|
HC PRO POSPARTUM CARE ONLY
|
Professional
|
Both
|
$325.00
|
|
|
Service Code
|
HCPCS 59430
|
| Hospital Charge Code |
9835943001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$143.48 |
| Max. Negotiated Rate |
$325.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$318.50
|
| Rate for Payer: Aetna of WY Medicare |
$168.80
|
| Rate for Payer: Beech Street Commercial |
$308.75
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: Cash Price |
$227.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$315.25
|
| Rate for Payer: Cigna of WY Commercial |
$318.50
|
| Rate for Payer: First Choice Health Commercial |
$292.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$308.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$168.80
|
| Rate for Payer: HealthUtah PPO |
$325.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$315.25
|
| Rate for Payer: Multiplan Medicare/VA |
$143.48
|
| Rate for Payer: One Health Plan of WY PPO |
$318.50
|
| Rate for Payer: PacificSource Commercial |
$292.50
|
| Rate for Payer: PHCS PPO |
$308.75
|
| Rate for Payer: Three Rivers PPO |
$243.75
|
| Rate for Payer: TriWest Veterans Administration |
$168.80
|
| Rate for Payer: United Healthcare Commercial |
$282.75
|
| Rate for Payer: United Healthcare Medicare |
$168.80
|
| Rate for Payer: WINHealth Partners Commercial |
$276.25
|
|
|
HC PRO POST COLPORRHAPHY RECTOCELE W/WO PERINEORRHAPHY
|
Professional
|
Both
|
$2,161.00
|
|
|
Service Code
|
HCPCS 57250
|
| Hospital Charge Code |
9835725001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$1,620.75 |
| Max. Negotiated Rate |
$2,161.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,117.78
|
| Rate for Payer: Beech Street Commercial |
$2,052.95
|
| Rate for Payer: Cash Price |
$1,512.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,096.17
|
| Rate for Payer: Cigna of WY Commercial |
$2,117.78
|
| Rate for Payer: First Choice Health Commercial |
$1,944.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,052.95
|
| Rate for Payer: HealthUtah PPO |
$2,161.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,096.17
|
| Rate for Payer: One Health Plan of WY PPO |
$2,117.78
|
| Rate for Payer: PacificSource Commercial |
$1,944.90
|
| Rate for Payer: PHCS PPO |
$2,052.95
|
| Rate for Payer: Three Rivers PPO |
$1,620.75
|
| Rate for Payer: United Healthcare Commercial |
$1,880.07
|
| Rate for Payer: WINHealth Partners Commercial |
$1,836.85
|
|
|
HC PRO POSTERIOR NON-SEGMENTAL INSTRUMENTATION
|
Professional
|
Both
|
$2,524.00
|
|
|
Service Code
|
HCPCS 22840
|
| Hospital Charge Code |
9832284001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$601.05 |
| Max. Negotiated Rate |
$2,524.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,473.52
|
| Rate for Payer: Aetna of WY Medicare |
$707.12
|
| Rate for Payer: Beech Street Commercial |
$2,397.80
|
| Rate for Payer: Cash Price |
$1,766.80
|
| Rate for Payer: Cash Price |
$1,766.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,448.28
|
| Rate for Payer: Cigna of WY Commercial |
$2,473.52
|
| Rate for Payer: First Choice Health Commercial |
$2,271.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,397.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$707.12
|
| Rate for Payer: HealthUtah PPO |
$2,524.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,448.28
|
| Rate for Payer: Multiplan Medicare/VA |
$601.05
|
| Rate for Payer: One Health Plan of WY PPO |
$2,473.52
|
| Rate for Payer: PacificSource Commercial |
$2,271.60
|
| Rate for Payer: PHCS PPO |
$2,397.80
|
| Rate for Payer: Three Rivers PPO |
$1,893.00
|
| Rate for Payer: TriWest Veterans Administration |
$707.12
|
| Rate for Payer: United Healthcare Commercial |
$2,195.88
|
| Rate for Payer: United Healthcare Medicare |
$707.12
|
| Rate for Payer: WINHealth Partners Commercial |
$2,145.40
|
|
|
HC PRO PREVENTIVE VISIT,EST,12-17
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
HCPCS 99394
|
| Hospital Charge Code |
9839939401
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$155.25 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$202.86
|
| Rate for Payer: Beech Street Commercial |
$196.65
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$200.79
|
| Rate for Payer: Cigna of WY Commercial |
$202.86
|
| Rate for Payer: First Choice Health Commercial |
$186.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$196.65
|
| Rate for Payer: HealthUtah PPO |
$207.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$200.79
|
| Rate for Payer: One Health Plan of WY PPO |
$202.86
|
| Rate for Payer: PacificSource Commercial |
$186.30
|
| Rate for Payer: PHCS PPO |
$196.65
|
| Rate for Payer: Three Rivers PPO |
$155.25
|
| Rate for Payer: United Healthcare Commercial |
$180.09
|
| Rate for Payer: WINHealth Partners Commercial |
$196.65
|
|
|
HC PRO PREVENTIVE VISIT,EST,18-39
|
Professional
|
Both
|
$277.00
|
|
|
Service Code
|
HCPCS 99395 NONPBBPAYER
|
| Hospital Charge Code |
9839939501
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$207.75 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$271.46
|
| Rate for Payer: Beech Street Commercial |
$263.15
|
| Rate for Payer: Cash Price |
$193.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$268.69
|
| Rate for Payer: Cigna of WY Commercial |
$271.46
|
| Rate for Payer: First Choice Health Commercial |
$249.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$263.15
|
| Rate for Payer: HealthUtah PPO |
$277.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$268.69
|
| Rate for Payer: One Health Plan of WY PPO |
$271.46
|
| Rate for Payer: PacificSource Commercial |
$249.30
|
| Rate for Payer: PHCS PPO |
$263.15
|
| Rate for Payer: Three Rivers PPO |
$207.75
|
| Rate for Payer: United Healthcare Commercial |
$240.99
|
| Rate for Payer: WINHealth Partners Commercial |
$263.15
|
|
|
HC PRO PREVENTIVE VISIT,EST,40-64
|
Professional
|
Both
|
$302.00
|
|
|
Service Code
|
HCPCS 99396
|
| Hospital Charge Code |
9839939601
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$226.50 |
| Max. Negotiated Rate |
$302.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$295.96
|
| Rate for Payer: Beech Street Commercial |
$286.90
|
| Rate for Payer: Cash Price |
$211.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$292.94
|
| Rate for Payer: Cigna of WY Commercial |
$295.96
|
| Rate for Payer: First Choice Health Commercial |
$271.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$286.90
|
| Rate for Payer: HealthUtah PPO |
$302.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$292.94
|
| Rate for Payer: One Health Plan of WY PPO |
$295.96
|
| Rate for Payer: PacificSource Commercial |
$271.80
|
| Rate for Payer: PHCS PPO |
$286.90
|
| Rate for Payer: Three Rivers PPO |
$226.50
|
| Rate for Payer: United Healthcare Commercial |
$262.74
|
| Rate for Payer: WINHealth Partners Commercial |
$286.90
|
|
|
HC PRO PREVENTIVE VISIT,EST,65 & OVER
|
Professional
|
Both
|
$349.00
|
|
|
Service Code
|
HCPCS 99397
|
| Hospital Charge Code |
9839939701
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$261.75 |
| Max. Negotiated Rate |
$349.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$342.02
|
| Rate for Payer: Beech Street Commercial |
$331.55
|
| Rate for Payer: Cash Price |
$244.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$338.53
|
| Rate for Payer: Cigna of WY Commercial |
$342.02
|
| Rate for Payer: First Choice Health Commercial |
$314.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$331.55
|
| Rate for Payer: HealthUtah PPO |
$349.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$338.53
|
| Rate for Payer: One Health Plan of WY PPO |
$342.02
|
| Rate for Payer: PacificSource Commercial |
$314.10
|
| Rate for Payer: PHCS PPO |
$331.55
|
| Rate for Payer: Three Rivers PPO |
$261.75
|
| Rate for Payer: United Healthcare Commercial |
$303.63
|
| Rate for Payer: WINHealth Partners Commercial |
$331.55
|
|
|
HC PRO PREVENTIVE VISIT,EST,AGE 1-4
|
Professional
|
Both
|
$188.00
|
|
|
Service Code
|
HCPCS 99392
|
| Hospital Charge Code |
9839939201
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$141.00 |
| Max. Negotiated Rate |
$188.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$184.24
|
| Rate for Payer: Beech Street Commercial |
$178.60
|
| Rate for Payer: Cash Price |
$131.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$182.36
|
| Rate for Payer: Cigna of WY Commercial |
$184.24
|
| Rate for Payer: First Choice Health Commercial |
$169.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$178.60
|
| Rate for Payer: HealthUtah PPO |
$188.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$182.36
|
| Rate for Payer: One Health Plan of WY PPO |
$184.24
|
| Rate for Payer: PacificSource Commercial |
$169.20
|
| Rate for Payer: PHCS PPO |
$178.60
|
| Rate for Payer: Three Rivers PPO |
$141.00
|
| Rate for Payer: United Healthcare Commercial |
$163.56
|
| Rate for Payer: WINHealth Partners Commercial |
$178.60
|
|
|
HC PRO PREVENTIVE VISIT,EST,AGE5-11
|
Professional
|
Both
|
$192.00
|
|
|
Service Code
|
HCPCS 99393
|
| Hospital Charge Code |
9839939301
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$144.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$188.16
|
| Rate for Payer: Beech Street Commercial |
$182.40
|
| Rate for Payer: Cash Price |
$134.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$186.24
|
| Rate for Payer: Cigna of WY Commercial |
$188.16
|
| Rate for Payer: First Choice Health Commercial |
$172.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$182.40
|
| Rate for Payer: HealthUtah PPO |
$192.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$186.24
|
| Rate for Payer: One Health Plan of WY PPO |
$188.16
|
| Rate for Payer: PacificSource Commercial |
$172.80
|
| Rate for Payer: PHCS PPO |
$182.40
|
| Rate for Payer: Three Rivers PPO |
$144.00
|
| Rate for Payer: United Healthcare Commercial |
$167.04
|
| Rate for Payer: WINHealth Partners Commercial |
$182.40
|
|
|
HC PRO PREVENTIVE VISIT,EST, INFANT < 1 YR
|
Professional
|
Both
|
$177.00
|
|
|
Service Code
|
HCPCS 99391
|
| Hospital Charge Code |
9839939101
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$132.75 |
| Max. Negotiated Rate |
$177.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$173.46
|
| Rate for Payer: Beech Street Commercial |
$168.15
|
| Rate for Payer: Cash Price |
$123.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$171.69
|
| Rate for Payer: Cigna of WY Commercial |
$173.46
|
| Rate for Payer: First Choice Health Commercial |
$159.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$168.15
|
| Rate for Payer: HealthUtah PPO |
$177.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$171.69
|
| Rate for Payer: One Health Plan of WY PPO |
$173.46
|
| Rate for Payer: PacificSource Commercial |
$159.30
|
| Rate for Payer: PHCS PPO |
$168.15
|
| Rate for Payer: Three Rivers PPO |
$132.75
|
| Rate for Payer: United Healthcare Commercial |
$153.99
|
| Rate for Payer: WINHealth Partners Commercial |
$168.15
|
|
|
HC PRO PREVENTIVE VISIT,NEW,12-17
|
Professional
|
Both
|
$227.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
9839938401
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$170.25 |
| Max. Negotiated Rate |
$227.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$222.46
|
| Rate for Payer: Beech Street Commercial |
$215.65
|
| Rate for Payer: Cash Price |
$158.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$220.19
|
| Rate for Payer: Cigna of WY Commercial |
$222.46
|
| Rate for Payer: First Choice Health Commercial |
$204.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$215.65
|
| Rate for Payer: HealthUtah PPO |
$227.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$220.19
|
| Rate for Payer: One Health Plan of WY PPO |
$222.46
|
| Rate for Payer: PacificSource Commercial |
$204.30
|
| Rate for Payer: PHCS PPO |
$215.65
|
| Rate for Payer: Three Rivers PPO |
$170.25
|
| Rate for Payer: United Healthcare Commercial |
$197.49
|
| Rate for Payer: WINHealth Partners Commercial |
$215.65
|
|
|
HC PRO PREVENTIVE VISIT,NEW,18-39
|
Professional
|
Both
|
$322.00
|
|
|
Service Code
|
HCPCS 99385 NONPBBPAYER
|
| Hospital Charge Code |
9839938501
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$241.50 |
| Max. Negotiated Rate |
$322.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$315.56
|
| Rate for Payer: Beech Street Commercial |
$305.90
|
| Rate for Payer: Cash Price |
$225.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$312.34
|
| Rate for Payer: Cigna of WY Commercial |
$315.56
|
| Rate for Payer: First Choice Health Commercial |
$289.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$305.90
|
| Rate for Payer: HealthUtah PPO |
$322.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$312.34
|
| Rate for Payer: One Health Plan of WY PPO |
$315.56
|
| Rate for Payer: PacificSource Commercial |
$289.80
|
| Rate for Payer: PHCS PPO |
$305.90
|
| Rate for Payer: Three Rivers PPO |
$241.50
|
| Rate for Payer: United Healthcare Commercial |
$280.14
|
| Rate for Payer: WINHealth Partners Commercial |
$305.90
|
|
|
HC PRO PREVENTIVE VISIT,NEW,40-64
|
Professional
|
Both
|
$359.00
|
|
|
Service Code
|
HCPCS 99386 NONPBBPAYER
|
| Hospital Charge Code |
9839938601
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$269.25 |
| Max. Negotiated Rate |
$359.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$351.82
|
| Rate for Payer: Beech Street Commercial |
$341.05
|
| Rate for Payer: Cash Price |
$251.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$348.23
|
| Rate for Payer: Cigna of WY Commercial |
$351.82
|
| Rate for Payer: First Choice Health Commercial |
$323.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$341.05
|
| Rate for Payer: HealthUtah PPO |
$359.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$348.23
|
| Rate for Payer: One Health Plan of WY PPO |
$351.82
|
| Rate for Payer: PacificSource Commercial |
$323.10
|
| Rate for Payer: PHCS PPO |
$341.05
|
| Rate for Payer: Three Rivers PPO |
$269.25
|
| Rate for Payer: United Healthcare Commercial |
$312.33
|
| Rate for Payer: WINHealth Partners Commercial |
$341.05
|
|
|
HC PRO PREVENTIVE VISIT,NEW,AGE 1-4
|
Professional
|
Both
|
$216.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
9839938201
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$162.00 |
| Max. Negotiated Rate |
$216.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$211.68
|
| Rate for Payer: Beech Street Commercial |
$205.20
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$209.52
|
| Rate for Payer: Cigna of WY Commercial |
$211.68
|
| Rate for Payer: First Choice Health Commercial |
$194.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$205.20
|
| Rate for Payer: HealthUtah PPO |
$216.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$209.52
|
| Rate for Payer: One Health Plan of WY PPO |
$211.68
|
| Rate for Payer: PacificSource Commercial |
$194.40
|
| Rate for Payer: PHCS PPO |
$205.20
|
| Rate for Payer: Three Rivers PPO |
$162.00
|
| Rate for Payer: United Healthcare Commercial |
$187.92
|
| Rate for Payer: WINHealth Partners Commercial |
$205.20
|
|
|
HC PRO PREVENTIVE VISIT,NEW,AGE 5-11
|
Professional
|
Both
|
$218.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
9839938301
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$163.50 |
| Max. Negotiated Rate |
$218.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$213.64
|
| Rate for Payer: Beech Street Commercial |
$207.10
|
| Rate for Payer: Cash Price |
$152.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$211.46
|
| Rate for Payer: Cigna of WY Commercial |
$213.64
|
| Rate for Payer: First Choice Health Commercial |
$196.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$207.10
|
| Rate for Payer: HealthUtah PPO |
$218.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$211.46
|
| Rate for Payer: One Health Plan of WY PPO |
$213.64
|
| Rate for Payer: PacificSource Commercial |
$196.20
|
| Rate for Payer: PHCS PPO |
$207.10
|
| Rate for Payer: Three Rivers PPO |
$163.50
|
| Rate for Payer: United Healthcare Commercial |
$189.66
|
| Rate for Payer: WINHealth Partners Commercial |
$207.10
|
|
|
HC PRO PREVENTIVE VISIT,NEW,INFANT < 1 YR
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
HCPCS 99381
|
| Hospital Charge Code |
9839938101
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$155.25 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$202.86
|
| Rate for Payer: Beech Street Commercial |
$196.65
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$200.79
|
| Rate for Payer: Cigna of WY Commercial |
$202.86
|
| Rate for Payer: First Choice Health Commercial |
$186.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$196.65
|
| Rate for Payer: HealthUtah PPO |
$207.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$200.79
|
| Rate for Payer: One Health Plan of WY PPO |
$202.86
|
| Rate for Payer: PacificSource Commercial |
$186.30
|
| Rate for Payer: PHCS PPO |
$196.65
|
| Rate for Payer: Three Rivers PPO |
$155.25
|
| Rate for Payer: United Healthcare Commercial |
$180.09
|
| Rate for Payer: WINHealth Partners Commercial |
$196.65
|
|
|
HC PRO PROCTOSIGMOIDOSCOPY,BIOPSY - ENDOSCOPY SIGMOID
|
Professional
|
Both
|
$885.00
|
|
|
Service Code
|
HCPCS 45305
|
| Hospital Charge Code |
9834530501
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$59.22 |
| Max. Negotiated Rate |
$885.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$867.30
|
| Rate for Payer: Aetna of WY Medicare |
$69.67
|
| Rate for Payer: Beech Street Commercial |
$840.75
|
| Rate for Payer: Cash Price |
$619.50
|
| Rate for Payer: Cash Price |
$619.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$858.45
|
| Rate for Payer: Cigna of WY Commercial |
$867.30
|
| Rate for Payer: First Choice Health Commercial |
$796.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$840.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$69.67
|
| Rate for Payer: HealthUtah PPO |
$885.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$858.45
|
| Rate for Payer: Multiplan Medicare/VA |
$59.22
|
| Rate for Payer: One Health Plan of WY PPO |
$867.30
|
| Rate for Payer: PacificSource Commercial |
$796.50
|
| Rate for Payer: PHCS PPO |
$840.75
|
| Rate for Payer: Three Rivers PPO |
$663.75
|
| Rate for Payer: TriWest Veterans Administration |
$69.67
|
| Rate for Payer: United Healthcare Commercial |
$769.95
|
| Rate for Payer: United Healthcare Medicare |
$69.67
|
| Rate for Payer: WINHealth Partners Commercial |
$752.25
|
|
|
HC PRO PROLNG E&M/PSYCTX SVC OFFICE O/P DIR CON 1ST HR
|
Professional
|
Both
|
$398.00
|
|
|
Service Code
|
HCPCS 99354
|
| Hospital Charge Code |
9839935401
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$298.50 |
| Max. Negotiated Rate |
$398.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$390.04
|
| Rate for Payer: Beech Street Commercial |
$378.10
|
| Rate for Payer: Cash Price |
$278.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$386.06
|
| Rate for Payer: Cigna of WY Commercial |
$390.04
|
| Rate for Payer: First Choice Health Commercial |
$358.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$378.10
|
| Rate for Payer: HealthUtah PPO |
$398.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$386.06
|
| Rate for Payer: One Health Plan of WY PPO |
$390.04
|
| Rate for Payer: PacificSource Commercial |
$358.20
|
| Rate for Payer: PHCS PPO |
$378.10
|
| Rate for Payer: Three Rivers PPO |
$298.50
|
| Rate for Payer: United Healthcare Commercial |
$346.26
|
| Rate for Payer: WINHealth Partners Commercial |
$378.10
|
|
|
HC PRO PROLONGED OFFICE/OUTPATIENT E/M SVC EA 15 MIN
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
HCPCS 99417
|
| Hospital Charge Code |
9839941701
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$76.50 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$99.96
|
| Rate for Payer: Beech Street Commercial |
$96.90
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$98.94
|
| Rate for Payer: Cigna of WY Commercial |
$99.96
|
| Rate for Payer: First Choice Health Commercial |
$91.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$96.90
|
| Rate for Payer: HealthUtah PPO |
$102.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$98.94
|
| Rate for Payer: One Health Plan of WY PPO |
$99.96
|
| Rate for Payer: PacificSource Commercial |
$91.80
|
| Rate for Payer: PHCS PPO |
$96.90
|
| Rate for Payer: Three Rivers PPO |
$76.50
|
| Rate for Payer: United Healthcare Commercial |
$88.74
|
| Rate for Payer: WINHealth Partners Commercial |
$96.90
|
|
|
HC PRO PROLONG OUTPT/OFFICE VIS
|
Professional
|
Both
|
$102.00
|
|
|
Service Code
|
HCPCS G2212
|
| Hospital Charge Code |
983G221201
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$25.52 |
| Max. Negotiated Rate |
$102.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$99.96
|
| Rate for Payer: Aetna of WY Medicare |
$30.02
|
| Rate for Payer: Beech Street Commercial |
$96.90
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: Cash Price |
$71.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$98.94
|
| Rate for Payer: Cigna of WY Commercial |
$99.96
|
| Rate for Payer: First Choice Health Commercial |
$91.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$96.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$30.02
|
| Rate for Payer: HealthUtah PPO |
$102.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$98.94
|
| Rate for Payer: Multiplan Medicare/VA |
$25.52
|
| Rate for Payer: One Health Plan of WY PPO |
$99.96
|
| Rate for Payer: PacificSource Commercial |
$91.80
|
| Rate for Payer: PHCS PPO |
$96.90
|
| Rate for Payer: Three Rivers PPO |
$76.50
|
| Rate for Payer: TriWest Veterans Administration |
$30.02
|
| Rate for Payer: United Healthcare Commercial |
$88.74
|
| Rate for Payer: United Healthcare Medicare |
$30.02
|
| Rate for Payer: WINHealth Partners Commercial |
$96.90
|
|
|
HC PRO PROSTHESIS REMOVAL HUMERAL AND GLENOID COMPONENT
|
Professional
|
Both
|
$6,512.00
|
|
|
Service Code
|
HCPCS 23335
|
| Hospital Charge Code |
9822333501
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$1,035.05 |
| Max. Negotiated Rate |
$6,512.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,381.76
|
| Rate for Payer: Aetna of WY Medicare |
$1,217.71
|
| Rate for Payer: Beech Street Commercial |
$6,186.40
|
| Rate for Payer: Cash Price |
$4,558.40
|
| Rate for Payer: Cash Price |
$4,558.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,316.64
|
| Rate for Payer: Cigna of WY Commercial |
$6,381.76
|
| Rate for Payer: First Choice Health Commercial |
$5,860.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,186.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,217.71
|
| Rate for Payer: HealthUtah PPO |
$6,512.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,316.64
|
| Rate for Payer: Multiplan Medicare/VA |
$1,035.05
|
| Rate for Payer: One Health Plan of WY PPO |
$6,381.76
|
| Rate for Payer: PacificSource Commercial |
$5,860.80
|
| Rate for Payer: PHCS PPO |
$6,186.40
|
| Rate for Payer: Three Rivers PPO |
$4,884.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,217.71
|
| Rate for Payer: United Healthcare Commercial |
$5,665.44
|
| Rate for Payer: United Healthcare Medicare |
$1,217.71
|
| Rate for Payer: WINHealth Partners Commercial |
$5,535.20
|
|
|
HC PRO PRQ IMPLTJ NEUROSTIM ELTRD SACRAL NRVE W/IMAGING
|
Professional
|
Both
|
$2,623.00
|
|
|
Service Code
|
HCPCS 64561
|
| Hospital Charge Code |
9836456101
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$246.79 |
| Max. Negotiated Rate |
$2,623.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,570.54
|
| Rate for Payer: Aetna of WY Medicare |
$290.34
|
| Rate for Payer: Beech Street Commercial |
$2,491.85
|
| Rate for Payer: Cash Price |
$1,836.10
|
| Rate for Payer: Cash Price |
$1,836.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,544.31
|
| Rate for Payer: Cigna of WY Commercial |
$2,570.54
|
| Rate for Payer: First Choice Health Commercial |
$2,360.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,491.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$290.34
|
| Rate for Payer: HealthUtah PPO |
$2,623.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,544.31
|
| Rate for Payer: Multiplan Medicare/VA |
$246.79
|
| Rate for Payer: One Health Plan of WY PPO |
$2,570.54
|
| Rate for Payer: PacificSource Commercial |
$2,360.70
|
| Rate for Payer: PHCS PPO |
$2,491.85
|
| Rate for Payer: Three Rivers PPO |
$1,967.25
|
| Rate for Payer: TriWest Veterans Administration |
$290.34
|
| Rate for Payer: United Healthcare Commercial |
$2,282.01
|
| Rate for Payer: United Healthcare Medicare |
$290.34
|
| Rate for Payer: WINHealth Partners Commercial |
$2,229.55
|
|
|
HC PRO PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL
|
Professional
|
Both
|
$7,955.00
|
|
|
Service Code
|
HCPCS 63650
|
| Hospital Charge Code |
9836365001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$339.73 |
| Max. Negotiated Rate |
$7,955.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7,795.90
|
| Rate for Payer: Aetna of WY Medicare |
$399.68
|
| Rate for Payer: Beech Street Commercial |
$7,557.25
|
| Rate for Payer: Cash Price |
$5,568.50
|
| Rate for Payer: Cash Price |
$5,568.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$7,716.35
|
| Rate for Payer: Cigna of WY Commercial |
$7,795.90
|
| Rate for Payer: First Choice Health Commercial |
$7,159.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7,557.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$399.68
|
| Rate for Payer: HealthUtah PPO |
$7,955.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7,716.35
|
| Rate for Payer: Multiplan Medicare/VA |
$339.73
|
| Rate for Payer: One Health Plan of WY PPO |
$7,795.90
|
| Rate for Payer: PacificSource Commercial |
$7,159.50
|
| Rate for Payer: PHCS PPO |
$7,557.25
|
| Rate for Payer: Three Rivers PPO |
$5,966.25
|
| Rate for Payer: TriWest Veterans Administration |
$399.68
|
| Rate for Payer: United Healthcare Commercial |
$6,920.85
|
| Rate for Payer: United Healthcare Medicare |
$399.68
|
| Rate for Payer: WINHealth Partners Commercial |
$6,761.75
|
|
|
HC PRO PRQ IMPLTJ NSTIM ELECTRODE ARRAY EPIDURAL
|
Professional
|
Both
|
$13,598.00
|
|
|
Service Code
|
HCPCS 63650 50
|
| Hospital Charge Code |
9836365001
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$339.73 |
| Max. Negotiated Rate |
$13,598.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$13,326.04
|
| Rate for Payer: Aetna of WY Medicare |
$399.68
|
| Rate for Payer: Beech Street Commercial |
$12,918.10
|
| Rate for Payer: Cash Price |
$9,518.60
|
| Rate for Payer: Cash Price |
$9,518.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$13,190.06
|
| Rate for Payer: Cigna of WY Commercial |
$13,326.04
|
| Rate for Payer: First Choice Health Commercial |
$12,238.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$12,918.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$399.68
|
| Rate for Payer: HealthUtah PPO |
$13,598.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$13,190.06
|
| Rate for Payer: Multiplan Medicare/VA |
$339.73
|
| Rate for Payer: One Health Plan of WY PPO |
$13,326.04
|
| Rate for Payer: PacificSource Commercial |
$12,238.20
|
| Rate for Payer: PHCS PPO |
$12,918.10
|
| Rate for Payer: Three Rivers PPO |
$10,198.50
|
| Rate for Payer: TriWest Veterans Administration |
$399.68
|
| Rate for Payer: United Healthcare Commercial |
$11,830.26
|
| Rate for Payer: United Healthcare Medicare |
$399.68
|
| Rate for Payer: WINHealth Partners Commercial |
$11,558.30
|
|
|
HC PRO PRQ LYSIS EPIDURAL ADHESIONS MULT SESSIONS 1 DAY
|
Professional
|
Both
|
$3,425.00
|
|
|
Service Code
|
HCPCS 62264
|
| Hospital Charge Code |
9836226401
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$199.70 |
| Max. Negotiated Rate |
$3,425.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,356.50
|
| Rate for Payer: Aetna of WY Medicare |
$234.94
|
| Rate for Payer: Beech Street Commercial |
$3,253.75
|
| Rate for Payer: Cash Price |
$2,397.50
|
| Rate for Payer: Cash Price |
$2,397.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,322.25
|
| Rate for Payer: Cigna of WY Commercial |
$3,356.50
|
| Rate for Payer: First Choice Health Commercial |
$3,082.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,253.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$234.94
|
| Rate for Payer: HealthUtah PPO |
$3,425.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,322.25
|
| Rate for Payer: Multiplan Medicare/VA |
$199.70
|
| Rate for Payer: One Health Plan of WY PPO |
$3,356.50
|
| Rate for Payer: PacificSource Commercial |
$3,082.50
|
| Rate for Payer: PHCS PPO |
$3,253.75
|
| Rate for Payer: Three Rivers PPO |
$2,568.75
|
| Rate for Payer: TriWest Veterans Administration |
$234.94
|
| Rate for Payer: United Healthcare Commercial |
$2,979.75
|
| Rate for Payer: United Healthcare Medicare |
$234.94
|
| Rate for Payer: WINHealth Partners Commercial |
$2,911.25
|
|
