|
HC CT SCAN OF PELVIS COMBO - CT PELVIS W WO CONTRAST
|
Facility
|
OP
|
$1,865.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
3527219401
|
|
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 OF PELVIS COMBO - CT PELVIS W WO CONTRAST
|
Facility
|
IP
|
$1,865.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
3527219401
|
|
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 OF PELVIS CONTRAST - CT PELVIS W CONTRAST
|
Facility
|
IP
|
$2,150.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
3527219301
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,348.05 |
| Max. Negotiated Rate |
$2,150.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,107.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,064.00
|
| Rate for Payer: Altius Commercial |
$2,064.00
|
| Rate for Payer: Beech Street Commercial |
$2,107.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,765.15
|
| Rate for Payer: Cash Price |
$1,505.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,085.50
|
| Rate for Payer: Cigna of WY Commercial |
$2,107.00
|
| Rate for Payer: Entrust Commercial |
$2,042.50
|
| Rate for Payer: First Choice Health Commercial |
$2,042.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,042.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,419.00
|
| Rate for Payer: HealthUtah PPO |
$2,150.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,085.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,348.05
|
| Rate for Payer: One Health Plan of WY PPO |
$2,107.00
|
| Rate for Payer: PacificSource Commercial |
$1,935.00
|
| Rate for Payer: PHCS PPO |
$2,107.00
|
| Rate for Payer: Three Rivers PPO |
$1,612.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,419.00
|
| Rate for Payer: United Healthcare Commercial |
$1,870.50
|
| Rate for Payer: United Healthcare Medicare |
$1,419.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,042.50
|
| Rate for Payer: Wise Provider Network Commercial |
$2,042.50
|
|
|
HC CT SCAN OF PELVIS CONTRAST - CT PELVIS W CONTRAST
|
Facility
|
OP
|
$2,150.00
|
|
|
Service Code
|
HCPCS 72193
|
| Hospital Charge Code |
3527219301
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,184.65 |
| Max. Negotiated Rate |
$2,150.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,107.00
|
| Rate for Payer: Aetna of WY Medicare |
$1,419.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,064.00
|
| Rate for Payer: Altius Commercial |
$2,064.00
|
| Rate for Payer: Beech Street Commercial |
$2,107.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,765.15
|
| Rate for Payer: Cash Price |
$1,505.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,085.50
|
| Rate for Payer: Cigna of WY Commercial |
$2,107.00
|
| Rate for Payer: Entrust Commercial |
$2,042.50
|
| Rate for Payer: First Choice Health Commercial |
$2,042.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,042.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,247.00
|
| Rate for Payer: HealthUtah PPO |
$2,150.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,085.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,184.65
|
| Rate for Payer: One Health Plan of WY PPO |
$2,107.00
|
| Rate for Payer: PacificSource Commercial |
$1,935.00
|
| Rate for Payer: PHCS PPO |
$2,107.00
|
| Rate for Payer: Three Rivers PPO |
$1,612.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,247.00
|
| Rate for Payer: United Healthcare Commercial |
$1,870.50
|
| Rate for Payer: United Healthcare Medicare |
$1,247.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,107.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,042.50
|
|
|
HC CT SCAN,ORBIT/SELLA/POST FOSSA/EAR,W/O - CT ORBITS/SELLA WO IV CONT
|
Facility
|
IP
|
$1,215.00
|
|
|
Service Code
|
HCPCS 70480
|
| Hospital Charge Code |
3517048001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$761.80 |
| Max. Negotiated Rate |
$1,215.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,190.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,166.40
|
| Rate for Payer: Altius Commercial |
$1,166.40
|
| Rate for Payer: Beech Street Commercial |
$1,190.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$997.52
|
| Rate for Payer: Cash Price |
$850.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,178.55
|
| Rate for Payer: Cigna of WY Commercial |
$1,190.70
|
| Rate for Payer: Entrust Commercial |
$1,154.25
|
| Rate for Payer: First Choice Health Commercial |
$1,154.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,154.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$801.90
|
| Rate for Payer: HealthUtah PPO |
$1,215.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,178.55
|
| Rate for Payer: Multiplan Medicare/VA |
$761.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1,190.70
|
| Rate for Payer: PacificSource Commercial |
$1,093.50
|
| Rate for Payer: PHCS PPO |
$1,190.70
|
| Rate for Payer: Three Rivers PPO |
$911.25
|
| Rate for Payer: TriWest Veterans Administration |
$801.90
|
| Rate for Payer: United Healthcare Commercial |
$1,057.05
|
| Rate for Payer: United Healthcare Medicare |
$801.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,154.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,154.25
|
|
|
HC CT SCAN,ORBIT/SELLA/POST FOSSA/EAR,W/O - CT ORBITS/SELLA WO IV CONT
|
Facility
|
OP
|
$1,215.00
|
|
|
Service Code
|
HCPCS 70480
|
| Hospital Charge Code |
3517048001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$669.46 |
| Max. Negotiated Rate |
$1,215.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,190.70
|
| Rate for Payer: Aetna of WY Medicare |
$801.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,166.40
|
| Rate for Payer: Altius Commercial |
$1,166.40
|
| Rate for Payer: Beech Street Commercial |
$1,190.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$997.52
|
| Rate for Payer: Cash Price |
$850.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,178.55
|
| Rate for Payer: Cigna of WY Commercial |
$1,190.70
|
| Rate for Payer: Entrust Commercial |
$1,154.25
|
| Rate for Payer: First Choice Health Commercial |
$1,154.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,154.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$704.70
|
| Rate for Payer: HealthUtah PPO |
$1,215.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,178.55
|
| Rate for Payer: Multiplan Medicare/VA |
$669.46
|
| Rate for Payer: One Health Plan of WY PPO |
$1,190.70
|
| Rate for Payer: PacificSource Commercial |
$1,093.50
|
| Rate for Payer: PHCS PPO |
$1,190.70
|
| Rate for Payer: Three Rivers PPO |
$911.25
|
| Rate for Payer: TriWest Veterans Administration |
$704.70
|
| Rate for Payer: United Healthcare Commercial |
$1,057.05
|
| Rate for Payer: United Healthcare Medicare |
$704.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,190.70
|
| Rate for Payer: Wise Provider Network Commercial |
$1,154.25
|
|
|
HC CT SCAN,PELVIS,W/O CONTRAST - CT PELVIS WO CONTRAST
|
Facility
|
IP
|
$2,585.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
3527219201
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,620.80 |
| Max. Negotiated Rate |
$2,585.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,533.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,481.60
|
| Rate for Payer: Altius Commercial |
$2,481.60
|
| Rate for Payer: Beech Street Commercial |
$2,533.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,122.28
|
| Rate for Payer: Cash Price |
$1,809.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,507.45
|
| Rate for Payer: Cigna of WY Commercial |
$2,533.30
|
| Rate for Payer: Entrust Commercial |
$2,455.75
|
| Rate for Payer: First Choice Health Commercial |
$2,455.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,455.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,706.10
|
| Rate for Payer: HealthUtah PPO |
$2,585.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,507.45
|
| Rate for Payer: Multiplan Medicare/VA |
$1,620.80
|
| Rate for Payer: One Health Plan of WY PPO |
$2,533.30
|
| Rate for Payer: PacificSource Commercial |
$2,326.50
|
| Rate for Payer: PHCS PPO |
$2,533.30
|
| Rate for Payer: Three Rivers PPO |
$1,938.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,706.10
|
| Rate for Payer: United Healthcare Commercial |
$2,248.95
|
| Rate for Payer: United Healthcare Medicare |
$1,706.10
|
| Rate for Payer: WINHealth Partners Commercial |
$2,455.75
|
| Rate for Payer: Wise Provider Network Commercial |
$2,455.75
|
|
|
HC CT SCAN,PELVIS,W/O CONTRAST - CT PELVIS WO CONTRAST
|
Facility
|
OP
|
$2,585.00
|
|
|
Service Code
|
HCPCS 72192
|
| Hospital Charge Code |
3527219201
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,424.34 |
| Max. Negotiated Rate |
$2,585.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,533.30
|
| Rate for Payer: Aetna of WY Medicare |
$1,706.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,481.60
|
| Rate for Payer: Altius Commercial |
$2,481.60
|
| Rate for Payer: Beech Street Commercial |
$2,533.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,122.28
|
| Rate for Payer: Cash Price |
$1,809.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,507.45
|
| Rate for Payer: Cigna of WY Commercial |
$2,533.30
|
| Rate for Payer: Entrust Commercial |
$2,455.75
|
| Rate for Payer: First Choice Health Commercial |
$2,455.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,455.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,499.30
|
| Rate for Payer: HealthUtah PPO |
$2,585.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,507.45
|
| Rate for Payer: Multiplan Medicare/VA |
$1,424.34
|
| Rate for Payer: One Health Plan of WY PPO |
$2,533.30
|
| Rate for Payer: PacificSource Commercial |
$2,326.50
|
| Rate for Payer: PHCS PPO |
$2,533.30
|
| Rate for Payer: Three Rivers PPO |
$1,938.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,499.30
|
| Rate for Payer: United Healthcare Commercial |
$2,248.95
|
| Rate for Payer: United Healthcare Medicare |
$1,499.30
|
| Rate for Payer: WINHealth Partners Commercial |
$2,533.30
|
| Rate for Payer: Wise Provider Network Commercial |
$2,455.75
|
|
|
HC CT SCANS FACE/JAW COMBO - CT SINUS FACIAL BONES W WO CONTRAST
|
Facility
|
IP
|
$1,860.00
|
|
|
Service Code
|
HCPCS 70488
|
| Hospital Charge Code |
3517048802
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,166.22 |
| Max. Negotiated Rate |
$1,860.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,822.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,785.60
|
| Rate for Payer: Altius Commercial |
$1,785.60
|
| Rate for Payer: Beech Street Commercial |
$1,822.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,527.06
|
| Rate for Payer: Cash Price |
$1,302.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,804.20
|
| Rate for Payer: Cigna of WY Commercial |
$1,822.80
|
| Rate for Payer: Entrust Commercial |
$1,767.00
|
| Rate for Payer: First Choice Health Commercial |
$1,767.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,767.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,227.60
|
| Rate for Payer: HealthUtah PPO |
$1,860.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,804.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,166.22
|
| Rate for Payer: One Health Plan of WY PPO |
$1,822.80
|
| Rate for Payer: PacificSource Commercial |
$1,674.00
|
| Rate for Payer: PHCS PPO |
$1,822.80
|
| Rate for Payer: Three Rivers PPO |
$1,395.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,227.60
|
| Rate for Payer: United Healthcare Commercial |
$1,618.20
|
| Rate for Payer: United Healthcare Medicare |
$1,227.60
|
| Rate for Payer: WINHealth Partners Commercial |
$1,767.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,767.00
|
|
|
HC CT SCANS FACE/JAW COMBO - CT SINUS FACIAL BONES W WO CONTRAST
|
Facility
|
OP
|
$1,860.00
|
|
|
Service Code
|
HCPCS 70488
|
| Hospital Charge Code |
3517048802
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,024.86 |
| Max. Negotiated Rate |
$1,860.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,822.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,227.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,785.60
|
| Rate for Payer: Altius Commercial |
$1,785.60
|
| Rate for Payer: Beech Street Commercial |
$1,822.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,527.06
|
| Rate for Payer: Cash Price |
$1,302.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,804.20
|
| Rate for Payer: Cigna of WY Commercial |
$1,822.80
|
| Rate for Payer: Entrust Commercial |
$1,767.00
|
| Rate for Payer: First Choice Health Commercial |
$1,767.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,767.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,078.80
|
| Rate for Payer: HealthUtah PPO |
$1,860.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,804.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,024.86
|
| Rate for Payer: One Health Plan of WY PPO |
$1,822.80
|
| Rate for Payer: PacificSource Commercial |
$1,674.00
|
| Rate for Payer: PHCS PPO |
$1,822.80
|
| Rate for Payer: Three Rivers PPO |
$1,395.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,078.80
|
| Rate for Payer: United Healthcare Commercial |
$1,618.20
|
| Rate for Payer: United Healthcare Medicare |
$1,078.80
|
| Rate for Payer: WINHealth Partners Commercial |
$1,822.80
|
| Rate for Payer: Wise Provider Network Commercial |
$1,767.00
|
|
|
HC CT SCAN SKULL COMBO - CT AUDITORY CANALS / POSTERIOR FOSSA W WO CONT
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 70482
|
| Hospital Charge Code |
3517048202
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,129.55 |
| Max. Negotiated Rate |
$2,050.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,009.00
|
| Rate for Payer: Aetna of WY Medicare |
$1,353.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,968.00
|
| Rate for Payer: Altius Commercial |
$1,968.00
|
| Rate for Payer: Beech Street Commercial |
$2,009.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,683.05
|
| Rate for Payer: Cash Price |
$1,435.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,988.50
|
| Rate for Payer: Cigna of WY Commercial |
$2,009.00
|
| Rate for Payer: Entrust Commercial |
$1,947.50
|
| Rate for Payer: First Choice Health Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,189.00
|
| Rate for Payer: HealthUtah PPO |
$2,050.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,988.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,129.55
|
| Rate for Payer: One Health Plan of WY PPO |
$2,009.00
|
| Rate for Payer: PacificSource Commercial |
$1,845.00
|
| Rate for Payer: PHCS PPO |
$2,009.00
|
| Rate for Payer: Three Rivers PPO |
$1,537.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,189.00
|
| Rate for Payer: United Healthcare Commercial |
$1,783.50
|
| Rate for Payer: United Healthcare Medicare |
$1,189.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,009.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,947.50
|
|
|
HC CT SCAN SKULL COMBO - CT AUDITORY CANALS / POSTERIOR FOSSA W WO CONT
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 70482
|
| Hospital Charge Code |
3517048202
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,285.35 |
| Max. Negotiated Rate |
$2,050.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,009.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,968.00
|
| Rate for Payer: Altius Commercial |
$1,968.00
|
| Rate for Payer: Beech Street Commercial |
$2,009.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,683.05
|
| Rate for Payer: Cash Price |
$1,435.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,988.50
|
| Rate for Payer: Cigna of WY Commercial |
$2,009.00
|
| Rate for Payer: Entrust Commercial |
$1,947.50
|
| Rate for Payer: First Choice Health Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,353.00
|
| Rate for Payer: HealthUtah PPO |
$2,050.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,988.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,285.35
|
| Rate for Payer: One Health Plan of WY PPO |
$2,009.00
|
| Rate for Payer: PacificSource Commercial |
$1,845.00
|
| Rate for Payer: PHCS PPO |
$2,009.00
|
| Rate for Payer: Three Rivers PPO |
$1,537.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,353.00
|
| Rate for Payer: United Healthcare Commercial |
$1,783.50
|
| Rate for Payer: United Healthcare Medicare |
$1,353.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,947.50
|
| Rate for Payer: Wise Provider Network Commercial |
$1,947.50
|
|
|
HC CT SCAN SKULL COMBO - CT ORBITS/SELLA W AND WO IV CONTRAST
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 70482
|
| Hospital Charge Code |
3517048201
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,129.55 |
| Max. Negotiated Rate |
$2,050.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,009.00
|
| Rate for Payer: Aetna of WY Medicare |
$1,353.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,968.00
|
| Rate for Payer: Altius Commercial |
$1,968.00
|
| Rate for Payer: Beech Street Commercial |
$2,009.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,683.05
|
| Rate for Payer: Cash Price |
$1,435.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,988.50
|
| Rate for Payer: Cigna of WY Commercial |
$2,009.00
|
| Rate for Payer: Entrust Commercial |
$1,947.50
|
| Rate for Payer: First Choice Health Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,189.00
|
| Rate for Payer: HealthUtah PPO |
$2,050.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,988.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,129.55
|
| Rate for Payer: One Health Plan of WY PPO |
$2,009.00
|
| Rate for Payer: PacificSource Commercial |
$1,845.00
|
| Rate for Payer: PHCS PPO |
$2,009.00
|
| Rate for Payer: Three Rivers PPO |
$1,537.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,189.00
|
| Rate for Payer: United Healthcare Commercial |
$1,783.50
|
| Rate for Payer: United Healthcare Medicare |
$1,189.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,009.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,947.50
|
|
|
HC CT SCAN SKULL COMBO - CT ORBITS/SELLA W AND WO IV CONTRAST
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 70482
|
| Hospital Charge Code |
3517048201
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,285.35 |
| Max. Negotiated Rate |
$2,050.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,009.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,968.00
|
| Rate for Payer: Altius Commercial |
$1,968.00
|
| Rate for Payer: Beech Street Commercial |
$2,009.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,683.05
|
| Rate for Payer: Cash Price |
$1,435.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,988.50
|
| Rate for Payer: Cigna of WY Commercial |
$2,009.00
|
| Rate for Payer: Entrust Commercial |
$1,947.50
|
| Rate for Payer: First Choice Health Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,353.00
|
| Rate for Payer: HealthUtah PPO |
$2,050.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,988.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,285.35
|
| Rate for Payer: One Health Plan of WY PPO |
$2,009.00
|
| Rate for Payer: PacificSource Commercial |
$1,845.00
|
| Rate for Payer: PHCS PPO |
$2,009.00
|
| Rate for Payer: Three Rivers PPO |
$1,537.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,353.00
|
| Rate for Payer: United Healthcare Commercial |
$1,783.50
|
| Rate for Payer: United Healthcare Medicare |
$1,353.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,947.50
|
| Rate for Payer: Wise Provider Network Commercial |
$1,947.50
|
|
|
HC CT SCAN SKULL CONTRAST - CT AUDITORY CANALS/POSTERIOR FOSSA W IV CNT
|
Facility
|
OP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 70481
|
| Hospital Charge Code |
3517048102
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,129.55 |
| Max. Negotiated Rate |
$2,050.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,009.00
|
| Rate for Payer: Aetna of WY Medicare |
$1,353.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,968.00
|
| Rate for Payer: Altius Commercial |
$1,968.00
|
| Rate for Payer: Beech Street Commercial |
$2,009.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,683.05
|
| Rate for Payer: Cash Price |
$1,435.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,988.50
|
| Rate for Payer: Cigna of WY Commercial |
$2,009.00
|
| Rate for Payer: Entrust Commercial |
$1,947.50
|
| Rate for Payer: First Choice Health Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,189.00
|
| Rate for Payer: HealthUtah PPO |
$2,050.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,988.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,129.55
|
| Rate for Payer: One Health Plan of WY PPO |
$2,009.00
|
| Rate for Payer: PacificSource Commercial |
$1,845.00
|
| Rate for Payer: PHCS PPO |
$2,009.00
|
| Rate for Payer: Three Rivers PPO |
$1,537.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,189.00
|
| Rate for Payer: United Healthcare Commercial |
$1,783.50
|
| Rate for Payer: United Healthcare Medicare |
$1,189.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,009.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,947.50
|
|
|
HC CT SCAN SKULL CONTRAST - CT AUDITORY CANALS/POSTERIOR FOSSA W IV CNT
|
Facility
|
IP
|
$2,050.00
|
|
|
Service Code
|
HCPCS 70481
|
| Hospital Charge Code |
3517048102
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,285.35 |
| Max. Negotiated Rate |
$2,050.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,009.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,968.00
|
| Rate for Payer: Altius Commercial |
$1,968.00
|
| Rate for Payer: Beech Street Commercial |
$2,009.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,683.05
|
| Rate for Payer: Cash Price |
$1,435.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,988.50
|
| Rate for Payer: Cigna of WY Commercial |
$2,009.00
|
| Rate for Payer: Entrust Commercial |
$1,947.50
|
| Rate for Payer: First Choice Health Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,947.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,353.00
|
| Rate for Payer: HealthUtah PPO |
$2,050.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,988.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,285.35
|
| Rate for Payer: One Health Plan of WY PPO |
$2,009.00
|
| Rate for Payer: PacificSource Commercial |
$1,845.00
|
| Rate for Payer: PHCS PPO |
$2,009.00
|
| Rate for Payer: Three Rivers PPO |
$1,537.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,353.00
|
| Rate for Payer: United Healthcare Commercial |
$1,783.50
|
| Rate for Payer: United Healthcare Medicare |
$1,353.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,947.50
|
| Rate for Payer: Wise Provider Network Commercial |
$1,947.50
|
|
|
HC CT SCAN SKULL CONTRAST - CT ORBITS/SELLA W IV CONTRAST
|
Facility
|
IP
|
$2,880.00
|
|
|
Service Code
|
HCPCS 70481
|
| Hospital Charge Code |
3517048101
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,805.76 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,822.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,764.80
|
| Rate for Payer: Altius Commercial |
$2,764.80
|
| Rate for Payer: Beech Street Commercial |
$2,822.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,364.48
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,793.60
|
| Rate for Payer: Cigna of WY Commercial |
$2,822.40
|
| Rate for Payer: Entrust Commercial |
$2,736.00
|
| Rate for Payer: First Choice Health Commercial |
$2,736.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,736.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,900.80
|
| Rate for Payer: HealthUtah PPO |
$2,880.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,793.60
|
| Rate for Payer: Multiplan Medicare/VA |
$1,805.76
|
| Rate for Payer: One Health Plan of WY PPO |
$2,822.40
|
| Rate for Payer: PacificSource Commercial |
$2,592.00
|
| Rate for Payer: PHCS PPO |
$2,822.40
|
| Rate for Payer: Three Rivers PPO |
$2,160.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,900.80
|
| Rate for Payer: United Healthcare Commercial |
$2,505.60
|
| Rate for Payer: United Healthcare Medicare |
$1,900.80
|
| Rate for Payer: WINHealth Partners Commercial |
$2,736.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,736.00
|
|
|
HC CT SCAN SKULL CONTRAST - CT ORBITS/SELLA W IV CONTRAST
|
Facility
|
OP
|
$2,880.00
|
|
|
Service Code
|
HCPCS 70481
|
| Hospital Charge Code |
3517048101
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,586.88 |
| Max. Negotiated Rate |
$2,880.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,822.40
|
| Rate for Payer: Aetna of WY Medicare |
$1,900.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,764.80
|
| Rate for Payer: Altius Commercial |
$2,764.80
|
| Rate for Payer: Beech Street Commercial |
$2,822.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,364.48
|
| Rate for Payer: Cash Price |
$2,016.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,793.60
|
| Rate for Payer: Cigna of WY Commercial |
$2,822.40
|
| Rate for Payer: Entrust Commercial |
$2,736.00
|
| Rate for Payer: First Choice Health Commercial |
$2,736.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,736.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,670.40
|
| Rate for Payer: HealthUtah PPO |
$2,880.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,793.60
|
| Rate for Payer: Multiplan Medicare/VA |
$1,586.88
|
| Rate for Payer: One Health Plan of WY PPO |
$2,822.40
|
| Rate for Payer: PacificSource Commercial |
$2,592.00
|
| Rate for Payer: PHCS PPO |
$2,822.40
|
| Rate for Payer: Three Rivers PPO |
$2,160.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,670.40
|
| Rate for Payer: United Healthcare Commercial |
$2,505.60
|
| Rate for Payer: United Healthcare Medicare |
$1,670.40
|
| Rate for Payer: WINHealth Partners Commercial |
$2,822.40
|
| Rate for Payer: Wise Provider Network Commercial |
$2,736.00
|
|
|
HC CT SCAN,SOFT TISSUE NECK,W/O CONTRAST - CT SOFT TISSUE NECK WO CONT
|
Facility
|
IP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 70490
|
| Hospital Charge Code |
3517049001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$940.50 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,470.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,440.00
|
| Rate for Payer: Altius Commercial |
$1,440.00
|
| Rate for Payer: Beech Street Commercial |
$1,470.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,231.50
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,455.00
|
| Rate for Payer: Cigna of WY Commercial |
$1,470.00
|
| Rate for Payer: Entrust Commercial |
$1,425.00
|
| Rate for Payer: First Choice Health Commercial |
$1,425.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,425.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$990.00
|
| Rate for Payer: HealthUtah PPO |
$1,500.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,455.00
|
| Rate for Payer: Multiplan Medicare/VA |
$940.50
|
| Rate for Payer: One Health Plan of WY PPO |
$1,470.00
|
| Rate for Payer: PacificSource Commercial |
$1,350.00
|
| Rate for Payer: PHCS PPO |
$1,470.00
|
| Rate for Payer: Three Rivers PPO |
$1,125.00
|
| Rate for Payer: TriWest Veterans Administration |
$990.00
|
| Rate for Payer: United Healthcare Commercial |
$1,305.00
|
| Rate for Payer: United Healthcare Medicare |
$990.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,425.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,425.00
|
|
|
HC CT SCAN,SOFT TISSUE NECK,W/O CONTRAST - CT SOFT TISSUE NECK WO CONT
|
Facility
|
OP
|
$1,500.00
|
|
|
Service Code
|
HCPCS 70490
|
| Hospital Charge Code |
3517049001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$826.50 |
| Max. Negotiated Rate |
$1,500.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,470.00
|
| Rate for Payer: Aetna of WY Medicare |
$990.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,440.00
|
| Rate for Payer: Altius Commercial |
$1,440.00
|
| Rate for Payer: Beech Street Commercial |
$1,470.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,231.50
|
| Rate for Payer: Cash Price |
$1,050.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,455.00
|
| Rate for Payer: Cigna of WY Commercial |
$1,470.00
|
| Rate for Payer: Entrust Commercial |
$1,425.00
|
| Rate for Payer: First Choice Health Commercial |
$1,425.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,425.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$870.00
|
| Rate for Payer: HealthUtah PPO |
$1,500.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,455.00
|
| Rate for Payer: Multiplan Medicare/VA |
$826.50
|
| Rate for Payer: One Health Plan of WY PPO |
$1,470.00
|
| Rate for Payer: PacificSource Commercial |
$1,350.00
|
| Rate for Payer: PHCS PPO |
$1,470.00
|
| Rate for Payer: Three Rivers PPO |
$1,125.00
|
| Rate for Payer: TriWest Veterans Administration |
$870.00
|
| Rate for Payer: United Healthcare Commercial |
$1,305.00
|
| Rate for Payer: United Healthcare Medicare |
$870.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,470.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,425.00
|
|
|
HC CT SCAN,THORACIC SPINE,W/O CONTRAST - CT THORACIC SPINE WO CONTRAST
|
Facility
|
IP
|
$2,610.00
|
|
|
Service Code
|
HCPCS 72128
|
| Hospital Charge Code |
3527212801
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,636.47 |
| Max. Negotiated Rate |
$2,610.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,557.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,505.60
|
| Rate for Payer: Altius Commercial |
$2,505.60
|
| Rate for Payer: Beech Street Commercial |
$2,557.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,142.81
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,531.70
|
| Rate for Payer: Cigna of WY Commercial |
$2,557.80
|
| Rate for Payer: Entrust Commercial |
$2,479.50
|
| Rate for Payer: First Choice Health Commercial |
$2,479.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,479.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,722.60
|
| Rate for Payer: HealthUtah PPO |
$2,610.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,531.70
|
| Rate for Payer: Multiplan Medicare/VA |
$1,636.47
|
| Rate for Payer: One Health Plan of WY PPO |
$2,557.80
|
| Rate for Payer: PacificSource Commercial |
$2,349.00
|
| Rate for Payer: PHCS PPO |
$2,557.80
|
| Rate for Payer: Three Rivers PPO |
$1,957.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,722.60
|
| Rate for Payer: United Healthcare Commercial |
$2,270.70
|
| Rate for Payer: United Healthcare Medicare |
$1,722.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2,479.50
|
| Rate for Payer: Wise Provider Network Commercial |
$2,479.50
|
|
|
HC CT SCAN,THORACIC SPINE,W/O CONTRAST - CT THORACIC SPINE WO CONTRAST
|
Facility
|
OP
|
$2,610.00
|
|
|
Service Code
|
HCPCS 72128
|
| Hospital Charge Code |
3527212801
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,438.11 |
| Max. Negotiated Rate |
$2,610.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,557.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,722.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,505.60
|
| Rate for Payer: Altius Commercial |
$2,505.60
|
| Rate for Payer: Beech Street Commercial |
$2,557.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,142.81
|
| Rate for Payer: Cash Price |
$1,827.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,531.70
|
| Rate for Payer: Cigna of WY Commercial |
$2,557.80
|
| Rate for Payer: Entrust Commercial |
$2,479.50
|
| Rate for Payer: First Choice Health Commercial |
$2,479.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,479.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,513.80
|
| Rate for Payer: HealthUtah PPO |
$2,610.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,531.70
|
| Rate for Payer: Multiplan Medicare/VA |
$1,438.11
|
| Rate for Payer: One Health Plan of WY PPO |
$2,557.80
|
| Rate for Payer: PacificSource Commercial |
$2,349.00
|
| Rate for Payer: PHCS PPO |
$2,557.80
|
| Rate for Payer: Three Rivers PPO |
$1,957.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,513.80
|
| Rate for Payer: United Healthcare Commercial |
$2,270.70
|
| Rate for Payer: United Healthcare Medicare |
$1,513.80
|
| Rate for Payer: WINHealth Partners Commercial |
$2,557.80
|
| Rate for Payer: Wise Provider Network Commercial |
$2,479.50
|
|
|
HC CT SCAN,THORAX,W/O CONTRAST - CT CHEST WO CONTRAST
|
Facility
|
IP
|
$2,130.00
|
|
|
Service Code
|
HCPCS 71250
|
| Hospital Charge Code |
3527125001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,335.51 |
| Max. Negotiated Rate |
$2,130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,087.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,044.80
|
| Rate for Payer: Altius Commercial |
$2,044.80
|
| Rate for Payer: Beech Street Commercial |
$2,087.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,748.73
|
| Rate for Payer: Cash Price |
$1,491.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,066.10
|
| Rate for Payer: Cigna of WY Commercial |
$2,087.40
|
| Rate for Payer: Entrust Commercial |
$2,023.50
|
| Rate for Payer: First Choice Health Commercial |
$2,023.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,023.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,405.80
|
| Rate for Payer: HealthUtah PPO |
$2,130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,066.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1,335.51
|
| Rate for Payer: One Health Plan of WY PPO |
$2,087.40
|
| Rate for Payer: PacificSource Commercial |
$1,917.00
|
| Rate for Payer: PHCS PPO |
$2,087.40
|
| Rate for Payer: Three Rivers PPO |
$1,597.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,405.80
|
| Rate for Payer: United Healthcare Commercial |
$1,853.10
|
| Rate for Payer: United Healthcare Medicare |
$1,405.80
|
| Rate for Payer: WINHealth Partners Commercial |
$2,023.50
|
| Rate for Payer: Wise Provider Network Commercial |
$2,023.50
|
|
|
HC CT SCAN,THORAX,W/O CONTRAST - CT CHEST WO CONTRAST
|
Facility
|
OP
|
$2,130.00
|
|
|
Service Code
|
HCPCS 71250
|
| Hospital Charge Code |
3527125001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,173.63 |
| Max. Negotiated Rate |
$2,130.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,087.40
|
| Rate for Payer: Aetna of WY Medicare |
$1,405.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,044.80
|
| Rate for Payer: Altius Commercial |
$2,044.80
|
| Rate for Payer: Beech Street Commercial |
$2,087.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,748.73
|
| Rate for Payer: Cash Price |
$1,491.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,066.10
|
| Rate for Payer: Cigna of WY Commercial |
$2,087.40
|
| Rate for Payer: Entrust Commercial |
$2,023.50
|
| Rate for Payer: First Choice Health Commercial |
$2,023.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,023.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,235.40
|
| Rate for Payer: HealthUtah PPO |
$2,130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,066.10
|
| Rate for Payer: Multiplan Medicare/VA |
$1,173.63
|
| Rate for Payer: One Health Plan of WY PPO |
$2,087.40
|
| Rate for Payer: PacificSource Commercial |
$1,917.00
|
| Rate for Payer: PHCS PPO |
$2,087.40
|
| Rate for Payer: Three Rivers PPO |
$1,597.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,235.40
|
| Rate for Payer: United Healthcare Commercial |
$1,853.10
|
| Rate for Payer: United Healthcare Medicare |
$1,235.40
|
| Rate for Payer: WINHealth Partners Commercial |
$2,087.40
|
| Rate for Payer: Wise Provider Network Commercial |
$2,023.50
|
|
|
HC CT SCAN UPPER EXTREMITY W/O DYE - CT ELBOW LEFT WO IV CONTRAST
|
Facility
|
OP
|
$1,870.00
|
|
|
Service Code
|
HCPCS 73200
|
| Hospital Charge Code |
3527320012
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,030.37 |
| Max. Negotiated Rate |
$1,870.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,832.60
|
| Rate for Payer: Aetna of WY Medicare |
$1,234.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,795.20
|
| Rate for Payer: Altius Commercial |
$1,795.20
|
| Rate for Payer: Beech Street Commercial |
$1,832.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,535.27
|
| Rate for Payer: Cash Price |
$1,309.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,813.90
|
| Rate for Payer: Cigna of WY Commercial |
$1,832.60
|
| Rate for Payer: Entrust Commercial |
$1,776.50
|
| Rate for Payer: First Choice Health Commercial |
$1,776.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,776.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,084.60
|
| Rate for Payer: HealthUtah PPO |
$1,870.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,813.90
|
| Rate for Payer: Multiplan Medicare/VA |
$1,030.37
|
| Rate for Payer: One Health Plan of WY PPO |
$1,832.60
|
| Rate for Payer: PacificSource Commercial |
$1,683.00
|
| Rate for Payer: PHCS PPO |
$1,832.60
|
| Rate for Payer: Three Rivers PPO |
$1,402.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,084.60
|
| Rate for Payer: United Healthcare Commercial |
$1,626.90
|
| Rate for Payer: United Healthcare Medicare |
$1,084.60
|
| Rate for Payer: WINHealth Partners Commercial |
$1,832.60
|
| Rate for Payer: Wise Provider Network Commercial |
$1,776.50
|
|
