|
HC CT ABDOMEN W/DYE - CT ABDOMEN W CONTRAST
|
Facility
|
IP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 74160
|
| Hospital Charge Code |
3527416001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,808.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,771.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,157.12
|
| Rate for Payer: Altius Commercial |
$1,735.68
|
| Rate for Payer: Beech Street Commercial |
$1,771.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,753.76
|
| Rate for Payer: Cash Price |
$1,265.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,753.76
|
| Rate for Payer: Cigna of WY Commercial |
$1,771.84
|
| Rate for Payer: Entrust Commercial |
$1,717.60
|
| Rate for Payer: First Choice Health Commercial |
$1,717.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,717.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,102.88
|
| Rate for Payer: HealthUtah PPO |
$1,808.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,753.76
|
| Rate for Payer: Multiplan Medicare/VA |
$1,047.74
|
| Rate for Payer: One Health Plan of WY PPO |
$1,771.84
|
| Rate for Payer: PacificSource Commercial |
$1,627.20
|
| Rate for Payer: PHCS PPO |
$1,771.84
|
| Rate for Payer: Three Rivers PPO |
$1,356.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,102.88
|
| Rate for Payer: United Healthcare Commercial |
$1,726.64
|
| Rate for Payer: United Healthcare Medicare |
$1,102.88
|
| Rate for Payer: WINHealth Partners Commercial |
$1,717.60
|
| Rate for Payer: Wise Provider Network Commercial |
$1,717.60
|
|
|
HC CT ABDOMEN W/DYE - CT ABDOMEN W CONTRAST
|
Facility
|
OP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 74160
|
| Hospital Charge Code |
3527416001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$979.03 |
| Max. Negotiated Rate |
$1,808.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,771.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,193.28
|
| Rate for Payer: Altius Commercial |
$1,735.68
|
| Rate for Payer: Beech Street Commercial |
$1,771.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,753.76
|
| Rate for Payer: Cash Price |
$1,265.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,753.76
|
| Rate for Payer: Cigna of WY Commercial |
$1,771.84
|
| Rate for Payer: Entrust Commercial |
$1,717.60
|
| Rate for Payer: First Choice Health Commercial |
$1,717.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,717.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,030.56
|
| Rate for Payer: HealthUtah PPO |
$1,808.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,753.76
|
| Rate for Payer: Multiplan Medicare/VA |
$979.03
|
| Rate for Payer: One Health Plan of WY PPO |
$1,771.84
|
| Rate for Payer: PacificSource Commercial |
$1,627.20
|
| Rate for Payer: PHCS PPO |
$1,771.84
|
| Rate for Payer: Three Rivers PPO |
$1,356.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,030.56
|
| Rate for Payer: United Healthcare Commercial |
$1,726.64
|
| Rate for Payer: United Healthcare Medicare |
$1,030.56
|
| Rate for Payer: WINHealth Partners Commercial |
$1,771.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,717.60
|
|
|
HC CT ABDOMEN W/O DYE - CT ABDOMEN WO CONTRAST
|
Facility
|
IP
|
$1,752.00
|
|
|
Service Code
|
HCPCS 74150
|
| Hospital Charge Code |
3527415001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,015.28 |
| Max. Negotiated Rate |
$1,752.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,716.96
|
| Rate for Payer: Aetna of WY Medicare |
$1,121.28
|
| Rate for Payer: Altius Commercial |
$1,681.92
|
| Rate for Payer: Beech Street Commercial |
$1,716.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,699.44
|
| Rate for Payer: Cash Price |
$1,226.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,699.44
|
| Rate for Payer: Cigna of WY Commercial |
$1,716.96
|
| Rate for Payer: Entrust Commercial |
$1,664.40
|
| Rate for Payer: First Choice Health Commercial |
$1,664.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,664.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,068.72
|
| Rate for Payer: HealthUtah PPO |
$1,752.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,699.44
|
| Rate for Payer: Multiplan Medicare/VA |
$1,015.28
|
| Rate for Payer: One Health Plan of WY PPO |
$1,716.96
|
| Rate for Payer: PacificSource Commercial |
$1,576.80
|
| Rate for Payer: PHCS PPO |
$1,716.96
|
| Rate for Payer: Three Rivers PPO |
$1,314.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,068.72
|
| Rate for Payer: United Healthcare Commercial |
$1,673.16
|
| Rate for Payer: United Healthcare Medicare |
$1,068.72
|
| Rate for Payer: WINHealth Partners Commercial |
$1,664.40
|
| Rate for Payer: Wise Provider Network Commercial |
$1,664.40
|
|
|
HC CT ABDOMEN W/O DYE - CT ABDOMEN WO CONTRAST
|
Facility
|
OP
|
$1,752.00
|
|
|
Service Code
|
HCPCS 74150
|
| Hospital Charge Code |
3527415001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$948.71 |
| Max. Negotiated Rate |
$1,752.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,716.96
|
| Rate for Payer: Aetna of WY Medicare |
$1,156.32
|
| Rate for Payer: Altius Commercial |
$1,681.92
|
| Rate for Payer: Beech Street Commercial |
$1,716.96
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,699.44
|
| Rate for Payer: Cash Price |
$1,226.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,699.44
|
| Rate for Payer: Cigna of WY Commercial |
$1,716.96
|
| Rate for Payer: Entrust Commercial |
$1,664.40
|
| Rate for Payer: First Choice Health Commercial |
$1,664.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,664.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$998.64
|
| Rate for Payer: HealthUtah PPO |
$1,752.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,699.44
|
| Rate for Payer: Multiplan Medicare/VA |
$948.71
|
| Rate for Payer: One Health Plan of WY PPO |
$1,716.96
|
| Rate for Payer: PacificSource Commercial |
$1,576.80
|
| Rate for Payer: PHCS PPO |
$1,716.96
|
| Rate for Payer: Three Rivers PPO |
$1,314.00
|
| Rate for Payer: TriWest Veterans Administration |
$998.64
|
| Rate for Payer: United Healthcare Commercial |
$1,673.16
|
| Rate for Payer: United Healthcare Medicare |
$998.64
|
| Rate for Payer: WINHealth Partners Commercial |
$1,716.96
|
| Rate for Payer: Wise Provider Network Commercial |
$1,664.40
|
|
|
HC CT ABDOMEN W/O & W/DYE - CT ABDOMEN W WO CONTRAST
|
Facility
|
OP
|
$2,119.00
|
|
|
Service Code
|
HCPCS 74170
|
| Hospital Charge Code |
3527417001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,147.44 |
| Max. Negotiated Rate |
$2,119.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,076.62
|
| Rate for Payer: Aetna of WY Medicare |
$1,398.54
|
| Rate for Payer: Altius Commercial |
$2,034.24
|
| Rate for Payer: Beech Street Commercial |
$2,076.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,055.43
|
| Rate for Payer: Cash Price |
$1,483.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,055.43
|
| Rate for Payer: Cigna of WY Commercial |
$2,076.62
|
| Rate for Payer: Entrust Commercial |
$2,013.05
|
| Rate for Payer: First Choice Health Commercial |
$2,013.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,013.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,207.83
|
| Rate for Payer: HealthUtah PPO |
$2,119.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,055.43
|
| Rate for Payer: Multiplan Medicare/VA |
$1,147.44
|
| Rate for Payer: One Health Plan of WY PPO |
$2,076.62
|
| Rate for Payer: PacificSource Commercial |
$1,907.10
|
| Rate for Payer: PHCS PPO |
$2,076.62
|
| Rate for Payer: Three Rivers PPO |
$1,589.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,207.83
|
| Rate for Payer: United Healthcare Commercial |
$2,023.64
|
| Rate for Payer: United Healthcare Medicare |
$1,207.83
|
| Rate for Payer: WINHealth Partners Commercial |
$2,076.62
|
| Rate for Payer: Wise Provider Network Commercial |
$2,013.05
|
|
|
HC CT ABDOMEN W/O & W/DYE - CT ABDOMEN W WO CONTRAST
|
Facility
|
IP
|
$2,119.00
|
|
|
Service Code
|
HCPCS 74170
|
| Hospital Charge Code |
3527417001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,227.96 |
| Max. Negotiated Rate |
$2,119.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,076.62
|
| Rate for Payer: Aetna of WY Medicare |
$1,356.16
|
| Rate for Payer: Altius Commercial |
$2,034.24
|
| Rate for Payer: Beech Street Commercial |
$2,076.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,055.43
|
| Rate for Payer: Cash Price |
$1,483.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,055.43
|
| Rate for Payer: Cigna of WY Commercial |
$2,076.62
|
| Rate for Payer: Entrust Commercial |
$2,013.05
|
| Rate for Payer: First Choice Health Commercial |
$2,013.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,013.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,292.59
|
| Rate for Payer: HealthUtah PPO |
$2,119.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,055.43
|
| Rate for Payer: Multiplan Medicare/VA |
$1,227.96
|
| Rate for Payer: One Health Plan of WY PPO |
$2,076.62
|
| Rate for Payer: PacificSource Commercial |
$1,907.10
|
| Rate for Payer: PHCS PPO |
$2,076.62
|
| Rate for Payer: Three Rivers PPO |
$1,589.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,292.59
|
| Rate for Payer: United Healthcare Commercial |
$2,023.64
|
| Rate for Payer: United Healthcare Medicare |
$1,292.59
|
| Rate for Payer: WINHealth Partners Commercial |
$2,013.05
|
| Rate for Payer: Wise Provider Network Commercial |
$2,013.05
|
|
|
HC CT ABD & PELV 1/> REGNS - CT ABDOMEN PELVIS W WO CONTRAST
|
Facility
|
OP
|
$5,553.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
3527417801
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$3,006.95 |
| Max. Negotiated Rate |
$5,553.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,441.94
|
| Rate for Payer: Aetna of WY Medicare |
$3,664.98
|
| Rate for Payer: Altius Commercial |
$5,330.88
|
| Rate for Payer: Beech Street Commercial |
$5,441.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,386.41
|
| Rate for Payer: Cash Price |
$3,887.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,386.41
|
| Rate for Payer: Cigna of WY Commercial |
$5,441.94
|
| Rate for Payer: Entrust Commercial |
$5,275.35
|
| Rate for Payer: First Choice Health Commercial |
$5,275.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,275.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,165.21
|
| Rate for Payer: HealthUtah PPO |
$5,553.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,386.41
|
| Rate for Payer: Multiplan Medicare/VA |
$3,006.95
|
| Rate for Payer: One Health Plan of WY PPO |
$5,441.94
|
| Rate for Payer: PacificSource Commercial |
$4,997.70
|
| Rate for Payer: PHCS PPO |
$5,441.94
|
| Rate for Payer: Three Rivers PPO |
$4,164.75
|
| Rate for Payer: TriWest Veterans Administration |
$3,165.21
|
| Rate for Payer: United Healthcare Commercial |
$5,303.12
|
| Rate for Payer: United Healthcare Medicare |
$3,165.21
|
| Rate for Payer: WINHealth Partners Commercial |
$5,441.94
|
| Rate for Payer: Wise Provider Network Commercial |
$5,275.35
|
|
|
HC CT ABD & PELV 1/> REGNS - CT ABDOMEN PELVIS W WO CONTRAST
|
Facility
|
IP
|
$5,553.00
|
|
|
Service Code
|
HCPCS 74178
|
| Hospital Charge Code |
3527417801
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$3,217.96 |
| Max. Negotiated Rate |
$5,553.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,441.94
|
| Rate for Payer: Aetna of WY Medicare |
$3,553.92
|
| Rate for Payer: Altius Commercial |
$5,330.88
|
| Rate for Payer: Beech Street Commercial |
$5,441.94
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$5,386.41
|
| Rate for Payer: Cash Price |
$3,887.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,386.41
|
| Rate for Payer: Cigna of WY Commercial |
$5,441.94
|
| Rate for Payer: Entrust Commercial |
$5,275.35
|
| Rate for Payer: First Choice Health Commercial |
$5,275.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,275.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,387.33
|
| Rate for Payer: HealthUtah PPO |
$5,553.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,386.41
|
| Rate for Payer: Multiplan Medicare/VA |
$3,217.96
|
| Rate for Payer: One Health Plan of WY PPO |
$5,441.94
|
| Rate for Payer: PacificSource Commercial |
$4,997.70
|
| Rate for Payer: PHCS PPO |
$5,441.94
|
| Rate for Payer: Three Rivers PPO |
$4,164.75
|
| Rate for Payer: TriWest Veterans Administration |
$3,387.33
|
| Rate for Payer: United Healthcare Commercial |
$5,303.12
|
| Rate for Payer: United Healthcare Medicare |
$3,387.33
|
| Rate for Payer: WINHealth Partners Commercial |
$5,275.35
|
| Rate for Payer: Wise Provider Network Commercial |
$5,275.35
|
|
|
HC CT ABD & PELVIS W/O CONTRAST - CT ABDOMEN PELVIS WO CONTRAST
|
Facility
|
IP
|
$4,008.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
3527417601
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$2,322.64 |
| Max. Negotiated Rate |
$4,008.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,927.84
|
| Rate for Payer: Aetna of WY Medicare |
$2,565.12
|
| Rate for Payer: Altius Commercial |
$3,847.68
|
| Rate for Payer: Beech Street Commercial |
$3,927.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,887.76
|
| Rate for Payer: Cash Price |
$2,805.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,887.76
|
| Rate for Payer: Cigna of WY Commercial |
$3,927.84
|
| Rate for Payer: Entrust Commercial |
$3,807.60
|
| Rate for Payer: First Choice Health Commercial |
$3,807.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,807.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,444.88
|
| Rate for Payer: HealthUtah PPO |
$4,008.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,887.76
|
| Rate for Payer: Multiplan Medicare/VA |
$2,322.64
|
| Rate for Payer: One Health Plan of WY PPO |
$3,927.84
|
| Rate for Payer: PacificSource Commercial |
$3,607.20
|
| Rate for Payer: PHCS PPO |
$3,927.84
|
| Rate for Payer: Three Rivers PPO |
$3,006.00
|
| Rate for Payer: TriWest Veterans Administration |
$2,444.88
|
| Rate for Payer: United Healthcare Commercial |
$3,827.64
|
| Rate for Payer: United Healthcare Medicare |
$2,444.88
|
| Rate for Payer: WINHealth Partners Commercial |
$3,807.60
|
| Rate for Payer: Wise Provider Network Commercial |
$3,807.60
|
|
|
HC CT ABD & PELVIS W/O CONTRAST - CT ABDOMEN PELVIS WO CONTRAST
|
Facility
|
OP
|
$4,008.00
|
|
|
Service Code
|
HCPCS 74176
|
| Hospital Charge Code |
3527417601
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$2,170.33 |
| Max. Negotiated Rate |
$4,008.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,927.84
|
| Rate for Payer: Aetna of WY Medicare |
$2,645.28
|
| Rate for Payer: Altius Commercial |
$3,847.68
|
| Rate for Payer: Beech Street Commercial |
$3,927.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,887.76
|
| Rate for Payer: Cash Price |
$2,805.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,887.76
|
| Rate for Payer: Cigna of WY Commercial |
$3,927.84
|
| Rate for Payer: Entrust Commercial |
$3,807.60
|
| Rate for Payer: First Choice Health Commercial |
$3,807.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,807.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,284.56
|
| Rate for Payer: HealthUtah PPO |
$4,008.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,887.76
|
| Rate for Payer: Multiplan Medicare/VA |
$2,170.33
|
| Rate for Payer: One Health Plan of WY PPO |
$3,927.84
|
| Rate for Payer: PacificSource Commercial |
$3,607.20
|
| Rate for Payer: PHCS PPO |
$3,927.84
|
| Rate for Payer: Three Rivers PPO |
$3,006.00
|
| Rate for Payer: TriWest Veterans Administration |
$2,284.56
|
| Rate for Payer: United Healthcare Commercial |
$3,827.64
|
| Rate for Payer: United Healthcare Medicare |
$2,284.56
|
| Rate for Payer: WINHealth Partners Commercial |
$3,927.84
|
| Rate for Payer: Wise Provider Network Commercial |
$3,807.60
|
|
|
HC CT ABD & PELV W/CONTRAST - CT ABDOMEN PELVIS W CONTRAST
|
Facility
|
OP
|
$4,683.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
3527417701
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$2,535.84 |
| Max. Negotiated Rate |
$4,683.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,589.34
|
| Rate for Payer: Aetna of WY Medicare |
$3,090.78
|
| Rate for Payer: Altius Commercial |
$4,495.68
|
| Rate for Payer: Beech Street Commercial |
$4,589.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,542.51
|
| Rate for Payer: Cash Price |
$3,278.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,542.51
|
| Rate for Payer: Cigna of WY Commercial |
$4,589.34
|
| Rate for Payer: Entrust Commercial |
$4,448.85
|
| Rate for Payer: First Choice Health Commercial |
$4,448.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,448.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,669.31
|
| Rate for Payer: HealthUtah PPO |
$4,683.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,542.51
|
| Rate for Payer: Multiplan Medicare/VA |
$2,535.84
|
| Rate for Payer: One Health Plan of WY PPO |
$4,589.34
|
| Rate for Payer: PacificSource Commercial |
$4,214.70
|
| Rate for Payer: PHCS PPO |
$4,589.34
|
| Rate for Payer: Three Rivers PPO |
$3,512.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,669.31
|
| Rate for Payer: United Healthcare Commercial |
$4,472.26
|
| Rate for Payer: United Healthcare Medicare |
$2,669.31
|
| Rate for Payer: WINHealth Partners Commercial |
$4,589.34
|
| Rate for Payer: Wise Provider Network Commercial |
$4,448.85
|
|
|
HC CT ABD & PELV W/CONTRAST - CT ABDOMEN PELVIS W CONTRAST
|
Facility
|
IP
|
$4,683.00
|
|
|
Service Code
|
HCPCS 74177
|
| Hospital Charge Code |
3527417701
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$2,713.80 |
| Max. Negotiated Rate |
$4,683.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,589.34
|
| Rate for Payer: Aetna of WY Medicare |
$2,997.12
|
| Rate for Payer: Altius Commercial |
$4,495.68
|
| Rate for Payer: Beech Street Commercial |
$4,589.34
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,542.51
|
| Rate for Payer: Cash Price |
$3,278.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,542.51
|
| Rate for Payer: Cigna of WY Commercial |
$4,589.34
|
| Rate for Payer: Entrust Commercial |
$4,448.85
|
| Rate for Payer: First Choice Health Commercial |
$4,448.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,448.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,856.63
|
| Rate for Payer: HealthUtah PPO |
$4,683.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,542.51
|
| Rate for Payer: Multiplan Medicare/VA |
$2,713.80
|
| Rate for Payer: One Health Plan of WY PPO |
$4,589.34
|
| Rate for Payer: PacificSource Commercial |
$4,214.70
|
| Rate for Payer: PHCS PPO |
$4,589.34
|
| Rate for Payer: Three Rivers PPO |
$3,512.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,856.63
|
| Rate for Payer: United Healthcare Commercial |
$4,472.26
|
| Rate for Payer: United Healthcare Medicare |
$2,856.63
|
| Rate for Payer: WINHealth Partners Commercial |
$4,448.85
|
| Rate for Payer: Wise Provider Network Commercial |
$4,448.85
|
|
|
HC CT ANGIO ABDOMINAL ARTERIES - CT ANGIO AORTA & BILAT ILIOFEMORAL RUN
|
Facility
|
OP
|
$3,425.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
3527563501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,854.64 |
| Max. Negotiated Rate |
$3,425.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,356.50
|
| Rate for Payer: Aetna of WY Medicare |
$2,260.50
|
| Rate for Payer: Altius Commercial |
$3,288.00
|
| Rate for Payer: Beech Street Commercial |
$3,356.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,322.25
|
| Rate for Payer: Cash Price |
$2,397.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,322.25
|
| Rate for Payer: Cigna of WY Commercial |
$3,356.50
|
| Rate for Payer: Entrust Commercial |
$3,253.75
|
| Rate for Payer: First Choice Health Commercial |
$3,253.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,253.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,952.25
|
| Rate for Payer: HealthUtah PPO |
$3,425.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,322.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,854.64
|
| Rate for Payer: One Health Plan of WY PPO |
$3,356.50
|
| Rate for Payer: PacificSource Commercial |
$3,082.50
|
| Rate for Payer: PHCS PPO |
$3,356.50
|
| Rate for Payer: Three Rivers PPO |
$2,568.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,952.25
|
| Rate for Payer: United Healthcare Commercial |
$3,270.88
|
| Rate for Payer: United Healthcare Medicare |
$1,952.25
|
| Rate for Payer: WINHealth Partners Commercial |
$3,356.50
|
| Rate for Payer: Wise Provider Network Commercial |
$3,253.75
|
|
|
HC CT ANGIO ABDOMINAL ARTERIES - CT ANGIO AORTA & BILAT ILIOFEMORAL RUN
|
Facility
|
IP
|
$3,425.00
|
|
|
Service Code
|
HCPCS 75635
|
| Hospital Charge Code |
3527563501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,984.79 |
| Max. Negotiated Rate |
$3,425.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,356.50
|
| Rate for Payer: Aetna of WY Medicare |
$2,192.00
|
| Rate for Payer: Altius Commercial |
$3,288.00
|
| Rate for Payer: Beech Street Commercial |
$3,356.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,322.25
|
| Rate for Payer: Cash Price |
$2,397.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,322.25
|
| Rate for Payer: Cigna of WY Commercial |
$3,356.50
|
| Rate for Payer: Entrust Commercial |
$3,253.75
|
| Rate for Payer: First Choice Health Commercial |
$3,253.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,253.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,089.25
|
| Rate for Payer: HealthUtah PPO |
$3,425.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,322.25
|
| Rate for Payer: Multiplan Medicare/VA |
$1,984.79
|
| Rate for Payer: One Health Plan of WY PPO |
$3,356.50
|
| Rate for Payer: PacificSource Commercial |
$3,082.50
|
| Rate for Payer: PHCS PPO |
$3,356.50
|
| Rate for Payer: Three Rivers PPO |
$2,568.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,089.25
|
| Rate for Payer: United Healthcare Commercial |
$3,270.88
|
| Rate for Payer: United Healthcare Medicare |
$2,089.25
|
| Rate for Payer: WINHealth Partners Commercial |
$3,253.75
|
| Rate for Payer: Wise Provider Network Commercial |
$3,253.75
|
|
|
HC CT ANGIO ABDOM W/O & W/DYE - CT ANGIOGRAM ABDOMEN W CONTRAST
|
Facility
|
IP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
3527417501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,047.74 |
| Max. Negotiated Rate |
$1,808.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,771.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,157.12
|
| Rate for Payer: Altius Commercial |
$1,735.68
|
| Rate for Payer: Beech Street Commercial |
$1,771.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,753.76
|
| Rate for Payer: Cash Price |
$1,265.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,753.76
|
| Rate for Payer: Cigna of WY Commercial |
$1,771.84
|
| Rate for Payer: Entrust Commercial |
$1,717.60
|
| Rate for Payer: First Choice Health Commercial |
$1,717.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,717.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,102.88
|
| Rate for Payer: HealthUtah PPO |
$1,808.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,753.76
|
| Rate for Payer: Multiplan Medicare/VA |
$1,047.74
|
| Rate for Payer: One Health Plan of WY PPO |
$1,771.84
|
| Rate for Payer: PacificSource Commercial |
$1,627.20
|
| Rate for Payer: PHCS PPO |
$1,771.84
|
| Rate for Payer: Three Rivers PPO |
$1,356.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,102.88
|
| Rate for Payer: United Healthcare Commercial |
$1,726.64
|
| Rate for Payer: United Healthcare Medicare |
$1,102.88
|
| Rate for Payer: WINHealth Partners Commercial |
$1,717.60
|
| Rate for Payer: Wise Provider Network Commercial |
$1,717.60
|
|
|
HC CT ANGIO ABDOM W/O & W/DYE - CT ANGIOGRAM ABDOMEN W CONTRAST
|
Facility
|
OP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 74175
|
| Hospital Charge Code |
3527417501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$979.03 |
| Max. Negotiated Rate |
$1,808.00 |
| Rate for Payer: United Healthcare Commercial |
$1,726.64
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,771.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,193.28
|
| Rate for Payer: Altius Commercial |
$1,735.68
|
| Rate for Payer: Beech Street Commercial |
$1,771.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,753.76
|
| Rate for Payer: Cash Price |
$1,265.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,753.76
|
| Rate for Payer: Cigna of WY Commercial |
$1,771.84
|
| Rate for Payer: Entrust Commercial |
$1,717.60
|
| Rate for Payer: First Choice Health Commercial |
$1,717.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,717.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,030.56
|
| Rate for Payer: HealthUtah PPO |
$1,808.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,753.76
|
| Rate for Payer: Multiplan Medicare/VA |
$979.03
|
| Rate for Payer: One Health Plan of WY PPO |
$1,771.84
|
| Rate for Payer: PacificSource Commercial |
$1,627.20
|
| Rate for Payer: PHCS PPO |
$1,771.84
|
| Rate for Payer: Three Rivers PPO |
$1,356.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,030.56
|
| Rate for Payer: United Healthcare Medicare |
$1,030.56
|
| Rate for Payer: WINHealth Partners Commercial |
$1,771.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,717.60
|
|
|
HC CT ANGIO ABD&PELV W/O&W/DYE - CT ANGIOGRAM ABDOMEN PELVIS W CONTRAST
|
Facility
|
OP
|
$4,331.00
|
|
|
Service Code
|
HCPCS 74174
|
| Hospital Charge Code |
3527417401
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$2,345.24 |
| Max. Negotiated Rate |
$4,331.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,244.38
|
| Rate for Payer: Aetna of WY Medicare |
$2,858.46
|
| Rate for Payer: Altius Commercial |
$4,157.76
|
| Rate for Payer: Beech Street Commercial |
$4,244.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,201.07
|
| Rate for Payer: Cash Price |
$3,031.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,201.07
|
| Rate for Payer: Cigna of WY Commercial |
$4,244.38
|
| Rate for Payer: Entrust Commercial |
$4,114.45
|
| Rate for Payer: First Choice Health Commercial |
$4,114.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,114.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,468.67
|
| Rate for Payer: HealthUtah PPO |
$4,331.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,201.07
|
| Rate for Payer: Multiplan Medicare/VA |
$2,345.24
|
| Rate for Payer: One Health Plan of WY PPO |
$4,244.38
|
| Rate for Payer: PacificSource Commercial |
$3,897.90
|
| Rate for Payer: PHCS PPO |
$4,244.38
|
| Rate for Payer: Three Rivers PPO |
$3,248.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,468.67
|
| Rate for Payer: United Healthcare Commercial |
$4,136.10
|
| Rate for Payer: United Healthcare Medicare |
$2,468.67
|
| Rate for Payer: WINHealth Partners Commercial |
$4,244.38
|
| Rate for Payer: Wise Provider Network Commercial |
$4,114.45
|
|
|
HC CT ANGIO ABD&PELV W/O&W/DYE - CT ANGIOGRAM ABDOMEN PELVIS W CONTRAST
|
Facility
|
IP
|
$4,331.00
|
|
|
Service Code
|
HCPCS 74174
|
| Hospital Charge Code |
3527417401
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$2,509.81 |
| Max. Negotiated Rate |
$4,331.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,244.38
|
| Rate for Payer: Aetna of WY Medicare |
$2,771.84
|
| Rate for Payer: Altius Commercial |
$4,157.76
|
| Rate for Payer: Beech Street Commercial |
$4,244.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,201.07
|
| Rate for Payer: Cash Price |
$3,031.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,201.07
|
| Rate for Payer: Cigna of WY Commercial |
$4,244.38
|
| Rate for Payer: Entrust Commercial |
$4,114.45
|
| Rate for Payer: First Choice Health Commercial |
$4,114.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,114.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,641.91
|
| Rate for Payer: HealthUtah PPO |
$4,331.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,201.07
|
| Rate for Payer: Multiplan Medicare/VA |
$2,509.81
|
| Rate for Payer: One Health Plan of WY PPO |
$4,244.38
|
| Rate for Payer: PacificSource Commercial |
$3,897.90
|
| Rate for Payer: PHCS PPO |
$4,244.38
|
| Rate for Payer: Three Rivers PPO |
$3,248.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,641.91
|
| Rate for Payer: United Healthcare Commercial |
$4,136.10
|
| Rate for Payer: United Healthcare Medicare |
$2,641.91
|
| Rate for Payer: WINHealth Partners Commercial |
$4,114.45
|
| Rate for Payer: Wise Provider Network Commercial |
$4,114.45
|
|
|
HC CT ANGIO, CHEST, COMBO, INCL IMAGE - CT CHEST ANGIO W AND WO IV CONT
|
Facility
|
IP
|
$2,460.00
|
|
|
Service Code
|
HCPCS 71275
|
| Hospital Charge Code |
3527127501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,425.57 |
| Max. Negotiated Rate |
$2,460.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,410.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,574.40
|
| Rate for Payer: Altius Commercial |
$2,361.60
|
| Rate for Payer: Beech Street Commercial |
$2,410.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,386.20
|
| Rate for Payer: Cash Price |
$1,722.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,386.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,410.80
|
| Rate for Payer: Entrust Commercial |
$2,337.00
|
| Rate for Payer: First Choice Health Commercial |
$2,337.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,337.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,500.60
|
| Rate for Payer: HealthUtah PPO |
$2,460.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,386.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,425.57
|
| Rate for Payer: One Health Plan of WY PPO |
$2,410.80
|
| Rate for Payer: PacificSource Commercial |
$2,214.00
|
| Rate for Payer: PHCS PPO |
$2,410.80
|
| Rate for Payer: Three Rivers PPO |
$1,845.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,500.60
|
| Rate for Payer: United Healthcare Commercial |
$2,349.30
|
| Rate for Payer: United Healthcare Medicare |
$1,500.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2,337.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,337.00
|
|
|
HC CT ANGIO, CHEST, COMBO, INCL IMAGE - CT CHEST ANGIO W AND WO IV CONT
|
Facility
|
OP
|
$2,460.00
|
|
|
Service Code
|
HCPCS 71275
|
| Hospital Charge Code |
3527127501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,332.09 |
| Max. Negotiated Rate |
$2,460.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,410.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,623.60
|
| Rate for Payer: Altius Commercial |
$2,361.60
|
| Rate for Payer: Beech Street Commercial |
$2,410.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,386.20
|
| Rate for Payer: Cash Price |
$1,722.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,386.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,410.80
|
| Rate for Payer: Entrust Commercial |
$2,337.00
|
| Rate for Payer: First Choice Health Commercial |
$2,337.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,337.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,402.20
|
| Rate for Payer: HealthUtah PPO |
$2,460.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,386.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,332.09
|
| Rate for Payer: One Health Plan of WY PPO |
$2,410.80
|
| Rate for Payer: PacificSource Commercial |
$2,214.00
|
| Rate for Payer: PHCS PPO |
$2,410.80
|
| Rate for Payer: Three Rivers PPO |
$1,845.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,402.20
|
| Rate for Payer: United Healthcare Commercial |
$2,349.30
|
| Rate for Payer: United Healthcare Medicare |
$1,402.20
|
| Rate for Payer: WINHealth Partners Commercial |
$2,410.80
|
| Rate for Payer: Wise Provider Network Commercial |
$2,337.00
|
|
|
HC CT ANGIO,HEAD COMBO - CT HEAD ANGIO W AND WO IV CONTRAST
|
Facility
|
OP
|
$2,132.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
3517049601
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,154.48 |
| Max. Negotiated Rate |
$2,132.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,089.36
|
| Rate for Payer: Aetna of WY Medicare |
$1,407.12
|
| Rate for Payer: Altius Commercial |
$2,046.72
|
| Rate for Payer: Beech Street Commercial |
$2,089.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,068.04
|
| Rate for Payer: Cash Price |
$1,492.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,068.04
|
| Rate for Payer: Cigna of WY Commercial |
$2,089.36
|
| Rate for Payer: Entrust Commercial |
$2,025.40
|
| Rate for Payer: First Choice Health Commercial |
$2,025.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,025.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,215.24
|
| Rate for Payer: HealthUtah PPO |
$2,132.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,068.04
|
| Rate for Payer: Multiplan Medicare/VA |
$1,154.48
|
| Rate for Payer: One Health Plan of WY PPO |
$2,089.36
|
| Rate for Payer: PacificSource Commercial |
$1,918.80
|
| Rate for Payer: PHCS PPO |
$2,089.36
|
| Rate for Payer: Three Rivers PPO |
$1,599.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,215.24
|
| Rate for Payer: United Healthcare Commercial |
$2,036.06
|
| Rate for Payer: United Healthcare Medicare |
$1,215.24
|
| Rate for Payer: WINHealth Partners Commercial |
$2,089.36
|
| Rate for Payer: Wise Provider Network Commercial |
$2,025.40
|
|
|
HC CT ANGIO,HEAD COMBO - CT HEAD ANGIO W AND WO IV CONTRAST
|
Facility
|
IP
|
$2,132.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
3517049601
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,235.49 |
| Max. Negotiated Rate |
$2,132.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,089.36
|
| Rate for Payer: Aetna of WY Medicare |
$1,364.48
|
| Rate for Payer: Altius Commercial |
$2,046.72
|
| Rate for Payer: Beech Street Commercial |
$2,089.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,068.04
|
| Rate for Payer: Cash Price |
$1,492.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,068.04
|
| Rate for Payer: Cigna of WY Commercial |
$2,089.36
|
| Rate for Payer: Entrust Commercial |
$2,025.40
|
| Rate for Payer: First Choice Health Commercial |
$2,025.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,025.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,300.52
|
| Rate for Payer: HealthUtah PPO |
$2,132.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,068.04
|
| Rate for Payer: Multiplan Medicare/VA |
$1,235.49
|
| Rate for Payer: One Health Plan of WY PPO |
$2,089.36
|
| Rate for Payer: PacificSource Commercial |
$1,918.80
|
| Rate for Payer: PHCS PPO |
$2,089.36
|
| Rate for Payer: Three Rivers PPO |
$1,599.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,300.52
|
| Rate for Payer: United Healthcare Commercial |
$2,036.06
|
| Rate for Payer: United Healthcare Medicare |
$1,300.52
|
| Rate for Payer: WINHealth Partners Commercial |
$2,025.40
|
| Rate for Payer: Wise Provider Network Commercial |
$2,025.40
|
|
|
HC CT ANGIO,HEAD COMBO - CT HEAD NECK ANGIO W AND WO IV CONTRAST
|
Facility
|
IP
|
$2,132.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
3517049602
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,235.49 |
| Max. Negotiated Rate |
$2,132.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,089.36
|
| Rate for Payer: Aetna of WY Medicare |
$1,364.48
|
| Rate for Payer: Altius Commercial |
$2,046.72
|
| Rate for Payer: Beech Street Commercial |
$2,089.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,068.04
|
| Rate for Payer: Cash Price |
$1,492.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,068.04
|
| Rate for Payer: Cigna of WY Commercial |
$2,089.36
|
| Rate for Payer: Entrust Commercial |
$2,025.40
|
| Rate for Payer: First Choice Health Commercial |
$2,025.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,025.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,300.52
|
| Rate for Payer: HealthUtah PPO |
$2,132.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,068.04
|
| Rate for Payer: Multiplan Medicare/VA |
$1,235.49
|
| Rate for Payer: One Health Plan of WY PPO |
$2,089.36
|
| Rate for Payer: PacificSource Commercial |
$1,918.80
|
| Rate for Payer: PHCS PPO |
$2,089.36
|
| Rate for Payer: Three Rivers PPO |
$1,599.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,300.52
|
| Rate for Payer: United Healthcare Commercial |
$2,036.06
|
| Rate for Payer: United Healthcare Medicare |
$1,300.52
|
| Rate for Payer: WINHealth Partners Commercial |
$2,025.40
|
| Rate for Payer: Wise Provider Network Commercial |
$2,025.40
|
|
|
HC CT ANGIO,HEAD COMBO - CT HEAD NECK ANGIO W AND WO IV CONTRAST
|
Facility
|
OP
|
$2,132.00
|
|
|
Service Code
|
HCPCS 70496
|
| Hospital Charge Code |
3517049602
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,154.48 |
| Max. Negotiated Rate |
$2,132.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,089.36
|
| Rate for Payer: Aetna of WY Medicare |
$1,407.12
|
| Rate for Payer: Altius Commercial |
$2,046.72
|
| Rate for Payer: Beech Street Commercial |
$2,089.36
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,068.04
|
| Rate for Payer: Cash Price |
$1,492.40
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,068.04
|
| Rate for Payer: Cigna of WY Commercial |
$2,089.36
|
| Rate for Payer: Entrust Commercial |
$2,025.40
|
| Rate for Payer: First Choice Health Commercial |
$2,025.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,025.40
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,215.24
|
| Rate for Payer: HealthUtah PPO |
$2,132.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,068.04
|
| Rate for Payer: Multiplan Medicare/VA |
$1,154.48
|
| Rate for Payer: One Health Plan of WY PPO |
$2,089.36
|
| Rate for Payer: PacificSource Commercial |
$1,918.80
|
| Rate for Payer: PHCS PPO |
$2,089.36
|
| Rate for Payer: Three Rivers PPO |
$1,599.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,215.24
|
| Rate for Payer: United Healthcare Commercial |
$2,036.06
|
| Rate for Payer: United Healthcare Medicare |
$1,215.24
|
| Rate for Payer: WINHealth Partners Commercial |
$2,089.36
|
| Rate for Payer: Wise Provider Network Commercial |
$2,025.40
|
|
|
HC CT ANGIO HRT W/3D IMAGE - CT HEART CORONARY ANGIOGRAM
|
Facility
|
OP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 75574
|
| Hospital Charge Code |
3527557401
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$979.03 |
| Max. Negotiated Rate |
$1,808.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,771.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,193.28
|
| Rate for Payer: Altius Commercial |
$1,735.68
|
| Rate for Payer: Beech Street Commercial |
$1,771.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,753.76
|
| Rate for Payer: Cash Price |
$1,265.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,753.76
|
| Rate for Payer: Cigna of WY Commercial |
$1,771.84
|
| Rate for Payer: Entrust Commercial |
$1,717.60
|
| Rate for Payer: First Choice Health Commercial |
$1,717.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,717.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,030.56
|
| Rate for Payer: HealthUtah PPO |
$1,808.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,753.76
|
| Rate for Payer: Multiplan Medicare/VA |
$979.03
|
| Rate for Payer: One Health Plan of WY PPO |
$1,771.84
|
| Rate for Payer: PacificSource Commercial |
$1,627.20
|
| Rate for Payer: PHCS PPO |
$1,771.84
|
| Rate for Payer: Three Rivers PPO |
$1,356.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,030.56
|
| Rate for Payer: United Healthcare Commercial |
$1,726.64
|
| Rate for Payer: United Healthcare Medicare |
$1,030.56
|
| Rate for Payer: WINHealth Partners Commercial |
$1,771.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,717.60
|
|
