|
HC CTRL NOSEBLEED,ANTER,SIMPLE
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
HCPCS 30901
|
| Hospital Charge Code |
7613090101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$294.23 |
| Max. Negotiated Rate |
$534.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$523.32
|
| Rate for Payer: Aetna of WY Medicare |
$352.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$512.64
|
| Rate for Payer: Altius Commercial |
$512.64
|
| Rate for Payer: Beech Street Commercial |
$523.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$438.41
|
| Rate for Payer: Cash Price |
$373.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$517.98
|
| Rate for Payer: Cigna of WY Commercial |
$523.32
|
| Rate for Payer: Entrust Commercial |
$507.30
|
| Rate for Payer: First Choice Health Commercial |
$507.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$507.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$309.72
|
| Rate for Payer: HealthUtah PPO |
$534.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$517.98
|
| Rate for Payer: Multiplan Medicare/VA |
$294.23
|
| Rate for Payer: One Health Plan of WY PPO |
$523.32
|
| Rate for Payer: PacificSource Commercial |
$480.60
|
| Rate for Payer: PHCS PPO |
$523.32
|
| Rate for Payer: Three Rivers PPO |
$400.50
|
| Rate for Payer: TriWest Veterans Administration |
$309.72
|
| Rate for Payer: United Healthcare Commercial |
$464.58
|
| Rate for Payer: United Healthcare Medicare |
$309.72
|
| Rate for Payer: WINHealth Partners Commercial |
$523.32
|
| Rate for Payer: Wise Provider Network Commercial |
$507.30
|
|
|
HC CTRL NOSEBLEED,POST,W/PACKS &/OR CAUT
|
Facility
|
OP
|
$534.00
|
|
|
Service Code
|
HCPCS 30905
|
| Hospital Charge Code |
7613090501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$294.23 |
| Max. Negotiated Rate |
$534.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$523.32
|
| Rate for Payer: Aetna of WY Medicare |
$352.44
|
| Rate for Payer: Altius Auto/Workers Compensation |
$512.64
|
| Rate for Payer: Altius Commercial |
$512.64
|
| Rate for Payer: Beech Street Commercial |
$523.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$438.41
|
| Rate for Payer: Cash Price |
$373.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$517.98
|
| Rate for Payer: Cigna of WY Commercial |
$523.32
|
| Rate for Payer: Entrust Commercial |
$507.30
|
| Rate for Payer: First Choice Health Commercial |
$507.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$507.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$309.72
|
| Rate for Payer: HealthUtah PPO |
$534.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$517.98
|
| Rate for Payer: Multiplan Medicare/VA |
$294.23
|
| Rate for Payer: One Health Plan of WY PPO |
$523.32
|
| Rate for Payer: PacificSource Commercial |
$480.60
|
| Rate for Payer: PHCS PPO |
$523.32
|
| Rate for Payer: Three Rivers PPO |
$400.50
|
| Rate for Payer: TriWest Veterans Administration |
$309.72
|
| Rate for Payer: United Healthcare Commercial |
$464.58
|
| Rate for Payer: United Healthcare Medicare |
$309.72
|
| Rate for Payer: WINHealth Partners Commercial |
$523.32
|
| Rate for Payer: Wise Provider Network Commercial |
$507.30
|
|
|
HC CTRL NOSEBLEED,POST,W/PACKS &/OR CAUT
|
Facility
|
IP
|
$534.00
|
|
|
Service Code
|
HCPCS 30905
|
| Hospital Charge Code |
7613090501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$334.82 |
| Max. Negotiated Rate |
$534.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$523.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$512.64
|
| Rate for Payer: Altius Commercial |
$512.64
|
| Rate for Payer: Beech Street Commercial |
$523.32
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$438.41
|
| Rate for Payer: Cash Price |
$373.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$517.98
|
| Rate for Payer: Cigna of WY Commercial |
$523.32
|
| Rate for Payer: Entrust Commercial |
$507.30
|
| Rate for Payer: First Choice Health Commercial |
$507.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$507.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$352.44
|
| Rate for Payer: HealthUtah PPO |
$534.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$517.98
|
| Rate for Payer: Multiplan Medicare/VA |
$334.82
|
| Rate for Payer: One Health Plan of WY PPO |
$523.32
|
| Rate for Payer: PacificSource Commercial |
$480.60
|
| Rate for Payer: PHCS PPO |
$523.32
|
| Rate for Payer: Three Rivers PPO |
$400.50
|
| Rate for Payer: TriWest Veterans Administration |
$352.44
|
| Rate for Payer: United Healthcare Commercial |
$464.58
|
| Rate for Payer: United Healthcare Medicare |
$352.44
|
| Rate for Payer: WINHealth Partners Commercial |
$507.30
|
| Rate for Payer: Wise Provider Network Commercial |
$507.30
|
|
|
HC CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST
|
Facility
|
IP
|
$243.00
|
|
|
Service Code
|
HCPCS 30905
|
| Hospital Charge Code |
5103090501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$152.36 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$238.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$233.28
|
| Rate for Payer: Altius Commercial |
$233.28
|
| Rate for Payer: Beech Street Commercial |
$238.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$199.50
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$235.71
|
| Rate for Payer: Cigna of WY Commercial |
$238.14
|
| Rate for Payer: Entrust Commercial |
$230.85
|
| Rate for Payer: First Choice Health Commercial |
$230.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$230.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$160.38
|
| Rate for Payer: HealthUtah PPO |
$243.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$235.71
|
| Rate for Payer: Multiplan Medicare/VA |
$152.36
|
| Rate for Payer: One Health Plan of WY PPO |
$238.14
|
| Rate for Payer: PacificSource Commercial |
$218.70
|
| Rate for Payer: PHCS PPO |
$238.14
|
| Rate for Payer: Three Rivers PPO |
$182.25
|
| Rate for Payer: TriWest Veterans Administration |
$160.38
|
| Rate for Payer: United Healthcare Commercial |
$211.41
|
| Rate for Payer: United Healthcare Medicare |
$160.38
|
| Rate for Payer: WINHealth Partners Commercial |
$230.85
|
| Rate for Payer: Wise Provider Network Commercial |
$230.85
|
|
|
HC CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST
|
Facility
|
IP
|
$253.00
|
|
|
Service Code
|
HCPCS 30905 50
|
| Hospital Charge Code |
5103090501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$158.63 |
| Max. Negotiated Rate |
$253.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$247.94
|
| Rate for Payer: Altius Auto/Workers Compensation |
$242.88
|
| Rate for Payer: Altius Commercial |
$242.88
|
| Rate for Payer: Beech Street Commercial |
$247.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$207.71
|
| Rate for Payer: Cash Price |
$177.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$245.41
|
| Rate for Payer: Cigna of WY Commercial |
$247.94
|
| Rate for Payer: Entrust Commercial |
$240.35
|
| Rate for Payer: First Choice Health Commercial |
$240.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$240.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$166.98
|
| Rate for Payer: HealthUtah PPO |
$253.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$245.41
|
| Rate for Payer: Multiplan Medicare/VA |
$158.63
|
| Rate for Payer: One Health Plan of WY PPO |
$247.94
|
| Rate for Payer: PacificSource Commercial |
$227.70
|
| Rate for Payer: PHCS PPO |
$247.94
|
| Rate for Payer: Three Rivers PPO |
$189.75
|
| Rate for Payer: TriWest Veterans Administration |
$166.98
|
| Rate for Payer: United Healthcare Commercial |
$220.11
|
| Rate for Payer: United Healthcare Medicare |
$166.98
|
| Rate for Payer: WINHealth Partners Commercial |
$240.35
|
| Rate for Payer: Wise Provider Network Commercial |
$240.35
|
|
|
HC CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST
|
Facility
|
OP
|
$253.00
|
|
|
Service Code
|
HCPCS 30905 50
|
| Hospital Charge Code |
5103090501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$139.40 |
| Max. Negotiated Rate |
$253.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$247.94
|
| Rate for Payer: Aetna of WY Medicare |
$166.98
|
| Rate for Payer: Altius Auto/Workers Compensation |
$242.88
|
| Rate for Payer: Altius Commercial |
$242.88
|
| Rate for Payer: Beech Street Commercial |
$247.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$207.71
|
| Rate for Payer: Cash Price |
$177.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$245.41
|
| Rate for Payer: Cigna of WY Commercial |
$247.94
|
| Rate for Payer: Entrust Commercial |
$240.35
|
| Rate for Payer: First Choice Health Commercial |
$240.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$240.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$146.74
|
| Rate for Payer: HealthUtah PPO |
$253.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$245.41
|
| Rate for Payer: Multiplan Medicare/VA |
$139.40
|
| Rate for Payer: One Health Plan of WY PPO |
$247.94
|
| Rate for Payer: PacificSource Commercial |
$227.70
|
| Rate for Payer: PHCS PPO |
$247.94
|
| Rate for Payer: Three Rivers PPO |
$189.75
|
| Rate for Payer: TriWest Veterans Administration |
$146.74
|
| Rate for Payer: United Healthcare Commercial |
$220.11
|
| Rate for Payer: United Healthcare Medicare |
$146.74
|
| Rate for Payer: WINHealth Partners Commercial |
$247.94
|
| Rate for Payer: Wise Provider Network Commercial |
$240.35
|
|
|
HC CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY 1ST
|
Facility
|
OP
|
$243.00
|
|
|
Service Code
|
HCPCS 30905
|
| Hospital Charge Code |
5103090501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$133.89 |
| Max. Negotiated Rate |
$243.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$238.14
|
| Rate for Payer: Aetna of WY Medicare |
$160.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$233.28
|
| Rate for Payer: Altius Commercial |
$233.28
|
| Rate for Payer: Beech Street Commercial |
$238.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$199.50
|
| Rate for Payer: Cash Price |
$170.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$235.71
|
| Rate for Payer: Cigna of WY Commercial |
$238.14
|
| Rate for Payer: Entrust Commercial |
$230.85
|
| Rate for Payer: First Choice Health Commercial |
$230.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$230.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$140.94
|
| Rate for Payer: HealthUtah PPO |
$243.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$235.71
|
| Rate for Payer: Multiplan Medicare/VA |
$133.89
|
| Rate for Payer: One Health Plan of WY PPO |
$238.14
|
| Rate for Payer: PacificSource Commercial |
$218.70
|
| Rate for Payer: PHCS PPO |
$238.14
|
| Rate for Payer: Three Rivers PPO |
$182.25
|
| Rate for Payer: TriWest Veterans Administration |
$140.94
|
| Rate for Payer: United Healthcare Commercial |
$211.41
|
| Rate for Payer: United Healthcare Medicare |
$140.94
|
| Rate for Payer: WINHealth Partners Commercial |
$238.14
|
| Rate for Payer: Wise Provider Network Commercial |
$230.85
|
|
|
HC CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ
|
Facility
|
IP
|
$522.00
|
|
|
Service Code
|
HCPCS 30906 50
|
| Hospital Charge Code |
5103090601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$327.29 |
| Max. Negotiated Rate |
$522.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$511.56
|
| Rate for Payer: Altius Auto/Workers Compensation |
$501.12
|
| Rate for Payer: Altius Commercial |
$501.12
|
| Rate for Payer: Beech Street Commercial |
$511.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$428.56
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$506.34
|
| Rate for Payer: Cigna of WY Commercial |
$511.56
|
| Rate for Payer: Entrust Commercial |
$495.90
|
| Rate for Payer: First Choice Health Commercial |
$495.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$495.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$344.52
|
| Rate for Payer: HealthUtah PPO |
$522.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$506.34
|
| Rate for Payer: Multiplan Medicare/VA |
$327.29
|
| Rate for Payer: One Health Plan of WY PPO |
$511.56
|
| Rate for Payer: PacificSource Commercial |
$469.80
|
| Rate for Payer: PHCS PPO |
$511.56
|
| Rate for Payer: Three Rivers PPO |
$391.50
|
| Rate for Payer: TriWest Veterans Administration |
$344.52
|
| Rate for Payer: United Healthcare Commercial |
$454.14
|
| Rate for Payer: United Healthcare Medicare |
$344.52
|
| Rate for Payer: WINHealth Partners Commercial |
$495.90
|
| Rate for Payer: Wise Provider Network Commercial |
$495.90
|
|
|
HC CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ
|
Facility
|
OP
|
$522.00
|
|
|
Service Code
|
HCPCS 30906 50
|
| Hospital Charge Code |
5103090601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$287.62 |
| Max. Negotiated Rate |
$522.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$511.56
|
| Rate for Payer: Aetna of WY Medicare |
$344.52
|
| Rate for Payer: Altius Auto/Workers Compensation |
$501.12
|
| Rate for Payer: Altius Commercial |
$501.12
|
| Rate for Payer: Beech Street Commercial |
$511.56
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$428.56
|
| Rate for Payer: Cash Price |
$365.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$506.34
|
| Rate for Payer: Cigna of WY Commercial |
$511.56
|
| Rate for Payer: Entrust Commercial |
$495.90
|
| Rate for Payer: First Choice Health Commercial |
$495.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$495.90
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$302.76
|
| Rate for Payer: HealthUtah PPO |
$522.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$506.34
|
| Rate for Payer: Multiplan Medicare/VA |
$287.62
|
| Rate for Payer: One Health Plan of WY PPO |
$511.56
|
| Rate for Payer: PacificSource Commercial |
$469.80
|
| Rate for Payer: PHCS PPO |
$511.56
|
| Rate for Payer: Three Rivers PPO |
$391.50
|
| Rate for Payer: TriWest Veterans Administration |
$302.76
|
| Rate for Payer: United Healthcare Commercial |
$454.14
|
| Rate for Payer: United Healthcare Medicare |
$302.76
|
| Rate for Payer: WINHealth Partners Commercial |
$511.56
|
| Rate for Payer: Wise Provider Network Commercial |
$495.90
|
|
|
HC CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ
|
Facility
|
OP
|
$261.00
|
|
|
Service Code
|
HCPCS 30906
|
| Hospital Charge Code |
5103090601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$143.81 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$255.78
|
| Rate for Payer: Aetna of WY Medicare |
$172.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$250.56
|
| Rate for Payer: Altius Commercial |
$250.56
|
| Rate for Payer: Beech Street Commercial |
$255.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$214.28
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$253.17
|
| Rate for Payer: Cigna of WY Commercial |
$255.78
|
| Rate for Payer: Entrust Commercial |
$247.95
|
| Rate for Payer: First Choice Health Commercial |
$247.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$247.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$151.38
|
| Rate for Payer: HealthUtah PPO |
$261.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$253.17
|
| Rate for Payer: Multiplan Medicare/VA |
$143.81
|
| Rate for Payer: One Health Plan of WY PPO |
$255.78
|
| Rate for Payer: PacificSource Commercial |
$234.90
|
| Rate for Payer: PHCS PPO |
$255.78
|
| Rate for Payer: Three Rivers PPO |
$195.75
|
| Rate for Payer: TriWest Veterans Administration |
$151.38
|
| Rate for Payer: United Healthcare Commercial |
$227.07
|
| Rate for Payer: United Healthcare Medicare |
$151.38
|
| Rate for Payer: WINHealth Partners Commercial |
$255.78
|
| Rate for Payer: Wise Provider Network Commercial |
$247.95
|
|
|
HC CTRL NSL HEMRRG PST NASAL PACKS&/CAUTERY SUBSQ
|
Facility
|
IP
|
$261.00
|
|
|
Service Code
|
HCPCS 30906
|
| Hospital Charge Code |
5103090601
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$163.65 |
| Max. Negotiated Rate |
$261.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$255.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$250.56
|
| Rate for Payer: Altius Commercial |
$250.56
|
| Rate for Payer: Beech Street Commercial |
$255.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$214.28
|
| Rate for Payer: Cash Price |
$182.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$253.17
|
| Rate for Payer: Cigna of WY Commercial |
$255.78
|
| Rate for Payer: Entrust Commercial |
$247.95
|
| Rate for Payer: First Choice Health Commercial |
$247.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$247.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$172.26
|
| Rate for Payer: HealthUtah PPO |
$261.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$253.17
|
| Rate for Payer: Multiplan Medicare/VA |
$163.65
|
| Rate for Payer: One Health Plan of WY PPO |
$255.78
|
| Rate for Payer: PacificSource Commercial |
$234.90
|
| Rate for Payer: PHCS PPO |
$255.78
|
| Rate for Payer: Three Rivers PPO |
$195.75
|
| Rate for Payer: TriWest Veterans Administration |
$172.26
|
| Rate for Payer: United Healthcare Commercial |
$227.07
|
| Rate for Payer: United Healthcare Medicare |
$172.26
|
| Rate for Payer: WINHealth Partners Commercial |
$247.95
|
| Rate for Payer: Wise Provider Network Commercial |
$247.95
|
|
|
HC CTR MOTR EP STD TRANSCRNL MOTR STIM UPR&LOW LI
|
Facility
|
OP
|
$1,280.00
|
|
|
Service Code
|
HCPCS 95939
|
| Hospital Charge Code |
9229593901
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$705.28 |
| Max. Negotiated Rate |
$1,280.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,254.40
|
| Rate for Payer: Aetna of WY Medicare |
$844.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,228.80
|
| Rate for Payer: Altius Commercial |
$1,228.80
|
| Rate for Payer: Beech Street Commercial |
$1,254.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,050.88
|
| Rate for Payer: Cash Price |
$896.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,241.60
|
| Rate for Payer: Cigna of WY Commercial |
$1,254.40
|
| Rate for Payer: Entrust Commercial |
$1,216.00
|
| Rate for Payer: First Choice Health Commercial |
$1,216.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,216.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$742.40
|
| Rate for Payer: HealthUtah PPO |
$1,280.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,241.60
|
| Rate for Payer: Multiplan Medicare/VA |
$705.28
|
| Rate for Payer: One Health Plan of WY PPO |
$1,254.40
|
| Rate for Payer: PacificSource Commercial |
$1,152.00
|
| Rate for Payer: PHCS PPO |
$1,254.40
|
| Rate for Payer: Three Rivers PPO |
$960.00
|
| Rate for Payer: TriWest Veterans Administration |
$742.40
|
| Rate for Payer: United Healthcare Commercial |
$1,113.60
|
| Rate for Payer: United Healthcare Medicare |
$742.40
|
| Rate for Payer: WINHealth Partners Commercial |
$1,254.40
|
| Rate for Payer: Wise Provider Network Commercial |
$1,216.00
|
|
|
HC CTR MOTR EP STD TRANSCRNL MOTR STIM UPR&LOW LI
|
Facility
|
IP
|
$1,280.00
|
|
|
Service Code
|
HCPCS 95939
|
| Hospital Charge Code |
9229593901
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$802.56 |
| Max. Negotiated Rate |
$1,280.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,254.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,228.80
|
| Rate for Payer: Altius Commercial |
$1,228.80
|
| Rate for Payer: Beech Street Commercial |
$1,254.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,050.88
|
| Rate for Payer: Cash Price |
$896.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,241.60
|
| Rate for Payer: Cigna of WY Commercial |
$1,254.40
|
| Rate for Payer: Entrust Commercial |
$1,216.00
|
| Rate for Payer: First Choice Health Commercial |
$1,216.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,216.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$844.80
|
| Rate for Payer: HealthUtah PPO |
$1,280.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,241.60
|
| Rate for Payer: Multiplan Medicare/VA |
$802.56
|
| Rate for Payer: One Health Plan of WY PPO |
$1,254.40
|
| Rate for Payer: PacificSource Commercial |
$1,152.00
|
| Rate for Payer: PHCS PPO |
$1,254.40
|
| Rate for Payer: Three Rivers PPO |
$960.00
|
| Rate for Payer: TriWest Veterans Administration |
$844.80
|
| Rate for Payer: United Healthcare Commercial |
$1,113.60
|
| Rate for Payer: United Healthcare Medicare |
$844.80
|
| Rate for Payer: WINHealth Partners Commercial |
$1,216.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,216.00
|
|
|
HC CT SCAN,CERVICAL SPINE,W/O CONTRAST - CT CERVICAL SPINE WO CONTRAST
|
Facility
|
OP
|
$2,575.00
|
|
|
Service Code
|
HCPCS 72125
|
| Hospital Charge Code |
3527212501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,418.82 |
| Max. Negotiated Rate |
$2,575.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,523.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,699.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,472.00
|
| Rate for Payer: Altius Commercial |
$2,472.00
|
| Rate for Payer: Beech Street Commercial |
$2,523.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,114.08
|
| Rate for Payer: Cash Price |
$1,802.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,497.75
|
| Rate for Payer: Cigna of WY Commercial |
$2,523.50
|
| Rate for Payer: Entrust Commercial |
$2,446.25
|
| Rate for Payer: First Choice Health Commercial |
$2,446.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,446.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,493.50
|
| Rate for Payer: HealthUtah PPO |
$2,575.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,497.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1,418.82
|
| Rate for Payer: One Health Plan of WY PPO |
$2,523.50
|
| Rate for Payer: PacificSource Commercial |
$2,317.50
|
| Rate for Payer: PHCS PPO |
$2,523.50
|
| Rate for Payer: Three Rivers PPO |
$1,931.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,493.50
|
| Rate for Payer: United Healthcare Commercial |
$2,240.25
|
| Rate for Payer: United Healthcare Medicare |
$1,493.50
|
| Rate for Payer: WINHealth Partners Commercial |
$2,523.50
|
| Rate for Payer: Wise Provider Network Commercial |
$2,446.25
|
|
|
HC CT SCAN,CERVICAL SPINE,W/O CONTRAST - CT CERVICAL SPINE WO CONTRAST
|
Facility
|
IP
|
$2,575.00
|
|
|
Service Code
|
HCPCS 72125
|
| Hospital Charge Code |
3527212501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,614.52 |
| Max. Negotiated Rate |
$2,575.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,523.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,472.00
|
| Rate for Payer: Altius Commercial |
$2,472.00
|
| Rate for Payer: Beech Street Commercial |
$2,523.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,114.08
|
| Rate for Payer: Cash Price |
$1,802.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,497.75
|
| Rate for Payer: Cigna of WY Commercial |
$2,523.50
|
| Rate for Payer: Entrust Commercial |
$2,446.25
|
| Rate for Payer: First Choice Health Commercial |
$2,446.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,446.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,699.50
|
| Rate for Payer: HealthUtah PPO |
$2,575.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,497.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1,614.52
|
| Rate for Payer: One Health Plan of WY PPO |
$2,523.50
|
| Rate for Payer: PacificSource Commercial |
$2,317.50
|
| Rate for Payer: PHCS PPO |
$2,523.50
|
| Rate for Payer: Three Rivers PPO |
$1,931.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,699.50
|
| Rate for Payer: United Healthcare Commercial |
$2,240.25
|
| Rate for Payer: United Healthcare Medicare |
$1,699.50
|
| Rate for Payer: WINHealth Partners Commercial |
$2,446.25
|
| Rate for Payer: Wise Provider Network Commercial |
$2,446.25
|
|
|
HC CT SCAN CERV SP COMBO - CT CERVICAL SPINE W WO CONTRAST
|
Facility
|
IP
|
$1,865.00
|
|
|
Service Code
|
HCPCS 72127
|
| Hospital Charge Code |
3527212701
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,169.36 |
| Max. Negotiated Rate |
$1,865.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,827.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,790.40
|
| Rate for Payer: Altius Commercial |
$1,790.40
|
| Rate for Payer: Beech Street Commercial |
$1,827.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,531.16
|
| Rate for Payer: Cash Price |
$1,305.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,809.05
|
| Rate for Payer: Cigna of WY Commercial |
$1,827.70
|
| Rate for Payer: Entrust Commercial |
$1,771.75
|
| Rate for Payer: First Choice Health Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,230.90
|
| Rate for Payer: HealthUtah PPO |
$1,865.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,809.05
|
| Rate for Payer: Multiplan Medicare/VA |
$1,169.36
|
| Rate for Payer: One Health Plan of WY PPO |
$1,827.70
|
| Rate for Payer: PacificSource Commercial |
$1,678.50
|
| Rate for Payer: PHCS PPO |
$1,827.70
|
| Rate for Payer: Three Rivers PPO |
$1,398.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,230.90
|
| Rate for Payer: United Healthcare Commercial |
$1,622.55
|
| Rate for Payer: United Healthcare Medicare |
$1,230.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,771.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1,771.75
|
|
|
HC CT SCAN CERV SP COMBO - CT CERVICAL SPINE W WO CONTRAST
|
Facility
|
OP
|
$1,865.00
|
|
|
Service Code
|
HCPCS 72127
|
| Hospital Charge Code |
3527212701
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,027.62 |
| Max. Negotiated Rate |
$1,865.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,827.70
|
| Rate for Payer: Aetna of WY Medicare |
$1,230.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,790.40
|
| Rate for Payer: Altius Commercial |
$1,790.40
|
| Rate for Payer: Beech Street Commercial |
$1,827.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,531.16
|
| Rate for Payer: Cash Price |
$1,305.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,809.05
|
| Rate for Payer: Cigna of WY Commercial |
$1,827.70
|
| Rate for Payer: Entrust Commercial |
$1,771.75
|
| Rate for Payer: First Choice Health Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,081.70
|
| Rate for Payer: HealthUtah PPO |
$1,865.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,809.05
|
| Rate for Payer: Multiplan Medicare/VA |
$1,027.62
|
| Rate for Payer: One Health Plan of WY PPO |
$1,827.70
|
| Rate for Payer: PacificSource Commercial |
$1,678.50
|
| Rate for Payer: PHCS PPO |
$1,827.70
|
| Rate for Payer: Three Rivers PPO |
$1,398.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,081.70
|
| Rate for Payer: United Healthcare Commercial |
$1,622.55
|
| Rate for Payer: United Healthcare Medicare |
$1,081.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,827.70
|
| Rate for Payer: Wise Provider Network Commercial |
$1,771.75
|
|
|
HC CT SCAN CERV SPINE CONTRAST - CT CERVICAL SPINE W CONTRAST
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 72126
|
| Hospital Charge Code |
3527212601
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,128.60 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,764.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,728.00
|
| Rate for Payer: Altius Commercial |
$1,728.00
|
| Rate for Payer: Beech Street Commercial |
$1,764.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,477.80
|
| Rate for Payer: Cash Price |
$1,260.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,746.00
|
| Rate for Payer: Cigna of WY Commercial |
$1,764.00
|
| Rate for Payer: Entrust Commercial |
$1,710.00
|
| Rate for Payer: First Choice Health Commercial |
$1,710.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,710.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,188.00
|
| Rate for Payer: HealthUtah PPO |
$1,800.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,746.00
|
| Rate for Payer: Multiplan Medicare/VA |
$1,128.60
|
| Rate for Payer: One Health Plan of WY PPO |
$1,764.00
|
| Rate for Payer: PacificSource Commercial |
$1,620.00
|
| Rate for Payer: PHCS PPO |
$1,764.00
|
| Rate for Payer: Three Rivers PPO |
$1,350.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,188.00
|
| Rate for Payer: United Healthcare Commercial |
$1,566.00
|
| Rate for Payer: United Healthcare Medicare |
$1,188.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,710.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,710.00
|
|
|
HC CT SCAN CERV SPINE CONTRAST - CT CERVICAL SPINE W CONTRAST
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS 72126
|
| Hospital Charge Code |
3527212601
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$991.80 |
| Max. Negotiated Rate |
$1,800.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,764.00
|
| Rate for Payer: Aetna of WY Medicare |
$1,188.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,728.00
|
| Rate for Payer: Altius Commercial |
$1,728.00
|
| Rate for Payer: Beech Street Commercial |
$1,764.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,477.80
|
| Rate for Payer: Cash Price |
$1,260.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,746.00
|
| Rate for Payer: Cigna of WY Commercial |
$1,764.00
|
| Rate for Payer: Entrust Commercial |
$1,710.00
|
| Rate for Payer: First Choice Health Commercial |
$1,710.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,710.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,044.00
|
| Rate for Payer: HealthUtah PPO |
$1,800.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,746.00
|
| Rate for Payer: Multiplan Medicare/VA |
$991.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1,764.00
|
| Rate for Payer: PacificSource Commercial |
$1,620.00
|
| Rate for Payer: PHCS PPO |
$1,764.00
|
| Rate for Payer: Three Rivers PPO |
$1,350.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,044.00
|
| Rate for Payer: United Healthcare Commercial |
$1,566.00
|
| Rate for Payer: United Healthcare Medicare |
$1,044.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,764.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,710.00
|
|
|
HC CT SCAN DORSAL SP COMBO - CT THORACIC SPINE W WO CONTRAST
|
Facility
|
IP
|
$1,865.00
|
|
|
Service Code
|
HCPCS 72130
|
| Hospital Charge Code |
3527213001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,169.36 |
| Max. Negotiated Rate |
$1,865.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,827.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,790.40
|
| Rate for Payer: Altius Commercial |
$1,790.40
|
| Rate for Payer: Beech Street Commercial |
$1,827.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,531.16
|
| Rate for Payer: Cash Price |
$1,305.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,809.05
|
| Rate for Payer: Cigna of WY Commercial |
$1,827.70
|
| Rate for Payer: Entrust Commercial |
$1,771.75
|
| Rate for Payer: First Choice Health Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,230.90
|
| Rate for Payer: HealthUtah PPO |
$1,865.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,809.05
|
| Rate for Payer: Multiplan Medicare/VA |
$1,169.36
|
| Rate for Payer: One Health Plan of WY PPO |
$1,827.70
|
| Rate for Payer: PacificSource Commercial |
$1,678.50
|
| Rate for Payer: PHCS PPO |
$1,827.70
|
| Rate for Payer: Three Rivers PPO |
$1,398.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,230.90
|
| Rate for Payer: United Healthcare Commercial |
$1,622.55
|
| Rate for Payer: United Healthcare Medicare |
$1,230.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,771.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1,771.75
|
|
|
HC CT SCAN DORSAL SP COMBO - CT THORACIC SPINE W WO CONTRAST
|
Facility
|
OP
|
$1,865.00
|
|
|
Service Code
|
HCPCS 72130
|
| Hospital Charge Code |
3527213001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,027.62 |
| Max. Negotiated Rate |
$1,865.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,827.70
|
| Rate for Payer: Aetna of WY Medicare |
$1,230.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,790.40
|
| Rate for Payer: Altius Commercial |
$1,790.40
|
| Rate for Payer: Beech Street Commercial |
$1,827.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,531.16
|
| Rate for Payer: Cash Price |
$1,305.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,809.05
|
| Rate for Payer: Cigna of WY Commercial |
$1,827.70
|
| Rate for Payer: Entrust Commercial |
$1,771.75
|
| Rate for Payer: First Choice Health Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,081.70
|
| Rate for Payer: HealthUtah PPO |
$1,865.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,809.05
|
| Rate for Payer: Multiplan Medicare/VA |
$1,027.62
|
| Rate for Payer: One Health Plan of WY PPO |
$1,827.70
|
| Rate for Payer: PacificSource Commercial |
$1,678.50
|
| Rate for Payer: PHCS PPO |
$1,827.70
|
| Rate for Payer: Three Rivers PPO |
$1,398.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,081.70
|
| Rate for Payer: United Healthcare Commercial |
$1,622.55
|
| Rate for Payer: United Healthcare Medicare |
$1,081.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,827.70
|
| Rate for Payer: Wise Provider Network Commercial |
$1,771.75
|
|
|
HC CT SCAN DORSAL SP CONTRAST - CT THORACIC SPINE W CONTRAST
|
Facility
|
IP
|
$1,865.00
|
|
|
Service Code
|
HCPCS 72129
|
| Hospital Charge Code |
3527212901
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,169.36 |
| Max. Negotiated Rate |
$1,865.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,827.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,790.40
|
| Rate for Payer: Altius Commercial |
$1,790.40
|
| Rate for Payer: Beech Street Commercial |
$1,827.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,531.16
|
| Rate for Payer: Cash Price |
$1,305.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,809.05
|
| Rate for Payer: Cigna of WY Commercial |
$1,827.70
|
| Rate for Payer: Entrust Commercial |
$1,771.75
|
| Rate for Payer: First Choice Health Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,230.90
|
| Rate for Payer: HealthUtah PPO |
$1,865.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,809.05
|
| Rate for Payer: Multiplan Medicare/VA |
$1,169.36
|
| Rate for Payer: One Health Plan of WY PPO |
$1,827.70
|
| Rate for Payer: PacificSource Commercial |
$1,678.50
|
| Rate for Payer: PHCS PPO |
$1,827.70
|
| Rate for Payer: Three Rivers PPO |
$1,398.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,230.90
|
| Rate for Payer: United Healthcare Commercial |
$1,622.55
|
| Rate for Payer: United Healthcare Medicare |
$1,230.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,771.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1,771.75
|
|
|
HC CT SCAN DORSAL SP CONTRAST - CT THORACIC SPINE W CONTRAST
|
Facility
|
OP
|
$1,865.00
|
|
|
Service Code
|
HCPCS 72129
|
| Hospital Charge Code |
3527212901
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,027.62 |
| Max. Negotiated Rate |
$1,865.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,827.70
|
| Rate for Payer: Aetna of WY Medicare |
$1,230.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,790.40
|
| Rate for Payer: Altius Commercial |
$1,790.40
|
| Rate for Payer: Beech Street Commercial |
$1,827.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,531.16
|
| Rate for Payer: Cash Price |
$1,305.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,809.05
|
| Rate for Payer: Cigna of WY Commercial |
$1,827.70
|
| Rate for Payer: Entrust Commercial |
$1,771.75
|
| Rate for Payer: First Choice Health Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,771.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,081.70
|
| Rate for Payer: HealthUtah PPO |
$1,865.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,809.05
|
| Rate for Payer: Multiplan Medicare/VA |
$1,027.62
|
| Rate for Payer: One Health Plan of WY PPO |
$1,827.70
|
| Rate for Payer: PacificSource Commercial |
$1,678.50
|
| Rate for Payer: PHCS PPO |
$1,827.70
|
| Rate for Payer: Three Rivers PPO |
$1,398.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,081.70
|
| Rate for Payer: United Healthcare Commercial |
$1,622.55
|
| Rate for Payer: United Healthcare Medicare |
$1,081.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,827.70
|
| Rate for Payer: Wise Provider Network Commercial |
$1,771.75
|
|
|
HC CT SCAN, FACE/JAW CONTRAST - CT SINUS FACIAL BONES W CONTRAST
|
Facility
|
OP
|
$1,740.00
|
|
|
Service Code
|
HCPCS 70487
|
| Hospital Charge Code |
3517048702
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$958.74 |
| Max. Negotiated Rate |
$1,740.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,705.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,148.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,670.40
|
| Rate for Payer: Altius Commercial |
$1,670.40
|
| Rate for Payer: Beech Street Commercial |
$1,705.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,428.54
|
| Rate for Payer: Cash Price |
$1,218.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,687.80
|
| Rate for Payer: Cigna of WY Commercial |
$1,705.20
|
| Rate for Payer: Entrust Commercial |
$1,653.00
|
| Rate for Payer: First Choice Health Commercial |
$1,653.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,653.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,009.20
|
| Rate for Payer: HealthUtah PPO |
$1,740.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,687.80
|
| Rate for Payer: Multiplan Medicare/VA |
$958.74
|
| Rate for Payer: One Health Plan of WY PPO |
$1,705.20
|
| Rate for Payer: PacificSource Commercial |
$1,566.00
|
| Rate for Payer: PHCS PPO |
$1,705.20
|
| Rate for Payer: Three Rivers PPO |
$1,305.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,009.20
|
| Rate for Payer: United Healthcare Commercial |
$1,513.80
|
| Rate for Payer: United Healthcare Medicare |
$1,009.20
|
| Rate for Payer: WINHealth Partners Commercial |
$1,705.20
|
| Rate for Payer: Wise Provider Network Commercial |
$1,653.00
|
|
|
HC CT SCAN, FACE/JAW CONTRAST - CT SINUS FACIAL BONES W CONTRAST
|
Facility
|
IP
|
$1,740.00
|
|
|
Service Code
|
HCPCS 70487
|
| Hospital Charge Code |
3517048702
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,090.98 |
| Max. Negotiated Rate |
$1,740.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,705.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,670.40
|
| Rate for Payer: Altius Commercial |
$1,670.40
|
| Rate for Payer: Beech Street Commercial |
$1,705.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,428.54
|
| Rate for Payer: Cash Price |
$1,218.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,687.80
|
| Rate for Payer: Cigna of WY Commercial |
$1,705.20
|
| Rate for Payer: Entrust Commercial |
$1,653.00
|
| Rate for Payer: First Choice Health Commercial |
$1,653.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,653.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,148.40
|
| Rate for Payer: HealthUtah PPO |
$1,740.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,687.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1,090.98
|
| Rate for Payer: One Health Plan of WY PPO |
$1,705.20
|
| Rate for Payer: PacificSource Commercial |
$1,566.00
|
| Rate for Payer: PHCS PPO |
$1,705.20
|
| Rate for Payer: Three Rivers PPO |
$1,305.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,148.40
|
| Rate for Payer: United Healthcare Commercial |
$1,513.80
|
| Rate for Payer: United Healthcare Medicare |
$1,148.40
|
| Rate for Payer: WINHealth Partners Commercial |
$1,653.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,653.00
|
|
