|
INJ, DUROLANE 1 MG
|
Professional
|
Both
|
$36.00
|
|
|
Service Code
|
HCPCS J7318
|
| Hospital Charge Code |
J7318
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$35.28
|
| Rate for Payer: Aetna of WY Medicare |
$6.55
|
| Rate for Payer: Beech Street Commercial |
$34.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$34.92
|
| Rate for Payer: Cigna of WY Commercial |
$35.28
|
| Rate for Payer: First Choice Health Commercial |
$32.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$34.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.55
|
| Rate for Payer: HealthUtah PPO |
$36.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$34.92
|
| Rate for Payer: Multiplan Medicare/VA |
$5.57
|
| Rate for Payer: One Health Plan of WY PPO |
$35.28
|
| Rate for Payer: PacificSource Commercial |
$32.40
|
| Rate for Payer: PHCS PPO |
$34.20
|
| Rate for Payer: Three Rivers PPO |
$27.00
|
| Rate for Payer: TriWest Veterans Administration |
$6.55
|
| Rate for Payer: United Healthcare Commercial |
$31.32
|
| Rate for Payer: United Healthcare Medicare |
$6.55
|
| Rate for Payer: WINHealth Partners Commercial |
$34.20
|
|
|
INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS
|
Professional
|
Both
|
$868.00
|
|
|
Service Code
|
HCPCS 20550 50
|
| Hospital Charge Code |
20550
|
| Min. Negotiated Rate |
$31.56 |
| Max. Negotiated Rate |
$868.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$850.64
|
| Rate for Payer: Aetna of WY Medicare |
$37.13
|
| Rate for Payer: Beech Street Commercial |
$824.60
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$841.96
|
| Rate for Payer: Cigna of WY Commercial |
$850.64
|
| Rate for Payer: First Choice Health Commercial |
$781.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$824.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.13
|
| Rate for Payer: HealthUtah PPO |
$868.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$841.96
|
| Rate for Payer: Multiplan Medicare/VA |
$31.56
|
| Rate for Payer: One Health Plan of WY PPO |
$850.64
|
| Rate for Payer: PacificSource Commercial |
$781.20
|
| Rate for Payer: PHCS PPO |
$824.60
|
| Rate for Payer: Three Rivers PPO |
$651.00
|
| Rate for Payer: TriWest Veterans Administration |
$37.13
|
| Rate for Payer: United Healthcare Commercial |
$755.16
|
| Rate for Payer: United Healthcare Medicare |
$37.13
|
| Rate for Payer: WINHealth Partners Commercial |
$737.80
|
|
|
INJECTION 1 TENDON SHEATH/LIGAMENT APONEUROSIS
|
Professional
|
Both
|
$434.00
|
|
|
Service Code
|
HCPCS 20550
|
| Hospital Charge Code |
20550
|
| Min. Negotiated Rate |
$31.56 |
| Max. Negotiated Rate |
$434.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$425.32
|
| Rate for Payer: Aetna of WY Medicare |
$37.13
|
| Rate for Payer: Beech Street Commercial |
$412.30
|
| Rate for Payer: Cash Price |
$303.80
|
| Rate for Payer: Cash Price |
$303.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$420.98
|
| Rate for Payer: Cigna of WY Commercial |
$425.32
|
| Rate for Payer: First Choice Health Commercial |
$390.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$412.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.13
|
| Rate for Payer: HealthUtah PPO |
$434.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$420.98
|
| Rate for Payer: Multiplan Medicare/VA |
$31.56
|
| Rate for Payer: One Health Plan of WY PPO |
$425.32
|
| Rate for Payer: PacificSource Commercial |
$390.60
|
| Rate for Payer: PHCS PPO |
$412.30
|
| Rate for Payer: Three Rivers PPO |
$325.50
|
| Rate for Payer: TriWest Veterans Administration |
$37.13
|
| Rate for Payer: United Healthcare Commercial |
$377.58
|
| Rate for Payer: United Healthcare Medicare |
$37.13
|
| Rate for Payer: WINHealth Partners Commercial |
$368.90
|
|
|
INJECTION AA&/STRD AXILLARY NERVE W/IMG GDN
|
Professional
|
Both
|
$558.00
|
|
|
Service Code
|
HCPCS 64417
|
| Hospital Charge Code |
64417
|
| Min. Negotiated Rate |
$51.94 |
| Max. Negotiated Rate |
$558.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$546.84
|
| Rate for Payer: Aetna of WY Medicare |
$61.10
|
| Rate for Payer: Beech Street Commercial |
$530.10
|
| Rate for Payer: Cash Price |
$390.60
|
| Rate for Payer: Cash Price |
$390.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$541.26
|
| Rate for Payer: Cigna of WY Commercial |
$546.84
|
| Rate for Payer: First Choice Health Commercial |
$502.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$530.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$61.10
|
| Rate for Payer: HealthUtah PPO |
$558.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$541.26
|
| Rate for Payer: Multiplan Medicare/VA |
$51.94
|
| Rate for Payer: One Health Plan of WY PPO |
$546.84
|
| Rate for Payer: PacificSource Commercial |
$502.20
|
| Rate for Payer: PHCS PPO |
$530.10
|
| Rate for Payer: Three Rivers PPO |
$418.50
|
| Rate for Payer: TriWest Veterans Administration |
$61.10
|
| Rate for Payer: United Healthcare Commercial |
$485.46
|
| Rate for Payer: United Healthcare Medicare |
$61.10
|
| Rate for Payer: WINHealth Partners Commercial |
$474.30
|
|
|
INJECTION AA&/STRD AXILLARY NERVE W/IMG GDN
|
Professional
|
Both
|
$1,116.00
|
|
|
Service Code
|
HCPCS 64417 50
|
| Hospital Charge Code |
64417
|
| Min. Negotiated Rate |
$51.94 |
| Max. Negotiated Rate |
$1,116.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,093.68
|
| Rate for Payer: Aetna of WY Medicare |
$61.10
|
| Rate for Payer: Beech Street Commercial |
$1,060.20
|
| Rate for Payer: Cash Price |
$781.20
|
| Rate for Payer: Cash Price |
$781.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,082.52
|
| Rate for Payer: Cigna of WY Commercial |
$1,093.68
|
| Rate for Payer: First Choice Health Commercial |
$1,004.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,060.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$61.10
|
| Rate for Payer: HealthUtah PPO |
$1,116.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,082.52
|
| Rate for Payer: Multiplan Medicare/VA |
$51.94
|
| Rate for Payer: One Health Plan of WY PPO |
$1,093.68
|
| Rate for Payer: PacificSource Commercial |
$1,004.40
|
| Rate for Payer: PHCS PPO |
$1,060.20
|
| Rate for Payer: Three Rivers PPO |
$837.00
|
| Rate for Payer: TriWest Veterans Administration |
$61.10
|
| Rate for Payer: United Healthcare Commercial |
$970.92
|
| Rate for Payer: United Healthcare Medicare |
$61.10
|
| Rate for Payer: WINHealth Partners Commercial |
$948.60
|
|
|
INJECTION AA&/STRD BRACHIAL PLEXUS W/IMG GDN
|
Professional
|
Both
|
$569.00
|
|
|
Service Code
|
HCPCS 64415
|
| Hospital Charge Code |
64415
|
| Min. Negotiated Rate |
$56.39 |
| Max. Negotiated Rate |
$569.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$557.62
|
| Rate for Payer: Aetna of WY Medicare |
$66.34
|
| Rate for Payer: Beech Street Commercial |
$540.55
|
| Rate for Payer: Cash Price |
$398.30
|
| Rate for Payer: Cash Price |
$398.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$551.93
|
| Rate for Payer: Cigna of WY Commercial |
$557.62
|
| Rate for Payer: First Choice Health Commercial |
$512.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$540.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$66.34
|
| Rate for Payer: HealthUtah PPO |
$569.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$551.93
|
| Rate for Payer: Multiplan Medicare/VA |
$56.39
|
| Rate for Payer: One Health Plan of WY PPO |
$557.62
|
| Rate for Payer: PacificSource Commercial |
$512.10
|
| Rate for Payer: PHCS PPO |
$540.55
|
| Rate for Payer: Three Rivers PPO |
$426.75
|
| Rate for Payer: TriWest Veterans Administration |
$66.34
|
| Rate for Payer: United Healthcare Commercial |
$495.03
|
| Rate for Payer: United Healthcare Medicare |
$66.34
|
| Rate for Payer: WINHealth Partners Commercial |
$483.65
|
|
|
INJECTION AA&/STRD BRACHIAL PLEXUS W/IMG GDN
|
Professional
|
Both
|
$1,137.00
|
|
|
Service Code
|
HCPCS 64415 50
|
| Hospital Charge Code |
64415
|
| Min. Negotiated Rate |
$56.39 |
| Max. Negotiated Rate |
$1,137.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,114.26
|
| Rate for Payer: Aetna of WY Medicare |
$66.34
|
| Rate for Payer: Beech Street Commercial |
$1,080.15
|
| Rate for Payer: Cash Price |
$795.90
|
| Rate for Payer: Cash Price |
$795.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,102.89
|
| Rate for Payer: Cigna of WY Commercial |
$1,114.26
|
| Rate for Payer: First Choice Health Commercial |
$1,023.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,080.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$66.34
|
| Rate for Payer: HealthUtah PPO |
$1,137.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,102.89
|
| Rate for Payer: Multiplan Medicare/VA |
$56.39
|
| Rate for Payer: One Health Plan of WY PPO |
$1,114.26
|
| Rate for Payer: PacificSource Commercial |
$1,023.30
|
| Rate for Payer: PHCS PPO |
$1,080.15
|
| Rate for Payer: Three Rivers PPO |
$852.75
|
| Rate for Payer: TriWest Veterans Administration |
$66.34
|
| Rate for Payer: United Healthcare Commercial |
$989.19
|
| Rate for Payer: United Healthcare Medicare |
$66.34
|
| Rate for Payer: WINHealth Partners Commercial |
$966.45
|
|
|
INJECTION AA&/STRD BRACH PLEX CONT NFS CATH IMG
|
Professional
|
Both
|
$332.00
|
|
|
Service Code
|
HCPCS 64416
|
| Hospital Charge Code |
64416
|
| Min. Negotiated Rate |
$62.36 |
| Max. Negotiated Rate |
$332.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$325.36
|
| Rate for Payer: Aetna of WY Medicare |
$73.37
|
| Rate for Payer: Beech Street Commercial |
$315.40
|
| Rate for Payer: Cash Price |
$232.40
|
| Rate for Payer: Cash Price |
$232.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$322.04
|
| Rate for Payer: Cigna of WY Commercial |
$325.36
|
| Rate for Payer: First Choice Health Commercial |
$298.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$315.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$73.37
|
| Rate for Payer: HealthUtah PPO |
$332.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$322.04
|
| Rate for Payer: Multiplan Medicare/VA |
$62.36
|
| Rate for Payer: One Health Plan of WY PPO |
$325.36
|
| Rate for Payer: PacificSource Commercial |
$298.80
|
| Rate for Payer: PHCS PPO |
$315.40
|
| Rate for Payer: Three Rivers PPO |
$249.00
|
| Rate for Payer: TriWest Veterans Administration |
$73.37
|
| Rate for Payer: United Healthcare Commercial |
$288.84
|
| Rate for Payer: United Healthcare Medicare |
$73.37
|
| Rate for Payer: WINHealth Partners Commercial |
$282.20
|
|
|
INJECTION AA&/STRD BRACH PLEX CONT NFS CATH IMG
|
Professional
|
Both
|
$665.00
|
|
|
Service Code
|
HCPCS 64416 50
|
| Hospital Charge Code |
64416
|
| Min. Negotiated Rate |
$62.36 |
| Max. Negotiated Rate |
$665.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$651.70
|
| Rate for Payer: Aetna of WY Medicare |
$73.37
|
| Rate for Payer: Beech Street Commercial |
$631.75
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: Cash Price |
$465.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$645.05
|
| Rate for Payer: Cigna of WY Commercial |
$651.70
|
| Rate for Payer: First Choice Health Commercial |
$598.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$631.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$73.37
|
| Rate for Payer: HealthUtah PPO |
$665.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$645.05
|
| Rate for Payer: Multiplan Medicare/VA |
$62.36
|
| Rate for Payer: One Health Plan of WY PPO |
$651.70
|
| Rate for Payer: PacificSource Commercial |
$598.50
|
| Rate for Payer: PHCS PPO |
$631.75
|
| Rate for Payer: Three Rivers PPO |
$498.75
|
| Rate for Payer: TriWest Veterans Administration |
$73.37
|
| Rate for Payer: United Healthcare Commercial |
$578.55
|
| Rate for Payer: United Healthcare Medicare |
$73.37
|
| Rate for Payer: WINHealth Partners Commercial |
$565.25
|
|
|
INJECTION AA&/STRD FEMORAL NERVE CONT NFS CATH
|
Professional
|
Both
|
$319.00
|
|
|
Service Code
|
HCPCS 64448
|
| Hospital Charge Code |
64448
|
| Min. Negotiated Rate |
$58.27 |
| Max. Negotiated Rate |
$319.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$312.62
|
| Rate for Payer: Aetna of WY Medicare |
$68.55
|
| Rate for Payer: Beech Street Commercial |
$303.05
|
| Rate for Payer: Cash Price |
$223.30
|
| Rate for Payer: Cash Price |
$223.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$309.43
|
| Rate for Payer: Cigna of WY Commercial |
$312.62
|
| Rate for Payer: First Choice Health Commercial |
$287.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$303.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$68.55
|
| Rate for Payer: HealthUtah PPO |
$319.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$309.43
|
| Rate for Payer: Multiplan Medicare/VA |
$58.27
|
| Rate for Payer: One Health Plan of WY PPO |
$312.62
|
| Rate for Payer: PacificSource Commercial |
$287.10
|
| Rate for Payer: PHCS PPO |
$303.05
|
| Rate for Payer: Three Rivers PPO |
$239.25
|
| Rate for Payer: TriWest Veterans Administration |
$68.55
|
| Rate for Payer: United Healthcare Commercial |
$277.53
|
| Rate for Payer: United Healthcare Medicare |
$68.55
|
| Rate for Payer: WINHealth Partners Commercial |
$271.15
|
|
|
INJECTION AA&/STRD FEMORAL NERVE CONT NFS CATH
|
Professional
|
Both
|
$639.00
|
|
|
Service Code
|
HCPCS 64448 50
|
| Hospital Charge Code |
64448
|
| Min. Negotiated Rate |
$58.27 |
| Max. Negotiated Rate |
$639.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$626.22
|
| Rate for Payer: Aetna of WY Medicare |
$68.55
|
| Rate for Payer: Beech Street Commercial |
$607.05
|
| Rate for Payer: Cash Price |
$447.30
|
| Rate for Payer: Cash Price |
$447.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$619.83
|
| Rate for Payer: Cigna of WY Commercial |
$626.22
|
| Rate for Payer: First Choice Health Commercial |
$575.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$607.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$68.55
|
| Rate for Payer: HealthUtah PPO |
$639.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$619.83
|
| Rate for Payer: Multiplan Medicare/VA |
$58.27
|
| Rate for Payer: One Health Plan of WY PPO |
$626.22
|
| Rate for Payer: PacificSource Commercial |
$575.10
|
| Rate for Payer: PHCS PPO |
$607.05
|
| Rate for Payer: Three Rivers PPO |
$479.25
|
| Rate for Payer: TriWest Veterans Administration |
$68.55
|
| Rate for Payer: United Healthcare Commercial |
$555.93
|
| Rate for Payer: United Healthcare Medicare |
$68.55
|
| Rate for Payer: WINHealth Partners Commercial |
$543.15
|
|
|
INJECTION AA&/STRD FEMORAL NERVE W/IMG GDN
|
Professional
|
Both
|
$808.00
|
|
|
Service Code
|
HCPCS 64447 50
|
| Hospital Charge Code |
64447
|
| Min. Negotiated Rate |
$51.25 |
| Max. Negotiated Rate |
$808.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$791.84
|
| Rate for Payer: Aetna of WY Medicare |
$60.29
|
| Rate for Payer: Beech Street Commercial |
$767.60
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: Cash Price |
$565.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$783.76
|
| Rate for Payer: Cigna of WY Commercial |
$791.84
|
| Rate for Payer: First Choice Health Commercial |
$727.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$767.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$60.29
|
| Rate for Payer: HealthUtah PPO |
$808.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$783.76
|
| Rate for Payer: Multiplan Medicare/VA |
$51.25
|
| Rate for Payer: One Health Plan of WY PPO |
$791.84
|
| Rate for Payer: PacificSource Commercial |
$727.20
|
| Rate for Payer: PHCS PPO |
$767.60
|
| Rate for Payer: Three Rivers PPO |
$606.00
|
| Rate for Payer: TriWest Veterans Administration |
$60.29
|
| Rate for Payer: United Healthcare Commercial |
$702.96
|
| Rate for Payer: United Healthcare Medicare |
$60.29
|
| Rate for Payer: WINHealth Partners Commercial |
$686.80
|
|
|
INJECTION AA&/STRD FEMORAL NERVE W/IMG GDN
|
Professional
|
Both
|
$404.00
|
|
|
Service Code
|
HCPCS 64447
|
| Hospital Charge Code |
64447
|
| Min. Negotiated Rate |
$51.25 |
| Max. Negotiated Rate |
$404.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$395.92
|
| Rate for Payer: Aetna of WY Medicare |
$60.29
|
| Rate for Payer: Beech Street Commercial |
$383.80
|
| Rate for Payer: Cash Price |
$282.80
|
| Rate for Payer: Cash Price |
$282.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$391.88
|
| Rate for Payer: Cigna of WY Commercial |
$395.92
|
| Rate for Payer: First Choice Health Commercial |
$363.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$383.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$60.29
|
| Rate for Payer: HealthUtah PPO |
$404.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$391.88
|
| Rate for Payer: Multiplan Medicare/VA |
$51.25
|
| Rate for Payer: One Health Plan of WY PPO |
$395.92
|
| Rate for Payer: PacificSource Commercial |
$363.60
|
| Rate for Payer: PHCS PPO |
$383.80
|
| Rate for Payer: Three Rivers PPO |
$303.00
|
| Rate for Payer: TriWest Veterans Administration |
$60.29
|
| Rate for Payer: United Healthcare Commercial |
$351.48
|
| Rate for Payer: United Healthcare Medicare |
$60.29
|
| Rate for Payer: WINHealth Partners Commercial |
$343.40
|
|
|
INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG
|
Professional
|
Both
|
$1,547.00
|
|
|
Service Code
|
HCPCS 64454 50
|
| Hospital Charge Code |
64454
|
| Min. Negotiated Rate |
$67.18 |
| Max. Negotiated Rate |
$1,547.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,516.06
|
| Rate for Payer: Aetna of WY Medicare |
$79.03
|
| Rate for Payer: Beech Street Commercial |
$1,469.65
|
| Rate for Payer: Cash Price |
$1,082.90
|
| Rate for Payer: Cash Price |
$1,082.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,500.59
|
| Rate for Payer: Cigna of WY Commercial |
$1,516.06
|
| Rate for Payer: First Choice Health Commercial |
$1,392.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,469.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.03
|
| Rate for Payer: HealthUtah PPO |
$1,547.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,500.59
|
| Rate for Payer: Multiplan Medicare/VA |
$67.18
|
| Rate for Payer: One Health Plan of WY PPO |
$1,516.06
|
| Rate for Payer: PacificSource Commercial |
$1,392.30
|
| Rate for Payer: PHCS PPO |
$1,469.65
|
| Rate for Payer: Three Rivers PPO |
$1,160.25
|
| Rate for Payer: TriWest Veterans Administration |
$79.03
|
| Rate for Payer: United Healthcare Commercial |
$1,345.89
|
| Rate for Payer: United Healthcare Medicare |
$79.03
|
| Rate for Payer: WINHealth Partners Commercial |
$1,314.95
|
|
|
INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG
|
Professional
|
Both
|
$773.00
|
|
|
Service Code
|
HCPCS 64454
|
| Hospital Charge Code |
64454
|
| Min. Negotiated Rate |
$67.18 |
| Max. Negotiated Rate |
$773.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$757.54
|
| Rate for Payer: Aetna of WY Medicare |
$79.03
|
| Rate for Payer: Beech Street Commercial |
$734.35
|
| Rate for Payer: Cash Price |
$541.10
|
| Rate for Payer: Cash Price |
$541.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$749.81
|
| Rate for Payer: Cigna of WY Commercial |
$757.54
|
| Rate for Payer: First Choice Health Commercial |
$695.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$734.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$79.03
|
| Rate for Payer: HealthUtah PPO |
$773.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$749.81
|
| Rate for Payer: Multiplan Medicare/VA |
$67.18
|
| Rate for Payer: One Health Plan of WY PPO |
$757.54
|
| Rate for Payer: PacificSource Commercial |
$695.70
|
| Rate for Payer: PHCS PPO |
$734.35
|
| Rate for Payer: Three Rivers PPO |
$579.75
|
| Rate for Payer: TriWest Veterans Administration |
$79.03
|
| Rate for Payer: United Healthcare Commercial |
$672.51
|
| Rate for Payer: United Healthcare Medicare |
$79.03
|
| Rate for Payer: WINHealth Partners Commercial |
$657.05
|
|
|
INJECTION AA&/STRD GREATER OCCIPITAL NERVE
|
Professional
|
Both
|
$276.00
|
|
|
Service Code
|
HCPCS 64405
|
| Hospital Charge Code |
64405
|
| Min. Negotiated Rate |
$42.38 |
| Max. Negotiated Rate |
$276.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$270.48
|
| Rate for Payer: Aetna of WY Medicare |
$49.86
|
| Rate for Payer: Beech Street Commercial |
$262.20
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: Cash Price |
$193.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$267.72
|
| Rate for Payer: Cigna of WY Commercial |
$270.48
|
| Rate for Payer: First Choice Health Commercial |
$248.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$262.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.86
|
| Rate for Payer: HealthUtah PPO |
$276.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$267.72
|
| Rate for Payer: Multiplan Medicare/VA |
$42.38
|
| Rate for Payer: One Health Plan of WY PPO |
$270.48
|
| Rate for Payer: PacificSource Commercial |
$248.40
|
| Rate for Payer: PHCS PPO |
$262.20
|
| Rate for Payer: Three Rivers PPO |
$207.00
|
| Rate for Payer: TriWest Veterans Administration |
$49.86
|
| Rate for Payer: United Healthcare Commercial |
$240.12
|
| Rate for Payer: United Healthcare Medicare |
$49.86
|
| Rate for Payer: WINHealth Partners Commercial |
$234.60
|
|
|
INJECTION AA&/STRD GREATER OCCIPITAL NERVE
|
Professional
|
Both
|
$552.00
|
|
|
Service Code
|
HCPCS 64405 50
|
| Hospital Charge Code |
64405
|
| Min. Negotiated Rate |
$42.38 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$540.96
|
| Rate for Payer: Aetna of WY Medicare |
$49.86
|
| Rate for Payer: Beech Street Commercial |
$524.40
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: Cash Price |
$386.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$535.44
|
| Rate for Payer: Cigna of WY Commercial |
$540.96
|
| Rate for Payer: First Choice Health Commercial |
$496.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$524.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.86
|
| Rate for Payer: HealthUtah PPO |
$552.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$535.44
|
| Rate for Payer: Multiplan Medicare/VA |
$42.38
|
| Rate for Payer: One Health Plan of WY PPO |
$540.96
|
| Rate for Payer: PacificSource Commercial |
$496.80
|
| Rate for Payer: PHCS PPO |
$524.40
|
| Rate for Payer: Three Rivers PPO |
$414.00
|
| Rate for Payer: TriWest Veterans Administration |
$49.86
|
| Rate for Payer: United Healthcare Commercial |
$480.24
|
| Rate for Payer: United Healthcare Medicare |
$49.86
|
| Rate for Payer: WINHealth Partners Commercial |
$469.20
|
|
|
INJECTION AA&/STRD ILIOINGUINAL IH NERVES
|
Professional
|
Both
|
$385.00
|
|
|
Service Code
|
HCPCS 64425
|
| Hospital Charge Code |
64425
|
| Min. Negotiated Rate |
$44.36 |
| Max. Negotiated Rate |
$385.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$377.30
|
| Rate for Payer: Aetna of WY Medicare |
$52.19
|
| Rate for Payer: Beech Street Commercial |
$365.75
|
| Rate for Payer: Cash Price |
$269.50
|
| Rate for Payer: Cash Price |
$269.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$373.45
|
| Rate for Payer: Cigna of WY Commercial |
$377.30
|
| Rate for Payer: First Choice Health Commercial |
$346.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$365.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$52.19
|
| Rate for Payer: HealthUtah PPO |
$385.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$373.45
|
| Rate for Payer: Multiplan Medicare/VA |
$44.36
|
| Rate for Payer: One Health Plan of WY PPO |
$377.30
|
| Rate for Payer: PacificSource Commercial |
$346.50
|
| Rate for Payer: PHCS PPO |
$365.75
|
| Rate for Payer: Three Rivers PPO |
$288.75
|
| Rate for Payer: TriWest Veterans Administration |
$52.19
|
| Rate for Payer: United Healthcare Commercial |
$334.95
|
| Rate for Payer: United Healthcare Medicare |
$52.19
|
| Rate for Payer: WINHealth Partners Commercial |
$327.25
|
|
|
INJECTION AA&/STRD ILIOINGUINAL IH NERVES
|
Professional
|
Both
|
$770.00
|
|
|
Service Code
|
HCPCS 64425 50
|
| Hospital Charge Code |
64425
|
| Min. Negotiated Rate |
$44.36 |
| Max. Negotiated Rate |
$770.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$754.60
|
| Rate for Payer: Aetna of WY Medicare |
$52.19
|
| Rate for Payer: Beech Street Commercial |
$731.50
|
| Rate for Payer: Cash Price |
$539.00
|
| Rate for Payer: Cash Price |
$539.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$746.90
|
| Rate for Payer: Cigna of WY Commercial |
$754.60
|
| Rate for Payer: First Choice Health Commercial |
$693.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$731.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$52.19
|
| Rate for Payer: HealthUtah PPO |
$770.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$746.90
|
| Rate for Payer: Multiplan Medicare/VA |
$44.36
|
| Rate for Payer: One Health Plan of WY PPO |
$754.60
|
| Rate for Payer: PacificSource Commercial |
$693.00
|
| Rate for Payer: PHCS PPO |
$731.50
|
| Rate for Payer: Three Rivers PPO |
$577.50
|
| Rate for Payer: TriWest Veterans Administration |
$52.19
|
| Rate for Payer: United Healthcare Commercial |
$669.90
|
| Rate for Payer: United Healthcare Medicare |
$52.19
|
| Rate for Payer: WINHealth Partners Commercial |
$654.50
|
|
|
INJECTION AA&/STRD INTERCOSTAL NRV EA ADDL LVL
|
Professional
|
Both
|
$132.00
|
|
|
Service Code
|
HCPCS 64421
|
| Hospital Charge Code |
64421
|
| Min. Negotiated Rate |
$20.23 |
| Max. Negotiated Rate |
$132.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$129.36
|
| Rate for Payer: Aetna of WY Medicare |
$23.80
|
| Rate for Payer: Beech Street Commercial |
$125.40
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: Cash Price |
$92.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$128.04
|
| Rate for Payer: Cigna of WY Commercial |
$129.36
|
| Rate for Payer: First Choice Health Commercial |
$118.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$125.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.80
|
| Rate for Payer: HealthUtah PPO |
$132.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$128.04
|
| Rate for Payer: Multiplan Medicare/VA |
$20.23
|
| Rate for Payer: One Health Plan of WY PPO |
$129.36
|
| Rate for Payer: PacificSource Commercial |
$118.80
|
| Rate for Payer: PHCS PPO |
$125.40
|
| Rate for Payer: Three Rivers PPO |
$99.00
|
| Rate for Payer: TriWest Veterans Administration |
$23.80
|
| Rate for Payer: United Healthcare Commercial |
$114.84
|
| Rate for Payer: United Healthcare Medicare |
$23.80
|
| Rate for Payer: WINHealth Partners Commercial |
$112.20
|
|
|
INJECTION AA&/STRD INTERCOSTAL NRV EA ADDL LVL
|
Professional
|
Both
|
$264.00
|
|
|
Service Code
|
HCPCS 64421 50
|
| Hospital Charge Code |
64421
|
| Min. Negotiated Rate |
$20.23 |
| Max. Negotiated Rate |
$264.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$258.72
|
| Rate for Payer: Aetna of WY Medicare |
$23.80
|
| Rate for Payer: Beech Street Commercial |
$250.80
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: Cash Price |
$184.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$256.08
|
| Rate for Payer: Cigna of WY Commercial |
$258.72
|
| Rate for Payer: First Choice Health Commercial |
$237.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$250.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$23.80
|
| Rate for Payer: HealthUtah PPO |
$264.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$256.08
|
| Rate for Payer: Multiplan Medicare/VA |
$20.23
|
| Rate for Payer: One Health Plan of WY PPO |
$258.72
|
| Rate for Payer: PacificSource Commercial |
$237.60
|
| Rate for Payer: PHCS PPO |
$250.80
|
| Rate for Payer: Three Rivers PPO |
$198.00
|
| Rate for Payer: TriWest Veterans Administration |
$23.80
|
| Rate for Payer: United Healthcare Commercial |
$229.68
|
| Rate for Payer: United Healthcare Medicare |
$23.80
|
| Rate for Payer: WINHealth Partners Commercial |
$224.40
|
|
|
INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
HCPCS 64420
|
| Hospital Charge Code |
64420
|
| Min. Negotiated Rate |
$47.42 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$333.20
|
| Rate for Payer: Aetna of WY Medicare |
$55.79
|
| Rate for Payer: Beech Street Commercial |
$323.00
|
| Rate for Payer: Cash Price |
$238.00
|
| Rate for Payer: Cash Price |
$238.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$329.80
|
| Rate for Payer: Cigna of WY Commercial |
$333.20
|
| Rate for Payer: First Choice Health Commercial |
$306.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$323.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.79
|
| Rate for Payer: HealthUtah PPO |
$340.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$329.80
|
| Rate for Payer: Multiplan Medicare/VA |
$47.42
|
| Rate for Payer: One Health Plan of WY PPO |
$333.20
|
| Rate for Payer: PacificSource Commercial |
$306.00
|
| Rate for Payer: PHCS PPO |
$323.00
|
| Rate for Payer: Three Rivers PPO |
$255.00
|
| Rate for Payer: TriWest Veterans Administration |
$55.79
|
| Rate for Payer: United Healthcare Commercial |
$295.80
|
| Rate for Payer: United Healthcare Medicare |
$55.79
|
| Rate for Payer: WINHealth Partners Commercial |
$289.00
|
|
|
INJECTION AA&/STRD INTERCOSTAL NRV SINGLE LVL
|
Professional
|
Both
|
$681.00
|
|
|
Service Code
|
HCPCS 64420 50
|
| Hospital Charge Code |
64420
|
| Min. Negotiated Rate |
$47.42 |
| Max. Negotiated Rate |
$681.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$667.38
|
| Rate for Payer: Aetna of WY Medicare |
$55.79
|
| Rate for Payer: Beech Street Commercial |
$646.95
|
| Rate for Payer: Cash Price |
$476.70
|
| Rate for Payer: Cash Price |
$476.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$660.57
|
| Rate for Payer: Cigna of WY Commercial |
$667.38
|
| Rate for Payer: First Choice Health Commercial |
$612.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$646.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$55.79
|
| Rate for Payer: HealthUtah PPO |
$681.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$660.57
|
| Rate for Payer: Multiplan Medicare/VA |
$47.42
|
| Rate for Payer: One Health Plan of WY PPO |
$667.38
|
| Rate for Payer: PacificSource Commercial |
$612.90
|
| Rate for Payer: PHCS PPO |
$646.95
|
| Rate for Payer: Three Rivers PPO |
$510.75
|
| Rate for Payer: TriWest Veterans Administration |
$55.79
|
| Rate for Payer: United Healthcare Commercial |
$592.47
|
| Rate for Payer: United Healthcare Medicare |
$55.79
|
| Rate for Payer: WINHealth Partners Commercial |
$578.85
|
|
|
INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG
|
Professional
|
Both
|
$1,061.00
|
|
|
Service Code
|
HCPCS 64451
|
| Hospital Charge Code |
64451
|
| Min. Negotiated Rate |
$66.61 |
| Max. Negotiated Rate |
$1,061.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,039.78
|
| Rate for Payer: Aetna of WY Medicare |
$78.37
|
| Rate for Payer: Beech Street Commercial |
$1,007.95
|
| Rate for Payer: Cash Price |
$742.70
|
| Rate for Payer: Cash Price |
$742.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,029.17
|
| Rate for Payer: Cigna of WY Commercial |
$1,039.78
|
| Rate for Payer: First Choice Health Commercial |
$954.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,007.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.37
|
| Rate for Payer: HealthUtah PPO |
$1,061.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,029.17
|
| Rate for Payer: Multiplan Medicare/VA |
$66.61
|
| Rate for Payer: One Health Plan of WY PPO |
$1,039.78
|
| Rate for Payer: PacificSource Commercial |
$954.90
|
| Rate for Payer: PHCS PPO |
$1,007.95
|
| Rate for Payer: Three Rivers PPO |
$795.75
|
| Rate for Payer: TriWest Veterans Administration |
$78.37
|
| Rate for Payer: United Healthcare Commercial |
$923.07
|
| Rate for Payer: United Healthcare Medicare |
$78.37
|
| Rate for Payer: WINHealth Partners Commercial |
$901.85
|
|
|
INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG
|
Professional
|
Both
|
$2,122.00
|
|
|
Service Code
|
HCPCS 64451 50
|
| Hospital Charge Code |
64451
|
| Min. Negotiated Rate |
$66.61 |
| Max. Negotiated Rate |
$2,122.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,079.56
|
| Rate for Payer: Aetna of WY Medicare |
$78.37
|
| Rate for Payer: Beech Street Commercial |
$2,015.90
|
| Rate for Payer: Cash Price |
$1,485.40
|
| Rate for Payer: Cash Price |
$1,485.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,058.34
|
| Rate for Payer: Cigna of WY Commercial |
$2,079.56
|
| Rate for Payer: First Choice Health Commercial |
$1,909.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,015.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.37
|
| Rate for Payer: HealthUtah PPO |
$2,122.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,058.34
|
| Rate for Payer: Multiplan Medicare/VA |
$66.61
|
| Rate for Payer: One Health Plan of WY PPO |
$2,079.56
|
| Rate for Payer: PacificSource Commercial |
$1,909.80
|
| Rate for Payer: PHCS PPO |
$2,015.90
|
| Rate for Payer: Three Rivers PPO |
$1,591.50
|
| Rate for Payer: TriWest Veterans Administration |
$78.37
|
| Rate for Payer: United Healthcare Commercial |
$1,846.14
|
| Rate for Payer: United Healthcare Medicare |
$78.37
|
| Rate for Payer: WINHealth Partners Commercial |
$1,803.70
|
|
