|
INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH
|
Professional
|
Both
|
$261.00
|
|
|
Service Code
|
HCPCS 64450
|
| Hospital Charge Code |
64450
|
| Min. Negotiated Rate |
$34.14 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$255.78
|
| Rate for Payer: Aetna of WY Medicare |
$40.16
|
| Rate for Payer: Beech Street Commercial |
$247.95
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$253.17
|
| Rate for Payer: Cigna of WY Commercial |
$255.78
|
| Rate for Payer: First Choice Health Commercial |
$234.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$247.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.16
|
| Rate for Payer: HealthUtah PPO |
$261.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$253.17
|
| Rate for Payer: Multiplan Medicare/VA |
$34.14
|
| Rate for Payer: One Health Plan of WY PPO |
$255.78
|
| Rate for Payer: PacificSource Commercial |
$234.90
|
| Rate for Payer: PHCS PPO |
$247.95
|
| Rate for Payer: Three Rivers PPO |
$195.75
|
| Rate for Payer: TriWest Veterans Administration |
$40.16
|
| Rate for Payer: United Healthcare Commercial |
$227.07
|
| Rate for Payer: United Healthcare Medicare |
$40.16
|
| Rate for Payer: WINHealth Partners Commercial |
$221.85
|
|
|
INJECTION AA&/STRD OTHER PERIPHERAL NERVE/BRANCH
|
Professional
|
Both
|
$522.00
|
|
|
Service Code
|
HCPCS 64450 50
|
| Hospital Charge Code |
64450
|
| Min. Negotiated Rate |
$34.14 |
| Max. Negotiated Rate |
$522.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$511.56
|
| Rate for Payer: Aetna of WY Medicare |
$40.16
|
| Rate for Payer: Beech Street Commercial |
$495.90
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$506.34
|
| Rate for Payer: Cigna of WY Commercial |
$511.56
|
| Rate for Payer: First Choice Health Commercial |
$469.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$495.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.16
|
| Rate for Payer: HealthUtah PPO |
$522.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$506.34
|
| Rate for Payer: Multiplan Medicare/VA |
$34.14
|
| Rate for Payer: One Health Plan of WY PPO |
$511.56
|
| Rate for Payer: PacificSource Commercial |
$469.80
|
| Rate for Payer: PHCS PPO |
$495.90
|
| Rate for Payer: Three Rivers PPO |
$391.50
|
| Rate for Payer: TriWest Veterans Administration |
$40.16
|
| Rate for Payer: United Healthcare Commercial |
$454.14
|
| Rate for Payer: United Healthcare Medicare |
$40.16
|
| Rate for Payer: WINHealth Partners Commercial |
$443.70
|
|
|
INJECTION AA&/STRD PARACERVICAL NERVE
|
Professional
|
Both
|
$679.00
|
|
|
Service Code
|
HCPCS 64435 50
|
| Hospital Charge Code |
64435
|
| Min. Negotiated Rate |
$35.51 |
| Max. Negotiated Rate |
$679.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$665.42
|
| Rate for Payer: Aetna of WY Medicare |
$41.78
|
| Rate for Payer: Beech Street Commercial |
$645.05
|
| Rate for Payer: Cash Price |
$475.30
|
| Rate for Payer: Cash Price |
$475.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$658.63
|
| Rate for Payer: Cigna of WY Commercial |
$665.42
|
| Rate for Payer: First Choice Health Commercial |
$611.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$645.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$41.78
|
| Rate for Payer: HealthUtah PPO |
$679.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$658.63
|
| Rate for Payer: Multiplan Medicare/VA |
$35.51
|
| Rate for Payer: One Health Plan of WY PPO |
$665.42
|
| Rate for Payer: PacificSource Commercial |
$611.10
|
| Rate for Payer: PHCS PPO |
$645.05
|
| Rate for Payer: Three Rivers PPO |
$509.25
|
| Rate for Payer: TriWest Veterans Administration |
$41.78
|
| Rate for Payer: United Healthcare Commercial |
$590.73
|
| Rate for Payer: United Healthcare Medicare |
$41.78
|
| Rate for Payer: WINHealth Partners Commercial |
$577.15
|
|
|
INJECTION AA&/STRD PARACERVICAL NERVE
|
Professional
|
Both
|
$339.00
|
|
|
Service Code
|
HCPCS 64435
|
| Hospital Charge Code |
64435
|
| Min. Negotiated Rate |
$35.51 |
| Max. Negotiated Rate |
$339.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$332.22
|
| Rate for Payer: Aetna of WY Medicare |
$41.78
|
| Rate for Payer: Beech Street Commercial |
$322.05
|
| Rate for Payer: Cash Price |
$237.30
|
| Rate for Payer: Cash Price |
$237.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$328.83
|
| Rate for Payer: Cigna of WY Commercial |
$332.22
|
| Rate for Payer: First Choice Health Commercial |
$305.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$322.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$41.78
|
| Rate for Payer: HealthUtah PPO |
$339.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$328.83
|
| Rate for Payer: Multiplan Medicare/VA |
$35.51
|
| Rate for Payer: One Health Plan of WY PPO |
$332.22
|
| Rate for Payer: PacificSource Commercial |
$305.10
|
| Rate for Payer: PHCS PPO |
$322.05
|
| Rate for Payer: Three Rivers PPO |
$254.25
|
| Rate for Payer: TriWest Veterans Administration |
$41.78
|
| Rate for Payer: United Healthcare Commercial |
$294.93
|
| Rate for Payer: United Healthcare Medicare |
$41.78
|
| Rate for Payer: WINHealth Partners Commercial |
$288.15
|
|
|
INJECTION AA&/STRD PUDENDAL NERVE
|
Professional
|
Both
|
$681.00
|
|
|
Service Code
|
HCPCS 64430 50
|
| Hospital Charge Code |
64430
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$681.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$667.38
|
| Rate for Payer: Aetna of WY Medicare |
$52.35
|
| 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 |
$52.35
|
| Rate for Payer: HealthUtah PPO |
$681.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$660.57
|
| Rate for Payer: Multiplan Medicare/VA |
$44.50
|
| 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 |
$52.35
|
| Rate for Payer: United Healthcare Commercial |
$592.47
|
| Rate for Payer: United Healthcare Medicare |
$52.35
|
| Rate for Payer: WINHealth Partners Commercial |
$578.85
|
|
|
INJECTION AA&/STRD PUDENDAL NERVE
|
Professional
|
Both
|
$340.00
|
|
|
Service Code
|
HCPCS 64430
|
| Hospital Charge Code |
64430
|
| Min. Negotiated Rate |
$44.50 |
| Max. Negotiated Rate |
$340.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$333.20
|
| Rate for Payer: Aetna of WY Medicare |
$52.35
|
| 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 |
$52.35
|
| Rate for Payer: HealthUtah PPO |
$340.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$329.80
|
| Rate for Payer: Multiplan Medicare/VA |
$44.50
|
| 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 |
$52.35
|
| Rate for Payer: United Healthcare Commercial |
$295.80
|
| Rate for Payer: United Healthcare Medicare |
$52.35
|
| Rate for Payer: WINHealth Partners Commercial |
$289.00
|
|
|
INJECTION AA&/STRD SCIATIC NERVE W/IMG GDN
|
Professional
|
Both
|
$1,104.00
|
|
|
Service Code
|
HCPCS 64445 50
|
| Hospital Charge Code |
64445
|
| Min. Negotiated Rate |
$58.55 |
| Max. Negotiated Rate |
$1,104.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,081.92
|
| Rate for Payer: Aetna of WY Medicare |
$68.88
|
| Rate for Payer: Beech Street Commercial |
$1,048.80
|
| Rate for Payer: Cash Price |
$772.80
|
| Rate for Payer: Cash Price |
$772.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,070.88
|
| Rate for Payer: Cigna of WY Commercial |
$1,081.92
|
| Rate for Payer: First Choice Health Commercial |
$993.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,048.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$68.88
|
| Rate for Payer: HealthUtah PPO |
$1,104.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,070.88
|
| Rate for Payer: Multiplan Medicare/VA |
$58.55
|
| Rate for Payer: One Health Plan of WY PPO |
$1,081.92
|
| Rate for Payer: PacificSource Commercial |
$993.60
|
| Rate for Payer: PHCS PPO |
$1,048.80
|
| Rate for Payer: Three Rivers PPO |
$828.00
|
| Rate for Payer: TriWest Veterans Administration |
$68.88
|
| Rate for Payer: United Healthcare Commercial |
$960.48
|
| Rate for Payer: United Healthcare Medicare |
$68.88
|
| Rate for Payer: WINHealth Partners Commercial |
$938.40
|
|
|
INJECTION AA&/STRD SCIATIC NERVE W/IMG GDN
|
Professional
|
Both
|
$552.00
|
|
|
Service Code
|
HCPCS 64445
|
| Hospital Charge Code |
64445
|
| Min. Negotiated Rate |
$58.55 |
| Max. Negotiated Rate |
$552.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$540.96
|
| Rate for Payer: Aetna of WY Medicare |
$68.88
|
| 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 |
$68.88
|
| Rate for Payer: HealthUtah PPO |
$552.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$535.44
|
| Rate for Payer: Multiplan Medicare/VA |
$58.55
|
| 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 |
$68.88
|
| Rate for Payer: United Healthcare Commercial |
$480.24
|
| Rate for Payer: United Healthcare Medicare |
$68.88
|
| Rate for Payer: WINHealth Partners Commercial |
$469.20
|
|
|
INJECTION AA&/STRD SCIATIC NRV CONT NFS CATH IMG
|
Professional
|
Both
|
$307.00
|
|
|
Service Code
|
HCPCS 64446
|
| Hospital Charge Code |
64446
|
| Min. Negotiated Rate |
$60.98 |
| Max. Negotiated Rate |
$307.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$300.86
|
| Rate for Payer: Aetna of WY Medicare |
$71.74
|
| Rate for Payer: Beech Street Commercial |
$291.65
|
| Rate for Payer: Cash Price |
$214.90
|
| Rate for Payer: Cash Price |
$214.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$297.79
|
| Rate for Payer: Cigna of WY Commercial |
$300.86
|
| Rate for Payer: First Choice Health Commercial |
$276.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$291.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$71.74
|
| Rate for Payer: HealthUtah PPO |
$307.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$297.79
|
| Rate for Payer: Multiplan Medicare/VA |
$60.98
|
| Rate for Payer: One Health Plan of WY PPO |
$300.86
|
| Rate for Payer: PacificSource Commercial |
$276.30
|
| Rate for Payer: PHCS PPO |
$291.65
|
| Rate for Payer: Three Rivers PPO |
$230.25
|
| Rate for Payer: TriWest Veterans Administration |
$71.74
|
| Rate for Payer: United Healthcare Commercial |
$267.09
|
| Rate for Payer: United Healthcare Medicare |
$71.74
|
| Rate for Payer: WINHealth Partners Commercial |
$260.95
|
|
|
INJECTION AA&/STRD SCIATIC NRV CONT NFS CATH IMG
|
Professional
|
Both
|
$613.00
|
|
|
Service Code
|
HCPCS 64446 50
|
| Hospital Charge Code |
64446
|
| Min. Negotiated Rate |
$60.98 |
| Max. Negotiated Rate |
$613.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$600.74
|
| Rate for Payer: Aetna of WY Medicare |
$71.74
|
| Rate for Payer: Beech Street Commercial |
$582.35
|
| Rate for Payer: Cash Price |
$429.10
|
| Rate for Payer: Cash Price |
$429.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$594.61
|
| Rate for Payer: Cigna of WY Commercial |
$600.74
|
| Rate for Payer: First Choice Health Commercial |
$551.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$582.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$71.74
|
| Rate for Payer: HealthUtah PPO |
$613.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$594.61
|
| Rate for Payer: Multiplan Medicare/VA |
$60.98
|
| Rate for Payer: One Health Plan of WY PPO |
$600.74
|
| Rate for Payer: PacificSource Commercial |
$551.70
|
| Rate for Payer: PHCS PPO |
$582.35
|
| Rate for Payer: Three Rivers PPO |
$459.75
|
| Rate for Payer: TriWest Veterans Administration |
$71.74
|
| Rate for Payer: United Healthcare Commercial |
$533.31
|
| Rate for Payer: United Healthcare Medicare |
$71.74
|
| Rate for Payer: WINHealth Partners Commercial |
$521.05
|
|
|
INJECTION AA&/STRD SUPRASCAPULAR NERVE
|
Professional
|
Both
|
$600.00
|
|
|
Service Code
|
HCPCS 64418 50
|
| Hospital Charge Code |
64418
|
| Min. Negotiated Rate |
$45.05 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$588.00
|
| Rate for Payer: Aetna of WY Medicare |
$53.00
|
| Rate for Payer: Beech Street Commercial |
$570.00
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$582.00
|
| Rate for Payer: Cigna of WY Commercial |
$588.00
|
| Rate for Payer: First Choice Health Commercial |
$540.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$570.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.00
|
| Rate for Payer: HealthUtah PPO |
$600.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$582.00
|
| Rate for Payer: Multiplan Medicare/VA |
$45.05
|
| Rate for Payer: One Health Plan of WY PPO |
$588.00
|
| Rate for Payer: PacificSource Commercial |
$540.00
|
| Rate for Payer: PHCS PPO |
$570.00
|
| Rate for Payer: Three Rivers PPO |
$450.00
|
| Rate for Payer: TriWest Veterans Administration |
$53.00
|
| Rate for Payer: United Healthcare Commercial |
$522.00
|
| Rate for Payer: United Healthcare Medicare |
$53.00
|
| Rate for Payer: WINHealth Partners Commercial |
$510.00
|
|
|
INJECTION AA&/STRD SUPRASCAPULAR NERVE
|
Professional
|
Both
|
$300.00
|
|
|
Service Code
|
HCPCS 64418
|
| Hospital Charge Code |
64418
|
| Min. Negotiated Rate |
$45.05 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$294.00
|
| Rate for Payer: Aetna of WY Medicare |
$53.00
|
| Rate for Payer: Beech Street Commercial |
$285.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$291.00
|
| Rate for Payer: Cigna of WY Commercial |
$294.00
|
| Rate for Payer: First Choice Health Commercial |
$270.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.00
|
| Rate for Payer: HealthUtah PPO |
$300.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$291.00
|
| Rate for Payer: Multiplan Medicare/VA |
$45.05
|
| Rate for Payer: One Health Plan of WY PPO |
$294.00
|
| Rate for Payer: PacificSource Commercial |
$270.00
|
| Rate for Payer: PHCS PPO |
$285.00
|
| Rate for Payer: Three Rivers PPO |
$225.00
|
| Rate for Payer: TriWest Veterans Administration |
$53.00
|
| Rate for Payer: United Healthcare Commercial |
$261.00
|
| Rate for Payer: United Healthcare Medicare |
$53.00
|
| Rate for Payer: WINHealth Partners Commercial |
$255.00
|
|
|
INJECTION AA&/STRD TRIGEMINAL NERVE EACH BRANCH
|
Professional
|
Both
|
$786.00
|
|
|
Service Code
|
HCPCS 64400 50
|
| Hospital Charge Code |
64400
|
| Min. Negotiated Rate |
$41.62 |
| Max. Negotiated Rate |
$786.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$770.28
|
| Rate for Payer: Aetna of WY Medicare |
$48.96
|
| Rate for Payer: Beech Street Commercial |
$746.70
|
| Rate for Payer: Cash Price |
$550.20
|
| Rate for Payer: Cash Price |
$550.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$762.42
|
| Rate for Payer: Cigna of WY Commercial |
$770.28
|
| Rate for Payer: First Choice Health Commercial |
$707.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$746.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.96
|
| Rate for Payer: HealthUtah PPO |
$786.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$762.42
|
| Rate for Payer: Multiplan Medicare/VA |
$41.62
|
| Rate for Payer: One Health Plan of WY PPO |
$770.28
|
| Rate for Payer: PacificSource Commercial |
$707.40
|
| Rate for Payer: PHCS PPO |
$746.70
|
| Rate for Payer: Three Rivers PPO |
$589.50
|
| Rate for Payer: TriWest Veterans Administration |
$48.96
|
| Rate for Payer: United Healthcare Commercial |
$683.82
|
| Rate for Payer: United Healthcare Medicare |
$48.96
|
| Rate for Payer: WINHealth Partners Commercial |
$668.10
|
|
|
INJECTION AA&/STRD TRIGEMINAL NERVE EACH BRANCH
|
Professional
|
Both
|
$393.00
|
|
|
Service Code
|
HCPCS 64400
|
| Hospital Charge Code |
64400
|
| Min. Negotiated Rate |
$41.62 |
| Max. Negotiated Rate |
$393.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$385.14
|
| Rate for Payer: Aetna of WY Medicare |
$48.96
|
| Rate for Payer: Beech Street Commercial |
$373.35
|
| Rate for Payer: Cash Price |
$275.10
|
| Rate for Payer: Cash Price |
$275.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$381.21
|
| Rate for Payer: Cigna of WY Commercial |
$385.14
|
| Rate for Payer: First Choice Health Commercial |
$353.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$373.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.96
|
| Rate for Payer: HealthUtah PPO |
$393.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$381.21
|
| Rate for Payer: Multiplan Medicare/VA |
$41.62
|
| Rate for Payer: One Health Plan of WY PPO |
$385.14
|
| Rate for Payer: PacificSource Commercial |
$353.70
|
| Rate for Payer: PHCS PPO |
$373.35
|
| Rate for Payer: Three Rivers PPO |
$294.75
|
| Rate for Payer: TriWest Veterans Administration |
$48.96
|
| Rate for Payer: United Healthcare Commercial |
$341.91
|
| Rate for Payer: United Healthcare Medicare |
$48.96
|
| Rate for Payer: WINHealth Partners Commercial |
$334.05
|
|
|
INJECTION ANES AGENT SPHENOPALATINE GANGLION
|
Professional
|
Both
|
$997.00
|
|
|
Service Code
|
HCPCS 64505 50
|
| Hospital Charge Code |
64505
|
| Min. Negotiated Rate |
$85.54 |
| Max. Negotiated Rate |
$997.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$977.06
|
| Rate for Payer: Aetna of WY Medicare |
$100.64
|
| Rate for Payer: Beech Street Commercial |
$947.15
|
| Rate for Payer: Cash Price |
$697.90
|
| Rate for Payer: Cash Price |
$697.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$967.09
|
| Rate for Payer: Cigna of WY Commercial |
$977.06
|
| Rate for Payer: First Choice Health Commercial |
$897.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$947.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$100.64
|
| Rate for Payer: HealthUtah PPO |
$997.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$967.09
|
| Rate for Payer: Multiplan Medicare/VA |
$85.54
|
| Rate for Payer: One Health Plan of WY PPO |
$977.06
|
| Rate for Payer: PacificSource Commercial |
$897.30
|
| Rate for Payer: PHCS PPO |
$947.15
|
| Rate for Payer: Three Rivers PPO |
$747.75
|
| Rate for Payer: TriWest Veterans Administration |
$100.64
|
| Rate for Payer: United Healthcare Commercial |
$867.39
|
| Rate for Payer: United Healthcare Medicare |
$100.64
|
| Rate for Payer: WINHealth Partners Commercial |
$847.45
|
|
|
INJECTION ANES AGENT SPHENOPALATINE GANGLION
|
Professional
|
Both
|
$498.00
|
|
|
Service Code
|
HCPCS 64505
|
| Hospital Charge Code |
64505
|
| Min. Negotiated Rate |
$85.54 |
| Max. Negotiated Rate |
$498.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$488.04
|
| Rate for Payer: Aetna of WY Medicare |
$100.64
|
| Rate for Payer: Beech Street Commercial |
$473.10
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: Cash Price |
$348.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$483.06
|
| Rate for Payer: Cigna of WY Commercial |
$488.04
|
| Rate for Payer: First Choice Health Commercial |
$448.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$473.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$100.64
|
| Rate for Payer: HealthUtah PPO |
$498.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$483.06
|
| Rate for Payer: Multiplan Medicare/VA |
$85.54
|
| Rate for Payer: One Health Plan of WY PPO |
$488.04
|
| Rate for Payer: PacificSource Commercial |
$448.20
|
| Rate for Payer: PHCS PPO |
$473.10
|
| Rate for Payer: Three Rivers PPO |
$373.50
|
| Rate for Payer: TriWest Veterans Administration |
$100.64
|
| Rate for Payer: United Healthcare Commercial |
$433.26
|
| Rate for Payer: United Healthcare Medicare |
$100.64
|
| Rate for Payer: WINHealth Partners Commercial |
$423.30
|
|
|
INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC
|
Professional
|
Both
|
$805.00
|
|
|
Service Code
|
HCPCS 64520
|
| Hospital Charge Code |
64520
|
| Min. Negotiated Rate |
$603.75 |
| Max. Negotiated Rate |
$805.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$788.90
|
| Rate for Payer: Beech Street Commercial |
$764.75
|
| Rate for Payer: Cash Price |
$563.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$780.85
|
| Rate for Payer: Cigna of WY Commercial |
$788.90
|
| Rate for Payer: First Choice Health Commercial |
$724.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$764.75
|
| Rate for Payer: HealthUtah PPO |
$805.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$780.85
|
| Rate for Payer: One Health Plan of WY PPO |
$788.90
|
| Rate for Payer: PacificSource Commercial |
$724.50
|
| Rate for Payer: PHCS PPO |
$764.75
|
| Rate for Payer: Three Rivers PPO |
$603.75
|
| Rate for Payer: United Healthcare Commercial |
$700.35
|
| Rate for Payer: WINHealth Partners Commercial |
$684.25
|
|
|
INJECTION ANES LMBR/THRC PARAVERTBRL SYMPATHETIC
|
Professional
|
Both
|
$1,610.00
|
|
|
Service Code
|
HCPCS 64520 50
|
| Hospital Charge Code |
64520
|
| Min. Negotiated Rate |
$1,207.50 |
| Max. Negotiated Rate |
$1,610.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,577.80
|
| Rate for Payer: Beech Street Commercial |
$1,529.50
|
| Rate for Payer: Cash Price |
$1,127.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,561.70
|
| Rate for Payer: Cigna of WY Commercial |
$1,577.80
|
| Rate for Payer: First Choice Health Commercial |
$1,449.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,529.50
|
| Rate for Payer: HealthUtah PPO |
$1,610.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,561.70
|
| Rate for Payer: One Health Plan of WY PPO |
$1,577.80
|
| Rate for Payer: PacificSource Commercial |
$1,449.00
|
| Rate for Payer: PHCS PPO |
$1,529.50
|
| Rate for Payer: Three Rivers PPO |
$1,207.50
|
| Rate for Payer: United Healthcare Commercial |
$1,400.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,368.50
|
|
|
INJECTION ENZYME PALMAR FASCIAL CORD
|
Professional
|
Both
|
$330.00
|
|
|
Service Code
|
HCPCS 20527
|
| Hospital Charge Code |
20527
|
| Min. Negotiated Rate |
$53.45 |
| Max. Negotiated Rate |
$330.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$323.40
|
| Rate for Payer: Aetna of WY Medicare |
$62.88
|
| Rate for Payer: Beech Street Commercial |
$313.50
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: Cash Price |
$231.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$320.10
|
| Rate for Payer: Cigna of WY Commercial |
$323.40
|
| Rate for Payer: First Choice Health Commercial |
$297.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$313.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.88
|
| Rate for Payer: HealthUtah PPO |
$330.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$320.10
|
| Rate for Payer: Multiplan Medicare/VA |
$53.45
|
| Rate for Payer: One Health Plan of WY PPO |
$323.40
|
| Rate for Payer: PacificSource Commercial |
$297.00
|
| Rate for Payer: PHCS PPO |
$313.50
|
| Rate for Payer: Three Rivers PPO |
$247.50
|
| Rate for Payer: TriWest Veterans Administration |
$62.88
|
| Rate for Payer: United Healthcare Commercial |
$287.10
|
| Rate for Payer: United Healthcare Medicare |
$62.88
|
| Rate for Payer: WINHealth Partners Commercial |
$280.50
|
|
|
INJECTION ENZYME PALMAR FASCIAL CORD
|
Professional
|
Both
|
$660.00
|
|
|
Service Code
|
HCPCS 20527 50
|
| Hospital Charge Code |
20527
|
| Min. Negotiated Rate |
$53.45 |
| Max. Negotiated Rate |
$660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$646.80
|
| Rate for Payer: Aetna of WY Medicare |
$62.88
|
| Rate for Payer: Beech Street Commercial |
$627.00
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$640.20
|
| Rate for Payer: Cigna of WY Commercial |
$646.80
|
| Rate for Payer: First Choice Health Commercial |
$594.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$627.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$62.88
|
| Rate for Payer: HealthUtah PPO |
$660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$640.20
|
| Rate for Payer: Multiplan Medicare/VA |
$53.45
|
| Rate for Payer: One Health Plan of WY PPO |
$646.80
|
| Rate for Payer: PacificSource Commercial |
$594.00
|
| Rate for Payer: PHCS PPO |
$627.00
|
| Rate for Payer: Three Rivers PPO |
$495.00
|
| Rate for Payer: TriWest Veterans Administration |
$62.88
|
| Rate for Payer: United Healthcare Commercial |
$574.20
|
| Rate for Payer: United Healthcare Medicare |
$62.88
|
| Rate for Payer: WINHealth Partners Commercial |
$561.00
|
|
|
INJECTION EPIDURAL BLOOD/CLOT PATCH
|
Professional
|
Both
|
$585.00
|
|
|
Service Code
|
HCPCS 62273
|
| Hospital Charge Code |
62273
|
| Min. Negotiated Rate |
$92.20 |
| Max. Negotiated Rate |
$585.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$573.30
|
| Rate for Payer: Aetna of WY Medicare |
$108.47
|
| Rate for Payer: Beech Street Commercial |
$555.75
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: Cash Price |
$409.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$567.45
|
| Rate for Payer: Cigna of WY Commercial |
$573.30
|
| Rate for Payer: First Choice Health Commercial |
$526.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$555.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$108.47
|
| Rate for Payer: HealthUtah PPO |
$585.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$567.45
|
| Rate for Payer: Multiplan Medicare/VA |
$92.20
|
| Rate for Payer: One Health Plan of WY PPO |
$573.30
|
| Rate for Payer: PacificSource Commercial |
$526.50
|
| Rate for Payer: PHCS PPO |
$555.75
|
| Rate for Payer: Three Rivers PPO |
$438.75
|
| Rate for Payer: TriWest Veterans Administration |
$108.47
|
| Rate for Payer: United Healthcare Commercial |
$508.95
|
| Rate for Payer: United Healthcare Medicare |
$108.47
|
| Rate for Payer: WINHealth Partners Commercial |
$497.25
|
|
|
INJECTION, FAMOTIDINE, 20 MG
|
Professional
|
Both
|
$43.00
|
|
|
Service Code
|
HCPCS S0028
|
| Hospital Charge Code |
S0028
|
| Min. Negotiated Rate |
$32.25 |
| Max. Negotiated Rate |
$43.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$42.14
|
| Rate for Payer: Beech Street Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$30.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$41.71
|
| Rate for Payer: Cigna of WY Commercial |
$42.14
|
| Rate for Payer: First Choice Health Commercial |
$38.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$40.85
|
| Rate for Payer: HealthUtah PPO |
$43.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$41.71
|
| Rate for Payer: One Health Plan of WY PPO |
$42.14
|
| Rate for Payer: PacificSource Commercial |
$38.70
|
| Rate for Payer: PHCS PPO |
$40.85
|
| Rate for Payer: Three Rivers PPO |
$32.25
|
| Rate for Payer: United Healthcare Commercial |
$37.41
|
| Rate for Payer: WINHealth Partners Commercial |
$40.85
|
|
|
INJECTION HIP ARTHROGRAPHY W/O ANESTHESIA
|
Professional
|
Both
|
$1,124.00
|
|
|
Service Code
|
HCPCS 27093
|
| Hospital Charge Code |
27093
|
| Min. Negotiated Rate |
$54.85 |
| Max. Negotiated Rate |
$1,124.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,101.52
|
| Rate for Payer: Aetna of WY Medicare |
$64.53
|
| Rate for Payer: Beech Street Commercial |
$1,067.80
|
| Rate for Payer: Cash Price |
$786.80
|
| Rate for Payer: Cash Price |
$786.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,090.28
|
| Rate for Payer: Cigna of WY Commercial |
$1,101.52
|
| Rate for Payer: First Choice Health Commercial |
$1,011.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,067.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$64.53
|
| Rate for Payer: HealthUtah PPO |
$1,124.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,090.28
|
| Rate for Payer: Multiplan Medicare/VA |
$54.85
|
| Rate for Payer: One Health Plan of WY PPO |
$1,101.52
|
| Rate for Payer: PacificSource Commercial |
$1,011.60
|
| Rate for Payer: PHCS PPO |
$1,067.80
|
| Rate for Payer: Three Rivers PPO |
$843.00
|
| Rate for Payer: TriWest Veterans Administration |
$64.53
|
| Rate for Payer: United Healthcare Commercial |
$977.88
|
| Rate for Payer: United Healthcare Medicare |
$64.53
|
| Rate for Payer: WINHealth Partners Commercial |
$955.40
|
|
|
INJECTION INTRALESIONAL UP TO & INCLUD 7 LESIONS
|
Professional
|
Both
|
$152.00
|
|
|
Service Code
|
HCPCS 11900
|
| Hospital Charge Code |
11900
|
| Min. Negotiated Rate |
$24.34 |
| Max. Negotiated Rate |
$152.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$148.96
|
| Rate for Payer: Aetna of WY Medicare |
$28.63
|
| Rate for Payer: Beech Street Commercial |
$144.40
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$147.44
|
| Rate for Payer: Cigna of WY Commercial |
$148.96
|
| Rate for Payer: First Choice Health Commercial |
$136.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$144.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$28.63
|
| Rate for Payer: HealthUtah PPO |
$152.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$147.44
|
| Rate for Payer: Multiplan Medicare/VA |
$24.34
|
| Rate for Payer: One Health Plan of WY PPO |
$148.96
|
| Rate for Payer: PacificSource Commercial |
$136.80
|
| Rate for Payer: PHCS PPO |
$144.40
|
| Rate for Payer: Three Rivers PPO |
$114.00
|
| Rate for Payer: TriWest Veterans Administration |
$28.63
|
| Rate for Payer: United Healthcare Commercial |
$132.24
|
| Rate for Payer: United Healthcare Medicare |
$28.63
|
| Rate for Payer: WINHealth Partners Commercial |
$129.20
|
|
|
INJECTION,ONABOTULINUMTOXINA
|
Professional
|
Both
|
$23.00
|
|
|
Service Code
|
HCPCS J0585
|
| Hospital Charge Code |
J0585
|
| Min. Negotiated Rate |
$5.37 |
| Max. Negotiated Rate |
$23.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$22.54
|
| Rate for Payer: Aetna of WY Medicare |
$6.32
|
| Rate for Payer: Beech Street Commercial |
$21.85
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: Cash Price |
$16.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$22.31
|
| Rate for Payer: Cigna of WY Commercial |
$22.54
|
| Rate for Payer: First Choice Health Commercial |
$20.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$21.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.32
|
| Rate for Payer: HealthUtah PPO |
$23.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$22.31
|
| Rate for Payer: Multiplan Medicare/VA |
$5.37
|
| Rate for Payer: One Health Plan of WY PPO |
$22.54
|
| Rate for Payer: PacificSource Commercial |
$20.70
|
| Rate for Payer: PHCS PPO |
$21.85
|
| Rate for Payer: Three Rivers PPO |
$17.25
|
| Rate for Payer: TriWest Veterans Administration |
$6.32
|
| Rate for Payer: United Healthcare Commercial |
$20.01
|
| Rate for Payer: United Healthcare Medicare |
$6.32
|
| Rate for Payer: WINHealth Partners Commercial |
$21.85
|
|
