|
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
|
|
|
GASTROJEJUNOSTOMY W/VAGOTOMY ANY TYPE
|
Professional
|
Both
|
$5,803.00
|
|
|
Service Code
|
HCPCS 43825 80
|
| Min. Negotiated Rate |
$1,055.57 |
| Max. Negotiated Rate |
$5,803.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,686.94
|
| Rate for Payer: Beech Street Commercial |
$5,512.85
|
| Rate for Payer: Cash Price |
$4,062.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,628.91
|
| Rate for Payer: Cigna of WY Commercial |
$5,686.94
|
| Rate for Payer: First Choice Health Commercial |
$5,222.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,512.85
|
| Rate for Payer: HealthUtah PPO |
$5,803.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,628.91
|
| Rate for Payer: One Health Plan of WY PPO |
$5,686.94
|
| Rate for Payer: PacificSource Commercial |
$5,222.70
|
| Rate for Payer: PHCS PPO |
$5,512.85
|
| Rate for Payer: Three Rivers PPO |
$4,352.25
|
| Rate for Payer: United Healthcare Commercial |
$5,512.85
|
| Rate for Payer: WINHealth Partners Commercial |
$4,932.55
|
|
|
GASTROJEJUNOSTOMY W/VAGOTOMY ANY TYPE
|
Professional
|
Both
|
$5,803.00
|
|
|
Service Code
|
HCPCS 43825
|
| Min. Negotiated Rate |
$1,055.57 |
| Max. Negotiated Rate |
$5,803.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,686.94
|
| Rate for Payer: Aetna of WY Medicare |
$1,241.85
|
| Rate for Payer: Beech Street Commercial |
$5,512.85
|
| Rate for Payer: Cash Price |
$4,062.10
|
| Rate for Payer: Cash Price |
$4,062.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,628.91
|
| Rate for Payer: Cigna of WY Commercial |
$5,686.94
|
| Rate for Payer: First Choice Health Commercial |
$5,222.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,512.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,241.85
|
| Rate for Payer: HealthUtah PPO |
$5,803.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,628.91
|
| Rate for Payer: Multiplan Medicare/VA |
$1,055.57
|
| Rate for Payer: One Health Plan of WY PPO |
$5,686.94
|
| Rate for Payer: PacificSource Commercial |
$5,222.70
|
| Rate for Payer: PHCS PPO |
$5,512.85
|
| Rate for Payer: Three Rivers PPO |
$4,352.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,241.85
|
| Rate for Payer: United Healthcare Commercial |
$5,512.85
|
| Rate for Payer: WINHealth Partners Commercial |
$4,932.55
|
|
|
GASTROJEJUNOSTOMY W/VAGOTOMY ANY TYPE
|
Professional
|
Both
|
$5,803.00
|
|
|
Service Code
|
HCPCS 43825 AS
|
| Min. Negotiated Rate |
$1,055.57 |
| Max. Negotiated Rate |
$5,803.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,686.94
|
| Rate for Payer: Beech Street Commercial |
$5,512.85
|
| Rate for Payer: Cash Price |
$4,062.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,628.91
|
| Rate for Payer: Cigna of WY Commercial |
$5,686.94
|
| Rate for Payer: First Choice Health Commercial |
$5,222.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,512.85
|
| Rate for Payer: HealthUtah PPO |
$5,803.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,628.91
|
| Rate for Payer: One Health Plan of WY PPO |
$5,686.94
|
| Rate for Payer: PacificSource Commercial |
$5,222.70
|
| Rate for Payer: PHCS PPO |
$5,512.85
|
| Rate for Payer: Three Rivers PPO |
$4,352.25
|
| Rate for Payer: United Healthcare Commercial |
$5,512.85
|
| Rate for Payer: WINHealth Partners Commercial |
$4,932.55
|
|
|
GASTRORRHAPHY SUTR PRF8 DUOL/GSTR ULCER WND/INJ
|
Professional
|
Both
|
$5,446.00
|
|
|
Service Code
|
HCPCS 43840
|
| Min. Negotiated Rate |
$1,094.38 |
| Max. Negotiated Rate |
$5,446.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,337.08
|
| Rate for Payer: Aetna of WY Medicare |
$1,287.51
|
| Rate for Payer: Beech Street Commercial |
$5,173.70
|
| Rate for Payer: Cash Price |
$3,812.20
|
| Rate for Payer: Cash Price |
$3,812.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,282.62
|
| Rate for Payer: Cigna of WY Commercial |
$5,337.08
|
| Rate for Payer: First Choice Health Commercial |
$4,901.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,173.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,287.51
|
| Rate for Payer: HealthUtah PPO |
$5,446.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,282.62
|
| Rate for Payer: Multiplan Medicare/VA |
$1,094.38
|
| Rate for Payer: One Health Plan of WY PPO |
$5,337.08
|
| Rate for Payer: PacificSource Commercial |
$4,901.40
|
| Rate for Payer: PHCS PPO |
$5,173.70
|
| Rate for Payer: Three Rivers PPO |
$4,084.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,287.51
|
| Rate for Payer: United Healthcare Commercial |
$5,173.70
|
| Rate for Payer: WINHealth Partners Commercial |
$4,629.10
|
|
|
GASTROSTOMY BALLOON SLG 18X2.0
|
Facility
|
IP
|
$288.19
|
|
| Hospital Charge Code |
2650848
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$167.01 |
| Max. Negotiated Rate |
$288.19 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$282.43
|
| Rate for Payer: Aetna of WY Medicare |
$184.44
|
| 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 |
$279.54
|
| 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 |
$175.80
|
| Rate for Payer: HealthUtah PPO |
$288.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$279.54
|
| Rate for Payer: Multiplan Medicare/VA |
$167.01
|
| 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 |
$175.80
|
| Rate for Payer: United Healthcare Commercial |
$275.22
|
| Rate for Payer: United Healthcare Medicare |
$175.80
|
| Rate for Payer: WINHealth Partners Commercial |
$273.78
|
| Rate for Payer: Wise Provider Network Commercial |
$273.78
|
|
|
GASTROSTOMY BALLOON SLG 18X2.0
|
Facility
|
OP
|
$288.19
|
|
| Hospital Charge Code |
2650848
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$156.05 |
| 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 Commercial |
$276.66
|
| Rate for Payer: Beech Street Commercial |
$282.43
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$279.54
|
| 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 |
$164.27
|
| Rate for Payer: HealthUtah PPO |
$288.19
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$279.54
|
| Rate for Payer: Multiplan Medicare/VA |
$156.05
|
| 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 |
$164.27
|
| Rate for Payer: United Healthcare Commercial |
$275.22
|
| Rate for Payer: United Healthcare Medicare |
$164.27
|
| Rate for Payer: WINHealth Partners Commercial |
$282.43
|
| Rate for Payer: Wise Provider Network Commercial |
$273.78
|
|
|
GASTROSTOMY BALLOON SLG 18X3.0
|
Facility
|
OP
|
$284.34
|
|
| Hospital Charge Code |
2650850
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$153.97 |
| Max. Negotiated Rate |
$284.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$278.65
|
| Rate for Payer: Aetna of WY Medicare |
$187.66
|
| Rate for Payer: Altius Commercial |
$272.97
|
| Rate for Payer: Beech Street Commercial |
$278.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$275.81
|
| Rate for Payer: Cash Price |
$199.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$275.81
|
| Rate for Payer: Cigna of WY Commercial |
$278.65
|
| Rate for Payer: Entrust Commercial |
$270.12
|
| Rate for Payer: First Choice Health Commercial |
$270.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$162.07
|
| Rate for Payer: HealthUtah PPO |
$284.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$275.81
|
| Rate for Payer: Multiplan Medicare/VA |
$153.97
|
| Rate for Payer: One Health Plan of WY PPO |
$278.65
|
| Rate for Payer: PacificSource Commercial |
$255.91
|
| Rate for Payer: PHCS PPO |
$278.65
|
| Rate for Payer: Three Rivers PPO |
$213.26
|
| Rate for Payer: TriWest Veterans Administration |
$162.07
|
| Rate for Payer: United Healthcare Commercial |
$271.54
|
| Rate for Payer: United Healthcare Medicare |
$162.07
|
| Rate for Payer: WINHealth Partners Commercial |
$278.65
|
| Rate for Payer: Wise Provider Network Commercial |
$270.12
|
|
|
GASTROSTOMY BALLOON SLG 18X3.0
|
Facility
|
IP
|
$284.34
|
|
| Hospital Charge Code |
2650850
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$164.78 |
| Max. Negotiated Rate |
$284.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$278.65
|
| Rate for Payer: Aetna of WY Medicare |
$181.98
|
| Rate for Payer: Altius Commercial |
$272.97
|
| Rate for Payer: Beech Street Commercial |
$278.65
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$275.81
|
| Rate for Payer: Cash Price |
$199.04
|
| Rate for Payer: ChoiceCare Network Commercial |
$275.81
|
| Rate for Payer: Cigna of WY Commercial |
$278.65
|
| Rate for Payer: Entrust Commercial |
$270.12
|
| Rate for Payer: First Choice Health Commercial |
$270.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$270.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$173.45
|
| Rate for Payer: HealthUtah PPO |
$284.34
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$275.81
|
| Rate for Payer: Multiplan Medicare/VA |
$164.78
|
| Rate for Payer: One Health Plan of WY PPO |
$278.65
|
| Rate for Payer: PacificSource Commercial |
$255.91
|
| Rate for Payer: PHCS PPO |
$278.65
|
| Rate for Payer: Three Rivers PPO |
$213.26
|
| Rate for Payer: TriWest Veterans Administration |
$173.45
|
| Rate for Payer: United Healthcare Commercial |
$271.54
|
| Rate for Payer: United Healthcare Medicare |
$173.45
|
| Rate for Payer: WINHealth Partners Commercial |
$270.12
|
| Rate for Payer: Wise Provider Network Commercial |
$270.12
|
|
|
GASTROSTOMY MIC TUBE 26 FR
|
Facility
|
IP
|
$73.82
|
|
| Hospital Charge Code |
2400169
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$42.78 |
| Max. Negotiated Rate |
$73.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$72.34
|
| Rate for Payer: Aetna of WY Medicare |
$47.24
|
| Rate for Payer: Altius Commercial |
$70.87
|
| Rate for Payer: Beech Street Commercial |
$72.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.61
|
| Rate for Payer: Cash Price |
$51.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$71.61
|
| Rate for Payer: Cigna of WY Commercial |
$72.34
|
| Rate for Payer: Entrust Commercial |
$70.13
|
| Rate for Payer: First Choice Health Commercial |
$70.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$70.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.03
|
| Rate for Payer: HealthUtah PPO |
$73.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$71.61
|
| Rate for Payer: Multiplan Medicare/VA |
$42.78
|
| Rate for Payer: One Health Plan of WY PPO |
$72.34
|
| Rate for Payer: PacificSource Commercial |
$66.44
|
| Rate for Payer: PHCS PPO |
$72.34
|
| Rate for Payer: Three Rivers PPO |
$55.36
|
| Rate for Payer: TriWest Veterans Administration |
$45.03
|
| Rate for Payer: United Healthcare Commercial |
$70.50
|
| Rate for Payer: United Healthcare Medicare |
$45.03
|
| Rate for Payer: WINHealth Partners Commercial |
$70.13
|
| Rate for Payer: Wise Provider Network Commercial |
$70.13
|
|
|
GASTROSTOMY MIC TUBE 26 FR
|
Facility
|
OP
|
$73.82
|
|
| Hospital Charge Code |
2400169
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$39.97 |
| Max. Negotiated Rate |
$73.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$72.34
|
| Rate for Payer: Aetna of WY Medicare |
$48.72
|
| Rate for Payer: Altius Commercial |
$70.87
|
| Rate for Payer: Beech Street Commercial |
$72.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.61
|
| Rate for Payer: Cash Price |
$51.67
|
| Rate for Payer: ChoiceCare Network Commercial |
$71.61
|
| Rate for Payer: Cigna of WY Commercial |
$72.34
|
| Rate for Payer: Entrust Commercial |
$70.13
|
| Rate for Payer: First Choice Health Commercial |
$70.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$70.13
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$42.08
|
| Rate for Payer: HealthUtah PPO |
$73.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$71.61
|
| Rate for Payer: Multiplan Medicare/VA |
$39.97
|
| Rate for Payer: One Health Plan of WY PPO |
$72.34
|
| Rate for Payer: PacificSource Commercial |
$66.44
|
| Rate for Payer: PHCS PPO |
$72.34
|
| Rate for Payer: Three Rivers PPO |
$55.36
|
| Rate for Payer: TriWest Veterans Administration |
$42.08
|
| Rate for Payer: United Healthcare Commercial |
$70.50
|
| Rate for Payer: United Healthcare Medicare |
$42.08
|
| Rate for Payer: WINHealth Partners Commercial |
$72.34
|
| Rate for Payer: Wise Provider Network Commercial |
$70.13
|
|
|
GASTROSTOMY TUBE 14 FR 1.2 CM
|
Facility
|
OP
|
$315.70
|
|
| Hospital Charge Code |
2400260
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$170.95 |
| Max. Negotiated Rate |
$315.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$309.39
|
| Rate for Payer: Aetna of WY Medicare |
$208.36
|
| Rate for Payer: Altius Commercial |
$303.07
|
| Rate for Payer: Beech Street Commercial |
$309.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$306.23
|
| Rate for Payer: Cash Price |
$220.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$306.23
|
| Rate for Payer: Cigna of WY Commercial |
$309.39
|
| Rate for Payer: Entrust Commercial |
$299.92
|
| Rate for Payer: First Choice Health Commercial |
$299.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$299.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$179.95
|
| Rate for Payer: HealthUtah PPO |
$315.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$306.23
|
| Rate for Payer: Multiplan Medicare/VA |
$170.95
|
| Rate for Payer: One Health Plan of WY PPO |
$309.39
|
| Rate for Payer: PacificSource Commercial |
$284.13
|
| Rate for Payer: PHCS PPO |
$309.39
|
| Rate for Payer: Three Rivers PPO |
$236.78
|
| Rate for Payer: TriWest Veterans Administration |
$179.95
|
| Rate for Payer: United Healthcare Commercial |
$301.49
|
| Rate for Payer: United Healthcare Medicare |
$179.95
|
| Rate for Payer: WINHealth Partners Commercial |
$309.39
|
| Rate for Payer: Wise Provider Network Commercial |
$299.92
|
|
|
GASTROSTOMY TUBE 14 FR 1.2 CM
|
Facility
|
IP
|
$315.70
|
|
| Hospital Charge Code |
2400260
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$182.95 |
| Max. Negotiated Rate |
$315.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$309.39
|
| Rate for Payer: Aetna of WY Medicare |
$202.05
|
| Rate for Payer: Altius Commercial |
$303.07
|
| Rate for Payer: Beech Street Commercial |
$309.39
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$306.23
|
| Rate for Payer: Cash Price |
$220.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$306.23
|
| Rate for Payer: Cigna of WY Commercial |
$309.39
|
| Rate for Payer: Entrust Commercial |
$299.92
|
| Rate for Payer: First Choice Health Commercial |
$299.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$299.92
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$192.58
|
| Rate for Payer: HealthUtah PPO |
$315.70
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$306.23
|
| Rate for Payer: Multiplan Medicare/VA |
$182.95
|
| Rate for Payer: One Health Plan of WY PPO |
$309.39
|
| Rate for Payer: PacificSource Commercial |
$284.13
|
| Rate for Payer: PHCS PPO |
$309.39
|
| Rate for Payer: Three Rivers PPO |
$236.78
|
| Rate for Payer: TriWest Veterans Administration |
$192.58
|
| Rate for Payer: United Healthcare Commercial |
$301.49
|
| Rate for Payer: United Healthcare Medicare |
$192.58
|
| Rate for Payer: WINHealth Partners Commercial |
$299.92
|
| Rate for Payer: Wise Provider Network Commercial |
$299.92
|
|
|
GASTROSTOMY TUBE 16 FR 3.5 CM
|
Facility
|
OP
|
$341.25
|
|
| Hospital Charge Code |
2400164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$184.79 |
| Max. Negotiated Rate |
$341.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$334.42
|
| Rate for Payer: Aetna of WY Medicare |
$225.22
|
| Rate for Payer: Altius Commercial |
$327.60
|
| Rate for Payer: Beech Street Commercial |
$334.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$331.01
|
| Rate for Payer: Cash Price |
$238.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$331.01
|
| Rate for Payer: Cigna of WY Commercial |
$334.42
|
| Rate for Payer: Entrust Commercial |
$324.19
|
| Rate for Payer: First Choice Health Commercial |
$324.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$324.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$194.51
|
| Rate for Payer: HealthUtah PPO |
$341.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$331.01
|
| Rate for Payer: Multiplan Medicare/VA |
$184.79
|
| Rate for Payer: One Health Plan of WY PPO |
$334.42
|
| Rate for Payer: PacificSource Commercial |
$307.12
|
| Rate for Payer: PHCS PPO |
$334.42
|
| Rate for Payer: Three Rivers PPO |
$255.94
|
| Rate for Payer: TriWest Veterans Administration |
$194.51
|
| Rate for Payer: United Healthcare Commercial |
$325.89
|
| Rate for Payer: United Healthcare Medicare |
$194.51
|
| Rate for Payer: WINHealth Partners Commercial |
$334.42
|
| Rate for Payer: Wise Provider Network Commercial |
$324.19
|
|
|
GASTROSTOMY TUBE 16 FR 3.5 CM
|
Facility
|
IP
|
$341.25
|
|
| Hospital Charge Code |
2400164
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$197.75 |
| Max. Negotiated Rate |
$341.25 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$334.42
|
| Rate for Payer: Aetna of WY Medicare |
$218.40
|
| Rate for Payer: Altius Commercial |
$327.60
|
| Rate for Payer: Beech Street Commercial |
$334.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$331.01
|
| Rate for Payer: Cash Price |
$238.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$331.01
|
| Rate for Payer: Cigna of WY Commercial |
$334.42
|
| Rate for Payer: Entrust Commercial |
$324.19
|
| Rate for Payer: First Choice Health Commercial |
$324.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$324.19
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$208.16
|
| Rate for Payer: HealthUtah PPO |
$341.25
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$331.01
|
| Rate for Payer: Multiplan Medicare/VA |
$197.75
|
| Rate for Payer: One Health Plan of WY PPO |
$334.42
|
| Rate for Payer: PacificSource Commercial |
$307.12
|
| Rate for Payer: PHCS PPO |
$334.42
|
| Rate for Payer: Three Rivers PPO |
$255.94
|
| Rate for Payer: TriWest Veterans Administration |
$208.16
|
| Rate for Payer: United Healthcare Commercial |
$325.89
|
| Rate for Payer: United Healthcare Medicare |
$208.16
|
| Rate for Payer: WINHealth Partners Commercial |
$324.19
|
| Rate for Payer: Wise Provider Network Commercial |
$324.19
|
|
|
GASTROSTOMY TUBE 20F
|
Facility
|
IP
|
$402.50
|
|
| Hospital Charge Code |
2400177
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$233.25 |
| Max. Negotiated Rate |
$402.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$394.45
|
| Rate for Payer: Aetna of WY Medicare |
$257.60
|
| Rate for Payer: Altius Commercial |
$386.40
|
| Rate for Payer: Beech Street Commercial |
$394.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$390.42
|
| Rate for Payer: Cash Price |
$281.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$390.42
|
| Rate for Payer: Cigna of WY Commercial |
$394.45
|
| Rate for Payer: Entrust Commercial |
$382.38
|
| Rate for Payer: First Choice Health Commercial |
$382.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$382.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$245.52
|
| Rate for Payer: HealthUtah PPO |
$402.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$390.42
|
| Rate for Payer: Multiplan Medicare/VA |
$233.25
|
| Rate for Payer: One Health Plan of WY PPO |
$394.45
|
| Rate for Payer: PacificSource Commercial |
$362.25
|
| Rate for Payer: PHCS PPO |
$394.45
|
| Rate for Payer: Three Rivers PPO |
$301.88
|
| Rate for Payer: TriWest Veterans Administration |
$245.52
|
| Rate for Payer: United Healthcare Commercial |
$384.39
|
| Rate for Payer: United Healthcare Medicare |
$245.52
|
| Rate for Payer: WINHealth Partners Commercial |
$382.38
|
| Rate for Payer: Wise Provider Network Commercial |
$382.38
|
|
|
GASTROSTOMY TUBE 20F
|
Facility
|
OP
|
$402.50
|
|
| Hospital Charge Code |
2400177
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$217.95 |
| Max. Negotiated Rate |
$402.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$394.45
|
| Rate for Payer: Aetna of WY Medicare |
$265.65
|
| Rate for Payer: Altius Commercial |
$386.40
|
| Rate for Payer: Beech Street Commercial |
$394.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$390.42
|
| Rate for Payer: Cash Price |
$281.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$390.42
|
| Rate for Payer: Cigna of WY Commercial |
$394.45
|
| Rate for Payer: Entrust Commercial |
$382.38
|
| Rate for Payer: First Choice Health Commercial |
$382.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$382.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$229.42
|
| Rate for Payer: HealthUtah PPO |
$402.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$390.42
|
| Rate for Payer: Multiplan Medicare/VA |
$217.95
|
| Rate for Payer: One Health Plan of WY PPO |
$394.45
|
| Rate for Payer: PacificSource Commercial |
$362.25
|
| Rate for Payer: PHCS PPO |
$394.45
|
| Rate for Payer: Three Rivers PPO |
$301.88
|
| Rate for Payer: TriWest Veterans Administration |
$229.42
|
| Rate for Payer: United Healthcare Commercial |
$384.39
|
| Rate for Payer: United Healthcare Medicare |
$229.42
|
| Rate for Payer: WINHealth Partners Commercial |
$394.45
|
| Rate for Payer: Wise Provider Network Commercial |
$382.38
|
|
|
GASTROTOMY W/EXPLORATION/FOREIGN BODY REMOVAL
|
Professional
|
Both
|
$1,462.00
|
|
|
Service Code
|
HCPCS 43500
|
| Min. Negotiated Rate |
$635.90 |
| Max. Negotiated Rate |
$1,462.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,432.76
|
| Rate for Payer: Aetna of WY Medicare |
$748.12
|
| Rate for Payer: Beech Street Commercial |
$1,388.90
|
| Rate for Payer: Cash Price |
$1,023.40
|
| Rate for Payer: Cash Price |
$1,023.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,418.14
|
| Rate for Payer: Cigna of WY Commercial |
$1,432.76
|
| Rate for Payer: First Choice Health Commercial |
$1,315.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,388.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$748.12
|
| Rate for Payer: HealthUtah PPO |
$1,462.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,418.14
|
| Rate for Payer: Multiplan Medicare/VA |
$635.90
|
| Rate for Payer: One Health Plan of WY PPO |
$1,432.76
|
| Rate for Payer: PacificSource Commercial |
$1,315.80
|
| Rate for Payer: PHCS PPO |
$1,388.90
|
| Rate for Payer: Three Rivers PPO |
$1,096.50
|
| Rate for Payer: TriWest Veterans Administration |
$748.12
|
| Rate for Payer: United Healthcare Commercial |
$1,388.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,242.70
|
|
|
GASTROTOMY W/EXPLORATION/FOREIGN BODY REMOVAL
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 43500 80
|
| Min. Negotiated Rate |
$225.00 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$294.00
|
| Rate for Payer: Beech Street Commercial |
$285.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$291.00
|
| Rate for Payer: Cigna of WY Commercial |
$294.00
|
| Rate for Payer: First Choice Health Commercial |
$270.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$285.00
|
| Rate for Payer: HealthUtah PPO |
$300.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$291.00
|
| Rate for Payer: One Health Plan of WY PPO |
$294.00
|
| Rate for Payer: PacificSource Commercial |
$270.00
|
| Rate for Payer: PHCS PPO |
$285.00
|
| Rate for Payer: Three Rivers PPO |
$225.00
|
| Rate for Payer: United Healthcare Commercial |
$285.00
|
| Rate for Payer: WINHealth Partners Commercial |
$255.00
|
|
|
GAUZE <=16 IN NO W/SAL W/O B
|
Professional
|
Both
|
$20.00
|
|
|
Service Code
|
HCPCS A6222
|
| Min. Negotiated Rate |
$15.00 |
| Max. Negotiated Rate |
$20.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$19.60
|
| Rate for Payer: Beech Street Commercial |
$19.00
|
| Rate for Payer: Cash Price |
$14.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.40
|
| Rate for Payer: Cigna of WY Commercial |
$19.60
|
| Rate for Payer: First Choice Health Commercial |
$18.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.00
|
| Rate for Payer: HealthUtah PPO |
$20.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.40
|
| Rate for Payer: One Health Plan of WY PPO |
$19.60
|
| Rate for Payer: PacificSource Commercial |
$18.00
|
| Rate for Payer: PHCS PPO |
$19.00
|
| Rate for Payer: Three Rivers PPO |
$15.00
|
| Rate for Payer: United Healthcare Commercial |
$19.00
|
| Rate for Payer: WINHealth Partners Commercial |
$19.00
|
|
|
GAUZE COMBAT QUIKCLOT 3" X 4YD
|
Facility
|
OP
|
$113.37
|
|
| Hospital Charge Code |
2000033
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$61.39 |
| Max. Negotiated Rate |
$113.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$111.10
|
| Rate for Payer: Aetna of WY Medicare |
$74.82
|
| Rate for Payer: Altius Commercial |
$108.84
|
| Rate for Payer: Beech Street Commercial |
$111.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$109.97
|
| Rate for Payer: Cash Price |
$79.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$109.97
|
| Rate for Payer: Cigna of WY Commercial |
$111.10
|
| Rate for Payer: Entrust Commercial |
$107.70
|
| Rate for Payer: First Choice Health Commercial |
$107.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$107.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.62
|
| Rate for Payer: HealthUtah PPO |
$113.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$109.97
|
| Rate for Payer: Multiplan Medicare/VA |
$61.39
|
| Rate for Payer: One Health Plan of WY PPO |
$111.10
|
| Rate for Payer: PacificSource Commercial |
$102.03
|
| Rate for Payer: PHCS PPO |
$111.10
|
| Rate for Payer: Three Rivers PPO |
$85.03
|
| Rate for Payer: TriWest Veterans Administration |
$64.62
|
| Rate for Payer: United Healthcare Commercial |
$108.27
|
| Rate for Payer: United Healthcare Medicare |
$64.62
|
| Rate for Payer: WINHealth Partners Commercial |
$111.10
|
| Rate for Payer: Wise Provider Network Commercial |
$107.70
|
|
|
GAUZE COMBAT QUIKCLOT 3" X 4YD
|
Facility
|
IP
|
$113.37
|
|
| Hospital Charge Code |
2000033
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$65.70 |
| Max. Negotiated Rate |
$113.37 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$111.10
|
| Rate for Payer: Aetna of WY Medicare |
$72.56
|
| Rate for Payer: Altius Commercial |
$108.84
|
| Rate for Payer: Beech Street Commercial |
$111.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$109.97
|
| Rate for Payer: Cash Price |
$79.36
|
| Rate for Payer: ChoiceCare Network Commercial |
$109.97
|
| Rate for Payer: Cigna of WY Commercial |
$111.10
|
| Rate for Payer: Entrust Commercial |
$107.70
|
| Rate for Payer: First Choice Health Commercial |
$107.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$107.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$69.16
|
| Rate for Payer: HealthUtah PPO |
$113.37
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$109.97
|
| Rate for Payer: Multiplan Medicare/VA |
$65.70
|
| Rate for Payer: One Health Plan of WY PPO |
$111.10
|
| Rate for Payer: PacificSource Commercial |
$102.03
|
| Rate for Payer: PHCS PPO |
$111.10
|
| Rate for Payer: Three Rivers PPO |
$85.03
|
| Rate for Payer: TriWest Veterans Administration |
$69.16
|
| Rate for Payer: United Healthcare Commercial |
$108.27
|
| Rate for Payer: United Healthcare Medicare |
$69.16
|
| Rate for Payer: WINHealth Partners Commercial |
$107.70
|
| Rate for Payer: Wise Provider Network Commercial |
$107.70
|
|
|
GAUZE PACKING PLAIN STRIP 1"
|
Facility
|
IP
|
$6.01
|
|
| Hospital Charge Code |
2000019
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.89
|
| Rate for Payer: Aetna of WY Medicare |
$3.85
|
| Rate for Payer: Altius Commercial |
$5.77
|
| Rate for Payer: Beech Street Commercial |
$5.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.83
|
| Rate for Payer: Cash Price |
$4.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.83
|
| Rate for Payer: Cigna of WY Commercial |
$5.89
|
| Rate for Payer: Entrust Commercial |
$5.71
|
| Rate for Payer: First Choice Health Commercial |
$5.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.67
|
| Rate for Payer: HealthUtah PPO |
$6.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.83
|
| Rate for Payer: Multiplan Medicare/VA |
$3.48
|
| Rate for Payer: One Health Plan of WY PPO |
$5.89
|
| Rate for Payer: PacificSource Commercial |
$5.41
|
| Rate for Payer: PHCS PPO |
$5.89
|
| Rate for Payer: Three Rivers PPO |
$4.51
|
| Rate for Payer: TriWest Veterans Administration |
$3.67
|
| Rate for Payer: United Healthcare Commercial |
$5.74
|
| Rate for Payer: United Healthcare Medicare |
$3.67
|
| Rate for Payer: WINHealth Partners Commercial |
$5.71
|
| Rate for Payer: Wise Provider Network Commercial |
$5.71
|
|
|
GAUZE PACKING PLAIN STRIP 1"
|
Facility
|
OP
|
$6.01
|
|
| Hospital Charge Code |
2000019
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.25 |
| Max. Negotiated Rate |
$6.01 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.89
|
| Rate for Payer: Aetna of WY Medicare |
$3.97
|
| Rate for Payer: Altius Commercial |
$5.77
|
| Rate for Payer: Beech Street Commercial |
$5.89
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5.83
|
| Rate for Payer: Cash Price |
$4.21
|
| Rate for Payer: ChoiceCare Network Commercial |
$5.83
|
| Rate for Payer: Cigna of WY Commercial |
$5.89
|
| Rate for Payer: Entrust Commercial |
$5.71
|
| Rate for Payer: First Choice Health Commercial |
$5.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5.71
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.43
|
| Rate for Payer: HealthUtah PPO |
$6.01
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.83
|
| Rate for Payer: Multiplan Medicare/VA |
$3.25
|
| Rate for Payer: One Health Plan of WY PPO |
$5.89
|
| Rate for Payer: PacificSource Commercial |
$5.41
|
| Rate for Payer: PHCS PPO |
$5.89
|
| Rate for Payer: Three Rivers PPO |
$4.51
|
| Rate for Payer: TriWest Veterans Administration |
$3.43
|
| Rate for Payer: United Healthcare Commercial |
$5.74
|
| Rate for Payer: United Healthcare Medicare |
$3.43
|
| Rate for Payer: WINHealth Partners Commercial |
$5.89
|
| Rate for Payer: Wise Provider Network Commercial |
$5.71
|
|
|
GAUZE PACKING PLAIN STRIP 1/2"
|
Facility
|
IP
|
$5.50
|
|
| Hospital Charge Code |
2000017
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$5.50 |
| Rate for Payer: United Healthcare Commercial |
$5.25
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5.39
|
| Rate for Payer: Aetna of WY Medicare |
$3.52
|
| 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 |
$5.34
|
| 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 |
$3.36
|
| Rate for Payer: HealthUtah PPO |
$5.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5.34
|
| Rate for Payer: Multiplan Medicare/VA |
$3.19
|
| 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 |
$3.36
|
| Rate for Payer: United Healthcare Medicare |
$3.36
|
| Rate for Payer: WINHealth Partners Commercial |
$5.22
|
| Rate for Payer: Wise Provider Network Commercial |
$5.22
|
|
