|
REPAIR BLOOD VESSEL DIRECT HAND FINGER
|
Professional
|
Both
|
$6,056.00
|
|
|
Service Code
|
HCPCS 35207
|
| Hospital Charge Code |
35207
|
| Min. Negotiated Rate |
$618.08 |
| Max. Negotiated Rate |
$6,056.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,934.88
|
| Rate for Payer: Aetna of WY Medicare |
$727.15
|
| Rate for Payer: Beech Street Commercial |
$5,753.20
|
| Rate for Payer: Cash Price |
$4,239.20
|
| Rate for Payer: Cash Price |
$4,239.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,874.32
|
| Rate for Payer: Cigna of WY Commercial |
$5,934.88
|
| Rate for Payer: First Choice Health Commercial |
$5,450.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,753.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$727.15
|
| Rate for Payer: HealthUtah PPO |
$6,056.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,874.32
|
| Rate for Payer: Multiplan Medicare/VA |
$618.08
|
| Rate for Payer: One Health Plan of WY PPO |
$5,934.88
|
| Rate for Payer: PacificSource Commercial |
$5,450.40
|
| Rate for Payer: PHCS PPO |
$5,753.20
|
| Rate for Payer: Three Rivers PPO |
$4,542.00
|
| Rate for Payer: TriWest Veterans Administration |
$727.15
|
| Rate for Payer: United Healthcare Commercial |
$5,268.72
|
| Rate for Payer: United Healthcare Medicare |
$727.15
|
| Rate for Payer: WINHealth Partners Commercial |
$5,147.60
|
|
|
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY
|
Professional
|
Both
|
$4,027.00
|
|
|
Service Code
|
HCPCS 35206 AS
|
| Hospital Charge Code |
35206
|
| Min. Negotiated Rate |
$627.33 |
| Max. Negotiated Rate |
$4,027.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,946.46
|
| Rate for Payer: Aetna of WY Medicare |
$738.04
|
| Rate for Payer: Beech Street Commercial |
$3,825.65
|
| Rate for Payer: Cash Price |
$2,818.90
|
| Rate for Payer: Cash Price |
$2,818.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,906.19
|
| Rate for Payer: Cigna of WY Commercial |
$3,946.46
|
| Rate for Payer: First Choice Health Commercial |
$3,624.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,825.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$738.04
|
| Rate for Payer: HealthUtah PPO |
$4,027.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,906.19
|
| Rate for Payer: Multiplan Medicare/VA |
$627.33
|
| Rate for Payer: One Health Plan of WY PPO |
$3,946.46
|
| Rate for Payer: PacificSource Commercial |
$3,624.30
|
| Rate for Payer: PHCS PPO |
$3,825.65
|
| Rate for Payer: Three Rivers PPO |
$3,020.25
|
| Rate for Payer: TriWest Veterans Administration |
$738.04
|
| Rate for Payer: United Healthcare Commercial |
$3,503.49
|
| Rate for Payer: United Healthcare Medicare |
$738.04
|
| Rate for Payer: WINHealth Partners Commercial |
$3,422.95
|
|
|
REPAIR BLOOD VESSEL DIRECT UPPER EXTREMITY
|
Professional
|
Both
|
$4,027.00
|
|
|
Service Code
|
HCPCS 35206
|
| Hospital Charge Code |
35206
|
| Min. Negotiated Rate |
$627.33 |
| Max. Negotiated Rate |
$4,027.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,946.46
|
| Rate for Payer: Aetna of WY Medicare |
$738.04
|
| Rate for Payer: Beech Street Commercial |
$3,825.65
|
| Rate for Payer: Cash Price |
$2,818.90
|
| Rate for Payer: Cash Price |
$2,818.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,906.19
|
| Rate for Payer: Cigna of WY Commercial |
$3,946.46
|
| Rate for Payer: First Choice Health Commercial |
$3,624.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,825.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$738.04
|
| Rate for Payer: HealthUtah PPO |
$4,027.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,906.19
|
| Rate for Payer: Multiplan Medicare/VA |
$627.33
|
| Rate for Payer: One Health Plan of WY PPO |
$3,946.46
|
| Rate for Payer: PacificSource Commercial |
$3,624.30
|
| Rate for Payer: PHCS PPO |
$3,825.65
|
| Rate for Payer: Three Rivers PPO |
$3,020.25
|
| Rate for Payer: TriWest Veterans Administration |
$738.04
|
| Rate for Payer: United Healthcare Commercial |
$3,503.49
|
| Rate for Payer: United Healthcare Medicare |
$738.04
|
| Rate for Payer: WINHealth Partners Commercial |
$3,422.95
|
|
|
REPAIR COMPLEX EYELID/NOSE/EAR/LIP 1.1-2.5 CM
|
Professional
|
Both
|
$1,411.00
|
|
|
Service Code
|
HCPCS 13151
|
| Hospital Charge Code |
13151
|
| Min. Negotiated Rate |
$226.53 |
| Max. Negotiated Rate |
$1,411.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,382.78
|
| Rate for Payer: Aetna of WY Medicare |
$266.51
|
| Rate for Payer: Beech Street Commercial |
$1,340.45
|
| Rate for Payer: Cash Price |
$987.70
|
| Rate for Payer: Cash Price |
$987.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,368.67
|
| Rate for Payer: Cigna of WY Commercial |
$1,382.78
|
| Rate for Payer: First Choice Health Commercial |
$1,269.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,340.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$266.51
|
| Rate for Payer: HealthUtah PPO |
$1,411.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,368.67
|
| Rate for Payer: Multiplan Medicare/VA |
$226.53
|
| Rate for Payer: One Health Plan of WY PPO |
$1,382.78
|
| Rate for Payer: PacificSource Commercial |
$1,269.90
|
| Rate for Payer: PHCS PPO |
$1,340.45
|
| Rate for Payer: Three Rivers PPO |
$1,058.25
|
| Rate for Payer: TriWest Veterans Administration |
$266.51
|
| Rate for Payer: United Healthcare Commercial |
$1,227.57
|
| Rate for Payer: United Healthcare Medicare |
$266.51
|
| Rate for Payer: WINHealth Partners Commercial |
$1,199.35
|
|
|
REPAIR COMPLEX EYELID/NOSE/EAR/LIP 2.6-7.5 CM
|
Professional
|
Both
|
$1,701.00
|
|
|
Service Code
|
HCPCS 13152
|
| Hospital Charge Code |
13152
|
| Min. Negotiated Rate |
$272.98 |
| Max. Negotiated Rate |
$1,701.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,666.98
|
| Rate for Payer: Aetna of WY Medicare |
$321.15
|
| Rate for Payer: Beech Street Commercial |
$1,615.95
|
| Rate for Payer: Cash Price |
$1,190.70
|
| Rate for Payer: Cash Price |
$1,190.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,649.97
|
| Rate for Payer: Cigna of WY Commercial |
$1,666.98
|
| Rate for Payer: First Choice Health Commercial |
$1,530.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,615.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$321.15
|
| Rate for Payer: HealthUtah PPO |
$1,701.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,649.97
|
| Rate for Payer: Multiplan Medicare/VA |
$272.98
|
| Rate for Payer: One Health Plan of WY PPO |
$1,666.98
|
| Rate for Payer: PacificSource Commercial |
$1,530.90
|
| Rate for Payer: PHCS PPO |
$1,615.95
|
| Rate for Payer: Three Rivers PPO |
$1,275.75
|
| Rate for Payer: TriWest Veterans Administration |
$321.15
|
| Rate for Payer: United Healthcare Commercial |
$1,479.87
|
| Rate for Payer: United Healthcare Medicare |
$321.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1,445.85
|
|
|
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 1.1-2.5 CM
|
Professional
|
Both
|
$1,229.00
|
|
|
Service Code
|
HCPCS 13131
|
| Hospital Charge Code |
13131
|
| Min. Negotiated Rate |
$197.33 |
| Max. Negotiated Rate |
$1,229.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,204.42
|
| Rate for Payer: Aetna of WY Medicare |
$232.15
|
| Rate for Payer: Beech Street Commercial |
$1,167.55
|
| Rate for Payer: Cash Price |
$860.30
|
| Rate for Payer: Cash Price |
$860.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,192.13
|
| Rate for Payer: Cigna of WY Commercial |
$1,204.42
|
| Rate for Payer: First Choice Health Commercial |
$1,106.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,167.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$232.15
|
| Rate for Payer: HealthUtah PPO |
$1,229.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,192.13
|
| Rate for Payer: Multiplan Medicare/VA |
$197.33
|
| Rate for Payer: One Health Plan of WY PPO |
$1,204.42
|
| Rate for Payer: PacificSource Commercial |
$1,106.10
|
| Rate for Payer: PHCS PPO |
$1,167.55
|
| Rate for Payer: Three Rivers PPO |
$921.75
|
| Rate for Payer: TriWest Veterans Administration |
$232.15
|
| Rate for Payer: United Healthcare Commercial |
$1,069.23
|
| Rate for Payer: United Healthcare Medicare |
$232.15
|
| Rate for Payer: WINHealth Partners Commercial |
$1,044.65
|
|
|
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM
|
Professional
|
Both
|
$1,537.00
|
|
|
Service Code
|
HCPCS 13132
|
| Hospital Charge Code |
13132
|
| Min. Negotiated Rate |
$246.50 |
| Max. Negotiated Rate |
$1,537.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,506.26
|
| Rate for Payer: Aetna of WY Medicare |
$290.00
|
| Rate for Payer: Beech Street Commercial |
$1,460.15
|
| Rate for Payer: Cash Price |
$1,075.90
|
| Rate for Payer: Cash Price |
$1,075.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,490.89
|
| Rate for Payer: Cigna of WY Commercial |
$1,506.26
|
| Rate for Payer: First Choice Health Commercial |
$1,383.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,460.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$290.00
|
| Rate for Payer: HealthUtah PPO |
$1,537.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,490.89
|
| Rate for Payer: Multiplan Medicare/VA |
$246.50
|
| Rate for Payer: One Health Plan of WY PPO |
$1,506.26
|
| Rate for Payer: PacificSource Commercial |
$1,383.30
|
| Rate for Payer: PHCS PPO |
$1,460.15
|
| Rate for Payer: Three Rivers PPO |
$1,152.75
|
| Rate for Payer: TriWest Veterans Administration |
$290.00
|
| Rate for Payer: United Healthcare Commercial |
$1,337.19
|
| Rate for Payer: United Healthcare Medicare |
$290.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,306.45
|
|
|
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F 2.6-7.5 CM
|
Professional
|
Both
|
$1,537.00
|
|
|
Service Code
|
HCPCS 13132 80
|
| Hospital Charge Code |
13132
|
| Min. Negotiated Rate |
$246.50 |
| Max. Negotiated Rate |
$1,537.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,506.26
|
| Rate for Payer: Aetna of WY Medicare |
$290.00
|
| Rate for Payer: Beech Street Commercial |
$1,460.15
|
| Rate for Payer: Cash Price |
$1,075.90
|
| Rate for Payer: Cash Price |
$1,075.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,490.89
|
| Rate for Payer: Cigna of WY Commercial |
$1,506.26
|
| Rate for Payer: First Choice Health Commercial |
$1,383.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,460.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$290.00
|
| Rate for Payer: HealthUtah PPO |
$1,537.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,490.89
|
| Rate for Payer: Multiplan Medicare/VA |
$246.50
|
| Rate for Payer: One Health Plan of WY PPO |
$1,506.26
|
| Rate for Payer: PacificSource Commercial |
$1,383.30
|
| Rate for Payer: PHCS PPO |
$1,460.15
|
| Rate for Payer: Three Rivers PPO |
$1,152.75
|
| Rate for Payer: TriWest Veterans Administration |
$290.00
|
| Rate for Payer: United Healthcare Commercial |
$1,337.19
|
| Rate for Payer: United Healthcare Medicare |
$290.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,306.45
|
|
|
REPAIR COMPLEX F/C/C/M/N/AX/G/H/F EA ADDL 5 CM/<
|
Professional
|
Both
|
$642.00
|
|
|
Service Code
|
HCPCS 13133
|
| Hospital Charge Code |
13133
|
| Min. Negotiated Rate |
$101.43 |
| Max. Negotiated Rate |
$642.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$629.16
|
| Rate for Payer: Aetna of WY Medicare |
$119.33
|
| Rate for Payer: Beech Street Commercial |
$609.90
|
| Rate for Payer: Cash Price |
$449.40
|
| Rate for Payer: Cash Price |
$449.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$622.74
|
| Rate for Payer: Cigna of WY Commercial |
$629.16
|
| Rate for Payer: First Choice Health Commercial |
$577.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$609.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$119.33
|
| Rate for Payer: HealthUtah PPO |
$642.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$622.74
|
| Rate for Payer: Multiplan Medicare/VA |
$101.43
|
| Rate for Payer: One Health Plan of WY PPO |
$629.16
|
| Rate for Payer: PacificSource Commercial |
$577.80
|
| Rate for Payer: PHCS PPO |
$609.90
|
| Rate for Payer: Three Rivers PPO |
$481.50
|
| Rate for Payer: TriWest Veterans Administration |
$119.33
|
| Rate for Payer: United Healthcare Commercial |
$558.54
|
| Rate for Payer: United Healthcare Medicare |
$119.33
|
| Rate for Payer: WINHealth Partners Commercial |
$545.70
|
|
|
REPAIR COMPLEX SCALP/ARM/LEG 1.1-2.5 CM
|
Professional
|
Both
|
$1,165.00
|
|
|
Service Code
|
HCPCS 13120
|
| Hospital Charge Code |
13120
|
| Min. Negotiated Rate |
$189.41 |
| Max. Negotiated Rate |
$1,165.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,141.70
|
| Rate for Payer: Aetna of WY Medicare |
$222.84
|
| Rate for Payer: Beech Street Commercial |
$1,106.75
|
| Rate for Payer: Cash Price |
$815.50
|
| Rate for Payer: Cash Price |
$815.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,130.05
|
| Rate for Payer: Cigna of WY Commercial |
$1,141.70
|
| Rate for Payer: First Choice Health Commercial |
$1,048.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,106.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$222.84
|
| Rate for Payer: HealthUtah PPO |
$1,165.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,130.05
|
| Rate for Payer: Multiplan Medicare/VA |
$189.41
|
| Rate for Payer: One Health Plan of WY PPO |
$1,141.70
|
| Rate for Payer: PacificSource Commercial |
$1,048.50
|
| Rate for Payer: PHCS PPO |
$1,106.75
|
| Rate for Payer: Three Rivers PPO |
$873.75
|
| Rate for Payer: TriWest Veterans Administration |
$222.84
|
| Rate for Payer: United Healthcare Commercial |
$1,013.55
|
| Rate for Payer: United Healthcare Medicare |
$222.84
|
| Rate for Payer: WINHealth Partners Commercial |
$990.25
|
|
|
REPAIR COMPLEX SCALP/ARM/LEG 2.6-7.5 CM
|
Professional
|
Both
|
$1,310.00
|
|
|
Service Code
|
HCPCS 13121
|
| Hospital Charge Code |
13121
|
| Min. Negotiated Rate |
$210.34 |
| Max. Negotiated Rate |
$1,310.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,283.80
|
| Rate for Payer: Aetna of WY Medicare |
$247.46
|
| Rate for Payer: Beech Street Commercial |
$1,244.50
|
| Rate for Payer: Cash Price |
$917.00
|
| Rate for Payer: Cash Price |
$917.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,270.70
|
| Rate for Payer: Cigna of WY Commercial |
$1,283.80
|
| Rate for Payer: First Choice Health Commercial |
$1,179.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,244.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$247.46
|
| Rate for Payer: HealthUtah PPO |
$1,310.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,270.70
|
| Rate for Payer: Multiplan Medicare/VA |
$210.34
|
| Rate for Payer: One Health Plan of WY PPO |
$1,283.80
|
| Rate for Payer: PacificSource Commercial |
$1,179.00
|
| Rate for Payer: PHCS PPO |
$1,244.50
|
| Rate for Payer: Three Rivers PPO |
$982.50
|
| Rate for Payer: TriWest Veterans Administration |
$247.46
|
| Rate for Payer: United Healthcare Commercial |
$1,139.70
|
| Rate for Payer: United Healthcare Medicare |
$247.46
|
| Rate for Payer: WINHealth Partners Commercial |
$1,113.50
|
|
|
REPAIR COMPLEX SCALP/ARM/LEG EA ADDL 5 CM/<
|
Professional
|
Both
|
$421.00
|
|
|
Service Code
|
HCPCS 13122
|
| Hospital Charge Code |
13122
|
| Min. Negotiated Rate |
$66.59 |
| Max. Negotiated Rate |
$421.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$412.58
|
| Rate for Payer: Aetna of WY Medicare |
$78.34
|
| Rate for Payer: Beech Street Commercial |
$399.95
|
| Rate for Payer: Cash Price |
$294.70
|
| Rate for Payer: Cash Price |
$294.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$408.37
|
| Rate for Payer: Cigna of WY Commercial |
$412.58
|
| Rate for Payer: First Choice Health Commercial |
$378.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$399.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.34
|
| Rate for Payer: HealthUtah PPO |
$421.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$408.37
|
| Rate for Payer: Multiplan Medicare/VA |
$66.59
|
| Rate for Payer: One Health Plan of WY PPO |
$412.58
|
| Rate for Payer: PacificSource Commercial |
$378.90
|
| Rate for Payer: PHCS PPO |
$399.95
|
| Rate for Payer: Three Rivers PPO |
$315.75
|
| Rate for Payer: TriWest Veterans Administration |
$78.34
|
| Rate for Payer: United Healthcare Commercial |
$366.27
|
| Rate for Payer: United Healthcare Medicare |
$78.34
|
| Rate for Payer: WINHealth Partners Commercial |
$357.85
|
|
|
REPAIR COMPLEX TRUNK 2.6-7.5 CM
|
Professional
|
Both
|
$1,246.00
|
|
|
Service Code
|
HCPCS 13101
|
| Hospital Charge Code |
13101
|
| Min. Negotiated Rate |
$201.80 |
| Max. Negotiated Rate |
$1,246.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,221.08
|
| Rate for Payer: Aetna of WY Medicare |
$237.41
|
| Rate for Payer: Beech Street Commercial |
$1,183.70
|
| Rate for Payer: Cash Price |
$872.20
|
| Rate for Payer: Cash Price |
$872.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,208.62
|
| Rate for Payer: Cigna of WY Commercial |
$1,221.08
|
| Rate for Payer: First Choice Health Commercial |
$1,121.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,183.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$237.41
|
| Rate for Payer: HealthUtah PPO |
$1,246.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,208.62
|
| Rate for Payer: Multiplan Medicare/VA |
$201.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1,221.08
|
| Rate for Payer: PacificSource Commercial |
$1,121.40
|
| Rate for Payer: PHCS PPO |
$1,183.70
|
| Rate for Payer: Three Rivers PPO |
$934.50
|
| Rate for Payer: TriWest Veterans Administration |
$237.41
|
| Rate for Payer: United Healthcare Commercial |
$1,084.02
|
| Rate for Payer: United Healthcare Medicare |
$237.41
|
| Rate for Payer: WINHealth Partners Commercial |
$1,059.10
|
|
|
REPAIR COMPLX EYELID/NOSE/EAR/LIP EA ADDL 5 CM/<
|
Professional
|
Both
|
$700.00
|
|
|
Service Code
|
HCPCS 13153
|
| Hospital Charge Code |
13153
|
| Min. Negotiated Rate |
$110.03 |
| Max. Negotiated Rate |
$700.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$686.00
|
| Rate for Payer: Aetna of WY Medicare |
$129.45
|
| Rate for Payer: Beech Street Commercial |
$665.00
|
| Rate for Payer: Cash Price |
$490.00
|
| Rate for Payer: Cash Price |
$490.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$679.00
|
| Rate for Payer: Cigna of WY Commercial |
$686.00
|
| Rate for Payer: First Choice Health Commercial |
$630.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$665.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$129.45
|
| Rate for Payer: HealthUtah PPO |
$700.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$679.00
|
| Rate for Payer: Multiplan Medicare/VA |
$110.03
|
| Rate for Payer: One Health Plan of WY PPO |
$686.00
|
| Rate for Payer: PacificSource Commercial |
$630.00
|
| Rate for Payer: PHCS PPO |
$665.00
|
| Rate for Payer: Three Rivers PPO |
$525.00
|
| Rate for Payer: TriWest Veterans Administration |
$129.45
|
| Rate for Payer: United Healthcare Commercial |
$609.00
|
| Rate for Payer: United Healthcare Medicare |
$129.45
|
| Rate for Payer: WINHealth Partners Commercial |
$595.00
|
|
|
REPAIR DISLOCATING PERONEAL TENDON W/FIB OSTEOT
|
Professional
|
Both
|
$2,687.00
|
|
|
Service Code
|
HCPCS 27676 AS
|
| Hospital Charge Code |
27676
|
| Min. Negotiated Rate |
$504.30 |
| Max. Negotiated Rate |
$2,687.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,633.26
|
| Rate for Payer: Aetna of WY Medicare |
$593.29
|
| Rate for Payer: Beech Street Commercial |
$2,552.65
|
| Rate for Payer: Cash Price |
$1,880.90
|
| Rate for Payer: Cash Price |
$1,880.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,606.39
|
| Rate for Payer: Cigna of WY Commercial |
$2,633.26
|
| Rate for Payer: First Choice Health Commercial |
$2,418.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,552.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$593.29
|
| Rate for Payer: HealthUtah PPO |
$2,687.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,606.39
|
| Rate for Payer: Multiplan Medicare/VA |
$504.30
|
| Rate for Payer: One Health Plan of WY PPO |
$2,633.26
|
| Rate for Payer: PacificSource Commercial |
$2,418.30
|
| Rate for Payer: PHCS PPO |
$2,552.65
|
| Rate for Payer: Three Rivers PPO |
$2,015.25
|
| Rate for Payer: TriWest Veterans Administration |
$593.29
|
| Rate for Payer: United Healthcare Commercial |
$2,337.69
|
| Rate for Payer: United Healthcare Medicare |
$593.29
|
| Rate for Payer: WINHealth Partners Commercial |
$2,283.95
|
|
|
REPAIR DISLOCATING PERONEAL TENDON W/FIB OSTEOT
|
Professional
|
Both
|
$2,687.00
|
|
|
Service Code
|
HCPCS 27676
|
| Hospital Charge Code |
27676
|
| Min. Negotiated Rate |
$504.30 |
| Max. Negotiated Rate |
$2,687.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,633.26
|
| Rate for Payer: Aetna of WY Medicare |
$593.29
|
| Rate for Payer: Beech Street Commercial |
$2,552.65
|
| Rate for Payer: Cash Price |
$1,880.90
|
| Rate for Payer: Cash Price |
$1,880.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,606.39
|
| Rate for Payer: Cigna of WY Commercial |
$2,633.26
|
| Rate for Payer: First Choice Health Commercial |
$2,418.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,552.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$593.29
|
| Rate for Payer: HealthUtah PPO |
$2,687.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,606.39
|
| Rate for Payer: Multiplan Medicare/VA |
$504.30
|
| Rate for Payer: One Health Plan of WY PPO |
$2,633.26
|
| Rate for Payer: PacificSource Commercial |
$2,418.30
|
| Rate for Payer: PHCS PPO |
$2,552.65
|
| Rate for Payer: Three Rivers PPO |
$2,015.25
|
| Rate for Payer: TriWest Veterans Administration |
$593.29
|
| Rate for Payer: United Healthcare Commercial |
$2,337.69
|
| Rate for Payer: United Healthcare Medicare |
$593.29
|
| Rate for Payer: WINHealth Partners Commercial |
$2,283.95
|
|
|
REPAIR DISLOCATING PERONEAL TENDON W/FIB OSTEOT
|
Professional
|
Both
|
$2,687.00
|
|
|
Service Code
|
HCPCS 27676 80
|
| Hospital Charge Code |
27676
|
| Min. Negotiated Rate |
$504.30 |
| Max. Negotiated Rate |
$2,687.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,633.26
|
| Rate for Payer: Aetna of WY Medicare |
$593.29
|
| Rate for Payer: Beech Street Commercial |
$2,552.65
|
| Rate for Payer: Cash Price |
$1,880.90
|
| Rate for Payer: Cash Price |
$1,880.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,606.39
|
| Rate for Payer: Cigna of WY Commercial |
$2,633.26
|
| Rate for Payer: First Choice Health Commercial |
$2,418.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,552.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$593.29
|
| Rate for Payer: HealthUtah PPO |
$2,687.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,606.39
|
| Rate for Payer: Multiplan Medicare/VA |
$504.30
|
| Rate for Payer: One Health Plan of WY PPO |
$2,633.26
|
| Rate for Payer: PacificSource Commercial |
$2,418.30
|
| Rate for Payer: PHCS PPO |
$2,552.65
|
| Rate for Payer: Three Rivers PPO |
$2,015.25
|
| Rate for Payer: TriWest Veterans Administration |
$593.29
|
| Rate for Payer: United Healthcare Commercial |
$2,337.69
|
| Rate for Payer: United Healthcare Medicare |
$593.29
|
| Rate for Payer: WINHealth Partners Commercial |
$2,283.95
|
|
|
REPAIR ENTEROCELE ABDOMINAL APPROACH SPX
|
Professional
|
Both
|
$4,074.00
|
|
|
Service Code
|
HCPCS 57270
|
| Hospital Charge Code |
57270
|
| Min. Negotiated Rate |
$666.33 |
| Max. Negotiated Rate |
$4,074.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,992.52
|
| Rate for Payer: Aetna of WY Medicare |
$783.92
|
| Rate for Payer: Beech Street Commercial |
$3,870.30
|
| Rate for Payer: Cash Price |
$2,851.80
|
| Rate for Payer: Cash Price |
$2,851.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,951.78
|
| Rate for Payer: Cigna of WY Commercial |
$3,992.52
|
| Rate for Payer: First Choice Health Commercial |
$3,666.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,870.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$783.92
|
| Rate for Payer: HealthUtah PPO |
$4,074.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,951.78
|
| Rate for Payer: Multiplan Medicare/VA |
$666.33
|
| Rate for Payer: One Health Plan of WY PPO |
$3,992.52
|
| Rate for Payer: PacificSource Commercial |
$3,666.60
|
| Rate for Payer: PHCS PPO |
$3,870.30
|
| Rate for Payer: Three Rivers PPO |
$3,055.50
|
| Rate for Payer: TriWest Veterans Administration |
$783.92
|
| Rate for Payer: United Healthcare Commercial |
$3,544.38
|
| Rate for Payer: United Healthcare Medicare |
$783.92
|
| Rate for Payer: WINHealth Partners Commercial |
$3,462.90
|
|
|
REPAIR EXTENSOR TENDON DISTAL INSERTION W/GRAFT
|
Professional
|
Both
|
$4,421.00
|
|
|
Service Code
|
HCPCS 26434
|
| Hospital Charge Code |
26434
|
| Min. Negotiated Rate |
$580.12 |
| Max. Negotiated Rate |
$4,421.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,332.58
|
| Rate for Payer: Aetna of WY Medicare |
$682.50
|
| Rate for Payer: Beech Street Commercial |
$4,199.95
|
| Rate for Payer: Cash Price |
$3,094.70
|
| Rate for Payer: Cash Price |
$3,094.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,288.37
|
| Rate for Payer: Cigna of WY Commercial |
$4,332.58
|
| Rate for Payer: First Choice Health Commercial |
$3,978.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,199.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$682.50
|
| Rate for Payer: HealthUtah PPO |
$4,421.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,288.37
|
| Rate for Payer: Multiplan Medicare/VA |
$580.12
|
| Rate for Payer: One Health Plan of WY PPO |
$4,332.58
|
| Rate for Payer: PacificSource Commercial |
$3,978.90
|
| Rate for Payer: PHCS PPO |
$4,199.95
|
| Rate for Payer: Three Rivers PPO |
$3,315.75
|
| Rate for Payer: TriWest Veterans Administration |
$682.50
|
| Rate for Payer: United Healthcare Commercial |
$3,846.27
|
| Rate for Payer: United Healthcare Medicare |
$682.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,757.85
|
|
|
REPAIR EXTENSOR TENDON DISTAL INSERTION W/GRAFT
|
Professional
|
Both
|
$4,421.00
|
|
|
Service Code
|
HCPCS 26434 AS
|
| Hospital Charge Code |
26434
|
| Min. Negotiated Rate |
$580.12 |
| Max. Negotiated Rate |
$4,421.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,332.58
|
| Rate for Payer: Aetna of WY Medicare |
$682.50
|
| Rate for Payer: Beech Street Commercial |
$4,199.95
|
| Rate for Payer: Cash Price |
$3,094.70
|
| Rate for Payer: Cash Price |
$3,094.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,288.37
|
| Rate for Payer: Cigna of WY Commercial |
$4,332.58
|
| Rate for Payer: First Choice Health Commercial |
$3,978.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,199.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$682.50
|
| Rate for Payer: HealthUtah PPO |
$4,421.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,288.37
|
| Rate for Payer: Multiplan Medicare/VA |
$580.12
|
| Rate for Payer: One Health Plan of WY PPO |
$4,332.58
|
| Rate for Payer: PacificSource Commercial |
$3,978.90
|
| Rate for Payer: PHCS PPO |
$4,199.95
|
| Rate for Payer: Three Rivers PPO |
$3,315.75
|
| Rate for Payer: TriWest Veterans Administration |
$682.50
|
| Rate for Payer: United Healthcare Commercial |
$3,846.27
|
| Rate for Payer: United Healthcare Medicare |
$682.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,757.85
|
|
|
REPAIR EXTENSOR TENDON DISTAL INSERTION W/O GRF
|
Professional
|
Both
|
$3,545.00
|
|
|
Service Code
|
HCPCS 26433
|
| Hospital Charge Code |
26433
|
| Min. Negotiated Rate |
$478.10 |
| Max. Negotiated Rate |
$3,545.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,474.10
|
| Rate for Payer: Aetna of WY Medicare |
$562.47
|
| Rate for Payer: Beech Street Commercial |
$3,367.75
|
| Rate for Payer: Cash Price |
$2,481.50
|
| Rate for Payer: Cash Price |
$2,481.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,438.65
|
| Rate for Payer: Cigna of WY Commercial |
$3,474.10
|
| Rate for Payer: First Choice Health Commercial |
$3,190.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,367.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$562.47
|
| Rate for Payer: HealthUtah PPO |
$3,545.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,438.65
|
| Rate for Payer: Multiplan Medicare/VA |
$478.10
|
| Rate for Payer: One Health Plan of WY PPO |
$3,474.10
|
| Rate for Payer: PacificSource Commercial |
$3,190.50
|
| Rate for Payer: PHCS PPO |
$3,367.75
|
| Rate for Payer: Three Rivers PPO |
$2,658.75
|
| Rate for Payer: TriWest Veterans Administration |
$562.47
|
| Rate for Payer: United Healthcare Commercial |
$3,084.15
|
| Rate for Payer: United Healthcare Medicare |
$562.47
|
| Rate for Payer: WINHealth Partners Commercial |
$3,013.25
|
|
|
REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH
|
Professional
|
Both
|
$4,554.00
|
|
|
Service Code
|
HCPCS 26420
|
| Hospital Charge Code |
26420
|
| Min. Negotiated Rate |
$618.87 |
| Max. Negotiated Rate |
$4,554.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,462.92
|
| Rate for Payer: Aetna of WY Medicare |
$728.08
|
| Rate for Payer: Beech Street Commercial |
$4,326.30
|
| Rate for Payer: Cash Price |
$3,187.80
|
| Rate for Payer: Cash Price |
$3,187.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,417.38
|
| Rate for Payer: Cigna of WY Commercial |
$4,462.92
|
| Rate for Payer: First Choice Health Commercial |
$4,098.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,326.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$728.08
|
| Rate for Payer: HealthUtah PPO |
$4,554.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,417.38
|
| Rate for Payer: Multiplan Medicare/VA |
$618.87
|
| Rate for Payer: One Health Plan of WY PPO |
$4,462.92
|
| Rate for Payer: PacificSource Commercial |
$4,098.60
|
| Rate for Payer: PHCS PPO |
$4,326.30
|
| Rate for Payer: Three Rivers PPO |
$3,415.50
|
| Rate for Payer: TriWest Veterans Administration |
$728.08
|
| Rate for Payer: United Healthcare Commercial |
$3,961.98
|
| Rate for Payer: United Healthcare Medicare |
$728.08
|
| Rate for Payer: WINHealth Partners Commercial |
$3,870.90
|
|
|
REPAIR EXTENSOR TENDON FINGER W/GRAFT EACH
|
Professional
|
Both
|
$4,554.00
|
|
|
Service Code
|
HCPCS 26420 80
|
| Hospital Charge Code |
26420
|
| Min. Negotiated Rate |
$618.87 |
| Max. Negotiated Rate |
$4,554.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,462.92
|
| Rate for Payer: Aetna of WY Medicare |
$728.08
|
| Rate for Payer: Beech Street Commercial |
$4,326.30
|
| Rate for Payer: Cash Price |
$3,187.80
|
| Rate for Payer: Cash Price |
$3,187.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,417.38
|
| Rate for Payer: Cigna of WY Commercial |
$4,462.92
|
| Rate for Payer: First Choice Health Commercial |
$4,098.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,326.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$728.08
|
| Rate for Payer: HealthUtah PPO |
$4,554.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,417.38
|
| Rate for Payer: Multiplan Medicare/VA |
$618.87
|
| Rate for Payer: One Health Plan of WY PPO |
$4,462.92
|
| Rate for Payer: PacificSource Commercial |
$4,098.60
|
| Rate for Payer: PHCS PPO |
$4,326.30
|
| Rate for Payer: Three Rivers PPO |
$3,415.50
|
| Rate for Payer: TriWest Veterans Administration |
$728.08
|
| Rate for Payer: United Healthcare Commercial |
$3,961.98
|
| Rate for Payer: United Healthcare Medicare |
$728.08
|
| Rate for Payer: WINHealth Partners Commercial |
$3,870.90
|
|
|
REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH
|
Professional
|
Both
|
$2,198.00
|
|
|
Service Code
|
HCPCS 26418
|
| Hospital Charge Code |
26418
|
| Min. Negotiated Rate |
$523.68 |
| Max. Negotiated Rate |
$2,198.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,154.04
|
| Rate for Payer: Aetna of WY Medicare |
$616.10
|
| Rate for Payer: Beech Street Commercial |
$2,088.10
|
| Rate for Payer: Cash Price |
$1,538.60
|
| Rate for Payer: Cash Price |
$1,538.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,132.06
|
| Rate for Payer: Cigna of WY Commercial |
$2,154.04
|
| Rate for Payer: First Choice Health Commercial |
$1,978.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,088.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$616.10
|
| Rate for Payer: HealthUtah PPO |
$2,198.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,132.06
|
| Rate for Payer: Multiplan Medicare/VA |
$523.68
|
| Rate for Payer: One Health Plan of WY PPO |
$2,154.04
|
| Rate for Payer: PacificSource Commercial |
$1,978.20
|
| Rate for Payer: PHCS PPO |
$2,088.10
|
| Rate for Payer: Three Rivers PPO |
$1,648.50
|
| Rate for Payer: TriWest Veterans Administration |
$616.10
|
| Rate for Payer: United Healthcare Commercial |
$1,912.26
|
| Rate for Payer: United Healthcare Medicare |
$616.10
|
| Rate for Payer: WINHealth Partners Commercial |
$1,868.30
|
|
|
REPAIR EXTENSOR TENDON FINGER W/O GRAFT EACH
|
Professional
|
Both
|
$2,198.00
|
|
|
Service Code
|
HCPCS 26418 80
|
| Hospital Charge Code |
26418
|
| Min. Negotiated Rate |
$523.68 |
| Max. Negotiated Rate |
$2,198.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,154.04
|
| Rate for Payer: Aetna of WY Medicare |
$616.10
|
| Rate for Payer: Beech Street Commercial |
$2,088.10
|
| Rate for Payer: Cash Price |
$1,538.60
|
| Rate for Payer: Cash Price |
$1,538.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,132.06
|
| Rate for Payer: Cigna of WY Commercial |
$2,154.04
|
| Rate for Payer: First Choice Health Commercial |
$1,978.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,088.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$616.10
|
| Rate for Payer: HealthUtah PPO |
$2,198.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,132.06
|
| Rate for Payer: Multiplan Medicare/VA |
$523.68
|
| Rate for Payer: One Health Plan of WY PPO |
$2,154.04
|
| Rate for Payer: PacificSource Commercial |
$1,978.20
|
| Rate for Payer: PHCS PPO |
$2,088.10
|
| Rate for Payer: Three Rivers PPO |
$1,648.50
|
| Rate for Payer: TriWest Veterans Administration |
$616.10
|
| Rate for Payer: United Healthcare Commercial |
$1,912.26
|
| Rate for Payer: United Healthcare Medicare |
$616.10
|
| Rate for Payer: WINHealth Partners Commercial |
$1,868.30
|
|
