|
CLOPIDOGREL 75 MG TABLET [7032]
|
Facility
|
OP
|
$16.04
|
|
|
Service Code
|
NDC 6808453601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.69 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.72
|
| Rate for Payer: Aetna of WY Medicare |
$10.59
|
| Rate for Payer: Altius Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.56
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.56
|
| Rate for Payer: Cigna of WY Commercial |
$15.72
|
| Rate for Payer: Entrust Commercial |
$15.24
|
| Rate for Payer: First Choice Health Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.14
|
| Rate for Payer: HealthUtah PPO |
$16.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.56
|
| Rate for Payer: Multiplan Medicare/VA |
$8.69
|
| Rate for Payer: One Health Plan of WY PPO |
$15.72
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.72
|
| Rate for Payer: Three Rivers PPO |
$12.03
|
| Rate for Payer: TriWest Veterans Administration |
$9.14
|
| Rate for Payer: United Healthcare Commercial |
$15.32
|
| Rate for Payer: United Healthcare Medicare |
$9.14
|
| Rate for Payer: WINHealth Partners Commercial |
$15.72
|
| Rate for Payer: Wise Provider Network Commercial |
$15.24
|
|
|
CLOPIDOGREL 75 MG TABLET [7032]
|
Facility
|
IP
|
$16.04
|
|
|
Service Code
|
NDC 6808453611
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.72
|
| Rate for Payer: Aetna of WY Medicare |
$10.27
|
| Rate for Payer: Altius Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.56
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.56
|
| Rate for Payer: Cigna of WY Commercial |
$15.72
|
| Rate for Payer: Entrust Commercial |
$15.24
|
| Rate for Payer: First Choice Health Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.78
|
| Rate for Payer: HealthUtah PPO |
$16.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.30
|
| Rate for Payer: One Health Plan of WY PPO |
$15.72
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.72
|
| Rate for Payer: Three Rivers PPO |
$12.03
|
| Rate for Payer: TriWest Veterans Administration |
$9.78
|
| Rate for Payer: United Healthcare Commercial |
$15.32
|
| Rate for Payer: United Healthcare Medicare |
$9.78
|
| Rate for Payer: WINHealth Partners Commercial |
$15.24
|
| Rate for Payer: Wise Provider Network Commercial |
$15.24
|
|
|
CLOPIDOGREL 75 MG TABLET [7032]
|
Facility
|
IP
|
$16.04
|
|
|
Service Code
|
NDC 6808453601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.30 |
| Max. Negotiated Rate |
$16.04 |
| Rate for Payer: United Healthcare Commercial |
$15.32
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.72
|
| Rate for Payer: Aetna of WY Medicare |
$10.27
|
| Rate for Payer: Altius Commercial |
$15.40
|
| Rate for Payer: Beech Street Commercial |
$15.72
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.56
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.56
|
| Rate for Payer: Cigna of WY Commercial |
$15.72
|
| Rate for Payer: Entrust Commercial |
$15.24
|
| Rate for Payer: First Choice Health Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.24
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$9.78
|
| Rate for Payer: HealthUtah PPO |
$16.04
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.56
|
| Rate for Payer: Multiplan Medicare/VA |
$9.30
|
| Rate for Payer: One Health Plan of WY PPO |
$15.72
|
| Rate for Payer: PacificSource Commercial |
$14.44
|
| Rate for Payer: PHCS PPO |
$15.72
|
| Rate for Payer: Three Rivers PPO |
$12.03
|
| Rate for Payer: TriWest Veterans Administration |
$9.78
|
| Rate for Payer: United Healthcare Medicare |
$9.78
|
| Rate for Payer: WINHealth Partners Commercial |
$15.24
|
| Rate for Payer: Wise Provider Network Commercial |
$15.24
|
|
|
CLOSED RX PELVIC RING FX/SUBLUX
|
Professional
|
Both
|
$1,535.00
|
|
|
Service Code
|
HCPCS 27193
|
| Min. Negotiated Rate |
$1,151.25 |
| Max. Negotiated Rate |
$1,535.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,504.30
|
| Rate for Payer: Beech Street Commercial |
$1,458.25
|
| Rate for Payer: Cash Price |
$1,074.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,488.95
|
| Rate for Payer: Cigna of WY Commercial |
$1,504.30
|
| Rate for Payer: First Choice Health Commercial |
$1,381.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,458.25
|
| Rate for Payer: HealthUtah PPO |
$1,535.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,488.95
|
| Rate for Payer: One Health Plan of WY PPO |
$1,504.30
|
| Rate for Payer: PacificSource Commercial |
$1,381.50
|
| Rate for Payer: PHCS PPO |
$1,458.25
|
| Rate for Payer: Three Rivers PPO |
$1,151.25
|
| Rate for Payer: United Healthcare Commercial |
$1,458.25
|
| Rate for Payer: WINHealth Partners Commercial |
$1,304.75
|
|
|
CLOSED TREATMENT COCCYGEAL FRACTURE
|
Professional
|
Both
|
$828.00
|
|
|
Service Code
|
HCPCS 27200
|
| Min. Negotiated Rate |
$163.68 |
| Max. Negotiated Rate |
$828.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$811.44
|
| Rate for Payer: Aetna of WY Medicare |
$192.56
|
| Rate for Payer: Beech Street Commercial |
$786.60
|
| Rate for Payer: Cash Price |
$579.60
|
| Rate for Payer: Cash Price |
$579.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$803.16
|
| Rate for Payer: Cigna of WY Commercial |
$811.44
|
| Rate for Payer: First Choice Health Commercial |
$745.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$786.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$192.56
|
| Rate for Payer: HealthUtah PPO |
$828.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$803.16
|
| Rate for Payer: Multiplan Medicare/VA |
$163.68
|
| Rate for Payer: One Health Plan of WY PPO |
$811.44
|
| Rate for Payer: PacificSource Commercial |
$745.20
|
| Rate for Payer: PHCS PPO |
$786.60
|
| Rate for Payer: Three Rivers PPO |
$621.00
|
| Rate for Payer: TriWest Veterans Administration |
$192.56
|
| Rate for Payer: United Healthcare Commercial |
$786.60
|
| Rate for Payer: WINHealth Partners Commercial |
$703.80
|
|
|
CLOSED TREATMENT PST MALLEOLUS FRACTURE W/O MANJ
|
Professional
|
Both
|
$377.00
|
|
|
Service Code
|
HCPCS 27767
|
| Min. Negotiated Rate |
$248.68 |
| Max. Negotiated Rate |
$377.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$369.46
|
| Rate for Payer: Aetna of WY Medicare |
$292.56
|
| Rate for Payer: Beech Street Commercial |
$358.15
|
| Rate for Payer: Cash Price |
$263.90
|
| Rate for Payer: Cash Price |
$263.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$365.69
|
| Rate for Payer: Cigna of WY Commercial |
$369.46
|
| Rate for Payer: First Choice Health Commercial |
$339.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$358.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$292.56
|
| Rate for Payer: HealthUtah PPO |
$377.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$365.69
|
| Rate for Payer: Multiplan Medicare/VA |
$248.68
|
| Rate for Payer: One Health Plan of WY PPO |
$369.46
|
| Rate for Payer: PacificSource Commercial |
$339.30
|
| Rate for Payer: PHCS PPO |
$358.15
|
| Rate for Payer: Three Rivers PPO |
$282.75
|
| Rate for Payer: TriWest Veterans Administration |
$292.56
|
| Rate for Payer: United Healthcare Commercial |
$358.15
|
| Rate for Payer: WINHealth Partners Commercial |
$320.45
|
|
|
CLOSED TREATMENT ULNAR STYLOID FRACTURE
|
Professional
|
Both
|
$426.00
|
|
|
Service Code
|
HCPCS 25650
|
| Min. Negotiated Rate |
$262.06 |
| Max. Negotiated Rate |
$426.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$417.48
|
| Rate for Payer: Aetna of WY Medicare |
$308.31
|
| Rate for Payer: Beech Street Commercial |
$404.70
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: Cash Price |
$298.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$413.22
|
| Rate for Payer: Cigna of WY Commercial |
$417.48
|
| Rate for Payer: First Choice Health Commercial |
$383.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$404.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$308.31
|
| Rate for Payer: HealthUtah PPO |
$426.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$413.22
|
| Rate for Payer: Multiplan Medicare/VA |
$262.06
|
| Rate for Payer: One Health Plan of WY PPO |
$417.48
|
| Rate for Payer: PacificSource Commercial |
$383.40
|
| Rate for Payer: PHCS PPO |
$404.70
|
| Rate for Payer: Three Rivers PPO |
$319.50
|
| Rate for Payer: TriWest Veterans Administration |
$308.31
|
| Rate for Payer: United Healthcare Commercial |
$404.70
|
| Rate for Payer: WINHealth Partners Commercial |
$362.10
|
|
|
CLOSED TREAT SPINE PROCESS FX
|
Professional
|
Both
|
$779.00
|
|
|
Service Code
|
HCPCS 22305
|
| Min. Negotiated Rate |
$584.25 |
| Max. Negotiated Rate |
$779.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$763.42
|
| Rate for Payer: Beech Street Commercial |
$740.05
|
| Rate for Payer: Cash Price |
$545.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$755.63
|
| Rate for Payer: Cigna of WY Commercial |
$763.42
|
| Rate for Payer: First Choice Health Commercial |
$701.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$740.05
|
| Rate for Payer: HealthUtah PPO |
$779.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$755.63
|
| Rate for Payer: One Health Plan of WY PPO |
$763.42
|
| Rate for Payer: PacificSource Commercial |
$701.10
|
| Rate for Payer: PHCS PPO |
$740.05
|
| Rate for Payer: Three Rivers PPO |
$584.25
|
| Rate for Payer: United Healthcare Commercial |
$740.05
|
| Rate for Payer: WINHealth Partners Commercial |
$662.15
|
|
|
CLOSED TX ANKLE DISLOCATION W/O ANESTHESIA
|
Professional
|
Both
|
$1,658.00
|
|
|
Service Code
|
HCPCS 27840
|
| Min. Negotiated Rate |
$326.94 |
| Max. Negotiated Rate |
$1,658.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,624.84
|
| Rate for Payer: Aetna of WY Medicare |
$384.64
|
| Rate for Payer: Beech Street Commercial |
$1,575.10
|
| Rate for Payer: Cash Price |
$1,160.60
|
| Rate for Payer: Cash Price |
$1,160.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,608.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,624.84
|
| Rate for Payer: First Choice Health Commercial |
$1,492.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,575.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$384.64
|
| Rate for Payer: HealthUtah PPO |
$1,658.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,608.26
|
| Rate for Payer: Multiplan Medicare/VA |
$326.94
|
| Rate for Payer: One Health Plan of WY PPO |
$1,624.84
|
| Rate for Payer: PacificSource Commercial |
$1,492.20
|
| Rate for Payer: PHCS PPO |
$1,575.10
|
| Rate for Payer: Three Rivers PPO |
$1,243.50
|
| Rate for Payer: TriWest Veterans Administration |
$384.64
|
| Rate for Payer: United Healthcare Commercial |
$1,575.10
|
| Rate for Payer: WINHealth Partners Commercial |
$1,409.30
|
|
|
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/MANJ
|
Professional
|
Both
|
$1,866.00
|
|
|
Service Code
|
HCPCS 27810
|
| Min. Negotiated Rate |
$361.34 |
| Max. Negotiated Rate |
$1,866.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,828.68
|
| Rate for Payer: Aetna of WY Medicare |
$425.11
|
| Rate for Payer: Beech Street Commercial |
$1,772.70
|
| Rate for Payer: Cash Price |
$1,306.20
|
| Rate for Payer: Cash Price |
$1,306.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,810.02
|
| Rate for Payer: Cigna of WY Commercial |
$1,828.68
|
| Rate for Payer: First Choice Health Commercial |
$1,679.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,772.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$425.11
|
| Rate for Payer: HealthUtah PPO |
$1,866.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,810.02
|
| Rate for Payer: Multiplan Medicare/VA |
$361.34
|
| Rate for Payer: One Health Plan of WY PPO |
$1,828.68
|
| Rate for Payer: PacificSource Commercial |
$1,679.40
|
| Rate for Payer: PHCS PPO |
$1,772.70
|
| Rate for Payer: Three Rivers PPO |
$1,399.50
|
| Rate for Payer: TriWest Veterans Administration |
$425.11
|
| Rate for Payer: United Healthcare Commercial |
$1,772.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,586.10
|
|
|
CLOSED TX BIMALLEOLAR ANKLE FRACTURE W/O MANJ
|
Professional
|
Both
|
$1,334.00
|
|
|
Service Code
|
HCPCS 27808
|
| Min. Negotiated Rate |
$262.22 |
| Max. Negotiated Rate |
$1,334.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,307.32
|
| Rate for Payer: Aetna of WY Medicare |
$308.49
|
| Rate for Payer: Beech Street Commercial |
$1,267.30
|
| Rate for Payer: Cash Price |
$933.80
|
| Rate for Payer: Cash Price |
$933.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,293.98
|
| Rate for Payer: Cigna of WY Commercial |
$1,307.32
|
| Rate for Payer: First Choice Health Commercial |
$1,200.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,267.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$308.49
|
| Rate for Payer: HealthUtah PPO |
$1,334.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,293.98
|
| Rate for Payer: Multiplan Medicare/VA |
$262.22
|
| Rate for Payer: One Health Plan of WY PPO |
$1,307.32
|
| Rate for Payer: PacificSource Commercial |
$1,200.60
|
| Rate for Payer: PHCS PPO |
$1,267.30
|
| Rate for Payer: Three Rivers PPO |
$1,000.50
|
| Rate for Payer: TriWest Veterans Administration |
$308.49
|
| Rate for Payer: United Healthcare Commercial |
$1,267.30
|
| Rate for Payer: WINHealth Partners Commercial |
$1,133.90
|
|
|
CLOSED TX CALCANEAL FRACTURE W/O MANIPULATION
|
Professional
|
Both
|
$1,006.00
|
|
|
Service Code
|
HCPCS 28400
|
| Min. Negotiated Rate |
$196.38 |
| Max. Negotiated Rate |
$1,006.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$985.88
|
| Rate for Payer: Aetna of WY Medicare |
$231.04
|
| Rate for Payer: Beech Street Commercial |
$955.70
|
| Rate for Payer: Cash Price |
$704.20
|
| Rate for Payer: Cash Price |
$704.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$975.82
|
| Rate for Payer: Cigna of WY Commercial |
$985.88
|
| Rate for Payer: First Choice Health Commercial |
$905.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$955.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$231.04
|
| Rate for Payer: HealthUtah PPO |
$1,006.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$975.82
|
| Rate for Payer: Multiplan Medicare/VA |
$196.38
|
| Rate for Payer: One Health Plan of WY PPO |
$985.88
|
| Rate for Payer: PacificSource Commercial |
$905.40
|
| Rate for Payer: PHCS PPO |
$955.70
|
| Rate for Payer: Three Rivers PPO |
$754.50
|
| Rate for Payer: TriWest Veterans Administration |
$231.04
|
| Rate for Payer: United Healthcare Commercial |
$955.70
|
| Rate for Payer: WINHealth Partners Commercial |
$855.10
|
|
|
CLOSED TX CARPAL SCAPHOID FRACTURE W/O MANJ
|
Professional
|
Both
|
$1,237.00
|
|
|
Service Code
|
HCPCS 25622
|
| Min. Negotiated Rate |
$244.42 |
| Max. Negotiated Rate |
$1,237.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,212.26
|
| Rate for Payer: Aetna of WY Medicare |
$287.55
|
| Rate for Payer: Beech Street Commercial |
$1,175.15
|
| Rate for Payer: Cash Price |
$865.90
|
| Rate for Payer: Cash Price |
$865.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,199.89
|
| Rate for Payer: Cigna of WY Commercial |
$1,212.26
|
| Rate for Payer: First Choice Health Commercial |
$1,113.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,175.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$287.55
|
| Rate for Payer: HealthUtah PPO |
$1,237.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,199.89
|
| Rate for Payer: Multiplan Medicare/VA |
$244.42
|
| Rate for Payer: One Health Plan of WY PPO |
$1,212.26
|
| Rate for Payer: PacificSource Commercial |
$1,113.30
|
| Rate for Payer: PHCS PPO |
$1,175.15
|
| Rate for Payer: Three Rivers PPO |
$927.75
|
| Rate for Payer: TriWest Veterans Administration |
$287.55
|
| Rate for Payer: United Healthcare Commercial |
$1,175.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1,051.45
|
|
|
CLOSED TX DISTAL RADIOULNAR DISLOCATION W/MANJ
|
Professional
|
Both
|
$1,812.00
|
|
|
Service Code
|
HCPCS 25675
|
| Min. Negotiated Rate |
$350.17 |
| Max. Negotiated Rate |
$1,812.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,775.76
|
| Rate for Payer: Aetna of WY Medicare |
$411.96
|
| Rate for Payer: Beech Street Commercial |
$1,721.40
|
| Rate for Payer: Cash Price |
$1,268.40
|
| Rate for Payer: Cash Price |
$1,268.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,757.64
|
| Rate for Payer: Cigna of WY Commercial |
$1,775.76
|
| Rate for Payer: First Choice Health Commercial |
$1,630.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,721.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$411.96
|
| Rate for Payer: HealthUtah PPO |
$1,812.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,757.64
|
| Rate for Payer: Multiplan Medicare/VA |
$350.17
|
| Rate for Payer: One Health Plan of WY PPO |
$1,775.76
|
| Rate for Payer: PacificSource Commercial |
$1,630.80
|
| Rate for Payer: PHCS PPO |
$1,721.40
|
| Rate for Payer: Three Rivers PPO |
$1,359.00
|
| Rate for Payer: TriWest Veterans Administration |
$411.96
|
| Rate for Payer: United Healthcare Commercial |
$1,721.40
|
| Rate for Payer: WINHealth Partners Commercial |
$1,540.20
|
|
|
CLOSED TX FEMORAL SHAFT FX W/O MANIPULATION
|
Professional
|
Both
|
$2,118.00
|
|
|
Service Code
|
HCPCS 27500
|
| Min. Negotiated Rate |
$400.88 |
| Max. Negotiated Rate |
$2,118.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,075.64
|
| Rate for Payer: Aetna of WY Medicare |
$471.62
|
| Rate for Payer: Beech Street Commercial |
$2,012.10
|
| Rate for Payer: Cash Price |
$1,482.60
|
| Rate for Payer: Cash Price |
$1,482.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,054.46
|
| Rate for Payer: Cigna of WY Commercial |
$2,075.64
|
| Rate for Payer: First Choice Health Commercial |
$1,906.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,012.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$471.62
|
| Rate for Payer: HealthUtah PPO |
$2,118.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,054.46
|
| Rate for Payer: Multiplan Medicare/VA |
$400.88
|
| Rate for Payer: One Health Plan of WY PPO |
$2,075.64
|
| Rate for Payer: PacificSource Commercial |
$1,906.20
|
| Rate for Payer: PHCS PPO |
$2,012.10
|
| Rate for Payer: Three Rivers PPO |
$1,588.50
|
| Rate for Payer: TriWest Veterans Administration |
$471.62
|
| Rate for Payer: United Healthcare Commercial |
$2,012.10
|
| Rate for Payer: WINHealth Partners Commercial |
$1,800.30
|
|
|
CLOSED TX KNEE DISLOCATION W/ANESTHESIA
|
Professional
|
Both
|
$2,774.00
|
|
|
Service Code
|
HCPCS 27552
|
| Min. Negotiated Rate |
$528.10 |
| Max. Negotiated Rate |
$2,774.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,718.52
|
| Rate for Payer: Aetna of WY Medicare |
$621.29
|
| Rate for Payer: Beech Street Commercial |
$2,635.30
|
| Rate for Payer: Cash Price |
$1,941.80
|
| Rate for Payer: Cash Price |
$1,941.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,690.78
|
| Rate for Payer: Cigna of WY Commercial |
$2,718.52
|
| Rate for Payer: First Choice Health Commercial |
$2,496.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,635.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$621.29
|
| Rate for Payer: HealthUtah PPO |
$2,774.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,690.78
|
| Rate for Payer: Multiplan Medicare/VA |
$528.10
|
| Rate for Payer: One Health Plan of WY PPO |
$2,718.52
|
| Rate for Payer: PacificSource Commercial |
$2,496.60
|
| Rate for Payer: PHCS PPO |
$2,635.30
|
| Rate for Payer: Three Rivers PPO |
$2,080.50
|
| Rate for Payer: TriWest Veterans Administration |
$621.29
|
| Rate for Payer: United Healthcare Commercial |
$2,635.30
|
| Rate for Payer: WINHealth Partners Commercial |
$2,357.90
|
|
|
CLOSED TX METATARSAL FRACTURE W/O MANIPULATION
|
Professional
|
Both
|
$898.00
|
|
|
Service Code
|
HCPCS 28470
|
| Min. Negotiated Rate |
$175.47 |
| Max. Negotiated Rate |
$898.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$880.04
|
| Rate for Payer: Aetna of WY Medicare |
$206.43
|
| Rate for Payer: Beech Street Commercial |
$853.10
|
| Rate for Payer: Cash Price |
$628.60
|
| Rate for Payer: Cash Price |
$628.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$871.06
|
| Rate for Payer: Cigna of WY Commercial |
$880.04
|
| Rate for Payer: First Choice Health Commercial |
$808.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$853.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$206.43
|
| Rate for Payer: HealthUtah PPO |
$898.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$871.06
|
| Rate for Payer: Multiplan Medicare/VA |
$175.47
|
| Rate for Payer: One Health Plan of WY PPO |
$880.04
|
| Rate for Payer: PacificSource Commercial |
$808.20
|
| Rate for Payer: PHCS PPO |
$853.10
|
| Rate for Payer: Three Rivers PPO |
$673.50
|
| Rate for Payer: TriWest Veterans Administration |
$206.43
|
| Rate for Payer: United Healthcare Commercial |
$853.10
|
| Rate for Payer: WINHealth Partners Commercial |
$763.30
|
|
|
CLOSED TX MONTEGGIA FX DISLOCATION ELBOW W/MANJ
|
Professional
|
Both
|
$2,445.00
|
|
|
Service Code
|
HCPCS 24620
|
| Min. Negotiated Rate |
$492.59 |
| Max. Negotiated Rate |
$2,445.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,396.10
|
| Rate for Payer: Aetna of WY Medicare |
$579.52
|
| Rate for Payer: Beech Street Commercial |
$2,322.75
|
| Rate for Payer: Cash Price |
$1,711.50
|
| Rate for Payer: Cash Price |
$1,711.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,371.65
|
| Rate for Payer: Cigna of WY Commercial |
$2,396.10
|
| Rate for Payer: First Choice Health Commercial |
$2,200.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,322.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$579.52
|
| Rate for Payer: HealthUtah PPO |
$2,445.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,371.65
|
| Rate for Payer: Multiplan Medicare/VA |
$492.59
|
| Rate for Payer: One Health Plan of WY PPO |
$2,396.10
|
| Rate for Payer: PacificSource Commercial |
$2,200.50
|
| Rate for Payer: PHCS PPO |
$2,322.75
|
| Rate for Payer: Three Rivers PPO |
$1,833.75
|
| Rate for Payer: TriWest Veterans Administration |
$579.52
|
| Rate for Payer: United Healthcare Commercial |
$2,322.75
|
| Rate for Payer: WINHealth Partners Commercial |
$2,078.25
|
|
|
CLOSED TX NASAL BONE FX W/MNPJ W/O STABILIZATION
|
Professional
|
Both
|
$660.00
|
|
|
Service Code
|
HCPCS 21315
|
| Min. Negotiated Rate |
$48.65 |
| Max. Negotiated Rate |
$660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$646.80
|
| Rate for Payer: Aetna of WY Medicare |
$57.24
|
| Rate for Payer: Beech Street Commercial |
$627.00
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$640.20
|
| Rate for Payer: Cigna of WY Commercial |
$646.80
|
| Rate for Payer: First Choice Health Commercial |
$594.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$627.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.24
|
| Rate for Payer: HealthUtah PPO |
$660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$640.20
|
| Rate for Payer: Multiplan Medicare/VA |
$48.65
|
| Rate for Payer: One Health Plan of WY PPO |
$646.80
|
| Rate for Payer: PacificSource Commercial |
$594.00
|
| Rate for Payer: PHCS PPO |
$627.00
|
| Rate for Payer: Three Rivers PPO |
$495.00
|
| Rate for Payer: TriWest Veterans Administration |
$57.24
|
| Rate for Payer: United Healthcare Commercial |
$627.00
|
| Rate for Payer: WINHealth Partners Commercial |
$561.00
|
|
|
CLOSED TX NASAL BONE FX W/MNPJ W/STABILIZATION
|
Professional
|
Both
|
$585.00
|
|
|
Service Code
|
HCPCS 21320
|
| Min. Negotiated Rate |
$77.58 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$573.30
|
| Rate for Payer: Aetna of WY Medicare |
$91.27
|
| Rate for Payer: Beech Street Commercial |
$555.75
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$567.45
|
| Rate for Payer: Cigna of WY Commercial |
$573.30
|
| Rate for Payer: First Choice Health Commercial |
$526.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$555.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$91.27
|
| Rate for Payer: HealthUtah PPO |
$585.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$567.45
|
| Rate for Payer: Multiplan Medicare/VA |
$77.58
|
| Rate for Payer: One Health Plan of WY PPO |
$573.30
|
| Rate for Payer: PacificSource Commercial |
$526.50
|
| Rate for Payer: PHCS PPO |
$555.75
|
| Rate for Payer: Three Rivers PPO |
$438.75
|
| Rate for Payer: TriWest Veterans Administration |
$91.27
|
| Rate for Payer: United Healthcare Commercial |
$555.75
|
| Rate for Payer: WINHealth Partners Commercial |
$497.25
|
|
|
CLOSED TX NASAL SEPTAL FRACT W/WO STABILIZATION
|
Professional
|
Both
|
$1,290.00
|
|
|
Service Code
|
HCPCS 21337
|
| Min. Negotiated Rate |
$250.61 |
| Max. Negotiated Rate |
$1,290.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,264.20
|
| Rate for Payer: Aetna of WY Medicare |
$294.84
|
| Rate for Payer: Beech Street Commercial |
$1,225.50
|
| Rate for Payer: Cash Price |
$903.00
|
| Rate for Payer: Cash Price |
$903.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,251.30
|
| Rate for Payer: Cigna of WY Commercial |
$1,264.20
|
| Rate for Payer: First Choice Health Commercial |
$1,161.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,225.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$294.84
|
| Rate for Payer: HealthUtah PPO |
$1,290.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,251.30
|
| Rate for Payer: Multiplan Medicare/VA |
$250.61
|
| Rate for Payer: One Health Plan of WY PPO |
$1,264.20
|
| Rate for Payer: PacificSource Commercial |
$1,161.00
|
| Rate for Payer: PHCS PPO |
$1,225.50
|
| Rate for Payer: Three Rivers PPO |
$967.50
|
| Rate for Payer: TriWest Veterans Administration |
$294.84
|
| Rate for Payer: United Healthcare Commercial |
$1,225.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,096.50
|
|
|
CLOSED TX PATELLAR DISLOCATION W/ANESTHESIA
|
Professional
|
Both
|
$2,144.00
|
|
|
Service Code
|
HCPCS 27562
|
| Min. Negotiated Rate |
$411.34 |
| Max. Negotiated Rate |
$2,144.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,101.12
|
| Rate for Payer: Aetna of WY Medicare |
$483.93
|
| Rate for Payer: Beech Street Commercial |
$2,036.80
|
| Rate for Payer: Cash Price |
$1,500.80
|
| Rate for Payer: Cash Price |
$1,500.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,079.68
|
| Rate for Payer: Cigna of WY Commercial |
$2,101.12
|
| Rate for Payer: First Choice Health Commercial |
$1,929.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,036.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$483.93
|
| Rate for Payer: HealthUtah PPO |
$2,144.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,079.68
|
| Rate for Payer: Multiplan Medicare/VA |
$411.34
|
| Rate for Payer: One Health Plan of WY PPO |
$2,101.12
|
| Rate for Payer: PacificSource Commercial |
$1,929.60
|
| Rate for Payer: PHCS PPO |
$2,036.80
|
| Rate for Payer: Three Rivers PPO |
$1,608.00
|
| Rate for Payer: TriWest Veterans Administration |
$483.93
|
| Rate for Payer: United Healthcare Commercial |
$2,036.80
|
| Rate for Payer: WINHealth Partners Commercial |
$1,822.40
|
|
|
CLOSED TX PATELLAR DISLOCATION W/O ANESTHESIA
|
Professional
|
Both
|
$1,513.00
|
|
|
Service Code
|
HCPCS 27560
|
| Min. Negotiated Rate |
$290.18 |
| Max. Negotiated Rate |
$1,513.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,482.74
|
| Rate for Payer: Aetna of WY Medicare |
$341.39
|
| Rate for Payer: Beech Street Commercial |
$1,437.35
|
| Rate for Payer: Cash Price |
$1,059.10
|
| Rate for Payer: Cash Price |
$1,059.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,467.61
|
| Rate for Payer: Cigna of WY Commercial |
$1,482.74
|
| Rate for Payer: First Choice Health Commercial |
$1,361.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,437.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$341.39
|
| Rate for Payer: HealthUtah PPO |
$1,513.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,467.61
|
| Rate for Payer: Multiplan Medicare/VA |
$290.18
|
| Rate for Payer: One Health Plan of WY PPO |
$1,482.74
|
| Rate for Payer: PacificSource Commercial |
$1,361.70
|
| Rate for Payer: PHCS PPO |
$1,437.35
|
| Rate for Payer: Three Rivers PPO |
$1,134.75
|
| Rate for Payer: TriWest Veterans Administration |
$341.39
|
| Rate for Payer: United Healthcare Commercial |
$1,437.35
|
| Rate for Payer: WINHealth Partners Commercial |
$1,286.05
|
|
|
CLOSED TX PATELLAR FRACTURE W/O MANIPULATION
|
Professional
|
Both
|
$1,310.00
|
|
|
Service Code
|
HCPCS 27520
|
| Min. Negotiated Rate |
$257.82 |
| Max. Negotiated Rate |
$1,310.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,283.80
|
| Rate for Payer: Aetna of WY Medicare |
$303.32
|
| Rate for Payer: Beech Street Commercial |
$1,244.50
|
| Rate for Payer: Cash Price |
$917.00
|
| Rate for Payer: Cash Price |
$917.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,270.70
|
| Rate for Payer: Cigna of WY Commercial |
$1,283.80
|
| Rate for Payer: First Choice Health Commercial |
$1,179.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,244.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$303.32
|
| Rate for Payer: HealthUtah PPO |
$1,310.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,270.70
|
| Rate for Payer: Multiplan Medicare/VA |
$257.82
|
| Rate for Payer: One Health Plan of WY PPO |
$1,283.80
|
| Rate for Payer: PacificSource Commercial |
$1,179.00
|
| Rate for Payer: PHCS PPO |
$1,244.50
|
| Rate for Payer: Three Rivers PPO |
$982.50
|
| Rate for Payer: TriWest Veterans Administration |
$303.32
|
| Rate for Payer: United Healthcare Commercial |
$1,244.50
|
| Rate for Payer: WINHealth Partners Commercial |
$1,113.50
|
|
|
CLOSED TX RADIAL HEAD/NECK FX W/MANIPULATION
|
Professional
|
Both
|
$1,757.00
|
|
|
Service Code
|
HCPCS 24655
|
| Min. Negotiated Rate |
$345.46 |
| Max. Negotiated Rate |
$1,757.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,721.86
|
| Rate for Payer: Aetna of WY Medicare |
$406.42
|
| Rate for Payer: Beech Street Commercial |
$1,669.15
|
| Rate for Payer: Cash Price |
$1,229.90
|
| Rate for Payer: Cash Price |
$1,229.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,704.29
|
| Rate for Payer: Cigna of WY Commercial |
$1,721.86
|
| Rate for Payer: First Choice Health Commercial |
$1,581.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,669.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$406.42
|
| Rate for Payer: HealthUtah PPO |
$1,757.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,704.29
|
| Rate for Payer: Multiplan Medicare/VA |
$345.46
|
| Rate for Payer: One Health Plan of WY PPO |
$1,721.86
|
| Rate for Payer: PacificSource Commercial |
$1,581.30
|
| Rate for Payer: PHCS PPO |
$1,669.15
|
| Rate for Payer: Three Rivers PPO |
$1,317.75
|
| Rate for Payer: TriWest Veterans Administration |
$406.42
|
| Rate for Payer: United Healthcare Commercial |
$1,669.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1,493.45
|
|
