|
HC BONE IMAGING, 3 PHASE - NM BONE WHOLE BODY 3 PHASE
|
Facility
|
IP
|
$2,617.00
|
|
|
Service Code
|
HCPCS 78315
|
| Hospital Charge Code |
3417831501
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,516.55 |
| Max. Negotiated Rate |
$2,617.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,564.66
|
| Rate for Payer: Aetna of WY Medicare |
$1,674.88
|
| Rate for Payer: Altius Commercial |
$2,512.32
|
| Rate for Payer: Beech Street Commercial |
$2,564.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,538.49
|
| Rate for Payer: Cash Price |
$1,831.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,538.49
|
| Rate for Payer: Cigna of WY Commercial |
$2,564.66
|
| Rate for Payer: Entrust Commercial |
$2,486.15
|
| Rate for Payer: First Choice Health Commercial |
$2,486.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,486.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,596.37
|
| Rate for Payer: HealthUtah PPO |
$2,617.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,538.49
|
| Rate for Payer: Multiplan Medicare/VA |
$1,516.55
|
| Rate for Payer: One Health Plan of WY PPO |
$2,564.66
|
| Rate for Payer: PacificSource Commercial |
$2,355.30
|
| Rate for Payer: PHCS PPO |
$2,564.66
|
| Rate for Payer: Three Rivers PPO |
$1,962.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,596.37
|
| Rate for Payer: United Healthcare Commercial |
$2,499.24
|
| Rate for Payer: United Healthcare Medicare |
$1,596.37
|
| Rate for Payer: WINHealth Partners Commercial |
$2,486.15
|
| Rate for Payer: Wise Provider Network Commercial |
$2,486.15
|
|
|
HC BONE IMAGING, 3 PHASE - NM BONE WHOLE BODY 3 PHASE
|
Facility
|
OP
|
$2,617.00
|
|
|
Service Code
|
HCPCS 78315
|
| Hospital Charge Code |
3417831501
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,417.11 |
| Max. Negotiated Rate |
$2,617.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,564.66
|
| Rate for Payer: Aetna of WY Medicare |
$1,727.22
|
| Rate for Payer: Altius Commercial |
$2,512.32
|
| Rate for Payer: Beech Street Commercial |
$2,564.66
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,538.49
|
| Rate for Payer: Cash Price |
$1,831.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,538.49
|
| Rate for Payer: Cigna of WY Commercial |
$2,564.66
|
| Rate for Payer: Entrust Commercial |
$2,486.15
|
| Rate for Payer: First Choice Health Commercial |
$2,486.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,486.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,491.69
|
| Rate for Payer: HealthUtah PPO |
$2,617.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,538.49
|
| Rate for Payer: Multiplan Medicare/VA |
$1,417.11
|
| Rate for Payer: One Health Plan of WY PPO |
$2,564.66
|
| Rate for Payer: PacificSource Commercial |
$2,355.30
|
| Rate for Payer: PHCS PPO |
$2,564.66
|
| Rate for Payer: Three Rivers PPO |
$1,962.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,491.69
|
| Rate for Payer: United Healthcare Commercial |
$2,499.24
|
| Rate for Payer: United Healthcare Medicare |
$1,491.69
|
| Rate for Payer: WINHealth Partners Commercial |
$2,564.66
|
| Rate for Payer: Wise Provider Network Commercial |
$2,486.15
|
|
|
HC BONE IMAGING, LIMITED AREA - NM BONE LIMITED
|
Facility
|
OP
|
$1,086.00
|
|
|
Service Code
|
HCPCS 78300
|
| Hospital Charge Code |
3417830001
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$588.07 |
| Max. Negotiated Rate |
$1,086.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,064.28
|
| Rate for Payer: Aetna of WY Medicare |
$716.76
|
| Rate for Payer: Altius Commercial |
$1,042.56
|
| Rate for Payer: Beech Street Commercial |
$1,064.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,053.42
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,053.42
|
| Rate for Payer: Cigna of WY Commercial |
$1,064.28
|
| Rate for Payer: Entrust Commercial |
$1,031.70
|
| Rate for Payer: First Choice Health Commercial |
$1,031.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,031.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$619.02
|
| Rate for Payer: HealthUtah PPO |
$1,086.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,053.42
|
| Rate for Payer: Multiplan Medicare/VA |
$588.07
|
| Rate for Payer: One Health Plan of WY PPO |
$1,064.28
|
| Rate for Payer: PacificSource Commercial |
$977.40
|
| Rate for Payer: PHCS PPO |
$1,064.28
|
| Rate for Payer: Three Rivers PPO |
$814.50
|
| Rate for Payer: TriWest Veterans Administration |
$619.02
|
| Rate for Payer: United Healthcare Commercial |
$1,037.13
|
| Rate for Payer: United Healthcare Medicare |
$619.02
|
| Rate for Payer: WINHealth Partners Commercial |
$1,064.28
|
| Rate for Payer: Wise Provider Network Commercial |
$1,031.70
|
|
|
HC BONE IMAGING, LIMITED AREA - NM BONE LIMITED
|
Facility
|
IP
|
$1,086.00
|
|
|
Service Code
|
HCPCS 78300
|
| Hospital Charge Code |
3417830001
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$629.34 |
| Max. Negotiated Rate |
$1,086.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,064.28
|
| Rate for Payer: Aetna of WY Medicare |
$695.04
|
| Rate for Payer: Altius Commercial |
$1,042.56
|
| Rate for Payer: Beech Street Commercial |
$1,064.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,053.42
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,053.42
|
| Rate for Payer: Cigna of WY Commercial |
$1,064.28
|
| Rate for Payer: Entrust Commercial |
$1,031.70
|
| Rate for Payer: First Choice Health Commercial |
$1,031.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,031.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$662.46
|
| Rate for Payer: HealthUtah PPO |
$1,086.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,053.42
|
| Rate for Payer: Multiplan Medicare/VA |
$629.34
|
| Rate for Payer: One Health Plan of WY PPO |
$1,064.28
|
| Rate for Payer: PacificSource Commercial |
$977.40
|
| Rate for Payer: PHCS PPO |
$1,064.28
|
| Rate for Payer: Three Rivers PPO |
$814.50
|
| Rate for Payer: TriWest Veterans Administration |
$662.46
|
| Rate for Payer: United Healthcare Commercial |
$1,037.13
|
| Rate for Payer: United Healthcare Medicare |
$662.46
|
| Rate for Payer: WINHealth Partners Commercial |
$1,031.70
|
| Rate for Payer: Wise Provider Network Commercial |
$1,031.70
|
|
|
HC BONE IMAGING, WHOLE BODY - NM BONE WHOLE BODY
|
Facility
|
IP
|
$2,495.00
|
|
|
Service Code
|
HCPCS 78306
|
| Hospital Charge Code |
3417830601
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,445.85 |
| Max. Negotiated Rate |
$2,495.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,445.10
|
| Rate for Payer: Aetna of WY Medicare |
$1,596.80
|
| Rate for Payer: Altius Commercial |
$2,395.20
|
| Rate for Payer: Beech Street Commercial |
$2,445.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,420.15
|
| Rate for Payer: Cash Price |
$1,746.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,420.15
|
| Rate for Payer: Cigna of WY Commercial |
$2,445.10
|
| Rate for Payer: Entrust Commercial |
$2,370.25
|
| Rate for Payer: First Choice Health Commercial |
$2,370.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,370.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,521.95
|
| Rate for Payer: HealthUtah PPO |
$2,495.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,420.15
|
| Rate for Payer: Multiplan Medicare/VA |
$1,445.85
|
| Rate for Payer: One Health Plan of WY PPO |
$2,445.10
|
| Rate for Payer: PacificSource Commercial |
$2,245.50
|
| Rate for Payer: PHCS PPO |
$2,445.10
|
| Rate for Payer: Three Rivers PPO |
$1,871.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,521.95
|
| Rate for Payer: United Healthcare Commercial |
$2,382.72
|
| Rate for Payer: United Healthcare Medicare |
$1,521.95
|
| Rate for Payer: WINHealth Partners Commercial |
$2,370.25
|
| Rate for Payer: Wise Provider Network Commercial |
$2,370.25
|
|
|
HC BONE IMAGING, WHOLE BODY - NM BONE WHOLE BODY
|
Facility
|
OP
|
$2,495.00
|
|
|
Service Code
|
HCPCS 78306
|
| Hospital Charge Code |
3417830601
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$1,351.04 |
| Max. Negotiated Rate |
$2,495.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,445.10
|
| Rate for Payer: Aetna of WY Medicare |
$1,646.70
|
| Rate for Payer: Altius Commercial |
$2,395.20
|
| Rate for Payer: Beech Street Commercial |
$2,445.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,420.15
|
| Rate for Payer: Cash Price |
$1,746.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,420.15
|
| Rate for Payer: Cigna of WY Commercial |
$2,445.10
|
| Rate for Payer: Entrust Commercial |
$2,370.25
|
| Rate for Payer: First Choice Health Commercial |
$2,370.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,370.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,422.15
|
| Rate for Payer: HealthUtah PPO |
$2,495.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,420.15
|
| Rate for Payer: Multiplan Medicare/VA |
$1,351.04
|
| Rate for Payer: One Health Plan of WY PPO |
$2,445.10
|
| Rate for Payer: PacificSource Commercial |
$2,245.50
|
| Rate for Payer: PHCS PPO |
$2,445.10
|
| Rate for Payer: Three Rivers PPO |
$1,871.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,422.15
|
| Rate for Payer: United Healthcare Commercial |
$2,382.72
|
| Rate for Payer: United Healthcare Medicare |
$1,422.15
|
| Rate for Payer: WINHealth Partners Commercial |
$2,445.10
|
| Rate for Payer: Wise Provider Network Commercial |
$2,370.25
|
|
|
HC BORDETELLA ANTIBODY - BORDETELLA PERTUSSIS ANTIBODY IGA
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 86615
|
| Hospital Charge Code |
3028661503
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$96.93 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$175.42
|
| Rate for Payer: Aetna of WY Medicare |
$118.14
|
| Rate for Payer: Altius Commercial |
$171.84
|
| Rate for Payer: Beech Street Commercial |
$175.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$173.63
|
| Rate for Payer: Cash Price |
$125.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.63
|
| Rate for Payer: Cigna of WY Commercial |
$175.42
|
| Rate for Payer: Entrust Commercial |
$170.05
|
| Rate for Payer: First Choice Health Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$102.03
|
| Rate for Payer: HealthUtah PPO |
$179.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.63
|
| Rate for Payer: Multiplan Medicare/VA |
$96.93
|
| Rate for Payer: One Health Plan of WY PPO |
$175.42
|
| Rate for Payer: PacificSource Commercial |
$161.10
|
| Rate for Payer: PHCS PPO |
$175.42
|
| Rate for Payer: Three Rivers PPO |
$134.25
|
| Rate for Payer: TriWest Veterans Administration |
$102.03
|
| Rate for Payer: United Healthcare Commercial |
$170.94
|
| Rate for Payer: United Healthcare Medicare |
$102.03
|
| Rate for Payer: WINHealth Partners Commercial |
$175.42
|
| Rate for Payer: Wise Provider Network Commercial |
$170.05
|
|
|
HC BORDETELLA ANTIBODY - BORDETELLA PERTUSSIS ANTIBODY IGA
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 86615
|
| Hospital Charge Code |
3028661503
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$103.73 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$175.42
|
| Rate for Payer: Aetna of WY Medicare |
$114.56
|
| Rate for Payer: Altius Commercial |
$171.84
|
| Rate for Payer: Beech Street Commercial |
$175.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$173.63
|
| Rate for Payer: Cash Price |
$125.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.63
|
| Rate for Payer: Cigna of WY Commercial |
$175.42
|
| Rate for Payer: Entrust Commercial |
$170.05
|
| Rate for Payer: First Choice Health Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$109.19
|
| Rate for Payer: HealthUtah PPO |
$179.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.63
|
| Rate for Payer: Multiplan Medicare/VA |
$103.73
|
| Rate for Payer: One Health Plan of WY PPO |
$175.42
|
| Rate for Payer: PacificSource Commercial |
$161.10
|
| Rate for Payer: PHCS PPO |
$175.42
|
| Rate for Payer: Three Rivers PPO |
$134.25
|
| Rate for Payer: TriWest Veterans Administration |
$109.19
|
| Rate for Payer: United Healthcare Commercial |
$170.94
|
| Rate for Payer: United Healthcare Medicare |
$109.19
|
| Rate for Payer: WINHealth Partners Commercial |
$170.05
|
| Rate for Payer: Wise Provider Network Commercial |
$170.05
|
|
|
HC BORDETELLA ANTIBODY - BORDETELLA PERTUSSIS ANTIBODY IGG
|
Facility
|
OP
|
$179.00
|
|
|
Service Code
|
HCPCS 86615
|
| Hospital Charge Code |
3028661502
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$96.93 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$175.42
|
| Rate for Payer: Aetna of WY Medicare |
$118.14
|
| Rate for Payer: Altius Commercial |
$171.84
|
| Rate for Payer: Beech Street Commercial |
$175.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$173.63
|
| Rate for Payer: Cash Price |
$125.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.63
|
| Rate for Payer: Cigna of WY Commercial |
$175.42
|
| Rate for Payer: Entrust Commercial |
$170.05
|
| Rate for Payer: First Choice Health Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$102.03
|
| Rate for Payer: HealthUtah PPO |
$179.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.63
|
| Rate for Payer: Multiplan Medicare/VA |
$96.93
|
| Rate for Payer: One Health Plan of WY PPO |
$175.42
|
| Rate for Payer: PacificSource Commercial |
$161.10
|
| Rate for Payer: PHCS PPO |
$175.42
|
| Rate for Payer: Three Rivers PPO |
$134.25
|
| Rate for Payer: TriWest Veterans Administration |
$102.03
|
| Rate for Payer: United Healthcare Commercial |
$170.94
|
| Rate for Payer: United Healthcare Medicare |
$102.03
|
| Rate for Payer: WINHealth Partners Commercial |
$175.42
|
| Rate for Payer: Wise Provider Network Commercial |
$170.05
|
|
|
HC BORDETELLA ANTIBODY - BORDETELLA PERTUSSIS ANTIBODY IGG
|
Facility
|
IP
|
$179.00
|
|
|
Service Code
|
HCPCS 86615
|
| Hospital Charge Code |
3028661502
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$103.73 |
| Max. Negotiated Rate |
$179.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$175.42
|
| Rate for Payer: Aetna of WY Medicare |
$114.56
|
| Rate for Payer: Altius Commercial |
$171.84
|
| Rate for Payer: Beech Street Commercial |
$175.42
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$173.63
|
| Rate for Payer: Cash Price |
$125.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$173.63
|
| Rate for Payer: Cigna of WY Commercial |
$175.42
|
| Rate for Payer: Entrust Commercial |
$170.05
|
| Rate for Payer: First Choice Health Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$170.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$109.19
|
| Rate for Payer: HealthUtah PPO |
$179.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$173.63
|
| Rate for Payer: Multiplan Medicare/VA |
$103.73
|
| Rate for Payer: One Health Plan of WY PPO |
$175.42
|
| Rate for Payer: PacificSource Commercial |
$161.10
|
| Rate for Payer: PHCS PPO |
$175.42
|
| Rate for Payer: Three Rivers PPO |
$134.25
|
| Rate for Payer: TriWest Veterans Administration |
$109.19
|
| Rate for Payer: United Healthcare Commercial |
$170.94
|
| Rate for Payer: United Healthcare Medicare |
$109.19
|
| Rate for Payer: WINHealth Partners Commercial |
$170.05
|
| Rate for Payer: Wise Provider Network Commercial |
$170.05
|
|
|
HC BOWEL IMAGING - NM MECKELS DIVERTICULUM
|
Facility
|
OP
|
$1,086.00
|
|
|
Service Code
|
HCPCS 78290
|
| Hospital Charge Code |
3417829001
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$588.07 |
| Max. Negotiated Rate |
$1,086.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,064.28
|
| Rate for Payer: Aetna of WY Medicare |
$716.76
|
| Rate for Payer: Altius Commercial |
$1,042.56
|
| Rate for Payer: Beech Street Commercial |
$1,064.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,053.42
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,053.42
|
| Rate for Payer: Cigna of WY Commercial |
$1,064.28
|
| Rate for Payer: Entrust Commercial |
$1,031.70
|
| Rate for Payer: First Choice Health Commercial |
$1,031.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,031.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$619.02
|
| Rate for Payer: HealthUtah PPO |
$1,086.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,053.42
|
| Rate for Payer: Multiplan Medicare/VA |
$588.07
|
| Rate for Payer: One Health Plan of WY PPO |
$1,064.28
|
| Rate for Payer: PacificSource Commercial |
$977.40
|
| Rate for Payer: PHCS PPO |
$1,064.28
|
| Rate for Payer: Three Rivers PPO |
$814.50
|
| Rate for Payer: TriWest Veterans Administration |
$619.02
|
| Rate for Payer: United Healthcare Commercial |
$1,037.13
|
| Rate for Payer: United Healthcare Medicare |
$619.02
|
| Rate for Payer: WINHealth Partners Commercial |
$1,064.28
|
| Rate for Payer: Wise Provider Network Commercial |
$1,031.70
|
|
|
HC BOWEL IMAGING - NM MECKELS DIVERTICULUM
|
Facility
|
IP
|
$1,086.00
|
|
|
Service Code
|
HCPCS 78290
|
| Hospital Charge Code |
3417829001
|
|
Hospital Revenue Code
|
341
|
| Min. Negotiated Rate |
$629.34 |
| Max. Negotiated Rate |
$1,086.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,064.28
|
| Rate for Payer: Aetna of WY Medicare |
$695.04
|
| Rate for Payer: Altius Commercial |
$1,042.56
|
| Rate for Payer: Beech Street Commercial |
$1,064.28
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,053.42
|
| Rate for Payer: Cash Price |
$760.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,053.42
|
| Rate for Payer: Cigna of WY Commercial |
$1,064.28
|
| Rate for Payer: Entrust Commercial |
$1,031.70
|
| Rate for Payer: First Choice Health Commercial |
$1,031.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,031.70
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$662.46
|
| Rate for Payer: HealthUtah PPO |
$1,086.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,053.42
|
| Rate for Payer: Multiplan Medicare/VA |
$629.34
|
| Rate for Payer: One Health Plan of WY PPO |
$1,064.28
|
| Rate for Payer: PacificSource Commercial |
$977.40
|
| Rate for Payer: PHCS PPO |
$1,064.28
|
| Rate for Payer: Three Rivers PPO |
$814.50
|
| Rate for Payer: TriWest Veterans Administration |
$662.46
|
| Rate for Payer: United Healthcare Commercial |
$1,037.13
|
| Rate for Payer: United Healthcare Medicare |
$662.46
|
| Rate for Payer: WINHealth Partners Commercial |
$1,031.70
|
| Rate for Payer: Wise Provider Network Commercial |
$1,031.70
|
|
|
HC BRACE
|
Facility
|
IP
|
$389.00
|
|
| Hospital Charge Code |
4200000002
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$225.43 |
| Max. Negotiated Rate |
$389.00 |
| Rate for Payer: United Healthcare Commercial |
$371.50
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$381.22
|
| Rate for Payer: Aetna of WY Medicare |
$248.96
|
| Rate for Payer: Altius Commercial |
$373.44
|
| Rate for Payer: Beech Street Commercial |
$381.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$377.33
|
| Rate for Payer: Cash Price |
$272.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$377.33
|
| Rate for Payer: Cigna of WY Commercial |
$381.22
|
| Rate for Payer: Entrust Commercial |
$369.55
|
| Rate for Payer: First Choice Health Commercial |
$369.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$369.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$237.29
|
| Rate for Payer: HealthUtah PPO |
$389.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$377.33
|
| Rate for Payer: Multiplan Medicare/VA |
$225.43
|
| Rate for Payer: One Health Plan of WY PPO |
$381.22
|
| Rate for Payer: PacificSource Commercial |
$350.10
|
| Rate for Payer: PHCS PPO |
$381.22
|
| Rate for Payer: Three Rivers PPO |
$291.75
|
| Rate for Payer: TriWest Veterans Administration |
$237.29
|
| Rate for Payer: United Healthcare Medicare |
$237.29
|
| Rate for Payer: WINHealth Partners Commercial |
$369.55
|
| Rate for Payer: Wise Provider Network Commercial |
$369.55
|
|
|
HC BRACE
|
Facility
|
OP
|
$389.00
|
|
| Hospital Charge Code |
4200000002
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$210.64 |
| Max. Negotiated Rate |
$389.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$381.22
|
| Rate for Payer: Aetna of WY Medicare |
$256.74
|
| Rate for Payer: Altius Commercial |
$373.44
|
| Rate for Payer: Beech Street Commercial |
$381.22
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$377.33
|
| Rate for Payer: Cash Price |
$272.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$377.33
|
| Rate for Payer: Cigna of WY Commercial |
$381.22
|
| Rate for Payer: Entrust Commercial |
$369.55
|
| Rate for Payer: First Choice Health Commercial |
$369.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$369.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$221.73
|
| Rate for Payer: HealthUtah PPO |
$389.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$377.33
|
| Rate for Payer: Multiplan Medicare/VA |
$210.64
|
| Rate for Payer: One Health Plan of WY PPO |
$381.22
|
| Rate for Payer: PacificSource Commercial |
$350.10
|
| Rate for Payer: PHCS PPO |
$381.22
|
| Rate for Payer: Three Rivers PPO |
$291.75
|
| Rate for Payer: TriWest Veterans Administration |
$221.73
|
| Rate for Payer: United Healthcare Commercial |
$371.50
|
| Rate for Payer: United Healthcare Medicare |
$221.73
|
| Rate for Payer: WINHealth Partners Commercial |
$381.22
|
| Rate for Payer: Wise Provider Network Commercial |
$369.55
|
|
|
HC BRCA1&BRCA2 FULL SEQ ANALYS/FULL DUP/DEL ANALYS
|
Facility
|
OP
|
$3,803.00
|
|
|
Service Code
|
HCPCS 81162
|
| Hospital Charge Code |
3108116201
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$2,059.32 |
| Max. Negotiated Rate |
$3,803.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,726.94
|
| Rate for Payer: Aetna of WY Medicare |
$2,509.98
|
| Rate for Payer: Altius Commercial |
$3,650.88
|
| Rate for Payer: Beech Street Commercial |
$3,726.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,688.91
|
| Rate for Payer: Cash Price |
$2,662.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,688.91
|
| Rate for Payer: Cigna of WY Commercial |
$3,726.94
|
| Rate for Payer: Entrust Commercial |
$3,612.85
|
| Rate for Payer: First Choice Health Commercial |
$3,612.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,612.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,167.71
|
| Rate for Payer: HealthUtah PPO |
$3,803.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,688.91
|
| Rate for Payer: Multiplan Medicare/VA |
$2,059.32
|
| Rate for Payer: One Health Plan of WY PPO |
$3,726.94
|
| Rate for Payer: PacificSource Commercial |
$3,422.70
|
| Rate for Payer: PHCS PPO |
$3,726.94
|
| Rate for Payer: Three Rivers PPO |
$2,852.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,167.71
|
| Rate for Payer: United Healthcare Commercial |
$3,631.86
|
| Rate for Payer: United Healthcare Medicare |
$2,167.71
|
| Rate for Payer: WINHealth Partners Commercial |
$3,726.94
|
| Rate for Payer: Wise Provider Network Commercial |
$3,612.85
|
|
|
HC BRCA1&BRCA2 FULL SEQ ANALYS/FULL DUP/DEL ANALYS
|
Facility
|
IP
|
$3,803.00
|
|
|
Service Code
|
HCPCS 81162
|
| Hospital Charge Code |
3108116201
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$2,203.84 |
| Max. Negotiated Rate |
$3,803.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,726.94
|
| Rate for Payer: Aetna of WY Medicare |
$2,433.92
|
| Rate for Payer: Altius Commercial |
$3,650.88
|
| Rate for Payer: Beech Street Commercial |
$3,726.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,688.91
|
| Rate for Payer: Cash Price |
$2,662.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,688.91
|
| Rate for Payer: Cigna of WY Commercial |
$3,726.94
|
| Rate for Payer: Entrust Commercial |
$3,612.85
|
| Rate for Payer: First Choice Health Commercial |
$3,612.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,612.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,319.83
|
| Rate for Payer: HealthUtah PPO |
$3,803.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,688.91
|
| Rate for Payer: Multiplan Medicare/VA |
$2,203.84
|
| Rate for Payer: One Health Plan of WY PPO |
$3,726.94
|
| Rate for Payer: PacificSource Commercial |
$3,422.70
|
| Rate for Payer: PHCS PPO |
$3,726.94
|
| Rate for Payer: Three Rivers PPO |
$2,852.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,319.83
|
| Rate for Payer: United Healthcare Commercial |
$3,631.86
|
| Rate for Payer: United Healthcare Medicare |
$2,319.83
|
| Rate for Payer: WINHealth Partners Commercial |
$3,612.85
|
| Rate for Payer: Wise Provider Network Commercial |
$3,612.85
|
|
|
HC BREAST TOMOSYNTHESIS BI - MAMMO BREAST DIAGNOSTIC TOMOSYNTHESIS BIL
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 77062
|
| Hospital Charge Code |
4017706201
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$29.78 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Aetna of WY Medicare |
$36.30
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.35
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.35
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$29.78
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$31.35
|
| Rate for Payer: United Healthcare Commercial |
$52.52
|
| Rate for Payer: United Healthcare Medicare |
$31.35
|
| Rate for Payer: WINHealth Partners Commercial |
$53.90
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
HC BREAST TOMOSYNTHESIS BI - MAMMO BREAST DIAGNOSTIC TOMOSYNTHESIS BIL
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 77062
|
| Hospital Charge Code |
4017706201
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$31.87 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Aetna of WY Medicare |
$35.20
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.35
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.55
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$31.87
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$33.55
|
| Rate for Payer: United Healthcare Commercial |
$52.52
|
| Rate for Payer: United Healthcare Medicare |
$33.55
|
| Rate for Payer: WINHealth Partners Commercial |
$52.25
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
HC BREAST TOMOSYNTHESIS BI - MAMMO BREAST DIAGNOSTIC TOMOSYNTHESIS IMP BIL
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 77062
|
| Hospital Charge Code |
4017706202
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$29.78 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Aetna of WY Medicare |
$36.30
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.35
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.35
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$29.78
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$31.35
|
| Rate for Payer: United Healthcare Commercial |
$52.52
|
| Rate for Payer: United Healthcare Medicare |
$31.35
|
| Rate for Payer: WINHealth Partners Commercial |
$53.90
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
HC BREAST TOMOSYNTHESIS BI - MAMMO BREAST DIAGNOSTIC TOMOSYNTHESIS IMP BIL
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 77062
|
| Hospital Charge Code |
4017706202
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$31.87 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Aetna of WY Medicare |
$35.20
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.35
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.55
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$31.87
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$33.55
|
| Rate for Payer: United Healthcare Commercial |
$52.52
|
| Rate for Payer: United Healthcare Medicare |
$33.55
|
| Rate for Payer: WINHealth Partners Commercial |
$52.25
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
HC BREAST TOMOSYNTHESIS BI - MAMMO BREAST SCREENING TOMOSYNTHESIS BILAT
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 77063
|
| Hospital Charge Code |
4037706301
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$29.78 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Aetna of WY Medicare |
$36.30
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.35
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.35
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$29.78
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$31.35
|
| Rate for Payer: United Healthcare Commercial |
$52.52
|
| Rate for Payer: United Healthcare Medicare |
$31.35
|
| Rate for Payer: WINHealth Partners Commercial |
$53.90
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
HC BREAST TOMOSYNTHESIS BI - MAMMO BREAST SCREENING TOMOSYNTHESIS BILAT
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 77063
|
| Hospital Charge Code |
4037706301
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$31.87 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Aetna of WY Medicare |
$35.20
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.35
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.55
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$31.87
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$33.55
|
| Rate for Payer: United Healthcare Commercial |
$52.52
|
| Rate for Payer: United Healthcare Medicare |
$33.55
|
| Rate for Payer: WINHealth Partners Commercial |
$52.25
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
HC BREAST TOMOSYNTHESIS BI - MAMMO BREAST SCREENING TOMOSYNTHESIS LEFT
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
HCPCS 77063
|
| Hospital Charge Code |
4037706302
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$29.78 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Aetna of WY Medicare |
$36.30
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.35
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$31.35
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$29.78
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$31.35
|
| Rate for Payer: United Healthcare Commercial |
$52.52
|
| Rate for Payer: United Healthcare Medicare |
$31.35
|
| Rate for Payer: WINHealth Partners Commercial |
$53.90
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
HC BREAST TOMOSYNTHESIS BI - MAMMO BREAST SCREENING TOMOSYNTHESIS LEFT
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
HCPCS 77063
|
| Hospital Charge Code |
4037706302
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$31.87 |
| Max. Negotiated Rate |
$55.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$53.90
|
| Rate for Payer: Aetna of WY Medicare |
$35.20
|
| Rate for Payer: Altius Commercial |
$52.80
|
| Rate for Payer: Beech Street Commercial |
$53.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$53.35
|
| Rate for Payer: Cash Price |
$38.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$53.35
|
| Rate for Payer: Cigna of WY Commercial |
$53.90
|
| Rate for Payer: Entrust Commercial |
$52.25
|
| Rate for Payer: First Choice Health Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$52.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$33.55
|
| Rate for Payer: HealthUtah PPO |
$55.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$53.35
|
| Rate for Payer: Multiplan Medicare/VA |
$31.87
|
| Rate for Payer: One Health Plan of WY PPO |
$53.90
|
| Rate for Payer: PacificSource Commercial |
$49.50
|
| Rate for Payer: PHCS PPO |
$53.90
|
| Rate for Payer: Three Rivers PPO |
$41.25
|
| Rate for Payer: TriWest Veterans Administration |
$33.55
|
| Rate for Payer: United Healthcare Commercial |
$52.52
|
| Rate for Payer: United Healthcare Medicare |
$33.55
|
| Rate for Payer: WINHealth Partners Commercial |
$52.25
|
| Rate for Payer: Wise Provider Network Commercial |
$52.25
|
|
|
HC BREAST TOMOSYNTHESIS BI - MAMMO BREAST SCREENING TOMOSYNTHESIS RIGHT
|
Facility
|
IP
|
$128.00
|
|
|
Service Code
|
HCPCS 77063
|
| Hospital Charge Code |
4037706303
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$74.18 |
| Max. Negotiated Rate |
$128.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$125.44
|
| Rate for Payer: Aetna of WY Medicare |
$81.92
|
| Rate for Payer: Altius Commercial |
$122.88
|
| Rate for Payer: Beech Street Commercial |
$125.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$124.16
|
| Rate for Payer: Cash Price |
$89.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$124.16
|
| Rate for Payer: Cigna of WY Commercial |
$125.44
|
| Rate for Payer: Entrust Commercial |
$121.60
|
| Rate for Payer: First Choice Health Commercial |
$121.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$121.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.08
|
| Rate for Payer: HealthUtah PPO |
$128.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$124.16
|
| Rate for Payer: Multiplan Medicare/VA |
$74.18
|
| Rate for Payer: One Health Plan of WY PPO |
$125.44
|
| Rate for Payer: PacificSource Commercial |
$115.20
|
| Rate for Payer: PHCS PPO |
$125.44
|
| Rate for Payer: Three Rivers PPO |
$96.00
|
| Rate for Payer: TriWest Veterans Administration |
$78.08
|
| Rate for Payer: United Healthcare Commercial |
$122.24
|
| Rate for Payer: United Healthcare Medicare |
$78.08
|
| Rate for Payer: WINHealth Partners Commercial |
$121.60
|
| Rate for Payer: Wise Provider Network Commercial |
$121.60
|
|
