|
EUFLEXXA INJ PER DOSE
|
Professional
|
Both
|
$702.00
|
|
|
Service Code
|
HCPCS J7323
|
| Min. Negotiated Rate |
$98.24 |
| Max. Negotiated Rate |
$702.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$687.96
|
| Rate for Payer: Aetna of WY Medicare |
$115.57
|
| Rate for Payer: Beech Street Commercial |
$666.90
|
| Rate for Payer: Cash Price |
$491.40
|
| Rate for Payer: Cash Price |
$491.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$680.94
|
| Rate for Payer: Cigna of WY Commercial |
$687.96
|
| Rate for Payer: First Choice Health Commercial |
$631.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$666.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$115.57
|
| Rate for Payer: HealthUtah PPO |
$702.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$680.94
|
| Rate for Payer: Multiplan Medicare/VA |
$98.24
|
| Rate for Payer: One Health Plan of WY PPO |
$687.96
|
| Rate for Payer: PacificSource Commercial |
$631.80
|
| Rate for Payer: PHCS PPO |
$666.90
|
| Rate for Payer: Three Rivers PPO |
$526.50
|
| Rate for Payer: TriWest Veterans Administration |
$115.57
|
| Rate for Payer: United Healthcare Commercial |
$666.90
|
| Rate for Payer: WINHealth Partners Commercial |
$666.90
|
|
|
EVAC PVC DRAINAGE BOTTLE 1000M
|
Facility
|
OP
|
$31.32
|
|
| Hospital Charge Code |
2400191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.96 |
| Max. Negotiated Rate |
$31.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.69
|
| Rate for Payer: Aetna of WY Medicare |
$20.67
|
| Rate for Payer: Altius Commercial |
$30.07
|
| Rate for Payer: Beech Street Commercial |
$30.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.38
|
| Rate for Payer: Cash Price |
$21.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$30.38
|
| Rate for Payer: Cigna of WY Commercial |
$30.69
|
| Rate for Payer: Entrust Commercial |
$29.75
|
| Rate for Payer: First Choice Health Commercial |
$29.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$17.85
|
| Rate for Payer: HealthUtah PPO |
$31.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$30.38
|
| Rate for Payer: Multiplan Medicare/VA |
$16.96
|
| Rate for Payer: One Health Plan of WY PPO |
$30.69
|
| Rate for Payer: PacificSource Commercial |
$28.19
|
| Rate for Payer: PHCS PPO |
$30.69
|
| Rate for Payer: Three Rivers PPO |
$23.49
|
| Rate for Payer: TriWest Veterans Administration |
$17.85
|
| Rate for Payer: United Healthcare Commercial |
$29.91
|
| Rate for Payer: United Healthcare Medicare |
$17.85
|
| Rate for Payer: WINHealth Partners Commercial |
$30.69
|
| Rate for Payer: Wise Provider Network Commercial |
$29.75
|
|
|
EVAC PVC DRAINAGE BOTTLE 1000M
|
Facility
|
IP
|
$31.32
|
|
| Hospital Charge Code |
2400191
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.15 |
| Max. Negotiated Rate |
$31.32 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$30.69
|
| Rate for Payer: Aetna of WY Medicare |
$20.04
|
| Rate for Payer: Altius Commercial |
$30.07
|
| Rate for Payer: Beech Street Commercial |
$30.69
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$30.38
|
| Rate for Payer: Cash Price |
$21.93
|
| Rate for Payer: ChoiceCare Network Commercial |
$30.38
|
| Rate for Payer: Cigna of WY Commercial |
$30.69
|
| Rate for Payer: Entrust Commercial |
$29.75
|
| Rate for Payer: First Choice Health Commercial |
$29.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$29.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$19.11
|
| Rate for Payer: HealthUtah PPO |
$31.32
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$30.38
|
| Rate for Payer: Multiplan Medicare/VA |
$18.15
|
| Rate for Payer: One Health Plan of WY PPO |
$30.69
|
| Rate for Payer: PacificSource Commercial |
$28.19
|
| Rate for Payer: PHCS PPO |
$30.69
|
| Rate for Payer: Three Rivers PPO |
$23.49
|
| Rate for Payer: TriWest Veterans Administration |
$19.11
|
| Rate for Payer: United Healthcare Commercial |
$29.91
|
| Rate for Payer: United Healthcare Medicare |
$19.11
|
| Rate for Payer: WINHealth Partners Commercial |
$29.75
|
| Rate for Payer: Wise Provider Network Commercial |
$29.75
|
|
|
EVACUATION SUBUNGUAL HEMATOMA
|
Professional
|
Both
|
$135.00
|
|
|
Service Code
|
HCPCS 11740
|
| Min. Negotiated Rate |
$26.78 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$132.30
|
| Rate for Payer: Aetna of WY Medicare |
$31.51
|
| Rate for Payer: Beech Street Commercial |
$128.25
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.95
|
| Rate for Payer: Cigna of WY Commercial |
$132.30
|
| Rate for Payer: First Choice Health Commercial |
$121.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$128.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.51
|
| Rate for Payer: HealthUtah PPO |
$135.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.95
|
| Rate for Payer: Multiplan Medicare/VA |
$26.78
|
| Rate for Payer: One Health Plan of WY PPO |
$132.30
|
| Rate for Payer: PacificSource Commercial |
$121.50
|
| Rate for Payer: PHCS PPO |
$128.25
|
| Rate for Payer: Three Rivers PPO |
$101.25
|
| Rate for Payer: TriWest Veterans Administration |
$31.51
|
| Rate for Payer: United Healthcare Commercial |
$128.25
|
| Rate for Payer: WINHealth Partners Commercial |
$114.75
|
|
|
EVAC U SPLINT EXTREMITY KIT
|
Facility
|
OP
|
$1,696.48
|
|
| Hospital Charge Code |
2200445
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$918.64 |
| Max. Negotiated Rate |
$1,696.48 |
| Rate for Payer: United Healthcare Commercial |
$1,620.14
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,662.55
|
| Rate for Payer: Aetna of WY Medicare |
$1,119.68
|
| Rate for Payer: Altius Commercial |
$1,628.62
|
| Rate for Payer: Beech Street Commercial |
$1,662.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,645.59
|
| Rate for Payer: Cash Price |
$1,187.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,645.59
|
| Rate for Payer: Cigna of WY Commercial |
$1,662.55
|
| Rate for Payer: Entrust Commercial |
$1,611.66
|
| Rate for Payer: First Choice Health Commercial |
$1,611.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,611.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$966.99
|
| Rate for Payer: HealthUtah PPO |
$1,696.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,645.59
|
| Rate for Payer: Multiplan Medicare/VA |
$918.64
|
| Rate for Payer: One Health Plan of WY PPO |
$1,662.55
|
| Rate for Payer: PacificSource Commercial |
$1,526.83
|
| Rate for Payer: PHCS PPO |
$1,662.55
|
| Rate for Payer: Three Rivers PPO |
$1,272.36
|
| Rate for Payer: TriWest Veterans Administration |
$966.99
|
| Rate for Payer: United Healthcare Medicare |
$966.99
|
| Rate for Payer: WINHealth Partners Commercial |
$1,662.55
|
| Rate for Payer: Wise Provider Network Commercial |
$1,611.66
|
|
|
EVAC U SPLINT EXTREMITY KIT
|
Facility
|
IP
|
$1,696.48
|
|
| Hospital Charge Code |
2200445
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$983.11 |
| Max. Negotiated Rate |
$1,696.48 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,662.55
|
| Rate for Payer: Aetna of WY Medicare |
$1,085.75
|
| Rate for Payer: Altius Commercial |
$1,628.62
|
| Rate for Payer: Beech Street Commercial |
$1,662.55
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,645.59
|
| Rate for Payer: Cash Price |
$1,187.54
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,645.59
|
| Rate for Payer: Cigna of WY Commercial |
$1,662.55
|
| Rate for Payer: Entrust Commercial |
$1,611.66
|
| Rate for Payer: First Choice Health Commercial |
$1,611.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,611.66
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,034.85
|
| Rate for Payer: HealthUtah PPO |
$1,696.48
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,645.59
|
| Rate for Payer: Multiplan Medicare/VA |
$983.11
|
| Rate for Payer: One Health Plan of WY PPO |
$1,662.55
|
| Rate for Payer: PacificSource Commercial |
$1,526.83
|
| Rate for Payer: PHCS PPO |
$1,662.55
|
| Rate for Payer: Three Rivers PPO |
$1,272.36
|
| Rate for Payer: TriWest Veterans Administration |
$1,034.85
|
| Rate for Payer: United Healthcare Commercial |
$1,620.14
|
| Rate for Payer: United Healthcare Medicare |
$1,034.85
|
| Rate for Payer: WINHealth Partners Commercial |
$1,611.66
|
| Rate for Payer: Wise Provider Network Commercial |
$1,611.66
|
|
|
EVAC U SPLINT EXTREMITY SMALL
|
Facility
|
IP
|
$290.64
|
|
| Hospital Charge Code |
2200446
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$168.43 |
| Max. Negotiated Rate |
$290.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$284.83
|
| Rate for Payer: Aetna of WY Medicare |
$186.01
|
| Rate for Payer: Altius Commercial |
$279.01
|
| Rate for Payer: Beech Street Commercial |
$284.83
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$281.92
|
| Rate for Payer: Cash Price |
$203.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$281.92
|
| Rate for Payer: Cigna of WY Commercial |
$284.83
|
| Rate for Payer: Entrust Commercial |
$276.11
|
| Rate for Payer: First Choice Health Commercial |
$276.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$276.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$177.29
|
| Rate for Payer: HealthUtah PPO |
$290.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$281.92
|
| Rate for Payer: Multiplan Medicare/VA |
$168.43
|
| Rate for Payer: One Health Plan of WY PPO |
$284.83
|
| Rate for Payer: PacificSource Commercial |
$261.58
|
| Rate for Payer: PHCS PPO |
$284.83
|
| Rate for Payer: Three Rivers PPO |
$217.98
|
| Rate for Payer: TriWest Veterans Administration |
$177.29
|
| Rate for Payer: United Healthcare Commercial |
$277.56
|
| Rate for Payer: United Healthcare Medicare |
$177.29
|
| Rate for Payer: WINHealth Partners Commercial |
$276.11
|
| Rate for Payer: Wise Provider Network Commercial |
$276.11
|
|
|
EVAC U SPLINT EXTREMITY SMALL
|
Facility
|
OP
|
$290.64
|
|
| Hospital Charge Code |
2200446
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$157.38 |
| Max. Negotiated Rate |
$290.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$284.83
|
| Rate for Payer: Aetna of WY Medicare |
$191.82
|
| Rate for Payer: Altius Commercial |
$279.01
|
| Rate for Payer: Beech Street Commercial |
$284.83
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$281.92
|
| Rate for Payer: Cash Price |
$203.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$281.92
|
| Rate for Payer: Cigna of WY Commercial |
$284.83
|
| Rate for Payer: Entrust Commercial |
$276.11
|
| Rate for Payer: First Choice Health Commercial |
$276.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$276.11
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$165.66
|
| Rate for Payer: HealthUtah PPO |
$290.64
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$281.92
|
| Rate for Payer: Multiplan Medicare/VA |
$157.38
|
| Rate for Payer: One Health Plan of WY PPO |
$284.83
|
| Rate for Payer: PacificSource Commercial |
$261.58
|
| Rate for Payer: PHCS PPO |
$284.83
|
| Rate for Payer: Three Rivers PPO |
$217.98
|
| Rate for Payer: TriWest Veterans Administration |
$165.66
|
| Rate for Payer: United Healthcare Commercial |
$277.56
|
| Rate for Payer: United Healthcare Medicare |
$165.66
|
| Rate for Payer: WINHealth Partners Commercial |
$284.83
|
| Rate for Payer: Wise Provider Network Commercial |
$276.11
|
|
|
EVAL C/V AMNIOTIC FLUID PROTEIN QUAL EA SPECIMEN
|
Professional
|
Both
|
$240.00
|
|
|
Service Code
|
HCPCS 84112
|
| Min. Negotiated Rate |
$83.39 |
| Max. Negotiated Rate |
$240.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$235.20
|
| Rate for Payer: Aetna of WY Medicare |
$98.11
|
| Rate for Payer: Beech Street Commercial |
$228.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: Cash Price |
$168.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$232.80
|
| Rate for Payer: Cigna of WY Commercial |
$235.20
|
| Rate for Payer: First Choice Health Commercial |
$216.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$228.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$98.11
|
| Rate for Payer: HealthUtah PPO |
$240.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$232.80
|
| Rate for Payer: Multiplan Medicare/VA |
$83.39
|
| Rate for Payer: One Health Plan of WY PPO |
$235.20
|
| Rate for Payer: PacificSource Commercial |
$216.00
|
| Rate for Payer: PHCS PPO |
$228.00
|
| Rate for Payer: Three Rivers PPO |
$180.00
|
| Rate for Payer: TriWest Veterans Administration |
$98.11
|
| Rate for Payer: United Healthcare Commercial |
$228.00
|
| Rate for Payer: WINHealth Partners Commercial |
$228.00
|
|
|
EVAL ORAL&PHARYNGEAL SWLNG FUNCJ
|
Professional
|
Both
|
$256.00
|
|
|
Service Code
|
HCPCS 92610
|
| Min. Negotiated Rate |
$58.16 |
| Max. Negotiated Rate |
$256.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$250.88
|
| Rate for Payer: Aetna of WY Medicare |
$68.42
|
| 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 |
$68.42
|
| Rate for Payer: HealthUtah PPO |
$256.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$248.32
|
| Rate for Payer: Multiplan Medicare/VA |
$58.16
|
| 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 |
$68.42
|
| Rate for Payer: United Healthcare Commercial |
$243.20
|
| Rate for Payer: WINHealth Partners Commercial |
$243.20
|
|
|
EVERLIFT SUBMUCOSAL LIFT AGENT
|
Facility
|
IP
|
$276.50
|
|
| Hospital Charge Code |
6650193
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$160.23 |
| Max. Negotiated Rate |
$276.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$270.97
|
| Rate for Payer: Aetna of WY Medicare |
$176.96
|
| Rate for Payer: Altius Commercial |
$265.44
|
| Rate for Payer: Beech Street Commercial |
$270.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$268.20
|
| Rate for Payer: Cash Price |
$193.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$268.20
|
| Rate for Payer: Cigna of WY Commercial |
$270.97
|
| Rate for Payer: Entrust Commercial |
$262.68
|
| Rate for Payer: First Choice Health Commercial |
$262.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$262.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$168.66
|
| Rate for Payer: HealthUtah PPO |
$276.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$268.20
|
| Rate for Payer: Multiplan Medicare/VA |
$160.23
|
| Rate for Payer: One Health Plan of WY PPO |
$270.97
|
| Rate for Payer: PacificSource Commercial |
$248.85
|
| Rate for Payer: PHCS PPO |
$270.97
|
| Rate for Payer: Three Rivers PPO |
$207.38
|
| Rate for Payer: TriWest Veterans Administration |
$168.66
|
| Rate for Payer: United Healthcare Commercial |
$264.06
|
| Rate for Payer: United Healthcare Medicare |
$168.66
|
| Rate for Payer: WINHealth Partners Commercial |
$262.68
|
| Rate for Payer: Wise Provider Network Commercial |
$262.68
|
|
|
EVERLIFT SUBMUCOSAL LIFT AGENT
|
Facility
|
OP
|
$276.50
|
|
| Hospital Charge Code |
6650193
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$149.72 |
| Max. Negotiated Rate |
$276.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$270.97
|
| Rate for Payer: Aetna of WY Medicare |
$182.49
|
| Rate for Payer: Altius Commercial |
$265.44
|
| Rate for Payer: Beech Street Commercial |
$270.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$268.20
|
| Rate for Payer: Cash Price |
$193.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$268.20
|
| Rate for Payer: Cigna of WY Commercial |
$270.97
|
| Rate for Payer: Entrust Commercial |
$262.68
|
| Rate for Payer: First Choice Health Commercial |
$262.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$262.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$157.60
|
| Rate for Payer: HealthUtah PPO |
$276.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$268.20
|
| Rate for Payer: Multiplan Medicare/VA |
$149.72
|
| Rate for Payer: One Health Plan of WY PPO |
$270.97
|
| Rate for Payer: PacificSource Commercial |
$248.85
|
| Rate for Payer: PHCS PPO |
$270.97
|
| Rate for Payer: Three Rivers PPO |
$207.38
|
| Rate for Payer: TriWest Veterans Administration |
$157.60
|
| Rate for Payer: United Healthcare Commercial |
$264.06
|
| Rate for Payer: United Healthcare Medicare |
$157.60
|
| Rate for Payer: WINHealth Partners Commercial |
$270.97
|
| Rate for Payer: Wise Provider Network Commercial |
$262.68
|
|
|
EWHFO RIGID W/O JNTS CF
|
Professional
|
Both
|
$1,627.00
|
|
|
Service Code
|
HCPCS L3765
|
| Min. Negotiated Rate |
$1,220.25 |
| Max. Negotiated Rate |
$1,627.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,594.46
|
| Rate for Payer: Beech Street Commercial |
$1,545.65
|
| Rate for Payer: Cash Price |
$1,138.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,578.19
|
| Rate for Payer: Cigna of WY Commercial |
$1,594.46
|
| Rate for Payer: First Choice Health Commercial |
$1,464.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,545.65
|
| Rate for Payer: HealthUtah PPO |
$1,627.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,578.19
|
| Rate for Payer: One Health Plan of WY PPO |
$1,594.46
|
| Rate for Payer: PacificSource Commercial |
$1,464.30
|
| Rate for Payer: PHCS PPO |
$1,545.65
|
| Rate for Payer: Three Rivers PPO |
$1,220.25
|
| Rate for Payer: United Healthcare Commercial |
$1,545.65
|
| Rate for Payer: WINHealth Partners Commercial |
$1,545.65
|
|
|
EWHFO W/JOINT(S) CF
|
Professional
|
Both
|
$1,723.00
|
|
|
Service Code
|
HCPCS L3766
|
| Min. Negotiated Rate |
$1,292.25 |
| Max. Negotiated Rate |
$1,723.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,688.54
|
| Rate for Payer: Beech Street Commercial |
$1,636.85
|
| Rate for Payer: Cash Price |
$1,206.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,671.31
|
| Rate for Payer: Cigna of WY Commercial |
$1,688.54
|
| Rate for Payer: First Choice Health Commercial |
$1,550.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,636.85
|
| Rate for Payer: HealthUtah PPO |
$1,723.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,671.31
|
| Rate for Payer: One Health Plan of WY PPO |
$1,688.54
|
| Rate for Payer: PacificSource Commercial |
$1,550.70
|
| Rate for Payer: PHCS PPO |
$1,636.85
|
| Rate for Payer: Three Rivers PPO |
$1,292.25
|
| Rate for Payer: United Healthcare Commercial |
$1,636.85
|
| Rate for Payer: WINHealth Partners Commercial |
$1,636.85
|
|
|
EWHO RIGID W/O JNTS CF
|
Professional
|
Both
|
$853.00
|
|
|
Service Code
|
HCPCS L3763
|
| Min. Negotiated Rate |
$639.75 |
| Max. Negotiated Rate |
$853.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$835.94
|
| Rate for Payer: Beech Street Commercial |
$810.35
|
| Rate for Payer: Cash Price |
$597.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$827.41
|
| Rate for Payer: Cigna of WY Commercial |
$835.94
|
| Rate for Payer: First Choice Health Commercial |
$767.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$810.35
|
| Rate for Payer: HealthUtah PPO |
$853.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$827.41
|
| Rate for Payer: One Health Plan of WY PPO |
$835.94
|
| Rate for Payer: PacificSource Commercial |
$767.70
|
| Rate for Payer: PHCS PPO |
$810.35
|
| Rate for Payer: Three Rivers PPO |
$639.75
|
| Rate for Payer: United Healthcare Commercial |
$810.35
|
| Rate for Payer: WINHealth Partners Commercial |
$810.35
|
|
|
EWHO W/JOINT(S) CF
|
Professional
|
Both
|
$973.00
|
|
|
Service Code
|
HCPCS L3764
|
| Min. Negotiated Rate |
$729.75 |
| Max. Negotiated Rate |
$973.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$953.54
|
| Rate for Payer: Beech Street Commercial |
$924.35
|
| Rate for Payer: Cash Price |
$681.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$943.81
|
| Rate for Payer: Cigna of WY Commercial |
$953.54
|
| Rate for Payer: First Choice Health Commercial |
$875.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$924.35
|
| Rate for Payer: HealthUtah PPO |
$973.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$943.81
|
| Rate for Payer: One Health Plan of WY PPO |
$953.54
|
| Rate for Payer: PacificSource Commercial |
$875.70
|
| Rate for Payer: PHCS PPO |
$924.35
|
| Rate for Payer: Three Rivers PPO |
$729.75
|
| Rate for Payer: United Healthcare Commercial |
$924.35
|
| Rate for Payer: WINHealth Partners Commercial |
$924.35
|
|
|
EXCALIBUR CURVED 4.0MM 8400CEX
|
Facility
|
IP
|
$269.82
|
|
| Hospital Charge Code |
2650867
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$156.36 |
| Max. Negotiated Rate |
$269.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.42
|
| Rate for Payer: Aetna of WY Medicare |
$172.68
|
| Rate for Payer: Altius Commercial |
$259.03
|
| Rate for Payer: Beech Street Commercial |
$264.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$261.73
|
| Rate for Payer: Cash Price |
$188.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.73
|
| Rate for Payer: Cigna of WY Commercial |
$264.42
|
| Rate for Payer: Entrust Commercial |
$256.33
|
| Rate for Payer: First Choice Health Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$164.59
|
| Rate for Payer: HealthUtah PPO |
$269.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.73
|
| Rate for Payer: Multiplan Medicare/VA |
$156.36
|
| Rate for Payer: One Health Plan of WY PPO |
$264.42
|
| Rate for Payer: PacificSource Commercial |
$242.84
|
| Rate for Payer: PHCS PPO |
$264.42
|
| Rate for Payer: Three Rivers PPO |
$202.36
|
| Rate for Payer: TriWest Veterans Administration |
$164.59
|
| Rate for Payer: United Healthcare Commercial |
$257.68
|
| Rate for Payer: United Healthcare Medicare |
$164.59
|
| Rate for Payer: WINHealth Partners Commercial |
$256.33
|
| Rate for Payer: Wise Provider Network Commercial |
$256.33
|
|
|
EXCALIBUR CURVED 4.0MM 8400CEX
|
Facility
|
OP
|
$269.82
|
|
| Hospital Charge Code |
2650867
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$146.11 |
| Max. Negotiated Rate |
$269.82 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$264.42
|
| Rate for Payer: Aetna of WY Medicare |
$178.08
|
| Rate for Payer: Altius Commercial |
$259.03
|
| Rate for Payer: Beech Street Commercial |
$264.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$261.73
|
| Rate for Payer: Cash Price |
$188.87
|
| Rate for Payer: ChoiceCare Network Commercial |
$261.73
|
| Rate for Payer: Cigna of WY Commercial |
$264.42
|
| Rate for Payer: Entrust Commercial |
$256.33
|
| Rate for Payer: First Choice Health Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$256.33
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$153.80
|
| Rate for Payer: HealthUtah PPO |
$269.82
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$261.73
|
| Rate for Payer: Multiplan Medicare/VA |
$146.11
|
| Rate for Payer: One Health Plan of WY PPO |
$264.42
|
| Rate for Payer: PacificSource Commercial |
$242.84
|
| Rate for Payer: PHCS PPO |
$264.42
|
| Rate for Payer: Three Rivers PPO |
$202.36
|
| Rate for Payer: TriWest Veterans Administration |
$153.80
|
| Rate for Payer: United Healthcare Commercial |
$257.68
|
| Rate for Payer: United Healthcare Medicare |
$153.80
|
| Rate for Payer: WINHealth Partners Commercial |
$264.42
|
| Rate for Payer: Wise Provider Network Commercial |
$256.33
|
|
|
EXCALIBUR SHAVER 4.0MM 8400EX
|
Facility
|
OP
|
$241.18
|
|
| Hospital Charge Code |
2650869
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$130.60 |
| Max. Negotiated Rate |
$241.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.36
|
| Rate for Payer: Aetna of WY Medicare |
$159.18
|
| Rate for Payer: Altius Commercial |
$231.53
|
| Rate for Payer: Beech Street Commercial |
$236.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.94
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.94
|
| Rate for Payer: Cigna of WY Commercial |
$236.36
|
| Rate for Payer: Entrust Commercial |
$229.12
|
| Rate for Payer: First Choice Health Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$137.47
|
| Rate for Payer: HealthUtah PPO |
$241.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.94
|
| Rate for Payer: Multiplan Medicare/VA |
$130.60
|
| Rate for Payer: One Health Plan of WY PPO |
$236.36
|
| Rate for Payer: PacificSource Commercial |
$217.06
|
| Rate for Payer: PHCS PPO |
$236.36
|
| Rate for Payer: Three Rivers PPO |
$180.88
|
| Rate for Payer: TriWest Veterans Administration |
$137.47
|
| Rate for Payer: United Healthcare Commercial |
$230.33
|
| Rate for Payer: United Healthcare Medicare |
$137.47
|
| Rate for Payer: WINHealth Partners Commercial |
$236.36
|
| Rate for Payer: Wise Provider Network Commercial |
$229.12
|
|
|
EXCALIBUR SHAVER 4.0MM 8400EX
|
Facility
|
IP
|
$241.18
|
|
| Hospital Charge Code |
2650869
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$139.76 |
| Max. Negotiated Rate |
$241.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.36
|
| Rate for Payer: Aetna of WY Medicare |
$154.36
|
| Rate for Payer: Altius Commercial |
$231.53
|
| Rate for Payer: Beech Street Commercial |
$236.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.94
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.94
|
| Rate for Payer: Cigna of WY Commercial |
$236.36
|
| Rate for Payer: Entrust Commercial |
$229.12
|
| Rate for Payer: First Choice Health Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$147.12
|
| Rate for Payer: HealthUtah PPO |
$241.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.94
|
| Rate for Payer: Multiplan Medicare/VA |
$139.76
|
| Rate for Payer: One Health Plan of WY PPO |
$236.36
|
| Rate for Payer: PacificSource Commercial |
$217.06
|
| Rate for Payer: PHCS PPO |
$236.36
|
| Rate for Payer: Three Rivers PPO |
$180.88
|
| Rate for Payer: TriWest Veterans Administration |
$147.12
|
| Rate for Payer: United Healthcare Commercial |
$230.33
|
| Rate for Payer: United Healthcare Medicare |
$147.12
|
| Rate for Payer: WINHealth Partners Commercial |
$229.12
|
| Rate for Payer: Wise Provider Network Commercial |
$229.12
|
|
|
EXCALIBUR SHAVER 5.5MM 8550EX
|
Facility
|
OP
|
$241.18
|
|
| Hospital Charge Code |
2650868
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$130.60 |
| Max. Negotiated Rate |
$241.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.36
|
| Rate for Payer: Aetna of WY Medicare |
$159.18
|
| Rate for Payer: Altius Commercial |
$231.53
|
| Rate for Payer: Beech Street Commercial |
$236.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.94
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.94
|
| Rate for Payer: Cigna of WY Commercial |
$236.36
|
| Rate for Payer: Entrust Commercial |
$229.12
|
| Rate for Payer: First Choice Health Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$137.47
|
| Rate for Payer: HealthUtah PPO |
$241.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.94
|
| Rate for Payer: Multiplan Medicare/VA |
$130.60
|
| Rate for Payer: One Health Plan of WY PPO |
$236.36
|
| Rate for Payer: PacificSource Commercial |
$217.06
|
| Rate for Payer: PHCS PPO |
$236.36
|
| Rate for Payer: Three Rivers PPO |
$180.88
|
| Rate for Payer: TriWest Veterans Administration |
$137.47
|
| Rate for Payer: United Healthcare Commercial |
$230.33
|
| Rate for Payer: United Healthcare Medicare |
$137.47
|
| Rate for Payer: WINHealth Partners Commercial |
$236.36
|
| Rate for Payer: Wise Provider Network Commercial |
$229.12
|
|
|
EXCALIBUR SHAVER 5.5MM 8550EX
|
Facility
|
IP
|
$241.18
|
|
| Hospital Charge Code |
2650868
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$139.76 |
| Max. Negotiated Rate |
$241.18 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$236.36
|
| Rate for Payer: Aetna of WY Medicare |
$154.36
|
| Rate for Payer: Altius Commercial |
$231.53
|
| Rate for Payer: Beech Street Commercial |
$236.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$233.94
|
| Rate for Payer: Cash Price |
$168.83
|
| Rate for Payer: ChoiceCare Network Commercial |
$233.94
|
| Rate for Payer: Cigna of WY Commercial |
$236.36
|
| Rate for Payer: Entrust Commercial |
$229.12
|
| Rate for Payer: First Choice Health Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$229.12
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$147.12
|
| Rate for Payer: HealthUtah PPO |
$241.18
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$233.94
|
| Rate for Payer: Multiplan Medicare/VA |
$139.76
|
| Rate for Payer: One Health Plan of WY PPO |
$236.36
|
| Rate for Payer: PacificSource Commercial |
$217.06
|
| Rate for Payer: PHCS PPO |
$236.36
|
| Rate for Payer: Three Rivers PPO |
$180.88
|
| Rate for Payer: TriWest Veterans Administration |
$147.12
|
| Rate for Payer: United Healthcare Commercial |
$230.33
|
| Rate for Payer: United Healthcare Medicare |
$147.12
|
| Rate for Payer: WINHealth Partners Commercial |
$229.12
|
| Rate for Payer: Wise Provider Network Commercial |
$229.12
|
|
|
EXC B9 LESION MRGN XCP SK TG F/E/E/N/L/M 0.5CM/<
|
Professional
|
Both
|
$440.00
|
|
|
Service Code
|
HCPCS 11440
|
| Min. Negotiated Rate |
$89.38 |
| Max. Negotiated Rate |
$440.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$431.20
|
| Rate for Payer: Aetna of WY Medicare |
$105.15
|
| Rate for Payer: Beech Street Commercial |
$418.00
|
| Rate for Payer: Cash Price |
$308.00
|
| Rate for Payer: Cash Price |
$308.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$426.80
|
| Rate for Payer: Cigna of WY Commercial |
$431.20
|
| Rate for Payer: First Choice Health Commercial |
$396.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$418.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$105.15
|
| Rate for Payer: HealthUtah PPO |
$440.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$426.80
|
| Rate for Payer: Multiplan Medicare/VA |
$89.38
|
| Rate for Payer: One Health Plan of WY PPO |
$431.20
|
| Rate for Payer: PacificSource Commercial |
$396.00
|
| Rate for Payer: PHCS PPO |
$418.00
|
| Rate for Payer: Three Rivers PPO |
$330.00
|
| Rate for Payer: TriWest Veterans Administration |
$105.15
|
| Rate for Payer: United Healthcare Commercial |
$418.00
|
| Rate for Payer: WINHealth Partners Commercial |
$374.00
|
|
|
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.5 CM/<
|
Professional
|
Both
|
$351.00
|
|
|
Service Code
|
HCPCS 11420
|
| Min. Negotiated Rate |
$68.30 |
| Max. Negotiated Rate |
$351.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$343.98
|
| Rate for Payer: Aetna of WY Medicare |
$80.35
|
| Rate for Payer: Beech Street Commercial |
$333.45
|
| Rate for Payer: Cash Price |
$245.70
|
| Rate for Payer: Cash Price |
$245.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$340.47
|
| Rate for Payer: Cigna of WY Commercial |
$343.98
|
| Rate for Payer: First Choice Health Commercial |
$315.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$333.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$80.35
|
| Rate for Payer: HealthUtah PPO |
$351.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$340.47
|
| Rate for Payer: Multiplan Medicare/VA |
$68.30
|
| Rate for Payer: One Health Plan of WY PPO |
$343.98
|
| Rate for Payer: PacificSource Commercial |
$315.90
|
| Rate for Payer: PHCS PPO |
$333.45
|
| Rate for Payer: Three Rivers PPO |
$263.25
|
| Rate for Payer: TriWest Veterans Administration |
$80.35
|
| Rate for Payer: United Healthcare Commercial |
$333.45
|
| Rate for Payer: WINHealth Partners Commercial |
$298.35
|
|
|
EXC B9 LESION MRGN XCP SK TG S/N/H/F/G 0.6-1.0CM
|
Professional
|
Both
|
$467.00
|
|
|
Service Code
|
HCPCS 11421
|
| Min. Negotiated Rate |
$90.34 |
| Max. Negotiated Rate |
$467.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$457.66
|
| Rate for Payer: Aetna of WY Medicare |
$106.28
|
| Rate for Payer: Beech Street Commercial |
$443.65
|
| Rate for Payer: Cash Price |
$326.90
|
| Rate for Payer: Cash Price |
$326.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$452.99
|
| Rate for Payer: Cigna of WY Commercial |
$457.66
|
| Rate for Payer: First Choice Health Commercial |
$420.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$443.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$106.28
|
| Rate for Payer: HealthUtah PPO |
$467.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$452.99
|
| Rate for Payer: Multiplan Medicare/VA |
$90.34
|
| Rate for Payer: One Health Plan of WY PPO |
$457.66
|
| Rate for Payer: PacificSource Commercial |
$420.30
|
| Rate for Payer: PHCS PPO |
$443.65
|
| Rate for Payer: Three Rivers PPO |
$350.25
|
| Rate for Payer: TriWest Veterans Administration |
$106.28
|
| Rate for Payer: United Healthcare Commercial |
$443.65
|
| Rate for Payer: WINHealth Partners Commercial |
$396.95
|
|
