|
INFUSOR BAG 1L
|
Facility
|
IP
|
$20.56
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.89 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$20.15
|
| Rate for Payer: Altius Auto/Workers Compensation |
$19.74
|
| Rate for Payer: Altius Commercial |
$19.74
|
| Rate for Payer: Beech Street Commercial |
$20.15
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$16.88
|
| Rate for Payer: Cash Price |
$14.39
|
| Rate for Payer: ChoiceCare Network Commercial |
$19.94
|
| Rate for Payer: Cigna of WY Commercial |
$20.15
|
| Rate for Payer: Entrust Commercial |
$19.53
|
| Rate for Payer: First Choice Health Commercial |
$19.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$19.53
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.57
|
| Rate for Payer: HealthUtah PPO |
$20.56
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$19.94
|
| Rate for Payer: Multiplan Medicare/VA |
$12.89
|
| Rate for Payer: One Health Plan of WY PPO |
$20.15
|
| Rate for Payer: PacificSource Commercial |
$18.50
|
| Rate for Payer: PHCS PPO |
$20.15
|
| Rate for Payer: Three Rivers PPO |
$15.42
|
| Rate for Payer: TriWest Veterans Administration |
$13.57
|
| Rate for Payer: United Healthcare Commercial |
$17.89
|
| Rate for Payer: United Healthcare Medicare |
$13.57
|
| Rate for Payer: WINHealth Partners Commercial |
$19.53
|
| Rate for Payer: Wise Provider Network Commercial |
$19.53
|
|
|
INGUINOFEM LMPHADEC SUPFC W/CLOQUETS NODE SPX
|
Professional
|
Both
|
$4,329.00
|
|
|
Service Code
|
HCPCS 38760 AS
|
| Hospital Charge Code |
38760
|
| Min. Negotiated Rate |
$679.99 |
| Max. Negotiated Rate |
$4,329.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,242.42
|
| Rate for Payer: Aetna of WY Medicare |
$799.99
|
| Rate for Payer: Beech Street Commercial |
$4,112.55
|
| Rate for Payer: Cash Price |
$3,030.30
|
| Rate for Payer: Cash Price |
$3,030.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,199.13
|
| Rate for Payer: Cigna of WY Commercial |
$4,242.42
|
| Rate for Payer: First Choice Health Commercial |
$3,896.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,112.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$799.99
|
| Rate for Payer: HealthUtah PPO |
$4,329.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,199.13
|
| Rate for Payer: Multiplan Medicare/VA |
$679.99
|
| Rate for Payer: One Health Plan of WY PPO |
$4,242.42
|
| Rate for Payer: PacificSource Commercial |
$3,896.10
|
| Rate for Payer: PHCS PPO |
$4,112.55
|
| Rate for Payer: Three Rivers PPO |
$3,246.75
|
| Rate for Payer: TriWest Veterans Administration |
$799.99
|
| Rate for Payer: United Healthcare Commercial |
$3,766.23
|
| Rate for Payer: United Healthcare Medicare |
$799.99
|
| Rate for Payer: WINHealth Partners Commercial |
$3,679.65
|
|
|
INGUINOFEM LMPHADEC SUPFC W/CLOQUETS NODE SPX
|
Professional
|
Both
|
$4,329.00
|
|
|
Service Code
|
HCPCS 38760
|
| Hospital Charge Code |
38760
|
| Min. Negotiated Rate |
$679.99 |
| Max. Negotiated Rate |
$4,329.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,242.42
|
| Rate for Payer: Aetna of WY Medicare |
$799.99
|
| Rate for Payer: Beech Street Commercial |
$4,112.55
|
| Rate for Payer: Cash Price |
$3,030.30
|
| Rate for Payer: Cash Price |
$3,030.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,199.13
|
| Rate for Payer: Cigna of WY Commercial |
$4,242.42
|
| Rate for Payer: First Choice Health Commercial |
$3,896.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,112.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$799.99
|
| Rate for Payer: HealthUtah PPO |
$4,329.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,199.13
|
| Rate for Payer: Multiplan Medicare/VA |
$679.99
|
| Rate for Payer: One Health Plan of WY PPO |
$4,242.42
|
| Rate for Payer: PacificSource Commercial |
$3,896.10
|
| Rate for Payer: PHCS PPO |
$4,112.55
|
| Rate for Payer: Three Rivers PPO |
$3,246.75
|
| Rate for Payer: TriWest Veterans Administration |
$799.99
|
| Rate for Payer: United Healthcare Commercial |
$3,766.23
|
| Rate for Payer: United Healthcare Medicare |
$799.99
|
| Rate for Payer: WINHealth Partners Commercial |
$3,679.65
|
|
|
INHALATIONAL SPACING DEVICE [28987]
|
Facility
|
OP
|
$18.90
|
|
|
Service Code
|
NDC 4213510000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.41 |
| Max. Negotiated Rate |
$18.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.52
|
| Rate for Payer: Aetna of WY Medicare |
$12.47
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.14
|
| Rate for Payer: Altius Commercial |
$18.14
|
| Rate for Payer: Beech Street Commercial |
$18.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.52
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.33
|
| Rate for Payer: Cigna of WY Commercial |
$18.52
|
| Rate for Payer: Entrust Commercial |
$17.96
|
| Rate for Payer: First Choice Health Commercial |
$17.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$10.96
|
| Rate for Payer: HealthUtah PPO |
$18.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.33
|
| Rate for Payer: Multiplan Medicare/VA |
$10.41
|
| Rate for Payer: One Health Plan of WY PPO |
$18.52
|
| Rate for Payer: PacificSource Commercial |
$17.01
|
| Rate for Payer: PHCS PPO |
$18.52
|
| Rate for Payer: Three Rivers PPO |
$14.18
|
| Rate for Payer: TriWest Veterans Administration |
$10.96
|
| Rate for Payer: United Healthcare Commercial |
$16.44
|
| Rate for Payer: United Healthcare Medicare |
$10.96
|
| Rate for Payer: WINHealth Partners Commercial |
$18.52
|
| Rate for Payer: Wise Provider Network Commercial |
$17.96
|
|
|
INHALATIONAL SPACING DEVICE [28987]
|
Facility
|
IP
|
$18.90
|
|
|
Service Code
|
NDC 4213510000
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$18.90 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$18.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$18.14
|
| Rate for Payer: Altius Commercial |
$18.14
|
| Rate for Payer: Beech Street Commercial |
$18.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$15.52
|
| Rate for Payer: Cash Price |
$13.23
|
| Rate for Payer: ChoiceCare Network Commercial |
$18.33
|
| Rate for Payer: Cigna of WY Commercial |
$18.52
|
| Rate for Payer: Entrust Commercial |
$17.96
|
| Rate for Payer: First Choice Health Commercial |
$17.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$17.96
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$12.47
|
| Rate for Payer: HealthUtah PPO |
$18.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$18.33
|
| Rate for Payer: Multiplan Medicare/VA |
$11.85
|
| Rate for Payer: One Health Plan of WY PPO |
$18.52
|
| Rate for Payer: PacificSource Commercial |
$17.01
|
| Rate for Payer: PHCS PPO |
$18.52
|
| Rate for Payer: Three Rivers PPO |
$14.18
|
| Rate for Payer: TriWest Veterans Administration |
$12.47
|
| Rate for Payer: United Healthcare Commercial |
$16.44
|
| Rate for Payer: United Healthcare Medicare |
$12.47
|
| Rate for Payer: WINHealth Partners Commercial |
$17.96
|
| Rate for Payer: Wise Provider Network Commercial |
$17.96
|
|
|
INHALATION SOLUTION FOR DME
|
Professional
|
Both
|
$7.00
|
|
|
Service Code
|
HCPCS J7699
|
| Hospital Charge Code |
J7699
|
| Min. Negotiated Rate |
$5.25 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6.86
|
| Rate for Payer: Beech Street Commercial |
$6.65
|
| Rate for Payer: Cash Price |
$4.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$6.79
|
| Rate for Payer: Cigna of WY Commercial |
$6.86
|
| Rate for Payer: First Choice Health Commercial |
$6.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6.65
|
| Rate for Payer: HealthUtah PPO |
$7.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6.79
|
| Rate for Payer: One Health Plan of WY PPO |
$6.86
|
| Rate for Payer: PacificSource Commercial |
$6.30
|
| Rate for Payer: PHCS PPO |
$6.65
|
| Rate for Payer: Three Rivers PPO |
$5.25
|
| Rate for Payer: United Healthcare Commercial |
$6.09
|
| Rate for Payer: WINHealth Partners Commercial |
$6.65
|
|
|
INITIAL HOSP NEONATE 28 D/< NOT CRITICALLY ILL
|
Professional
|
Both
|
$2,133.00
|
|
|
Service Code
|
HCPCS 99477
|
| Hospital Charge Code |
99477
|
| Min. Negotiated Rate |
$275.75 |
| Max. Negotiated Rate |
$2,133.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,090.34
|
| Rate for Payer: Aetna of WY Medicare |
$324.41
|
| Rate for Payer: Beech Street Commercial |
$2,026.35
|
| Rate for Payer: Cash Price |
$1,493.10
|
| Rate for Payer: Cash Price |
$1,493.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,069.01
|
| Rate for Payer: Cigna of WY Commercial |
$2,090.34
|
| Rate for Payer: First Choice Health Commercial |
$1,919.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,026.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$324.41
|
| Rate for Payer: HealthUtah PPO |
$2,133.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,069.01
|
| Rate for Payer: Multiplan Medicare/VA |
$275.75
|
| Rate for Payer: One Health Plan of WY PPO |
$2,090.34
|
| Rate for Payer: PacificSource Commercial |
$1,919.70
|
| Rate for Payer: PHCS PPO |
$2,026.35
|
| Rate for Payer: Three Rivers PPO |
$1,599.75
|
| Rate for Payer: TriWest Veterans Administration |
$324.41
|
| Rate for Payer: United Healthcare Commercial |
$1,855.71
|
| Rate for Payer: United Healthcare Medicare |
$324.41
|
| Rate for Payer: WINHealth Partners Commercial |
$2,026.35
|
|
|
INITIAL NURSING FACILITY CARE HI MDM 50 MINUTES
|
Professional
|
Both
|
$331.00
|
|
|
Service Code
|
HCPCS 99306
|
| Hospital Charge Code |
99306
|
| Min. Negotiated Rate |
$149.18 |
| Max. Negotiated Rate |
$331.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$324.38
|
| Rate for Payer: Aetna of WY Medicare |
$175.51
|
| Rate for Payer: Beech Street Commercial |
$314.45
|
| Rate for Payer: Cash Price |
$231.70
|
| Rate for Payer: Cash Price |
$231.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$321.07
|
| Rate for Payer: Cigna of WY Commercial |
$324.38
|
| Rate for Payer: First Choice Health Commercial |
$297.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$314.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$175.51
|
| Rate for Payer: HealthUtah PPO |
$331.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$321.07
|
| Rate for Payer: Multiplan Medicare/VA |
$149.18
|
| Rate for Payer: One Health Plan of WY PPO |
$324.38
|
| Rate for Payer: PacificSource Commercial |
$297.90
|
| Rate for Payer: PHCS PPO |
$314.45
|
| Rate for Payer: Three Rivers PPO |
$248.25
|
| Rate for Payer: TriWest Veterans Administration |
$175.51
|
| Rate for Payer: United Healthcare Commercial |
$287.97
|
| Rate for Payer: United Healthcare Medicare |
$175.51
|
| Rate for Payer: WINHealth Partners Commercial |
$314.45
|
|
|
INITIAL NURSING FACILITY CARE MOD MDM 35 MINUTES
|
Professional
|
Both
|
$223.00
|
|
|
Service Code
|
HCPCS 99305
|
| Hospital Charge Code |
99305
|
| Min. Negotiated Rate |
$109.26 |
| Max. Negotiated Rate |
$223.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$218.54
|
| Rate for Payer: Aetna of WY Medicare |
$128.54
|
| Rate for Payer: Beech Street Commercial |
$211.85
|
| Rate for Payer: Cash Price |
$156.10
|
| Rate for Payer: Cash Price |
$156.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$216.31
|
| Rate for Payer: Cigna of WY Commercial |
$218.54
|
| Rate for Payer: First Choice Health Commercial |
$200.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$211.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$128.54
|
| Rate for Payer: HealthUtah PPO |
$223.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$216.31
|
| Rate for Payer: Multiplan Medicare/VA |
$109.26
|
| Rate for Payer: One Health Plan of WY PPO |
$218.54
|
| Rate for Payer: PacificSource Commercial |
$200.70
|
| Rate for Payer: PHCS PPO |
$211.85
|
| Rate for Payer: Three Rivers PPO |
$167.25
|
| Rate for Payer: TriWest Veterans Administration |
$128.54
|
| Rate for Payer: United Healthcare Commercial |
$194.01
|
| Rate for Payer: United Healthcare Medicare |
$128.54
|
| Rate for Payer: WINHealth Partners Commercial |
$211.85
|
|
|
INITIAL NURSING FACILITY CARE SF/LOW MDM 25 MIN
|
Professional
|
Both
|
$178.00
|
|
|
Service Code
|
HCPCS 99304
|
| Hospital Charge Code |
99304
|
| Min. Negotiated Rate |
$65.72 |
| Max. Negotiated Rate |
$178.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$174.44
|
| Rate for Payer: Aetna of WY Medicare |
$77.32
|
| Rate for Payer: Beech Street Commercial |
$169.10
|
| Rate for Payer: Cash Price |
$124.60
|
| Rate for Payer: Cash Price |
$124.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$172.66
|
| Rate for Payer: Cigna of WY Commercial |
$174.44
|
| Rate for Payer: First Choice Health Commercial |
$160.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$169.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$77.32
|
| Rate for Payer: HealthUtah PPO |
$178.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$172.66
|
| Rate for Payer: Multiplan Medicare/VA |
$65.72
|
| Rate for Payer: One Health Plan of WY PPO |
$174.44
|
| Rate for Payer: PacificSource Commercial |
$160.20
|
| Rate for Payer: PHCS PPO |
$169.10
|
| Rate for Payer: Three Rivers PPO |
$133.50
|
| Rate for Payer: TriWest Veterans Administration |
$77.32
|
| Rate for Payer: United Healthcare Commercial |
$154.86
|
| Rate for Payer: United Healthcare Medicare |
$77.32
|
| Rate for Payer: WINHealth Partners Commercial |
$169.10
|
|
|
INITIAL OBSERVATION CARE/DAY 30 MINUTES
|
Professional
|
Both
|
$268.00
|
|
|
Service Code
|
HCPCS 99218
|
| Hospital Charge Code |
99218
|
| Min. Negotiated Rate |
$81.84 |
| Max. Negotiated Rate |
$262.64 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$262.64
|
| Rate for Payer: Beech Street Commercial |
$254.60
|
| Rate for Payer: Cash Price |
$187.60
|
| Rate for Payer: Cash Price |
$187.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$259.96
|
| Rate for Payer: Cigna of WY Commercial |
$262.64
|
| Rate for Payer: First Choice Health Commercial |
$241.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$254.60
|
| Rate for Payer: HealthUtah PPO |
$81.84
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$259.96
|
| Rate for Payer: One Health Plan of WY PPO |
$262.64
|
| Rate for Payer: PacificSource Commercial |
$241.20
|
| Rate for Payer: PHCS PPO |
$254.60
|
| Rate for Payer: Three Rivers PPO |
$201.00
|
| Rate for Payer: United Healthcare Commercial |
$233.16
|
| Rate for Payer: WINHealth Partners Commercial |
$254.60
|
|
|
INITIAL OBSERVATION CARE/DAY 50 MINUTES
|
Professional
|
Both
|
$365.00
|
|
|
Service Code
|
HCPCS 99219
|
| Hospital Charge Code |
99219
|
| Min. Negotiated Rate |
$136.60 |
| Max. Negotiated Rate |
$357.70 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$357.70
|
| Rate for Payer: Beech Street Commercial |
$346.75
|
| Rate for Payer: Cash Price |
$255.50
|
| Rate for Payer: Cash Price |
$255.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$354.05
|
| Rate for Payer: Cigna of WY Commercial |
$357.70
|
| Rate for Payer: First Choice Health Commercial |
$328.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$346.75
|
| Rate for Payer: HealthUtah PPO |
$136.60
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$354.05
|
| Rate for Payer: One Health Plan of WY PPO |
$357.70
|
| Rate for Payer: PacificSource Commercial |
$328.50
|
| Rate for Payer: PHCS PPO |
$346.75
|
| Rate for Payer: Three Rivers PPO |
$273.75
|
| Rate for Payer: United Healthcare Commercial |
$317.55
|
| Rate for Payer: WINHealth Partners Commercial |
$346.75
|
|
|
INITIAL OBSERVATION CARE/DAY 70 MINUTES
|
Professional
|
Both
|
$460.00
|
|
|
Service Code
|
HCPCS 99220
|
| Hospital Charge Code |
99220
|
| Min. Negotiated Rate |
$191.35 |
| Max. Negotiated Rate |
$450.80 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$450.80
|
| Rate for Payer: Beech Street Commercial |
$437.00
|
| Rate for Payer: Cash Price |
$322.00
|
| Rate for Payer: Cash Price |
$322.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$446.20
|
| Rate for Payer: Cigna of WY Commercial |
$450.80
|
| Rate for Payer: First Choice Health Commercial |
$414.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$437.00
|
| Rate for Payer: HealthUtah PPO |
$191.35
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$446.20
|
| Rate for Payer: One Health Plan of WY PPO |
$450.80
|
| Rate for Payer: PacificSource Commercial |
$414.00
|
| Rate for Payer: PHCS PPO |
$437.00
|
| Rate for Payer: Three Rivers PPO |
$345.00
|
| Rate for Payer: United Healthcare Commercial |
$400.20
|
| Rate for Payer: WINHealth Partners Commercial |
$437.00
|
|
|
INITIAL PREVENTIVE EXAM
|
Professional
|
Both
|
$359.00
|
|
|
Service Code
|
HCPCS G0402
|
| Hospital Charge Code |
G0402
|
| Min. Negotiated Rate |
$107.31 |
| Max. Negotiated Rate |
$359.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$351.82
|
| Rate for Payer: Aetna of WY Medicare |
$126.25
|
| Rate for Payer: Beech Street Commercial |
$341.05
|
| Rate for Payer: Cash Price |
$251.30
|
| 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: Government Employees Health Association (GEHA) Medicare |
$126.25
|
| Rate for Payer: HealthUtah PPO |
$359.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$348.23
|
| Rate for Payer: Multiplan Medicare/VA |
$107.31
|
| 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: TriWest Veterans Administration |
$126.25
|
| Rate for Payer: United Healthcare Commercial |
$312.33
|
| Rate for Payer: United Healthcare Medicare |
$126.25
|
| Rate for Payer: WINHealth Partners Commercial |
$341.05
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PATIENT <1YEAR
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
HCPCS 99381
|
| Hospital Charge Code |
99381
|
| 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
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PATIENT 40-64YRS
|
Professional
|
Both
|
$359.00
|
|
|
Service Code
|
HCPCS 99386
|
| Hospital Charge Code |
99386
|
| 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
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PATIENT 65YRS&>
|
Professional
|
Both
|
$391.00
|
|
|
Service Code
|
HCPCS 99387
|
| Hospital Charge Code |
99387
|
| Min. Negotiated Rate |
$293.25 |
| Max. Negotiated Rate |
$391.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$383.18
|
| Rate for Payer: Beech Street Commercial |
$371.45
|
| Rate for Payer: Cash Price |
$273.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$379.27
|
| Rate for Payer: Cigna of WY Commercial |
$383.18
|
| Rate for Payer: First Choice Health Commercial |
$351.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$371.45
|
| Rate for Payer: HealthUtah PPO |
$391.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$379.27
|
| Rate for Payer: One Health Plan of WY PPO |
$383.18
|
| Rate for Payer: PacificSource Commercial |
$351.90
|
| Rate for Payer: PHCS PPO |
$371.45
|
| Rate for Payer: Three Rivers PPO |
$293.25
|
| Rate for Payer: United Healthcare Commercial |
$340.17
|
| Rate for Payer: WINHealth Partners Commercial |
$371.45
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PT AGE 12-17 YR
|
Professional
|
Both
|
$227.00
|
|
|
Service Code
|
HCPCS 99384
|
| Hospital Charge Code |
99384
|
| 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
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PT AGE 1-4 YRS
|
Professional
|
Both
|
$216.00
|
|
|
Service Code
|
HCPCS 99382
|
| Hospital Charge Code |
99382
|
| 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
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PT AGE 18-39YRS
|
Professional
|
Both
|
$322.00
|
|
|
Service Code
|
HCPCS 99385
|
| Hospital Charge Code |
99385
|
| 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
|
|
|
INITIAL PREVENTIVE MEDICINE NEW PT AGE 5-11 YRS
|
Professional
|
Both
|
$218.00
|
|
|
Service Code
|
HCPCS 99383
|
| Hospital Charge Code |
99383
|
| 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
|
|
|
INITIAL TX 1ST DEGREE BURN LOCAL TX
|
Professional
|
Both
|
$230.00
|
|
|
Service Code
|
HCPCS 16000
|
| Hospital Charge Code |
16000
|
| Min. Negotiated Rate |
$36.84 |
| Max. Negotiated Rate |
$230.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$225.40
|
| Rate for Payer: Aetna of WY Medicare |
$43.34
|
| Rate for Payer: Beech Street Commercial |
$218.50
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: Cash Price |
$161.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$223.10
|
| Rate for Payer: Cigna of WY Commercial |
$225.40
|
| Rate for Payer: First Choice Health Commercial |
$207.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$218.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$43.34
|
| Rate for Payer: HealthUtah PPO |
$230.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$223.10
|
| Rate for Payer: Multiplan Medicare/VA |
$36.84
|
| Rate for Payer: One Health Plan of WY PPO |
$225.40
|
| Rate for Payer: PacificSource Commercial |
$207.00
|
| Rate for Payer: PHCS PPO |
$218.50
|
| Rate for Payer: Three Rivers PPO |
$172.50
|
| Rate for Payer: TriWest Veterans Administration |
$43.34
|
| Rate for Payer: United Healthcare Commercial |
$200.10
|
| Rate for Payer: United Healthcare Medicare |
$43.34
|
| Rate for Payer: WINHealth Partners Commercial |
$195.50
|
|
|
INJ CERV/THORAC, W/WO CNTRST
|
Professional
|
Both
|
$2,416.00
|
|
|
Service Code
|
HCPCS 62310
|
| Hospital Charge Code |
62310
|
| Min. Negotiated Rate |
$1,812.00 |
| Max. Negotiated Rate |
$2,416.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,367.68
|
| Rate for Payer: Beech Street Commercial |
$2,295.20
|
| Rate for Payer: Cash Price |
$1,691.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,343.52
|
| Rate for Payer: Cigna of WY Commercial |
$2,367.68
|
| Rate for Payer: First Choice Health Commercial |
$2,174.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,295.20
|
| Rate for Payer: HealthUtah PPO |
$2,416.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,343.52
|
| Rate for Payer: One Health Plan of WY PPO |
$2,367.68
|
| Rate for Payer: PacificSource Commercial |
$2,174.40
|
| Rate for Payer: PHCS PPO |
$2,295.20
|
| Rate for Payer: Three Rivers PPO |
$1,812.00
|
| Rate for Payer: United Healthcare Commercial |
$2,101.92
|
| Rate for Payer: WINHealth Partners Commercial |
$2,053.60
|
|
|
INJ CERV/THORAC, W/WO CNTRST
|
Professional
|
Both
|
$4,832.00
|
|
|
Service Code
|
HCPCS 62310 50
|
| Hospital Charge Code |
62310
|
| Min. Negotiated Rate |
$3,624.00 |
| Max. Negotiated Rate |
$4,832.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,735.36
|
| Rate for Payer: Beech Street Commercial |
$4,590.40
|
| Rate for Payer: Cash Price |
$3,382.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,687.04
|
| Rate for Payer: Cigna of WY Commercial |
$4,735.36
|
| Rate for Payer: First Choice Health Commercial |
$4,348.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,590.40
|
| Rate for Payer: HealthUtah PPO |
$4,832.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,687.04
|
| Rate for Payer: One Health Plan of WY PPO |
$4,735.36
|
| Rate for Payer: PacificSource Commercial |
$4,348.80
|
| Rate for Payer: PHCS PPO |
$4,590.40
|
| Rate for Payer: Three Rivers PPO |
$3,624.00
|
| Rate for Payer: United Healthcare Commercial |
$4,203.84
|
| Rate for Payer: WINHealth Partners Commercial |
$4,107.20
|
|
|
INJ DEXAMETHASONE ACETATE
|
Professional
|
Both
|
$8.00
|
|
|
Service Code
|
HCPCS J1094
|
| Hospital Charge Code |
J1094
|
| Min. Negotiated Rate |
$6.00 |
| Max. Negotiated Rate |
$8.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$7.84
|
| Rate for Payer: Beech Street Commercial |
$7.60
|
| Rate for Payer: Cash Price |
$5.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$7.76
|
| Rate for Payer: Cigna of WY Commercial |
$7.84
|
| Rate for Payer: First Choice Health Commercial |
$7.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$7.60
|
| Rate for Payer: HealthUtah PPO |
$8.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$7.76
|
| Rate for Payer: One Health Plan of WY PPO |
$7.84
|
| Rate for Payer: PacificSource Commercial |
$7.20
|
| Rate for Payer: PHCS PPO |
$7.60
|
| Rate for Payer: Three Rivers PPO |
$6.00
|
| Rate for Payer: United Healthcare Commercial |
$6.96
|
| Rate for Payer: WINHealth Partners Commercial |
$7.60
|
|
