|
HC COMPLEMENT, ANTIGEN - C4 COMPLEMENT
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
3028616001
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$99.18 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$176.40
|
| Rate for Payer: Aetna of WY Medicare |
$118.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$172.80
|
| Rate for Payer: Altius Commercial |
$172.80
|
| Rate for Payer: Beech Street Commercial |
$176.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$147.78
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$174.60
|
| Rate for Payer: Cigna of WY Commercial |
$176.40
|
| Rate for Payer: Entrust Commercial |
$171.00
|
| Rate for Payer: First Choice Health Commercial |
$171.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$171.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$104.40
|
| Rate for Payer: HealthUtah PPO |
$180.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$174.60
|
| Rate for Payer: Multiplan Medicare/VA |
$99.18
|
| Rate for Payer: One Health Plan of WY PPO |
$176.40
|
| Rate for Payer: PacificSource Commercial |
$162.00
|
| Rate for Payer: PHCS PPO |
$176.40
|
| Rate for Payer: Three Rivers PPO |
$135.00
|
| Rate for Payer: TriWest Veterans Administration |
$104.40
|
| Rate for Payer: United Healthcare Commercial |
$156.60
|
| Rate for Payer: United Healthcare Medicare |
$104.40
|
| Rate for Payer: WINHealth Partners Commercial |
$176.40
|
| Rate for Payer: Wise Provider Network Commercial |
$171.00
|
|
|
HC COMPLEMENT, ANTIGEN - C4 COMPLEMENT
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
3028616001
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$112.86 |
| Max. Negotiated Rate |
$180.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$176.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$172.80
|
| Rate for Payer: Altius Commercial |
$172.80
|
| Rate for Payer: Beech Street Commercial |
$176.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$147.78
|
| Rate for Payer: Cash Price |
$126.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$174.60
|
| Rate for Payer: Cigna of WY Commercial |
$176.40
|
| Rate for Payer: Entrust Commercial |
$171.00
|
| Rate for Payer: First Choice Health Commercial |
$171.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$171.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$118.80
|
| Rate for Payer: HealthUtah PPO |
$180.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$174.60
|
| Rate for Payer: Multiplan Medicare/VA |
$112.86
|
| Rate for Payer: One Health Plan of WY PPO |
$176.40
|
| Rate for Payer: PacificSource Commercial |
$162.00
|
| Rate for Payer: PHCS PPO |
$176.40
|
| Rate for Payer: Three Rivers PPO |
$135.00
|
| Rate for Payer: TriWest Veterans Administration |
$118.80
|
| Rate for Payer: United Healthcare Commercial |
$156.60
|
| Rate for Payer: United Healthcare Medicare |
$118.80
|
| Rate for Payer: WINHealth Partners Commercial |
$171.00
|
| Rate for Payer: Wise Provider Network Commercial |
$171.00
|
|
|
HC COMPLEMENT, ANTIGEN - C5 COMPLEMENT
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
3028616004
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$60.61 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$107.80
|
| Rate for Payer: Aetna of WY Medicare |
$72.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$105.60
|
| Rate for Payer: Altius Commercial |
$105.60
|
| Rate for Payer: Beech Street Commercial |
$107.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$90.31
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$106.70
|
| Rate for Payer: Cigna of WY Commercial |
$107.80
|
| Rate for Payer: Entrust Commercial |
$104.50
|
| Rate for Payer: First Choice Health Commercial |
$104.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$104.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$63.80
|
| Rate for Payer: HealthUtah PPO |
$110.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$106.70
|
| Rate for Payer: Multiplan Medicare/VA |
$60.61
|
| Rate for Payer: One Health Plan of WY PPO |
$107.80
|
| Rate for Payer: PacificSource Commercial |
$99.00
|
| Rate for Payer: PHCS PPO |
$107.80
|
| Rate for Payer: Three Rivers PPO |
$82.50
|
| Rate for Payer: TriWest Veterans Administration |
$63.80
|
| Rate for Payer: United Healthcare Commercial |
$95.70
|
| Rate for Payer: United Healthcare Medicare |
$63.80
|
| Rate for Payer: WINHealth Partners Commercial |
$107.80
|
| Rate for Payer: Wise Provider Network Commercial |
$104.50
|
|
|
HC COMPLEMENT, ANTIGEN - C5 COMPLEMENT
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
3028616004
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$68.97 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$107.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$105.60
|
| Rate for Payer: Altius Commercial |
$105.60
|
| Rate for Payer: Beech Street Commercial |
$107.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$90.31
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$106.70
|
| Rate for Payer: Cigna of WY Commercial |
$107.80
|
| Rate for Payer: Entrust Commercial |
$104.50
|
| Rate for Payer: First Choice Health Commercial |
$104.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$104.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$72.60
|
| Rate for Payer: HealthUtah PPO |
$110.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$106.70
|
| Rate for Payer: Multiplan Medicare/VA |
$68.97
|
| Rate for Payer: One Health Plan of WY PPO |
$107.80
|
| Rate for Payer: PacificSource Commercial |
$99.00
|
| Rate for Payer: PHCS PPO |
$107.80
|
| Rate for Payer: Three Rivers PPO |
$82.50
|
| Rate for Payer: TriWest Veterans Administration |
$72.60
|
| Rate for Payer: United Healthcare Commercial |
$95.70
|
| Rate for Payer: United Healthcare Medicare |
$72.60
|
| Rate for Payer: WINHealth Partners Commercial |
$104.50
|
| Rate for Payer: Wise Provider Network Commercial |
$104.50
|
|
|
HC COMPLEMENT, ANTIGEN - C6 COMPLEMENT
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
3028616005
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$60.61 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$107.80
|
| Rate for Payer: Aetna of WY Medicare |
$72.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$105.60
|
| Rate for Payer: Altius Commercial |
$105.60
|
| Rate for Payer: Beech Street Commercial |
$107.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$90.31
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$106.70
|
| Rate for Payer: Cigna of WY Commercial |
$107.80
|
| Rate for Payer: Entrust Commercial |
$104.50
|
| Rate for Payer: First Choice Health Commercial |
$104.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$104.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$63.80
|
| Rate for Payer: HealthUtah PPO |
$110.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$106.70
|
| Rate for Payer: Multiplan Medicare/VA |
$60.61
|
| Rate for Payer: One Health Plan of WY PPO |
$107.80
|
| Rate for Payer: PacificSource Commercial |
$99.00
|
| Rate for Payer: PHCS PPO |
$107.80
|
| Rate for Payer: Three Rivers PPO |
$82.50
|
| Rate for Payer: TriWest Veterans Administration |
$63.80
|
| Rate for Payer: United Healthcare Commercial |
$95.70
|
| Rate for Payer: United Healthcare Medicare |
$63.80
|
| Rate for Payer: WINHealth Partners Commercial |
$107.80
|
| Rate for Payer: Wise Provider Network Commercial |
$104.50
|
|
|
HC COMPLEMENT, ANTIGEN - C6 COMPLEMENT
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
3028616005
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$68.97 |
| Max. Negotiated Rate |
$110.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$107.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$105.60
|
| Rate for Payer: Altius Commercial |
$105.60
|
| Rate for Payer: Beech Street Commercial |
$107.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$90.31
|
| Rate for Payer: Cash Price |
$77.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$106.70
|
| Rate for Payer: Cigna of WY Commercial |
$107.80
|
| Rate for Payer: Entrust Commercial |
$104.50
|
| Rate for Payer: First Choice Health Commercial |
$104.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$104.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$72.60
|
| Rate for Payer: HealthUtah PPO |
$110.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$106.70
|
| Rate for Payer: Multiplan Medicare/VA |
$68.97
|
| Rate for Payer: One Health Plan of WY PPO |
$107.80
|
| Rate for Payer: PacificSource Commercial |
$99.00
|
| Rate for Payer: PHCS PPO |
$107.80
|
| Rate for Payer: Three Rivers PPO |
$82.50
|
| Rate for Payer: TriWest Veterans Administration |
$72.60
|
| Rate for Payer: United Healthcare Commercial |
$95.70
|
| Rate for Payer: United Healthcare Medicare |
$72.60
|
| Rate for Payer: WINHealth Partners Commercial |
$104.50
|
| Rate for Payer: Wise Provider Network Commercial |
$104.50
|
|
|
HC COMPLEMENT, ANTIGEN -COMPLEMENT COMPONENT C1Q
|
Facility
|
OP
|
$190.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
3028616006
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$104.69 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$186.20
|
| Rate for Payer: Aetna of WY Medicare |
$125.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$182.40
|
| Rate for Payer: Altius Commercial |
$182.40
|
| Rate for Payer: Beech Street Commercial |
$186.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$155.99
|
| Rate for Payer: Cash Price |
$133.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$184.30
|
| Rate for Payer: Cigna of WY Commercial |
$186.20
|
| Rate for Payer: Entrust Commercial |
$180.50
|
| Rate for Payer: First Choice Health Commercial |
$180.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$180.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$110.20
|
| Rate for Payer: HealthUtah PPO |
$190.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$184.30
|
| Rate for Payer: Multiplan Medicare/VA |
$104.69
|
| Rate for Payer: One Health Plan of WY PPO |
$186.20
|
| Rate for Payer: PacificSource Commercial |
$171.00
|
| Rate for Payer: PHCS PPO |
$186.20
|
| Rate for Payer: Three Rivers PPO |
$142.50
|
| Rate for Payer: TriWest Veterans Administration |
$110.20
|
| Rate for Payer: United Healthcare Commercial |
$165.30
|
| Rate for Payer: United Healthcare Medicare |
$110.20
|
| Rate for Payer: WINHealth Partners Commercial |
$186.20
|
| Rate for Payer: Wise Provider Network Commercial |
$180.50
|
|
|
HC COMPLEMENT, ANTIGEN -COMPLEMENT COMPONENT C1Q
|
Facility
|
IP
|
$190.00
|
|
|
Service Code
|
HCPCS 86160
|
| Hospital Charge Code |
3028616006
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$119.13 |
| Max. Negotiated Rate |
$190.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$186.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$182.40
|
| Rate for Payer: Altius Commercial |
$182.40
|
| Rate for Payer: Beech Street Commercial |
$186.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$155.99
|
| Rate for Payer: Cash Price |
$133.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$184.30
|
| Rate for Payer: Cigna of WY Commercial |
$186.20
|
| Rate for Payer: Entrust Commercial |
$180.50
|
| Rate for Payer: First Choice Health Commercial |
$180.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$180.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$125.40
|
| Rate for Payer: HealthUtah PPO |
$190.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$184.30
|
| Rate for Payer: Multiplan Medicare/VA |
$119.13
|
| Rate for Payer: One Health Plan of WY PPO |
$186.20
|
| Rate for Payer: PacificSource Commercial |
$171.00
|
| Rate for Payer: PHCS PPO |
$186.20
|
| Rate for Payer: Three Rivers PPO |
$142.50
|
| Rate for Payer: TriWest Veterans Administration |
$125.40
|
| Rate for Payer: United Healthcare Commercial |
$165.30
|
| Rate for Payer: United Healthcare Medicare |
$125.40
|
| Rate for Payer: WINHealth Partners Commercial |
$180.50
|
| Rate for Payer: Wise Provider Network Commercial |
$180.50
|
|
|
HC COMPLEMENT/FUNCTION ACTIVITY - C1 ESTERASE INHIBITOR, FUNCTIONAL
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
HCPCS 86161
|
| Hospital Charge Code |
3028616102
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$46.84 |
| Max. Negotiated Rate |
$85.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$83.30
|
| Rate for Payer: Aetna of WY Medicare |
$56.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$81.60
|
| Rate for Payer: Altius Commercial |
$81.60
|
| Rate for Payer: Beech Street Commercial |
$83.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$69.78
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$82.45
|
| Rate for Payer: Cigna of WY Commercial |
$83.30
|
| Rate for Payer: Entrust Commercial |
$80.75
|
| Rate for Payer: First Choice Health Commercial |
$80.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$80.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.30
|
| Rate for Payer: HealthUtah PPO |
$85.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$82.45
|
| Rate for Payer: Multiplan Medicare/VA |
$46.84
|
| Rate for Payer: One Health Plan of WY PPO |
$83.30
|
| Rate for Payer: PacificSource Commercial |
$76.50
|
| Rate for Payer: PHCS PPO |
$83.30
|
| Rate for Payer: Three Rivers PPO |
$63.75
|
| Rate for Payer: TriWest Veterans Administration |
$49.30
|
| Rate for Payer: United Healthcare Commercial |
$73.95
|
| Rate for Payer: United Healthcare Medicare |
$49.30
|
| Rate for Payer: WINHealth Partners Commercial |
$83.30
|
| Rate for Payer: Wise Provider Network Commercial |
$80.75
|
|
|
HC COMPLEMENT/FUNCTION ACTIVITY - C1 ESTERASE INHIBITOR, FUNCTIONAL
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS 86161
|
| Hospital Charge Code |
3028616102
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$53.30 |
| Max. Negotiated Rate |
$85.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$83.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$81.60
|
| Rate for Payer: Altius Commercial |
$81.60
|
| Rate for Payer: Beech Street Commercial |
$83.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$69.78
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$82.45
|
| Rate for Payer: Cigna of WY Commercial |
$83.30
|
| Rate for Payer: Entrust Commercial |
$80.75
|
| Rate for Payer: First Choice Health Commercial |
$80.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$80.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.10
|
| Rate for Payer: HealthUtah PPO |
$85.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$82.45
|
| Rate for Payer: Multiplan Medicare/VA |
$53.30
|
| Rate for Payer: One Health Plan of WY PPO |
$83.30
|
| Rate for Payer: PacificSource Commercial |
$76.50
|
| Rate for Payer: PHCS PPO |
$83.30
|
| Rate for Payer: Three Rivers PPO |
$63.75
|
| Rate for Payer: TriWest Veterans Administration |
$56.10
|
| Rate for Payer: United Healthcare Commercial |
$73.95
|
| Rate for Payer: United Healthcare Medicare |
$56.10
|
| Rate for Payer: WINHealth Partners Commercial |
$80.75
|
| Rate for Payer: Wise Provider Network Commercial |
$80.75
|
|
|
HC COMPLEMENT/FUNCTION ACTIVITY - C1 ESTERASE INHIBITOR PANEL
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS 86161
|
| Hospital Charge Code |
3028616101
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$68.88 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$122.50
|
| Rate for Payer: Aetna of WY Medicare |
$82.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$120.00
|
| Rate for Payer: Altius Commercial |
$120.00
|
| Rate for Payer: Beech Street Commercial |
$122.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$102.62
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$121.25
|
| Rate for Payer: Cigna of WY Commercial |
$122.50
|
| Rate for Payer: Entrust Commercial |
$118.75
|
| Rate for Payer: First Choice Health Commercial |
$118.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$118.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$72.50
|
| Rate for Payer: HealthUtah PPO |
$125.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$121.25
|
| Rate for Payer: Multiplan Medicare/VA |
$68.88
|
| Rate for Payer: One Health Plan of WY PPO |
$122.50
|
| Rate for Payer: PacificSource Commercial |
$112.50
|
| Rate for Payer: PHCS PPO |
$122.50
|
| Rate for Payer: Three Rivers PPO |
$93.75
|
| Rate for Payer: TriWest Veterans Administration |
$72.50
|
| Rate for Payer: United Healthcare Commercial |
$108.75
|
| Rate for Payer: United Healthcare Medicare |
$72.50
|
| Rate for Payer: WINHealth Partners Commercial |
$122.50
|
| Rate for Payer: Wise Provider Network Commercial |
$118.75
|
|
|
HC COMPLEMENT/FUNCTION ACTIVITY - C1 ESTERASE INHIBITOR PANEL
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS 86161
|
| Hospital Charge Code |
3028616101
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$78.38 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$122.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$120.00
|
| Rate for Payer: Altius Commercial |
$120.00
|
| Rate for Payer: Beech Street Commercial |
$122.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$102.62
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$121.25
|
| Rate for Payer: Cigna of WY Commercial |
$122.50
|
| Rate for Payer: Entrust Commercial |
$118.75
|
| Rate for Payer: First Choice Health Commercial |
$118.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$118.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$82.50
|
| Rate for Payer: HealthUtah PPO |
$125.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$121.25
|
| Rate for Payer: Multiplan Medicare/VA |
$78.38
|
| Rate for Payer: One Health Plan of WY PPO |
$122.50
|
| Rate for Payer: PacificSource Commercial |
$112.50
|
| Rate for Payer: PHCS PPO |
$122.50
|
| Rate for Payer: Three Rivers PPO |
$93.75
|
| Rate for Payer: TriWest Veterans Administration |
$82.50
|
| Rate for Payer: United Healthcare Commercial |
$108.75
|
| Rate for Payer: United Healthcare Medicare |
$82.50
|
| Rate for Payer: WINHealth Partners Commercial |
$118.75
|
| Rate for Payer: Wise Provider Network Commercial |
$118.75
|
|
|
HC COMPLEMENT, TOTAL (CH50) - COMPLEMENT TOTAL
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
3028616201
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$165.30 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$294.00
|
| Rate for Payer: Aetna of WY Medicare |
$198.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$288.00
|
| Rate for Payer: Altius Commercial |
$288.00
|
| Rate for Payer: Beech Street Commercial |
$294.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$246.30
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$291.00
|
| Rate for Payer: Cigna of WY Commercial |
$294.00
|
| Rate for Payer: Entrust Commercial |
$285.00
|
| Rate for Payer: First Choice Health Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$174.00
|
| Rate for Payer: HealthUtah PPO |
$300.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$291.00
|
| Rate for Payer: Multiplan Medicare/VA |
$165.30
|
| Rate for Payer: One Health Plan of WY PPO |
$294.00
|
| Rate for Payer: PacificSource Commercial |
$270.00
|
| Rate for Payer: PHCS PPO |
$294.00
|
| Rate for Payer: Three Rivers PPO |
$225.00
|
| Rate for Payer: TriWest Veterans Administration |
$174.00
|
| Rate for Payer: United Healthcare Commercial |
$261.00
|
| Rate for Payer: United Healthcare Medicare |
$174.00
|
| Rate for Payer: WINHealth Partners Commercial |
$294.00
|
| Rate for Payer: Wise Provider Network Commercial |
$285.00
|
|
|
HC COMPLEMENT, TOTAL (CH50) - COMPLEMENT TOTAL
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS 86162
|
| Hospital Charge Code |
3028616201
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$188.10 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$294.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$288.00
|
| Rate for Payer: Altius Commercial |
$288.00
|
| Rate for Payer: Beech Street Commercial |
$294.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$246.30
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$291.00
|
| Rate for Payer: Cigna of WY Commercial |
$294.00
|
| Rate for Payer: Entrust Commercial |
$285.00
|
| Rate for Payer: First Choice Health Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$198.00
|
| Rate for Payer: HealthUtah PPO |
$300.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$291.00
|
| Rate for Payer: Multiplan Medicare/VA |
$188.10
|
| Rate for Payer: One Health Plan of WY PPO |
$294.00
|
| Rate for Payer: PacificSource Commercial |
$270.00
|
| Rate for Payer: PHCS PPO |
$294.00
|
| Rate for Payer: Three Rivers PPO |
$225.00
|
| Rate for Payer: TriWest Veterans Administration |
$198.00
|
| Rate for Payer: United Healthcare Commercial |
$261.00
|
| Rate for Payer: United Healthcare Medicare |
$198.00
|
| Rate for Payer: WINHealth Partners Commercial |
$285.00
|
| Rate for Payer: Wise Provider Network Commercial |
$285.00
|
|
|
HC COMPLETE CBC & AUTO DIFF WBC
|
Facility
|
IP
|
$85.00
|
|
|
Service Code
|
HCPCS 85025
|
| Hospital Charge Code |
3058502501
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$53.30 |
| Max. Negotiated Rate |
$85.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$83.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$81.60
|
| Rate for Payer: Altius Commercial |
$81.60
|
| Rate for Payer: Beech Street Commercial |
$83.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$69.78
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$82.45
|
| Rate for Payer: Cigna of WY Commercial |
$83.30
|
| Rate for Payer: Entrust Commercial |
$80.75
|
| Rate for Payer: First Choice Health Commercial |
$80.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$80.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$56.10
|
| Rate for Payer: HealthUtah PPO |
$85.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$82.45
|
| Rate for Payer: Multiplan Medicare/VA |
$53.30
|
| Rate for Payer: One Health Plan of WY PPO |
$83.30
|
| Rate for Payer: PacificSource Commercial |
$76.50
|
| Rate for Payer: PHCS PPO |
$83.30
|
| Rate for Payer: Three Rivers PPO |
$63.75
|
| Rate for Payer: TriWest Veterans Administration |
$56.10
|
| Rate for Payer: United Healthcare Commercial |
$73.95
|
| Rate for Payer: United Healthcare Medicare |
$56.10
|
| Rate for Payer: WINHealth Partners Commercial |
$80.75
|
| Rate for Payer: Wise Provider Network Commercial |
$80.75
|
|
|
HC COMPLETE CBC & AUTO DIFF WBC
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
HCPCS 85025
|
| Hospital Charge Code |
3058502501
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$46.84 |
| Max. Negotiated Rate |
$85.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$83.30
|
| Rate for Payer: Aetna of WY Medicare |
$56.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$81.60
|
| Rate for Payer: Altius Commercial |
$81.60
|
| Rate for Payer: Beech Street Commercial |
$83.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$69.78
|
| Rate for Payer: Cash Price |
$59.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$82.45
|
| Rate for Payer: Cigna of WY Commercial |
$83.30
|
| Rate for Payer: Entrust Commercial |
$80.75
|
| Rate for Payer: First Choice Health Commercial |
$80.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$80.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$49.30
|
| Rate for Payer: HealthUtah PPO |
$85.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$82.45
|
| Rate for Payer: Multiplan Medicare/VA |
$46.84
|
| Rate for Payer: One Health Plan of WY PPO |
$83.30
|
| Rate for Payer: PacificSource Commercial |
$76.50
|
| Rate for Payer: PHCS PPO |
$83.30
|
| Rate for Payer: Three Rivers PPO |
$63.75
|
| Rate for Payer: TriWest Veterans Administration |
$49.30
|
| Rate for Payer: United Healthcare Commercial |
$73.95
|
| Rate for Payer: United Healthcare Medicare |
$49.30
|
| Rate for Payer: WINHealth Partners Commercial |
$83.30
|
| Rate for Payer: Wise Provider Network Commercial |
$80.75
|
|
|
HC COMPLETE CBC - CBC
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS 85027
|
| Hospital Charge Code |
3058502701
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$63.36 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$112.70
|
| Rate for Payer: Aetna of WY Medicare |
$75.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$110.40
|
| Rate for Payer: Altius Commercial |
$110.40
|
| Rate for Payer: Beech Street Commercial |
$112.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$94.42
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$111.55
|
| Rate for Payer: Cigna of WY Commercial |
$112.70
|
| Rate for Payer: Entrust Commercial |
$109.25
|
| Rate for Payer: First Choice Health Commercial |
$109.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$109.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$66.70
|
| Rate for Payer: HealthUtah PPO |
$115.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$111.55
|
| Rate for Payer: Multiplan Medicare/VA |
$63.36
|
| Rate for Payer: One Health Plan of WY PPO |
$112.70
|
| Rate for Payer: PacificSource Commercial |
$103.50
|
| Rate for Payer: PHCS PPO |
$112.70
|
| Rate for Payer: Three Rivers PPO |
$86.25
|
| Rate for Payer: TriWest Veterans Administration |
$66.70
|
| Rate for Payer: United Healthcare Commercial |
$100.05
|
| Rate for Payer: United Healthcare Medicare |
$66.70
|
| Rate for Payer: WINHealth Partners Commercial |
$112.70
|
| Rate for Payer: Wise Provider Network Commercial |
$109.25
|
|
|
HC COMPLETE CBC - CBC
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS 85027
|
| Hospital Charge Code |
3058502701
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$72.10 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$112.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$110.40
|
| Rate for Payer: Altius Commercial |
$110.40
|
| Rate for Payer: Beech Street Commercial |
$112.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$94.42
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$111.55
|
| Rate for Payer: Cigna of WY Commercial |
$112.70
|
| Rate for Payer: Entrust Commercial |
$109.25
|
| Rate for Payer: First Choice Health Commercial |
$109.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$109.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$75.90
|
| Rate for Payer: HealthUtah PPO |
$115.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$111.55
|
| Rate for Payer: Multiplan Medicare/VA |
$72.10
|
| Rate for Payer: One Health Plan of WY PPO |
$112.70
|
| Rate for Payer: PacificSource Commercial |
$103.50
|
| Rate for Payer: PHCS PPO |
$112.70
|
| Rate for Payer: Three Rivers PPO |
$86.25
|
| Rate for Payer: TriWest Veterans Administration |
$75.90
|
| Rate for Payer: United Healthcare Commercial |
$100.05
|
| Rate for Payer: United Healthcare Medicare |
$75.90
|
| Rate for Payer: WINHealth Partners Commercial |
$109.25
|
| Rate for Payer: Wise Provider Network Commercial |
$109.25
|
|
|
HC COMPLETE CBC - POCT CBC
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
HCPCS 85027
|
| Hospital Charge Code |
3058502702
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$13.22 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.52
|
| Rate for Payer: Aetna of WY Medicare |
$15.84
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.04
|
| Rate for Payer: Altius Commercial |
$23.04
|
| Rate for Payer: Beech Street Commercial |
$23.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.70
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.28
|
| Rate for Payer: Cigna of WY Commercial |
$23.52
|
| Rate for Payer: Entrust Commercial |
$22.80
|
| Rate for Payer: First Choice Health Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$13.92
|
| Rate for Payer: HealthUtah PPO |
$24.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.28
|
| Rate for Payer: Multiplan Medicare/VA |
$13.22
|
| Rate for Payer: One Health Plan of WY PPO |
$23.52
|
| Rate for Payer: PacificSource Commercial |
$21.60
|
| Rate for Payer: PHCS PPO |
$23.52
|
| Rate for Payer: Three Rivers PPO |
$18.00
|
| Rate for Payer: TriWest Veterans Administration |
$13.92
|
| Rate for Payer: United Healthcare Commercial |
$20.88
|
| Rate for Payer: United Healthcare Medicare |
$13.92
|
| Rate for Payer: WINHealth Partners Commercial |
$23.52
|
| Rate for Payer: Wise Provider Network Commercial |
$22.80
|
|
|
HC COMPLETE CBC - POCT CBC
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
HCPCS 85027
|
| Hospital Charge Code |
3058502702
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$15.05 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$23.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$23.04
|
| Rate for Payer: Altius Commercial |
$23.04
|
| Rate for Payer: Beech Street Commercial |
$23.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$19.70
|
| Rate for Payer: Cash Price |
$16.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$23.28
|
| Rate for Payer: Cigna of WY Commercial |
$23.52
|
| Rate for Payer: Entrust Commercial |
$22.80
|
| Rate for Payer: First Choice Health Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$22.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$15.84
|
| Rate for Payer: HealthUtah PPO |
$24.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$23.28
|
| Rate for Payer: Multiplan Medicare/VA |
$15.05
|
| Rate for Payer: One Health Plan of WY PPO |
$23.52
|
| Rate for Payer: PacificSource Commercial |
$21.60
|
| Rate for Payer: PHCS PPO |
$23.52
|
| Rate for Payer: Three Rivers PPO |
$18.00
|
| Rate for Payer: TriWest Veterans Administration |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$20.88
|
| Rate for Payer: United Healthcare Medicare |
$15.84
|
| Rate for Payer: WINHealth Partners Commercial |
$22.80
|
| Rate for Payer: Wise Provider Network Commercial |
$22.80
|
|
|
HC COMPLEX DRAINAGE, WOUND
|
Facility
|
IP
|
$785.00
|
|
|
Service Code
|
HCPCS 10180
|
| Hospital Charge Code |
7611018001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$492.20 |
| Max. Negotiated Rate |
$785.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$769.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$753.60
|
| Rate for Payer: Altius Commercial |
$753.60
|
| Rate for Payer: Beech Street Commercial |
$769.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$644.48
|
| Rate for Payer: Cash Price |
$549.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$761.45
|
| Rate for Payer: Cigna of WY Commercial |
$769.30
|
| Rate for Payer: Entrust Commercial |
$745.75
|
| Rate for Payer: First Choice Health Commercial |
$745.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$745.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$518.10
|
| Rate for Payer: HealthUtah PPO |
$785.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$761.45
|
| Rate for Payer: Multiplan Medicare/VA |
$492.20
|
| Rate for Payer: One Health Plan of WY PPO |
$769.30
|
| Rate for Payer: PacificSource Commercial |
$706.50
|
| Rate for Payer: PHCS PPO |
$769.30
|
| Rate for Payer: Three Rivers PPO |
$588.75
|
| Rate for Payer: TriWest Veterans Administration |
$518.10
|
| Rate for Payer: United Healthcare Commercial |
$682.95
|
| Rate for Payer: United Healthcare Medicare |
$518.10
|
| Rate for Payer: WINHealth Partners Commercial |
$745.75
|
| Rate for Payer: Wise Provider Network Commercial |
$745.75
|
|
|
HC COMPLEX DRAINAGE, WOUND
|
Facility
|
OP
|
$785.00
|
|
|
Service Code
|
HCPCS 10180
|
| Hospital Charge Code |
7611018001
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$432.54 |
| Max. Negotiated Rate |
$785.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$769.30
|
| Rate for Payer: Aetna of WY Medicare |
$518.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$753.60
|
| Rate for Payer: Altius Commercial |
$753.60
|
| Rate for Payer: Beech Street Commercial |
$769.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$644.48
|
| Rate for Payer: Cash Price |
$549.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$761.45
|
| Rate for Payer: Cigna of WY Commercial |
$769.30
|
| Rate for Payer: Entrust Commercial |
$745.75
|
| Rate for Payer: First Choice Health Commercial |
$745.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$745.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$455.30
|
| Rate for Payer: HealthUtah PPO |
$785.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$761.45
|
| Rate for Payer: Multiplan Medicare/VA |
$432.54
|
| Rate for Payer: One Health Plan of WY PPO |
$769.30
|
| Rate for Payer: PacificSource Commercial |
$706.50
|
| Rate for Payer: PHCS PPO |
$769.30
|
| Rate for Payer: Three Rivers PPO |
$588.75
|
| Rate for Payer: TriWest Veterans Administration |
$455.30
|
| Rate for Payer: United Healthcare Commercial |
$682.95
|
| Rate for Payer: United Healthcare Medicare |
$455.30
|
| Rate for Payer: WINHealth Partners Commercial |
$769.30
|
| Rate for Payer: Wise Provider Network Commercial |
$745.75
|
|
|
HC COMPLEX UROFLOWMETRY
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
HCPCS 51741
|
| Hospital Charge Code |
5105174101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.90 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.56
|
| Rate for Payer: Altius Commercial |
$10.56
|
| Rate for Payer: Beech Street Commercial |
$10.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.03
|
| Rate for Payer: Cash Price |
$7.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.67
|
| Rate for Payer: Cigna of WY Commercial |
$10.78
|
| Rate for Payer: Entrust Commercial |
$10.45
|
| Rate for Payer: First Choice Health Commercial |
$10.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$7.26
|
| Rate for Payer: HealthUtah PPO |
$11.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.67
|
| Rate for Payer: Multiplan Medicare/VA |
$6.90
|
| Rate for Payer: One Health Plan of WY PPO |
$10.78
|
| Rate for Payer: PacificSource Commercial |
$9.90
|
| Rate for Payer: PHCS PPO |
$10.78
|
| Rate for Payer: Three Rivers PPO |
$8.25
|
| Rate for Payer: TriWest Veterans Administration |
$7.26
|
| Rate for Payer: United Healthcare Commercial |
$9.57
|
| Rate for Payer: United Healthcare Medicare |
$7.26
|
| Rate for Payer: WINHealth Partners Commercial |
$10.45
|
| Rate for Payer: Wise Provider Network Commercial |
$10.45
|
|
|
HC COMPLEX UROFLOWMETRY
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS 51741
|
| Hospital Charge Code |
5105174101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.06 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.78
|
| Rate for Payer: Aetna of WY Medicare |
$7.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.56
|
| Rate for Payer: Altius Commercial |
$10.56
|
| Rate for Payer: Beech Street Commercial |
$10.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.03
|
| Rate for Payer: Cash Price |
$7.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.67
|
| Rate for Payer: Cigna of WY Commercial |
$10.78
|
| Rate for Payer: Entrust Commercial |
$10.45
|
| Rate for Payer: First Choice Health Commercial |
$10.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.38
|
| Rate for Payer: HealthUtah PPO |
$11.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.67
|
| Rate for Payer: Multiplan Medicare/VA |
$6.06
|
| Rate for Payer: One Health Plan of WY PPO |
$10.78
|
| Rate for Payer: PacificSource Commercial |
$9.90
|
| Rate for Payer: PHCS PPO |
$10.78
|
| Rate for Payer: Three Rivers PPO |
$8.25
|
| Rate for Payer: TriWest Veterans Administration |
$6.38
|
| Rate for Payer: United Healthcare Commercial |
$9.57
|
| Rate for Payer: United Healthcare Medicare |
$6.38
|
| Rate for Payer: WINHealth Partners Commercial |
$10.78
|
| Rate for Payer: Wise Provider Network Commercial |
$10.45
|
|
|
HC COMPLEX UROFLOWMETRY
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
HCPCS 51741 26
|
| Hospital Charge Code |
5105174101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$6.06 |
| Max. Negotiated Rate |
$11.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$10.78
|
| Rate for Payer: Aetna of WY Medicare |
$7.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$10.56
|
| Rate for Payer: Altius Commercial |
$10.56
|
| Rate for Payer: Beech Street Commercial |
$10.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$9.03
|
| Rate for Payer: Cash Price |
$7.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$10.67
|
| Rate for Payer: Cigna of WY Commercial |
$10.78
|
| Rate for Payer: Entrust Commercial |
$10.45
|
| Rate for Payer: First Choice Health Commercial |
$10.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$10.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$6.38
|
| Rate for Payer: HealthUtah PPO |
$11.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$10.67
|
| Rate for Payer: Multiplan Medicare/VA |
$6.06
|
| Rate for Payer: One Health Plan of WY PPO |
$10.78
|
| Rate for Payer: PacificSource Commercial |
$9.90
|
| Rate for Payer: PHCS PPO |
$10.78
|
| Rate for Payer: Three Rivers PPO |
$8.25
|
| Rate for Payer: TriWest Veterans Administration |
$6.38
|
| Rate for Payer: United Healthcare Commercial |
$9.57
|
| Rate for Payer: United Healthcare Medicare |
$6.38
|
| Rate for Payer: WINHealth Partners Commercial |
$10.78
|
| Rate for Payer: Wise Provider Network Commercial |
$10.45
|
|
