|
DAVINCI TIP COVER ACCESSORY
|
Facility
|
OP
|
$73.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$40.50 |
| Max. Negotiated Rate |
$73.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$72.03
|
| Rate for Payer: Aetna of WY Medicare |
$48.51
|
| Rate for Payer: Altius Auto/Workers Compensation |
$70.56
|
| Rate for Payer: Altius Commercial |
$70.56
|
| Rate for Payer: Beech Street Commercial |
$72.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$60.34
|
| Rate for Payer: Cash Price |
$51.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$71.30
|
| Rate for Payer: Cigna of WY Commercial |
$72.03
|
| Rate for Payer: Entrust Commercial |
$69.82
|
| Rate for Payer: First Choice Health Commercial |
$69.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$69.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$42.63
|
| Rate for Payer: HealthUtah PPO |
$73.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$71.30
|
| Rate for Payer: Multiplan Medicare/VA |
$40.50
|
| Rate for Payer: One Health Plan of WY PPO |
$72.03
|
| Rate for Payer: PacificSource Commercial |
$66.15
|
| Rate for Payer: PHCS PPO |
$72.03
|
| Rate for Payer: Three Rivers PPO |
$55.12
|
| Rate for Payer: TriWest Veterans Administration |
$42.63
|
| Rate for Payer: United Healthcare Commercial |
$63.94
|
| Rate for Payer: United Healthcare Medicare |
$42.63
|
| Rate for Payer: WINHealth Partners Commercial |
$72.03
|
| Rate for Payer: Wise Provider Network Commercial |
$69.82
|
|
|
DAVINCI TIP COVER ACCESSORY
|
Facility
|
IP
|
$73.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.08 |
| Max. Negotiated Rate |
$73.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$72.03
|
| Rate for Payer: Altius Auto/Workers Compensation |
$70.56
|
| Rate for Payer: Altius Commercial |
$70.56
|
| Rate for Payer: Beech Street Commercial |
$72.03
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$60.34
|
| Rate for Payer: Cash Price |
$51.45
|
| Rate for Payer: ChoiceCare Network Commercial |
$71.30
|
| Rate for Payer: Cigna of WY Commercial |
$72.03
|
| Rate for Payer: Entrust Commercial |
$69.82
|
| Rate for Payer: First Choice Health Commercial |
$69.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$69.82
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$48.51
|
| Rate for Payer: HealthUtah PPO |
$73.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$71.30
|
| Rate for Payer: Multiplan Medicare/VA |
$46.08
|
| Rate for Payer: One Health Plan of WY PPO |
$72.03
|
| Rate for Payer: PacificSource Commercial |
$66.15
|
| Rate for Payer: PHCS PPO |
$72.03
|
| Rate for Payer: Three Rivers PPO |
$55.12
|
| Rate for Payer: TriWest Veterans Administration |
$48.51
|
| Rate for Payer: United Healthcare Commercial |
$63.94
|
| Rate for Payer: United Healthcare Medicare |
$48.51
|
| Rate for Payer: WINHealth Partners Commercial |
$69.82
|
| Rate for Payer: Wise Provider Network Commercial |
$69.82
|
|
|
DAVINCI UNIVERSAL SEAL 5-12MM
|
Facility
|
OP
|
$70.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.57 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$68.60
|
| Rate for Payer: Aetna of WY Medicare |
$46.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$67.20
|
| Rate for Payer: Altius Commercial |
$67.20
|
| Rate for Payer: Beech Street Commercial |
$68.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.47
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$67.90
|
| Rate for Payer: Cigna of WY Commercial |
$68.60
|
| Rate for Payer: Entrust Commercial |
$66.50
|
| Rate for Payer: First Choice Health Commercial |
$66.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$40.60
|
| Rate for Payer: HealthUtah PPO |
$70.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$67.90
|
| Rate for Payer: Multiplan Medicare/VA |
$38.57
|
| Rate for Payer: One Health Plan of WY PPO |
$68.60
|
| Rate for Payer: PacificSource Commercial |
$63.00
|
| Rate for Payer: PHCS PPO |
$68.60
|
| Rate for Payer: Three Rivers PPO |
$52.50
|
| Rate for Payer: TriWest Veterans Administration |
$40.60
|
| Rate for Payer: United Healthcare Commercial |
$60.90
|
| Rate for Payer: United Healthcare Medicare |
$40.60
|
| Rate for Payer: WINHealth Partners Commercial |
$68.60
|
| Rate for Payer: Wise Provider Network Commercial |
$66.50
|
|
|
DAVINCI UNIVERSAL SEAL 5-12MM
|
Facility
|
IP
|
$70.00
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$43.89 |
| Max. Negotiated Rate |
$70.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$68.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$67.20
|
| Rate for Payer: Altius Commercial |
$67.20
|
| Rate for Payer: Beech Street Commercial |
$68.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$57.47
|
| Rate for Payer: Cash Price |
$49.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$67.90
|
| Rate for Payer: Cigna of WY Commercial |
$68.60
|
| Rate for Payer: Entrust Commercial |
$66.50
|
| Rate for Payer: First Choice Health Commercial |
$66.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$66.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$46.20
|
| Rate for Payer: HealthUtah PPO |
$70.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$67.90
|
| Rate for Payer: Multiplan Medicare/VA |
$43.89
|
| Rate for Payer: One Health Plan of WY PPO |
$68.60
|
| Rate for Payer: PacificSource Commercial |
$63.00
|
| Rate for Payer: PHCS PPO |
$68.60
|
| Rate for Payer: Three Rivers PPO |
$52.50
|
| Rate for Payer: TriWest Veterans Administration |
$46.20
|
| Rate for Payer: United Healthcare Commercial |
$60.90
|
| Rate for Payer: United Healthcare Medicare |
$46.20
|
| Rate for Payer: WINHealth Partners Commercial |
$66.50
|
| Rate for Payer: Wise Provider Network Commercial |
$66.50
|
|
|
DAVINCI VESSEL SEALER EXTEND
|
Facility
|
IP
|
$1,396.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$875.61 |
| Max. Negotiated Rate |
$1,396.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,368.57
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,340.64
|
| Rate for Payer: Altius Commercial |
$1,340.64
|
| Rate for Payer: Beech Street Commercial |
$1,368.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,146.53
|
| Rate for Payer: Cash Price |
$977.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,354.60
|
| Rate for Payer: Cigna of WY Commercial |
$1,368.57
|
| Rate for Payer: Entrust Commercial |
$1,326.68
|
| Rate for Payer: First Choice Health Commercial |
$1,326.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,326.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$921.69
|
| Rate for Payer: HealthUtah PPO |
$1,396.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,354.60
|
| Rate for Payer: Multiplan Medicare/VA |
$875.61
|
| Rate for Payer: One Health Plan of WY PPO |
$1,368.57
|
| Rate for Payer: PacificSource Commercial |
$1,256.85
|
| Rate for Payer: PHCS PPO |
$1,368.57
|
| Rate for Payer: Three Rivers PPO |
$1,047.38
|
| Rate for Payer: TriWest Veterans Administration |
$921.69
|
| Rate for Payer: United Healthcare Commercial |
$1,214.96
|
| Rate for Payer: United Healthcare Medicare |
$921.69
|
| Rate for Payer: WINHealth Partners Commercial |
$1,326.68
|
| Rate for Payer: Wise Provider Network Commercial |
$1,326.68
|
|
|
DAVINCI VESSEL SEALER EXTEND
|
Facility
|
OP
|
$1,396.50
|
|
| Hospital Charge Code |
27200000S1
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$769.47 |
| Max. Negotiated Rate |
$1,396.50 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,368.57
|
| Rate for Payer: Aetna of WY Medicare |
$921.69
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,340.64
|
| Rate for Payer: Altius Commercial |
$1,340.64
|
| Rate for Payer: Beech Street Commercial |
$1,368.57
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,146.53
|
| Rate for Payer: Cash Price |
$977.55
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,354.60
|
| Rate for Payer: Cigna of WY Commercial |
$1,368.57
|
| Rate for Payer: Entrust Commercial |
$1,326.68
|
| Rate for Payer: First Choice Health Commercial |
$1,326.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,326.68
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$809.97
|
| Rate for Payer: HealthUtah PPO |
$1,396.50
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,354.60
|
| Rate for Payer: Multiplan Medicare/VA |
$769.47
|
| Rate for Payer: One Health Plan of WY PPO |
$1,368.57
|
| Rate for Payer: PacificSource Commercial |
$1,256.85
|
| Rate for Payer: PHCS PPO |
$1,368.57
|
| Rate for Payer: Three Rivers PPO |
$1,047.38
|
| Rate for Payer: TriWest Veterans Administration |
$809.97
|
| Rate for Payer: United Healthcare Commercial |
$1,214.96
|
| Rate for Payer: United Healthcare Medicare |
$809.97
|
| Rate for Payer: WINHealth Partners Commercial |
$1,368.57
|
| Rate for Payer: Wise Provider Network Commercial |
$1,326.68
|
|
|
DBRDMT EXTENSV ECZMT/INFCT SKIN UP 10% BDY SURF
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
HCPCS 11000
|
| Hospital Charge Code |
11000
|
| Min. Negotiated Rate |
$22.46 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$202.86
|
| Rate for Payer: Aetna of WY Medicare |
$26.42
|
| Rate for Payer: Beech Street Commercial |
$196.65
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$200.79
|
| Rate for Payer: Cigna of WY Commercial |
$202.86
|
| Rate for Payer: First Choice Health Commercial |
$186.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$196.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.42
|
| Rate for Payer: HealthUtah PPO |
$207.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$200.79
|
| Rate for Payer: Multiplan Medicare/VA |
$22.46
|
| Rate for Payer: One Health Plan of WY PPO |
$202.86
|
| Rate for Payer: PacificSource Commercial |
$186.30
|
| Rate for Payer: PHCS PPO |
$196.65
|
| Rate for Payer: Three Rivers PPO |
$155.25
|
| Rate for Payer: TriWest Veterans Administration |
$26.42
|
| Rate for Payer: United Healthcare Commercial |
$180.09
|
| Rate for Payer: United Healthcare Medicare |
$26.42
|
| Rate for Payer: WINHealth Partners Commercial |
$175.95
|
|
|
DBRDMT EXTENSV ECZMT/INFCT SKIN UP 10% BDY SURF
|
Professional
|
Both
|
$207.00
|
|
|
Service Code
|
HCPCS 11000 80
|
| Hospital Charge Code |
11000
|
| Min. Negotiated Rate |
$22.46 |
| Max. Negotiated Rate |
$207.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$202.86
|
| Rate for Payer: Aetna of WY Medicare |
$26.42
|
| Rate for Payer: Beech Street Commercial |
$196.65
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: Cash Price |
$144.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$200.79
|
| Rate for Payer: Cigna of WY Commercial |
$202.86
|
| Rate for Payer: First Choice Health Commercial |
$186.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$196.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$26.42
|
| Rate for Payer: HealthUtah PPO |
$207.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$200.79
|
| Rate for Payer: Multiplan Medicare/VA |
$22.46
|
| Rate for Payer: One Health Plan of WY PPO |
$202.86
|
| Rate for Payer: PacificSource Commercial |
$186.30
|
| Rate for Payer: PHCS PPO |
$196.65
|
| Rate for Payer: Three Rivers PPO |
$155.25
|
| Rate for Payer: TriWest Veterans Administration |
$26.42
|
| Rate for Payer: United Healthcare Commercial |
$180.09
|
| Rate for Payer: United Healthcare Medicare |
$26.42
|
| Rate for Payer: WINHealth Partners Commercial |
$175.95
|
|
|
DBRDMT FX&/DISLC SUBQ T/M/F BONE
|
Professional
|
Both
|
$2,243.00
|
|
|
Service Code
|
HCPCS 11012
|
| Hospital Charge Code |
11012
|
| Min. Negotiated Rate |
$335.39 |
| Max. Negotiated Rate |
$2,243.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,198.14
|
| Rate for Payer: Aetna of WY Medicare |
$394.58
|
| Rate for Payer: Beech Street Commercial |
$2,130.85
|
| Rate for Payer: Cash Price |
$1,570.10
|
| Rate for Payer: Cash Price |
$1,570.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,175.71
|
| Rate for Payer: Cigna of WY Commercial |
$2,198.14
|
| Rate for Payer: First Choice Health Commercial |
$2,018.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,130.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$394.58
|
| Rate for Payer: HealthUtah PPO |
$2,243.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,175.71
|
| Rate for Payer: Multiplan Medicare/VA |
$335.39
|
| Rate for Payer: One Health Plan of WY PPO |
$2,198.14
|
| Rate for Payer: PacificSource Commercial |
$2,018.70
|
| Rate for Payer: PHCS PPO |
$2,130.85
|
| Rate for Payer: Three Rivers PPO |
$1,682.25
|
| Rate for Payer: TriWest Veterans Administration |
$394.58
|
| Rate for Payer: United Healthcare Commercial |
$1,951.41
|
| Rate for Payer: United Healthcare Medicare |
$394.58
|
| Rate for Payer: WINHealth Partners Commercial |
$1,906.55
|
|
|
DBRDMT FX&/DISLC SUBQ T/M/F BONE
|
Professional
|
Both
|
$2,243.00
|
|
|
Service Code
|
HCPCS 11012 AS
|
| Hospital Charge Code |
11012
|
| Min. Negotiated Rate |
$335.39 |
| Max. Negotiated Rate |
$2,243.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,198.14
|
| Rate for Payer: Aetna of WY Medicare |
$394.58
|
| Rate for Payer: Beech Street Commercial |
$2,130.85
|
| Rate for Payer: Cash Price |
$1,570.10
|
| Rate for Payer: Cash Price |
$1,570.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,175.71
|
| Rate for Payer: Cigna of WY Commercial |
$2,198.14
|
| Rate for Payer: First Choice Health Commercial |
$2,018.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,130.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$394.58
|
| Rate for Payer: HealthUtah PPO |
$2,243.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,175.71
|
| Rate for Payer: Multiplan Medicare/VA |
$335.39
|
| Rate for Payer: One Health Plan of WY PPO |
$2,198.14
|
| Rate for Payer: PacificSource Commercial |
$2,018.70
|
| Rate for Payer: PHCS PPO |
$2,130.85
|
| Rate for Payer: Three Rivers PPO |
$1,682.25
|
| Rate for Payer: TriWest Veterans Administration |
$394.58
|
| Rate for Payer: United Healthcare Commercial |
$1,951.41
|
| Rate for Payer: United Healthcare Medicare |
$394.58
|
| Rate for Payer: WINHealth Partners Commercial |
$1,906.55
|
|
|
DBRDMT FX&/DISLC SUBQ T/M/F BONE
|
Professional
|
Both
|
$2,243.00
|
|
|
Service Code
|
HCPCS 11012 80
|
| Hospital Charge Code |
11012
|
| Min. Negotiated Rate |
$335.39 |
| Max. Negotiated Rate |
$2,243.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,198.14
|
| Rate for Payer: Aetna of WY Medicare |
$394.58
|
| Rate for Payer: Beech Street Commercial |
$2,130.85
|
| Rate for Payer: Cash Price |
$1,570.10
|
| Rate for Payer: Cash Price |
$1,570.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,175.71
|
| Rate for Payer: Cigna of WY Commercial |
$2,198.14
|
| Rate for Payer: First Choice Health Commercial |
$2,018.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,130.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$394.58
|
| Rate for Payer: HealthUtah PPO |
$2,243.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,175.71
|
| Rate for Payer: Multiplan Medicare/VA |
$335.39
|
| Rate for Payer: One Health Plan of WY PPO |
$2,198.14
|
| Rate for Payer: PacificSource Commercial |
$2,018.70
|
| Rate for Payer: PHCS PPO |
$2,130.85
|
| Rate for Payer: Three Rivers PPO |
$1,682.25
|
| Rate for Payer: TriWest Veterans Administration |
$394.58
|
| Rate for Payer: United Healthcare Commercial |
$1,951.41
|
| Rate for Payer: United Healthcare Medicare |
$394.58
|
| Rate for Payer: WINHealth Partners Commercial |
$1,906.55
|
|
|
DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS
|
Professional
|
Both
|
$1,383.00
|
|
|
Service Code
|
HCPCS 11010 80
|
| Hospital Charge Code |
11010
|
| Min. Negotiated Rate |
$224.52 |
| Max. Negotiated Rate |
$1,383.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,355.34
|
| Rate for Payer: Aetna of WY Medicare |
$264.14
|
| Rate for Payer: Beech Street Commercial |
$1,313.85
|
| Rate for Payer: Cash Price |
$968.10
|
| Rate for Payer: Cash Price |
$968.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,341.51
|
| Rate for Payer: Cigna of WY Commercial |
$1,355.34
|
| Rate for Payer: First Choice Health Commercial |
$1,244.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,313.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$264.14
|
| Rate for Payer: HealthUtah PPO |
$1,383.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,341.51
|
| Rate for Payer: Multiplan Medicare/VA |
$224.52
|
| Rate for Payer: One Health Plan of WY PPO |
$1,355.34
|
| Rate for Payer: PacificSource Commercial |
$1,244.70
|
| Rate for Payer: PHCS PPO |
$1,313.85
|
| Rate for Payer: Three Rivers PPO |
$1,037.25
|
| Rate for Payer: TriWest Veterans Administration |
$264.14
|
| Rate for Payer: United Healthcare Commercial |
$1,203.21
|
| Rate for Payer: United Healthcare Medicare |
$264.14
|
| Rate for Payer: WINHealth Partners Commercial |
$1,175.55
|
|
|
DBRDMT W/RMVL FM FX&/DISLC SKIN&SUBQ TISSUS
|
Professional
|
Both
|
$1,383.00
|
|
|
Service Code
|
HCPCS 11010
|
| Hospital Charge Code |
11010
|
| Min. Negotiated Rate |
$224.52 |
| Max. Negotiated Rate |
$1,383.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,355.34
|
| Rate for Payer: Aetna of WY Medicare |
$264.14
|
| Rate for Payer: Beech Street Commercial |
$1,313.85
|
| Rate for Payer: Cash Price |
$968.10
|
| Rate for Payer: Cash Price |
$968.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,341.51
|
| Rate for Payer: Cigna of WY Commercial |
$1,355.34
|
| Rate for Payer: First Choice Health Commercial |
$1,244.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,313.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$264.14
|
| Rate for Payer: HealthUtah PPO |
$1,383.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,341.51
|
| Rate for Payer: Multiplan Medicare/VA |
$224.52
|
| Rate for Payer: One Health Plan of WY PPO |
$1,355.34
|
| Rate for Payer: PacificSource Commercial |
$1,244.70
|
| Rate for Payer: PHCS PPO |
$1,313.85
|
| Rate for Payer: Three Rivers PPO |
$1,037.25
|
| Rate for Payer: TriWest Veterans Administration |
$264.14
|
| Rate for Payer: United Healthcare Commercial |
$1,203.21
|
| Rate for Payer: United Healthcare Medicare |
$264.14
|
| Rate for Payer: WINHealth Partners Commercial |
$1,175.55
|
|
|
DBRDMT W/RMVL FM FX&/DISLC SKN SUBQ T/M/F MUSC
|
Professional
|
Both
|
$1,506.00
|
|
|
Service Code
|
HCPCS 11011
|
| Hospital Charge Code |
11011
|
| Min. Negotiated Rate |
$240.11 |
| Max. Negotiated Rate |
$1,506.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,475.88
|
| Rate for Payer: Aetna of WY Medicare |
$282.48
|
| Rate for Payer: Beech Street Commercial |
$1,430.70
|
| Rate for Payer: Cash Price |
$1,054.20
|
| Rate for Payer: Cash Price |
$1,054.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,460.82
|
| Rate for Payer: Cigna of WY Commercial |
$1,475.88
|
| Rate for Payer: First Choice Health Commercial |
$1,355.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,430.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$282.48
|
| Rate for Payer: HealthUtah PPO |
$1,506.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,460.82
|
| Rate for Payer: Multiplan Medicare/VA |
$240.11
|
| Rate for Payer: One Health Plan of WY PPO |
$1,475.88
|
| Rate for Payer: PacificSource Commercial |
$1,355.40
|
| Rate for Payer: PHCS PPO |
$1,430.70
|
| Rate for Payer: Three Rivers PPO |
$1,129.50
|
| Rate for Payer: TriWest Veterans Administration |
$282.48
|
| Rate for Payer: United Healthcare Commercial |
$1,310.22
|
| Rate for Payer: United Healthcare Medicare |
$282.48
|
| Rate for Payer: WINHealth Partners Commercial |
$1,280.10
|
|
|
DCMPRN FASCIOTOMY THIGH&/KNEE MLT COMPARTMENTS
|
Professional
|
Both
|
$3,378.00
|
|
|
Service Code
|
HCPCS 27498 AS
|
| Hospital Charge Code |
27498
|
| Min. Negotiated Rate |
$545.11 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,310.44
|
| Rate for Payer: Aetna of WY Medicare |
$641.31
|
| Rate for Payer: Beech Street Commercial |
$3,209.10
|
| Rate for Payer: Cash Price |
$2,364.60
|
| Rate for Payer: Cash Price |
$2,364.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,276.66
|
| Rate for Payer: Cigna of WY Commercial |
$3,310.44
|
| Rate for Payer: First Choice Health Commercial |
$3,040.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,209.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$641.31
|
| Rate for Payer: HealthUtah PPO |
$3,378.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,276.66
|
| Rate for Payer: Multiplan Medicare/VA |
$545.11
|
| Rate for Payer: One Health Plan of WY PPO |
$3,310.44
|
| Rate for Payer: PacificSource Commercial |
$3,040.20
|
| Rate for Payer: PHCS PPO |
$3,209.10
|
| Rate for Payer: Three Rivers PPO |
$2,533.50
|
| Rate for Payer: TriWest Veterans Administration |
$641.31
|
| Rate for Payer: United Healthcare Commercial |
$2,938.86
|
| Rate for Payer: United Healthcare Medicare |
$641.31
|
| Rate for Payer: WINHealth Partners Commercial |
$2,871.30
|
|
|
DCMPRN FASCIOTOMY THIGH&/KNEE MLT COMPARTMENTS
|
Professional
|
Both
|
$3,378.00
|
|
|
Service Code
|
HCPCS 27498
|
| Hospital Charge Code |
27498
|
| Min. Negotiated Rate |
$545.11 |
| Max. Negotiated Rate |
$3,378.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,310.44
|
| Rate for Payer: Aetna of WY Medicare |
$641.31
|
| Rate for Payer: Beech Street Commercial |
$3,209.10
|
| Rate for Payer: Cash Price |
$2,364.60
|
| Rate for Payer: Cash Price |
$2,364.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,276.66
|
| Rate for Payer: Cigna of WY Commercial |
$3,310.44
|
| Rate for Payer: First Choice Health Commercial |
$3,040.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,209.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$641.31
|
| Rate for Payer: HealthUtah PPO |
$3,378.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,276.66
|
| Rate for Payer: Multiplan Medicare/VA |
$545.11
|
| Rate for Payer: One Health Plan of WY PPO |
$3,310.44
|
| Rate for Payer: PacificSource Commercial |
$3,040.20
|
| Rate for Payer: PHCS PPO |
$3,209.10
|
| Rate for Payer: Three Rivers PPO |
$2,533.50
|
| Rate for Payer: TriWest Veterans Administration |
$641.31
|
| Rate for Payer: United Healthcare Commercial |
$2,938.86
|
| Rate for Payer: United Healthcare Medicare |
$641.31
|
| Rate for Payer: WINHealth Partners Commercial |
$2,871.30
|
|
|
DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR DBRDMT
|
Professional
|
Both
|
$6,090.00
|
|
|
Service Code
|
HCPCS 25025 80
|
| Hospital Charge Code |
25025
|
| Min. Negotiated Rate |
$1,004.04 |
| Max. Negotiated Rate |
$6,090.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,968.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,181.22
|
| Rate for Payer: Beech Street Commercial |
$5,785.50
|
| Rate for Payer: Cash Price |
$4,263.00
|
| Rate for Payer: Cash Price |
$4,263.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,907.30
|
| Rate for Payer: Cigna of WY Commercial |
$5,968.20
|
| Rate for Payer: First Choice Health Commercial |
$5,481.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,785.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,181.22
|
| Rate for Payer: HealthUtah PPO |
$6,090.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,907.30
|
| Rate for Payer: Multiplan Medicare/VA |
$1,004.04
|
| Rate for Payer: One Health Plan of WY PPO |
$5,968.20
|
| Rate for Payer: PacificSource Commercial |
$5,481.00
|
| Rate for Payer: PHCS PPO |
$5,785.50
|
| Rate for Payer: Three Rivers PPO |
$4,567.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,181.22
|
| Rate for Payer: United Healthcare Commercial |
$5,298.30
|
| Rate for Payer: United Healthcare Medicare |
$1,181.22
|
| Rate for Payer: WINHealth Partners Commercial |
$5,176.50
|
|
|
DCMPRN FASCT F/ARM&/WRST FLXR&XTNSR DBRDMT
|
Professional
|
Both
|
$6,090.00
|
|
|
Service Code
|
HCPCS 25025
|
| Hospital Charge Code |
25025
|
| Min. Negotiated Rate |
$1,004.04 |
| Max. Negotiated Rate |
$6,090.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,968.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,181.22
|
| Rate for Payer: Beech Street Commercial |
$5,785.50
|
| Rate for Payer: Cash Price |
$4,263.00
|
| Rate for Payer: Cash Price |
$4,263.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,907.30
|
| Rate for Payer: Cigna of WY Commercial |
$5,968.20
|
| Rate for Payer: First Choice Health Commercial |
$5,481.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,785.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,181.22
|
| Rate for Payer: HealthUtah PPO |
$6,090.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,907.30
|
| Rate for Payer: Multiplan Medicare/VA |
$1,004.04
|
| Rate for Payer: One Health Plan of WY PPO |
$5,968.20
|
| Rate for Payer: PacificSource Commercial |
$5,481.00
|
| Rate for Payer: PHCS PPO |
$5,785.50
|
| Rate for Payer: Three Rivers PPO |
$4,567.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,181.22
|
| Rate for Payer: United Healthcare Commercial |
$5,298.30
|
| Rate for Payer: United Healthcare Medicare |
$1,181.22
|
| Rate for Payer: WINHealth Partners Commercial |
$5,176.50
|
|
|
DCMPRN FASCT F/ARM&/WRST FLXR/XTNSR W/DBRDMT
|
Professional
|
Both
|
$5,160.00
|
|
|
Service Code
|
HCPCS 25023 AS
|
| Hospital Charge Code |
25023
|
| Min. Negotiated Rate |
$1,080.65 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,056.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,271.35
|
| Rate for Payer: Beech Street Commercial |
$4,902.00
|
| Rate for Payer: Cash Price |
$3,612.00
|
| Rate for Payer: Cash Price |
$3,612.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,005.20
|
| Rate for Payer: Cigna of WY Commercial |
$5,056.80
|
| Rate for Payer: First Choice Health Commercial |
$4,644.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,902.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,271.35
|
| Rate for Payer: HealthUtah PPO |
$5,160.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,005.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,080.65
|
| Rate for Payer: One Health Plan of WY PPO |
$5,056.80
|
| Rate for Payer: PacificSource Commercial |
$4,644.00
|
| Rate for Payer: PHCS PPO |
$4,902.00
|
| Rate for Payer: Three Rivers PPO |
$3,870.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,271.35
|
| Rate for Payer: United Healthcare Commercial |
$4,489.20
|
| Rate for Payer: United Healthcare Medicare |
$1,271.35
|
| Rate for Payer: WINHealth Partners Commercial |
$4,386.00
|
|
|
DCMPRN FASCT F/ARM&/WRST FLXR/XTNSR W/DBRDMT
|
Professional
|
Both
|
$5,160.00
|
|
|
Service Code
|
HCPCS 25023
|
| Hospital Charge Code |
25023
|
| Min. Negotiated Rate |
$1,080.65 |
| Max. Negotiated Rate |
$5,160.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,056.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,271.35
|
| Rate for Payer: Beech Street Commercial |
$4,902.00
|
| Rate for Payer: Cash Price |
$3,612.00
|
| Rate for Payer: Cash Price |
$3,612.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,005.20
|
| Rate for Payer: Cigna of WY Commercial |
$5,056.80
|
| Rate for Payer: First Choice Health Commercial |
$4,644.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,902.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,271.35
|
| Rate for Payer: HealthUtah PPO |
$5,160.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,005.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,080.65
|
| Rate for Payer: One Health Plan of WY PPO |
$5,056.80
|
| Rate for Payer: PacificSource Commercial |
$4,644.00
|
| Rate for Payer: PHCS PPO |
$4,902.00
|
| Rate for Payer: Three Rivers PPO |
$3,870.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,271.35
|
| Rate for Payer: United Healthcare Commercial |
$4,489.20
|
| Rate for Payer: United Healthcare Medicare |
$1,271.35
|
| Rate for Payer: WINHealth Partners Commercial |
$4,386.00
|
|
|
DCMPRN FASCT F/ARM&WRST FLXR/XTNSR W/O DBRDMT
|
Professional
|
Both
|
$5,164.00
|
|
|
Service Code
|
HCPCS 25020 50
|
| Hospital Charge Code |
25020
|
| Min. Negotiated Rate |
$615.15 |
| Max. Negotiated Rate |
$5,164.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,060.72
|
| Rate for Payer: Aetna of WY Medicare |
$723.71
|
| Rate for Payer: Beech Street Commercial |
$4,905.80
|
| Rate for Payer: Cash Price |
$3,614.80
|
| Rate for Payer: Cash Price |
$3,614.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,009.08
|
| Rate for Payer: Cigna of WY Commercial |
$5,060.72
|
| Rate for Payer: First Choice Health Commercial |
$4,647.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,905.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$723.71
|
| Rate for Payer: HealthUtah PPO |
$5,164.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,009.08
|
| Rate for Payer: Multiplan Medicare/VA |
$615.15
|
| Rate for Payer: One Health Plan of WY PPO |
$5,060.72
|
| Rate for Payer: PacificSource Commercial |
$4,647.60
|
| Rate for Payer: PHCS PPO |
$4,905.80
|
| Rate for Payer: Three Rivers PPO |
$3,873.00
|
| Rate for Payer: TriWest Veterans Administration |
$723.71
|
| Rate for Payer: United Healthcare Commercial |
$4,492.68
|
| Rate for Payer: United Healthcare Medicare |
$723.71
|
| Rate for Payer: WINHealth Partners Commercial |
$4,389.40
|
|
|
DCMPRN FASCT F/ARM&WRST FLXR/XTNSR W/O DBRDMT
|
Professional
|
Both
|
$2,582.00
|
|
|
Service Code
|
HCPCS 25020
|
| Hospital Charge Code |
25020
|
| Min. Negotiated Rate |
$615.15 |
| Max. Negotiated Rate |
$2,582.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,530.36
|
| Rate for Payer: Aetna of WY Medicare |
$723.71
|
| Rate for Payer: Beech Street Commercial |
$2,452.90
|
| Rate for Payer: Cash Price |
$1,807.40
|
| Rate for Payer: Cash Price |
$1,807.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,504.54
|
| Rate for Payer: Cigna of WY Commercial |
$2,530.36
|
| Rate for Payer: First Choice Health Commercial |
$2,323.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,452.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$723.71
|
| Rate for Payer: HealthUtah PPO |
$2,582.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,504.54
|
| Rate for Payer: Multiplan Medicare/VA |
$615.15
|
| Rate for Payer: One Health Plan of WY PPO |
$2,530.36
|
| Rate for Payer: PacificSource Commercial |
$2,323.80
|
| Rate for Payer: PHCS PPO |
$2,452.90
|
| Rate for Payer: Three Rivers PPO |
$1,936.50
|
| Rate for Payer: TriWest Veterans Administration |
$723.71
|
| Rate for Payer: United Healthcare Commercial |
$2,246.34
|
| Rate for Payer: United Healthcare Medicare |
$723.71
|
| Rate for Payer: WINHealth Partners Commercial |
$2,194.70
|
|
|
DCMPRN FASCT LEG ANT&/LAT COMPARTMENTS ONLY
|
Professional
|
Both
|
$2,090.00
|
|
|
Service Code
|
HCPCS 27600
|
| Hospital Charge Code |
27600
|
| Min. Negotiated Rate |
$326.66 |
| Max. Negotiated Rate |
$2,090.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,048.20
|
| Rate for Payer: Aetna of WY Medicare |
$384.30
|
| Rate for Payer: Beech Street Commercial |
$1,985.50
|
| Rate for Payer: Cash Price |
$1,463.00
|
| Rate for Payer: Cash Price |
$1,463.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,027.30
|
| Rate for Payer: Cigna of WY Commercial |
$2,048.20
|
| Rate for Payer: First Choice Health Commercial |
$1,881.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,985.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$384.30
|
| Rate for Payer: HealthUtah PPO |
$2,090.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,027.30
|
| Rate for Payer: Multiplan Medicare/VA |
$326.66
|
| Rate for Payer: One Health Plan of WY PPO |
$2,048.20
|
| Rate for Payer: PacificSource Commercial |
$1,881.00
|
| Rate for Payer: PHCS PPO |
$1,985.50
|
| Rate for Payer: Three Rivers PPO |
$1,567.50
|
| Rate for Payer: TriWest Veterans Administration |
$384.30
|
| Rate for Payer: United Healthcare Commercial |
$1,818.30
|
| Rate for Payer: United Healthcare Medicare |
$384.30
|
| Rate for Payer: WINHealth Partners Commercial |
$1,776.50
|
|
|
DCMPRN FASCT LEG ANT&/LAT COMPARTMENTS ONLY
|
Professional
|
Both
|
$2,090.00
|
|
|
Service Code
|
HCPCS 27600 80
|
| Hospital Charge Code |
27600
|
| Min. Negotiated Rate |
$326.66 |
| Max. Negotiated Rate |
$2,090.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,048.20
|
| Rate for Payer: Aetna of WY Medicare |
$384.30
|
| Rate for Payer: Beech Street Commercial |
$1,985.50
|
| Rate for Payer: Cash Price |
$1,463.00
|
| Rate for Payer: Cash Price |
$1,463.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,027.30
|
| Rate for Payer: Cigna of WY Commercial |
$2,048.20
|
| Rate for Payer: First Choice Health Commercial |
$1,881.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,985.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$384.30
|
| Rate for Payer: HealthUtah PPO |
$2,090.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,027.30
|
| Rate for Payer: Multiplan Medicare/VA |
$326.66
|
| Rate for Payer: One Health Plan of WY PPO |
$2,048.20
|
| Rate for Payer: PacificSource Commercial |
$1,881.00
|
| Rate for Payer: PHCS PPO |
$1,985.50
|
| Rate for Payer: Three Rivers PPO |
$1,567.50
|
| Rate for Payer: TriWest Veterans Administration |
$384.30
|
| Rate for Payer: United Healthcare Commercial |
$1,818.30
|
| Rate for Payer: United Healthcare Medicare |
$384.30
|
| Rate for Payer: WINHealth Partners Commercial |
$1,776.50
|
|
|
DCMPRN FASCT LEG ANT&/LAT&PST CMPRT
|
Professional
|
Both
|
$6,539.00
|
|
|
Service Code
|
HCPCS 27602
|
| Hospital Charge Code |
27602
|
| Min. Negotiated Rate |
$383.94 |
| Max. Negotiated Rate |
$6,539.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$6,408.22
|
| Rate for Payer: Aetna of WY Medicare |
$451.69
|
| Rate for Payer: Beech Street Commercial |
$6,212.05
|
| Rate for Payer: Cash Price |
$4,577.30
|
| Rate for Payer: Cash Price |
$4,577.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$6,342.83
|
| Rate for Payer: Cigna of WY Commercial |
$6,408.22
|
| Rate for Payer: First Choice Health Commercial |
$5,885.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$6,212.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$451.69
|
| Rate for Payer: HealthUtah PPO |
$6,539.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$6,342.83
|
| Rate for Payer: Multiplan Medicare/VA |
$383.94
|
| Rate for Payer: One Health Plan of WY PPO |
$6,408.22
|
| Rate for Payer: PacificSource Commercial |
$5,885.10
|
| Rate for Payer: PHCS PPO |
$6,212.05
|
| Rate for Payer: Three Rivers PPO |
$4,904.25
|
| Rate for Payer: TriWest Veterans Administration |
$451.69
|
| Rate for Payer: United Healthcare Commercial |
$5,688.93
|
| Rate for Payer: United Healthcare Medicare |
$451.69
|
| Rate for Payer: WINHealth Partners Commercial |
$5,558.15
|
|
