|
HC APPLY LONG ARM CAST
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS 29065
|
| Hospital Charge Code |
7612906501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$127.40
|
| Rate for Payer: Aetna of WY Medicare |
$85.80
|
| Rate for Payer: Altius Commercial |
$124.80
|
| Rate for Payer: Beech Street Commercial |
$127.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.10
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.10
|
| Rate for Payer: Cigna of WY Commercial |
$127.40
|
| Rate for Payer: Entrust Commercial |
$123.50
|
| Rate for Payer: First Choice Health Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.10
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.10
|
| Rate for Payer: Multiplan Medicare/VA |
$70.40
|
| Rate for Payer: One Health Plan of WY PPO |
$127.40
|
| Rate for Payer: PacificSource Commercial |
$117.00
|
| Rate for Payer: PHCS PPO |
$127.40
|
| Rate for Payer: Three Rivers PPO |
$97.50
|
| Rate for Payer: TriWest Veterans Administration |
$74.10
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
| Rate for Payer: United Healthcare Medicare |
$74.10
|
| Rate for Payer: WINHealth Partners Commercial |
$127.40
|
| Rate for Payer: Wise Provider Network Commercial |
$123.50
|
|
|
HC APPLY LONG ARM SPLINT
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
7612910501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$127.40
|
| Rate for Payer: Aetna of WY Medicare |
$85.80
|
| Rate for Payer: Altius Commercial |
$124.80
|
| Rate for Payer: Beech Street Commercial |
$127.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.10
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.10
|
| Rate for Payer: Cigna of WY Commercial |
$127.40
|
| Rate for Payer: Entrust Commercial |
$123.50
|
| Rate for Payer: First Choice Health Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.10
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.10
|
| Rate for Payer: Multiplan Medicare/VA |
$70.40
|
| Rate for Payer: One Health Plan of WY PPO |
$127.40
|
| Rate for Payer: PacificSource Commercial |
$117.00
|
| Rate for Payer: PHCS PPO |
$127.40
|
| Rate for Payer: Three Rivers PPO |
$97.50
|
| Rate for Payer: TriWest Veterans Administration |
$74.10
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
| Rate for Payer: United Healthcare Medicare |
$74.10
|
| Rate for Payer: WINHealth Partners Commercial |
$127.40
|
| Rate for Payer: Wise Provider Network Commercial |
$123.50
|
|
|
HC APPLY LONG ARM SPLINT
|
Facility
|
IP
|
$33.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
5102910501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$19.12 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.34
|
| Rate for Payer: Aetna of WY Medicare |
$21.12
|
| Rate for Payer: Altius Commercial |
$31.68
|
| Rate for Payer: Beech Street Commercial |
$32.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.01
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.01
|
| Rate for Payer: Cigna of WY Commercial |
$32.34
|
| Rate for Payer: Entrust Commercial |
$31.35
|
| Rate for Payer: First Choice Health Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.13
|
| Rate for Payer: HealthUtah PPO |
$33.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.01
|
| Rate for Payer: Multiplan Medicare/VA |
$19.12
|
| Rate for Payer: One Health Plan of WY PPO |
$32.34
|
| Rate for Payer: PacificSource Commercial |
$29.70
|
| Rate for Payer: PHCS PPO |
$32.34
|
| Rate for Payer: Three Rivers PPO |
$24.75
|
| Rate for Payer: TriWest Veterans Administration |
$20.13
|
| Rate for Payer: United Healthcare Commercial |
$31.52
|
| Rate for Payer: United Healthcare Medicare |
$20.13
|
| Rate for Payer: WINHealth Partners Commercial |
$31.35
|
| Rate for Payer: Wise Provider Network Commercial |
$31.35
|
|
|
HC APPLY LONG ARM SPLINT
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
7612910501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.34 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$127.40
|
| Rate for Payer: Aetna of WY Medicare |
$83.20
|
| Rate for Payer: Altius Commercial |
$124.80
|
| Rate for Payer: Beech Street Commercial |
$127.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.10
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.10
|
| Rate for Payer: Cigna of WY Commercial |
$127.40
|
| Rate for Payer: Entrust Commercial |
$123.50
|
| Rate for Payer: First Choice Health Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.30
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.10
|
| Rate for Payer: Multiplan Medicare/VA |
$75.34
|
| Rate for Payer: One Health Plan of WY PPO |
$127.40
|
| Rate for Payer: PacificSource Commercial |
$117.00
|
| Rate for Payer: PHCS PPO |
$127.40
|
| Rate for Payer: Three Rivers PPO |
$97.50
|
| Rate for Payer: TriWest Veterans Administration |
$79.30
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
| Rate for Payer: United Healthcare Medicare |
$79.30
|
| Rate for Payer: WINHealth Partners Commercial |
$123.50
|
| Rate for Payer: Wise Provider Network Commercial |
$123.50
|
|
|
HC APPLY LONG ARM SPLINT
|
Facility
|
OP
|
$33.00
|
|
|
Service Code
|
HCPCS 29105
|
| Hospital Charge Code |
5102910501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$17.87 |
| Max. Negotiated Rate |
$33.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$32.34
|
| Rate for Payer: Aetna of WY Medicare |
$21.78
|
| Rate for Payer: Altius Commercial |
$31.68
|
| Rate for Payer: Beech Street Commercial |
$32.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$32.01
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$32.01
|
| Rate for Payer: Cigna of WY Commercial |
$32.34
|
| Rate for Payer: Entrust Commercial |
$31.35
|
| Rate for Payer: First Choice Health Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$31.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$18.81
|
| Rate for Payer: HealthUtah PPO |
$33.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$32.01
|
| Rate for Payer: Multiplan Medicare/VA |
$17.87
|
| Rate for Payer: One Health Plan of WY PPO |
$32.34
|
| Rate for Payer: PacificSource Commercial |
$29.70
|
| Rate for Payer: PHCS PPO |
$32.34
|
| Rate for Payer: Three Rivers PPO |
$24.75
|
| Rate for Payer: TriWest Veterans Administration |
$18.81
|
| Rate for Payer: United Healthcare Commercial |
$31.52
|
| Rate for Payer: United Healthcare Medicare |
$18.81
|
| Rate for Payer: WINHealth Partners Commercial |
$32.34
|
| Rate for Payer: Wise Provider Network Commercial |
$31.35
|
|
|
HC APPLY LONG LEG SPLINT
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS 29505
|
| Hospital Charge Code |
7002950501
|
|
Hospital Revenue Code
|
700
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$127.40
|
| Rate for Payer: Aetna of WY Medicare |
$85.80
|
| Rate for Payer: Altius Commercial |
$124.80
|
| Rate for Payer: Beech Street Commercial |
$127.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.10
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.10
|
| Rate for Payer: Cigna of WY Commercial |
$127.40
|
| Rate for Payer: Entrust Commercial |
$123.50
|
| Rate for Payer: First Choice Health Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.10
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.10
|
| Rate for Payer: Multiplan Medicare/VA |
$70.40
|
| Rate for Payer: One Health Plan of WY PPO |
$127.40
|
| Rate for Payer: PacificSource Commercial |
$117.00
|
| Rate for Payer: PHCS PPO |
$127.40
|
| Rate for Payer: Three Rivers PPO |
$97.50
|
| Rate for Payer: TriWest Veterans Administration |
$74.10
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
| Rate for Payer: United Healthcare Medicare |
$74.10
|
| Rate for Payer: WINHealth Partners Commercial |
$127.40
|
| Rate for Payer: Wise Provider Network Commercial |
$123.50
|
|
|
HC APPLY LONG LEG SPLINT
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS 29505
|
| Hospital Charge Code |
7002950501
|
|
Hospital Revenue Code
|
700
|
| Min. Negotiated Rate |
$75.34 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$127.40
|
| Rate for Payer: Aetna of WY Medicare |
$83.20
|
| Rate for Payer: Altius Commercial |
$124.80
|
| Rate for Payer: Beech Street Commercial |
$127.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.10
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.10
|
| Rate for Payer: Cigna of WY Commercial |
$127.40
|
| Rate for Payer: Entrust Commercial |
$123.50
|
| Rate for Payer: First Choice Health Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.30
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.10
|
| Rate for Payer: Multiplan Medicare/VA |
$75.34
|
| Rate for Payer: One Health Plan of WY PPO |
$127.40
|
| Rate for Payer: PacificSource Commercial |
$117.00
|
| Rate for Payer: PHCS PPO |
$127.40
|
| Rate for Payer: Three Rivers PPO |
$97.50
|
| Rate for Payer: TriWest Veterans Administration |
$79.30
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
| Rate for Payer: United Healthcare Medicare |
$79.30
|
| Rate for Payer: WINHealth Partners Commercial |
$123.50
|
| Rate for Payer: Wise Provider Network Commercial |
$123.50
|
|
|
HC APPLY LOWER LEG SPLINT
|
Facility
|
IP
|
$39.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
5102951501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$22.60 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.22
|
| Rate for Payer: Aetna of WY Medicare |
$24.96
|
| Rate for Payer: Altius Commercial |
$37.44
|
| Rate for Payer: Beech Street Commercial |
$38.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37.83
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$37.83
|
| Rate for Payer: Cigna of WY Commercial |
$38.22
|
| Rate for Payer: Entrust Commercial |
$37.05
|
| Rate for Payer: First Choice Health Commercial |
$37.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.79
|
| Rate for Payer: HealthUtah PPO |
$39.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$37.83
|
| Rate for Payer: Multiplan Medicare/VA |
$22.60
|
| Rate for Payer: One Health Plan of WY PPO |
$38.22
|
| Rate for Payer: PacificSource Commercial |
$35.10
|
| Rate for Payer: PHCS PPO |
$38.22
|
| Rate for Payer: Three Rivers PPO |
$29.25
|
| Rate for Payer: TriWest Veterans Administration |
$23.79
|
| Rate for Payer: United Healthcare Commercial |
$37.24
|
| Rate for Payer: United Healthcare Medicare |
$23.79
|
| Rate for Payer: WINHealth Partners Commercial |
$37.05
|
| Rate for Payer: Wise Provider Network Commercial |
$37.05
|
|
|
HC APPLY LOWER LEG SPLINT
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
7612951501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$75.34 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$127.40
|
| Rate for Payer: Aetna of WY Medicare |
$83.20
|
| Rate for Payer: Altius Commercial |
$124.80
|
| Rate for Payer: Beech Street Commercial |
$127.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.10
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.10
|
| Rate for Payer: Cigna of WY Commercial |
$127.40
|
| Rate for Payer: Entrust Commercial |
$123.50
|
| Rate for Payer: First Choice Health Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.30
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.10
|
| Rate for Payer: Multiplan Medicare/VA |
$75.34
|
| Rate for Payer: One Health Plan of WY PPO |
$127.40
|
| Rate for Payer: PacificSource Commercial |
$117.00
|
| Rate for Payer: PHCS PPO |
$127.40
|
| Rate for Payer: Three Rivers PPO |
$97.50
|
| Rate for Payer: TriWest Veterans Administration |
$79.30
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
| Rate for Payer: United Healthcare Medicare |
$79.30
|
| Rate for Payer: WINHealth Partners Commercial |
$123.50
|
| Rate for Payer: Wise Provider Network Commercial |
$123.50
|
|
|
HC APPLY LOWER LEG SPLINT
|
Facility
|
OP
|
$39.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
5102951501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$21.12 |
| Max. Negotiated Rate |
$39.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$38.22
|
| Rate for Payer: Aetna of WY Medicare |
$25.74
|
| Rate for Payer: Altius Commercial |
$37.44
|
| Rate for Payer: Beech Street Commercial |
$38.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$37.83
|
| Rate for Payer: Cash Price |
$27.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$37.83
|
| Rate for Payer: Cigna of WY Commercial |
$38.22
|
| Rate for Payer: Entrust Commercial |
$37.05
|
| Rate for Payer: First Choice Health Commercial |
$37.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$37.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$22.23
|
| Rate for Payer: HealthUtah PPO |
$39.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$37.83
|
| Rate for Payer: Multiplan Medicare/VA |
$21.12
|
| Rate for Payer: One Health Plan of WY PPO |
$38.22
|
| Rate for Payer: PacificSource Commercial |
$35.10
|
| Rate for Payer: PHCS PPO |
$38.22
|
| Rate for Payer: Three Rivers PPO |
$29.25
|
| Rate for Payer: TriWest Veterans Administration |
$22.23
|
| Rate for Payer: United Healthcare Commercial |
$37.24
|
| Rate for Payer: United Healthcare Medicare |
$22.23
|
| Rate for Payer: WINHealth Partners Commercial |
$38.22
|
| Rate for Payer: Wise Provider Network Commercial |
$37.05
|
|
|
HC APPLY LOWER LEG SPLINT
|
Facility
|
IP
|
$130.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
7002951501
|
|
Hospital Revenue Code
|
700
|
| Min. Negotiated Rate |
$75.34 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$127.40
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$449.82
|
| Rate for Payer: Aetna of WY Medicare |
$293.76
|
| Rate for Payer: Aetna of WY Medicare |
$83.20
|
| Rate for Payer: Altius Commercial |
$440.64
|
| Rate for Payer: Altius Commercial |
$124.80
|
| Rate for Payer: Beech Street Commercial |
$449.82
|
| Rate for Payer: Beech Street Commercial |
$127.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$445.23
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.10
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: Cash Price |
$321.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$445.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.10
|
| Rate for Payer: Cigna of WY Commercial |
$127.40
|
| Rate for Payer: Cigna of WY Commercial |
$449.82
|
| Rate for Payer: Entrust Commercial |
$123.50
|
| Rate for Payer: Entrust Commercial |
$436.05
|
| Rate for Payer: First Choice Health Commercial |
$436.05
|
| Rate for Payer: First Choice Health Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$436.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$279.99
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.30
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: HealthUtah PPO |
$459.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$445.23
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.10
|
| Rate for Payer: Multiplan Medicare/VA |
$75.34
|
| Rate for Payer: Multiplan Medicare/VA |
$265.99
|
| Rate for Payer: One Health Plan of WY PPO |
$127.40
|
| Rate for Payer: One Health Plan of WY PPO |
$449.82
|
| Rate for Payer: PacificSource Commercial |
$413.10
|
| Rate for Payer: PacificSource Commercial |
$117.00
|
| Rate for Payer: PHCS PPO |
$127.40
|
| Rate for Payer: PHCS PPO |
$449.82
|
| Rate for Payer: Three Rivers PPO |
$97.50
|
| Rate for Payer: Three Rivers PPO |
$344.25
|
| Rate for Payer: TriWest Veterans Administration |
$279.99
|
| Rate for Payer: TriWest Veterans Administration |
$79.30
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
| Rate for Payer: United Healthcare Commercial |
$438.34
|
| Rate for Payer: United Healthcare Medicare |
$279.99
|
| Rate for Payer: United Healthcare Medicare |
$79.30
|
| Rate for Payer: WINHealth Partners Commercial |
$123.50
|
| Rate for Payer: WINHealth Partners Commercial |
$436.05
|
| Rate for Payer: Wise Provider Network Commercial |
$436.05
|
| Rate for Payer: Wise Provider Network Commercial |
$123.50
|
|
|
HC APPLY LOWER LEG SPLINT
|
Facility
|
OP
|
$459.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
7002951501
|
|
Hospital Revenue Code
|
700
|
| Min. Negotiated Rate |
$248.55 |
| Max. Negotiated Rate |
$459.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$449.82
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$127.40
|
| Rate for Payer: Aetna of WY Medicare |
$302.94
|
| Rate for Payer: Aetna of WY Medicare |
$85.80
|
| Rate for Payer: Altius Commercial |
$124.80
|
| Rate for Payer: Altius Commercial |
$440.64
|
| Rate for Payer: Beech Street Commercial |
$127.40
|
| Rate for Payer: Beech Street Commercial |
$449.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$445.23
|
| Rate for Payer: Cash Price |
$321.30
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$445.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.10
|
| Rate for Payer: Cigna of WY Commercial |
$127.40
|
| Rate for Payer: Cigna of WY Commercial |
$449.82
|
| Rate for Payer: Entrust Commercial |
$436.05
|
| Rate for Payer: Entrust Commercial |
$123.50
|
| Rate for Payer: First Choice Health Commercial |
$123.50
|
| Rate for Payer: First Choice Health Commercial |
$436.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$436.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$261.63
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.10
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: HealthUtah PPO |
$459.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$445.23
|
| Rate for Payer: Multiplan Medicare/VA |
$248.55
|
| Rate for Payer: Multiplan Medicare/VA |
$70.40
|
| Rate for Payer: One Health Plan of WY PPO |
$127.40
|
| Rate for Payer: One Health Plan of WY PPO |
$449.82
|
| Rate for Payer: PacificSource Commercial |
$413.10
|
| Rate for Payer: PacificSource Commercial |
$117.00
|
| Rate for Payer: PHCS PPO |
$127.40
|
| Rate for Payer: PHCS PPO |
$449.82
|
| Rate for Payer: Three Rivers PPO |
$344.25
|
| Rate for Payer: Three Rivers PPO |
$97.50
|
| Rate for Payer: TriWest Veterans Administration |
$261.63
|
| Rate for Payer: TriWest Veterans Administration |
$74.10
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
| Rate for Payer: United Healthcare Commercial |
$438.34
|
| Rate for Payer: United Healthcare Medicare |
$261.63
|
| Rate for Payer: United Healthcare Medicare |
$74.10
|
| Rate for Payer: WINHealth Partners Commercial |
$449.82
|
| Rate for Payer: WINHealth Partners Commercial |
$127.40
|
| Rate for Payer: Wise Provider Network Commercial |
$123.50
|
| Rate for Payer: Wise Provider Network Commercial |
$436.05
|
|
|
HC APPLY LOWER LEG SPLINT
|
Facility
|
OP
|
$130.00
|
|
|
Service Code
|
HCPCS 29515
|
| Hospital Charge Code |
7612951501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$70.40 |
| Max. Negotiated Rate |
$130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$127.40
|
| Rate for Payer: Aetna of WY Medicare |
$85.80
|
| Rate for Payer: Altius Commercial |
$124.80
|
| Rate for Payer: Beech Street Commercial |
$127.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$126.10
|
| Rate for Payer: Cash Price |
$91.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$126.10
|
| Rate for Payer: Cigna of WY Commercial |
$127.40
|
| Rate for Payer: Entrust Commercial |
$123.50
|
| Rate for Payer: First Choice Health Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$123.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.10
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$126.10
|
| Rate for Payer: Multiplan Medicare/VA |
$70.40
|
| Rate for Payer: One Health Plan of WY PPO |
$127.40
|
| Rate for Payer: PacificSource Commercial |
$117.00
|
| Rate for Payer: PHCS PPO |
$127.40
|
| Rate for Payer: Three Rivers PPO |
$97.50
|
| Rate for Payer: TriWest Veterans Administration |
$74.10
|
| Rate for Payer: United Healthcare Commercial |
$124.15
|
| Rate for Payer: United Healthcare Medicare |
$74.10
|
| Rate for Payer: WINHealth Partners Commercial |
$127.40
|
| Rate for Payer: Wise Provider Network Commercial |
$123.50
|
|
|
HC APP SKN SUB GRFT T/A/L AREA/100SQ CM /<1ST 25
|
Facility
|
OP
|
$66.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
5101527101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.74 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$64.68
|
| Rate for Payer: Aetna of WY Medicare |
$43.56
|
| Rate for Payer: Altius Commercial |
$63.36
|
| Rate for Payer: Beech Street Commercial |
$64.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$64.02
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$64.02
|
| Rate for Payer: Cigna of WY Commercial |
$64.68
|
| Rate for Payer: Entrust Commercial |
$62.70
|
| Rate for Payer: First Choice Health Commercial |
$62.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$62.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.62
|
| Rate for Payer: HealthUtah PPO |
$66.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64.02
|
| Rate for Payer: Multiplan Medicare/VA |
$35.74
|
| Rate for Payer: One Health Plan of WY PPO |
$64.68
|
| Rate for Payer: PacificSource Commercial |
$59.40
|
| Rate for Payer: PHCS PPO |
$64.68
|
| Rate for Payer: Three Rivers PPO |
$49.50
|
| Rate for Payer: TriWest Veterans Administration |
$37.62
|
| Rate for Payer: United Healthcare Commercial |
$63.03
|
| Rate for Payer: United Healthcare Medicare |
$37.62
|
| Rate for Payer: WINHealth Partners Commercial |
$64.68
|
| Rate for Payer: Wise Provider Network Commercial |
$62.70
|
|
|
HC APP SKN SUB GRFT T/A/L AREA/100SQ CM /<1ST 25
|
Facility
|
IP
|
$66.00
|
|
|
Service Code
|
HCPCS 15271
|
| Hospital Charge Code |
5101527101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$38.25 |
| Max. Negotiated Rate |
$66.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$64.68
|
| Rate for Payer: Aetna of WY Medicare |
$42.24
|
| Rate for Payer: Altius Commercial |
$63.36
|
| Rate for Payer: Beech Street Commercial |
$64.68
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$64.02
|
| Rate for Payer: Cash Price |
$46.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$64.02
|
| Rate for Payer: Cigna of WY Commercial |
$64.68
|
| Rate for Payer: Entrust Commercial |
$62.70
|
| Rate for Payer: First Choice Health Commercial |
$62.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$62.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.26
|
| Rate for Payer: HealthUtah PPO |
$66.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$64.02
|
| Rate for Payer: Multiplan Medicare/VA |
$38.25
|
| Rate for Payer: One Health Plan of WY PPO |
$64.68
|
| Rate for Payer: PacificSource Commercial |
$59.40
|
| Rate for Payer: PHCS PPO |
$64.68
|
| Rate for Payer: Three Rivers PPO |
$49.50
|
| Rate for Payer: TriWest Veterans Administration |
$40.26
|
| Rate for Payer: United Healthcare Commercial |
$63.03
|
| Rate for Payer: United Healthcare Medicare |
$40.26
|
| Rate for Payer: WINHealth Partners Commercial |
$62.70
|
| Rate for Payer: Wise Provider Network Commercial |
$62.70
|
|
|
HC AQUAPORIN-4 ANTB CBA
|
Facility
|
IP
|
$36.00
|
|
|
Service Code
|
HCPCS 86052
|
| Hospital Charge Code |
3008605201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.86 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.28
|
| Rate for Payer: Aetna of WY Medicare |
$23.04
|
| Rate for Payer: Altius Commercial |
$34.56
|
| Rate for Payer: Beech Street Commercial |
$35.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.92
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.92
|
| Rate for Payer: Cigna of WY Commercial |
$35.28
|
| Rate for Payer: Entrust Commercial |
$34.20
|
| Rate for Payer: First Choice Health Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$21.96
|
| Rate for Payer: HealthUtah PPO |
$36.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.92
|
| Rate for Payer: Multiplan Medicare/VA |
$20.86
|
| Rate for Payer: One Health Plan of WY PPO |
$35.28
|
| Rate for Payer: PacificSource Commercial |
$32.40
|
| Rate for Payer: PHCS PPO |
$35.28
|
| Rate for Payer: Three Rivers PPO |
$27.00
|
| Rate for Payer: TriWest Veterans Administration |
$21.96
|
| Rate for Payer: United Healthcare Commercial |
$34.38
|
| Rate for Payer: United Healthcare Medicare |
$21.96
|
| Rate for Payer: WINHealth Partners Commercial |
$34.20
|
| Rate for Payer: Wise Provider Network Commercial |
$34.20
|
|
|
HC AQUAPORIN-4 ANTB CBA
|
Facility
|
OP
|
$36.00
|
|
|
Service Code
|
HCPCS 86052
|
| Hospital Charge Code |
3008605201
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.49 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.28
|
| Rate for Payer: Aetna of WY Medicare |
$23.76
|
| Rate for Payer: Altius Commercial |
$34.56
|
| Rate for Payer: Beech Street Commercial |
$35.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$34.92
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.92
|
| Rate for Payer: Cigna of WY Commercial |
$35.28
|
| Rate for Payer: Entrust Commercial |
$34.20
|
| Rate for Payer: First Choice Health Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$20.52
|
| Rate for Payer: HealthUtah PPO |
$36.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.92
|
| Rate for Payer: Multiplan Medicare/VA |
$19.49
|
| Rate for Payer: One Health Plan of WY PPO |
$35.28
|
| Rate for Payer: PacificSource Commercial |
$32.40
|
| Rate for Payer: PHCS PPO |
$35.28
|
| Rate for Payer: Three Rivers PPO |
$27.00
|
| Rate for Payer: TriWest Veterans Administration |
$20.52
|
| Rate for Payer: United Healthcare Commercial |
$34.38
|
| Rate for Payer: United Healthcare Medicare |
$20.52
|
| Rate for Payer: WINHealth Partners Commercial |
$35.28
|
| Rate for Payer: Wise Provider Network Commercial |
$34.20
|
|
|
HC AQUAPORIN-4 RECEPTOR AB
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS 86256
|
| Hospital Charge Code |
3008625601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$104.31 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$176.40
|
| Rate for Payer: Aetna of WY Medicare |
$115.20
|
| Rate for Payer: Altius Commercial |
$172.80
|
| Rate for Payer: Beech Street Commercial |
$176.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$174.60
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$174.60
|
| Rate for Payer: Cigna of WY Commercial |
$176.40
|
| Rate for Payer: Entrust Commercial |
$171.00
|
| Rate for Payer: First Choice Health Commercial |
$171.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$171.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$109.80
|
| Rate for Payer: HealthUtah PPO |
$180.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$174.60
|
| Rate for Payer: Multiplan Medicare/VA |
$104.31
|
| Rate for Payer: One Health Plan of WY PPO |
$176.40
|
| Rate for Payer: PacificSource Commercial |
$162.00
|
| Rate for Payer: PHCS PPO |
$176.40
|
| Rate for Payer: Three Rivers PPO |
$135.00
|
| Rate for Payer: TriWest Veterans Administration |
$109.80
|
| Rate for Payer: United Healthcare Commercial |
$171.90
|
| Rate for Payer: United Healthcare Medicare |
$109.80
|
| Rate for Payer: WINHealth Partners Commercial |
$171.00
|
| Rate for Payer: Wise Provider Network Commercial |
$171.00
|
|
|
HC AQUAPORIN-4 RECEPTOR AB
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS 86256
|
| Hospital Charge Code |
3008625601
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$97.47 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$176.40
|
| Rate for Payer: Aetna of WY Medicare |
$118.80
|
| Rate for Payer: Altius Commercial |
$172.80
|
| Rate for Payer: Beech Street Commercial |
$176.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$174.60
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$174.60
|
| Rate for Payer: Cigna of WY Commercial |
$176.40
|
| Rate for Payer: Entrust Commercial |
$171.00
|
| Rate for Payer: First Choice Health Commercial |
$171.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$171.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$102.60
|
| Rate for Payer: HealthUtah PPO |
$180.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$174.60
|
| Rate for Payer: Multiplan Medicare/VA |
$97.47
|
| Rate for Payer: One Health Plan of WY PPO |
$176.40
|
| Rate for Payer: PacificSource Commercial |
$162.00
|
| Rate for Payer: PHCS PPO |
$176.40
|
| Rate for Payer: Three Rivers PPO |
$135.00
|
| Rate for Payer: TriWest Veterans Administration |
$102.60
|
| Rate for Payer: United Healthcare Commercial |
$171.90
|
| Rate for Payer: United Healthcare Medicare |
$102.60
|
| Rate for Payer: WINHealth Partners Commercial |
$176.40
|
| Rate for Payer: Wise Provider Network Commercial |
$171.00
|
|
|
HC ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD
|
Facility
|
IP
|
$118.00
|
|
|
Service Code
|
HCPCS 36600
|
| Hospital Charge Code |
3003660001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$68.38 |
| Max. Negotiated Rate |
$118.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$115.64
|
| Rate for Payer: Aetna of WY Medicare |
$75.52
|
| Rate for Payer: Altius Commercial |
$113.28
|
| Rate for Payer: Beech Street Commercial |
$115.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$114.46
|
| Rate for Payer: Cash Price |
$82.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$114.46
|
| Rate for Payer: Cigna of WY Commercial |
$115.64
|
| Rate for Payer: Entrust Commercial |
$112.10
|
| Rate for Payer: First Choice Health Commercial |
$112.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$112.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$71.98
|
| Rate for Payer: HealthUtah PPO |
$118.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$114.46
|
| Rate for Payer: Multiplan Medicare/VA |
$68.38
|
| Rate for Payer: One Health Plan of WY PPO |
$115.64
|
| Rate for Payer: PacificSource Commercial |
$106.20
|
| Rate for Payer: PHCS PPO |
$115.64
|
| Rate for Payer: Three Rivers PPO |
$88.50
|
| Rate for Payer: TriWest Veterans Administration |
$71.98
|
| Rate for Payer: United Healthcare Commercial |
$112.69
|
| Rate for Payer: United Healthcare Medicare |
$71.98
|
| Rate for Payer: WINHealth Partners Commercial |
$112.10
|
| Rate for Payer: Wise Provider Network Commercial |
$112.10
|
|
|
HC ARTERIAL PUNCTURE WITHDRAWAL OF BLOOD
|
Facility
|
OP
|
$118.00
|
|
|
Service Code
|
HCPCS 36600
|
| Hospital Charge Code |
3003660001
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.90 |
| Max. Negotiated Rate |
$118.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$115.64
|
| Rate for Payer: Aetna of WY Medicare |
$77.88
|
| Rate for Payer: Altius Commercial |
$113.28
|
| Rate for Payer: Beech Street Commercial |
$115.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$114.46
|
| Rate for Payer: Cash Price |
$82.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$114.46
|
| Rate for Payer: Cigna of WY Commercial |
$115.64
|
| Rate for Payer: Entrust Commercial |
$112.10
|
| Rate for Payer: First Choice Health Commercial |
$112.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$112.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$67.26
|
| Rate for Payer: HealthUtah PPO |
$118.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$114.46
|
| Rate for Payer: Multiplan Medicare/VA |
$63.90
|
| Rate for Payer: One Health Plan of WY PPO |
$115.64
|
| Rate for Payer: PacificSource Commercial |
$106.20
|
| Rate for Payer: PHCS PPO |
$115.64
|
| Rate for Payer: Three Rivers PPO |
$88.50
|
| Rate for Payer: TriWest Veterans Administration |
$67.26
|
| Rate for Payer: United Healthcare Commercial |
$112.69
|
| Rate for Payer: United Healthcare Medicare |
$67.26
|
| Rate for Payer: WINHealth Partners Commercial |
$115.64
|
| Rate for Payer: Wise Provider Network Commercial |
$112.10
|
|
|
HC ARTHORSCOPY PROCEDURE
|
Facility
|
OP
|
$2,400.00
|
|
| Hospital Charge Code |
3600000039
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,299.60 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,352.00
|
| Rate for Payer: Aetna of WY Medicare |
$1,584.00
|
| Rate for Payer: Altius Commercial |
$2,304.00
|
| Rate for Payer: Beech Street Commercial |
$2,352.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,328.00
|
| Rate for Payer: Cash Price |
$1,680.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,328.00
|
| Rate for Payer: Cigna of WY Commercial |
$2,352.00
|
| Rate for Payer: Entrust Commercial |
$2,280.00
|
| Rate for Payer: First Choice Health Commercial |
$2,280.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,280.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,368.00
|
| Rate for Payer: HealthUtah PPO |
$2,400.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,328.00
|
| Rate for Payer: Multiplan Medicare/VA |
$1,299.60
|
| Rate for Payer: One Health Plan of WY PPO |
$2,352.00
|
| Rate for Payer: PacificSource Commercial |
$2,160.00
|
| Rate for Payer: PHCS PPO |
$2,352.00
|
| Rate for Payer: Three Rivers PPO |
$1,800.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,368.00
|
| Rate for Payer: United Healthcare Commercial |
$2,292.00
|
| Rate for Payer: United Healthcare Medicare |
$1,368.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,352.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,280.00
|
|
|
HC ARTHORSCOPY PROCEDURE
|
Facility
|
IP
|
$2,400.00
|
|
| Hospital Charge Code |
3600000039
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,390.80 |
| Max. Negotiated Rate |
$2,400.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,352.00
|
| Rate for Payer: Aetna of WY Medicare |
$1,536.00
|
| Rate for Payer: Altius Commercial |
$2,304.00
|
| Rate for Payer: Beech Street Commercial |
$2,352.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,328.00
|
| Rate for Payer: Cash Price |
$1,680.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,328.00
|
| Rate for Payer: Cigna of WY Commercial |
$2,352.00
|
| Rate for Payer: Entrust Commercial |
$2,280.00
|
| Rate for Payer: First Choice Health Commercial |
$2,280.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,280.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,464.00
|
| Rate for Payer: HealthUtah PPO |
$2,400.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,328.00
|
| Rate for Payer: Multiplan Medicare/VA |
$1,390.80
|
| Rate for Payer: One Health Plan of WY PPO |
$2,352.00
|
| Rate for Payer: PacificSource Commercial |
$2,160.00
|
| Rate for Payer: PHCS PPO |
$2,352.00
|
| Rate for Payer: Three Rivers PPO |
$1,800.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,464.00
|
| Rate for Payer: United Healthcare Commercial |
$2,292.00
|
| Rate for Payer: United Healthcare Medicare |
$1,464.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,280.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,280.00
|
|
|
HC ARTHROCENTESIS ASPIR INJ INTERM JT/BURS W/O US
|
Facility
|
OP
|
$670.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
3522060501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$362.80 |
| Max. Negotiated Rate |
$670.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$656.60
|
| Rate for Payer: Aetna of WY Medicare |
$442.20
|
| Rate for Payer: Altius Commercial |
$643.20
|
| Rate for Payer: Beech Street Commercial |
$656.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$649.90
|
| Rate for Payer: Cash Price |
$469.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$649.90
|
| Rate for Payer: Cigna of WY Commercial |
$656.60
|
| Rate for Payer: Entrust Commercial |
$636.50
|
| Rate for Payer: First Choice Health Commercial |
$636.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$636.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$381.90
|
| Rate for Payer: HealthUtah PPO |
$670.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$649.90
|
| Rate for Payer: Multiplan Medicare/VA |
$362.80
|
| Rate for Payer: One Health Plan of WY PPO |
$656.60
|
| Rate for Payer: PacificSource Commercial |
$603.00
|
| Rate for Payer: PHCS PPO |
$656.60
|
| Rate for Payer: Three Rivers PPO |
$502.50
|
| Rate for Payer: TriWest Veterans Administration |
$381.90
|
| Rate for Payer: United Healthcare Commercial |
$639.85
|
| Rate for Payer: United Healthcare Medicare |
$381.90
|
| Rate for Payer: WINHealth Partners Commercial |
$656.60
|
| Rate for Payer: Wise Provider Network Commercial |
$636.50
|
|
|
HC ARTHROCENTESIS ASPIR INJ INTERM JT/BURS W/O US
|
Facility
|
IP
|
$670.00
|
|
|
Service Code
|
HCPCS 20605
|
| Hospital Charge Code |
3522060501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$388.26 |
| Max. Negotiated Rate |
$670.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$656.60
|
| Rate for Payer: Aetna of WY Medicare |
$428.80
|
| Rate for Payer: Altius Commercial |
$643.20
|
| Rate for Payer: Beech Street Commercial |
$656.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$649.90
|
| Rate for Payer: Cash Price |
$469.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$649.90
|
| Rate for Payer: Cigna of WY Commercial |
$656.60
|
| Rate for Payer: Entrust Commercial |
$636.50
|
| Rate for Payer: First Choice Health Commercial |
$636.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$636.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$408.70
|
| Rate for Payer: HealthUtah PPO |
$670.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$649.90
|
| Rate for Payer: Multiplan Medicare/VA |
$388.26
|
| Rate for Payer: One Health Plan of WY PPO |
$656.60
|
| Rate for Payer: PacificSource Commercial |
$603.00
|
| Rate for Payer: PHCS PPO |
$656.60
|
| Rate for Payer: Three Rivers PPO |
$502.50
|
| Rate for Payer: TriWest Veterans Administration |
$408.70
|
| Rate for Payer: United Healthcare Commercial |
$639.85
|
| Rate for Payer: United Healthcare Medicare |
$408.70
|
| Rate for Payer: WINHealth Partners Commercial |
$636.50
|
| Rate for Payer: Wise Provider Network Commercial |
$636.50
|
|
