|
DBM 5CC PUTTY STRYKER
|
Facility
|
OP
|
$2,590.00
|
|
| Hospital Charge Code |
3350074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,402.48 |
| Max. Negotiated Rate |
$2,590.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,538.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,709.40
|
| Rate for Payer: Altius Commercial |
$2,486.40
|
| Rate for Payer: Beech Street Commercial |
$2,538.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,512.30
|
| Rate for Payer: Cash Price |
$1,813.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,512.30
|
| Rate for Payer: Cigna of WY Commercial |
$2,538.20
|
| Rate for Payer: Entrust Commercial |
$2,460.50
|
| Rate for Payer: First Choice Health Commercial |
$2,460.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,460.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,476.30
|
| Rate for Payer: HealthUtah PPO |
$2,590.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,512.30
|
| Rate for Payer: Multiplan Medicare/VA |
$1,402.48
|
| Rate for Payer: One Health Plan of WY PPO |
$2,538.20
|
| Rate for Payer: PacificSource Commercial |
$2,331.00
|
| Rate for Payer: PHCS PPO |
$2,538.20
|
| Rate for Payer: Three Rivers PPO |
$1,942.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,476.30
|
| Rate for Payer: United Healthcare Commercial |
$2,473.45
|
| Rate for Payer: United Healthcare Medicare |
$1,476.30
|
| Rate for Payer: WINHealth Partners Commercial |
$2,538.20
|
| Rate for Payer: Wise Provider Network Commercial |
$2,460.50
|
|
|
DBM 5CC PUTTY STRYKER
|
Facility
|
IP
|
$2,590.00
|
|
| Hospital Charge Code |
3350074
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,500.90 |
| Max. Negotiated Rate |
$2,590.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,538.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,657.60
|
| Rate for Payer: Altius Commercial |
$2,486.40
|
| Rate for Payer: Beech Street Commercial |
$2,538.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,512.30
|
| Rate for Payer: Cash Price |
$1,813.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,512.30
|
| Rate for Payer: Cigna of WY Commercial |
$2,538.20
|
| Rate for Payer: Entrust Commercial |
$2,460.50
|
| Rate for Payer: First Choice Health Commercial |
$2,460.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,460.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,579.90
|
| Rate for Payer: HealthUtah PPO |
$2,590.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,512.30
|
| Rate for Payer: Multiplan Medicare/VA |
$1,500.90
|
| Rate for Payer: One Health Plan of WY PPO |
$2,538.20
|
| Rate for Payer: PacificSource Commercial |
$2,331.00
|
| Rate for Payer: PHCS PPO |
$2,538.20
|
| Rate for Payer: Three Rivers PPO |
$1,942.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,579.90
|
| Rate for Payer: United Healthcare Commercial |
$2,473.45
|
| Rate for Payer: United Healthcare Medicare |
$1,579.90
|
| Rate for Payer: WINHealth Partners Commercial |
$2,460.50
|
| Rate for Payer: Wise Provider Network Commercial |
$2,460.50
|
|
|
DBM GEL ALLOSYNC 1CC
|
Facility
|
OP
|
$817.60
|
|
| Hospital Charge Code |
3004298
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$442.73 |
| Max. Negotiated Rate |
$817.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$801.25
|
| Rate for Payer: Aetna of WY Medicare |
$539.62
|
| Rate for Payer: Altius Commercial |
$784.90
|
| Rate for Payer: Beech Street Commercial |
$801.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$793.07
|
| Rate for Payer: Cash Price |
$572.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$793.07
|
| Rate for Payer: Cigna of WY Commercial |
$801.25
|
| Rate for Payer: Entrust Commercial |
$776.72
|
| Rate for Payer: First Choice Health Commercial |
$776.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$776.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$466.03
|
| Rate for Payer: HealthUtah PPO |
$817.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$793.07
|
| Rate for Payer: Multiplan Medicare/VA |
$442.73
|
| Rate for Payer: One Health Plan of WY PPO |
$801.25
|
| Rate for Payer: PacificSource Commercial |
$735.84
|
| Rate for Payer: PHCS PPO |
$801.25
|
| Rate for Payer: Three Rivers PPO |
$613.20
|
| Rate for Payer: TriWest Veterans Administration |
$466.03
|
| Rate for Payer: United Healthcare Commercial |
$780.81
|
| Rate for Payer: United Healthcare Medicare |
$466.03
|
| Rate for Payer: WINHealth Partners Commercial |
$801.25
|
| Rate for Payer: Wise Provider Network Commercial |
$776.72
|
|
|
DBM GEL ALLOSYNC 1CC
|
Facility
|
IP
|
$817.60
|
|
| Hospital Charge Code |
3004298
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$473.80 |
| Max. Negotiated Rate |
$817.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$801.25
|
| Rate for Payer: Aetna of WY Medicare |
$523.26
|
| Rate for Payer: Altius Commercial |
$784.90
|
| Rate for Payer: Beech Street Commercial |
$801.25
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$793.07
|
| Rate for Payer: Cash Price |
$572.32
|
| Rate for Payer: ChoiceCare Network Commercial |
$793.07
|
| Rate for Payer: Cigna of WY Commercial |
$801.25
|
| Rate for Payer: Entrust Commercial |
$776.72
|
| Rate for Payer: First Choice Health Commercial |
$776.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$776.72
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$498.74
|
| Rate for Payer: HealthUtah PPO |
$817.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$793.07
|
| Rate for Payer: Multiplan Medicare/VA |
$473.80
|
| Rate for Payer: One Health Plan of WY PPO |
$801.25
|
| Rate for Payer: PacificSource Commercial |
$735.84
|
| Rate for Payer: PHCS PPO |
$801.25
|
| Rate for Payer: Three Rivers PPO |
$613.20
|
| Rate for Payer: TriWest Veterans Administration |
$498.74
|
| Rate for Payer: United Healthcare Commercial |
$780.81
|
| Rate for Payer: United Healthcare Medicare |
$498.74
|
| Rate for Payer: WINHealth Partners Commercial |
$776.72
|
| Rate for Payer: Wise Provider Network Commercial |
$776.72
|
|
|
DBM H-GENIN PUTTY 10CC
|
Facility
|
IP
|
$5,215.00
|
|
| Hospital Charge Code |
2800209
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,022.09 |
| Max. Negotiated Rate |
$5,215.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,110.70
|
| Rate for Payer: Aetna of WY Medicare |
$3,337.60
|
| Rate for Payer: Altius Commercial |
$5,006.40
|
| Rate for Payer: Beech Street Commercial |
$5,110.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,058.55
|
| Rate for Payer: Cash Price |
$3,650.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,058.55
|
| Rate for Payer: Cigna of WY Commercial |
$5,110.70
|
| Rate for Payer: Entrust Commercial |
$4,954.25
|
| Rate for Payer: First Choice Health Commercial |
$4,954.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,954.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,181.15
|
| Rate for Payer: HealthUtah PPO |
$5,215.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,058.55
|
| Rate for Payer: Multiplan Medicare/VA |
$3,022.09
|
| Rate for Payer: One Health Plan of WY PPO |
$5,110.70
|
| Rate for Payer: PacificSource Commercial |
$4,693.50
|
| Rate for Payer: PHCS PPO |
$5,110.70
|
| Rate for Payer: Three Rivers PPO |
$3,911.25
|
| Rate for Payer: TriWest Veterans Administration |
$3,181.15
|
| Rate for Payer: United Healthcare Commercial |
$4,980.32
|
| Rate for Payer: United Healthcare Medicare |
$3,181.15
|
| Rate for Payer: WINHealth Partners Commercial |
$4,954.25
|
| Rate for Payer: Wise Provider Network Commercial |
$4,954.25
|
|
|
DBM H-GENIN PUTTY 10CC
|
Facility
|
OP
|
$5,215.00
|
|
| Hospital Charge Code |
2800209
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,823.92 |
| Max. Negotiated Rate |
$5,215.00 |
| Rate for Payer: United Healthcare Commercial |
$4,980.32
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,110.70
|
| Rate for Payer: Aetna of WY Medicare |
$3,441.90
|
| Rate for Payer: Altius Commercial |
$5,006.40
|
| Rate for Payer: Beech Street Commercial |
$5,110.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,058.55
|
| Rate for Payer: Cash Price |
$3,650.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,058.55
|
| Rate for Payer: Cigna of WY Commercial |
$5,110.70
|
| Rate for Payer: Entrust Commercial |
$4,954.25
|
| Rate for Payer: First Choice Health Commercial |
$4,954.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,954.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,972.55
|
| Rate for Payer: HealthUtah PPO |
$5,215.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,058.55
|
| Rate for Payer: Multiplan Medicare/VA |
$2,823.92
|
| Rate for Payer: One Health Plan of WY PPO |
$5,110.70
|
| Rate for Payer: PacificSource Commercial |
$4,693.50
|
| Rate for Payer: PHCS PPO |
$5,110.70
|
| Rate for Payer: Three Rivers PPO |
$3,911.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,972.55
|
| Rate for Payer: United Healthcare Medicare |
$2,972.55
|
| Rate for Payer: WINHealth Partners Commercial |
$5,110.70
|
| Rate for Payer: Wise Provider Network Commercial |
$4,954.25
|
|
|
DBRDMT EXTENSV ECZMT/INFCT SKIN UP 10% BDY SURF
|
Professional
|
Both
|
$248.00
|
|
|
Service Code
|
HCPCS 11000 80
|
| Min. Negotiated Rate |
$186.00 |
| Max. Negotiated Rate |
$248.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$243.04
|
| Rate for Payer: Beech Street Commercial |
$235.60
|
| Rate for Payer: Cash Price |
$173.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$240.56
|
| Rate for Payer: Cigna of WY Commercial |
$243.04
|
| Rate for Payer: First Choice Health Commercial |
$223.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$235.60
|
| Rate for Payer: HealthUtah PPO |
$248.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$240.56
|
| Rate for Payer: One Health Plan of WY PPO |
$243.04
|
| Rate for Payer: PacificSource Commercial |
$223.20
|
| Rate for Payer: PHCS PPO |
$235.60
|
| Rate for Payer: Three Rivers PPO |
$186.00
|
| Rate for Payer: United Healthcare Commercial |
$235.60
|
| Rate for Payer: WINHealth Partners Commercial |
$210.80
|
|
|
DBRDMT EXTENSV ECZMT/INFCT SKIN UP 10% BDY SURF
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
HCPCS 11000
|
| Min. Negotiated Rate |
$22.46 |
| Max. Negotiated Rate |
$123.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$120.54
|
| Rate for Payer: Aetna of WY Medicare |
$26.42
|
| Rate for Payer: Beech Street Commercial |
$116.85
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: Cash Price |
$86.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$119.31
|
| Rate for Payer: Cigna of WY Commercial |
$120.54
|
| Rate for Payer: First Choice Health Commercial |
$110.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$116.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.42
|
| Rate for Payer: HealthUtah PPO |
$123.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$119.31
|
| Rate for Payer: Multiplan Medicare/VA |
$22.46
|
| Rate for Payer: One Health Plan of WY PPO |
$120.54
|
| Rate for Payer: PacificSource Commercial |
$110.70
|
| Rate for Payer: PHCS PPO |
$116.85
|
| Rate for Payer: Three Rivers PPO |
$92.25
|
| Rate for Payer: TriWest Veterans Administration |
$26.42
|
| Rate for Payer: United Healthcare Commercial |
$116.85
|
| Rate for Payer: WINHealth Partners Commercial |
$104.55
|
|
|
DBRDMT FX&/DISLC SUBQ T/M/F BONE
|
Professional
|
Both
|
$1,441.00
|
|
|
Service Code
|
HCPCS 11012 AS
|
| Min. Negotiated Rate |
$1,080.75 |
| Max. Negotiated Rate |
$1,441.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,412.18
|
| Rate for Payer: Beech Street Commercial |
$1,368.95
|
| Rate for Payer: Cash Price |
$1,008.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,397.77
|
| Rate for Payer: Cigna of WY Commercial |
$1,412.18
|
| Rate for Payer: First Choice Health Commercial |
$1,296.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,368.95
|
| Rate for Payer: HealthUtah PPO |
$1,441.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,397.77
|
| Rate for Payer: One Health Plan of WY PPO |
$1,412.18
|
| Rate for Payer: PacificSource Commercial |
$1,296.90
|
| Rate for Payer: PHCS PPO |
$1,368.95
|
| Rate for Payer: Three Rivers PPO |
$1,080.75
|
| Rate for Payer: United Healthcare Commercial |
$1,368.95
|
| Rate for Payer: WINHealth Partners Commercial |
$1,224.85
|
|
|
DBRDMT FX&/DISLC SUBQ T/M/F BONE
|
Professional
|
Both
|
$352.00
|
|
|
Service Code
|
HCPCS 11012 80
|
| Min. Negotiated Rate |
$264.00 |
| Max. Negotiated Rate |
$352.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$344.96
|
| Rate for Payer: Beech Street Commercial |
$334.40
|
| Rate for Payer: Cash Price |
$246.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$341.44
|
| Rate for Payer: Cigna of WY Commercial |
$344.96
|
| Rate for Payer: First Choice Health Commercial |
$316.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$334.40
|
| Rate for Payer: HealthUtah PPO |
$352.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$341.44
|
| Rate for Payer: One Health Plan of WY PPO |
$344.96
|
| Rate for Payer: PacificSource Commercial |
$316.80
|
| Rate for Payer: PHCS PPO |
$334.40
|
| Rate for Payer: Three Rivers PPO |
$264.00
|
| Rate for Payer: United Healthcare Commercial |
$334.40
|
| Rate for Payer: WINHealth Partners Commercial |
$299.20
|
|
|
DBRDMT FX&/DISLC SUBQ T/M/F BONE
|
Professional
|
Both
|
$1,792.00
|
|
|
Service Code
|
HCPCS 11012
|
| Min. Negotiated Rate |
$335.39 |
| Max. Negotiated Rate |
$1,792.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,756.16
|
| Rate for Payer: Aetna of WY Medicare |
$394.58
|
| Rate for Payer: Beech Street Commercial |
$1,702.40
|
| Rate for Payer: Cash Price |
$1,254.40
|
| Rate for Payer: Cash Price |
$1,254.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,738.24
|
| Rate for Payer: Cigna of WY Commercial |
$1,756.16
|
| Rate for Payer: First Choice Health Commercial |
$1,612.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,702.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$394.58
|
| Rate for Payer: HealthUtah PPO |
$1,792.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,738.24
|
| Rate for Payer: Multiplan Medicare/VA |
$335.39
|
| Rate for Payer: One Health Plan of WY PPO |
$1,756.16
|
| Rate for Payer: PacificSource Commercial |
$1,612.80
|
| Rate for Payer: PHCS PPO |
$1,702.40
|
| Rate for Payer: Three Rivers PPO |
$1,344.00
|
| Rate for Payer: TriWest Veterans Administration |
$394.58
|
| Rate for Payer: United Healthcare Commercial |
$1,702.40
|
| Rate for Payer: WINHealth Partners Commercial |
$1,523.20
|
|
|
DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS
|
Professional
|
Both
|
$260.00
|
|
|
Service Code
|
HCPCS 11010 80
|
| Min. Negotiated Rate |
$195.00 |
| Max. Negotiated Rate |
$260.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$254.80
|
| Rate for Payer: Beech Street Commercial |
$247.00
|
| Rate for Payer: Cash Price |
$182.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$252.20
|
| Rate for Payer: Cigna of WY Commercial |
$254.80
|
| Rate for Payer: First Choice Health Commercial |
$234.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$247.00
|
| Rate for Payer: HealthUtah PPO |
$260.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$252.20
|
| Rate for Payer: One Health Plan of WY PPO |
$254.80
|
| Rate for Payer: PacificSource Commercial |
$234.00
|
| Rate for Payer: PHCS PPO |
$247.00
|
| Rate for Payer: Three Rivers PPO |
$195.00
|
| Rate for Payer: United Healthcare Commercial |
$247.00
|
| Rate for Payer: WINHealth Partners Commercial |
$221.00
|
|
|
DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS
|
Professional
|
Both
|
$1,182.00
|
|
|
Service Code
|
HCPCS 11010
|
| Min. Negotiated Rate |
$224.52 |
| Max. Negotiated Rate |
$1,182.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,158.36
|
| Rate for Payer: Aetna of WY Medicare |
$264.14
|
| Rate for Payer: Beech Street Commercial |
$1,122.90
|
| Rate for Payer: Cash Price |
$827.40
|
| Rate for Payer: Cash Price |
$827.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,146.54
|
| Rate for Payer: Cigna of WY Commercial |
$1,158.36
|
| Rate for Payer: First Choice Health Commercial |
$1,063.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,122.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$264.14
|
| Rate for Payer: HealthUtah PPO |
$1,182.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,146.54
|
| Rate for Payer: Multiplan Medicare/VA |
$224.52
|
| Rate for Payer: One Health Plan of WY PPO |
$1,158.36
|
| Rate for Payer: PacificSource Commercial |
$1,063.80
|
| Rate for Payer: PHCS PPO |
$1,122.90
|
| Rate for Payer: Three Rivers PPO |
$886.50
|
| Rate for Payer: TriWest Veterans Administration |
$264.14
|
| Rate for Payer: United Healthcare Commercial |
$1,122.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,004.70
|
|
|
DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC
|
Professional
|
Both
|
$1,287.00
|
|
|
Service Code
|
HCPCS 11011
|
| Min. Negotiated Rate |
$240.11 |
| Max. Negotiated Rate |
$1,287.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,261.26
|
| Rate for Payer: Aetna of WY Medicare |
$282.48
|
| Rate for Payer: Beech Street Commercial |
$1,222.65
|
| Rate for Payer: Cash Price |
$900.90
|
| Rate for Payer: Cash Price |
$900.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,248.39
|
| Rate for Payer: Cigna of WY Commercial |
$1,261.26
|
| Rate for Payer: First Choice Health Commercial |
$1,158.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,222.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$282.48
|
| Rate for Payer: HealthUtah PPO |
$1,287.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,248.39
|
| Rate for Payer: Multiplan Medicare/VA |
$240.11
|
| Rate for Payer: One Health Plan of WY PPO |
$1,261.26
|
| Rate for Payer: PacificSource Commercial |
$1,158.30
|
| Rate for Payer: PHCS PPO |
$1,222.65
|
| Rate for Payer: Three Rivers PPO |
$965.25
|
| Rate for Payer: TriWest Veterans Administration |
$282.48
|
| Rate for Payer: United Healthcare Commercial |
$1,222.65
|
| Rate for Payer: WINHealth Partners Commercial |
$1,093.95
|
|
|
DCMPRN FASCIOTOMY THIGH&/KNEE MLT COMPARTMENTS
|
Professional
|
Both
|
$2,887.00
|
|
|
Service Code
|
HCPCS 27498 AS
|
| Min. Negotiated Rate |
$545.11 |
| Max. Negotiated Rate |
$2,887.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,829.26
|
| Rate for Payer: Beech Street Commercial |
$2,742.65
|
| Rate for Payer: Cash Price |
$2,020.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,800.39
|
| Rate for Payer: Cigna of WY Commercial |
$2,829.26
|
| Rate for Payer: First Choice Health Commercial |
$2,598.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,742.65
|
| Rate for Payer: HealthUtah PPO |
$2,887.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,800.39
|
| Rate for Payer: One Health Plan of WY PPO |
$2,829.26
|
| Rate for Payer: PacificSource Commercial |
$2,598.30
|
| Rate for Payer: PHCS PPO |
$2,742.65
|
| Rate for Payer: Three Rivers PPO |
$2,165.25
|
| Rate for Payer: United Healthcare Commercial |
$2,742.65
|
| Rate for Payer: WINHealth Partners Commercial |
$2,453.95
|
|
|
DCMPRN FASCIOTOMY THIGH&/KNEE MLT COMPARTMENTS
|
Professional
|
Both
|
$2,887.00
|
|
|
Service Code
|
HCPCS 27498
|
| Min. Negotiated Rate |
$545.11 |
| Max. Negotiated Rate |
$2,887.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,829.26
|
| Rate for Payer: Aetna of WY Medicare |
$641.31
|
| Rate for Payer: Beech Street Commercial |
$2,742.65
|
| Rate for Payer: Cash Price |
$2,020.90
|
| Rate for Payer: Cash Price |
$2,020.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,800.39
|
| Rate for Payer: Cigna of WY Commercial |
$2,829.26
|
| Rate for Payer: First Choice Health Commercial |
$2,598.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,742.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$641.31
|
| Rate for Payer: HealthUtah PPO |
$2,887.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,800.39
|
| Rate for Payer: Multiplan Medicare/VA |
$545.11
|
| Rate for Payer: One Health Plan of WY PPO |
$2,829.26
|
| Rate for Payer: PacificSource Commercial |
$2,598.30
|
| Rate for Payer: PHCS PPO |
$2,742.65
|
| Rate for Payer: Three Rivers PPO |
$2,165.25
|
| Rate for Payer: TriWest Veterans Administration |
$641.31
|
| Rate for Payer: United Healthcare Commercial |
$2,742.65
|
| Rate for Payer: WINHealth Partners Commercial |
$2,453.95
|
|
|
DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR DBRDMT
|
Professional
|
Both
|
$5,205.00
|
|
|
Service Code
|
HCPCS 25025 80
|
| Min. Negotiated Rate |
$1,004.04 |
| Max. Negotiated Rate |
$5,205.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,100.90
|
| Rate for Payer: Beech Street Commercial |
$4,944.75
|
| Rate for Payer: Cash Price |
$3,643.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,048.85
|
| Rate for Payer: Cigna of WY Commercial |
$5,100.90
|
| Rate for Payer: First Choice Health Commercial |
$4,684.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,944.75
|
| Rate for Payer: HealthUtah PPO |
$5,205.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,048.85
|
| Rate for Payer: One Health Plan of WY PPO |
$5,100.90
|
| Rate for Payer: PacificSource Commercial |
$4,684.50
|
| Rate for Payer: PHCS PPO |
$4,944.75
|
| Rate for Payer: Three Rivers PPO |
$3,903.75
|
| Rate for Payer: United Healthcare Commercial |
$4,944.75
|
| Rate for Payer: WINHealth Partners Commercial |
$4,424.25
|
|
|
DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR DBRDMT
|
Professional
|
Both
|
$5,205.00
|
|
|
Service Code
|
HCPCS 25025
|
| Min. Negotiated Rate |
$1,004.04 |
| Max. Negotiated Rate |
$5,205.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,100.90
|
| Rate for Payer: Aetna of WY Medicare |
$1,181.22
|
| Rate for Payer: Beech Street Commercial |
$4,944.75
|
| Rate for Payer: Cash Price |
$3,643.50
|
| Rate for Payer: Cash Price |
$3,643.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,048.85
|
| Rate for Payer: Cigna of WY Commercial |
$5,100.90
|
| Rate for Payer: First Choice Health Commercial |
$4,684.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,944.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,181.22
|
| Rate for Payer: HealthUtah PPO |
$5,205.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,048.85
|
| Rate for Payer: Multiplan Medicare/VA |
$1,004.04
|
| Rate for Payer: One Health Plan of WY PPO |
$5,100.90
|
| Rate for Payer: PacificSource Commercial |
$4,684.50
|
| Rate for Payer: PHCS PPO |
$4,944.75
|
| Rate for Payer: Three Rivers PPO |
$3,903.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,181.22
|
| Rate for Payer: United Healthcare Commercial |
$4,944.75
|
| Rate for Payer: WINHealth Partners Commercial |
$4,424.25
|
|
|
DCMPRN FASCT F/ARM&/WRST FLXR/XTNSR W/DBRDMT
|
Professional
|
Both
|
$4,410.00
|
|
|
Service Code
|
HCPCS 25023 AS
|
| Min. Negotiated Rate |
$1,080.65 |
| Max. Negotiated Rate |
$4,410.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,321.80
|
| Rate for Payer: Beech Street Commercial |
$4,189.50
|
| Rate for Payer: Cash Price |
$3,087.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,277.70
|
| Rate for Payer: Cigna of WY Commercial |
$4,321.80
|
| Rate for Payer: First Choice Health Commercial |
$3,969.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,189.50
|
| Rate for Payer: HealthUtah PPO |
$4,410.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,277.70
|
| Rate for Payer: One Health Plan of WY PPO |
$4,321.80
|
| Rate for Payer: PacificSource Commercial |
$3,969.00
|
| Rate for Payer: PHCS PPO |
$4,189.50
|
| Rate for Payer: Three Rivers PPO |
$3,307.50
|
| Rate for Payer: United Healthcare Commercial |
$4,189.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,748.50
|
|
|
DCMPRN FASCT F/ARM&/WRST FLXR/XTNSR W/DBRDMT
|
Professional
|
Both
|
$4,410.00
|
|
|
Service Code
|
HCPCS 25023
|
| Min. Negotiated Rate |
$1,080.65 |
| Max. Negotiated Rate |
$4,410.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,321.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,271.35
|
| Rate for Payer: Beech Street Commercial |
$4,189.50
|
| Rate for Payer: Cash Price |
$3,087.00
|
| Rate for Payer: Cash Price |
$3,087.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,277.70
|
| Rate for Payer: Cigna of WY Commercial |
$4,321.80
|
| Rate for Payer: First Choice Health Commercial |
$3,969.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,189.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,271.35
|
| Rate for Payer: HealthUtah PPO |
$4,410.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,277.70
|
| Rate for Payer: Multiplan Medicare/VA |
$1,080.65
|
| Rate for Payer: One Health Plan of WY PPO |
$4,321.80
|
| Rate for Payer: PacificSource Commercial |
$3,969.00
|
| Rate for Payer: PHCS PPO |
$4,189.50
|
| Rate for Payer: Three Rivers PPO |
$3,307.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,271.35
|
| Rate for Payer: United Healthcare Commercial |
$4,189.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,748.50
|
|
|
DCMPRN FASCT F/ARM&WRST FLXR/XTNSR W/O DBRDMT
|
Professional
|
Both
|
$4,455.00
|
|
|
Service Code
|
HCPCS 25020
|
| Min. Negotiated Rate |
$615.15 |
| Max. Negotiated Rate |
$4,455.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,365.90
|
| Rate for Payer: Aetna of WY Medicare |
$723.71
|
| Rate for Payer: Beech Street Commercial |
$4,232.25
|
| Rate for Payer: Cash Price |
$3,118.50
|
| Rate for Payer: Cash Price |
$3,118.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,321.35
|
| Rate for Payer: Cigna of WY Commercial |
$4,365.90
|
| Rate for Payer: First Choice Health Commercial |
$4,009.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,232.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$723.71
|
| Rate for Payer: HealthUtah PPO |
$4,455.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,321.35
|
| Rate for Payer: Multiplan Medicare/VA |
$615.15
|
| Rate for Payer: One Health Plan of WY PPO |
$4,365.90
|
| Rate for Payer: PacificSource Commercial |
$4,009.50
|
| Rate for Payer: PHCS PPO |
$4,232.25
|
| Rate for Payer: Three Rivers PPO |
$3,341.25
|
| Rate for Payer: TriWest Veterans Administration |
$723.71
|
| Rate for Payer: United Healthcare Commercial |
$4,232.25
|
| Rate for Payer: WINHealth Partners Commercial |
$3,786.75
|
|
|
DCMPRN FASCT F/ARM&WRST FLXR/XTNSR W/O DBRDMT
|
Professional
|
Both
|
$8,911.00
|
|
|
Service Code
|
HCPCS 25020 50
|
| Min. Negotiated Rate |
$6,683.25 |
| Max. Negotiated Rate |
$8,911.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$8,732.78
|
| Rate for Payer: Beech Street Commercial |
$8,465.45
|
| Rate for Payer: Cash Price |
$6,237.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$8,643.67
|
| Rate for Payer: Cigna of WY Commercial |
$8,732.78
|
| Rate for Payer: First Choice Health Commercial |
$8,019.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$8,465.45
|
| Rate for Payer: HealthUtah PPO |
$8,911.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$8,643.67
|
| Rate for Payer: One Health Plan of WY PPO |
$8,732.78
|
| Rate for Payer: PacificSource Commercial |
$8,019.90
|
| Rate for Payer: PHCS PPO |
$8,465.45
|
| Rate for Payer: Three Rivers PPO |
$6,683.25
|
| Rate for Payer: United Healthcare Commercial |
$8,465.45
|
| Rate for Payer: WINHealth Partners Commercial |
$7,574.35
|
|
|
DCMPRN FASCT LEG ANT&/LAT COMPARTMENTS ONLY
|
Professional
|
Both
|
$399.00
|
|
|
Service Code
|
HCPCS 27600 80
|
| Min. Negotiated Rate |
$299.25 |
| Max. Negotiated Rate |
$399.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$391.02
|
| Rate for Payer: Beech Street Commercial |
$379.05
|
| Rate for Payer: Cash Price |
$279.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$387.03
|
| Rate for Payer: Cigna of WY Commercial |
$391.02
|
| Rate for Payer: First Choice Health Commercial |
$359.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$379.05
|
| Rate for Payer: HealthUtah PPO |
$399.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$387.03
|
| Rate for Payer: One Health Plan of WY PPO |
$391.02
|
| Rate for Payer: PacificSource Commercial |
$359.10
|
| Rate for Payer: PHCS PPO |
$379.05
|
| Rate for Payer: Three Rivers PPO |
$299.25
|
| Rate for Payer: United Healthcare Commercial |
$379.05
|
| Rate for Payer: WINHealth Partners Commercial |
$339.15
|
|
|
DCMPRN FASCT LEG ANT&/LAT COMPARTMENTS ONLY
|
Professional
|
Both
|
$1,786.00
|
|
|
Service Code
|
HCPCS 27600
|
| Min. Negotiated Rate |
$326.66 |
| Max. Negotiated Rate |
$1,786.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,750.28
|
| Rate for Payer: Aetna of WY Medicare |
$384.30
|
| Rate for Payer: Beech Street Commercial |
$1,696.70
|
| Rate for Payer: Cash Price |
$1,250.20
|
| Rate for Payer: Cash Price |
$1,250.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,732.42
|
| Rate for Payer: Cigna of WY Commercial |
$1,750.28
|
| Rate for Payer: First Choice Health Commercial |
$1,607.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,696.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$384.30
|
| Rate for Payer: HealthUtah PPO |
$1,786.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,732.42
|
| Rate for Payer: Multiplan Medicare/VA |
$326.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1,750.28
|
| Rate for Payer: PacificSource Commercial |
$1,607.40
|
| Rate for Payer: PHCS PPO |
$1,696.70
|
| Rate for Payer: Three Rivers PPO |
$1,339.50
|
| Rate for Payer: TriWest Veterans Administration |
$384.30
|
| Rate for Payer: United Healthcare Commercial |
$1,696.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,518.10
|
|
|
DCMPRN FASCT LEG ANT&/LAT&PST CMPRT
|
Professional
|
Both
|
$5,589.00
|
|
|
Service Code
|
HCPCS 27602
|
| Min. Negotiated Rate |
$383.94 |
| Max. Negotiated Rate |
$5,589.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,477.22
|
| Rate for Payer: Aetna of WY Medicare |
$451.69
|
| Rate for Payer: Beech Street Commercial |
$5,309.55
|
| Rate for Payer: Cash Price |
$3,912.30
|
| Rate for Payer: Cash Price |
$3,912.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,421.33
|
| Rate for Payer: Cigna of WY Commercial |
$5,477.22
|
| Rate for Payer: First Choice Health Commercial |
$5,030.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,309.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$451.69
|
| Rate for Payer: HealthUtah PPO |
$5,589.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,421.33
|
| Rate for Payer: Multiplan Medicare/VA |
$383.94
|
| Rate for Payer: One Health Plan of WY PPO |
$5,477.22
|
| Rate for Payer: PacificSource Commercial |
$5,030.10
|
| Rate for Payer: PHCS PPO |
$5,309.55
|
| Rate for Payer: Three Rivers PPO |
$4,191.75
|
| Rate for Payer: TriWest Veterans Administration |
$451.69
|
| Rate for Payer: United Healthcare Commercial |
$5,309.55
|
| Rate for Payer: WINHealth Partners Commercial |
$4,750.65
|
|
