|
NJX DX/THER AGT PVRT FACET JT CRV/THRC 3+ LEVEL
|
Professional
|
Both
|
$338.00
|
|
|
Service Code
|
HCPCS 64492
|
| Hospital Charge Code |
64492
|
| Min. Negotiated Rate |
$48.95 |
| Max. Negotiated Rate |
$338.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$331.24
|
| Rate for Payer: Aetna of WY Medicare |
$57.59
|
| Rate for Payer: Beech Street Commercial |
$321.10
|
| Rate for Payer: Cash Price |
$236.60
|
| Rate for Payer: Cash Price |
$236.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$327.86
|
| Rate for Payer: Cigna of WY Commercial |
$331.24
|
| Rate for Payer: First Choice Health Commercial |
$304.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$321.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$57.59
|
| Rate for Payer: HealthUtah PPO |
$338.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$327.86
|
| Rate for Payer: Multiplan Medicare/VA |
$48.95
|
| Rate for Payer: One Health Plan of WY PPO |
$331.24
|
| Rate for Payer: PacificSource Commercial |
$304.20
|
| Rate for Payer: PHCS PPO |
$321.10
|
| Rate for Payer: Three Rivers PPO |
$253.50
|
| Rate for Payer: TriWest Veterans Administration |
$57.59
|
| Rate for Payer: United Healthcare Commercial |
$294.06
|
| Rate for Payer: United Healthcare Medicare |
$57.59
|
| Rate for Payer: WINHealth Partners Commercial |
$287.30
|
|
|
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL
|
Professional
|
Both
|
$618.00
|
|
|
Service Code
|
HCPCS 64493
|
| Hospital Charge Code |
64493
|
| Min. Negotiated Rate |
$74.06 |
| Max. Negotiated Rate |
$618.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$605.64
|
| Rate for Payer: Aetna of WY Medicare |
$87.13
|
| Rate for Payer: Beech Street Commercial |
$587.10
|
| Rate for Payer: Cash Price |
$432.60
|
| Rate for Payer: Cash Price |
$432.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$599.46
|
| Rate for Payer: Cigna of WY Commercial |
$605.64
|
| Rate for Payer: First Choice Health Commercial |
$556.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$587.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$87.13
|
| Rate for Payer: HealthUtah PPO |
$618.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$599.46
|
| Rate for Payer: Multiplan Medicare/VA |
$74.06
|
| Rate for Payer: One Health Plan of WY PPO |
$605.64
|
| Rate for Payer: PacificSource Commercial |
$556.20
|
| Rate for Payer: PHCS PPO |
$587.10
|
| Rate for Payer: Three Rivers PPO |
$463.50
|
| Rate for Payer: TriWest Veterans Administration |
$87.13
|
| Rate for Payer: United Healthcare Commercial |
$537.66
|
| Rate for Payer: United Healthcare Medicare |
$87.13
|
| Rate for Payer: WINHealth Partners Commercial |
$525.30
|
|
|
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 1 LEVEL
|
Professional
|
Both
|
$1,236.00
|
|
|
Service Code
|
HCPCS 64493 50
|
| Hospital Charge Code |
64493
|
| Min. Negotiated Rate |
$74.06 |
| Max. Negotiated Rate |
$1,236.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,211.28
|
| Rate for Payer: Aetna of WY Medicare |
$87.13
|
| Rate for Payer: Beech Street Commercial |
$1,174.20
|
| Rate for Payer: Cash Price |
$865.20
|
| Rate for Payer: Cash Price |
$865.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,198.92
|
| Rate for Payer: Cigna of WY Commercial |
$1,211.28
|
| Rate for Payer: First Choice Health Commercial |
$1,112.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,174.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$87.13
|
| Rate for Payer: HealthUtah PPO |
$1,236.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,198.92
|
| Rate for Payer: Multiplan Medicare/VA |
$74.06
|
| Rate for Payer: One Health Plan of WY PPO |
$1,211.28
|
| Rate for Payer: PacificSource Commercial |
$1,112.40
|
| Rate for Payer: PHCS PPO |
$1,174.20
|
| Rate for Payer: Three Rivers PPO |
$927.00
|
| Rate for Payer: TriWest Veterans Administration |
$87.13
|
| Rate for Payer: United Healthcare Commercial |
$1,075.32
|
| Rate for Payer: United Healthcare Medicare |
$87.13
|
| Rate for Payer: WINHealth Partners Commercial |
$1,050.60
|
|
|
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL
|
Professional
|
Both
|
$632.00
|
|
|
Service Code
|
HCPCS 64494 50
|
| Hospital Charge Code |
64494
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$632.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$619.36
|
| Rate for Payer: Aetna of WY Medicare |
$48.59
|
| Rate for Payer: Beech Street Commercial |
$600.40
|
| Rate for Payer: Cash Price |
$442.40
|
| Rate for Payer: Cash Price |
$442.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$613.04
|
| Rate for Payer: Cigna of WY Commercial |
$619.36
|
| Rate for Payer: First Choice Health Commercial |
$568.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$600.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.59
|
| Rate for Payer: HealthUtah PPO |
$632.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$613.04
|
| Rate for Payer: Multiplan Medicare/VA |
$41.30
|
| Rate for Payer: One Health Plan of WY PPO |
$619.36
|
| Rate for Payer: PacificSource Commercial |
$568.80
|
| Rate for Payer: PHCS PPO |
$600.40
|
| Rate for Payer: Three Rivers PPO |
$474.00
|
| Rate for Payer: TriWest Veterans Administration |
$48.59
|
| Rate for Payer: United Healthcare Commercial |
$549.84
|
| Rate for Payer: United Healthcare Medicare |
$48.59
|
| Rate for Payer: WINHealth Partners Commercial |
$537.20
|
|
|
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 2ND LEVEL
|
Professional
|
Both
|
$316.00
|
|
|
Service Code
|
HCPCS 64494
|
| Hospital Charge Code |
64494
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$309.68
|
| Rate for Payer: Aetna of WY Medicare |
$48.59
|
| Rate for Payer: Beech Street Commercial |
$300.20
|
| Rate for Payer: Cash Price |
$221.20
|
| Rate for Payer: Cash Price |
$221.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$306.52
|
| Rate for Payer: Cigna of WY Commercial |
$309.68
|
| Rate for Payer: First Choice Health Commercial |
$284.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$300.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.59
|
| Rate for Payer: HealthUtah PPO |
$316.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$306.52
|
| Rate for Payer: Multiplan Medicare/VA |
$41.30
|
| Rate for Payer: One Health Plan of WY PPO |
$309.68
|
| Rate for Payer: PacificSource Commercial |
$284.40
|
| Rate for Payer: PHCS PPO |
$300.20
|
| Rate for Payer: Three Rivers PPO |
$237.00
|
| Rate for Payer: TriWest Veterans Administration |
$48.59
|
| Rate for Payer: United Healthcare Commercial |
$274.92
|
| Rate for Payer: United Healthcare Medicare |
$48.59
|
| Rate for Payer: WINHealth Partners Commercial |
$268.60
|
|
|
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL
|
Professional
|
Both
|
$632.00
|
|
|
Service Code
|
HCPCS 64495 50
|
| Hospital Charge Code |
64495
|
| Min. Negotiated Rate |
$42.13 |
| Max. Negotiated Rate |
$632.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$619.36
|
| Rate for Payer: Aetna of WY Medicare |
$49.57
|
| Rate for Payer: Beech Street Commercial |
$600.40
|
| Rate for Payer: Cash Price |
$442.40
|
| Rate for Payer: Cash Price |
$442.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$613.04
|
| Rate for Payer: Cigna of WY Commercial |
$619.36
|
| Rate for Payer: First Choice Health Commercial |
$568.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$600.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.57
|
| Rate for Payer: HealthUtah PPO |
$632.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$613.04
|
| Rate for Payer: Multiplan Medicare/VA |
$42.13
|
| Rate for Payer: One Health Plan of WY PPO |
$619.36
|
| Rate for Payer: PacificSource Commercial |
$568.80
|
| Rate for Payer: PHCS PPO |
$600.40
|
| Rate for Payer: Three Rivers PPO |
$474.00
|
| Rate for Payer: TriWest Veterans Administration |
$49.57
|
| Rate for Payer: United Healthcare Commercial |
$549.84
|
| Rate for Payer: United Healthcare Medicare |
$49.57
|
| Rate for Payer: WINHealth Partners Commercial |
$537.20
|
|
|
NJX DX/THER AGT PVRT FACET JT LMBR/SAC 3+ LEVEL
|
Professional
|
Both
|
$316.00
|
|
|
Service Code
|
HCPCS 64495
|
| Hospital Charge Code |
64495
|
| Min. Negotiated Rate |
$42.13 |
| Max. Negotiated Rate |
$316.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$309.68
|
| Rate for Payer: Aetna of WY Medicare |
$49.57
|
| Rate for Payer: Beech Street Commercial |
$300.20
|
| Rate for Payer: Cash Price |
$221.20
|
| Rate for Payer: Cash Price |
$221.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$306.52
|
| Rate for Payer: Cigna of WY Commercial |
$309.68
|
| Rate for Payer: First Choice Health Commercial |
$284.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$300.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.57
|
| Rate for Payer: HealthUtah PPO |
$316.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$306.52
|
| Rate for Payer: Multiplan Medicare/VA |
$42.13
|
| Rate for Payer: One Health Plan of WY PPO |
$309.68
|
| Rate for Payer: PacificSource Commercial |
$284.40
|
| Rate for Payer: PHCS PPO |
$300.20
|
| Rate for Payer: Three Rivers PPO |
$237.00
|
| Rate for Payer: TriWest Veterans Administration |
$49.57
|
| Rate for Payer: United Healthcare Commercial |
$274.92
|
| Rate for Payer: United Healthcare Medicare |
$49.57
|
| Rate for Payer: WINHealth Partners Commercial |
$268.60
|
|
|
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN
|
Professional
|
Both
|
$1,128.00
|
|
|
Service Code
|
HCPCS 62325 50
|
| Hospital Charge Code |
62325
|
| Min. Negotiated Rate |
$89.84 |
| Max. Negotiated Rate |
$1,128.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,105.44
|
| Rate for Payer: Aetna of WY Medicare |
$105.69
|
| Rate for Payer: Beech Street Commercial |
$1,071.60
|
| Rate for Payer: Cash Price |
$789.60
|
| Rate for Payer: Cash Price |
$789.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,094.16
|
| Rate for Payer: Cigna of WY Commercial |
$1,105.44
|
| Rate for Payer: First Choice Health Commercial |
$1,015.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,071.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$105.69
|
| Rate for Payer: HealthUtah PPO |
$1,128.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,094.16
|
| Rate for Payer: Multiplan Medicare/VA |
$89.84
|
| Rate for Payer: One Health Plan of WY PPO |
$1,105.44
|
| Rate for Payer: PacificSource Commercial |
$1,015.20
|
| Rate for Payer: PHCS PPO |
$1,071.60
|
| Rate for Payer: Three Rivers PPO |
$846.00
|
| Rate for Payer: TriWest Veterans Administration |
$105.69
|
| Rate for Payer: United Healthcare Commercial |
$981.36
|
| Rate for Payer: United Healthcare Medicare |
$105.69
|
| Rate for Payer: WINHealth Partners Commercial |
$958.80
|
|
|
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN
|
Professional
|
Both
|
$1,112.00
|
|
|
Service Code
|
HCPCS 62321 50
|
| Hospital Charge Code |
62321
|
| Min. Negotiated Rate |
$87.69 |
| Max. Negotiated Rate |
$1,112.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,089.76
|
| Rate for Payer: Aetna of WY Medicare |
$103.16
|
| Rate for Payer: Beech Street Commercial |
$1,056.40
|
| Rate for Payer: Cash Price |
$778.40
|
| Rate for Payer: Cash Price |
$778.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,078.64
|
| Rate for Payer: Cigna of WY Commercial |
$1,089.76
|
| Rate for Payer: First Choice Health Commercial |
$1,000.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,056.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.16
|
| Rate for Payer: HealthUtah PPO |
$1,112.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,078.64
|
| Rate for Payer: Multiplan Medicare/VA |
$87.69
|
| Rate for Payer: One Health Plan of WY PPO |
$1,089.76
|
| Rate for Payer: PacificSource Commercial |
$1,000.80
|
| Rate for Payer: PHCS PPO |
$1,056.40
|
| Rate for Payer: Three Rivers PPO |
$834.00
|
| Rate for Payer: TriWest Veterans Administration |
$103.16
|
| Rate for Payer: United Healthcare Commercial |
$967.44
|
| Rate for Payer: United Healthcare Medicare |
$103.16
|
| Rate for Payer: WINHealth Partners Commercial |
$945.20
|
|
|
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN
|
Professional
|
Both
|
$564.00
|
|
|
Service Code
|
HCPCS 62325
|
| Hospital Charge Code |
62325
|
| Min. Negotiated Rate |
$89.84 |
| Max. Negotiated Rate |
$564.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$552.72
|
| Rate for Payer: Aetna of WY Medicare |
$105.69
|
| Rate for Payer: Beech Street Commercial |
$535.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: Cash Price |
$394.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$547.08
|
| Rate for Payer: Cigna of WY Commercial |
$552.72
|
| Rate for Payer: First Choice Health Commercial |
$507.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$535.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$105.69
|
| Rate for Payer: HealthUtah PPO |
$564.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$547.08
|
| Rate for Payer: Multiplan Medicare/VA |
$89.84
|
| Rate for Payer: One Health Plan of WY PPO |
$552.72
|
| Rate for Payer: PacificSource Commercial |
$507.60
|
| Rate for Payer: PHCS PPO |
$535.80
|
| Rate for Payer: Three Rivers PPO |
$423.00
|
| Rate for Payer: TriWest Veterans Administration |
$105.69
|
| Rate for Payer: United Healthcare Commercial |
$490.68
|
| Rate for Payer: United Healthcare Medicare |
$105.69
|
| Rate for Payer: WINHealth Partners Commercial |
$479.40
|
|
|
NJX DX/THER SBST INTRLMNR CRV/THRC W/IMG GDN
|
Professional
|
Both
|
$556.00
|
|
|
Service Code
|
HCPCS 62321
|
| Hospital Charge Code |
62321
|
| Min. Negotiated Rate |
$87.69 |
| Max. Negotiated Rate |
$556.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$544.88
|
| Rate for Payer: Aetna of WY Medicare |
$103.16
|
| Rate for Payer: Beech Street Commercial |
$528.20
|
| Rate for Payer: Cash Price |
$389.20
|
| Rate for Payer: Cash Price |
$389.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$539.32
|
| Rate for Payer: Cigna of WY Commercial |
$544.88
|
| Rate for Payer: First Choice Health Commercial |
$500.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$528.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.16
|
| Rate for Payer: HealthUtah PPO |
$556.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$539.32
|
| Rate for Payer: Multiplan Medicare/VA |
$87.69
|
| Rate for Payer: One Health Plan of WY PPO |
$544.88
|
| Rate for Payer: PacificSource Commercial |
$500.40
|
| Rate for Payer: PHCS PPO |
$528.20
|
| Rate for Payer: Three Rivers PPO |
$417.00
|
| Rate for Payer: TriWest Veterans Administration |
$103.16
|
| Rate for Payer: United Healthcare Commercial |
$483.72
|
| Rate for Payer: United Healthcare Medicare |
$103.16
|
| Rate for Payer: WINHealth Partners Commercial |
$472.60
|
|
|
NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN
|
Professional
|
Both
|
$929.00
|
|
|
Service Code
|
HCPCS 62324 50
|
| Hospital Charge Code |
62324
|
| Min. Negotiated Rate |
$72.32 |
| Max. Negotiated Rate |
$929.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$910.42
|
| Rate for Payer: Aetna of WY Medicare |
$85.08
|
| Rate for Payer: Beech Street Commercial |
$882.55
|
| Rate for Payer: Cash Price |
$650.30
|
| Rate for Payer: Cash Price |
$650.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$901.13
|
| Rate for Payer: Cigna of WY Commercial |
$910.42
|
| Rate for Payer: First Choice Health Commercial |
$836.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$882.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$85.08
|
| Rate for Payer: HealthUtah PPO |
$929.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$901.13
|
| Rate for Payer: Multiplan Medicare/VA |
$72.32
|
| Rate for Payer: One Health Plan of WY PPO |
$910.42
|
| Rate for Payer: PacificSource Commercial |
$836.10
|
| Rate for Payer: PHCS PPO |
$882.55
|
| Rate for Payer: Three Rivers PPO |
$696.75
|
| Rate for Payer: TriWest Veterans Administration |
$85.08
|
| Rate for Payer: United Healthcare Commercial |
$808.23
|
| Rate for Payer: United Healthcare Medicare |
$85.08
|
| Rate for Payer: WINHealth Partners Commercial |
$789.65
|
|
|
NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN
|
Professional
|
Both
|
$464.00
|
|
|
Service Code
|
HCPCS 62324
|
| Hospital Charge Code |
62324
|
| Min. Negotiated Rate |
$72.32 |
| Max. Negotiated Rate |
$464.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$454.72
|
| Rate for Payer: Aetna of WY Medicare |
$85.08
|
| Rate for Payer: Beech Street Commercial |
$440.80
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: Cash Price |
$324.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$450.08
|
| Rate for Payer: Cigna of WY Commercial |
$454.72
|
| Rate for Payer: First Choice Health Commercial |
$417.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$440.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$85.08
|
| Rate for Payer: HealthUtah PPO |
$464.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$450.08
|
| Rate for Payer: Multiplan Medicare/VA |
$72.32
|
| Rate for Payer: One Health Plan of WY PPO |
$454.72
|
| Rate for Payer: PacificSource Commercial |
$417.60
|
| Rate for Payer: PHCS PPO |
$440.80
|
| Rate for Payer: Three Rivers PPO |
$348.00
|
| Rate for Payer: TriWest Veterans Administration |
$85.08
|
| Rate for Payer: United Healthcare Commercial |
$403.68
|
| Rate for Payer: United Healthcare Medicare |
$85.08
|
| Rate for Payer: WINHealth Partners Commercial |
$394.40
|
|
|
NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN
|
Professional
|
Both
|
$514.00
|
|
|
Service Code
|
HCPCS 62320
|
| Hospital Charge Code |
62320
|
| Min. Negotiated Rate |
$81.12 |
| Max. Negotiated Rate |
$514.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$503.72
|
| Rate for Payer: Aetna of WY Medicare |
$95.44
|
| Rate for Payer: Beech Street Commercial |
$488.30
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$498.58
|
| Rate for Payer: Cigna of WY Commercial |
$503.72
|
| Rate for Payer: First Choice Health Commercial |
$462.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$488.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$95.44
|
| Rate for Payer: HealthUtah PPO |
$514.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$498.58
|
| Rate for Payer: Multiplan Medicare/VA |
$81.12
|
| Rate for Payer: One Health Plan of WY PPO |
$503.72
|
| Rate for Payer: PacificSource Commercial |
$462.60
|
| Rate for Payer: PHCS PPO |
$488.30
|
| Rate for Payer: Three Rivers PPO |
$385.50
|
| Rate for Payer: TriWest Veterans Administration |
$95.44
|
| Rate for Payer: United Healthcare Commercial |
$447.18
|
| Rate for Payer: United Healthcare Medicare |
$95.44
|
| Rate for Payer: WINHealth Partners Commercial |
$436.90
|
|
|
NJX DX/THER SBST INTRLMNR CRV/THRC W/O IMG GDN
|
Professional
|
Both
|
$1,027.00
|
|
|
Service Code
|
HCPCS 62320 50
|
| Hospital Charge Code |
62320
|
| Min. Negotiated Rate |
$81.12 |
| Max. Negotiated Rate |
$1,027.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,006.46
|
| Rate for Payer: Aetna of WY Medicare |
$95.44
|
| Rate for Payer: Beech Street Commercial |
$975.65
|
| Rate for Payer: Cash Price |
$718.90
|
| Rate for Payer: Cash Price |
$718.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$996.19
|
| Rate for Payer: Cigna of WY Commercial |
$1,006.46
|
| Rate for Payer: First Choice Health Commercial |
$924.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$975.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$95.44
|
| Rate for Payer: HealthUtah PPO |
$1,027.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$996.19
|
| Rate for Payer: Multiplan Medicare/VA |
$81.12
|
| Rate for Payer: One Health Plan of WY PPO |
$1,006.46
|
| Rate for Payer: PacificSource Commercial |
$924.30
|
| Rate for Payer: PHCS PPO |
$975.65
|
| Rate for Payer: Three Rivers PPO |
$770.25
|
| Rate for Payer: TriWest Veterans Administration |
$95.44
|
| Rate for Payer: United Healthcare Commercial |
$893.49
|
| Rate for Payer: United Healthcare Medicare |
$95.44
|
| Rate for Payer: WINHealth Partners Commercial |
$872.95
|
|
|
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN
|
Professional
|
Both
|
$514.00
|
|
|
Service Code
|
HCPCS 62323
|
| Hospital Charge Code |
62323
|
| Min. Negotiated Rate |
$81.07 |
| Max. Negotiated Rate |
$514.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$503.72
|
| Rate for Payer: Aetna of WY Medicare |
$95.38
|
| Rate for Payer: Beech Street Commercial |
$488.30
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: Cash Price |
$359.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$498.58
|
| Rate for Payer: Cigna of WY Commercial |
$503.72
|
| Rate for Payer: First Choice Health Commercial |
$462.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$488.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$95.38
|
| Rate for Payer: HealthUtah PPO |
$514.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$498.58
|
| Rate for Payer: Multiplan Medicare/VA |
$81.07
|
| Rate for Payer: One Health Plan of WY PPO |
$503.72
|
| Rate for Payer: PacificSource Commercial |
$462.60
|
| Rate for Payer: PHCS PPO |
$488.30
|
| Rate for Payer: Three Rivers PPO |
$385.50
|
| Rate for Payer: TriWest Veterans Administration |
$95.38
|
| Rate for Payer: United Healthcare Commercial |
$447.18
|
| Rate for Payer: United Healthcare Medicare |
$95.38
|
| Rate for Payer: WINHealth Partners Commercial |
$436.90
|
|
|
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN
|
Professional
|
Both
|
$1,027.00
|
|
|
Service Code
|
HCPCS 62323 50
|
| Hospital Charge Code |
62323
|
| Min. Negotiated Rate |
$81.07 |
| Max. Negotiated Rate |
$1,027.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,006.46
|
| Rate for Payer: Aetna of WY Medicare |
$95.38
|
| Rate for Payer: Beech Street Commercial |
$975.65
|
| Rate for Payer: Cash Price |
$718.90
|
| Rate for Payer: Cash Price |
$718.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$996.19
|
| Rate for Payer: Cigna of WY Commercial |
$1,006.46
|
| Rate for Payer: First Choice Health Commercial |
$924.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$975.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$95.38
|
| Rate for Payer: HealthUtah PPO |
$1,027.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$996.19
|
| Rate for Payer: Multiplan Medicare/VA |
$81.07
|
| Rate for Payer: One Health Plan of WY PPO |
$1,006.46
|
| Rate for Payer: PacificSource Commercial |
$924.30
|
| Rate for Payer: PHCS PPO |
$975.65
|
| Rate for Payer: Three Rivers PPO |
$770.25
|
| Rate for Payer: TriWest Veterans Administration |
$95.38
|
| Rate for Payer: United Healthcare Commercial |
$893.49
|
| Rate for Payer: United Healthcare Medicare |
$95.38
|
| Rate for Payer: WINHealth Partners Commercial |
$872.95
|
|
|
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN
|
Professional
|
Both
|
$518.00
|
|
|
Service Code
|
HCPCS 62327
|
| Hospital Charge Code |
62327
|
| Min. Negotiated Rate |
$87.61 |
| Max. Negotiated Rate |
$518.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$507.64
|
| Rate for Payer: Aetna of WY Medicare |
$103.07
|
| Rate for Payer: Beech Street Commercial |
$492.10
|
| Rate for Payer: Cash Price |
$362.60
|
| Rate for Payer: Cash Price |
$362.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$502.46
|
| Rate for Payer: Cigna of WY Commercial |
$507.64
|
| Rate for Payer: First Choice Health Commercial |
$466.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$492.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.07
|
| Rate for Payer: HealthUtah PPO |
$518.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$502.46
|
| Rate for Payer: Multiplan Medicare/VA |
$87.61
|
| Rate for Payer: One Health Plan of WY PPO |
$507.64
|
| Rate for Payer: PacificSource Commercial |
$466.20
|
| Rate for Payer: PHCS PPO |
$492.10
|
| Rate for Payer: Three Rivers PPO |
$388.50
|
| Rate for Payer: TriWest Veterans Administration |
$103.07
|
| Rate for Payer: United Healthcare Commercial |
$450.66
|
| Rate for Payer: United Healthcare Medicare |
$103.07
|
| Rate for Payer: WINHealth Partners Commercial |
$440.30
|
|
|
NJX DX/THER SBST INTRLMNR LMBR/SAC W/IMG GDN
|
Professional
|
Both
|
$1,037.00
|
|
|
Service Code
|
HCPCS 62327 50
|
| Hospital Charge Code |
62327
|
| Min. Negotiated Rate |
$87.61 |
| Max. Negotiated Rate |
$1,037.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,016.26
|
| Rate for Payer: Aetna of WY Medicare |
$103.07
|
| Rate for Payer: Beech Street Commercial |
$985.15
|
| Rate for Payer: Cash Price |
$725.90
|
| Rate for Payer: Cash Price |
$725.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,005.89
|
| Rate for Payer: Cigna of WY Commercial |
$1,016.26
|
| Rate for Payer: First Choice Health Commercial |
$933.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$985.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$103.07
|
| Rate for Payer: HealthUtah PPO |
$1,037.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,005.89
|
| Rate for Payer: Multiplan Medicare/VA |
$87.61
|
| Rate for Payer: One Health Plan of WY PPO |
$1,016.26
|
| Rate for Payer: PacificSource Commercial |
$933.30
|
| Rate for Payer: PHCS PPO |
$985.15
|
| Rate for Payer: Three Rivers PPO |
$777.75
|
| Rate for Payer: TriWest Veterans Administration |
$103.07
|
| Rate for Payer: United Healthcare Commercial |
$902.19
|
| Rate for Payer: United Healthcare Medicare |
$103.07
|
| Rate for Payer: WINHealth Partners Commercial |
$881.45
|
|
|
NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN
|
Professional
|
Both
|
$436.00
|
|
|
Service Code
|
HCPCS 62322
|
| Hospital Charge Code |
62322
|
| Min. Negotiated Rate |
$64.45 |
| Max. Negotiated Rate |
$436.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$427.28
|
| Rate for Payer: Aetna of WY Medicare |
$75.82
|
| Rate for Payer: Beech Street Commercial |
$414.20
|
| Rate for Payer: Cash Price |
$305.20
|
| Rate for Payer: Cash Price |
$305.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$422.92
|
| Rate for Payer: Cigna of WY Commercial |
$427.28
|
| Rate for Payer: First Choice Health Commercial |
$392.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$414.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$75.82
|
| Rate for Payer: HealthUtah PPO |
$436.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$422.92
|
| Rate for Payer: Multiplan Medicare/VA |
$64.45
|
| Rate for Payer: One Health Plan of WY PPO |
$427.28
|
| Rate for Payer: PacificSource Commercial |
$392.40
|
| Rate for Payer: PHCS PPO |
$414.20
|
| Rate for Payer: Three Rivers PPO |
$327.00
|
| Rate for Payer: TriWest Veterans Administration |
$75.82
|
| Rate for Payer: United Healthcare Commercial |
$379.32
|
| Rate for Payer: United Healthcare Medicare |
$75.82
|
| Rate for Payer: WINHealth Partners Commercial |
$370.60
|
|
|
NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN
|
Professional
|
Both
|
$682.00
|
|
|
Service Code
|
HCPCS 62326
|
| Hospital Charge Code |
62326
|
| Min. Negotiated Rate |
$69.26 |
| Max. Negotiated Rate |
$682.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$668.36
|
| Rate for Payer: Aetna of WY Medicare |
$81.48
|
| Rate for Payer: Beech Street Commercial |
$647.90
|
| Rate for Payer: Cash Price |
$477.40
|
| Rate for Payer: Cash Price |
$477.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$661.54
|
| Rate for Payer: Cigna of WY Commercial |
$668.36
|
| Rate for Payer: First Choice Health Commercial |
$613.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$647.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$81.48
|
| Rate for Payer: HealthUtah PPO |
$682.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$661.54
|
| Rate for Payer: Multiplan Medicare/VA |
$69.26
|
| Rate for Payer: One Health Plan of WY PPO |
$668.36
|
| Rate for Payer: PacificSource Commercial |
$613.80
|
| Rate for Payer: PHCS PPO |
$647.90
|
| Rate for Payer: Three Rivers PPO |
$511.50
|
| Rate for Payer: TriWest Veterans Administration |
$81.48
|
| Rate for Payer: United Healthcare Commercial |
$593.34
|
| Rate for Payer: United Healthcare Medicare |
$81.48
|
| Rate for Payer: WINHealth Partners Commercial |
$579.70
|
|
|
NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN
|
Professional
|
Both
|
$1,364.00
|
|
|
Service Code
|
HCPCS 62326 50
|
| Hospital Charge Code |
62326
|
| Min. Negotiated Rate |
$69.26 |
| Max. Negotiated Rate |
$1,364.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,336.72
|
| Rate for Payer: Aetna of WY Medicare |
$81.48
|
| Rate for Payer: Beech Street Commercial |
$1,295.80
|
| Rate for Payer: Cash Price |
$954.80
|
| Rate for Payer: Cash Price |
$954.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,323.08
|
| Rate for Payer: Cigna of WY Commercial |
$1,336.72
|
| Rate for Payer: First Choice Health Commercial |
$1,227.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,295.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$81.48
|
| Rate for Payer: HealthUtah PPO |
$1,364.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,323.08
|
| Rate for Payer: Multiplan Medicare/VA |
$69.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,336.72
|
| Rate for Payer: PacificSource Commercial |
$1,227.60
|
| Rate for Payer: PHCS PPO |
$1,295.80
|
| Rate for Payer: Three Rivers PPO |
$1,023.00
|
| Rate for Payer: TriWest Veterans Administration |
$81.48
|
| Rate for Payer: United Healthcare Commercial |
$1,186.68
|
| Rate for Payer: United Healthcare Medicare |
$81.48
|
| Rate for Payer: WINHealth Partners Commercial |
$1,159.40
|
|
|
NJX DX/THER SBST INTRLMNR LMBR/SAC W/O IMG GDN
|
Professional
|
Both
|
$873.00
|
|
|
Service Code
|
HCPCS 62322 50
|
| Hospital Charge Code |
62322
|
| Min. Negotiated Rate |
$64.45 |
| Max. Negotiated Rate |
$873.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$855.54
|
| Rate for Payer: Aetna of WY Medicare |
$75.82
|
| Rate for Payer: Beech Street Commercial |
$829.35
|
| Rate for Payer: Cash Price |
$611.10
|
| Rate for Payer: Cash Price |
$611.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$846.81
|
| Rate for Payer: Cigna of WY Commercial |
$855.54
|
| Rate for Payer: First Choice Health Commercial |
$785.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$829.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$75.82
|
| Rate for Payer: HealthUtah PPO |
$873.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$846.81
|
| Rate for Payer: Multiplan Medicare/VA |
$64.45
|
| Rate for Payer: One Health Plan of WY PPO |
$855.54
|
| Rate for Payer: PacificSource Commercial |
$785.70
|
| Rate for Payer: PHCS PPO |
$829.35
|
| Rate for Payer: Three Rivers PPO |
$654.75
|
| Rate for Payer: TriWest Veterans Administration |
$75.82
|
| Rate for Payer: United Healthcare Commercial |
$759.51
|
| Rate for Payer: United Healthcare Medicare |
$75.82
|
| Rate for Payer: WINHealth Partners Commercial |
$742.05
|
|
|
NJX PLTLT PLASMA W/IMG HARVEST/PREPARATION
|
Professional
|
Both
|
$500.00
|
|
|
Service Code
|
HCPCS 0232T
|
| Hospital Charge Code |
0232T
|
| Min. Negotiated Rate |
$375.00 |
| Max. Negotiated Rate |
$500.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$490.00
|
| Rate for Payer: Beech Street Commercial |
$475.00
|
| Rate for Payer: Cash Price |
$350.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$485.00
|
| Rate for Payer: Cigna of WY Commercial |
$490.00
|
| Rate for Payer: First Choice Health Commercial |
$450.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$475.00
|
| Rate for Payer: HealthUtah PPO |
$500.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$485.00
|
| Rate for Payer: One Health Plan of WY PPO |
$490.00
|
| Rate for Payer: PacificSource Commercial |
$450.00
|
| Rate for Payer: PHCS PPO |
$475.00
|
| Rate for Payer: Three Rivers PPO |
$375.00
|
| Rate for Payer: United Healthcare Commercial |
$435.00
|
| Rate for Payer: WINHealth Partners Commercial |
$475.00
|
|
|
NON-INVASIVE PHYSIOLOGIC STUDY EXTREMITY 3 LEVLS
|
Professional
|
Both
|
$662.00
|
|
|
Service Code
|
HCPCS 93923
|
| Hospital Charge Code |
93923
|
| Min. Negotiated Rate |
$17.37 |
| Max. Negotiated Rate |
$662.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$648.76
|
| Rate for Payer: Aetna of WY Medicare |
$127.26
|
| Rate for Payer: Beech Street Commercial |
$628.90
|
| Rate for Payer: Cash Price |
$463.40
|
| Rate for Payer: Cash Price |
$463.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$642.14
|
| Rate for Payer: Cigna of WY Commercial |
$648.76
|
| Rate for Payer: First Choice Health Commercial |
$595.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$628.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$127.26
|
| Rate for Payer: HealthUtah PPO |
$662.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$642.14
|
| Rate for Payer: Multiplan Medicare/VA |
$108.17
|
| Rate for Payer: One Health Plan of WY PPO |
$648.76
|
| Rate for Payer: PacificSource Commercial |
$595.80
|
| Rate for Payer: PHCS PPO |
$628.90
|
| Rate for Payer: Three Rivers PPO |
$496.50
|
| Rate for Payer: TriWest Veterans Administration |
$127.26
|
| Rate for Payer: United Healthcare Commercial |
$575.94
|
| Rate for Payer: United Healthcare Medicare |
$127.26
|
| Rate for Payer: WINHealth Partners Commercial |
$628.90
|
|
