|
DRIVE SHAFT CAN T15 HEXALOBE
|
Facility
|
OP
|
$385.00
|
|
| Hospital Charge Code |
3004184
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$208.48 |
| Max. Negotiated Rate |
$385.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$377.30
|
| Rate for Payer: Aetna of WY Medicare |
$254.10
|
| Rate for Payer: Altius Commercial |
$369.60
|
| Rate for Payer: Beech Street Commercial |
$377.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$373.45
|
| Rate for Payer: Cash Price |
$269.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$373.45
|
| Rate for Payer: Cigna of WY Commercial |
$377.30
|
| Rate for Payer: Entrust Commercial |
$365.75
|
| Rate for Payer: First Choice Health Commercial |
$365.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$365.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$219.45
|
| Rate for Payer: HealthUtah PPO |
$385.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$373.45
|
| Rate for Payer: Multiplan Medicare/VA |
$208.48
|
| Rate for Payer: One Health Plan of WY PPO |
$377.30
|
| Rate for Payer: PacificSource Commercial |
$346.50
|
| Rate for Payer: PHCS PPO |
$377.30
|
| Rate for Payer: Three Rivers PPO |
$288.75
|
| Rate for Payer: TriWest Veterans Administration |
$219.45
|
| Rate for Payer: United Healthcare Commercial |
$367.68
|
| Rate for Payer: United Healthcare Medicare |
$219.45
|
| Rate for Payer: WINHealth Partners Commercial |
$377.30
|
| Rate for Payer: Wise Provider Network Commercial |
$365.75
|
|
|
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION [9438]
|
Facility
|
IP
|
$32.46
|
|
|
Service Code
|
HCPCS J1790
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.81 |
| Max. Negotiated Rate |
$32.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.81
|
| Rate for Payer: Aetna of WY Medicare |
$20.77
|
| Rate for Payer: Altius Commercial |
$31.16
|
| Rate for Payer: Beech Street Commercial |
$31.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.49
|
| Rate for Payer: Cash Price |
$22.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.49
|
| Rate for Payer: Cigna of WY Commercial |
$31.81
|
| Rate for Payer: Entrust Commercial |
$30.84
|
| Rate for Payer: First Choice Health Commercial |
$30.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.80
|
| Rate for Payer: HealthUtah PPO |
$32.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.49
|
| Rate for Payer: Multiplan Medicare/VA |
$18.81
|
| Rate for Payer: One Health Plan of WY PPO |
$31.81
|
| Rate for Payer: PacificSource Commercial |
$29.21
|
| Rate for Payer: PHCS PPO |
$31.81
|
| Rate for Payer: Three Rivers PPO |
$24.34
|
| Rate for Payer: TriWest Veterans Administration |
$19.80
|
| Rate for Payer: United Healthcare Commercial |
$31.00
|
| Rate for Payer: United Healthcare Medicare |
$19.80
|
| Rate for Payer: WINHealth Partners Commercial |
$30.84
|
| Rate for Payer: Wise Provider Network Commercial |
$30.84
|
|
|
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION [9438]
|
Facility
|
OP
|
$32.46
|
|
|
Service Code
|
HCPCS J1790
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$17.58 |
| Max. Negotiated Rate |
$32.46 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$31.81
|
| Rate for Payer: Aetna of WY Medicare |
$21.42
|
| Rate for Payer: Altius Commercial |
$31.16
|
| Rate for Payer: Beech Street Commercial |
$31.81
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$31.49
|
| Rate for Payer: Cash Price |
$22.72
|
| Rate for Payer: ChoiceCare Network Commercial |
$31.49
|
| Rate for Payer: Cigna of WY Commercial |
$31.81
|
| Rate for Payer: Entrust Commercial |
$30.84
|
| Rate for Payer: First Choice Health Commercial |
$30.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$30.84
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.50
|
| Rate for Payer: HealthUtah PPO |
$32.46
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$31.49
|
| Rate for Payer: Multiplan Medicare/VA |
$17.58
|
| Rate for Payer: One Health Plan of WY PPO |
$31.81
|
| Rate for Payer: PacificSource Commercial |
$29.21
|
| Rate for Payer: PHCS PPO |
$31.81
|
| Rate for Payer: Three Rivers PPO |
$24.34
|
| Rate for Payer: TriWest Veterans Administration |
$18.50
|
| Rate for Payer: United Healthcare Commercial |
$31.00
|
| Rate for Payer: United Healthcare Medicare |
$18.50
|
| Rate for Payer: WINHealth Partners Commercial |
$31.81
|
| Rate for Payer: Wise Provider Network Commercial |
$30.84
|
|
|
DROPERIDOL INJECTION
|
Professional
|
Both
|
$21.00
|
|
|
Service Code
|
HCPCS J1790
|
| Min. Negotiated Rate |
$15.75 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.58
|
| Rate for Payer: Beech Street Commercial |
$19.95
|
| Rate for Payer: Cash Price |
$14.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$20.37
|
| Rate for Payer: Cigna of WY Commercial |
$20.58
|
| Rate for Payer: First Choice Health Commercial |
$18.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.95
|
| Rate for Payer: HealthUtah PPO |
$21.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$20.37
|
| Rate for Payer: One Health Plan of WY PPO |
$20.58
|
| Rate for Payer: PacificSource Commercial |
$18.90
|
| Rate for Payer: PHCS PPO |
$19.95
|
| Rate for Payer: Three Rivers PPO |
$15.75
|
| Rate for Payer: United Healthcare Commercial |
$19.95
|
| Rate for Payer: WINHealth Partners Commercial |
$19.95
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ LARGE
|
Professional
|
Both
|
$570.00
|
|
|
Service Code
|
HCPCS 16030
|
| Min. Negotiated Rate |
$106.89 |
| Max. Negotiated Rate |
$570.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$558.60
|
| Rate for Payer: Aetna of WY Medicare |
$125.75
|
| Rate for Payer: Beech Street Commercial |
$541.50
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$552.90
|
| Rate for Payer: Cigna of WY Commercial |
$558.60
|
| Rate for Payer: First Choice Health Commercial |
$513.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$541.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$125.75
|
| Rate for Payer: HealthUtah PPO |
$570.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$552.90
|
| Rate for Payer: Multiplan Medicare/VA |
$106.89
|
| Rate for Payer: One Health Plan of WY PPO |
$558.60
|
| Rate for Payer: PacificSource Commercial |
$513.00
|
| Rate for Payer: PHCS PPO |
$541.50
|
| Rate for Payer: Three Rivers PPO |
$427.50
|
| Rate for Payer: TriWest Veterans Administration |
$125.75
|
| Rate for Payer: United Healthcare Commercial |
$541.50
|
| Rate for Payer: WINHealth Partners Commercial |
$484.50
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ MEDIUM
|
Professional
|
Both
|
$473.00
|
|
|
Service Code
|
HCPCS 16025
|
| Min. Negotiated Rate |
$90.86 |
| Max. Negotiated Rate |
$473.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$463.54
|
| Rate for Payer: Aetna of WY Medicare |
$106.89
|
| Rate for Payer: Beech Street Commercial |
$449.35
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: Cash Price |
$331.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$458.81
|
| Rate for Payer: Cigna of WY Commercial |
$463.54
|
| Rate for Payer: First Choice Health Commercial |
$425.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$449.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.89
|
| Rate for Payer: HealthUtah PPO |
$473.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$458.81
|
| Rate for Payer: Multiplan Medicare/VA |
$90.86
|
| Rate for Payer: One Health Plan of WY PPO |
$463.54
|
| Rate for Payer: PacificSource Commercial |
$425.70
|
| Rate for Payer: PHCS PPO |
$449.35
|
| Rate for Payer: Three Rivers PPO |
$354.75
|
| Rate for Payer: TriWest Veterans Administration |
$106.89
|
| Rate for Payer: United Healthcare Commercial |
$449.35
|
| Rate for Payer: WINHealth Partners Commercial |
$402.05
|
|
|
DRS&/DBRDMT PRTL-THKNS BURNS 1ST/SBSQ SMALL
|
Professional
|
Both
|
$231.00
|
|
|
Service Code
|
HCPCS 16020
|
| Min. Negotiated Rate |
$45.88 |
| Max. Negotiated Rate |
$231.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$226.38
|
| Rate for Payer: Aetna of WY Medicare |
$53.98
|
| Rate for Payer: Beech Street Commercial |
$219.45
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: Cash Price |
$161.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$224.07
|
| Rate for Payer: Cigna of WY Commercial |
$226.38
|
| Rate for Payer: First Choice Health Commercial |
$207.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$219.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.98
|
| Rate for Payer: HealthUtah PPO |
$231.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$224.07
|
| Rate for Payer: Multiplan Medicare/VA |
$45.88
|
| Rate for Payer: One Health Plan of WY PPO |
$226.38
|
| Rate for Payer: PacificSource Commercial |
$207.90
|
| Rate for Payer: PHCS PPO |
$219.45
|
| Rate for Payer: Three Rivers PPO |
$173.25
|
| Rate for Payer: TriWest Veterans Administration |
$53.98
|
| Rate for Payer: United Healthcare Commercial |
$219.45
|
| Rate for Payer: WINHealth Partners Commercial |
$196.35
|
|
|
DRUG SCREEN LIST A ANY NMBR NON TLC DEVICES
|
Professional
|
Both
|
$26.00
|
|
|
Service Code
|
HCPCS 80300
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.48
|
| Rate for Payer: Beech Street Commercial |
$24.70
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.22
|
| Rate for Payer: Cigna of WY Commercial |
$25.48
|
| Rate for Payer: First Choice Health Commercial |
$23.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.70
|
| Rate for Payer: HealthUtah PPO |
$26.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.22
|
| Rate for Payer: One Health Plan of WY PPO |
$25.48
|
| Rate for Payer: PacificSource Commercial |
$23.40
|
| Rate for Payer: PHCS PPO |
$24.70
|
| Rate for Payer: Three Rivers PPO |
$19.50
|
| Rate for Payer: United Healthcare Commercial |
$24.70
|
| Rate for Payer: WINHealth Partners Commercial |
$24.70
|
|
|
DRUG SCREEN MULT CLASSES
|
Professional
|
Both
|
$26.00
|
|
|
Service Code
|
HCPCS 80100
|
| Min. Negotiated Rate |
$19.50 |
| Max. Negotiated Rate |
$26.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$25.48
|
| Rate for Payer: Beech Street Commercial |
$24.70
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$25.22
|
| Rate for Payer: Cigna of WY Commercial |
$25.48
|
| Rate for Payer: First Choice Health Commercial |
$23.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$24.70
|
| Rate for Payer: HealthUtah PPO |
$26.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$25.22
|
| Rate for Payer: One Health Plan of WY PPO |
$25.48
|
| Rate for Payer: PacificSource Commercial |
$23.40
|
| Rate for Payer: PHCS PPO |
$24.70
|
| Rate for Payer: Three Rivers PPO |
$19.50
|
| Rate for Payer: United Healthcare Commercial |
$24.70
|
| Rate for Payer: WINHealth Partners Commercial |
$24.70
|
|
|
DRUG SCREEN MULTIPLE CLASS
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS G0431
|
| Min. Negotiated Rate |
$27.75 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.26
|
| Rate for Payer: Beech Street Commercial |
$35.15
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.89
|
| Rate for Payer: Cigna of WY Commercial |
$36.26
|
| Rate for Payer: First Choice Health Commercial |
$33.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.15
|
| Rate for Payer: HealthUtah PPO |
$37.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.89
|
| Rate for Payer: One Health Plan of WY PPO |
$36.26
|
| Rate for Payer: PacificSource Commercial |
$33.30
|
| Rate for Payer: PHCS PPO |
$35.15
|
| Rate for Payer: Three Rivers PPO |
$27.75
|
| Rate for Payer: United Healthcare Commercial |
$35.15
|
| Rate for Payer: WINHealth Partners Commercial |
$35.15
|
|
|
DRUGS UNCLASSIFIED INJECTION
|
Professional
|
Both
|
$18.00
|
|
|
Service Code
|
HCPCS J3490
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$17.64
|
| Rate for Payer: Beech Street Commercial |
$17.10
|
| 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: HealthUtah PPO |
$18.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$17.46
|
| 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: United Healthcare Commercial |
$17.10
|
| Rate for Payer: WINHealth Partners Commercial |
$17.10
|
|
|
DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE
|
Professional
|
Both
|
$37.00
|
|
|
Service Code
|
HCPCS 80305
|
| Min. Negotiated Rate |
$10.71 |
| Max. Negotiated Rate |
$37.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$36.26
|
| Rate for Payer: Aetna of WY Medicare |
$12.60
|
| Rate for Payer: Beech Street Commercial |
$35.15
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: Cash Price |
$25.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$35.89
|
| Rate for Payer: Cigna of WY Commercial |
$36.26
|
| Rate for Payer: First Choice Health Commercial |
$33.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$35.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.60
|
| Rate for Payer: HealthUtah PPO |
$37.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$35.89
|
| Rate for Payer: Multiplan Medicare/VA |
$10.71
|
| Rate for Payer: One Health Plan of WY PPO |
$36.26
|
| Rate for Payer: PacificSource Commercial |
$33.30
|
| Rate for Payer: PHCS PPO |
$35.15
|
| Rate for Payer: Three Rivers PPO |
$27.75
|
| Rate for Payer: TriWest Veterans Administration |
$12.60
|
| Rate for Payer: United Healthcare Commercial |
$35.15
|
| Rate for Payer: WINHealth Partners Commercial |
$35.15
|
|
|
DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE
|
Professional
|
Both
|
$392.00
|
|
|
Service Code
|
HCPCS 80307
|
| Min. Negotiated Rate |
$52.82 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$384.16
|
| Rate for Payer: Aetna of WY Medicare |
$62.14
|
| Rate for Payer: Beech Street Commercial |
$372.40
|
| Rate for Payer: Cash Price |
$274.40
|
| Rate for Payer: Cash Price |
$274.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$380.24
|
| Rate for Payer: Cigna of WY Commercial |
$384.16
|
| Rate for Payer: First Choice Health Commercial |
$352.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$372.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.14
|
| Rate for Payer: HealthUtah PPO |
$392.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$380.24
|
| Rate for Payer: Multiplan Medicare/VA |
$52.82
|
| Rate for Payer: One Health Plan of WY PPO |
$384.16
|
| Rate for Payer: PacificSource Commercial |
$352.80
|
| Rate for Payer: PHCS PPO |
$372.40
|
| Rate for Payer: Three Rivers PPO |
$294.00
|
| Rate for Payer: TriWest Veterans Administration |
$62.14
|
| Rate for Payer: United Healthcare Commercial |
$372.40
|
| Rate for Payer: WINHealth Partners Commercial |
$372.40
|
|
|
DSTRJ LESION ANUS SIMPLE CHEMICAL
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 46900
|
| Min. Negotiated Rate |
$113.62 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$588.00
|
| Rate for Payer: Aetna of WY Medicare |
$133.67
|
| Rate for Payer: Beech Street Commercial |
$570.00
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$582.00
|
| Rate for Payer: Cigna of WY Commercial |
$588.00
|
| Rate for Payer: First Choice Health Commercial |
$540.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$570.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$133.67
|
| Rate for Payer: HealthUtah PPO |
$600.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$582.00
|
| Rate for Payer: Multiplan Medicare/VA |
$113.62
|
| Rate for Payer: One Health Plan of WY PPO |
$588.00
|
| Rate for Payer: PacificSource Commercial |
$540.00
|
| Rate for Payer: PHCS PPO |
$570.00
|
| Rate for Payer: Three Rivers PPO |
$450.00
|
| Rate for Payer: TriWest Veterans Administration |
$133.67
|
| Rate for Payer: United Healthcare Commercial |
$570.00
|
| Rate for Payer: WINHealth Partners Commercial |
$510.00
|
|
|
DSTRJ NEUROLYTIC AGENT INTERCOSTAL NERVE
|
Professional
|
Both
|
$773.00
|
|
|
Service Code
|
HCPCS 64620
|
| Min. Negotiated Rate |
$145.60 |
| Max. Negotiated Rate |
$773.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$757.54
|
| Rate for Payer: Aetna of WY Medicare |
$171.29
|
| Rate for Payer: Beech Street Commercial |
$734.35
|
| Rate for Payer: Cash Price |
$541.10
|
| Rate for Payer: Cash Price |
$541.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$749.81
|
| Rate for Payer: Cigna of WY Commercial |
$757.54
|
| Rate for Payer: First Choice Health Commercial |
$695.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$734.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$171.29
|
| Rate for Payer: HealthUtah PPO |
$773.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$749.81
|
| Rate for Payer: Multiplan Medicare/VA |
$145.60
|
| Rate for Payer: One Health Plan of WY PPO |
$757.54
|
| Rate for Payer: PacificSource Commercial |
$695.70
|
| Rate for Payer: PHCS PPO |
$734.35
|
| Rate for Payer: Three Rivers PPO |
$579.75
|
| Rate for Payer: TriWest Veterans Administration |
$171.29
|
| Rate for Payer: United Healthcare Commercial |
$734.35
|
| Rate for Payer: WINHealth Partners Commercial |
$657.05
|
|
|
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE
|
Professional
|
Both
|
$519.00
|
|
|
Service Code
|
HCPCS 64640
|
| Min. Negotiated Rate |
$97.55 |
| Max. Negotiated Rate |
$519.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$508.62
|
| Rate for Payer: Aetna of WY Medicare |
$114.77
|
| Rate for Payer: Beech Street Commercial |
$493.05
|
| Rate for Payer: Cash Price |
$363.30
|
| Rate for Payer: Cash Price |
$363.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$503.43
|
| Rate for Payer: Cigna of WY Commercial |
$508.62
|
| Rate for Payer: First Choice Health Commercial |
$467.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$493.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$114.77
|
| Rate for Payer: HealthUtah PPO |
$519.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$503.43
|
| Rate for Payer: Multiplan Medicare/VA |
$97.55
|
| Rate for Payer: One Health Plan of WY PPO |
$508.62
|
| Rate for Payer: PacificSource Commercial |
$467.10
|
| Rate for Payer: PHCS PPO |
$493.05
|
| Rate for Payer: Three Rivers PPO |
$389.25
|
| Rate for Payer: TriWest Veterans Administration |
$114.77
|
| Rate for Payer: United Healthcare Commercial |
$493.05
|
| Rate for Payer: WINHealth Partners Commercial |
$441.15
|
|
|
DSTRJ NEUROLYTIC AGENT OTHER PERIPHERAL NERVE
|
Professional
|
Both
|
$1,038.00
|
|
|
Service Code
|
HCPCS 64640 50
|
| Min. Negotiated Rate |
$778.50 |
| Max. Negotiated Rate |
$1,038.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,017.24
|
| Rate for Payer: Beech Street Commercial |
$986.10
|
| Rate for Payer: Cash Price |
$726.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,006.86
|
| Rate for Payer: Cigna of WY Commercial |
$1,017.24
|
| Rate for Payer: First Choice Health Commercial |
$934.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$986.10
|
| Rate for Payer: HealthUtah PPO |
$1,038.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,006.86
|
| Rate for Payer: One Health Plan of WY PPO |
$1,017.24
|
| Rate for Payer: PacificSource Commercial |
$934.20
|
| Rate for Payer: PHCS PPO |
$986.10
|
| Rate for Payer: Three Rivers PPO |
$778.50
|
| Rate for Payer: United Healthcare Commercial |
$986.10
|
| Rate for Payer: WINHealth Partners Commercial |
$882.30
|
|
|
DSTRJ NEUROLYTIC W/WO RAD MONITOR CELIAC PLEXUS
|
Professional
|
Both
|
$1,444.00
|
|
|
Service Code
|
HCPCS 64680
|
| Min. Negotiated Rate |
$131.43 |
| Max. Negotiated Rate |
$1,444.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,415.12
|
| Rate for Payer: Aetna of WY Medicare |
$154.62
|
| Rate for Payer: Beech Street Commercial |
$1,371.80
|
| Rate for Payer: Cash Price |
$1,010.80
|
| Rate for Payer: Cash Price |
$1,010.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,400.68
|
| Rate for Payer: Cigna of WY Commercial |
$1,415.12
|
| Rate for Payer: First Choice Health Commercial |
$1,299.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,371.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$154.62
|
| Rate for Payer: HealthUtah PPO |
$1,444.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,400.68
|
| Rate for Payer: Multiplan Medicare/VA |
$131.43
|
| Rate for Payer: One Health Plan of WY PPO |
$1,415.12
|
| Rate for Payer: PacificSource Commercial |
$1,299.60
|
| Rate for Payer: PHCS PPO |
$1,371.80
|
| Rate for Payer: Three Rivers PPO |
$1,083.00
|
| Rate for Payer: TriWest Veterans Administration |
$154.62
|
| Rate for Payer: United Healthcare Commercial |
$1,371.80
|
| Rate for Payer: WINHealth Partners Commercial |
$1,227.40
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 64634 50
|
| Min. Negotiated Rate |
$450.00 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$588.00
|
| Rate for Payer: Beech Street Commercial |
$570.00
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$582.00
|
| Rate for Payer: Cigna of WY Commercial |
$588.00
|
| Rate for Payer: First Choice Health Commercial |
$540.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$570.00
|
| Rate for Payer: HealthUtah PPO |
$600.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$582.00
|
| Rate for Payer: One Health Plan of WY PPO |
$588.00
|
| Rate for Payer: PacificSource Commercial |
$540.00
|
| Rate for Payer: PHCS PPO |
$570.00
|
| Rate for Payer: Three Rivers PPO |
$450.00
|
| Rate for Payer: United Healthcare Commercial |
$570.00
|
| Rate for Payer: WINHealth Partners Commercial |
$510.00
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT ADDL CRVCL/THORA
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 64634
|
| Min. Negotiated Rate |
$54.44 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$294.00
|
| Rate for Payer: Aetna of WY Medicare |
$64.05
|
| Rate for Payer: Beech Street Commercial |
$285.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$291.00
|
| Rate for Payer: Cigna of WY Commercial |
$294.00
|
| Rate for Payer: First Choice Health Commercial |
$270.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.05
|
| Rate for Payer: HealthUtah PPO |
$300.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$291.00
|
| Rate for Payer: Multiplan Medicare/VA |
$54.44
|
| Rate for Payer: One Health Plan of WY PPO |
$294.00
|
| Rate for Payer: PacificSource Commercial |
$270.00
|
| Rate for Payer: PHCS PPO |
$285.00
|
| Rate for Payer: Three Rivers PPO |
$225.00
|
| Rate for Payer: TriWest Veterans Administration |
$64.05
|
| Rate for Payer: United Healthcare Commercial |
$285.00
|
| Rate for Payer: WINHealth Partners Commercial |
$255.00
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL
|
Professional
|
Both
|
$529.00
|
|
|
Service Code
|
HCPCS 64636 50
|
| Min. Negotiated Rate |
$396.75 |
| Max. Negotiated Rate |
$529.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$518.42
|
| Rate for Payer: Beech Street Commercial |
$502.55
|
| Rate for Payer: Cash Price |
$370.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$513.13
|
| Rate for Payer: Cigna of WY Commercial |
$518.42
|
| Rate for Payer: First Choice Health Commercial |
$476.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$502.55
|
| Rate for Payer: HealthUtah PPO |
$529.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$513.13
|
| Rate for Payer: One Health Plan of WY PPO |
$518.42
|
| Rate for Payer: PacificSource Commercial |
$476.10
|
| Rate for Payer: PHCS PPO |
$502.55
|
| Rate for Payer: Three Rivers PPO |
$396.75
|
| Rate for Payer: United Healthcare Commercial |
$502.55
|
| Rate for Payer: WINHealth Partners Commercial |
$449.65
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT ADDL LMBR/SACRAL
|
Professional
|
Both
|
$265.00
|
|
|
Service Code
|
HCPCS 64636
|
| Min. Negotiated Rate |
$47.63 |
| Max. Negotiated Rate |
$265.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$259.70
|
| Rate for Payer: Aetna of WY Medicare |
$56.03
|
| Rate for Payer: Beech Street Commercial |
$251.75
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: Cash Price |
$185.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$257.05
|
| Rate for Payer: Cigna of WY Commercial |
$259.70
|
| Rate for Payer: First Choice Health Commercial |
$238.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$251.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.03
|
| Rate for Payer: HealthUtah PPO |
$265.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$257.05
|
| Rate for Payer: Multiplan Medicare/VA |
$47.63
|
| Rate for Payer: One Health Plan of WY PPO |
$259.70
|
| Rate for Payer: PacificSource Commercial |
$238.50
|
| Rate for Payer: PHCS PPO |
$251.75
|
| Rate for Payer: Three Rivers PPO |
$198.75
|
| Rate for Payer: TriWest Veterans Administration |
$56.03
|
| Rate for Payer: United Healthcare Commercial |
$251.75
|
| Rate for Payer: WINHealth Partners Commercial |
$225.25
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA
|
Professional
|
Both
|
$1,985.00
|
|
|
Service Code
|
HCPCS 64633 50
|
| Min. Negotiated Rate |
$1,488.75 |
| Max. Negotiated Rate |
$1,985.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,945.30
|
| Rate for Payer: Beech Street Commercial |
$1,885.75
|
| Rate for Payer: Cash Price |
$1,389.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,925.45
|
| Rate for Payer: Cigna of WY Commercial |
$1,945.30
|
| Rate for Payer: First Choice Health Commercial |
$1,786.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,885.75
|
| Rate for Payer: HealthUtah PPO |
$1,985.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,925.45
|
| Rate for Payer: One Health Plan of WY PPO |
$1,945.30
|
| Rate for Payer: PacificSource Commercial |
$1,786.50
|
| Rate for Payer: PHCS PPO |
$1,885.75
|
| Rate for Payer: Three Rivers PPO |
$1,488.75
|
| Rate for Payer: United Healthcare Commercial |
$1,885.75
|
| Rate for Payer: WINHealth Partners Commercial |
$1,687.25
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL CRVCL/THORA
|
Professional
|
Both
|
$992.00
|
|
|
Service Code
|
HCPCS 64633
|
| Min. Negotiated Rate |
$157.44 |
| Max. Negotiated Rate |
$992.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$972.16
|
| Rate for Payer: Aetna of WY Medicare |
$185.22
|
| Rate for Payer: Beech Street Commercial |
$942.40
|
| Rate for Payer: Cash Price |
$694.40
|
| Rate for Payer: Cash Price |
$694.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$962.24
|
| Rate for Payer: Cigna of WY Commercial |
$972.16
|
| Rate for Payer: First Choice Health Commercial |
$892.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$942.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$185.22
|
| Rate for Payer: HealthUtah PPO |
$992.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$962.24
|
| Rate for Payer: Multiplan Medicare/VA |
$157.44
|
| Rate for Payer: One Health Plan of WY PPO |
$972.16
|
| Rate for Payer: PacificSource Commercial |
$892.80
|
| Rate for Payer: PHCS PPO |
$942.40
|
| Rate for Payer: Three Rivers PPO |
$744.00
|
| Rate for Payer: TriWest Veterans Administration |
$185.22
|
| Rate for Payer: United Healthcare Commercial |
$942.40
|
| Rate for Payer: WINHealth Partners Commercial |
$843.20
|
|
|
DSTR NROLYTC AGNT PARVERTEB FCT SNGL LMBR/SACRAL
|
Professional
|
Both
|
$979.00
|
|
|
Service Code
|
HCPCS 64635
|
| Min. Negotiated Rate |
$157.71 |
| Max. Negotiated Rate |
$979.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$959.42
|
| Rate for Payer: Aetna of WY Medicare |
$185.54
|
| Rate for Payer: Beech Street Commercial |
$930.05
|
| Rate for Payer: Cash Price |
$685.30
|
| Rate for Payer: Cash Price |
$685.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$949.63
|
| Rate for Payer: Cigna of WY Commercial |
$959.42
|
| Rate for Payer: First Choice Health Commercial |
$881.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$930.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$185.54
|
| Rate for Payer: HealthUtah PPO |
$979.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$949.63
|
| Rate for Payer: Multiplan Medicare/VA |
$157.71
|
| Rate for Payer: One Health Plan of WY PPO |
$959.42
|
| Rate for Payer: PacificSource Commercial |
$881.10
|
| Rate for Payer: PHCS PPO |
$930.05
|
| Rate for Payer: Three Rivers PPO |
$734.25
|
| Rate for Payer: TriWest Veterans Administration |
$185.54
|
| Rate for Payer: United Healthcare Commercial |
$930.05
|
| Rate for Payer: WINHealth Partners Commercial |
$832.15
|
|
