|
HC REPAIR INTERMEDIATE S/A/T/E 7.6-12.5 CM
|
Facility
|
IP
|
$206.00
|
|
|
Service Code
|
HCPCS 12034
|
| Hospital Charge Code |
5101203401
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$129.16 |
| Max. Negotiated Rate |
$206.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$201.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$197.76
|
| Rate for Payer: Altius Commercial |
$197.76
|
| Rate for Payer: Beech Street Commercial |
$201.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$169.13
|
| Rate for Payer: Cash Price |
$144.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$199.82
|
| Rate for Payer: Cigna of WY Commercial |
$201.88
|
| Rate for Payer: Entrust Commercial |
$195.70
|
| Rate for Payer: First Choice Health Commercial |
$195.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$195.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$135.96
|
| Rate for Payer: HealthUtah PPO |
$206.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$199.82
|
| Rate for Payer: Multiplan Medicare/VA |
$129.16
|
| Rate for Payer: One Health Plan of WY PPO |
$201.88
|
| Rate for Payer: PacificSource Commercial |
$185.40
|
| Rate for Payer: PHCS PPO |
$201.88
|
| Rate for Payer: Three Rivers PPO |
$154.50
|
| Rate for Payer: TriWest Veterans Administration |
$135.96
|
| Rate for Payer: United Healthcare Commercial |
$179.22
|
| Rate for Payer: United Healthcare Medicare |
$135.96
|
| Rate for Payer: WINHealth Partners Commercial |
$195.70
|
| Rate for Payer: Wise Provider Network Commercial |
$195.70
|
|
|
HC REPAIR LIP,FULL THICK,OVER ONE-HALF VERTICAL HEIGHT, OR COMPLEX
|
Facility
|
OP
|
$672.00
|
|
|
Service Code
|
HCPCS 40654
|
| Hospital Charge Code |
7614065401
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$370.27 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$658.56
|
| Rate for Payer: Aetna of WY Medicare |
$443.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$645.12
|
| Rate for Payer: Altius Commercial |
$645.12
|
| Rate for Payer: Beech Street Commercial |
$658.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$551.71
|
| Rate for Payer: Cash Price |
$470.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$651.84
|
| Rate for Payer: Cigna of WY Commercial |
$658.56
|
| Rate for Payer: Entrust Commercial |
$638.40
|
| Rate for Payer: First Choice Health Commercial |
$638.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$638.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$389.76
|
| Rate for Payer: HealthUtah PPO |
$672.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$651.84
|
| Rate for Payer: Multiplan Medicare/VA |
$370.27
|
| Rate for Payer: One Health Plan of WY PPO |
$658.56
|
| Rate for Payer: PacificSource Commercial |
$604.80
|
| Rate for Payer: PHCS PPO |
$658.56
|
| Rate for Payer: Three Rivers PPO |
$504.00
|
| Rate for Payer: TriWest Veterans Administration |
$389.76
|
| Rate for Payer: United Healthcare Commercial |
$584.64
|
| Rate for Payer: United Healthcare Medicare |
$389.76
|
| Rate for Payer: WINHealth Partners Commercial |
$658.56
|
| Rate for Payer: Wise Provider Network Commercial |
$638.40
|
|
|
HC REPAIR LIP,FULL THICK,OVER ONE-HALF VERTICAL HEIGHT, OR COMPLEX
|
Facility
|
IP
|
$672.00
|
|
|
Service Code
|
HCPCS 40654
|
| Hospital Charge Code |
7614065401
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$421.34 |
| Max. Negotiated Rate |
$672.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$658.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$645.12
|
| Rate for Payer: Altius Commercial |
$645.12
|
| Rate for Payer: Beech Street Commercial |
$658.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$551.71
|
| Rate for Payer: Cash Price |
$470.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$651.84
|
| Rate for Payer: Cigna of WY Commercial |
$658.56
|
| Rate for Payer: Entrust Commercial |
$638.40
|
| Rate for Payer: First Choice Health Commercial |
$638.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$638.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$443.52
|
| Rate for Payer: HealthUtah PPO |
$672.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$651.84
|
| Rate for Payer: Multiplan Medicare/VA |
$421.34
|
| Rate for Payer: One Health Plan of WY PPO |
$658.56
|
| Rate for Payer: PacificSource Commercial |
$604.80
|
| Rate for Payer: PHCS PPO |
$658.56
|
| Rate for Payer: Three Rivers PPO |
$504.00
|
| Rate for Payer: TriWest Veterans Administration |
$443.52
|
| Rate for Payer: United Healthcare Commercial |
$584.64
|
| Rate for Payer: United Healthcare Medicare |
$443.52
|
| Rate for Payer: WINHealth Partners Commercial |
$638.40
|
| Rate for Payer: Wise Provider Network Commercial |
$638.40
|
|
|
HC REPAIR LIP,FULL THICK,VERMILION
|
Facility
|
OP
|
$455.00
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
7614065001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$250.70 |
| Max. Negotiated Rate |
$455.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$445.90
|
| Rate for Payer: Aetna of WY Medicare |
$300.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$436.80
|
| Rate for Payer: Altius Commercial |
$436.80
|
| Rate for Payer: Beech Street Commercial |
$445.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$373.56
|
| Rate for Payer: Cash Price |
$318.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$441.35
|
| Rate for Payer: Cigna of WY Commercial |
$445.90
|
| Rate for Payer: Entrust Commercial |
$432.25
|
| Rate for Payer: First Choice Health Commercial |
$432.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$432.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$263.90
|
| Rate for Payer: HealthUtah PPO |
$455.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$441.35
|
| Rate for Payer: Multiplan Medicare/VA |
$250.70
|
| Rate for Payer: One Health Plan of WY PPO |
$445.90
|
| Rate for Payer: PacificSource Commercial |
$409.50
|
| Rate for Payer: PHCS PPO |
$445.90
|
| Rate for Payer: Three Rivers PPO |
$341.25
|
| Rate for Payer: TriWest Veterans Administration |
$263.90
|
| Rate for Payer: United Healthcare Commercial |
$395.85
|
| Rate for Payer: United Healthcare Medicare |
$263.90
|
| Rate for Payer: WINHealth Partners Commercial |
$445.90
|
| Rate for Payer: Wise Provider Network Commercial |
$432.25
|
|
|
HC REPAIR LIP,FULL THICK,VERMILION
|
Facility
|
IP
|
$455.00
|
|
|
Service Code
|
HCPCS 40650
|
| Hospital Charge Code |
7614065001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$285.28 |
| Max. Negotiated Rate |
$455.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$445.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$436.80
|
| Rate for Payer: Altius Commercial |
$436.80
|
| Rate for Payer: Beech Street Commercial |
$445.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$373.56
|
| Rate for Payer: Cash Price |
$318.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$441.35
|
| Rate for Payer: Cigna of WY Commercial |
$445.90
|
| Rate for Payer: Entrust Commercial |
$432.25
|
| Rate for Payer: First Choice Health Commercial |
$432.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$432.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$300.30
|
| Rate for Payer: HealthUtah PPO |
$455.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$441.35
|
| Rate for Payer: Multiplan Medicare/VA |
$285.28
|
| Rate for Payer: One Health Plan of WY PPO |
$445.90
|
| Rate for Payer: PacificSource Commercial |
$409.50
|
| Rate for Payer: PHCS PPO |
$445.90
|
| Rate for Payer: Three Rivers PPO |
$341.25
|
| Rate for Payer: TriWest Veterans Administration |
$300.30
|
| Rate for Payer: United Healthcare Commercial |
$395.85
|
| Rate for Payer: United Healthcare Medicare |
$300.30
|
| Rate for Payer: WINHealth Partners Commercial |
$432.25
|
| Rate for Payer: Wise Provider Network Commercial |
$432.25
|
|
|
HC REPAIR NAIL BED
|
Facility
|
IP
|
$129.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
5101176001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$80.88 |
| Max. Negotiated Rate |
$129.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$126.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$123.84
|
| Rate for Payer: Altius Commercial |
$123.84
|
| Rate for Payer: Beech Street Commercial |
$126.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$105.91
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$125.13
|
| Rate for Payer: Cigna of WY Commercial |
$126.42
|
| Rate for Payer: Entrust Commercial |
$122.55
|
| Rate for Payer: First Choice Health Commercial |
$122.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$122.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$85.14
|
| Rate for Payer: HealthUtah PPO |
$129.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$125.13
|
| Rate for Payer: Multiplan Medicare/VA |
$80.88
|
| Rate for Payer: One Health Plan of WY PPO |
$126.42
|
| Rate for Payer: PacificSource Commercial |
$116.10
|
| Rate for Payer: PHCS PPO |
$126.42
|
| Rate for Payer: Three Rivers PPO |
$96.75
|
| Rate for Payer: TriWest Veterans Administration |
$85.14
|
| Rate for Payer: United Healthcare Commercial |
$112.23
|
| Rate for Payer: United Healthcare Medicare |
$85.14
|
| Rate for Payer: WINHealth Partners Commercial |
$122.55
|
| Rate for Payer: Wise Provider Network Commercial |
$122.55
|
|
|
HC REPAIR NAIL BED
|
Facility
|
OP
|
$129.00
|
|
|
Service Code
|
HCPCS 11760
|
| Hospital Charge Code |
5101176001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$71.08 |
| Max. Negotiated Rate |
$129.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$126.42
|
| Rate for Payer: Aetna of WY Medicare |
$85.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$123.84
|
| Rate for Payer: Altius Commercial |
$123.84
|
| Rate for Payer: Beech Street Commercial |
$126.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$105.91
|
| Rate for Payer: Cash Price |
$90.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$125.13
|
| Rate for Payer: Cigna of WY Commercial |
$126.42
|
| Rate for Payer: Entrust Commercial |
$122.55
|
| Rate for Payer: First Choice Health Commercial |
$122.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$122.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$74.82
|
| Rate for Payer: HealthUtah PPO |
$129.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$125.13
|
| Rate for Payer: Multiplan Medicare/VA |
$71.08
|
| Rate for Payer: One Health Plan of WY PPO |
$126.42
|
| Rate for Payer: PacificSource Commercial |
$116.10
|
| Rate for Payer: PHCS PPO |
$126.42
|
| Rate for Payer: Three Rivers PPO |
$96.75
|
| Rate for Payer: TriWest Veterans Administration |
$74.82
|
| Rate for Payer: United Healthcare Commercial |
$112.23
|
| Rate for Payer: United Healthcare Medicare |
$74.82
|
| Rate for Payer: WINHealth Partners Commercial |
$126.42
|
| Rate for Payer: Wise Provider Network Commercial |
$122.55
|
|
|
HC REPAIR SUPERFICAL WND BODY <2.5CM
|
Facility
|
OP
|
$76.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
5101200101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$41.88 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$74.48
|
| Rate for Payer: Aetna of WY Medicare |
$50.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$72.96
|
| Rate for Payer: Altius Commercial |
$72.96
|
| Rate for Payer: Beech Street Commercial |
$74.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$62.40
|
| Rate for Payer: Cash Price |
$53.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$73.72
|
| Rate for Payer: Cigna of WY Commercial |
$74.48
|
| Rate for Payer: Entrust Commercial |
$72.20
|
| Rate for Payer: First Choice Health Commercial |
$72.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$72.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$44.08
|
| Rate for Payer: HealthUtah PPO |
$76.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$73.72
|
| Rate for Payer: Multiplan Medicare/VA |
$41.88
|
| Rate for Payer: One Health Plan of WY PPO |
$74.48
|
| Rate for Payer: PacificSource Commercial |
$68.40
|
| Rate for Payer: PHCS PPO |
$74.48
|
| Rate for Payer: Three Rivers PPO |
$57.00
|
| Rate for Payer: TriWest Veterans Administration |
$44.08
|
| Rate for Payer: United Healthcare Commercial |
$66.12
|
| Rate for Payer: United Healthcare Medicare |
$44.08
|
| Rate for Payer: WINHealth Partners Commercial |
$74.48
|
| Rate for Payer: Wise Provider Network Commercial |
$72.20
|
|
|
HC REPAIR SUPERFICAL WND BODY <2.5CM
|
Facility
|
IP
|
$76.00
|
|
|
Service Code
|
HCPCS 12001
|
| Hospital Charge Code |
5101200101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$47.65 |
| Max. Negotiated Rate |
$76.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$74.48
|
| Rate for Payer: Altius Auto/Workers Compensation |
$72.96
|
| Rate for Payer: Altius Commercial |
$72.96
|
| Rate for Payer: Beech Street Commercial |
$74.48
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$62.40
|
| Rate for Payer: Cash Price |
$53.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$73.72
|
| Rate for Payer: Cigna of WY Commercial |
$74.48
|
| Rate for Payer: Entrust Commercial |
$72.20
|
| Rate for Payer: First Choice Health Commercial |
$72.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$72.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$50.16
|
| Rate for Payer: HealthUtah PPO |
$76.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$73.72
|
| Rate for Payer: Multiplan Medicare/VA |
$47.65
|
| Rate for Payer: One Health Plan of WY PPO |
$74.48
|
| Rate for Payer: PacificSource Commercial |
$68.40
|
| Rate for Payer: PHCS PPO |
$74.48
|
| Rate for Payer: Three Rivers PPO |
$57.00
|
| Rate for Payer: TriWest Veterans Administration |
$50.16
|
| Rate for Payer: United Healthcare Commercial |
$66.12
|
| Rate for Payer: United Healthcare Medicare |
$50.16
|
| Rate for Payer: WINHealth Partners Commercial |
$72.20
|
| Rate for Payer: Wise Provider Network Commercial |
$72.20
|
|
|
HC REPAIR SUPERFICAL WND BODY 2.6-7.5 CM
|
Facility
|
OP
|
$79.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
5101200201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$43.53 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$77.42
|
| Rate for Payer: Aetna of WY Medicare |
$52.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$75.84
|
| Rate for Payer: Altius Commercial |
$75.84
|
| Rate for Payer: Beech Street Commercial |
$77.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$64.86
|
| Rate for Payer: Cash Price |
$55.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$76.63
|
| Rate for Payer: Cigna of WY Commercial |
$77.42
|
| Rate for Payer: Entrust Commercial |
$75.05
|
| Rate for Payer: First Choice Health Commercial |
$75.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$75.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$45.82
|
| Rate for Payer: HealthUtah PPO |
$79.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$76.63
|
| Rate for Payer: Multiplan Medicare/VA |
$43.53
|
| Rate for Payer: One Health Plan of WY PPO |
$77.42
|
| Rate for Payer: PacificSource Commercial |
$71.10
|
| Rate for Payer: PHCS PPO |
$77.42
|
| Rate for Payer: Three Rivers PPO |
$59.25
|
| Rate for Payer: TriWest Veterans Administration |
$45.82
|
| Rate for Payer: United Healthcare Commercial |
$68.73
|
| Rate for Payer: United Healthcare Medicare |
$45.82
|
| Rate for Payer: WINHealth Partners Commercial |
$77.42
|
| Rate for Payer: Wise Provider Network Commercial |
$75.05
|
|
|
HC REPAIR SUPERFICAL WND BODY 2.6-7.5 CM
|
Facility
|
IP
|
$79.00
|
|
|
Service Code
|
HCPCS 12002
|
| Hospital Charge Code |
5101200201
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$49.53 |
| Max. Negotiated Rate |
$79.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$77.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$75.84
|
| Rate for Payer: Altius Commercial |
$75.84
|
| Rate for Payer: Beech Street Commercial |
$77.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$64.86
|
| Rate for Payer: Cash Price |
$55.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$76.63
|
| Rate for Payer: Cigna of WY Commercial |
$77.42
|
| Rate for Payer: Entrust Commercial |
$75.05
|
| Rate for Payer: First Choice Health Commercial |
$75.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$75.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$52.14
|
| Rate for Payer: HealthUtah PPO |
$79.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$76.63
|
| Rate for Payer: Multiplan Medicare/VA |
$49.53
|
| Rate for Payer: One Health Plan of WY PPO |
$77.42
|
| Rate for Payer: PacificSource Commercial |
$71.10
|
| Rate for Payer: PHCS PPO |
$77.42
|
| Rate for Payer: Three Rivers PPO |
$59.25
|
| Rate for Payer: TriWest Veterans Administration |
$52.14
|
| Rate for Payer: United Healthcare Commercial |
$68.73
|
| Rate for Payer: United Healthcare Medicare |
$52.14
|
| Rate for Payer: WINHealth Partners Commercial |
$75.05
|
| Rate for Payer: Wise Provider Network Commercial |
$75.05
|
|
|
HC REPAIR SUPERFICIAL WND FACE <2.5CM
|
Facility
|
IP
|
$56.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
5101201101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$35.11 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.76
|
| Rate for Payer: Altius Commercial |
$53.76
|
| Rate for Payer: Beech Street Commercial |
$54.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.98
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.32
|
| Rate for Payer: Cigna of WY Commercial |
$54.88
|
| Rate for Payer: Entrust Commercial |
$53.20
|
| Rate for Payer: First Choice Health Commercial |
$53.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$36.96
|
| Rate for Payer: HealthUtah PPO |
$56.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.32
|
| Rate for Payer: Multiplan Medicare/VA |
$35.11
|
| Rate for Payer: One Health Plan of WY PPO |
$54.88
|
| Rate for Payer: PacificSource Commercial |
$50.40
|
| Rate for Payer: PHCS PPO |
$54.88
|
| Rate for Payer: Three Rivers PPO |
$42.00
|
| Rate for Payer: TriWest Veterans Administration |
$36.96
|
| Rate for Payer: United Healthcare Commercial |
$48.72
|
| Rate for Payer: United Healthcare Medicare |
$36.96
|
| Rate for Payer: WINHealth Partners Commercial |
$53.20
|
| Rate for Payer: Wise Provider Network Commercial |
$53.20
|
|
|
HC REPAIR SUPERFICIAL WND FACE <2.5CM
|
Facility
|
OP
|
$56.00
|
|
|
Service Code
|
HCPCS 12011
|
| Hospital Charge Code |
5101201101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$30.86 |
| Max. Negotiated Rate |
$56.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$54.88
|
| Rate for Payer: Aetna of WY Medicare |
$36.96
|
| Rate for Payer: Altius Auto/Workers Compensation |
$53.76
|
| Rate for Payer: Altius Commercial |
$53.76
|
| Rate for Payer: Beech Street Commercial |
$54.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$45.98
|
| Rate for Payer: Cash Price |
$39.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$54.32
|
| Rate for Payer: Cigna of WY Commercial |
$54.88
|
| Rate for Payer: Entrust Commercial |
$53.20
|
| Rate for Payer: First Choice Health Commercial |
$53.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$53.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$32.48
|
| Rate for Payer: HealthUtah PPO |
$56.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$54.32
|
| Rate for Payer: Multiplan Medicare/VA |
$30.86
|
| Rate for Payer: One Health Plan of WY PPO |
$54.88
|
| Rate for Payer: PacificSource Commercial |
$50.40
|
| Rate for Payer: PHCS PPO |
$54.88
|
| Rate for Payer: Three Rivers PPO |
$42.00
|
| Rate for Payer: TriWest Veterans Administration |
$32.48
|
| Rate for Payer: United Healthcare Commercial |
$48.72
|
| Rate for Payer: United Healthcare Medicare |
$32.48
|
| Rate for Payer: WINHealth Partners Commercial |
$54.88
|
| Rate for Payer: Wise Provider Network Commercial |
$53.20
|
|
|
HC REPAIR SUPERFICIAL WND FACE 2.6-5 CM
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
5101201301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$32.51 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.82
|
| Rate for Payer: Aetna of WY Medicare |
$38.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$56.64
|
| Rate for Payer: Altius Commercial |
$56.64
|
| Rate for Payer: Beech Street Commercial |
$57.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.44
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.23
|
| Rate for Payer: Cigna of WY Commercial |
$57.82
|
| Rate for Payer: Entrust Commercial |
$56.05
|
| Rate for Payer: First Choice Health Commercial |
$56.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$34.22
|
| Rate for Payer: HealthUtah PPO |
$59.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.23
|
| Rate for Payer: Multiplan Medicare/VA |
$32.51
|
| Rate for Payer: One Health Plan of WY PPO |
$57.82
|
| Rate for Payer: PacificSource Commercial |
$53.10
|
| Rate for Payer: PHCS PPO |
$57.82
|
| Rate for Payer: Three Rivers PPO |
$44.25
|
| Rate for Payer: TriWest Veterans Administration |
$34.22
|
| Rate for Payer: United Healthcare Commercial |
$51.33
|
| Rate for Payer: United Healthcare Medicare |
$34.22
|
| Rate for Payer: WINHealth Partners Commercial |
$57.82
|
| Rate for Payer: Wise Provider Network Commercial |
$56.05
|
|
|
HC REPAIR SUPERFICIAL WND FACE 2.6-5 CM
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
HCPCS 12013
|
| Hospital Charge Code |
5101201301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.99 |
| Max. Negotiated Rate |
$59.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$57.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$56.64
|
| Rate for Payer: Altius Commercial |
$56.64
|
| Rate for Payer: Beech Street Commercial |
$57.82
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$48.44
|
| Rate for Payer: Cash Price |
$41.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$57.23
|
| Rate for Payer: Cigna of WY Commercial |
$57.82
|
| Rate for Payer: Entrust Commercial |
$56.05
|
| Rate for Payer: First Choice Health Commercial |
$56.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$56.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$38.94
|
| Rate for Payer: HealthUtah PPO |
$59.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$57.23
|
| Rate for Payer: Multiplan Medicare/VA |
$36.99
|
| Rate for Payer: One Health Plan of WY PPO |
$57.82
|
| Rate for Payer: PacificSource Commercial |
$53.10
|
| Rate for Payer: PHCS PPO |
$57.82
|
| Rate for Payer: Three Rivers PPO |
$44.25
|
| Rate for Payer: TriWest Veterans Administration |
$38.94
|
| Rate for Payer: United Healthcare Commercial |
$51.33
|
| Rate for Payer: United Healthcare Medicare |
$38.94
|
| Rate for Payer: WINHealth Partners Commercial |
$56.05
|
| Rate for Payer: Wise Provider Network Commercial |
$56.05
|
|
|
HC REPAIR TONGUE LACER,2.6 CM+/COMPLX
|
Facility
|
OP
|
$618.00
|
|
|
Service Code
|
HCPCS 41252
|
| Hospital Charge Code |
7614125201
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$340.52 |
| Max. Negotiated Rate |
$618.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$605.64
|
| Rate for Payer: Aetna of WY Medicare |
$407.88
|
| Rate for Payer: Altius Auto/Workers Compensation |
$593.28
|
| Rate for Payer: Altius Commercial |
$593.28
|
| Rate for Payer: Beech Street Commercial |
$605.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$507.38
|
| Rate for Payer: Cash Price |
$432.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$599.46
|
| Rate for Payer: Cigna of WY Commercial |
$605.64
|
| Rate for Payer: Entrust Commercial |
$587.10
|
| Rate for Payer: First Choice Health Commercial |
$587.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$587.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$358.44
|
| Rate for Payer: HealthUtah PPO |
$618.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$599.46
|
| Rate for Payer: Multiplan Medicare/VA |
$340.52
|
| Rate for Payer: One Health Plan of WY PPO |
$605.64
|
| Rate for Payer: PacificSource Commercial |
$556.20
|
| Rate for Payer: PHCS PPO |
$605.64
|
| Rate for Payer: Three Rivers PPO |
$463.50
|
| Rate for Payer: TriWest Veterans Administration |
$358.44
|
| Rate for Payer: United Healthcare Commercial |
$537.66
|
| Rate for Payer: United Healthcare Medicare |
$358.44
|
| Rate for Payer: WINHealth Partners Commercial |
$605.64
|
| Rate for Payer: Wise Provider Network Commercial |
$587.10
|
|
|
HC REPAIR TONGUE LACER,2.6 CM+/COMPLX
|
Facility
|
IP
|
$618.00
|
|
|
Service Code
|
HCPCS 41252
|
| Hospital Charge Code |
7614125201
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$387.49 |
| Max. Negotiated Rate |
$618.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$605.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$593.28
|
| Rate for Payer: Altius Commercial |
$593.28
|
| Rate for Payer: Beech Street Commercial |
$605.64
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$507.38
|
| Rate for Payer: Cash Price |
$432.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$599.46
|
| Rate for Payer: Cigna of WY Commercial |
$605.64
|
| Rate for Payer: Entrust Commercial |
$587.10
|
| Rate for Payer: First Choice Health Commercial |
$587.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$587.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$407.88
|
| Rate for Payer: HealthUtah PPO |
$618.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$599.46
|
| Rate for Payer: Multiplan Medicare/VA |
$387.49
|
| Rate for Payer: One Health Plan of WY PPO |
$605.64
|
| Rate for Payer: PacificSource Commercial |
$556.20
|
| Rate for Payer: PHCS PPO |
$605.64
|
| Rate for Payer: Three Rivers PPO |
$463.50
|
| Rate for Payer: TriWest Veterans Administration |
$407.88
|
| Rate for Payer: United Healthcare Commercial |
$537.66
|
| Rate for Payer: United Healthcare Medicare |
$407.88
|
| Rate for Payer: WINHealth Partners Commercial |
$587.10
|
| Rate for Payer: Wise Provider Network Commercial |
$587.10
|
|
|
HC REPOSITION GASTROSTOMY TUBE - GASTROSTOMY TUBE, CHANGE / REPOSITION
|
Facility
|
IP
|
$534.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
7504376101
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$334.82 |
| Max. Negotiated Rate |
$534.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$523.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$512.64
|
| Rate for Payer: Altius Commercial |
$512.64
|
| Rate for Payer: Beech Street Commercial |
$523.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$438.41
|
| Rate for Payer: Cash Price |
$373.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$517.98
|
| Rate for Payer: Cigna of WY Commercial |
$523.32
|
| Rate for Payer: Entrust Commercial |
$507.30
|
| Rate for Payer: First Choice Health Commercial |
$507.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$507.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$352.44
|
| Rate for Payer: HealthUtah PPO |
$534.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$517.98
|
| Rate for Payer: Multiplan Medicare/VA |
$334.82
|
| Rate for Payer: One Health Plan of WY PPO |
$523.32
|
| Rate for Payer: PacificSource Commercial |
$480.60
|
| Rate for Payer: PHCS PPO |
$523.32
|
| Rate for Payer: Three Rivers PPO |
$400.50
|
| Rate for Payer: TriWest Veterans Administration |
$352.44
|
| Rate for Payer: United Healthcare Commercial |
$464.58
|
| Rate for Payer: United Healthcare Medicare |
$352.44
|
| Rate for Payer: WINHealth Partners Commercial |
$507.30
|
| Rate for Payer: Wise Provider Network Commercial |
$507.30
|
|
|
HC REPOSITION GASTROSTOMY TUBE - GASTROSTOMY TUBE, CHANGE / REPOSITION
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
HCPCS 43761
|
| Hospital Charge Code |
7504376101
|
|
Hospital Revenue Code
|
750
|
| Min. Negotiated Rate |
$294.23 |
| Max. Negotiated Rate |
$534.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$523.32
|
| Rate for Payer: Aetna of WY Medicare |
$352.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$512.64
|
| Rate for Payer: Altius Commercial |
$512.64
|
| Rate for Payer: Beech Street Commercial |
$523.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$438.41
|
| Rate for Payer: Cash Price |
$373.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$517.98
|
| Rate for Payer: Cigna of WY Commercial |
$523.32
|
| Rate for Payer: Entrust Commercial |
$507.30
|
| Rate for Payer: First Choice Health Commercial |
$507.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$507.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$309.72
|
| Rate for Payer: HealthUtah PPO |
$534.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$517.98
|
| Rate for Payer: Multiplan Medicare/VA |
$294.23
|
| Rate for Payer: One Health Plan of WY PPO |
$523.32
|
| Rate for Payer: PacificSource Commercial |
$480.60
|
| Rate for Payer: PHCS PPO |
$523.32
|
| Rate for Payer: Three Rivers PPO |
$400.50
|
| Rate for Payer: TriWest Veterans Administration |
$309.72
|
| Rate for Payer: United Healthcare Commercial |
$464.58
|
| Rate for Payer: United Healthcare Medicare |
$309.72
|
| Rate for Payer: WINHealth Partners Commercial |
$523.32
|
| Rate for Payer: Wise Provider Network Commercial |
$507.30
|
|
|
HC REP,SKIN,SCALP/EXTREM+5 CM/<
|
Facility
|
IP
|
$54.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
7611312201
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$33.86 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$52.92
|
| Rate for Payer: Altius Auto/Workers Compensation |
$51.84
|
| Rate for Payer: Altius Commercial |
$51.84
|
| Rate for Payer: Beech Street Commercial |
$52.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$44.33
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$52.38
|
| Rate for Payer: Cigna of WY Commercial |
$52.92
|
| Rate for Payer: Entrust Commercial |
$51.30
|
| Rate for Payer: First Choice Health Commercial |
$51.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$51.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.64
|
| Rate for Payer: HealthUtah PPO |
$54.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$52.38
|
| Rate for Payer: Multiplan Medicare/VA |
$33.86
|
| Rate for Payer: One Health Plan of WY PPO |
$52.92
|
| Rate for Payer: PacificSource Commercial |
$48.60
|
| Rate for Payer: PHCS PPO |
$52.92
|
| Rate for Payer: Three Rivers PPO |
$40.50
|
| Rate for Payer: TriWest Veterans Administration |
$35.64
|
| Rate for Payer: United Healthcare Commercial |
$46.98
|
| Rate for Payer: United Healthcare Medicare |
$35.64
|
| Rate for Payer: WINHealth Partners Commercial |
$51.30
|
| Rate for Payer: Wise Provider Network Commercial |
$51.30
|
|
|
HC REP,SKIN,SCALP/EXTREM+5 CM/<
|
Facility
|
OP
|
$54.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
7611312201
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$29.75 |
| Max. Negotiated Rate |
$54.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$52.92
|
| Rate for Payer: Aetna of WY Medicare |
$35.64
|
| Rate for Payer: Altius Auto/Workers Compensation |
$51.84
|
| Rate for Payer: Altius Commercial |
$51.84
|
| Rate for Payer: Beech Street Commercial |
$52.92
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$44.33
|
| Rate for Payer: Cash Price |
$37.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$52.38
|
| Rate for Payer: Cigna of WY Commercial |
$52.92
|
| Rate for Payer: Entrust Commercial |
$51.30
|
| Rate for Payer: First Choice Health Commercial |
$51.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$51.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.32
|
| Rate for Payer: HealthUtah PPO |
$54.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$52.38
|
| Rate for Payer: Multiplan Medicare/VA |
$29.75
|
| Rate for Payer: One Health Plan of WY PPO |
$52.92
|
| Rate for Payer: PacificSource Commercial |
$48.60
|
| Rate for Payer: PHCS PPO |
$52.92
|
| Rate for Payer: Three Rivers PPO |
$40.50
|
| Rate for Payer: TriWest Veterans Administration |
$31.32
|
| Rate for Payer: United Healthcare Commercial |
$46.98
|
| Rate for Payer: United Healthcare Medicare |
$31.32
|
| Rate for Payer: WINHealth Partners Commercial |
$52.92
|
| Rate for Payer: Wise Provider Network Commercial |
$51.30
|
|
|
HC RESPIRATORY FLOW VOLUME LOOP - FLOW VOLUME LOOP
|
Facility
|
OP
|
$865.00
|
|
|
Service Code
|
HCPCS 94375
|
| Hospital Charge Code |
4609437501
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$476.62 |
| Max. Negotiated Rate |
$865.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$847.70
|
| Rate for Payer: Aetna of WY Medicare |
$570.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$830.40
|
| Rate for Payer: Altius Commercial |
$830.40
|
| Rate for Payer: Beech Street Commercial |
$847.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$710.16
|
| Rate for Payer: Cash Price |
$605.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$839.05
|
| Rate for Payer: Cigna of WY Commercial |
$847.70
|
| Rate for Payer: Entrust Commercial |
$821.75
|
| Rate for Payer: First Choice Health Commercial |
$821.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$821.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$501.70
|
| Rate for Payer: HealthUtah PPO |
$865.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$839.05
|
| Rate for Payer: Multiplan Medicare/VA |
$476.62
|
| Rate for Payer: One Health Plan of WY PPO |
$847.70
|
| Rate for Payer: PacificSource Commercial |
$778.50
|
| Rate for Payer: PHCS PPO |
$847.70
|
| Rate for Payer: Three Rivers PPO |
$648.75
|
| Rate for Payer: TriWest Veterans Administration |
$501.70
|
| Rate for Payer: United Healthcare Commercial |
$752.55
|
| Rate for Payer: United Healthcare Medicare |
$501.70
|
| Rate for Payer: WINHealth Partners Commercial |
$847.70
|
| Rate for Payer: Wise Provider Network Commercial |
$821.75
|
|
|
HC RESPIRATORY FLOW VOLUME LOOP - FLOW VOLUME LOOP
|
Facility
|
IP
|
$865.00
|
|
|
Service Code
|
HCPCS 94375
|
| Hospital Charge Code |
4609437501
|
|
Hospital Revenue Code
|
460
|
| Min. Negotiated Rate |
$542.36 |
| Max. Negotiated Rate |
$865.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$847.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$830.40
|
| Rate for Payer: Altius Commercial |
$830.40
|
| Rate for Payer: Beech Street Commercial |
$847.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$710.16
|
| Rate for Payer: Cash Price |
$605.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$839.05
|
| Rate for Payer: Cigna of WY Commercial |
$847.70
|
| Rate for Payer: Entrust Commercial |
$821.75
|
| Rate for Payer: First Choice Health Commercial |
$821.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$821.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$570.90
|
| Rate for Payer: HealthUtah PPO |
$865.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$839.05
|
| Rate for Payer: Multiplan Medicare/VA |
$542.36
|
| Rate for Payer: One Health Plan of WY PPO |
$847.70
|
| Rate for Payer: PacificSource Commercial |
$778.50
|
| Rate for Payer: PHCS PPO |
$847.70
|
| Rate for Payer: Three Rivers PPO |
$648.75
|
| Rate for Payer: TriWest Veterans Administration |
$570.90
|
| Rate for Payer: United Healthcare Commercial |
$752.55
|
| Rate for Payer: United Healthcare Medicare |
$570.90
|
| Rate for Payer: WINHealth Partners Commercial |
$821.75
|
| Rate for Payer: Wise Provider Network Commercial |
$821.75
|
|
|
HC RESP SYNCYTIAL AG, DFA - RESP SYNCYTIAL VIRUS DFA
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
HCPCS 87280
|
| Hospital Charge Code |
3068728001
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$66.12 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$117.60
|
| Rate for Payer: Aetna of WY Medicare |
$79.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$115.20
|
| Rate for Payer: Altius Commercial |
$115.20
|
| Rate for Payer: Beech Street Commercial |
$117.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$98.52
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$116.40
|
| Rate for Payer: Cigna of WY Commercial |
$117.60
|
| Rate for Payer: Entrust Commercial |
$114.00
|
| Rate for Payer: First Choice Health Commercial |
$114.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$114.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$69.60
|
| Rate for Payer: HealthUtah PPO |
$120.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$116.40
|
| Rate for Payer: Multiplan Medicare/VA |
$66.12
|
| Rate for Payer: One Health Plan of WY PPO |
$117.60
|
| Rate for Payer: PacificSource Commercial |
$108.00
|
| Rate for Payer: PHCS PPO |
$117.60
|
| Rate for Payer: Three Rivers PPO |
$90.00
|
| Rate for Payer: TriWest Veterans Administration |
$69.60
|
| Rate for Payer: United Healthcare Commercial |
$104.40
|
| Rate for Payer: United Healthcare Medicare |
$69.60
|
| Rate for Payer: WINHealth Partners Commercial |
$117.60
|
| Rate for Payer: Wise Provider Network Commercial |
$114.00
|
|
|
HC RESP SYNCYTIAL AG, DFA - RESP SYNCYTIAL VIRUS DFA
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
HCPCS 87280
|
| Hospital Charge Code |
3068728001
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$75.24 |
| Max. Negotiated Rate |
$120.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$117.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$115.20
|
| Rate for Payer: Altius Commercial |
$115.20
|
| Rate for Payer: Beech Street Commercial |
$117.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$98.52
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$116.40
|
| Rate for Payer: Cigna of WY Commercial |
$117.60
|
| Rate for Payer: Entrust Commercial |
$114.00
|
| Rate for Payer: First Choice Health Commercial |
$114.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$114.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.20
|
| Rate for Payer: HealthUtah PPO |
$120.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$116.40
|
| Rate for Payer: Multiplan Medicare/VA |
$75.24
|
| Rate for Payer: One Health Plan of WY PPO |
$117.60
|
| Rate for Payer: PacificSource Commercial |
$108.00
|
| Rate for Payer: PHCS PPO |
$117.60
|
| Rate for Payer: Three Rivers PPO |
$90.00
|
| Rate for Payer: TriWest Veterans Administration |
$79.20
|
| Rate for Payer: United Healthcare Commercial |
$104.40
|
| Rate for Payer: United Healthcare Medicare |
$79.20
|
| Rate for Payer: WINHealth Partners Commercial |
$114.00
|
| Rate for Payer: Wise Provider Network Commercial |
$114.00
|
|
