPO |
$570.34
|
| Rate for Payer: PacificSource Commercial |
$523.78
|
| Rate for Payer: PHCS PPO |
$570.34
|
| Rate for Payer: Three Rivers PPO |
$436.48
|
| Rate for Payer: TriWest Veterans Administration |
$355.01
|
| Rate for Payer: United Healthcare Commercial |
$555.79
|
| Rate for Payer: United Healthcare Medicare |
$355.01
|
| Rate for Payer: WINHealth Partners Commercial |
$552.88
|
| Rate for Payer: Wise Provider Network Commercial |
$552.88
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [42881]
|
Facility
|
OP
|
$35.75
|
|
|
Service Code
|
HCPCS A9578
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.36 |
| Max. Negotiated Rate |
$35.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.04
|
| Rate for Payer: Aetna of WY Medicare |
$23.60
|
| Rate for Payer: Altius Commercial |
$34.32
|
| Rate for Payer: Beech Street Commercial |
$35.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.68
|
| Rate for Payer: Cash Price |
$25.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.68
|
| Rate for Payer: Cigna of WY Commercial |
$35.04
|
| Rate for Payer: Entrust Commercial |
$33.96
|
| Rate for Payer: First Choice Health Commercial |
$33.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.38
|
| Rate for Payer: HealthUtah PPO |
$35.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.68
|
| Rate for Payer: Multiplan Medicare/VA |
$19.36
|
| Rate for Payer: One Health Plan of WY PPO |
$35.04
|
| Rate for Payer: PacificSource Commercial |
$32.18
|
| Rate for Payer: PHCS PPO |
$35.04
|
| Rate for Payer: Three Rivers PPO |
$26.81
|
| Rate for Payer: TriWest Veterans Administration |
$20.38
|
| Rate for Payer: United Healthcare Commercial |
$34.14
|
| Rate for Payer: United Healthcare Medicare |
$20.38
|
| Rate for Payer: WINHealth Partners Commercial |
$35.04
|
| Rate for Payer: Wise Provider Network Commercial |
$33.96
|
|
|
GADOBENATE DIMEGLUMINE 529 MG/ML(0.1 MMOL/0.2 ML) INTRAVENOUS SOLUTION [42881]
|
Facility
|
IP
|
$35.75
|
|
|
Service Code
|
HCPCS A9578
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.72 |
| Max. Negotiated Rate |
$35.75 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.04
|
| Rate for Payer: Aetna of WY Medicare |
$22.88
|
| Rate for Payer: Altius Commercial |
$34.32
|
| Rate for Payer: Beech Street Commercial |
$35.04
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.68
|
| Rate for Payer: Cash Price |
$25.03
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.68
|
| Rate for Payer: Cigna of WY Commercial |
$35.04
|
| Rate for Payer: Entrust Commercial |
$33.96
|
| Rate for Payer: First Choice Health Commercial |
$33.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$33.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.81
|
| Rate for Payer: HealthUtah PPO |
$35.75
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.68
|
| Rate for Payer: Multiplan Medicare/VA |
$20.72
|
| Rate for Payer: One Health Plan of WY PPO |
$35.04
|
| Rate for Payer: PacificSource Commercial |
$32.18
|
| Rate for Payer: PHCS PPO |
$35.04
|
| Rate for Payer: Three Rivers PPO |
$26.81
|
| Rate for Payer: TriWest Veterans Administration |
$21.81
|
| Rate for Payer: United Healthcare Commercial |
$34.14
|
| Rate for Payer: United Healthcare Medicare |
$21.81
|
| Rate for Payer: WINHealth Partners Commercial |
$33.96
|
| Rate for Payer: Wise Provider Network Commercial |
$33.96
|
|
|
GADOBUTROL 2 MMOL/2 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [135580]
|
Facility
|
IP
|
$41.98
|
|
|
Service Code
|
HCPCS A9585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.33 |
| Max. Negotiated Rate |
$41.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$41.14
|
| Rate for Payer: Aetna of WY Medicare |
$26.87
|
| Rate for Payer: Altius Commercial |
$40.30
|
| Rate for Payer: Beech Street Commercial |
$41.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.72
|
| Rate for Payer: Cash Price |
$29.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.72
|
| Rate for Payer: Cigna of WY Commercial |
$41.14
|
| Rate for Payer: Entrust Commercial |
$39.88
|
| Rate for Payer: First Choice Health Commercial |
$39.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.61
|
| Rate for Payer: HealthUtah PPO |
$41.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.72
|
| Rate for Payer: Multiplan Medicare/VA |
$24.33
|
| Rate for Payer: One Health Plan of WY PPO |
$41.14
|
| Rate for Payer: PacificSource Commercial |
$37.78
|
| Rate for Payer: PHCS PPO |
$41.14
|
| Rate for Payer: Three Rivers PPO |
$31.48
|
| Rate for Payer: TriWest Veterans Administration |
$25.61
|
| Rate for Payer: United Healthcare Commercial |
$40.09
|
| Rate for Payer: United Healthcare Medicare |
$25.61
|
| Rate for Payer: WINHealth Partners Commercial |
$39.88
|
| Rate for Payer: Wise Provider Network Commercial |
$39.88
|
|
|
GADOBUTROL 2 MMOL/2 ML (1 MMOL/ML) INTRAVENOUS SOLUTION [135580]
|
Facility
|
OP
|
$41.98
|
|
|
Service Code
|
HCPCS A9585
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$22.73 |
| Max. Negotiated Rate |
$41.98 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$41.14
|
| Rate for Payer: Aetna of WY Medicare |
$27.71
|
| Rate for Payer: Altius Commercial |
$40.30
|
| Rate for Payer: Beech Street Commercial |
$41.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$40.72
|
| Rate for Payer: Cash Price |
$29.38
|
| Rate for Payer: ChoiceCare Network Commercial |
$40.72
|
| Rate for Payer: Cigna of WY Commercial |
$41.14
|
| Rate for Payer: Entrust Commercial |
$39.88
|
| Rate for Payer: First Choice Health Commercial |
$39.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$39.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.93
|
| Rate for Payer: HealthUtah PPO |
$41.98
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$40.72
|
| Rate for Payer: Multiplan Medicare/VA |
$22.73
|
| Rate for Payer: One Health Plan of WY PPO |
$41.14
|
| Rate for Payer: PacificSource Commercial |
$37.78
|
| Rate for Payer: PHCS PPO |
$41.14
|
| Rate for Payer: Three Rivers PPO |
$31.48
|
| Rate for Payer: TriWest Veterans Administration |
$23.93
|
| Rate for Payer: United Healthcare Commercial |
$40.09
|
| Rate for Payer: United Healthcare Medicare |
$23.93
|
| Rate for Payer: WINHealth Partners Commercial |
$41.14
|
| Rate for Payer: Wise Provider Network Commercial |
$39.88
|
|
|
GAIT BELT 60"
|
Facility
|
IP
|
$10.46
|
|
| Hospital Charge Code |
4400367
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$6.06 |
| Max. Negotiated Rate |
$10.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.25
|
| Rate for Payer: Aetna of WY Medicare |
$6.69
|
| Rate for Payer: Altius Commercial |
$10.04
|
| Rate for Payer: Beech Street Commercial |
$10.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.15
|
| Rate for Payer: Cash Price |
$7.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.15
|
| Rate for Payer: Cigna of WY Commercial |
$10.25
|
| Rate for Payer: Entrust Commercial |
$9.94
|
| Rate for Payer: First Choice Health Commercial |
$9.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.38
|
| Rate for Payer: HealthUtah PPO |
$10.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.15
|
| Rate for Payer: Multiplan Medicare/VA |
$6.06
|
| Rate for Payer: One Health Plan of WY PPO |
$10.25
|
| Rate for Payer: PacificSource Commercial |
$9.41
|
| Rate for Payer: PHCS PPO |
$10.25
|
| Rate for Payer: Three Rivers PPO |
$7.84
|
| Rate for Payer: TriWest Veterans Administration |
$6.38
|
| Rate for Payer: United Healthcare Commercial |
$9.99
|
| Rate for Payer: United Healthcare Medicare |
$6.38
|
| Rate for Payer: WINHealth Partners Commercial |
$9.94
|
| Rate for Payer: Wise Provider Network Commercial |
$9.94
|
|
|
GAIT BELT 60"
|
Facility
|
OP
|
$10.46
|
|
| Hospital Charge Code |
4400367
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$5.66 |
| Max. Negotiated Rate |
$10.46 |
| Rate for Payer: United Healthcare Commercial |
$9.99
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.25
|
| Rate for Payer: Aetna of WY Medicare |
$6.90
|
| Rate for Payer: Altius Commercial |
$10.04
|
| Rate for Payer: Beech Street Commercial |
$10.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$10.15
|
| Rate for Payer: Cash Price |
$7.33
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.15
|
| Rate for Payer: Cigna of WY Commercial |
$10.25
|
| Rate for Payer: Entrust Commercial |
$9.94
|
| Rate for Payer: First Choice Health Commercial |
$9.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$9.94
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5.96
|
| Rate for Payer: HealthUtah PPO |
$10.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.15
|
| Rate for Payer: Multiplan Medicare/VA |
$5.66
|
| Rate for Payer: One Health Plan of WY PPO |
$10.25
|
| Rate for Payer: PacificSource Commercial |
$9.41
|
| Rate for Payer: PHCS PPO |
$10.25
|
| Rate for Payer: Three Rivers PPO |
$7.84
|
| Rate for Payer: TriWest Veterans Administration |
$5.96
|
| Rate for Payer: United Healthcare Medicare |
$5.96
|
| Rate for Payer: WINHealth Partners Commercial |
$10.25
|
| Rate for Payer: Wise Provider Network Commercial |
$9.94
|
|
|
GAIT BELT 72" HEAVY DUTYIN
|
Facility
|
OP
|
$16.91
|
|
| Hospital Charge Code |
4400075
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.16 |
| Max. Negotiated Rate |
$16.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.57
|
| Rate for Payer: Aetna of WY Medicare |
$11.16
|
| Rate for Payer: Altius Commercial |
$16.23
|
| Rate for Payer: Beech Street Commercial |
$16.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.40
|
| Rate for Payer: Cash Price |
$11.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.40
|
| Rate for Payer: Cigna of WY Commercial |
$16.57
|
| 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 |
$9.64
|
| Rate for Payer: HealthUtah PPO |
$16.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.40
|
| Rate for Payer: Multiplan Medicare/VA |
$9.16
|
| Rate for Payer: One Health Plan of WY PPO |
$16.57
|
| Rate for Payer: PacificSource Commercial |
$15.22
|
| Rate for Payer: PHCS PPO |
$16.57
|
| Rate for Payer: Three Rivers PPO |
$12.68
|
| Rate for Payer: TriWest Veterans Administration |
$9.64
|
| Rate for Payer: United Healthcare Commercial |
$16.15
|
| Rate for Payer: United Healthcare Medicare |
$9.64
|
| Rate for Payer: WINHealth Partners Commercial |
$16.57
|
| Rate for Payer: Wise Provider Network Commercial |
$16.06
|
|
|
GAIT BELT 72" HEAVY DUTYIN
|
Facility
|
IP
|
$16.91
|
|
| Hospital Charge Code |
4400075
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$9.80 |
| Max. Negotiated Rate |
$16.91 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$16.57
|
| Rate for Payer: Aetna of WY Medicare |
$10.82
|
| Rate for Payer: Altius Commercial |
$16.23
|
| Rate for Payer: Beech Street Commercial |
$16.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.40
|
| Rate for Payer: Cash Price |
$11.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$16.40
|
| Rate for Payer: Cigna of WY Commercial |
$16.57
|
| 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 |
$10.32
|
| Rate for Payer: HealthUtah PPO |
$16.91
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$16.40
|
| Rate for Payer: Multiplan Medicare/VA |
$9.80
|
| Rate for Payer: One Health Plan of WY PPO |
$16.57
|
| Rate for Payer: PacificSource Commercial |
$15.22
|
| Rate for Payer: PHCS PPO |
$16.57
|
| Rate for Payer: Three Rivers PPO |
$12.68
|
| Rate for Payer: TriWest Veterans Administration |
$10.32
|
| Rate for Payer: United Healthcare Commercial |
$16.15
|
| Rate for Payer: United Healthcare Medicare |
$10.32
|
| Rate for Payer: WINHealth Partners Commercial |
$16.06
|
| Rate for Payer: Wise Provider Network Commercial |
$16.06
|
|
|
GAMMA3 CLOSED TUBE CLIP
|
Facility
|
OP
|
$379.05
|
|
| Hospital Charge Code |
3100580
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$205.26 |
| Max. Negotiated Rate |
$379.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$371.47
|
| Rate for Payer: Aetna of WY Medicare |
$250.17
|
| Rate for Payer: Altius Commercial |
$363.89
|
| Rate for Payer: Beech Street Commercial |
$371.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$367.68
|
| Rate for Payer: Cash Price |
$265.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$367.68
|
| Rate for Payer: Cigna of WY Commercial |
$371.47
|
| Rate for Payer: Entrust Commercial |
$360.10
|
| Rate for Payer: First Choice Health Commercial |
$360.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$360.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$216.06
|
| Rate for Payer: HealthUtah PPO |
$379.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$367.68
|
| Rate for Payer: Multiplan Medicare/VA |
$205.26
|
| Rate for Payer: One Health Plan of WY PPO |
$371.47
|
| Rate for Payer: PacificSource Commercial |
$341.14
|
| Rate for Payer: PHCS PPO |
$371.47
|
| Rate for Payer: Three Rivers PPO |
$284.29
|
| Rate for Payer: TriWest Veterans Administration |
$216.06
|
| Rate for Payer: United Healthcare Commercial |
$361.99
|
| Rate for Payer: United Healthcare Medicare |
$216.06
|
| Rate for Payer: WINHealth Partners Commercial |
$371.47
|
| Rate for Payer: Wise Provider Network Commercial |
$360.10
|
|
|
GAMMA3 CLOSED TUBE CLIP
|
Facility
|
IP
|
$379.05
|
|
| Hospital Charge Code |
3100580
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$219.66 |
| Max. Negotiated Rate |
$379.05 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$371.47
|
| Rate for Payer: Aetna of WY Medicare |
$242.59
|
| Rate for Payer: Altius Commercial |
$363.89
|
| Rate for Payer: Beech Street Commercial |
$371.47
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$367.68
|
| Rate for Payer: Cash Price |
$265.34
|
| Rate for Payer: ChoiceCare Network Commercial |
$367.68
|
| Rate for Payer: Cigna of WY Commercial |
$371.47
|
| Rate for Payer: Entrust Commercial |
$360.10
|
| Rate for Payer: First Choice Health Commercial |
$360.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$360.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$231.22
|
| Rate for Payer: HealthUtah PPO |
$379.05
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$367.68
|
| Rate for Payer: Multiplan Medicare/VA |
$219.66
|
| Rate for Payer: One Health Plan of WY PPO |
$371.47
|
| Rate for Payer: PacificSource Commercial |
$341.14
|
| Rate for Payer: PHCS PPO |
$371.47
|
| Rate for Payer: Three Rivers PPO |
$284.29
|
| Rate for Payer: TriWest Veterans Administration |
$231.22
|
| Rate for Payer: United Healthcare Commercial |
$361.99
|
| Rate for Payer: United Healthcare Medicare |
$231.22
|
| Rate for Payer: WINHealth Partners Commercial |
$360.10
|
| Rate for Payer: Wise Provider Network Commercial |
$360.10
|
|
|
GAMMAGARD LIQUID 10 % INJECTION SOLUTION [38825]
|
Facility
|
IP
|
$57.38
|
|
|
Service Code
|
HCPCS J1569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$57.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56.23
|
| Rate for Payer: Aetna of WY Medicare |
$36.72
|
| Rate for Payer: Altius Commercial |
$55.08
|
| Rate for Payer: Beech Street Commercial |
$56.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$55.66
|
| Rate for Payer: Cash Price |
$40.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.66
|
| Rate for Payer: Cigna of WY Commercial |
$56.23
|
| Rate for Payer: Entrust Commercial |
$54.51
|
| Rate for Payer: First Choice Health Commercial |
$54.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.00
|
| Rate for Payer: HealthUtah PPO |
$57.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.66
|
| Rate for Payer: Multiplan Medicare/VA |
$33.25
|
| Rate for Payer: One Health Plan of WY PPO |
$56.23
|
| Rate for Payer: PacificSource Commercial |
$51.64
|
| Rate for Payer: PHCS PPO |
$56.23
|
| Rate for Payer: Three Rivers PPO |
$43.04
|
| Rate for Payer: TriWest Veterans Administration |
$35.00
|
| Rate for Payer: United Healthcare Commercial |
$54.80
|
| Rate for Payer: United Healthcare Medicare |
$35.00
|
| Rate for Payer: WINHealth Partners Commercial |
$54.51
|
| Rate for Payer: Wise Provider Network Commercial |
$54.51
|
|
|
GAMMAGARD LIQUID 10 % INJECTION SOLUTION [38825]
|
Facility
|
OP
|
$57.38
|
|
|
Service Code
|
HCPCS J1569
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.07 |
| Max. Negotiated Rate |
$57.38 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$56.23
|
| Rate for Payer: Aetna of WY Medicare |
$37.87
|
| Rate for Payer: Altius Commercial |
$55.08
|
| Rate for Payer: Beech Street Commercial |
$56.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$55.66
|
| Rate for Payer: Cash Price |
$40.17
|
| Rate for Payer: ChoiceCare Network Commercial |
$55.66
|
| Rate for Payer: Cigna of WY Commercial |
$56.23
|
| Rate for Payer: Entrust Commercial |
$54.51
|
| Rate for Payer: First Choice Health Commercial |
$54.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$54.51
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.71
|
| Rate for Payer: HealthUtah PPO |
$57.38
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$55.66
|
| Rate for Payer: Multiplan Medicare/VA |
$31.07
|
| Rate for Payer: One Health Plan of WY PPO |
$56.23
|
| Rate for Payer: PacificSource Commercial |
$51.64
|
| Rate for Payer: PHCS PPO |
$56.23
|
| Rate for Payer: Three Rivers PPO |
$43.04
|
| Rate for Payer: TriWest Veterans Administration |
$32.71
|
| Rate for Payer: United Healthcare Commercial |
$54.80
|
| Rate for Payer: United Healthcare Medicare |
$32.71
|
| Rate for Payer: WINHealth Partners Commercial |
$56.23
|
| Rate for Payer: Wise Provider Network Commercial |
$54.51
|
|
|
GAS DILUT/WASHOUT LUNG VOL W/WO DISTRIB VENT&V
|
Professional
|
Both
|
$72.00
|
|
|
Service Code
|
HCPCS 94727 26
|
| Min. Negotiated Rate |
$9.67 |
| Max. Negotiated Rate |
$72.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$70.56
|
| Rate for Payer: Aetna of WY Medicare |
$11.38
|
| Rate for Payer: Beech Street Commercial |
$68.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$69.84
|
| Rate for Payer: Cigna of WY Commercial |
$70.56
|
| Rate for Payer: First Choice Health Commercial |
$64.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$68.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.38
|
| Rate for Payer: HealthUtah PPO |
$72.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$69.84
|
| Rate for Payer: Multiplan Medicare/VA |
$9.67
|
| Rate for Payer: One Health Plan of WY PPO |
$70.56
|
| Rate for Payer: PacificSource Commercial |
$64.80
|
| Rate for Payer: PHCS PPO |
$68.40
|
| Rate for Payer: Three Rivers PPO |
$54.00
|
| Rate for Payer: TriWest Veterans Administration |
$11.38
|
| Rate for Payer: United Healthcare Commercial |
$68.40
|
| Rate for Payer: WINHealth Partners Commercial |
$68.40
|
|
|
GASTRIC INTUBATION DX & ASPIRATJ MULTIPLE SPEC
|
Professional
|
Both
|
$261.00
|
|
|
Service Code
|
HCPCS 43755
|
| Min. Negotiated Rate |
$48.74 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$255.78
|
| Rate for Payer: Aetna of WY Medicare |
$57.34
|
| Rate for Payer: Beech Street Commercial |
$247.95
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$253.17
|
| Rate for Payer: Cigna of WY Commercial |
$255.78
|
| Rate for Payer: First Choice Health Commercial |
$234.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$247.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.34
|
| Rate for Payer: HealthUtah PPO |
$261.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$253.17
|
| Rate for Payer: Multiplan Medicare/VA |
$48.74
|
| Rate for Payer: One Health Plan of WY PPO |
$255.78
|
| Rate for Payer: PacificSource Commercial |
$234.90
|
| Rate for Payer: PHCS PPO |
$247.95
|
| Rate for Payer: Three Rivers PPO |
$195.75
|
| Rate for Payer: TriWest Veterans Administration |
$57.34
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: WINHealth Partners Commercial |
$221.85
|
|
|
GASTRIC INTUBATION DX & ASPIRATJ MULTIPLE SPEC
|
Professional
|
Both
|
$261.00
|
|
|
Service Code
|
HCPCS 43755 80
|
| Min. Negotiated Rate |
$48.74 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$255.78
|
| Rate for Payer: Beech Street Commercial |
$247.95
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$253.17
|
| Rate for Payer: Cigna of WY Commercial |
$255.78
|
| Rate for Payer: First Choice Health Commercial |
$234.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$247.95
|
| Rate for Payer: HealthUtah PPO |
$261.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$253.17
|
| Rate for Payer: One Health Plan of WY PPO |
$255.78
|
| Rate for Payer: PacificSource Commercial |
$234.90
|
| Rate for Payer: PHCS PPO |
$247.95
|
| Rate for Payer: Three Rivers PPO |
$195.75
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: WINHealth Partners Commercial |
$221.85
|
|
|
GASTRIC INTUBATION TREATMENT
|
Professional
|
Both
|
$199.00
|
|
|
Service Code
|
HCPCS 91105
|
| Min. Negotiated Rate |
$149.25 |
| Max. Negotiated Rate |
$199.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$195.02
|
| Rate for Payer: Beech Street Commercial |
$189.05
|
| Rate for Payer: Cash Price |
$139.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$193.03
|
| Rate for Payer: Cigna of WY Commercial |
$195.02
|
| Rate for Payer: First Choice Health Commercial |
$179.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$189.05
|
| Rate for Payer: HealthUtah PPO |
$199.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$193.03
|
| Rate for Payer: One Health Plan of WY PPO |
$195.02
|
| Rate for Payer: PacificSource Commercial |
$179.10
|
| Rate for Payer: PHCS PPO |
$189.05
|
| Rate for Payer: Three Rivers PPO |
$149.25
|
| Rate for Payer: United Healthcare Commercial |
$189.05
|
| Rate for Payer: WINHealth Partners Commercial |
$189.05
|
|
|
GASTRIC INTUBATJ & ASPIRAJ W/PHYS SKILL/LAVAGE
|
Professional
|
Both
|
$98.00
|
|
|
Service Code
|
HCPCS 43753
|
| Min. Negotiated Rate |
$17.23 |
| Max. Negotiated Rate |
$98.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$96.04
|
| Rate for Payer: Aetna of WY Medicare |
$20.27
|
| Rate for Payer: Beech Street Commercial |
$93.10
|
| Rate for Payer: Cash Price |
$68.60
|
| Rate for Payer: Cash Price |
$68.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$95.06
|
| Rate for Payer: Cigna of WY Commercial |
$96.04
|
| Rate for Payer: First Choice Health Commercial |
$88.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$93.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.27
|
| Rate for Payer: HealthUtah PPO |
$98.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$95.06
|
| Rate for Payer: Multiplan Medicare/VA |
$17.23
|
| Rate for Payer: One Health Plan of WY PPO |
$96.04
|
| Rate for Payer: PacificSource Commercial |
$88.20
|
| Rate for Payer: PHCS PPO |
$93.10
|
| Rate for Payer: Three Rivers PPO |
$73.50
|
| Rate for Payer: TriWest Veterans Administration |
$20.27
|
| Rate for Payer: United Healthcare Commercial |
$93.10
|
| Rate for Payer: WINHealth Partners Commercial |
$83.30
|
|
|
GASTRIC LAVAGE SYSTEM
|
Facility
|
IP
|
$31.15
|
|
| Hospital Charge Code |
2600024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.05 |
| Max. Negotiated Rate |
$31.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.53
|
| Rate for Payer: Aetna of WY Medicare |
$19.94
|
| Rate for Payer: Altius Commercial |
$29.90
|
| Rate for Payer: Beech Street Commercial |
$30.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.22
|
| Rate for Payer: Cash Price |
$21.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$30.22
|
| Rate for Payer: Cigna of WY Commercial |
$30.53
|
| Rate for Payer: Entrust Commercial |
$29.59
|
| Rate for Payer: First Choice Health Commercial |
$29.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.00
|
| Rate for Payer: HealthUtah PPO |
$31.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$30.22
|
| Rate for Payer: Multiplan Medicare/VA |
$18.05
|
| Rate for Payer: One Health Plan of WY PPO |
$30.53
|
| Rate for Payer: PacificSource Commercial |
$28.04
|
| Rate for Payer: PHCS PPO |
$30.53
|
| Rate for Payer: Three Rivers PPO |
$23.36
|
| Rate for Payer: TriWest Veterans Administration |
$19.00
|
| Rate for Payer: United Healthcare Commercial |
$29.75
|
| Rate for Payer: United Healthcare Medicare |
$19.00
|
| Rate for Payer: WINHealth Partners Commercial |
$29.59
|
| Rate for Payer: Wise Provider Network Commercial |
$29.59
|
|
|
GASTRIC LAVAGE SYSTEM
|
Facility
|
OP
|
$31.15
|
|
| Hospital Charge Code |
2600024
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.87 |
| Max. Negotiated Rate |
$31.15 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.53
|
| Rate for Payer: Aetna of WY Medicare |
$20.56
|
| Rate for Payer: Altius Commercial |
$29.90
|
| Rate for Payer: Beech Street Commercial |
$30.53
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.22
|
| Rate for Payer: Cash Price |
$21.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$30.22
|
| Rate for Payer: Cigna of WY Commercial |
$30.53
|
| Rate for Payer: Entrust Commercial |
$29.59
|
| Rate for Payer: First Choice Health Commercial |
$29.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.59
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.76
|
| Rate for Payer: HealthUtah PPO |
$31.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$30.22
|
| Rate for Payer: Multiplan Medicare/VA |
$16.87
|
| Rate for Payer: One Health Plan of WY PPO |
$30.53
|
| Rate for Payer: PacificSource Commercial |
$28.04
|
| Rate for Payer: PHCS PPO |
$30.53
|
| Rate for Payer: Three Rivers PPO |
$23.36
|
| Rate for Payer: TriWest Veterans Administration |
$17.76
|
| Rate for Payer: United Healthcare Commercial |
$29.75
|
| Rate for Payer: United Healthcare Medicare |
$17.76
|
| Rate for Payer: WINHealth Partners Commercial |
$30.53
|
| Rate for Payer: Wise Provider Network Commercial |
$29.59
|
|
|
GASTROGRAFIN ORAL 30ML
|
Facility
|
OP
|
$25.61
|
|
| Hospital Charge Code |
6550149A
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.87 |
| Max. Negotiated Rate |
$25.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.10
|
| Rate for Payer: Aetna of WY Medicare |
$16.90
|
| Rate for Payer: Altius Commercial |
$24.59
|
| Rate for Payer: Beech Street Commercial |
$25.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.84
|
| Rate for Payer: Cash Price |
$17.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.84
|
| Rate for Payer: Cigna of WY Commercial |
$25.10
|
| Rate for Payer: Entrust Commercial |
$24.33
|
| Rate for Payer: First Choice Health Commercial |
$24.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.60
|
| Rate for Payer: HealthUtah PPO |
$25.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.84
|
| Rate for Payer: Multiplan Medicare/VA |
$13.87
|
| Rate for Payer: One Health Plan of WY PPO |
$25.10
|
| Rate for Payer: PacificSource Commercial |
$23.05
|
| Rate for Payer: PHCS PPO |
$25.10
|
| Rate for Payer: Three Rivers PPO |
$19.21
|
| Rate for Payer: TriWest Veterans Administration |
$14.60
|
| Rate for Payer: United Healthcare Commercial |
$24.46
|
| Rate for Payer: United Healthcare Medicare |
$14.60
|
| Rate for Payer: WINHealth Partners Commercial |
$25.10
|
| Rate for Payer: Wise Provider Network Commercial |
$24.33
|
|
|
GASTROGRAFIN ORAL 30ML
|
Facility
|
OP
|
$25.61
|
|
| Hospital Charge Code |
6550149
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.87 |
| Max. Negotiated Rate |
$25.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.10
|
| Rate for Payer: Aetna of WY Medicare |
$16.90
|
| Rate for Payer: Altius Commercial |
$24.59
|
| Rate for Payer: Beech Street Commercial |
$25.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.84
|
| Rate for Payer: Cash Price |
$17.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.84
|
| Rate for Payer: Cigna of WY Commercial |
$25.10
|
| Rate for Payer: Entrust Commercial |
$24.33
|
| Rate for Payer: First Choice Health Commercial |
$24.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$14.60
|
| Rate for Payer: HealthUtah PPO |
$25.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.84
|
| Rate for Payer: Multiplan Medicare/VA |
$13.87
|
| Rate for Payer: One Health Plan of WY PPO |
$25.10
|
| Rate for Payer: PacificSource Commercial |
$23.05
|
| Rate for Payer: PHCS PPO |
$25.10
|
| Rate for Payer: Three Rivers PPO |
$19.21
|
| Rate for Payer: TriWest Veterans Administration |
$14.60
|
| Rate for Payer: United Healthcare Commercial |
$24.46
|
| Rate for Payer: United Healthcare Medicare |
$14.60
|
| Rate for Payer: WINHealth Partners Commercial |
$25.10
|
| Rate for Payer: Wise Provider Network Commercial |
$24.33
|
|
|
GASTROGRAFIN ORAL 30ML
|
Facility
|
IP
|
$25.61
|
|
| Hospital Charge Code |
6550149
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.84 |
| Max. Negotiated Rate |
$25.61 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.10
|
| Rate for Payer: Aetna of WY Medicare |
$16.39
|
| Rate for Payer: Altius Commercial |
$24.59
|
| Rate for Payer: Beech Street Commercial |
$25.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$24.84
|
| Rate for Payer: Cash Price |
$17.92
|
| Rate for Payer: ChoiceCare Network Commercial |
$24.84
|
| Rate for Payer: Cigna of WY Commercial |
$25.10
|
| Rate for Payer: Entrust Commercial |
$24.33
|
| Rate for Payer: First Choice Health Commercial |
$24.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.62
|
| Rate for Payer: HealthUtah PPO |
$25.61
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$24.84
|
| Rate for Payer: Multiplan Medicare/VA |
$14.84
|
| Rate for Payer: One Health Plan of WY PPO |
$25.10
|
| Rate for Payer: PacificSource Commercial |
$23.05
|
| Rate for Payer: PHCS PPO |
$25.10
|
| Rate for Payer: Three Rivers PPO |
$19.21
|
| Rate for Payer: TriWest Veterans Administration |
$15.62
|
| Rate for Payer: United Healthcare Commercial |
$24.46
|
| Rate for Payer: United Healthcare Medicare |
$15.62
|
| Rate for Payer: WINHealth Partners Commercial |
$24.33
|
| Rate for Payer: Wise Provider Network Commercial |
$24.33
|
|
