|
HC EKG TRACING 12 LEADS FOR INITIAL PREV
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS G0404
|
| Hospital Charge Code |
730G040401
|
|
Hospital Revenue Code
|
730
|
| 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 ELASTASE PANCREATIC FECAL QUANTITATIVE
|
Facility
|
IP
|
$385.00
|
|
|
Service Code
|
HCPCS 82653
|
| Hospital Charge Code |
3018265301
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$241.40 |
| Max. Negotiated Rate |
$385.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$377.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$369.60
|
| Rate for Payer: Altius Commercial |
$369.60
|
| Rate for Payer: Beech Street Commercial |
$377.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$316.08
|
| Rate for Payer: Cash Price |
$269.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$373.45
|
| Rate for Payer: Cigna of WY Commercial |
$377.30
|
| Rate for Payer: Entrust Commercial |
$365.75
|
| Rate for Payer: First Choice Health Commercial |
$365.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$365.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$254.10
|
| Rate for Payer: HealthUtah PPO |
$385.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$373.45
|
| Rate for Payer: Multiplan Medicare/VA |
$241.40
|
| Rate for Payer: One Health Plan of WY PPO |
$377.30
|
| Rate for Payer: PacificSource Commercial |
$346.50
|
| Rate for Payer: PHCS PPO |
$377.30
|
| Rate for Payer: Three Rivers PPO |
$288.75
|
| Rate for Payer: TriWest Veterans Administration |
$254.10
|
| Rate for Payer: United Healthcare Commercial |
$334.95
|
| Rate for Payer: United Healthcare Medicare |
$254.10
|
| Rate for Payer: WINHealth Partners Commercial |
$365.75
|
| Rate for Payer: Wise Provider Network Commercial |
$365.75
|
|
|
HC ELASTASE PANCREATIC FECAL QUANTITATIVE
|
Facility
|
OP
|
$385.00
|
|
|
Service Code
|
HCPCS 82653
|
| Hospital Charge Code |
3018265301
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$212.14 |
| Max. Negotiated Rate |
$385.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$377.30
|
| Rate for Payer: Aetna of WY Medicare |
$254.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$369.60
|
| Rate for Payer: Altius Commercial |
$369.60
|
| Rate for Payer: Beech Street Commercial |
$377.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$316.08
|
| Rate for Payer: Cash Price |
$269.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$373.45
|
| Rate for Payer: Cigna of WY Commercial |
$377.30
|
| Rate for Payer: Entrust Commercial |
$365.75
|
| Rate for Payer: First Choice Health Commercial |
$365.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$365.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$223.30
|
| Rate for Payer: HealthUtah PPO |
$385.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$373.45
|
| Rate for Payer: Multiplan Medicare/VA |
$212.14
|
| Rate for Payer: One Health Plan of WY PPO |
$377.30
|
| Rate for Payer: PacificSource Commercial |
$346.50
|
| Rate for Payer: PHCS PPO |
$377.30
|
| Rate for Payer: Three Rivers PPO |
$288.75
|
| Rate for Payer: TriWest Veterans Administration |
$223.30
|
| Rate for Payer: United Healthcare Commercial |
$334.95
|
| Rate for Payer: United Healthcare Medicare |
$223.30
|
| Rate for Payer: WINHealth Partners Commercial |
$377.30
|
| Rate for Payer: Wise Provider Network Commercial |
$365.75
|
|
|
HC ELECTROCARDIOGRAM, TRACING
|
Facility
|
OP
|
$143.00
|
|
|
Service Code
|
HCPCS 93005
|
| Hospital Charge Code |
5109300501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$78.79 |
| Max. Negotiated Rate |
$143.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.14
|
| Rate for Payer: Aetna of WY Medicare |
$94.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.28
|
| Rate for Payer: Altius Commercial |
$137.28
|
| Rate for Payer: Beech Street Commercial |
$140.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.40
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$138.71
|
| Rate for Payer: Cigna of WY Commercial |
$140.14
|
| Rate for Payer: Entrust Commercial |
$135.85
|
| Rate for Payer: First Choice Health Commercial |
$135.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$135.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$82.94
|
| Rate for Payer: HealthUtah PPO |
$143.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$138.71
|
| Rate for Payer: Multiplan Medicare/VA |
$78.79
|
| Rate for Payer: One Health Plan of WY PPO |
$140.14
|
| Rate for Payer: PacificSource Commercial |
$128.70
|
| Rate for Payer: PHCS PPO |
$140.14
|
| Rate for Payer: Three Rivers PPO |
$107.25
|
| Rate for Payer: TriWest Veterans Administration |
$82.94
|
| Rate for Payer: United Healthcare Commercial |
$124.41
|
| Rate for Payer: United Healthcare Medicare |
$82.94
|
| Rate for Payer: WINHealth Partners Commercial |
$140.14
|
| Rate for Payer: Wise Provider Network Commercial |
$135.85
|
|
|
HC ELECTROCARDIOGRAM, TRACING
|
Facility
|
IP
|
$615.00
|
|
|
Service Code
|
HCPCS 93005
|
| Hospital Charge Code |
7309300501
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$385.60 |
| Max. Negotiated Rate |
$615.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$602.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$590.40
|
| Rate for Payer: Altius Commercial |
$590.40
|
| Rate for Payer: Beech Street Commercial |
$602.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$504.92
|
| Rate for Payer: Cash Price |
$430.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$596.55
|
| Rate for Payer: Cigna of WY Commercial |
$602.70
|
| Rate for Payer: Entrust Commercial |
$584.25
|
| Rate for Payer: First Choice Health Commercial |
$584.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$584.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$405.90
|
| Rate for Payer: HealthUtah PPO |
$615.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$596.55
|
| Rate for Payer: Multiplan Medicare/VA |
$385.60
|
| Rate for Payer: One Health Plan of WY PPO |
$602.70
|
| Rate for Payer: PacificSource Commercial |
$553.50
|
| Rate for Payer: PHCS PPO |
$602.70
|
| Rate for Payer: Three Rivers PPO |
$461.25
|
| Rate for Payer: TriWest Veterans Administration |
$405.90
|
| Rate for Payer: United Healthcare Commercial |
$535.05
|
| Rate for Payer: United Healthcare Medicare |
$405.90
|
| Rate for Payer: WINHealth Partners Commercial |
$584.25
|
| Rate for Payer: Wise Provider Network Commercial |
$584.25
|
|
|
HC ELECTROCARDIOGRAM, TRACING
|
Facility
|
OP
|
$615.00
|
|
|
Service Code
|
HCPCS 93005
|
| Hospital Charge Code |
7309300501
|
|
Hospital Revenue Code
|
730
|
| Min. Negotiated Rate |
$338.86 |
| Max. Negotiated Rate |
$615.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$602.70
|
| Rate for Payer: Aetna of WY Medicare |
$405.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$590.40
|
| Rate for Payer: Altius Commercial |
$590.40
|
| Rate for Payer: Beech Street Commercial |
$602.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$504.92
|
| Rate for Payer: Cash Price |
$430.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$596.55
|
| Rate for Payer: Cigna of WY Commercial |
$602.70
|
| Rate for Payer: Entrust Commercial |
$584.25
|
| Rate for Payer: First Choice Health Commercial |
$584.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$584.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$356.70
|
| Rate for Payer: HealthUtah PPO |
$615.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$596.55
|
| Rate for Payer: Multiplan Medicare/VA |
$338.86
|
| Rate for Payer: One Health Plan of WY PPO |
$602.70
|
| Rate for Payer: PacificSource Commercial |
$553.50
|
| Rate for Payer: PHCS PPO |
$602.70
|
| Rate for Payer: Three Rivers PPO |
$461.25
|
| Rate for Payer: TriWest Veterans Administration |
$356.70
|
| Rate for Payer: United Healthcare Commercial |
$535.05
|
| Rate for Payer: United Healthcare Medicare |
$356.70
|
| Rate for Payer: WINHealth Partners Commercial |
$602.70
|
| Rate for Payer: Wise Provider Network Commercial |
$584.25
|
|
|
HC ELECTROCARDIOGRAM, TRACING
|
Facility
|
IP
|
$143.00
|
|
|
Service Code
|
HCPCS 93005
|
| Hospital Charge Code |
5109300501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$89.66 |
| Max. Negotiated Rate |
$143.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$140.14
|
| Rate for Payer: Altius Auto/Workers Compensation |
$137.28
|
| Rate for Payer: Altius Commercial |
$137.28
|
| Rate for Payer: Beech Street Commercial |
$140.14
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$117.40
|
| Rate for Payer: Cash Price |
$100.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$138.71
|
| Rate for Payer: Cigna of WY Commercial |
$140.14
|
| Rate for Payer: Entrust Commercial |
$135.85
|
| Rate for Payer: First Choice Health Commercial |
$135.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$135.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$94.38
|
| Rate for Payer: HealthUtah PPO |
$143.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$138.71
|
| Rate for Payer: Multiplan Medicare/VA |
$89.66
|
| Rate for Payer: One Health Plan of WY PPO |
$140.14
|
| Rate for Payer: PacificSource Commercial |
$128.70
|
| Rate for Payer: PHCS PPO |
$140.14
|
| Rate for Payer: Three Rivers PPO |
$107.25
|
| Rate for Payer: TriWest Veterans Administration |
$94.38
|
| Rate for Payer: United Healthcare Commercial |
$124.41
|
| Rate for Payer: United Healthcare Medicare |
$94.38
|
| Rate for Payer: WINHealth Partners Commercial |
$135.85
|
| Rate for Payer: Wise Provider Network Commercial |
$135.85
|
|
|
HC ELECTROLYTE PANEL
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS 80051
|
| Hospital Charge Code |
3018005101
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$35.82 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$63.70
|
| Rate for Payer: Aetna of WY Medicare |
$42.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$62.40
|
| Rate for Payer: Altius Commercial |
$62.40
|
| Rate for Payer: Beech Street Commercial |
$63.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.36
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$63.05
|
| Rate for Payer: Cigna of WY Commercial |
$63.70
|
| Rate for Payer: Entrust Commercial |
$61.75
|
| Rate for Payer: First Choice Health Commercial |
$61.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$61.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$37.70
|
| Rate for Payer: HealthUtah PPO |
$65.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$63.05
|
| Rate for Payer: Multiplan Medicare/VA |
$35.82
|
| Rate for Payer: One Health Plan of WY PPO |
$63.70
|
| Rate for Payer: PacificSource Commercial |
$58.50
|
| Rate for Payer: PHCS PPO |
$63.70
|
| Rate for Payer: Three Rivers PPO |
$48.75
|
| Rate for Payer: TriWest Veterans Administration |
$37.70
|
| Rate for Payer: United Healthcare Commercial |
$56.55
|
| Rate for Payer: United Healthcare Medicare |
$37.70
|
| Rate for Payer: WINHealth Partners Commercial |
$63.70
|
| Rate for Payer: Wise Provider Network Commercial |
$61.75
|
|
|
HC ELECTROLYTE PANEL
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS 80051
|
| Hospital Charge Code |
3018005101
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$40.76 |
| Max. Negotiated Rate |
$65.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$63.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$62.40
|
| Rate for Payer: Altius Commercial |
$62.40
|
| Rate for Payer: Beech Street Commercial |
$63.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.36
|
| Rate for Payer: Cash Price |
$45.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$63.05
|
| Rate for Payer: Cigna of WY Commercial |
$63.70
|
| Rate for Payer: Entrust Commercial |
$61.75
|
| Rate for Payer: First Choice Health Commercial |
$61.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$61.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$42.90
|
| Rate for Payer: HealthUtah PPO |
$65.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$63.05
|
| Rate for Payer: Multiplan Medicare/VA |
$40.76
|
| Rate for Payer: One Health Plan of WY PPO |
$63.70
|
| Rate for Payer: PacificSource Commercial |
$58.50
|
| Rate for Payer: PHCS PPO |
$63.70
|
| Rate for Payer: Three Rivers PPO |
$48.75
|
| Rate for Payer: TriWest Veterans Administration |
$42.90
|
| Rate for Payer: United Healthcare Commercial |
$56.55
|
| Rate for Payer: United Healthcare Medicare |
$42.90
|
| Rate for Payer: WINHealth Partners Commercial |
$61.75
|
| Rate for Payer: Wise Provider Network Commercial |
$61.75
|
|
|
HC ELECTROPHORETIC TEST, NOS - LIPOPROTEIN ELECTROPHORE
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 82664
|
| Hospital Charge Code |
3018266403
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$250.80 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$392.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$384.00
|
| Rate for Payer: Altius Commercial |
$384.00
|
| Rate for Payer: Beech Street Commercial |
$392.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$328.40
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$388.00
|
| Rate for Payer: Cigna of WY Commercial |
$392.00
|
| Rate for Payer: Entrust Commercial |
$380.00
|
| Rate for Payer: First Choice Health Commercial |
$380.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$380.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$264.00
|
| Rate for Payer: HealthUtah PPO |
$400.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$388.00
|
| Rate for Payer: Multiplan Medicare/VA |
$250.80
|
| Rate for Payer: One Health Plan of WY PPO |
$392.00
|
| Rate for Payer: PacificSource Commercial |
$360.00
|
| Rate for Payer: PHCS PPO |
$392.00
|
| Rate for Payer: Three Rivers PPO |
$300.00
|
| Rate for Payer: TriWest Veterans Administration |
$264.00
|
| Rate for Payer: United Healthcare Commercial |
$348.00
|
| Rate for Payer: United Healthcare Medicare |
$264.00
|
| Rate for Payer: WINHealth Partners Commercial |
$380.00
|
| Rate for Payer: Wise Provider Network Commercial |
$380.00
|
|
|
HC ELECTROPHORETIC TEST, NOS - LIPOPROTEIN ELECTROPHORE
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 82664
|
| Hospital Charge Code |
3018266403
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$220.40 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$392.00
|
| Rate for Payer: Aetna of WY Medicare |
$264.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$384.00
|
| Rate for Payer: Altius Commercial |
$384.00
|
| Rate for Payer: Beech Street Commercial |
$392.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$328.40
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$388.00
|
| Rate for Payer: Cigna of WY Commercial |
$392.00
|
| Rate for Payer: Entrust Commercial |
$380.00
|
| Rate for Payer: First Choice Health Commercial |
$380.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$380.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$232.00
|
| Rate for Payer: HealthUtah PPO |
$400.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$388.00
|
| Rate for Payer: Multiplan Medicare/VA |
$220.40
|
| Rate for Payer: One Health Plan of WY PPO |
$392.00
|
| Rate for Payer: PacificSource Commercial |
$360.00
|
| Rate for Payer: PHCS PPO |
$392.00
|
| Rate for Payer: Three Rivers PPO |
$300.00
|
| Rate for Payer: TriWest Veterans Administration |
$232.00
|
| Rate for Payer: United Healthcare Commercial |
$348.00
|
| Rate for Payer: United Healthcare Medicare |
$232.00
|
| Rate for Payer: WINHealth Partners Commercial |
$392.00
|
| Rate for Payer: Wise Provider Network Commercial |
$380.00
|
|
|
HC ELECTROPHORETIC TEST, NOS - MUCOPOLY SNCCHARIDE SCREEN
|
Facility
|
OP
|
$400.00
|
|
|
Service Code
|
HCPCS 82664
|
| Hospital Charge Code |
3018266402
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$220.40 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$392.00
|
| Rate for Payer: Aetna of WY Medicare |
$264.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$384.00
|
| Rate for Payer: Altius Commercial |
$384.00
|
| Rate for Payer: Beech Street Commercial |
$392.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$328.40
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$388.00
|
| Rate for Payer: Cigna of WY Commercial |
$392.00
|
| Rate for Payer: Entrust Commercial |
$380.00
|
| Rate for Payer: First Choice Health Commercial |
$380.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$380.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$232.00
|
| Rate for Payer: HealthUtah PPO |
$400.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$388.00
|
| Rate for Payer: Multiplan Medicare/VA |
$220.40
|
| Rate for Payer: One Health Plan of WY PPO |
$392.00
|
| Rate for Payer: PacificSource Commercial |
$360.00
|
| Rate for Payer: PHCS PPO |
$392.00
|
| Rate for Payer: Three Rivers PPO |
$300.00
|
| Rate for Payer: TriWest Veterans Administration |
$232.00
|
| Rate for Payer: United Healthcare Commercial |
$348.00
|
| Rate for Payer: United Healthcare Medicare |
$232.00
|
| Rate for Payer: WINHealth Partners Commercial |
$392.00
|
| Rate for Payer: Wise Provider Network Commercial |
$380.00
|
|
|
HC ELECTROPHORETIC TEST, NOS - MUCOPOLY SNCCHARIDE SCREEN
|
Facility
|
IP
|
$400.00
|
|
|
Service Code
|
HCPCS 82664
|
| Hospital Charge Code |
3018266402
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$250.80 |
| Max. Negotiated Rate |
$400.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$392.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$384.00
|
| Rate for Payer: Altius Commercial |
$384.00
|
| Rate for Payer: Beech Street Commercial |
$392.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$328.40
|
| Rate for Payer: Cash Price |
$280.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$388.00
|
| Rate for Payer: Cigna of WY Commercial |
$392.00
|
| Rate for Payer: Entrust Commercial |
$380.00
|
| Rate for Payer: First Choice Health Commercial |
$380.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$380.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$264.00
|
| Rate for Payer: HealthUtah PPO |
$400.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$388.00
|
| Rate for Payer: Multiplan Medicare/VA |
$250.80
|
| Rate for Payer: One Health Plan of WY PPO |
$392.00
|
| Rate for Payer: PacificSource Commercial |
$360.00
|
| Rate for Payer: PHCS PPO |
$392.00
|
| Rate for Payer: Three Rivers PPO |
$300.00
|
| Rate for Payer: TriWest Veterans Administration |
$264.00
|
| Rate for Payer: United Healthcare Commercial |
$348.00
|
| Rate for Payer: United Healthcare Medicare |
$264.00
|
| Rate for Payer: WINHealth Partners Commercial |
$380.00
|
| Rate for Payer: Wise Provider Network Commercial |
$380.00
|
|
|
HC EMBLC/THRMBC W/WO CATH RADIAL/ULNAR ART ARM INC
|
Facility
|
IP
|
$392.00
|
|
|
Service Code
|
HCPCS 34111
|
| Hospital Charge Code |
5103411101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$245.78 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$384.16
|
| Rate for Payer: Altius Auto/Workers Compensation |
$376.32
|
| Rate for Payer: Altius Commercial |
$376.32
|
| Rate for Payer: Beech Street Commercial |
$384.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$321.83
|
| Rate for Payer: Cash Price |
$274.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$380.24
|
| Rate for Payer: Cigna of WY Commercial |
$384.16
|
| Rate for Payer: Entrust Commercial |
$372.40
|
| Rate for Payer: First Choice Health Commercial |
$372.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$372.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$258.72
|
| Rate for Payer: HealthUtah PPO |
$392.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$380.24
|
| Rate for Payer: Multiplan Medicare/VA |
$245.78
|
| Rate for Payer: One Health Plan of WY PPO |
$384.16
|
| Rate for Payer: PacificSource Commercial |
$352.80
|
| Rate for Payer: PHCS PPO |
$384.16
|
| Rate for Payer: Three Rivers PPO |
$294.00
|
| Rate for Payer: TriWest Veterans Administration |
$258.72
|
| Rate for Payer: United Healthcare Commercial |
$341.04
|
| Rate for Payer: United Healthcare Medicare |
$258.72
|
| Rate for Payer: WINHealth Partners Commercial |
$372.40
|
| Rate for Payer: Wise Provider Network Commercial |
$372.40
|
|
|
HC EMBLC/THRMBC W/WO CATH RADIAL/ULNAR ART ARM INC
|
Facility
|
OP
|
$392.00
|
|
|
Service Code
|
HCPCS 34111
|
| Hospital Charge Code |
5103411101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$215.99 |
| Max. Negotiated Rate |
$392.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$384.16
|
| Rate for Payer: Aetna of WY Medicare |
$258.72
|
| Rate for Payer: Altius Auto/Workers Compensation |
$376.32
|
| Rate for Payer: Altius Commercial |
$376.32
|
| Rate for Payer: Beech Street Commercial |
$384.16
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$321.83
|
| Rate for Payer: Cash Price |
$274.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$380.24
|
| Rate for Payer: Cigna of WY Commercial |
$384.16
|
| Rate for Payer: Entrust Commercial |
$372.40
|
| Rate for Payer: First Choice Health Commercial |
$372.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$372.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$227.36
|
| Rate for Payer: HealthUtah PPO |
$392.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$380.24
|
| Rate for Payer: Multiplan Medicare/VA |
$215.99
|
| Rate for Payer: One Health Plan of WY PPO |
$384.16
|
| Rate for Payer: PacificSource Commercial |
$352.80
|
| Rate for Payer: PHCS PPO |
$384.16
|
| Rate for Payer: Three Rivers PPO |
$294.00
|
| Rate for Payer: TriWest Veterans Administration |
$227.36
|
| Rate for Payer: United Healthcare Commercial |
$341.04
|
| Rate for Payer: United Healthcare Medicare |
$227.36
|
| Rate for Payer: WINHealth Partners Commercial |
$384.16
|
| Rate for Payer: Wise Provider Network Commercial |
$372.40
|
|
|
HC EMERGENCY DEPARTMENT LEVEL 1 VISIT LIMITED/MINOR PROB
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
HCPCS 99281
|
| Hospital Charge Code |
4509928101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$19.56 |
| Max. Negotiated Rate |
$558.60 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$558.60
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$555.66
|
| Rate for Payer: Aetna of WY Medicare |
$374.22
|
| Rate for Payer: Aetna of WY Medicare |
$376.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$547.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$544.32
|
| Rate for Payer: Altius Commercial |
$544.32
|
| Rate for Payer: Altius Commercial |
$547.20
|
| Rate for Payer: Beech Street Commercial |
$555.66
|
| Rate for Payer: Beech Street Commercial |
$558.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$465.51
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$467.97
|
| Rate for Payer: Cash Price |
$396.90
|
| Rate for Payer: Cash Price |
$396.90
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$549.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$552.90
|
| Rate for Payer: Cigna of WY Commercial |
$558.60
|
| Rate for Payer: Cigna of WY Commercial |
$555.66
|
| Rate for Payer: Entrust Commercial |
$538.65
|
| Rate for Payer: Entrust Commercial |
$541.50
|
| Rate for Payer: First Choice Health Commercial |
$538.65
|
| Rate for Payer: First Choice Health Commercial |
$541.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$541.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$538.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$328.86
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$330.60
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: HealthUtah PPO |
$49.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$552.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$549.99
|
| Rate for Payer: Multiplan Medicare/VA |
$314.07
|
| Rate for Payer: Multiplan Medicare/VA |
$312.42
|
| Rate for Payer: One Health Plan of WY PPO |
$555.66
|
| Rate for Payer: One Health Plan of WY PPO |
$558.60
|
| Rate for Payer: Optum Behavioral Health Commercial |
$19.56
|
| Rate for Payer: Optum Behavioral Health Commercial |
$19.56
|
| Rate for Payer: PacificSource Commercial |
$513.00
|
| Rate for Payer: PacificSource Commercial |
$510.30
|
| Rate for Payer: PHCS PPO |
$555.66
|
| Rate for Payer: PHCS PPO |
$558.60
|
| Rate for Payer: Three Rivers PPO |
$425.25
|
| Rate for Payer: Three Rivers PPO |
$427.50
|
| Rate for Payer: TriWest Veterans Administration |
$330.60
|
| Rate for Payer: TriWest Veterans Administration |
$328.86
|
| Rate for Payer: United Healthcare Commercial |
$493.29
|
| Rate for Payer: United Healthcare Commercial |
$495.90
|
| Rate for Payer: United Healthcare Medicare |
$328.86
|
| Rate for Payer: United Healthcare Medicare |
$330.60
|
| Rate for Payer: WINHealth Partners Commercial |
$558.60
|
| Rate for Payer: WINHealth Partners Commercial |
$555.66
|
| Rate for Payer: Wise Provider Network Commercial |
$541.50
|
| Rate for Payer: Wise Provider Network Commercial |
$538.65
|
|
|
HC EMERGENCY DEPARTMENT LEVEL 1 VISIT LIMITED/MINOR PROB
|
Facility
|
IP
|
$567.00
|
|
|
Service Code
|
HCPCS 99281
|
| Hospital Charge Code |
4509928101
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$355.51 |
| Max. Negotiated Rate |
$567.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$555.66
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$558.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$544.32
|
| Rate for Payer: Altius Auto/Workers Compensation |
$547.20
|
| Rate for Payer: Altius Commercial |
$547.20
|
| Rate for Payer: Altius Commercial |
$544.32
|
| Rate for Payer: Beech Street Commercial |
$555.66
|
| Rate for Payer: Beech Street Commercial |
$558.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$467.97
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$465.51
|
| Rate for Payer: Cash Price |
$396.90
|
| Rate for Payer: Cash Price |
$399.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$549.99
|
| Rate for Payer: ChoiceCare Network Commercial |
$552.90
|
| Rate for Payer: Cigna of WY Commercial |
$558.60
|
| Rate for Payer: Cigna of WY Commercial |
$555.66
|
| Rate for Payer: Entrust Commercial |
$538.65
|
| Rate for Payer: Entrust Commercial |
$541.50
|
| Rate for Payer: First Choice Health Commercial |
$541.50
|
| Rate for Payer: First Choice Health Commercial |
$538.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$541.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$538.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$376.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$374.22
|
| Rate for Payer: HealthUtah PPO |
$570.00
|
| Rate for Payer: HealthUtah PPO |
$567.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$552.90
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$549.99
|
| Rate for Payer: Multiplan Medicare/VA |
$357.39
|
| Rate for Payer: Multiplan Medicare/VA |
$355.51
|
| Rate for Payer: One Health Plan of WY PPO |
$555.66
|
| Rate for Payer: One Health Plan of WY PPO |
$558.60
|
| Rate for Payer: PacificSource Commercial |
$510.30
|
| Rate for Payer: PacificSource Commercial |
$513.00
|
| Rate for Payer: PHCS PPO |
$558.60
|
| Rate for Payer: PHCS PPO |
$555.66
|
| Rate for Payer: Three Rivers PPO |
$427.50
|
| Rate for Payer: Three Rivers PPO |
$425.25
|
| Rate for Payer: TriWest Veterans Administration |
$376.20
|
| Rate for Payer: TriWest Veterans Administration |
$374.22
|
| Rate for Payer: United Healthcare Commercial |
$495.90
|
| Rate for Payer: United Healthcare Commercial |
$493.29
|
| Rate for Payer: United Healthcare Medicare |
$376.20
|
| Rate for Payer: United Healthcare Medicare |
$374.22
|
| Rate for Payer: WINHealth Partners Commercial |
$538.65
|
| Rate for Payer: WINHealth Partners Commercial |
$541.50
|
| Rate for Payer: Wise Provider Network Commercial |
$541.50
|
| Rate for Payer: Wise Provider Network Commercial |
$538.65
|
|
|
HC EMERGENCY DEPARTMENT LEVEL 2 VISIT LOW/MODER SEVERITY
|
Facility
|
OP
|
$1,285.00
|
|
|
Service Code
|
HCPCS 99282
|
| Hospital Charge Code |
4509928201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$37.89 |
| Max. Negotiated Rate |
$1,259.30 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,259.30
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$980.00
|
| Rate for Payer: Aetna of WY Medicare |
$660.00
|
| Rate for Payer: Aetna of WY Medicare |
$848.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,233.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$960.00
|
| Rate for Payer: Altius Commercial |
$960.00
|
| Rate for Payer: Altius Commercial |
$1,233.60
|
| Rate for Payer: Beech Street Commercial |
$980.00
|
| Rate for Payer: Beech Street Commercial |
$1,259.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$821.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,054.98
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: Cash Price |
$899.50
|
| Rate for Payer: Cash Price |
$899.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$970.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,246.45
|
| Rate for Payer: Cigna of WY Commercial |
$1,259.30
|
| Rate for Payer: Cigna of WY Commercial |
$980.00
|
| Rate for Payer: Entrust Commercial |
$950.00
|
| Rate for Payer: Entrust Commercial |
$1,220.75
|
| Rate for Payer: First Choice Health Commercial |
$950.00
|
| Rate for Payer: First Choice Health Commercial |
$1,220.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,220.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$950.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$580.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$745.30
|
| Rate for Payer: HealthUtah PPO |
$79.00
|
| Rate for Payer: HealthUtah PPO |
$79.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,246.45
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$970.00
|
| Rate for Payer: Multiplan Medicare/VA |
$708.04
|
| Rate for Payer: Multiplan Medicare/VA |
$551.00
|
| Rate for Payer: One Health Plan of WY PPO |
$980.00
|
| Rate for Payer: One Health Plan of WY PPO |
$1,259.30
|
| Rate for Payer: Optum Behavioral Health Commercial |
$37.89
|
| Rate for Payer: Optum Behavioral Health Commercial |
$37.89
|
| Rate for Payer: PacificSource Commercial |
$1,156.50
|
| Rate for Payer: PacificSource Commercial |
$900.00
|
| Rate for Payer: PHCS PPO |
$980.00
|
| Rate for Payer: PHCS PPO |
$1,259.30
|
| Rate for Payer: Three Rivers PPO |
$750.00
|
| Rate for Payer: Three Rivers PPO |
$963.75
|
| Rate for Payer: TriWest Veterans Administration |
$745.30
|
| Rate for Payer: TriWest Veterans Administration |
$580.00
|
| Rate for Payer: United Healthcare Commercial |
$870.00
|
| Rate for Payer: United Healthcare Commercial |
$1,117.95
|
| Rate for Payer: United Healthcare Medicare |
$580.00
|
| Rate for Payer: United Healthcare Medicare |
$745.30
|
| Rate for Payer: WINHealth Partners Commercial |
$1,259.30
|
| Rate for Payer: WINHealth Partners Commercial |
$980.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,220.75
|
| Rate for Payer: Wise Provider Network Commercial |
$950.00
|
|
|
HC EMERGENCY DEPARTMENT LEVEL 2 VISIT LOW/MODER SEVERITY
|
Facility
|
IP
|
$1,285.00
|
|
|
Service Code
|
HCPCS 99282
|
| Hospital Charge Code |
4509928201
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$805.70 |
| Max. Negotiated Rate |
$1,285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,259.30
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$980.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,233.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$960.00
|
| Rate for Payer: Altius Commercial |
$960.00
|
| Rate for Payer: Altius Commercial |
$1,233.60
|
| Rate for Payer: Beech Street Commercial |
$1,259.30
|
| Rate for Payer: Beech Street Commercial |
$980.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$821.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,054.98
|
| Rate for Payer: Cash Price |
$899.50
|
| Rate for Payer: Cash Price |
$700.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$970.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,246.45
|
| Rate for Payer: Cigna of WY Commercial |
$1,259.30
|
| Rate for Payer: Cigna of WY Commercial |
$980.00
|
| Rate for Payer: Entrust Commercial |
$950.00
|
| Rate for Payer: Entrust Commercial |
$1,220.75
|
| Rate for Payer: First Choice Health Commercial |
$950.00
|
| Rate for Payer: First Choice Health Commercial |
$1,220.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$950.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,220.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$848.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$660.00
|
| Rate for Payer: HealthUtah PPO |
$1,285.00
|
| Rate for Payer: HealthUtah PPO |
$1,000.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$970.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,246.45
|
| Rate for Payer: Multiplan Medicare/VA |
$805.70
|
| Rate for Payer: Multiplan Medicare/VA |
$627.00
|
| Rate for Payer: One Health Plan of WY PPO |
$1,259.30
|
| Rate for Payer: One Health Plan of WY PPO |
$980.00
|
| Rate for Payer: PacificSource Commercial |
$1,156.50
|
| Rate for Payer: PacificSource Commercial |
$900.00
|
| Rate for Payer: PHCS PPO |
$980.00
|
| Rate for Payer: PHCS PPO |
$1,259.30
|
| Rate for Payer: Three Rivers PPO |
$750.00
|
| Rate for Payer: Three Rivers PPO |
$963.75
|
| Rate for Payer: TriWest Veterans Administration |
$848.10
|
| Rate for Payer: TriWest Veterans Administration |
$660.00
|
| Rate for Payer: United Healthcare Commercial |
$870.00
|
| Rate for Payer: United Healthcare Commercial |
$1,117.95
|
| Rate for Payer: United Healthcare Medicare |
$848.10
|
| Rate for Payer: United Healthcare Medicare |
$660.00
|
| Rate for Payer: WINHealth Partners Commercial |
$950.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,220.75
|
| Rate for Payer: Wise Provider Network Commercial |
$950.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,220.75
|
|
|
HC EMERGENCY DEPARTMENT LEVEL 3 VISIT MODERATE SEVERITY
|
Facility
|
OP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 99283
|
| Hospital Charge Code |
4509928301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$64.44 |
| Max. Negotiated Rate |
$2,450.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,450.00
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,661.10
|
| Rate for Payer: Aetna of WY Medicare |
$1,118.70
|
| Rate for Payer: Aetna of WY Medicare |
$1,650.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,400.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,627.20
|
| Rate for Payer: Altius Commercial |
$1,627.20
|
| Rate for Payer: Altius Commercial |
$2,400.00
|
| Rate for Payer: Beech Street Commercial |
$1,661.10
|
| Rate for Payer: Beech Street Commercial |
$2,450.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,391.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,052.50
|
| Rate for Payer: Cash Price |
$1,186.50
|
| Rate for Payer: Cash Price |
$1,186.50
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,644.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,425.00
|
| Rate for Payer: Cigna of WY Commercial |
$2,450.00
|
| Rate for Payer: Cigna of WY Commercial |
$1,661.10
|
| Rate for Payer: Entrust Commercial |
$1,610.25
|
| Rate for Payer: Entrust Commercial |
$2,375.00
|
| Rate for Payer: First Choice Health Commercial |
$1,610.25
|
| Rate for Payer: First Choice Health Commercial |
$2,375.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,375.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,610.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$983.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,450.00
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: HealthUtah PPO |
$130.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,425.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,644.15
|
| Rate for Payer: Multiplan Medicare/VA |
$1,377.50
|
| Rate for Payer: Multiplan Medicare/VA |
$933.94
|
| Rate for Payer: One Health Plan of WY PPO |
$1,661.10
|
| Rate for Payer: One Health Plan of WY PPO |
$2,450.00
|
| Rate for Payer: Optum Behavioral Health Commercial |
$64.44
|
| Rate for Payer: Optum Behavioral Health Commercial |
$64.44
|
| Rate for Payer: PacificSource Commercial |
$2,250.00
|
| Rate for Payer: PacificSource Commercial |
$1,525.50
|
| Rate for Payer: PHCS PPO |
$1,661.10
|
| Rate for Payer: PHCS PPO |
$2,450.00
|
| Rate for Payer: Three Rivers PPO |
$1,271.25
|
| Rate for Payer: Three Rivers PPO |
$1,875.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,450.00
|
| Rate for Payer: TriWest Veterans Administration |
$983.10
|
| Rate for Payer: United Healthcare Commercial |
$1,474.65
|
| Rate for Payer: United Healthcare Commercial |
$2,175.00
|
| Rate for Payer: United Healthcare Medicare |
$983.10
|
| Rate for Payer: United Healthcare Medicare |
$1,450.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,450.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,661.10
|
| Rate for Payer: Wise Provider Network Commercial |
$2,375.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,610.25
|
|
|
HC EMERGENCY DEPARTMENT LEVEL 3 VISIT MODERATE SEVERITY
|
Facility
|
IP
|
$2,500.00
|
|
|
Service Code
|
HCPCS 99283
|
| Hospital Charge Code |
4509928301
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$1,567.50 |
| Max. Negotiated Rate |
$2,500.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,450.00
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,661.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,400.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,627.20
|
| Rate for Payer: Altius Commercial |
$1,627.20
|
| Rate for Payer: Altius Commercial |
$2,400.00
|
| Rate for Payer: Beech Street Commercial |
$2,450.00
|
| Rate for Payer: Beech Street Commercial |
$1,661.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,391.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,052.50
|
| Rate for Payer: Cash Price |
$1,750.00
|
| Rate for Payer: Cash Price |
$1,186.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,644.15
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,425.00
|
| Rate for Payer: Cigna of WY Commercial |
$2,450.00
|
| Rate for Payer: Cigna of WY Commercial |
$1,661.10
|
| Rate for Payer: Entrust Commercial |
$1,610.25
|
| Rate for Payer: Entrust Commercial |
$2,375.00
|
| Rate for Payer: First Choice Health Commercial |
$1,610.25
|
| Rate for Payer: First Choice Health Commercial |
$2,375.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,610.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,375.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,650.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,118.70
|
| Rate for Payer: HealthUtah PPO |
$2,500.00
|
| Rate for Payer: HealthUtah PPO |
$1,695.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,644.15
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,425.00
|
| Rate for Payer: Multiplan Medicare/VA |
$1,567.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,062.76
|
| Rate for Payer: One Health Plan of WY PPO |
$2,450.00
|
| Rate for Payer: One Health Plan of WY PPO |
$1,661.10
|
| Rate for Payer: PacificSource Commercial |
$2,250.00
|
| Rate for Payer: PacificSource Commercial |
$1,525.50
|
| Rate for Payer: PHCS PPO |
$1,661.10
|
| Rate for Payer: PHCS PPO |
$2,450.00
|
| Rate for Payer: Three Rivers PPO |
$1,271.25
|
| Rate for Payer: Three Rivers PPO |
$1,875.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,650.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,118.70
|
| Rate for Payer: United Healthcare Commercial |
$1,474.65
|
| Rate for Payer: United Healthcare Commercial |
$2,175.00
|
| Rate for Payer: United Healthcare Medicare |
$1,650.00
|
| Rate for Payer: United Healthcare Medicare |
$1,118.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,610.25
|
| Rate for Payer: WINHealth Partners Commercial |
$2,375.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,610.25
|
| Rate for Payer: Wise Provider Network Commercial |
$2,375.00
|
|
|
HC EMERGENCY DEPARTMENT LEVEL 4 VISIT HIGH/URGENT SEVERITY
|
Facility
|
IP
|
$4,230.00
|
|
|
Service Code
|
HCPCS 99284
|
| Hospital Charge Code |
4509928401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,652.21 |
| Max. Negotiated Rate |
$4,230.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,145.40
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,668.54
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,060.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,614.08
|
| Rate for Payer: Altius Commercial |
$2,614.08
|
| Rate for Payer: Altius Commercial |
$4,060.80
|
| Rate for Payer: Beech Street Commercial |
$4,145.40
|
| Rate for Payer: Beech Street Commercial |
$2,668.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,235.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,472.83
|
| Rate for Payer: Cash Price |
$2,961.00
|
| Rate for Payer: Cash Price |
$1,906.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,641.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,103.10
|
| Rate for Payer: Cigna of WY Commercial |
$4,145.40
|
| Rate for Payer: Cigna of WY Commercial |
$2,668.54
|
| Rate for Payer: Entrust Commercial |
$2,586.85
|
| Rate for Payer: Entrust Commercial |
$4,018.50
|
| Rate for Payer: First Choice Health Commercial |
$2,586.85
|
| Rate for Payer: First Choice Health Commercial |
$4,018.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,586.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,018.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,791.80
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,797.18
|
| Rate for Payer: HealthUtah PPO |
$4,230.00
|
| Rate for Payer: HealthUtah PPO |
$2,723.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,641.31
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,103.10
|
| Rate for Payer: Multiplan Medicare/VA |
$2,652.21
|
| Rate for Payer: Multiplan Medicare/VA |
$1,707.32
|
| Rate for Payer: One Health Plan of WY PPO |
$4,145.40
|
| Rate for Payer: One Health Plan of WY PPO |
$2,668.54
|
| Rate for Payer: PacificSource Commercial |
$3,807.00
|
| Rate for Payer: PacificSource Commercial |
$2,450.70
|
| Rate for Payer: PHCS PPO |
$2,668.54
|
| Rate for Payer: PHCS PPO |
$4,145.40
|
| Rate for Payer: Three Rivers PPO |
$2,042.25
|
| Rate for Payer: Three Rivers PPO |
$3,172.50
|
| Rate for Payer: TriWest Veterans Administration |
$2,791.80
|
| Rate for Payer: TriWest Veterans Administration |
$1,797.18
|
| Rate for Payer: United Healthcare Commercial |
$2,369.01
|
| Rate for Payer: United Healthcare Commercial |
$3,680.10
|
| Rate for Payer: United Healthcare Medicare |
$2,791.80
|
| Rate for Payer: United Healthcare Medicare |
$1,797.18
|
| Rate for Payer: WINHealth Partners Commercial |
$2,586.85
|
| Rate for Payer: WINHealth Partners Commercial |
$4,018.50
|
| Rate for Payer: Wise Provider Network Commercial |
$2,586.85
|
| Rate for Payer: Wise Provider Network Commercial |
$4,018.50
|
|
|
HC EMERGENCY DEPARTMENT LEVEL 4 VISIT HIGH/URGENT SEVERITY
|
Facility
|
OP
|
$4,230.00
|
|
|
Service Code
|
HCPCS 99284
|
| Hospital Charge Code |
4509928401
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$108.84 |
| Max. Negotiated Rate |
$4,145.40 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,145.40
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,668.54
|
| Rate for Payer: Aetna of WY Medicare |
$1,797.18
|
| Rate for Payer: Aetna of WY Medicare |
$2,791.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,060.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,614.08
|
| Rate for Payer: Altius Commercial |
$2,614.08
|
| Rate for Payer: Altius Commercial |
$4,060.80
|
| Rate for Payer: Beech Street Commercial |
$2,668.54
|
| Rate for Payer: Beech Street Commercial |
$4,145.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,235.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,472.83
|
| Rate for Payer: Cash Price |
$1,906.10
|
| Rate for Payer: Cash Price |
$1,906.10
|
| Rate for Payer: Cash Price |
$2,961.00
|
| Rate for Payer: Cash Price |
$2,961.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,641.31
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,103.10
|
| Rate for Payer: Cigna of WY Commercial |
$4,145.40
|
| Rate for Payer: Cigna of WY Commercial |
$2,668.54
|
| Rate for Payer: Entrust Commercial |
$2,586.85
|
| Rate for Payer: Entrust Commercial |
$4,018.50
|
| Rate for Payer: First Choice Health Commercial |
$2,586.85
|
| Rate for Payer: First Choice Health Commercial |
$4,018.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,018.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,586.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,579.34
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,453.40
|
| Rate for Payer: HealthUtah PPO |
$197.00
|
| Rate for Payer: HealthUtah PPO |
$197.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,103.10
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,641.31
|
| Rate for Payer: Multiplan Medicare/VA |
$2,330.73
|
| Rate for Payer: Multiplan Medicare/VA |
$1,500.37
|
| Rate for Payer: One Health Plan of WY PPO |
$2,668.54
|
| Rate for Payer: One Health Plan of WY PPO |
$4,145.40
|
| Rate for Payer: Optum Behavioral Health Commercial |
$108.84
|
| Rate for Payer: Optum Behavioral Health Commercial |
$108.84
|
| Rate for Payer: PacificSource Commercial |
$3,807.00
|
| Rate for Payer: PacificSource Commercial |
$2,450.70
|
| Rate for Payer: PHCS PPO |
$2,668.54
|
| Rate for Payer: PHCS PPO |
$4,145.40
|
| Rate for Payer: Three Rivers PPO |
$2,042.25
|
| Rate for Payer: Three Rivers PPO |
$3,172.50
|
| Rate for Payer: TriWest Veterans Administration |
$2,453.40
|
| Rate for Payer: TriWest Veterans Administration |
$1,579.34
|
| Rate for Payer: United Healthcare Commercial |
$2,369.01
|
| Rate for Payer: United Healthcare Commercial |
$3,680.10
|
| Rate for Payer: United Healthcare Medicare |
$1,579.34
|
| Rate for Payer: United Healthcare Medicare |
$2,453.40
|
| Rate for Payer: WINHealth Partners Commercial |
$4,145.40
|
| Rate for Payer: WINHealth Partners Commercial |
$2,668.54
|
| Rate for Payer: Wise Provider Network Commercial |
$4,018.50
|
| Rate for Payer: Wise Provider Network Commercial |
$2,586.85
|
|
|
HC EMERGENCY DEPARTMENT LEVEL 5 VISIT HIGH SEVERITY&THREAT FUNC
|
Facility
|
OP
|
$3,733.00
|
|
|
Service Code
|
HCPCS 99285
|
| Hospital Charge Code |
4509928501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$157.98 |
| Max. Negotiated Rate |
$3,658.34 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,658.34
|
| Rate for Payer: Aetna of WY Medicare |
$2,463.78
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,583.68
|
| Rate for Payer: Altius Commercial |
$3,583.68
|
| Rate for Payer: Beech Street Commercial |
$3,658.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,064.79
|
| Rate for Payer: Cash Price |
$2,613.10
|
| Rate for Payer: Cash Price |
$2,613.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,621.01
|
| Rate for Payer: Cigna of WY Commercial |
$3,658.34
|
| Rate for Payer: Entrust Commercial |
$3,546.35
|
| Rate for Payer: First Choice Health Commercial |
$3,546.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,546.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,165.14
|
| Rate for Payer: HealthUtah PPO |
$291.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,621.01
|
| Rate for Payer: Multiplan Medicare/VA |
$2,056.88
|
| Rate for Payer: One Health Plan of WY PPO |
$3,658.34
|
| Rate for Payer: Optum Behavioral Health Commercial |
$157.98
|
| Rate for Payer: PacificSource Commercial |
$3,359.70
|
| Rate for Payer: PHCS PPO |
$3,658.34
|
| Rate for Payer: Three Rivers PPO |
$2,799.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,165.14
|
| Rate for Payer: United Healthcare Commercial |
$3,247.71
|
| Rate for Payer: United Healthcare Medicare |
$2,165.14
|
| Rate for Payer: WINHealth Partners Commercial |
$3,658.34
|
| Rate for Payer: Wise Provider Network Commercial |
$3,546.35
|
|
|
HC EMERGENCY DEPARTMENT LEVEL 5 VISIT HIGH SEVERITY&THREAT FUNC
|
Facility
|
IP
|
$3,733.00
|
|
|
Service Code
|
HCPCS 99285
|
| Hospital Charge Code |
4509928501
|
|
Hospital Revenue Code
|
450
|
| Min. Negotiated Rate |
$2,340.59 |
| Max. Negotiated Rate |
$3,733.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,658.34
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,583.68
|
| Rate for Payer: Altius Commercial |
$3,583.68
|
| Rate for Payer: Beech Street Commercial |
$3,658.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,064.79
|
| Rate for Payer: Cash Price |
$2,613.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,621.01
|
| Rate for Payer: Cigna of WY Commercial |
$3,658.34
|
| Rate for Payer: Entrust Commercial |
$3,546.35
|
| Rate for Payer: First Choice Health Commercial |
$3,546.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,546.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,463.78
|
| Rate for Payer: HealthUtah PPO |
$3,733.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,621.01
|
| Rate for Payer: Multiplan Medicare/VA |
$2,340.59
|
| Rate for Payer: One Health Plan of WY PPO |
$3,658.34
|
| Rate for Payer: PacificSource Commercial |
$3,359.70
|
| Rate for Payer: PHCS PPO |
$3,658.34
|
| Rate for Payer: Three Rivers PPO |
$2,799.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,463.78
|
| Rate for Payer: United Healthcare Commercial |
$3,247.71
|
| Rate for Payer: United Healthcare Medicare |
$2,463.78
|
| Rate for Payer: WINHealth Partners Commercial |
$3,546.35
|
| Rate for Payer: Wise Provider Network Commercial |
$3,546.35
|
|
