|
APPLIED KII 12MM BALLOON CFF73
|
Facility
|
IP
|
$87.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$54.86 |
| Max. Negotiated Rate |
$87.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$85.75
|
| 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 |
$57.75
|
| Rate for Payer: HealthUtah PPO |
$87.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$84.88
|
| Rate for Payer: Multiplan Medicare/VA |
$54.86
|
| 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 |
$57.75
|
| Rate for Payer: United Healthcare Commercial |
$76.12
|
| Rate for Payer: United Healthcare Medicare |
$57.75
|
| Rate for Payer: WINHealth Partners Commercial |
$83.12
|
| Rate for Payer: Wise Provider Network Commercial |
$83.12
|
|
|
APPLIED KII 5MM BALLOON CFF03
|
Facility
|
IP
|
$59.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$57.12
|
| Rate for Payer: Altius Commercial |
$57.12
|
| Rate for Payer: Beech Street Commercial |
$58.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.85
|
| Rate for Payer: Cash Price |
$41.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.72
|
| Rate for Payer: Cigna of WY Commercial |
$58.31
|
| Rate for Payer: Entrust Commercial |
$56.52
|
| Rate for Payer: First Choice Health Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.27
|
| Rate for Payer: HealthUtah PPO |
$59.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.72
|
| Rate for Payer: Multiplan Medicare/VA |
$37.31
|
| Rate for Payer: One Health Plan of WY PPO |
$58.31
|
| Rate for Payer: PacificSource Commercial |
$53.55
|
| Rate for Payer: PHCS PPO |
$58.31
|
| Rate for Payer: Three Rivers PPO |
$44.62
|
| Rate for Payer: TriWest Veterans Administration |
$39.27
|
| Rate for Payer: United Healthcare Commercial |
$51.76
|
| Rate for Payer: United Healthcare Medicare |
$39.27
|
| Rate for Payer: WINHealth Partners Commercial |
$56.52
|
| Rate for Payer: Wise Provider Network Commercial |
$56.52
|
|
|
APPLIED KII 5MM BALLOON CFF03
|
Facility
|
OP
|
$59.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$32.78 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.31
|
| Rate for Payer: Aetna of WY Medicare |
$39.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$57.12
|
| Rate for Payer: Altius Commercial |
$57.12
|
| Rate for Payer: Beech Street Commercial |
$58.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.85
|
| Rate for Payer: Cash Price |
$41.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.72
|
| Rate for Payer: Cigna of WY Commercial |
$58.31
|
| Rate for Payer: Entrust Commercial |
$56.52
|
| Rate for Payer: First Choice Health Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.51
|
| Rate for Payer: HealthUtah PPO |
$59.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.72
|
| Rate for Payer: Multiplan Medicare/VA |
$32.78
|
| Rate for Payer: One Health Plan of WY PPO |
$58.31
|
| Rate for Payer: PacificSource Commercial |
$53.55
|
| Rate for Payer: PHCS PPO |
$58.31
|
| Rate for Payer: Three Rivers PPO |
$44.62
|
| Rate for Payer: TriWest Veterans Administration |
$34.51
|
| Rate for Payer: United Healthcare Commercial |
$51.76
|
| Rate for Payer: United Healthcare Medicare |
$34.51
|
| Rate for Payer: WINHealth Partners Commercial |
$58.31
|
| Rate for Payer: Wise Provider Network Commercial |
$56.52
|
|
|
APPLIED KII 5X100MM CFS02
|
Facility
|
OP
|
$28.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.43 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.44
|
| Rate for Payer: Aetna of WY Medicare |
$18.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$26.88
|
| Rate for Payer: Altius Commercial |
$26.88
|
| Rate for Payer: Beech Street Commercial |
$27.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.99
|
| Rate for Payer: Cash Price |
$19.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.16
|
| Rate for Payer: Cigna of WY Commercial |
$27.44
|
| Rate for Payer: Entrust Commercial |
$26.60
|
| Rate for Payer: First Choice Health Commercial |
$26.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$16.24
|
| Rate for Payer: HealthUtah PPO |
$28.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.16
|
| Rate for Payer: Multiplan Medicare/VA |
$15.43
|
| Rate for Payer: One Health Plan of WY PPO |
$27.44
|
| Rate for Payer: PacificSource Commercial |
$25.20
|
| Rate for Payer: PHCS PPO |
$27.44
|
| Rate for Payer: Three Rivers PPO |
$21.00
|
| Rate for Payer: TriWest Veterans Administration |
$16.24
|
| Rate for Payer: United Healthcare Commercial |
$24.36
|
| Rate for Payer: United Healthcare Medicare |
$16.24
|
| Rate for Payer: WINHealth Partners Commercial |
$27.44
|
| Rate for Payer: Wise Provider Network Commercial |
$26.60
|
|
|
APPLIED KII 5X100MM CFS02
|
Facility
|
IP
|
$28.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$17.56 |
| Max. Negotiated Rate |
$28.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$27.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$26.88
|
| Rate for Payer: Altius Commercial |
$26.88
|
| Rate for Payer: Beech Street Commercial |
$27.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$22.99
|
| Rate for Payer: Cash Price |
$19.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$27.16
|
| Rate for Payer: Cigna of WY Commercial |
$27.44
|
| Rate for Payer: Entrust Commercial |
$26.60
|
| Rate for Payer: First Choice Health Commercial |
$26.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$26.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.48
|
| Rate for Payer: HealthUtah PPO |
$28.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$27.16
|
| Rate for Payer: Multiplan Medicare/VA |
$17.56
|
| Rate for Payer: One Health Plan of WY PPO |
$27.44
|
| Rate for Payer: PacificSource Commercial |
$25.20
|
| Rate for Payer: PHCS PPO |
$27.44
|
| Rate for Payer: Three Rivers PPO |
$21.00
|
| Rate for Payer: TriWest Veterans Administration |
$18.48
|
| Rate for Payer: United Healthcare Commercial |
$24.36
|
| Rate for Payer: United Healthcare Medicare |
$18.48
|
| Rate for Payer: WINHealth Partners Commercial |
$26.60
|
| Rate for Payer: Wise Provider Network Commercial |
$26.60
|
|
|
APPLIED KII BALLOO 12MM C0R47
|
Facility
|
IP
|
$94.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.25 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.61
|
| Rate for Payer: Altius Auto/Workers Compensation |
$90.72
|
| Rate for Payer: Altius Commercial |
$90.72
|
| Rate for Payer: Beech Street Commercial |
$92.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.58
|
| Rate for Payer: Cash Price |
$66.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.66
|
| Rate for Payer: Cigna of WY Commercial |
$92.61
|
| Rate for Payer: Entrust Commercial |
$89.78
|
| Rate for Payer: First Choice Health Commercial |
$89.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.37
|
| Rate for Payer: HealthUtah PPO |
$94.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.66
|
| Rate for Payer: Multiplan Medicare/VA |
$59.25
|
| Rate for Payer: One Health Plan of WY PPO |
$92.61
|
| Rate for Payer: PacificSource Commercial |
$85.05
|
| Rate for Payer: PHCS PPO |
$92.61
|
| Rate for Payer: Three Rivers PPO |
$70.88
|
| Rate for Payer: TriWest Veterans Administration |
$62.37
|
| Rate for Payer: United Healthcare Commercial |
$82.22
|
| Rate for Payer: United Healthcare Medicare |
$62.37
|
| Rate for Payer: WINHealth Partners Commercial |
$89.78
|
| Rate for Payer: Wise Provider Network Commercial |
$89.78
|
|
|
APPLIED KII BALLOO 12MM C0R47
|
Facility
|
OP
|
$94.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.07 |
| Max. Negotiated Rate |
$94.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$92.61
|
| Rate for Payer: Aetna of WY Medicare |
$62.37
|
| Rate for Payer: Altius Auto/Workers Compensation |
$90.72
|
| Rate for Payer: Altius Commercial |
$90.72
|
| Rate for Payer: Beech Street Commercial |
$92.61
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.58
|
| Rate for Payer: Cash Price |
$66.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$91.66
|
| Rate for Payer: Cigna of WY Commercial |
$92.61
|
| Rate for Payer: Entrust Commercial |
$89.78
|
| Rate for Payer: First Choice Health Commercial |
$89.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$89.78
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$54.81
|
| Rate for Payer: HealthUtah PPO |
$94.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$91.66
|
| Rate for Payer: Multiplan Medicare/VA |
$52.07
|
| Rate for Payer: One Health Plan of WY PPO |
$92.61
|
| Rate for Payer: PacificSource Commercial |
$85.05
|
| Rate for Payer: PHCS PPO |
$92.61
|
| Rate for Payer: Three Rivers PPO |
$70.88
|
| Rate for Payer: TriWest Veterans Administration |
$54.81
|
| Rate for Payer: United Healthcare Commercial |
$82.22
|
| Rate for Payer: United Healthcare Medicare |
$54.81
|
| Rate for Payer: WINHealth Partners Commercial |
$92.61
|
| Rate for Payer: Wise Provider Network Commercial |
$89.78
|
|
|
APPLIED KII FIOS 5X150MM CFF01
|
Facility
|
IP
|
$59.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$37.31 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.31
|
| Rate for Payer: Altius Auto/Workers Compensation |
$57.12
|
| Rate for Payer: Altius Commercial |
$57.12
|
| Rate for Payer: Beech Street Commercial |
$58.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.85
|
| Rate for Payer: Cash Price |
$41.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.72
|
| Rate for Payer: Cigna of WY Commercial |
$58.31
|
| Rate for Payer: Entrust Commercial |
$56.52
|
| Rate for Payer: First Choice Health Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$39.27
|
| Rate for Payer: HealthUtah PPO |
$59.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.72
|
| Rate for Payer: Multiplan Medicare/VA |
$37.31
|
| Rate for Payer: One Health Plan of WY PPO |
$58.31
|
| Rate for Payer: PacificSource Commercial |
$53.55
|
| Rate for Payer: PHCS PPO |
$58.31
|
| Rate for Payer: Three Rivers PPO |
$44.62
|
| Rate for Payer: TriWest Veterans Administration |
$39.27
|
| Rate for Payer: United Healthcare Commercial |
$51.76
|
| Rate for Payer: United Healthcare Medicare |
$39.27
|
| Rate for Payer: WINHealth Partners Commercial |
$56.52
|
| Rate for Payer: Wise Provider Network Commercial |
$56.52
|
|
|
APPLIED KII FIOS 5X150MM CFF01
|
Facility
|
OP
|
$59.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$32.78 |
| Max. Negotiated Rate |
$59.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$58.31
|
| Rate for Payer: Aetna of WY Medicare |
$39.27
|
| Rate for Payer: Altius Auto/Workers Compensation |
$57.12
|
| Rate for Payer: Altius Commercial |
$57.12
|
| Rate for Payer: Beech Street Commercial |
$58.31
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.85
|
| Rate for Payer: Cash Price |
$41.65
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.72
|
| Rate for Payer: Cigna of WY Commercial |
$58.31
|
| Rate for Payer: Entrust Commercial |
$56.52
|
| Rate for Payer: First Choice Health Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.52
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.51
|
| Rate for Payer: HealthUtah PPO |
$59.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.72
|
| Rate for Payer: Multiplan Medicare/VA |
$32.78
|
| Rate for Payer: One Health Plan of WY PPO |
$58.31
|
| Rate for Payer: PacificSource Commercial |
$53.55
|
| Rate for Payer: PHCS PPO |
$58.31
|
| Rate for Payer: Three Rivers PPO |
$44.62
|
| Rate for Payer: TriWest Veterans Administration |
$34.51
|
| Rate for Payer: United Healthcare Commercial |
$51.76
|
| Rate for Payer: United Healthcare Medicare |
$34.51
|
| Rate for Payer: WINHealth Partners Commercial |
$58.31
|
| Rate for Payer: Wise Provider Network Commercial |
$56.52
|
|
|
APPL MLTLAYR COMPRES LEG BELOW KNEE W/ANKLE FOOT
|
Professional
|
Both
|
$553.00
|
|
|
Service Code
|
HCPCS 29581
|
| Hospital Charge Code |
29581
|
| Min. Negotiated Rate |
$21.91 |
| Max. Negotiated Rate |
$553.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$541.94
|
| Rate for Payer: Aetna of WY Medicare |
$25.78
|
| Rate for Payer: Beech Street Commercial |
$525.35
|
| Rate for Payer: Cash Price |
$387.10
|
| Rate for Payer: Cash Price |
$387.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$536.41
|
| Rate for Payer: Cigna of WY Commercial |
$541.94
|
| Rate for Payer: First Choice Health Commercial |
$497.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$525.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.78
|
| Rate for Payer: HealthUtah PPO |
$553.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$536.41
|
| Rate for Payer: Multiplan Medicare/VA |
$21.91
|
| Rate for Payer: One Health Plan of WY PPO |
$541.94
|
| Rate for Payer: PacificSource Commercial |
$497.70
|
| Rate for Payer: PHCS PPO |
$525.35
|
| Rate for Payer: Three Rivers PPO |
$414.75
|
| Rate for Payer: TriWest Veterans Administration |
$25.78
|
| Rate for Payer: United Healthcare Commercial |
$481.11
|
| Rate for Payer: United Healthcare Medicare |
$25.78
|
| Rate for Payer: WINHealth Partners Commercial |
$470.05
|
|
|
APPL MODALITY 1/> AREAS ELEC STIMJ UNATTENDED
|
Professional
|
Both
|
$92.00
|
|
|
Service Code
|
HCPCS 97014
|
| Hospital Charge Code |
97014
|
| Min. Negotiated Rate |
$69.00 |
| Max. Negotiated Rate |
$92.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$90.16
|
| Rate for Payer: Beech Street Commercial |
$87.40
|
| Rate for Payer: Cash Price |
$64.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$89.24
|
| Rate for Payer: Cigna of WY Commercial |
$90.16
|
| Rate for Payer: First Choice Health Commercial |
$82.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$87.40
|
| Rate for Payer: HealthUtah PPO |
$92.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$89.24
|
| Rate for Payer: One Health Plan of WY PPO |
$90.16
|
| Rate for Payer: PacificSource Commercial |
$82.80
|
| Rate for Payer: PHCS PPO |
$87.40
|
| Rate for Payer: Three Rivers PPO |
$69.00
|
| Rate for Payer: United Healthcare Commercial |
$80.04
|
| Rate for Payer: WINHealth Partners Commercial |
$87.40
|
|
|
APPL MODALITY 1+ AREAS ESTIM EA 15 MIN
|
Professional
|
Both
|
$105.00
|
|
|
Service Code
|
HCPCS 97032
|
| Hospital Charge Code |
97032
|
| Min. Negotiated Rate |
$11.89 |
| Max. Negotiated Rate |
$105.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.90
|
| Rate for Payer: Aetna of WY Medicare |
$13.99
|
| Rate for Payer: Beech Street Commercial |
$99.75
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: Cash Price |
$73.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.85
|
| Rate for Payer: Cigna of WY Commercial |
$102.90
|
| Rate for Payer: First Choice Health Commercial |
$94.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.99
|
| Rate for Payer: HealthUtah PPO |
$105.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.85
|
| Rate for Payer: Multiplan Medicare/VA |
$11.89
|
| Rate for Payer: One Health Plan of WY PPO |
$102.90
|
| Rate for Payer: PacificSource Commercial |
$94.50
|
| Rate for Payer: PHCS PPO |
$99.75
|
| Rate for Payer: Three Rivers PPO |
$78.75
|
| Rate for Payer: TriWest Veterans Administration |
$13.99
|
| Rate for Payer: United Healthcare Commercial |
$91.35
|
| Rate for Payer: United Healthcare Medicare |
$13.99
|
| Rate for Payer: WINHealth Partners Commercial |
$99.75
|
|
|
APPL MODALITY 1+ AREAS IONTOPHORESIS EA 15 MIN
|
Professional
|
Both
|
$256.00
|
|
|
Service Code
|
HCPCS 97033
|
| Hospital Charge Code |
97033
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$250.88
|
| Rate for Payer: Aetna of WY Medicare |
$18.91
|
| Rate for Payer: Beech Street Commercial |
$243.20
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: Cash Price |
$179.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$248.32
|
| Rate for Payer: Cigna of WY Commercial |
$250.88
|
| Rate for Payer: First Choice Health Commercial |
$230.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$243.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.91
|
| Rate for Payer: HealthUtah PPO |
$256.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$248.32
|
| Rate for Payer: Multiplan Medicare/VA |
$16.07
|
| Rate for Payer: One Health Plan of WY PPO |
$250.88
|
| Rate for Payer: PacificSource Commercial |
$230.40
|
| Rate for Payer: PHCS PPO |
$243.20
|
| Rate for Payer: Three Rivers PPO |
$192.00
|
| Rate for Payer: TriWest Veterans Administration |
$18.91
|
| Rate for Payer: United Healthcare Commercial |
$222.72
|
| Rate for Payer: United Healthcare Medicare |
$18.91
|
| Rate for Payer: WINHealth Partners Commercial |
$243.20
|
|
|
APPL MODALITY 1/> AREAS PARAFFIN BATH
|
Professional
|
Both
|
$16.00
|
|
|
Service Code
|
HCPCS 97018
|
| Hospital Charge Code |
97018
|
| 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
|
|
|
APPL MODALITY 1/> AREAS TRACTION MECHANICAL
|
Professional
|
Both
|
$123.00
|
|
|
Service Code
|
HCPCS 97012
|
| Hospital Charge Code |
97012
|
| Min. Negotiated Rate |
$11.62 |
| Max. Negotiated Rate |
$123.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$120.54
|
| Rate for Payer: Aetna of WY Medicare |
$13.67
|
| 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 |
$13.67
|
| Rate for Payer: HealthUtah PPO |
$123.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$119.31
|
| Rate for Payer: Multiplan Medicare/VA |
$11.62
|
| 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 |
$13.67
|
| Rate for Payer: United Healthcare Commercial |
$107.01
|
| Rate for Payer: United Healthcare Medicare |
$13.67
|
| Rate for Payer: WINHealth Partners Commercial |
$116.85
|
|
|
APPL MODALITY 1+ AREAS ULTRASOUND EA 15 MIN
|
Professional
|
Both
|
$91.00
|
|
|
Service Code
|
HCPCS 97035
|
| Hospital Charge Code |
97035
|
| Min. Negotiated Rate |
$11.62 |
| Max. Negotiated Rate |
$91.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$89.18
|
| Rate for Payer: Aetna of WY Medicare |
$13.67
|
| Rate for Payer: Beech Street Commercial |
$86.45
|
| Rate for Payer: Cash Price |
$63.70
|
| Rate for Payer: Cash Price |
$63.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$88.27
|
| Rate for Payer: Cigna of WY Commercial |
$89.18
|
| Rate for Payer: First Choice Health Commercial |
$81.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$86.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.67
|
| Rate for Payer: HealthUtah PPO |
$91.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$88.27
|
| Rate for Payer: Multiplan Medicare/VA |
$11.62
|
| Rate for Payer: One Health Plan of WY PPO |
$89.18
|
| Rate for Payer: PacificSource Commercial |
$81.90
|
| Rate for Payer: PHCS PPO |
$86.45
|
| Rate for Payer: Three Rivers PPO |
$68.25
|
| Rate for Payer: TriWest Veterans Administration |
$13.67
|
| Rate for Payer: United Healthcare Commercial |
$79.17
|
| Rate for Payer: United Healthcare Medicare |
$13.67
|
| Rate for Payer: WINHealth Partners Commercial |
$86.45
|
|
|
APPL MODALITY 1/> AREAS VASOPNEUMATIC DEVICES
|
Professional
|
Both
|
$97.00
|
|
|
Service Code
|
HCPCS 97016
|
| Hospital Charge Code |
97016
|
| Min. Negotiated Rate |
$9.67 |
| Max. Negotiated Rate |
$97.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$95.06
|
| Rate for Payer: Aetna of WY Medicare |
$11.38
|
| Rate for Payer: Beech Street Commercial |
$92.15
|
| Rate for Payer: Cash Price |
$67.90
|
| Rate for Payer: Cash Price |
$67.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$94.09
|
| Rate for Payer: Cigna of WY Commercial |
$95.06
|
| Rate for Payer: First Choice Health Commercial |
$87.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$92.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$11.38
|
| Rate for Payer: HealthUtah PPO |
$97.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$94.09
|
| Rate for Payer: Multiplan Medicare/VA |
$9.67
|
| Rate for Payer: One Health Plan of WY PPO |
$95.06
|
| Rate for Payer: PacificSource Commercial |
$87.30
|
| Rate for Payer: PHCS PPO |
$92.15
|
| Rate for Payer: Three Rivers PPO |
$72.75
|
| Rate for Payer: TriWest Veterans Administration |
$11.38
|
| Rate for Payer: United Healthcare Commercial |
$84.39
|
| Rate for Payer: United Healthcare Medicare |
$11.38
|
| Rate for Payer: WINHealth Partners Commercial |
$92.15
|
|
|
APP SKN SUB GRFT T/A/L AREA/100SQ CM /<1ST 25
|
Professional
|
Both
|
$425.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
15271
|
| Min. Negotiated Rate |
$67.98 |
| Max. Negotiated Rate |
$425.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$416.50
|
| Rate for Payer: Aetna of WY Medicare |
$79.98
|
| Rate for Payer: Beech Street Commercial |
$403.75
|
| Rate for Payer: Cash Price |
$297.50
|
| Rate for Payer: Cash Price |
$297.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$412.25
|
| Rate for Payer: Cigna of WY Commercial |
$416.50
|
| Rate for Payer: First Choice Health Commercial |
$382.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$403.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.98
|
| Rate for Payer: HealthUtah PPO |
$425.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$412.25
|
| Rate for Payer: Multiplan Medicare/VA |
$67.98
|
| Rate for Payer: One Health Plan of WY PPO |
$416.50
|
| Rate for Payer: PacificSource Commercial |
$382.50
|
| Rate for Payer: PHCS PPO |
$403.75
|
| Rate for Payer: Three Rivers PPO |
$318.75
|
| Rate for Payer: TriWest Veterans Administration |
$79.98
|
| Rate for Payer: United Healthcare Commercial |
$369.75
|
| Rate for Payer: United Healthcare Medicare |
$79.98
|
| Rate for Payer: WINHealth Partners Commercial |
$361.25
|
|
|
AQUACEL AG DRESSING 10"
|
Facility
|
IP
|
$94.93
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$94.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$93.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$91.13
|
| Rate for Payer: Altius Commercial |
$91.13
|
| Rate for Payer: Beech Street Commercial |
$93.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.94
|
| Rate for Payer: Cash Price |
$66.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$92.08
|
| Rate for Payer: Cigna of WY Commercial |
$93.03
|
| Rate for Payer: Entrust Commercial |
$90.18
|
| Rate for Payer: First Choice Health Commercial |
$90.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$90.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.65
|
| Rate for Payer: HealthUtah PPO |
$94.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$92.08
|
| Rate for Payer: Multiplan Medicare/VA |
$59.52
|
| Rate for Payer: One Health Plan of WY PPO |
$93.03
|
| Rate for Payer: PacificSource Commercial |
$85.44
|
| Rate for Payer: PHCS PPO |
$93.03
|
| Rate for Payer: Three Rivers PPO |
$71.20
|
| Rate for Payer: TriWest Veterans Administration |
$62.65
|
| Rate for Payer: United Healthcare Commercial |
$82.59
|
| Rate for Payer: United Healthcare Medicare |
$62.65
|
| Rate for Payer: WINHealth Partners Commercial |
$90.18
|
| Rate for Payer: Wise Provider Network Commercial |
$90.18
|
|
|
AQUACEL AG DRESSING 10"
|
Facility
|
OP
|
$94.93
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$52.31 |
| Max. Negotiated Rate |
$94.93 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$93.03
|
| Rate for Payer: Aetna of WY Medicare |
$62.65
|
| Rate for Payer: Altius Auto/Workers Compensation |
$91.13
|
| Rate for Payer: Altius Commercial |
$91.13
|
| Rate for Payer: Beech Street Commercial |
$93.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$77.94
|
| Rate for Payer: Cash Price |
$66.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$92.08
|
| Rate for Payer: Cigna of WY Commercial |
$93.03
|
| Rate for Payer: Entrust Commercial |
$90.18
|
| Rate for Payer: First Choice Health Commercial |
$90.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$90.18
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.06
|
| Rate for Payer: HealthUtah PPO |
$94.93
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$92.08
|
| Rate for Payer: Multiplan Medicare/VA |
$52.31
|
| Rate for Payer: One Health Plan of WY PPO |
$93.03
|
| Rate for Payer: PacificSource Commercial |
$85.44
|
| Rate for Payer: PHCS PPO |
$93.03
|
| Rate for Payer: Three Rivers PPO |
$71.20
|
| Rate for Payer: TriWest Veterans Administration |
$55.06
|
| Rate for Payer: United Healthcare Commercial |
$82.59
|
| Rate for Payer: United Healthcare Medicare |
$55.06
|
| Rate for Payer: WINHealth Partners Commercial |
$93.03
|
| Rate for Payer: Wise Provider Network Commercial |
$90.18
|
|
|
AQUACEL AG DRESSING 12"
|
Facility
|
IP
|
$104.67
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$65.63 |
| Max. Negotiated Rate |
$104.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.58
|
| Rate for Payer: Altius Auto/Workers Compensation |
$100.48
|
| Rate for Payer: Altius Commercial |
$100.48
|
| Rate for Payer: Beech Street Commercial |
$102.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$85.93
|
| Rate for Payer: Cash Price |
$73.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.53
|
| Rate for Payer: Cigna of WY Commercial |
$102.58
|
| Rate for Payer: Entrust Commercial |
$99.44
|
| Rate for Payer: First Choice Health Commercial |
$99.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$69.08
|
| Rate for Payer: HealthUtah PPO |
$104.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.53
|
| Rate for Payer: Multiplan Medicare/VA |
$65.63
|
| Rate for Payer: One Health Plan of WY PPO |
$102.58
|
| Rate for Payer: PacificSource Commercial |
$94.20
|
| Rate for Payer: PHCS PPO |
$102.58
|
| Rate for Payer: Three Rivers PPO |
$78.50
|
| Rate for Payer: TriWest Veterans Administration |
$69.08
|
| Rate for Payer: United Healthcare Commercial |
$91.06
|
| Rate for Payer: United Healthcare Medicare |
$69.08
|
| Rate for Payer: WINHealth Partners Commercial |
$99.44
|
| Rate for Payer: Wise Provider Network Commercial |
$99.44
|
|
|
AQUACEL AG DRESSING 12"
|
Facility
|
OP
|
$104.67
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$57.67 |
| Max. Negotiated Rate |
$104.67 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$102.58
|
| Rate for Payer: Aetna of WY Medicare |
$69.08
|
| Rate for Payer: Altius Auto/Workers Compensation |
$100.48
|
| Rate for Payer: Altius Commercial |
$100.48
|
| Rate for Payer: Beech Street Commercial |
$102.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$85.93
|
| Rate for Payer: Cash Price |
$73.27
|
| Rate for Payer: ChoiceCare Network Commercial |
$101.53
|
| Rate for Payer: Cigna of WY Commercial |
$102.58
|
| Rate for Payer: Entrust Commercial |
$99.44
|
| Rate for Payer: First Choice Health Commercial |
$99.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$99.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$60.71
|
| Rate for Payer: HealthUtah PPO |
$104.67
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$101.53
|
| Rate for Payer: Multiplan Medicare/VA |
$57.67
|
| Rate for Payer: One Health Plan of WY PPO |
$102.58
|
| Rate for Payer: PacificSource Commercial |
$94.20
|
| Rate for Payer: PHCS PPO |
$102.58
|
| Rate for Payer: Three Rivers PPO |
$78.50
|
| Rate for Payer: TriWest Veterans Administration |
$60.71
|
| Rate for Payer: United Healthcare Commercial |
$91.06
|
| Rate for Payer: United Healthcare Medicare |
$60.71
|
| Rate for Payer: WINHealth Partners Commercial |
$102.58
|
| Rate for Payer: Wise Provider Network Commercial |
$99.44
|
|
|
AQUACEL AG DRESSING 14"
|
Facility
|
IP
|
$105.73
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$66.29 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$103.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$101.50
|
| Rate for Payer: Altius Commercial |
$101.50
|
| Rate for Payer: Beech Street Commercial |
$103.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$86.80
|
| Rate for Payer: Cash Price |
$74.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$102.56
|
| Rate for Payer: Cigna of WY Commercial |
$103.62
|
| Rate for Payer: Entrust Commercial |
$100.44
|
| Rate for Payer: First Choice Health Commercial |
$100.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$100.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$69.78
|
| Rate for Payer: HealthUtah PPO |
$105.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$102.56
|
| Rate for Payer: Multiplan Medicare/VA |
$66.29
|
| Rate for Payer: One Health Plan of WY PPO |
$103.62
|
| Rate for Payer: PacificSource Commercial |
$95.16
|
| Rate for Payer: PHCS PPO |
$103.62
|
| Rate for Payer: Three Rivers PPO |
$79.30
|
| Rate for Payer: TriWest Veterans Administration |
$69.78
|
| Rate for Payer: United Healthcare Commercial |
$91.99
|
| Rate for Payer: United Healthcare Medicare |
$69.78
|
| Rate for Payer: WINHealth Partners Commercial |
$100.44
|
| Rate for Payer: Wise Provider Network Commercial |
$100.44
|
|
|
AQUACEL AG DRESSING 14"
|
Facility
|
OP
|
$105.73
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.26 |
| Max. Negotiated Rate |
$105.73 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$103.62
|
| Rate for Payer: Aetna of WY Medicare |
$69.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$101.50
|
| Rate for Payer: Altius Commercial |
$101.50
|
| Rate for Payer: Beech Street Commercial |
$103.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$86.80
|
| Rate for Payer: Cash Price |
$74.01
|
| Rate for Payer: ChoiceCare Network Commercial |
$102.56
|
| Rate for Payer: Cigna of WY Commercial |
$103.62
|
| Rate for Payer: Entrust Commercial |
$100.44
|
| Rate for Payer: First Choice Health Commercial |
$100.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$100.44
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$61.32
|
| Rate for Payer: HealthUtah PPO |
$105.73
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$102.56
|
| Rate for Payer: Multiplan Medicare/VA |
$58.26
|
| Rate for Payer: One Health Plan of WY PPO |
$103.62
|
| Rate for Payer: PacificSource Commercial |
$95.16
|
| Rate for Payer: PHCS PPO |
$103.62
|
| Rate for Payer: Three Rivers PPO |
$79.30
|
| Rate for Payer: TriWest Veterans Administration |
$61.32
|
| Rate for Payer: United Healthcare Commercial |
$91.99
|
| Rate for Payer: United Healthcare Medicare |
$61.32
|
| Rate for Payer: WINHealth Partners Commercial |
$103.62
|
| Rate for Payer: Wise Provider Network Commercial |
$100.44
|
|
|
AQUAMANTIS 6.0 BIPOLAR SEALER
|
Facility
|
IP
|
$1,221.99
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$766.19 |
| Max. Negotiated Rate |
$1,221.99 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,197.55
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,173.11
|
| Rate for Payer: Altius Commercial |
$1,173.11
|
| Rate for Payer: Beech Street Commercial |
$1,197.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,003.25
|
| Rate for Payer: Cash Price |
$855.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,185.33
|
| Rate for Payer: Cigna of WY Commercial |
$1,197.55
|
| Rate for Payer: Entrust Commercial |
$1,160.89
|
| Rate for Payer: First Choice Health Commercial |
$1,160.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,160.89
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$806.51
|
| Rate for Payer: HealthUtah PPO |
$1,221.99
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,185.33
|
| Rate for Payer: Multiplan Medicare/VA |
$766.19
|
| Rate for Payer: One Health Plan of WY PPO |
$1,197.55
|
| Rate for Payer: PacificSource Commercial |
$1,099.79
|
| Rate for Payer: PHCS PPO |
$1,197.55
|
| Rate for Payer: Three Rivers PPO |
$916.49
|
| Rate for Payer: TriWest Veterans Administration |
$806.51
|
| Rate for Payer: United Healthcare Commercial |
$1,063.13
|
| Rate for Payer: United Healthcare Medicare |
$806.51
|
| Rate for Payer: WINHealth Partners Commercial |
$1,160.89
|
| Rate for Payer: Wise Provider Network Commercial |
$1,160.89
|
|
