|
APPLICATION CAST SHOULDER HAND LONG ARM
|
Professional
|
Both
|
$344.00
|
|
|
Service Code
|
HCPCS 29065
|
| Hospital Charge Code |
29065
|
| Min. Negotiated Rate |
$56.10 |
| Max. Negotiated Rate |
$344.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$337.12
|
| Rate for Payer: Aetna of WY Medicare |
$66.00
|
| Rate for Payer: Beech Street Commercial |
$326.80
|
| Rate for Payer: Cash Price |
$240.80
|
| Rate for Payer: Cash Price |
$240.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$333.68
|
| Rate for Payer: Cigna of WY Commercial |
$337.12
|
| Rate for Payer: First Choice Health Commercial |
$309.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$326.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$66.00
|
| Rate for Payer: HealthUtah PPO |
$344.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$333.68
|
| Rate for Payer: Multiplan Medicare/VA |
$56.10
|
| Rate for Payer: One Health Plan of WY PPO |
$337.12
|
| Rate for Payer: PacificSource Commercial |
$309.60
|
| Rate for Payer: PHCS PPO |
$326.80
|
| Rate for Payer: Three Rivers PPO |
$258.00
|
| Rate for Payer: TriWest Veterans Administration |
$66.00
|
| Rate for Payer: United Healthcare Commercial |
$299.28
|
| Rate for Payer: United Healthcare Medicare |
$66.00
|
| Rate for Payer: WINHealth Partners Commercial |
$292.40
|
|
|
APPLICATION FINGER SPLINT STATIC
|
Professional
|
Both
|
$146.00
|
|
|
Service Code
|
HCPCS 29130
|
| Hospital Charge Code |
29130
|
| Min. Negotiated Rate |
$23.56 |
| Max. Negotiated Rate |
$146.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$143.08
|
| Rate for Payer: Aetna of WY Medicare |
$27.72
|
| Rate for Payer: Beech Street Commercial |
$138.70
|
| Rate for Payer: Cash Price |
$102.20
|
| Rate for Payer: Cash Price |
$102.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$141.62
|
| Rate for Payer: Cigna of WY Commercial |
$143.08
|
| Rate for Payer: First Choice Health Commercial |
$131.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$138.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.72
|
| Rate for Payer: HealthUtah PPO |
$146.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$141.62
|
| Rate for Payer: Multiplan Medicare/VA |
$23.56
|
| Rate for Payer: One Health Plan of WY PPO |
$143.08
|
| Rate for Payer: PacificSource Commercial |
$131.40
|
| Rate for Payer: PHCS PPO |
$138.70
|
| Rate for Payer: Three Rivers PPO |
$109.50
|
| Rate for Payer: TriWest Veterans Administration |
$27.72
|
| Rate for Payer: United Healthcare Commercial |
$127.02
|
| Rate for Payer: United Healthcare Medicare |
$27.72
|
| Rate for Payer: WINHealth Partners Commercial |
$124.10
|
|
|
APPLICATION INTERVERTEBRAL BIOMECHANICAL DEVICE
|
Professional
|
Both
|
$873.00
|
|
|
Service Code
|
HCPCS 22851 80
|
| Hospital Charge Code |
22851
|
| Min. Negotiated Rate |
$654.75 |
| Max. Negotiated Rate |
$873.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$855.54
|
| Rate for Payer: Beech Street Commercial |
$829.35
|
| Rate for Payer: Cash Price |
$611.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$846.81
|
| Rate for Payer: Cigna of WY Commercial |
$855.54
|
| Rate for Payer: First Choice Health Commercial |
$785.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$829.35
|
| Rate for Payer: HealthUtah PPO |
$873.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$846.81
|
| Rate for Payer: One Health Plan of WY PPO |
$855.54
|
| Rate for Payer: PacificSource Commercial |
$785.70
|
| Rate for Payer: PHCS PPO |
$829.35
|
| Rate for Payer: Three Rivers PPO |
$654.75
|
| Rate for Payer: United Healthcare Commercial |
$759.51
|
| Rate for Payer: WINHealth Partners Commercial |
$742.05
|
|
|
APPLICATION INTERVERTEBRAL BIOMECHANICAL DEVICE
|
Professional
|
Both
|
$873.00
|
|
|
Service Code
|
HCPCS 22851 AS
|
| Hospital Charge Code |
22851
|
| Min. Negotiated Rate |
$654.75 |
| Max. Negotiated Rate |
$873.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$855.54
|
| Rate for Payer: Beech Street Commercial |
$829.35
|
| Rate for Payer: Cash Price |
$611.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$846.81
|
| Rate for Payer: Cigna of WY Commercial |
$855.54
|
| Rate for Payer: First Choice Health Commercial |
$785.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$829.35
|
| Rate for Payer: HealthUtah PPO |
$873.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$846.81
|
| Rate for Payer: One Health Plan of WY PPO |
$855.54
|
| Rate for Payer: PacificSource Commercial |
$785.70
|
| Rate for Payer: PHCS PPO |
$829.35
|
| Rate for Payer: Three Rivers PPO |
$654.75
|
| Rate for Payer: United Healthcare Commercial |
$759.51
|
| Rate for Payer: WINHealth Partners Commercial |
$742.05
|
|
|
APPLICATION LONG ARM SPLINT SHOULDER HAND
|
Professional
|
Both
|
$291.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
29105
|
| Min. Negotiated Rate |
$33.63 |
| Max. Negotiated Rate |
$291.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$285.18
|
| Rate for Payer: Aetna of WY Medicare |
$39.56
|
| Rate for Payer: Beech Street Commercial |
$276.45
|
| Rate for Payer: Cash Price |
$203.70
|
| Rate for Payer: Cash Price |
$203.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$282.27
|
| Rate for Payer: Cigna of WY Commercial |
$285.18
|
| Rate for Payer: First Choice Health Commercial |
$261.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$276.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.56
|
| Rate for Payer: HealthUtah PPO |
$291.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$282.27
|
| Rate for Payer: Multiplan Medicare/VA |
$33.63
|
| Rate for Payer: One Health Plan of WY PPO |
$285.18
|
| Rate for Payer: PacificSource Commercial |
$261.90
|
| Rate for Payer: PHCS PPO |
$276.45
|
| Rate for Payer: Three Rivers PPO |
$218.25
|
| Rate for Payer: TriWest Veterans Administration |
$39.56
|
| Rate for Payer: United Healthcare Commercial |
$253.17
|
| Rate for Payer: United Healthcare Medicare |
$39.56
|
| Rate for Payer: WINHealth Partners Commercial |
$247.35
|
|
|
APPLICATION LONG ARM SPLINT SHOULDER HAND
|
Professional
|
Both
|
$583.00
|
|
|
Service Code
|
HCPCS 29105 50
|
| Hospital Charge Code |
29105
|
| Min. Negotiated Rate |
$33.63 |
| Max. Negotiated Rate |
$583.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$571.34
|
| Rate for Payer: Aetna of WY Medicare |
$39.56
|
| Rate for Payer: Beech Street Commercial |
$553.85
|
| Rate for Payer: Cash Price |
$408.10
|
| Rate for Payer: Cash Price |
$408.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$565.51
|
| Rate for Payer: Cigna of WY Commercial |
$571.34
|
| Rate for Payer: First Choice Health Commercial |
$524.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$553.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.56
|
| Rate for Payer: HealthUtah PPO |
$583.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$565.51
|
| Rate for Payer: Multiplan Medicare/VA |
$33.63
|
| Rate for Payer: One Health Plan of WY PPO |
$571.34
|
| Rate for Payer: PacificSource Commercial |
$524.70
|
| Rate for Payer: PHCS PPO |
$553.85
|
| Rate for Payer: Three Rivers PPO |
$437.25
|
| Rate for Payer: TriWest Veterans Administration |
$39.56
|
| Rate for Payer: United Healthcare Commercial |
$507.21
|
| Rate for Payer: United Healthcare Medicare |
$39.56
|
| Rate for Payer: WINHealth Partners Commercial |
$495.55
|
|
|
APPLICATION LONG LEG CAST THIGH-TOE
|
Professional
|
Both
|
$498.00
|
|
|
Service Code
|
HCPCS 29345
|
| Hospital Charge Code |
29345
|
| Min. Negotiated Rate |
$81.06 |
| Max. Negotiated Rate |
$498.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$488.04
|
| Rate for Payer: Aetna of WY Medicare |
$95.36
|
| Rate for Payer: Beech Street Commercial |
$473.10
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$483.06
|
| Rate for Payer: Cigna of WY Commercial |
$488.04
|
| Rate for Payer: First Choice Health Commercial |
$448.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$473.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$95.36
|
| Rate for Payer: HealthUtah PPO |
$498.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$483.06
|
| Rate for Payer: Multiplan Medicare/VA |
$81.06
|
| Rate for Payer: One Health Plan of WY PPO |
$488.04
|
| Rate for Payer: PacificSource Commercial |
$448.20
|
| Rate for Payer: PHCS PPO |
$473.10
|
| Rate for Payer: Three Rivers PPO |
$373.50
|
| Rate for Payer: TriWest Veterans Administration |
$95.36
|
| Rate for Payer: United Healthcare Commercial |
$433.26
|
| Rate for Payer: United Healthcare Medicare |
$95.36
|
| Rate for Payer: WINHealth Partners Commercial |
$423.30
|
|
|
APPLICATION LONG LEG CAST WALKER/AMBULATORY TYPE
|
Professional
|
Both
|
$535.00
|
|
|
Service Code
|
HCPCS 29355
|
| Hospital Charge Code |
29355
|
| Min. Negotiated Rate |
$86.89 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$524.30
|
| Rate for Payer: Aetna of WY Medicare |
$102.22
|
| Rate for Payer: Beech Street Commercial |
$508.25
|
| Rate for Payer: Cash Price |
$374.50
|
| Rate for Payer: Cash Price |
$374.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$518.95
|
| Rate for Payer: Cigna of WY Commercial |
$524.30
|
| Rate for Payer: First Choice Health Commercial |
$481.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$508.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$102.22
|
| Rate for Payer: HealthUtah PPO |
$535.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$518.95
|
| Rate for Payer: Multiplan Medicare/VA |
$86.89
|
| Rate for Payer: One Health Plan of WY PPO |
$524.30
|
| Rate for Payer: PacificSource Commercial |
$481.50
|
| Rate for Payer: PHCS PPO |
$508.25
|
| Rate for Payer: Three Rivers PPO |
$401.25
|
| Rate for Payer: TriWest Veterans Administration |
$102.22
|
| Rate for Payer: United Healthcare Commercial |
$465.45
|
| Rate for Payer: United Healthcare Medicare |
$102.22
|
| Rate for Payer: WINHealth Partners Commercial |
$454.75
|
|
|
APPLICATION LONG LEG SPLINT THIGH ANKLE/TOES
|
Professional
|
Both
|
$252.00
|
|
|
Service Code
|
HCPCS 29505
|
| Hospital Charge Code |
29505
|
| Min. Negotiated Rate |
$43.10 |
| Max. Negotiated Rate |
$252.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$246.96
|
| Rate for Payer: Aetna of WY Medicare |
$50.71
|
| Rate for Payer: Beech Street Commercial |
$239.40
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: Cash Price |
$176.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$244.44
|
| Rate for Payer: Cigna of WY Commercial |
$246.96
|
| Rate for Payer: First Choice Health Commercial |
$226.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$239.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.71
|
| Rate for Payer: HealthUtah PPO |
$252.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$244.44
|
| Rate for Payer: Multiplan Medicare/VA |
$43.10
|
| Rate for Payer: One Health Plan of WY PPO |
$246.96
|
| Rate for Payer: PacificSource Commercial |
$226.80
|
| Rate for Payer: PHCS PPO |
$239.40
|
| Rate for Payer: Three Rivers PPO |
$189.00
|
| Rate for Payer: TriWest Veterans Administration |
$50.71
|
| Rate for Payer: United Healthcare Commercial |
$219.24
|
| Rate for Payer: United Healthcare Medicare |
$50.71
|
| Rate for Payer: WINHealth Partners Commercial |
$214.20
|
|
|
APPLICATION MODALITY 1/> AREAS INFRARED
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
HCPCS 97026
|
| Hospital Charge Code |
97026
|
| Min. Negotiated Rate |
$5.49 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.64
|
| Rate for Payer: Aetna of WY Medicare |
$6.46
|
| Rate for Payer: Beech Street Commercial |
$17.10
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: Cash Price |
$12.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$17.46
|
| Rate for Payer: Cigna of WY Commercial |
$17.64
|
| Rate for Payer: First Choice Health Commercial |
$16.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.46
|
| Rate for Payer: HealthUtah PPO |
$18.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.46
|
| Rate for Payer: Multiplan Medicare/VA |
$5.49
|
| Rate for Payer: One Health Plan of WY PPO |
$17.64
|
| Rate for Payer: PacificSource Commercial |
$16.20
|
| Rate for Payer: PHCS PPO |
$17.10
|
| Rate for Payer: Three Rivers PPO |
$13.50
|
| Rate for Payer: TriWest Veterans Administration |
$6.46
|
| Rate for Payer: United Healthcare Commercial |
$15.66
|
| Rate for Payer: United Healthcare Medicare |
$6.46
|
| Rate for Payer: WINHealth Partners Commercial |
$17.10
|
|
|
APPLICATION MODALITY 1/> AREAS WHIRLPOOL
|
Professional
|
Both
|
$73.00
|
|
|
Service Code
|
HCPCS 97022
|
| Hospital Charge Code |
97022
|
| Min. Negotiated Rate |
$14.12 |
| Max. Negotiated Rate |
$73.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$71.54
|
| Rate for Payer: Aetna of WY Medicare |
$16.61
|
| Rate for Payer: Beech Street Commercial |
$69.35
|
| Rate for Payer: Cash Price |
$51.10
|
| Rate for Payer: Cash Price |
$51.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$70.81
|
| Rate for Payer: Cigna of WY Commercial |
$71.54
|
| Rate for Payer: First Choice Health Commercial |
$65.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$69.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.61
|
| Rate for Payer: HealthUtah PPO |
$73.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$70.81
|
| Rate for Payer: Multiplan Medicare/VA |
$14.12
|
| Rate for Payer: One Health Plan of WY PPO |
$71.54
|
| Rate for Payer: PacificSource Commercial |
$65.70
|
| Rate for Payer: PHCS PPO |
$69.35
|
| Rate for Payer: Three Rivers PPO |
$54.75
|
| Rate for Payer: TriWest Veterans Administration |
$16.61
|
| Rate for Payer: United Healthcare Commercial |
$63.51
|
| Rate for Payer: United Healthcare Medicare |
$16.61
|
| Rate for Payer: WINHealth Partners Commercial |
$69.35
|
|
|
APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM
|
Professional
|
Both
|
$5,733.00
|
|
|
Service Code
|
HCPCS 20692 AS
|
| Hospital Charge Code |
20692
|
| Min. Negotiated Rate |
$927.89 |
| Max. Negotiated Rate |
$5,733.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,618.34
|
| Rate for Payer: Aetna of WY Medicare |
$1,091.64
|
| Rate for Payer: Beech Street Commercial |
$5,446.35
|
| Rate for Payer: Cash Price |
$4,013.10
|
| Rate for Payer: Cash Price |
$4,013.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,561.01
|
| Rate for Payer: Cigna of WY Commercial |
$5,618.34
|
| Rate for Payer: First Choice Health Commercial |
$5,159.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,446.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,091.64
|
| Rate for Payer: HealthUtah PPO |
$5,733.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,561.01
|
| Rate for Payer: Multiplan Medicare/VA |
$927.89
|
| Rate for Payer: One Health Plan of WY PPO |
$5,618.34
|
| Rate for Payer: PacificSource Commercial |
$5,159.70
|
| Rate for Payer: PHCS PPO |
$5,446.35
|
| Rate for Payer: Three Rivers PPO |
$4,299.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,091.64
|
| Rate for Payer: United Healthcare Commercial |
$4,987.71
|
| Rate for Payer: United Healthcare Medicare |
$1,091.64
|
| Rate for Payer: WINHealth Partners Commercial |
$4,873.05
|
|
|
APPLICATION MULTIPLANE EXTERNAL FIXATION SYSTEM
|
Professional
|
Both
|
$5,733.00
|
|
|
Service Code
|
HCPCS 20692
|
| Hospital Charge Code |
20692
|
| Min. Negotiated Rate |
$927.89 |
| Max. Negotiated Rate |
$5,733.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,618.34
|
| Rate for Payer: Aetna of WY Medicare |
$1,091.64
|
| Rate for Payer: Beech Street Commercial |
$5,446.35
|
| Rate for Payer: Cash Price |
$4,013.10
|
| Rate for Payer: Cash Price |
$4,013.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,561.01
|
| Rate for Payer: Cigna of WY Commercial |
$5,618.34
|
| Rate for Payer: First Choice Health Commercial |
$5,159.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,446.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,091.64
|
| Rate for Payer: HealthUtah PPO |
$5,733.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,561.01
|
| Rate for Payer: Multiplan Medicare/VA |
$927.89
|
| Rate for Payer: One Health Plan of WY PPO |
$5,618.34
|
| Rate for Payer: PacificSource Commercial |
$5,159.70
|
| Rate for Payer: PHCS PPO |
$5,446.35
|
| Rate for Payer: Three Rivers PPO |
$4,299.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,091.64
|
| Rate for Payer: United Healthcare Commercial |
$4,987.71
|
| Rate for Payer: United Healthcare Medicare |
$1,091.64
|
| Rate for Payer: WINHealth Partners Commercial |
$4,873.05
|
|
|
APPLICATION RIGHT & LEFT PULMONARY ARTERY BAND
|
Professional
|
Both
|
$5,444.00
|
|
|
Service Code
|
HCPCS 33620
|
| Hospital Charge Code |
33620
|
| Min. Negotiated Rate |
$1,297.02 |
| Max. Negotiated Rate |
$5,444.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,335.12
|
| Rate for Payer: Aetna of WY Medicare |
$1,525.90
|
| Rate for Payer: Beech Street Commercial |
$5,171.80
|
| Rate for Payer: Cash Price |
$3,810.80
|
| Rate for Payer: Cash Price |
$3,810.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,280.68
|
| Rate for Payer: Cigna of WY Commercial |
$5,335.12
|
| Rate for Payer: First Choice Health Commercial |
$4,899.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,171.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,525.90
|
| Rate for Payer: HealthUtah PPO |
$5,444.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,280.68
|
| Rate for Payer: Multiplan Medicare/VA |
$1,297.02
|
| Rate for Payer: One Health Plan of WY PPO |
$5,335.12
|
| Rate for Payer: PacificSource Commercial |
$4,899.60
|
| Rate for Payer: PHCS PPO |
$5,171.80
|
| Rate for Payer: Three Rivers PPO |
$4,083.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,525.90
|
| Rate for Payer: United Healthcare Commercial |
$4,736.28
|
| Rate for Payer: United Healthcare Medicare |
$1,525.90
|
| Rate for Payer: WINHealth Partners Commercial |
$4,627.40
|
|
|
APPLICATION SHORT ARM SPLINT FOREARM-HAND STATIC
|
Professional
|
Both
|
$239.00
|
|
|
Service Code
|
HCPCS 29125
|
| Hospital Charge Code |
29125
|
| Min. Negotiated Rate |
$33.30 |
| Max. Negotiated Rate |
$239.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$234.22
|
| Rate for Payer: Aetna of WY Medicare |
$39.18
|
| Rate for Payer: Beech Street Commercial |
$227.05
|
| Rate for Payer: Cash Price |
$167.30
|
| Rate for Payer: Cash Price |
$167.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$231.83
|
| Rate for Payer: Cigna of WY Commercial |
$234.22
|
| Rate for Payer: First Choice Health Commercial |
$215.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$227.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.18
|
| Rate for Payer: HealthUtah PPO |
$239.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$231.83
|
| Rate for Payer: Multiplan Medicare/VA |
$33.30
|
| Rate for Payer: One Health Plan of WY PPO |
$234.22
|
| Rate for Payer: PacificSource Commercial |
$215.10
|
| Rate for Payer: PHCS PPO |
$227.05
|
| Rate for Payer: Three Rivers PPO |
$179.25
|
| Rate for Payer: TriWest Veterans Administration |
$39.18
|
| Rate for Payer: United Healthcare Commercial |
$207.93
|
| Rate for Payer: United Healthcare Medicare |
$39.18
|
| Rate for Payer: WINHealth Partners Commercial |
$203.15
|
|
|
APPLICATION SHORT LEG CAST BELOW KNEE-TOE
|
Professional
|
Both
|
$296.00
|
|
|
Service Code
|
HCPCS 29405
|
| Hospital Charge Code |
29405
|
| Min. Negotiated Rate |
$48.32 |
| Max. Negotiated Rate |
$296.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$290.08
|
| Rate for Payer: Aetna of WY Medicare |
$56.85
|
| Rate for Payer: Beech Street Commercial |
$281.20
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: Cash Price |
$207.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$287.12
|
| Rate for Payer: Cigna of WY Commercial |
$290.08
|
| Rate for Payer: First Choice Health Commercial |
$266.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$281.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.85
|
| Rate for Payer: HealthUtah PPO |
$296.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$287.12
|
| Rate for Payer: Multiplan Medicare/VA |
$48.32
|
| Rate for Payer: One Health Plan of WY PPO |
$290.08
|
| Rate for Payer: PacificSource Commercial |
$266.40
|
| Rate for Payer: PHCS PPO |
$281.20
|
| Rate for Payer: Three Rivers PPO |
$222.00
|
| Rate for Payer: TriWest Veterans Administration |
$56.85
|
| Rate for Payer: United Healthcare Commercial |
$257.52
|
| Rate for Payer: United Healthcare Medicare |
$56.85
|
| Rate for Payer: WINHealth Partners Commercial |
$251.60
|
|
|
APPLICATION SHORT LEG CAST WALKING/AMBULATORY
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
HCPCS 29425
|
| Hospital Charge Code |
29425
|
| Min. Negotiated Rate |
$44.64 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$271.46
|
| Rate for Payer: Aetna of WY Medicare |
$52.52
|
| Rate for Payer: Beech Street Commercial |
$263.15
|
| Rate for Payer: Cash Price |
$193.90
|
| Rate for Payer: Cash Price |
$193.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$268.69
|
| Rate for Payer: Cigna of WY Commercial |
$271.46
|
| Rate for Payer: First Choice Health Commercial |
$249.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$263.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$52.52
|
| Rate for Payer: HealthUtah PPO |
$277.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$268.69
|
| Rate for Payer: Multiplan Medicare/VA |
$44.64
|
| Rate for Payer: One Health Plan of WY PPO |
$271.46
|
| Rate for Payer: PacificSource Commercial |
$249.30
|
| Rate for Payer: PHCS PPO |
$263.15
|
| Rate for Payer: Three Rivers PPO |
$207.75
|
| Rate for Payer: TriWest Veterans Administration |
$52.52
|
| Rate for Payer: United Healthcare Commercial |
$240.99
|
| Rate for Payer: United Healthcare Medicare |
$52.52
|
| Rate for Payer: WINHealth Partners Commercial |
$235.45
|
|
|
APPLICATION SHORT LEG SPLINT CALF FOOT
|
Professional
|
Both
|
$510.00
|
|
|
Service Code
|
HCPCS 29515 50
|
| Hospital Charge Code |
29515
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$510.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$499.80
|
| Rate for Payer: Aetna of WY Medicare |
$48.18
|
| Rate for Payer: Beech Street Commercial |
$484.50
|
| Rate for Payer: Cash Price |
$357.00
|
| Rate for Payer: Cash Price |
$357.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$494.70
|
| Rate for Payer: Cigna of WY Commercial |
$499.80
|
| Rate for Payer: First Choice Health Commercial |
$459.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$484.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.18
|
| Rate for Payer: HealthUtah PPO |
$510.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$494.70
|
| Rate for Payer: Multiplan Medicare/VA |
$40.95
|
| Rate for Payer: One Health Plan of WY PPO |
$499.80
|
| Rate for Payer: PacificSource Commercial |
$459.00
|
| Rate for Payer: PHCS PPO |
$484.50
|
| Rate for Payer: Three Rivers PPO |
$382.50
|
| Rate for Payer: TriWest Veterans Administration |
$48.18
|
| Rate for Payer: United Healthcare Commercial |
$443.70
|
| Rate for Payer: United Healthcare Medicare |
$48.18
|
| Rate for Payer: WINHealth Partners Commercial |
$433.50
|
|
|
APPLICATION SHORT LEG SPLINT CALF FOOT
|
Professional
|
Both
|
$255.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
29515
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$255.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$249.90
|
| Rate for Payer: Aetna of WY Medicare |
$48.18
|
| Rate for Payer: Beech Street Commercial |
$242.25
|
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: Cash Price |
$178.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$247.35
|
| Rate for Payer: Cigna of WY Commercial |
$249.90
|
| Rate for Payer: First Choice Health Commercial |
$229.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$242.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.18
|
| Rate for Payer: HealthUtah PPO |
$255.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$247.35
|
| Rate for Payer: Multiplan Medicare/VA |
$40.95
|
| Rate for Payer: One Health Plan of WY PPO |
$249.90
|
| Rate for Payer: PacificSource Commercial |
$229.50
|
| Rate for Payer: PHCS PPO |
$242.25
|
| Rate for Payer: Three Rivers PPO |
$191.25
|
| Rate for Payer: TriWest Veterans Administration |
$48.18
|
| Rate for Payer: United Healthcare Commercial |
$221.85
|
| Rate for Payer: United Healthcare Medicare |
$48.18
|
| Rate for Payer: WINHealth Partners Commercial |
$216.75
|
|
|
APPLICATION TOPICAL FLUORIDE VARNISH BY PHS/QHP
|
Professional
|
Both
|
$16.00
|
|
|
Service Code
|
HCPCS 99188
|
| Hospital Charge Code |
99188
|
| Min. Negotiated Rate |
$12.00 |
| Max. Negotiated Rate |
$16.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$15.68
|
| Rate for Payer: Beech Street Commercial |
$15.20
|
| Rate for Payer: Cash Price |
$11.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$15.52
|
| Rate for Payer: Cigna of WY Commercial |
$15.68
|
| Rate for Payer: First Choice Health Commercial |
$14.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$15.20
|
| Rate for Payer: HealthUtah PPO |
$16.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$15.52
|
| Rate for Payer: One Health Plan of WY PPO |
$15.68
|
| Rate for Payer: PacificSource Commercial |
$14.40
|
| Rate for Payer: PHCS PPO |
$15.20
|
| Rate for Payer: Three Rivers PPO |
$12.00
|
| Rate for Payer: United Healthcare Commercial |
$13.92
|
| Rate for Payer: WINHealth Partners Commercial |
$15.20
|
|
|
APPLICATION UNIPLANE EXTERNAL FIXATION SYSTEM
|
Professional
|
Both
|
$3,055.00
|
|
|
Service Code
|
HCPCS 20690
|
| Hospital Charge Code |
20690
|
| Min. Negotiated Rate |
$489.61 |
| Max. Negotiated Rate |
$3,055.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,993.90
|
| Rate for Payer: Aetna of WY Medicare |
$576.01
|
| Rate for Payer: Beech Street Commercial |
$2,902.25
|
| Rate for Payer: Cash Price |
$2,138.50
|
| Rate for Payer: Cash Price |
$2,138.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,963.35
|
| Rate for Payer: Cigna of WY Commercial |
$2,993.90
|
| Rate for Payer: First Choice Health Commercial |
$2,749.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,902.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$576.01
|
| Rate for Payer: HealthUtah PPO |
$3,055.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,963.35
|
| Rate for Payer: Multiplan Medicare/VA |
$489.61
|
| Rate for Payer: One Health Plan of WY PPO |
$2,993.90
|
| Rate for Payer: PacificSource Commercial |
$2,749.50
|
| Rate for Payer: PHCS PPO |
$2,902.25
|
| Rate for Payer: Three Rivers PPO |
$2,291.25
|
| Rate for Payer: TriWest Veterans Administration |
$576.01
|
| Rate for Payer: United Healthcare Commercial |
$2,657.85
|
| Rate for Payer: United Healthcare Medicare |
$576.01
|
| Rate for Payer: WINHealth Partners Commercial |
$2,596.75
|
|
|
APPLICATION UNIPLANE EXTERNAL FIXATION SYSTEM
|
Professional
|
Both
|
$3,055.00
|
|
|
Service Code
|
HCPCS 20690 80
|
| Hospital Charge Code |
20690
|
| Min. Negotiated Rate |
$489.61 |
| Max. Negotiated Rate |
$3,055.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,993.90
|
| Rate for Payer: Aetna of WY Medicare |
$576.01
|
| Rate for Payer: Beech Street Commercial |
$2,902.25
|
| Rate for Payer: Cash Price |
$2,138.50
|
| Rate for Payer: Cash Price |
$2,138.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,963.35
|
| Rate for Payer: Cigna of WY Commercial |
$2,993.90
|
| Rate for Payer: First Choice Health Commercial |
$2,749.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,902.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$576.01
|
| Rate for Payer: HealthUtah PPO |
$3,055.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,963.35
|
| Rate for Payer: Multiplan Medicare/VA |
$489.61
|
| Rate for Payer: One Health Plan of WY PPO |
$2,993.90
|
| Rate for Payer: PacificSource Commercial |
$2,749.50
|
| Rate for Payer: PHCS PPO |
$2,902.25
|
| Rate for Payer: Three Rivers PPO |
$2,291.25
|
| Rate for Payer: TriWest Veterans Administration |
$576.01
|
| Rate for Payer: United Healthcare Commercial |
$2,657.85
|
| Rate for Payer: United Healthcare Medicare |
$576.01
|
| Rate for Payer: WINHealth Partners Commercial |
$2,596.75
|
|
|
APPLIED INSUFF NEED 120M C2201
|
Facility
|
IP
|
$45.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.53 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.59
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.68
|
| Rate for Payer: Altius Commercial |
$43.68
|
| Rate for Payer: Beech Street Commercial |
$44.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37.36
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$44.14
|
| Rate for Payer: Cigna of WY Commercial |
$44.59
|
| Rate for Payer: Entrust Commercial |
$43.22
|
| Rate for Payer: First Choice Health Commercial |
$43.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$43.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.03
|
| Rate for Payer: HealthUtah PPO |
$45.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$44.14
|
| Rate for Payer: Multiplan Medicare/VA |
$28.53
|
| Rate for Payer: One Health Plan of WY PPO |
$44.59
|
| Rate for Payer: PacificSource Commercial |
$40.95
|
| Rate for Payer: PHCS PPO |
$44.59
|
| Rate for Payer: Three Rivers PPO |
$34.12
|
| Rate for Payer: TriWest Veterans Administration |
$30.03
|
| Rate for Payer: United Healthcare Commercial |
$39.58
|
| Rate for Payer: United Healthcare Medicare |
$30.03
|
| Rate for Payer: WINHealth Partners Commercial |
$43.22
|
| Rate for Payer: Wise Provider Network Commercial |
$43.22
|
|
|
APPLIED INSUFF NEED 120M C2201
|
Facility
|
OP
|
$45.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.07 |
| Max. Negotiated Rate |
$45.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.59
|
| Rate for Payer: Aetna of WY Medicare |
$30.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$43.68
|
| Rate for Payer: Altius Commercial |
$43.68
|
| Rate for Payer: Beech Street Commercial |
$44.59
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37.36
|
| Rate for Payer: Cash Price |
$31.85
|
| Rate for Payer: ChoiceCare Network Commercial |
$44.14
|
| Rate for Payer: Cigna of WY Commercial |
$44.59
|
| Rate for Payer: Entrust Commercial |
$43.22
|
| Rate for Payer: First Choice Health Commercial |
$43.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$43.22
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.39
|
| Rate for Payer: HealthUtah PPO |
$45.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$44.14
|
| Rate for Payer: Multiplan Medicare/VA |
$25.07
|
| Rate for Payer: One Health Plan of WY PPO |
$44.59
|
| Rate for Payer: PacificSource Commercial |
$40.95
|
| Rate for Payer: PHCS PPO |
$44.59
|
| Rate for Payer: Three Rivers PPO |
$34.12
|
| Rate for Payer: TriWest Veterans Administration |
$26.39
|
| Rate for Payer: United Healthcare Commercial |
$39.58
|
| Rate for Payer: United Healthcare Medicare |
$26.39
|
| Rate for Payer: WINHealth Partners Commercial |
$44.59
|
| Rate for Payer: Wise Provider Network Commercial |
$43.22
|
|
|
APPLIED KII 12MM BALLOON CFF73
|
Facility
|
OP
|
$87.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$48.21 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.75
|
| Rate for Payer: Aetna of WY Medicare |
$57.75
|
| Rate for Payer: Altius Auto/Workers Compensation |
$84.00
|
| Rate for Payer: Altius Commercial |
$84.00
|
| Rate for Payer: Beech Street Commercial |
$85.75
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$71.84
|
| Rate for Payer: Cash Price |
$61.25
|
| Rate for Payer: ChoiceCare Network Commercial |
$84.88
|
| Rate for Payer: Cigna of WY Commercial |
$85.75
|
| Rate for Payer: Entrust Commercial |
$83.12
|
| Rate for Payer: First Choice Health Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$83.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.75
|
| Rate for Payer: HealthUtah PPO |
$87.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.88
|
| Rate for Payer: Multiplan Medicare/VA |
$48.21
|
| Rate for Payer: One Health Plan of WY PPO |
$85.75
|
| Rate for Payer: PacificSource Commercial |
$78.75
|
| Rate for Payer: PHCS PPO |
$85.75
|
| Rate for Payer: Three Rivers PPO |
$65.62
|
| Rate for Payer: TriWest Veterans Administration |
$50.75
|
| Rate for Payer: United Healthcare Commercial |
$76.12
|
| Rate for Payer: United Healthcare Medicare |
$50.75
|
| Rate for Payer: WINHealth Partners Commercial |
$85.75
|
| Rate for Payer: Wise Provider Network Commercial |
$83.12
|
|
