|
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
|
|
|
GAUZE PACKING PLAIN STRIP 1/4"
|
Facility
|
IP
|
$5.03
|
|
| Hospital Charge Code |
2000018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.91 |
| Max. Negotiated Rate |
$5.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.93
|
| Rate for Payer: Aetna of WY Medicare |
$3.22
|
| Rate for Payer: Altius Commercial |
$4.83
|
| Rate for Payer: Beech Street Commercial |
$4.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.88
|
| Rate for Payer: Cash Price |
$3.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.88
|
| Rate for Payer: Cigna of WY Commercial |
$4.93
|
| Rate for Payer: Entrust Commercial |
$4.78
|
| Rate for Payer: First Choice Health Commercial |
$4.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3.07
|
| Rate for Payer: HealthUtah PPO |
$5.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.88
|
| Rate for Payer: Multiplan Medicare/VA |
$2.91
|
| Rate for Payer: One Health Plan of WY PPO |
$4.93
|
| Rate for Payer: PacificSource Commercial |
$4.53
|
| Rate for Payer: PHCS PPO |
$4.93
|
| Rate for Payer: Three Rivers PPO |
$3.77
|
| Rate for Payer: TriWest Veterans Administration |
$3.07
|
| Rate for Payer: United Healthcare Commercial |
$4.80
|
| Rate for Payer: United Healthcare Medicare |
$3.07
|
| Rate for Payer: WINHealth Partners Commercial |
$4.78
|
| Rate for Payer: Wise Provider Network Commercial |
$4.78
|
|
|
GAUZE PACKING PLAIN STRIP 1/4"
|
Facility
|
OP
|
$5.03
|
|
| Hospital Charge Code |
2000018
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$5.03 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4.93
|
| Rate for Payer: Aetna of WY Medicare |
$3.32
|
| Rate for Payer: Altius Commercial |
$4.83
|
| Rate for Payer: Beech Street Commercial |
$4.93
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4.88
|
| Rate for Payer: Cash Price |
$3.52
|
| Rate for Payer: ChoiceCare Network Commercial |
$4.88
|
| Rate for Payer: Cigna of WY Commercial |
$4.93
|
| Rate for Payer: Entrust Commercial |
$4.78
|
| Rate for Payer: First Choice Health Commercial |
$4.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2.87
|
| Rate for Payer: HealthUtah PPO |
$5.03
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4.88
|
| Rate for Payer: Multiplan Medicare/VA |
$2.72
|
| Rate for Payer: One Health Plan of WY PPO |
$4.93
|
| Rate for Payer: PacificSource Commercial |
$4.53
|
| Rate for Payer: PHCS PPO |
$4.93
|
| Rate for Payer: Three Rivers PPO |
$3.77
|
| Rate for Payer: TriWest Veterans Administration |
$2.87
|
| Rate for Payer: United Healthcare Commercial |
$4.80
|
| Rate for Payer: United Healthcare Medicare |
$2.87
|
| Rate for Payer: WINHealth Partners Commercial |
$4.93
|
| Rate for Payer: Wise Provider Network Commercial |
$4.78
|
|
|
GC STOCKING FULL LNGTH 40+
|
Professional
|
Both
|
$646.00
|
|
|
Service Code
|
HCPCS A6538
|
| Min. Negotiated Rate |
$484.50 |
| Max. Negotiated Rate |
$646.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$633.08
|
| Rate for Payer: Beech Street Commercial |
$613.70
|
| Rate for Payer: Cash Price |
$452.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$626.62
|
| Rate for Payer: Cigna of WY Commercial |
$633.08
|
| Rate for Payer: First Choice Health Commercial |
$581.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$613.70
|
| Rate for Payer: HealthUtah PPO |
$646.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$626.62
|
| Rate for Payer: One Health Plan of WY PPO |
$633.08
|
| Rate for Payer: PacificSource Commercial |
$581.40
|
| Rate for Payer: PHCS PPO |
$613.70
|
| Rate for Payer: Three Rivers PPO |
$484.50
|
| Rate for Payer: United Healthcare Commercial |
$613.70
|
| Rate for Payer: WINHealth Partners Commercial |
$613.70
|
|
|
GC STOCKING THIGHLNGTH 18-30
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS A6533
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$40.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$39.20
|
| Rate for Payer: Beech Street Commercial |
$38.00
|
| Rate for Payer: Cash Price |
$28.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$38.80
|
| Rate for Payer: Cigna of WY Commercial |
$39.20
|
| Rate for Payer: First Choice Health Commercial |
$36.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$38.00
|
| Rate for Payer: HealthUtah PPO |
$40.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$38.80
|
| Rate for Payer: One Health Plan of WY PPO |
$39.20
|
| Rate for Payer: PacificSource Commercial |
$36.00
|
| Rate for Payer: PHCS PPO |
$38.00
|
| Rate for Payer: Three Rivers PPO |
$30.00
|
| Rate for Payer: United Healthcare Commercial |
$38.00
|
| Rate for Payer: WINHealth Partners Commercial |
$38.00
|
|
|
GC STOCKING THIGHLNGTH 30-40
|
Professional
|
Both
|
$238.00
|
|
|
Service Code
|
HCPCS A6534
|
| Min. Negotiated Rate |
$178.50 |
| Max. Negotiated Rate |
$238.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$233.24
|
| Rate for Payer: Beech Street Commercial |
$226.10
|
| Rate for Payer: Cash Price |
$166.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$230.86
|
| Rate for Payer: Cigna of WY Commercial |
$233.24
|
| Rate for Payer: First Choice Health Commercial |
$214.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$226.10
|
| Rate for Payer: HealthUtah PPO |
$238.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$230.86
|
| Rate for Payer: One Health Plan of WY PPO |
$233.24
|
| Rate for Payer: PacificSource Commercial |
$214.20
|
| Rate for Payer: PHCS PPO |
$226.10
|
| Rate for Payer: Three Rivers PPO |
$178.50
|
| Rate for Payer: United Healthcare Commercial |
$226.10
|
| Rate for Payer: WINHealth Partners Commercial |
$226.10
|
|
|
GC STOCKING THIGHLNGTH 40+
|
Professional
|
Both
|
$63.00
|
|
|
Service Code
|
HCPCS A6535
|
| Min. Negotiated Rate |
$47.25 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.74
|
| Rate for Payer: Beech Street Commercial |
$59.85
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.11
|
| Rate for Payer: Cigna of WY Commercial |
$61.74
|
| Rate for Payer: First Choice Health Commercial |
$56.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.85
|
| Rate for Payer: HealthUtah PPO |
$63.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.11
|
| Rate for Payer: One Health Plan of WY PPO |
$61.74
|
| Rate for Payer: PacificSource Commercial |
$56.70
|
| Rate for Payer: PHCS PPO |
$59.85
|
| Rate for Payer: Three Rivers PPO |
$47.25
|
| Rate for Payer: United Healthcare Commercial |
$59.85
|
| Rate for Payer: WINHealth Partners Commercial |
$59.85
|
|
|
GC STOCKING WAISTLNGTH 30-40
|
Professional
|
Both
|
$238.00
|
|
|
Service Code
|
HCPCS A6540
|
| Min. Negotiated Rate |
$178.50 |
| Max. Negotiated Rate |
$238.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$233.24
|
| Rate for Payer: Beech Street Commercial |
$226.10
|
| Rate for Payer: Cash Price |
$166.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$230.86
|
| Rate for Payer: Cigna of WY Commercial |
$233.24
|
| Rate for Payer: First Choice Health Commercial |
$214.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$226.10
|
| Rate for Payer: HealthUtah PPO |
$238.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$230.86
|
| Rate for Payer: One Health Plan of WY PPO |
$233.24
|
| Rate for Payer: PacificSource Commercial |
$214.20
|
| Rate for Payer: PHCS PPO |
$226.10
|
| Rate for Payer: Three Rivers PPO |
$178.50
|
| Rate for Payer: United Healthcare Commercial |
$226.10
|
| Rate for Payer: WINHealth Partners Commercial |
$226.10
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE [16878]
|
Facility
|
IP
|
$34.66
|
|
|
Service Code
|
NDC 6371301972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.09 |
| Max. Negotiated Rate |
$34.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.97
|
| Rate for Payer: Aetna of WY Medicare |
$22.18
|
| Rate for Payer: Altius Commercial |
$33.27
|
| Rate for Payer: Beech Street Commercial |
$33.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.62
|
| Rate for Payer: Cash Price |
$24.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.62
|
| Rate for Payer: Cigna of WY Commercial |
$33.97
|
| Rate for Payer: Entrust Commercial |
$32.93
|
| Rate for Payer: First Choice Health Commercial |
$32.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.14
|
| Rate for Payer: HealthUtah PPO |
$34.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.62
|
| Rate for Payer: Multiplan Medicare/VA |
$20.09
|
| Rate for Payer: One Health Plan of WY PPO |
$33.97
|
| Rate for Payer: PacificSource Commercial |
$31.19
|
| Rate for Payer: PHCS PPO |
$33.97
|
| Rate for Payer: Three Rivers PPO |
$26.00
|
| Rate for Payer: TriWest Veterans Administration |
$21.14
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$21.14
|
| Rate for Payer: WINHealth Partners Commercial |
$32.93
|
| Rate for Payer: Wise Provider Network Commercial |
$32.93
|
|
|
GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 12 MM-7 MM TOPICAL SPONGE [16878]
|
Facility
|
OP
|
$34.66
|
|
|
Service Code
|
NDC 6371301972
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.77 |
| Max. Negotiated Rate |
$34.66 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$33.97
|
| Rate for Payer: Aetna of WY Medicare |
$22.88
|
| Rate for Payer: Altius Commercial |
$33.27
|
| Rate for Payer: Beech Street Commercial |
$33.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$33.62
|
| Rate for Payer: Cash Price |
$24.26
|
| Rate for Payer: ChoiceCare Network Commercial |
$33.62
|
| Rate for Payer: Cigna of WY Commercial |
$33.97
|
| Rate for Payer: Entrust Commercial |
$32.93
|
| Rate for Payer: First Choice Health Commercial |
$32.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$32.93
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.76
|
| Rate for Payer: HealthUtah PPO |
$34.66
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$33.62
|
| Rate for Payer: Multiplan Medicare/VA |
$18.77
|
| Rate for Payer: One Health Plan of WY PPO |
$33.97
|
| Rate for Payer: PacificSource Commercial |
$31.19
|
| Rate for Payer: PHCS PPO |
$33.97
|
| Rate for Payer: Three Rivers PPO |
$26.00
|
| Rate for Payer: TriWest Veterans Administration |
$19.76
|
| Rate for Payer: United Healthcare Commercial |
$33.10
|
| Rate for Payer: United Healthcare Medicare |
$19.76
|
| Rate for Payer: WINHealth Partners Commercial |
$33.97
|
| Rate for Payer: Wise Provider Network Commercial |
$32.93
|
|
|
GEL-ONE
|
Professional
|
Both
|
$2,220.00
|
|
|
Service Code
|
HCPCS J7326
|
| Min. Negotiated Rate |
$444.02 |
| Max. Negotiated Rate |
$2,220.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,175.60
|
| Rate for Payer: Aetna of WY Medicare |
$522.37
|
| Rate for Payer: Beech Street Commercial |
$2,109.00
|
| Rate for Payer: Cash Price |
$1,554.00
|
| Rate for Payer: Cash Price |
$1,554.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,153.40
|
| Rate for Payer: Cigna of WY Commercial |
$2,175.60
|
| Rate for Payer: First Choice Health Commercial |
$1,998.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,109.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$522.37
|
| Rate for Payer: HealthUtah PPO |
$2,220.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,153.40
|
| Rate for Payer: Multiplan Medicare/VA |
$444.02
|
| Rate for Payer: One Health Plan of WY PPO |
$2,175.60
|
| Rate for Payer: PacificSource Commercial |
$1,998.00
|
| Rate for Payer: PHCS PPO |
$2,109.00
|
| Rate for Payer: Three Rivers PPO |
$1,665.00
|
| Rate for Payer: TriWest Veterans Administration |
$522.37
|
| Rate for Payer: United Healthcare Commercial |
$2,109.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,109.00
|
|
|
GEL-ONE CROSS LINKED HYALURONA
|
Facility
|
IP
|
$1,732.50
|
|
| Hospital Charge Code |
3002954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,003.98 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,697.85
|
| Rate for Payer: Aetna of WY Medicare |
$1,108.80
|
| Rate for Payer: Altius Commercial |
$1,663.20
|
| Rate for Payer: Beech Street Commercial |
$1,697.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,680.52
|
| Rate for Payer: Cash Price |
$1,212.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,680.52
|
| Rate for Payer: Cigna of WY Commercial |
$1,697.85
|
| Rate for Payer: Entrust Commercial |
$1,645.88
|
| Rate for Payer: First Choice Health Commercial |
$1,645.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,645.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,056.82
|
| Rate for Payer: HealthUtah PPO |
$1,732.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,680.52
|
| Rate for Payer: Multiplan Medicare/VA |
$1,003.98
|
| Rate for Payer: One Health Plan of WY PPO |
$1,697.85
|
| Rate for Payer: PacificSource Commercial |
$1,559.25
|
| Rate for Payer: PHCS PPO |
$1,697.85
|
| Rate for Payer: Three Rivers PPO |
$1,299.38
|
| Rate for Payer: TriWest Veterans Administration |
$1,056.82
|
| Rate for Payer: United Healthcare Commercial |
$1,654.54
|
| Rate for Payer: United Healthcare Medicare |
$1,056.82
|
| Rate for Payer: WINHealth Partners Commercial |
$1,645.88
|
| Rate for Payer: Wise Provider Network Commercial |
$1,645.88
|
|
|
GEL-ONE CROSS LINKED HYALURONA
|
Facility
|
OP
|
$1,662.50
|
|
| Hospital Charge Code |
3002954A
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$900.24 |
| Max. Negotiated Rate |
$1,662.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,629.25
|
| Rate for Payer: Aetna of WY Medicare |
$1,097.25
|
| Rate for Payer: Altius Commercial |
$1,596.00
|
| Rate for Payer: Beech Street Commercial |
$1,629.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,612.62
|
| Rate for Payer: Cash Price |
$1,163.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,612.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,629.25
|
| Rate for Payer: Entrust Commercial |
$1,579.38
|
| Rate for Payer: First Choice Health Commercial |
$1,579.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,579.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$947.62
|
| Rate for Payer: HealthUtah PPO |
$1,662.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,612.62
|
| Rate for Payer: Multiplan Medicare/VA |
$900.24
|
| Rate for Payer: One Health Plan of WY PPO |
$1,629.25
|
| Rate for Payer: PacificSource Commercial |
$1,496.25
|
| Rate for Payer: PHCS PPO |
$1,629.25
|
| Rate for Payer: Three Rivers PPO |
$1,246.88
|
| Rate for Payer: TriWest Veterans Administration |
$947.62
|
| Rate for Payer: United Healthcare Commercial |
$1,587.69
|
| Rate for Payer: United Healthcare Medicare |
$947.62
|
| Rate for Payer: WINHealth Partners Commercial |
$1,629.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,579.38
|
|
|
GEL-ONE CROSS LINKED HYALURONA
|
Facility
|
IP
|
$1,662.50
|
|
| Hospital Charge Code |
3002954A
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$963.42 |
| Max. Negotiated Rate |
$1,662.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,629.25
|
| Rate for Payer: Aetna of WY Medicare |
$1,064.00
|
| Rate for Payer: Altius Commercial |
$1,596.00
|
| Rate for Payer: Beech Street Commercial |
$1,629.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,612.62
|
| Rate for Payer: Cash Price |
$1,163.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,612.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,629.25
|
| Rate for Payer: Entrust Commercial |
$1,579.38
|
| Rate for Payer: First Choice Health Commercial |
$1,579.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,579.38
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,014.12
|
| Rate for Payer: HealthUtah PPO |
$1,662.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,612.62
|
| Rate for Payer: Multiplan Medicare/VA |
$963.42
|
| Rate for Payer: One Health Plan of WY PPO |
$1,629.25
|
| Rate for Payer: PacificSource Commercial |
$1,496.25
|
| Rate for Payer: PHCS PPO |
$1,629.25
|
| Rate for Payer: Three Rivers PPO |
$1,246.88
|
| Rate for Payer: TriWest Veterans Administration |
$1,014.12
|
| Rate for Payer: United Healthcare Commercial |
$1,587.69
|
| Rate for Payer: United Healthcare Medicare |
$1,014.12
|
| Rate for Payer: WINHealth Partners Commercial |
$1,579.38
|
| Rate for Payer: Wise Provider Network Commercial |
$1,579.38
|
|
|
GEL-ONE CROSS LINKED HYALURONA
|
Facility
|
OP
|
$1,732.50
|
|
| Hospital Charge Code |
3002954
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$938.15 |
| Max. Negotiated Rate |
$1,732.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,697.85
|
| Rate for Payer: Aetna of WY Medicare |
$1,143.45
|
| Rate for Payer: Altius Commercial |
$1,663.20
|
| Rate for Payer: Beech Street Commercial |
$1,697.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,680.52
|
| Rate for Payer: Cash Price |
$1,212.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,680.52
|
| Rate for Payer: Cigna of WY Commercial |
$1,697.85
|
| Rate for Payer: Entrust Commercial |
$1,645.88
|
| Rate for Payer: First Choice Health Commercial |
$1,645.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,645.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$987.52
|
| Rate for Payer: HealthUtah PPO |
$1,732.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,680.52
|
| Rate for Payer: Multiplan Medicare/VA |
$938.15
|
| Rate for Payer: One Health Plan of WY PPO |
$1,697.85
|
| Rate for Payer: PacificSource Commercial |
$1,559.25
|
| Rate for Payer: PHCS PPO |
$1,697.85
|
| Rate for Payer: Three Rivers PPO |
$1,299.38
|
| Rate for Payer: TriWest Veterans Administration |
$987.52
|
| Rate for Payer: United Healthcare Commercial |
$1,654.54
|
| Rate for Payer: United Healthcare Medicare |
$987.52
|
| Rate for Payer: WINHealth Partners Commercial |
$1,697.85
|
| Rate for Payer: Wise Provider Network Commercial |
$1,645.88
|
|
|
GELPORT 120 MM SYSTEM C8XX2
|
Facility
|
IP
|
$2,012.50
|
|
| Hospital Charge Code |
2650768
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,166.24 |
| Max. Negotiated Rate |
$2,012.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,972.25
|
| Rate for Payer: Aetna of WY Medicare |
$1,288.00
|
| Rate for Payer: Altius Commercial |
$1,932.00
|
| Rate for Payer: Beech Street Commercial |
$1,972.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,952.12
|
| Rate for Payer: Cash Price |
$1,408.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,952.12
|
| Rate for Payer: Cigna of WY Commercial |
$1,972.25
|
| Rate for Payer: Entrust Commercial |
$1,911.88
|
| Rate for Payer: First Choice Health Commercial |
$1,911.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,911.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,227.62
|
| Rate for Payer: HealthUtah PPO |
$2,012.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,952.12
|
| Rate for Payer: Multiplan Medicare/VA |
$1,166.24
|
| Rate for Payer: One Health Plan of WY PPO |
$1,972.25
|
| Rate for Payer: PacificSource Commercial |
$1,811.25
|
| Rate for Payer: PHCS PPO |
$1,972.25
|
| Rate for Payer: Three Rivers PPO |
$1,509.38
|
| Rate for Payer: TriWest Veterans Administration |
$1,227.62
|
| Rate for Payer: United Healthcare Commercial |
$1,921.94
|
| Rate for Payer: United Healthcare Medicare |
$1,227.62
|
| Rate for Payer: WINHealth Partners Commercial |
$1,911.88
|
| Rate for Payer: Wise Provider Network Commercial |
$1,911.88
|
|
|
GELPORT 120 MM SYSTEM C8XX2
|
Facility
|
OP
|
$2,012.50
|
|
| Hospital Charge Code |
2650768
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,089.77 |
| Max. Negotiated Rate |
$2,012.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,972.25
|
| Rate for Payer: Aetna of WY Medicare |
$1,328.25
|
| Rate for Payer: Altius Commercial |
$1,932.00
|
| Rate for Payer: Beech Street Commercial |
$1,972.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,952.12
|
| Rate for Payer: Cash Price |
$1,408.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,952.12
|
| Rate for Payer: Cigna of WY Commercial |
$1,972.25
|
| Rate for Payer: Entrust Commercial |
$1,911.88
|
| Rate for Payer: First Choice Health Commercial |
$1,911.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,911.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,147.12
|
| Rate for Payer: HealthUtah PPO |
$2,012.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,952.12
|
| Rate for Payer: Multiplan Medicare/VA |
$1,089.77
|
| Rate for Payer: One Health Plan of WY PPO |
$1,972.25
|
| Rate for Payer: PacificSource Commercial |
$1,811.25
|
| Rate for Payer: PHCS PPO |
$1,972.25
|
| Rate for Payer: Three Rivers PPO |
$1,509.38
|
| Rate for Payer: TriWest Veterans Administration |
$1,147.12
|
| Rate for Payer: United Healthcare Commercial |
$1,921.94
|
| Rate for Payer: United Healthcare Medicare |
$1,147.12
|
| Rate for Payer: WINHealth Partners Commercial |
$1,972.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,911.88
|
|
|
GEMCITABINE 38 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000726]
|
Facility
|
IP
|
$21.89
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.69 |
| Max. Negotiated Rate |
$21.89 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.45
|
| Rate for Payer: Aetna of WY Medicare |
$14.01
|
| Rate for Payer: Altius Commercial |
$21.01
|
| Rate for Payer: Beech Street Commercial |
$21.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.23
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.23
|
| Rate for Payer: Cigna of WY Commercial |
$21.45
|
| Rate for Payer: Entrust Commercial |
$20.80
|
| Rate for Payer: First Choice Health Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.35
|
| Rate for Payer: HealthUtah PPO |
$21.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.23
|
| Rate for Payer: Multiplan Medicare/VA |
$12.69
|
| Rate for Payer: One Health Plan of WY PPO |
$21.45
|
| Rate for Payer: PacificSource Commercial |
$19.70
|
| Rate for Payer: PHCS PPO |
$21.45
|
| Rate for Payer: Three Rivers PPO |
$16.42
|
| Rate for Payer: TriWest Veterans Administration |
$13.35
|
| Rate for Payer: United Healthcare Commercial |
$20.90
|
| Rate for Payer: United Healthcare Medicare |
$13.35
|
| Rate for Payer: WINHealth Partners Commercial |
$20.80
|
| Rate for Payer: Wise Provider Network Commercial |
$20.80
|
|
|
GEMCITABINE 38 MG/ML INTRAVENOUS SOLUTION (WRAPPED) [4000726]
|
Facility
|
OP
|
$21.89
|
|
|
Service Code
|
HCPCS J9201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$21.89 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$21.45
|
| Rate for Payer: Aetna of WY Medicare |
$14.45
|
| Rate for Payer: Altius Commercial |
$21.01
|
| Rate for Payer: Beech Street Commercial |
$21.45
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$21.23
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$21.23
|
| Rate for Payer: Cigna of WY Commercial |
$21.45
|
| Rate for Payer: Entrust Commercial |
$20.80
|
| Rate for Payer: First Choice Health Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$20.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.48
|
| Rate for Payer: HealthUtah PPO |
$21.89
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$21.23
|
| Rate for Payer: Multiplan Medicare/VA |
$11.85
|
| Rate for Payer: One Health Plan of WY PPO |
$21.45
|
| Rate for Payer: PacificSource Commercial |
$19.70
|
| Rate for Payer: PHCS PPO |
$21.45
|
| Rate for Payer: Three Rivers PPO |
$16.42
|
| Rate for Payer: TriWest Veterans Administration |
$12.48
|
| Rate for Payer: United Healthcare Commercial |
$20.90
|
| Rate for Payer: United Healthcare Medicare |
$12.48
|
| Rate for Payer: WINHealth Partners Commercial |
$21.45
|
| Rate for Payer: Wise Provider Network Commercial |
$20.80
|
|
|
GEMINI SR8 AR-6572
|
Facility
|
IP
|
$112.00
|
|
| Hospital Charge Code |
3001534
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$64.90 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$109.76
|
| Rate for Payer: Aetna of WY Medicare |
$71.68
|
| Rate for Payer: Altius Commercial |
$107.52
|
| Rate for Payer: Beech Street Commercial |
$109.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$108.64
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$108.64
|
| Rate for Payer: Cigna of WY Commercial |
$109.76
|
| Rate for Payer: Entrust Commercial |
$106.40
|
| Rate for Payer: First Choice Health Commercial |
$106.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$106.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$68.32
|
| Rate for Payer: HealthUtah PPO |
$112.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$108.64
|
| Rate for Payer: Multiplan Medicare/VA |
$64.90
|
| Rate for Payer: One Health Plan of WY PPO |
$109.76
|
| Rate for Payer: PacificSource Commercial |
$100.80
|
| Rate for Payer: PHCS PPO |
$109.76
|
| Rate for Payer: Three Rivers PPO |
$84.00
|
| Rate for Payer: TriWest Veterans Administration |
$68.32
|
| Rate for Payer: United Healthcare Commercial |
$106.96
|
| Rate for Payer: United Healthcare Medicare |
$68.32
|
| Rate for Payer: WINHealth Partners Commercial |
$106.40
|
| Rate for Payer: Wise Provider Network Commercial |
$106.40
|
|
|
GEMINI SR8 AR-6572
|
Facility
|
OP
|
$112.00
|
|
| Hospital Charge Code |
3001534
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$60.65 |
| Max. Negotiated Rate |
$112.00 |
| Rate for Payer: United Healthcare Commercial |
$106.96
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$109.76
|
| Rate for Payer: Aetna of WY Medicare |
$73.92
|
| Rate for Payer: Altius Commercial |
$107.52
|
| Rate for Payer: Beech Street Commercial |
$109.76
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$108.64
|
| Rate for Payer: Cash Price |
$78.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$108.64
|
| Rate for Payer: Cigna of WY Commercial |
$109.76
|
| Rate for Payer: Entrust Commercial |
$106.40
|
| Rate for Payer: First Choice Health Commercial |
$106.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$106.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$63.84
|
| Rate for Payer: HealthUtah PPO |
$112.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$108.64
|
| Rate for Payer: Multiplan Medicare/VA |
$60.65
|
| Rate for Payer: One Health Plan of WY PPO |
$109.76
|
| Rate for Payer: PacificSource Commercial |
$100.80
|
| Rate for Payer: PHCS PPO |
$109.76
|
| Rate for Payer: Three Rivers PPO |
$84.00
|
| Rate for Payer: TriWest Veterans Administration |
$63.84
|
| Rate for Payer: United Healthcare Medicare |
$63.84
|
| Rate for Payer: WINHealth Partners Commercial |
$109.76
|
| Rate for Payer: Wise Provider Network Commercial |
$106.40
|
|
|
GENEX BIOCOMPOSITES 10CC
|
Facility
|
IP
|
$8,732.50
|
|
| Hospital Charge Code |
3003442
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,060.48 |
| Max. Negotiated Rate |
$8,732.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,557.85
|
| Rate for Payer: Aetna of WY Medicare |
$5,588.80
|
| Rate for Payer: Altius Commercial |
$8,383.20
|
| Rate for Payer: Beech Street Commercial |
$8,557.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,470.52
|
| Rate for Payer: Cash Price |
$6,112.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,470.52
|
| Rate for Payer: Cigna of WY Commercial |
$8,557.85
|
| Rate for Payer: Entrust Commercial |
$8,295.88
|
| Rate for Payer: First Choice Health Commercial |
$8,295.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,295.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$5,326.82
|
| Rate for Payer: HealthUtah PPO |
$8,732.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,470.52
|
| Rate for Payer: Multiplan Medicare/VA |
$5,060.48
|
| Rate for Payer: One Health Plan of WY PPO |
$8,557.85
|
| Rate for Payer: PacificSource Commercial |
$7,859.25
|
| Rate for Payer: PHCS PPO |
$8,557.85
|
| Rate for Payer: Three Rivers PPO |
$6,549.38
|
| Rate for Payer: TriWest Veterans Administration |
$5,326.82
|
| Rate for Payer: United Healthcare Commercial |
$8,339.54
|
| Rate for Payer: United Healthcare Medicare |
$5,326.82
|
| Rate for Payer: WINHealth Partners Commercial |
$8,295.88
|
| Rate for Payer: Wise Provider Network Commercial |
$8,295.88
|
|
|
GENEX BIOCOMPOSITES 10CC
|
Facility
|
OP
|
$8,732.50
|
|
| Hospital Charge Code |
3003442
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,728.65 |
| Max. Negotiated Rate |
$8,732.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,557.85
|
| Rate for Payer: Aetna of WY Medicare |
$5,763.45
|
| Rate for Payer: Altius Commercial |
$8,383.20
|
| Rate for Payer: Beech Street Commercial |
$8,557.85
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$8,470.52
|
| Rate for Payer: Cash Price |
$6,112.75
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,470.52
|
| Rate for Payer: Cigna of WY Commercial |
$8,557.85
|
| Rate for Payer: Entrust Commercial |
$8,295.88
|
| Rate for Payer: First Choice Health Commercial |
$8,295.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,295.88
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$4,977.52
|
| Rate for Payer: HealthUtah PPO |
$8,732.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,470.52
|
| Rate for Payer: Multiplan Medicare/VA |
$4,728.65
|
| Rate for Payer: One Health Plan of WY PPO |
$8,557.85
|
| Rate for Payer: PacificSource Commercial |
$7,859.25
|
| Rate for Payer: PHCS PPO |
$8,557.85
|
| Rate for Payer: Three Rivers PPO |
$6,549.38
|
| Rate for Payer: TriWest Veterans Administration |
$4,977.52
|
| Rate for Payer: United Healthcare Commercial |
$8,339.54
|
| Rate for Payer: United Healthcare Medicare |
$4,977.52
|
| Rate for Payer: WINHealth Partners Commercial |
$8,557.85
|
| Rate for Payer: Wise Provider Network Commercial |
$8,295.88
|
|
|
GENTAMICIN 0.3 % EYE DROPS [10905]
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 6131463305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.01 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.62
|
| Rate for Payer: Aetna of WY Medicare |
$12.16
|
| Rate for Payer: Altius Commercial |
$18.24
|
| Rate for Payer: Beech Street Commercial |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.43
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.43
|
| Rate for Payer: Cigna of WY Commercial |
$18.62
|
| Rate for Payer: Entrust Commercial |
$18.05
|
| Rate for Payer: First Choice Health Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.59
|
| Rate for Payer: HealthUtah PPO |
$19.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.43
|
| Rate for Payer: Multiplan Medicare/VA |
$11.01
|
| Rate for Payer: One Health Plan of WY PPO |
$18.62
|
| Rate for Payer: PacificSource Commercial |
$17.10
|
| Rate for Payer: PHCS PPO |
$18.62
|
| Rate for Payer: Three Rivers PPO |
$14.25
|
| Rate for Payer: TriWest Veterans Administration |
$11.59
|
| Rate for Payer: United Healthcare Commercial |
$18.14
|
| Rate for Payer: United Healthcare Medicare |
$11.59
|
| Rate for Payer: WINHealth Partners Commercial |
$18.05
|
| Rate for Payer: Wise Provider Network Commercial |
$18.05
|
|
|
GENTAMICIN 0.3 % EYE DROPS [10905]
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 6131463305
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.29 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.62
|
| Rate for Payer: Aetna of WY Medicare |
$12.54
|
| Rate for Payer: Altius Commercial |
$18.24
|
| Rate for Payer: Beech Street Commercial |
$18.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$18.43
|
| Rate for Payer: Cash Price |
$13.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.43
|
| Rate for Payer: Cigna of WY Commercial |
$18.62
|
| Rate for Payer: Entrust Commercial |
$18.05
|
| Rate for Payer: First Choice Health Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$18.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.83
|
| Rate for Payer: HealthUtah PPO |
$19.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.43
|
| Rate for Payer: Multiplan Medicare/VA |
$10.29
|
| Rate for Payer: One Health Plan of WY PPO |
$18.62
|
| Rate for Payer: PacificSource Commercial |
$17.10
|
| Rate for Payer: PHCS PPO |
$18.62
|
| Rate for Payer: Three Rivers PPO |
$14.25
|
| Rate for Payer: TriWest Veterans Administration |
$10.83
|
| Rate for Payer: United Healthcare Commercial |
$18.14
|
| Rate for Payer: United Healthcare Medicare |
$10.83
|
| Rate for Payer: WINHealth Partners Commercial |
$18.62
|
| Rate for Payer: Wise Provider Network Commercial |
$18.05
|
|
