|
HC CTRL NOSEBLEED,ANTER,COMPLEX
|
Facility
|
IP
|
$63.00
|
|
|
Service Code
|
HCPCS 30903
|
| Hospital Charge Code |
5103090301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$36.51 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.74
|
| Rate for Payer: Aetna of WY Medicare |
$40.32
|
| Rate for Payer: Altius Commercial |
$60.48
|
| Rate for Payer: Beech Street Commercial |
$61.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.11
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.11
|
| Rate for Payer: Cigna of WY Commercial |
$61.74
|
| Rate for Payer: Entrust Commercial |
$59.85
|
| Rate for Payer: First Choice Health Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$38.43
|
| Rate for Payer: HealthUtah PPO |
$63.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.11
|
| Rate for Payer: Multiplan Medicare/VA |
$36.51
|
| Rate for Payer: One Health Plan of WY PPO |
$61.74
|
| Rate for Payer: PacificSource Commercial |
$56.70
|
| Rate for Payer: PHCS PPO |
$61.74
|
| Rate for Payer: Three Rivers PPO |
$47.25
|
| Rate for Payer: TriWest Veterans Administration |
$38.43
|
| Rate for Payer: United Healthcare Commercial |
$60.16
|
| Rate for Payer: United Healthcare Medicare |
$38.43
|
| Rate for Payer: WINHealth Partners Commercial |
$59.85
|
| Rate for Payer: Wise Provider Network Commercial |
$59.85
|
|
|
HC CTRL NOSEBLEED,ANTER,COMPLEX
|
Facility
|
IP
|
$456.00
|
|
|
Service Code
|
HCPCS 30903
|
| Hospital Charge Code |
7613090301
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$264.25 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$446.88
|
| Rate for Payer: Aetna of WY Medicare |
$291.84
|
| Rate for Payer: Altius Commercial |
$437.76
|
| Rate for Payer: Beech Street Commercial |
$446.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$442.32
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$442.32
|
| Rate for Payer: Cigna of WY Commercial |
$446.88
|
| Rate for Payer: Entrust Commercial |
$433.20
|
| Rate for Payer: First Choice Health Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$278.16
|
| Rate for Payer: HealthUtah PPO |
$456.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$442.32
|
| Rate for Payer: Multiplan Medicare/VA |
$264.25
|
| Rate for Payer: One Health Plan of WY PPO |
$446.88
|
| Rate for Payer: PacificSource Commercial |
$410.40
|
| Rate for Payer: PHCS PPO |
$446.88
|
| Rate for Payer: Three Rivers PPO |
$342.00
|
| Rate for Payer: TriWest Veterans Administration |
$278.16
|
| Rate for Payer: United Healthcare Commercial |
$435.48
|
| Rate for Payer: United Healthcare Medicare |
$278.16
|
| Rate for Payer: WINHealth Partners Commercial |
$433.20
|
| Rate for Payer: Wise Provider Network Commercial |
$433.20
|
|
|
HC CTRL NOSEBLEED,ANTER,COMPLEX
|
Facility
|
OP
|
$63.00
|
|
|
Service Code
|
HCPCS 30903
|
| Hospital Charge Code |
5103090301
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$34.11 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$61.74
|
| Rate for Payer: Aetna of WY Medicare |
$41.58
|
| Rate for Payer: Altius Commercial |
$60.48
|
| Rate for Payer: Beech Street Commercial |
$61.74
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$61.11
|
| Rate for Payer: Cash Price |
$44.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$61.11
|
| Rate for Payer: Cigna of WY Commercial |
$61.74
|
| Rate for Payer: Entrust Commercial |
$59.85
|
| Rate for Payer: First Choice Health Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$59.85
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$35.91
|
| Rate for Payer: HealthUtah PPO |
$63.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$61.11
|
| Rate for Payer: Multiplan Medicare/VA |
$34.11
|
| Rate for Payer: One Health Plan of WY PPO |
$61.74
|
| Rate for Payer: PacificSource Commercial |
$56.70
|
| Rate for Payer: PHCS PPO |
$61.74
|
| Rate for Payer: Three Rivers PPO |
$47.25
|
| Rate for Payer: TriWest Veterans Administration |
$35.91
|
| Rate for Payer: United Healthcare Commercial |
$60.16
|
| Rate for Payer: United Healthcare Medicare |
$35.91
|
| Rate for Payer: WINHealth Partners Commercial |
$61.74
|
| Rate for Payer: Wise Provider Network Commercial |
$59.85
|
|
|
HC CTRL NOSEBLEED,ANTER,COMPLEX
|
Facility
|
OP
|
$456.00
|
|
|
Service Code
|
HCPCS 30903
|
| Hospital Charge Code |
7613090301
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$246.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$446.88
|
| Rate for Payer: Aetna of WY Medicare |
$300.96
|
| Rate for Payer: Altius Commercial |
$437.76
|
| Rate for Payer: Beech Street Commercial |
$446.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$442.32
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$442.32
|
| Rate for Payer: Cigna of WY Commercial |
$446.88
|
| Rate for Payer: Entrust Commercial |
$433.20
|
| Rate for Payer: First Choice Health Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$259.92
|
| Rate for Payer: HealthUtah PPO |
$456.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$442.32
|
| Rate for Payer: Multiplan Medicare/VA |
$246.92
|
| Rate for Payer: One Health Plan of WY PPO |
$446.88
|
| Rate for Payer: PacificSource Commercial |
$410.40
|
| Rate for Payer: PHCS PPO |
$446.88
|
| Rate for Payer: Three Rivers PPO |
$342.00
|
| Rate for Payer: TriWest Veterans Administration |
$259.92
|
| Rate for Payer: United Healthcare Commercial |
$435.48
|
| Rate for Payer: United Healthcare Medicare |
$259.92
|
| Rate for Payer: WINHealth Partners Commercial |
$446.88
|
| Rate for Payer: Wise Provider Network Commercial |
$433.20
|
|
|
HC CTRL NOSEBLEED,ANTER,SIMPLE
|
Facility
|
IP
|
$456.00
|
|
|
Service Code
|
HCPCS 30901
|
| Hospital Charge Code |
7613090101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$264.25 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$446.88
|
| Rate for Payer: Aetna of WY Medicare |
$291.84
|
| Rate for Payer: Altius Commercial |
$437.76
|
| Rate for Payer: Beech Street Commercial |
$446.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$442.32
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$442.32
|
| Rate for Payer: Cigna of WY Commercial |
$446.88
|
| Rate for Payer: Entrust Commercial |
$433.20
|
| Rate for Payer: First Choice Health Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$278.16
|
| Rate for Payer: HealthUtah PPO |
$456.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$442.32
|
| Rate for Payer: Multiplan Medicare/VA |
$264.25
|
| Rate for Payer: One Health Plan of WY PPO |
$446.88
|
| Rate for Payer: PacificSource Commercial |
$410.40
|
| Rate for Payer: PHCS PPO |
$446.88
|
| Rate for Payer: Three Rivers PPO |
$342.00
|
| Rate for Payer: TriWest Veterans Administration |
$278.16
|
| Rate for Payer: United Healthcare Commercial |
$435.48
|
| Rate for Payer: United Healthcare Medicare |
$278.16
|
| Rate for Payer: WINHealth Partners Commercial |
$433.20
|
| Rate for Payer: Wise Provider Network Commercial |
$433.20
|
|
|
HC CTRL NOSEBLEED,ANTER,SIMPLE
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
HCPCS 30901
|
| Hospital Charge Code |
5103090101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$24.37 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.10
|
| Rate for Payer: Aetna of WY Medicare |
$29.70
|
| Rate for Payer: Altius Commercial |
$43.20
|
| Rate for Payer: Beech Street Commercial |
$44.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$43.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.65
|
| Rate for Payer: Cigna of WY Commercial |
$44.10
|
| Rate for Payer: Entrust Commercial |
$42.75
|
| Rate for Payer: First Choice Health Commercial |
$42.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$25.65
|
| Rate for Payer: HealthUtah PPO |
$45.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.65
|
| Rate for Payer: Multiplan Medicare/VA |
$24.37
|
| Rate for Payer: One Health Plan of WY PPO |
$44.10
|
| Rate for Payer: PacificSource Commercial |
$40.50
|
| Rate for Payer: PHCS PPO |
$44.10
|
| Rate for Payer: Three Rivers PPO |
$33.75
|
| Rate for Payer: TriWest Veterans Administration |
$25.65
|
| Rate for Payer: United Healthcare Commercial |
$42.98
|
| Rate for Payer: United Healthcare Medicare |
$25.65
|
| Rate for Payer: WINHealth Partners Commercial |
$44.10
|
| Rate for Payer: Wise Provider Network Commercial |
$42.75
|
|
|
HC CTRL NOSEBLEED,ANTER,SIMPLE
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
HCPCS 30901
|
| Hospital Charge Code |
5103090101
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$44.10
|
| Rate for Payer: Aetna of WY Medicare |
$28.80
|
| Rate for Payer: Altius Commercial |
$43.20
|
| Rate for Payer: Beech Street Commercial |
$44.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$43.65
|
| Rate for Payer: Cash Price |
$31.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$43.65
|
| Rate for Payer: Cigna of WY Commercial |
$44.10
|
| Rate for Payer: Entrust Commercial |
$42.75
|
| Rate for Payer: First Choice Health Commercial |
$42.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$42.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$27.45
|
| Rate for Payer: HealthUtah PPO |
$45.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$43.65
|
| Rate for Payer: Multiplan Medicare/VA |
$26.08
|
| Rate for Payer: One Health Plan of WY PPO |
$44.10
|
| Rate for Payer: PacificSource Commercial |
$40.50
|
| Rate for Payer: PHCS PPO |
$44.10
|
| Rate for Payer: Three Rivers PPO |
$33.75
|
| Rate for Payer: TriWest Veterans Administration |
$27.45
|
| Rate for Payer: United Healthcare Commercial |
$42.98
|
| Rate for Payer: United Healthcare Medicare |
$27.45
|
| Rate for Payer: WINHealth Partners Commercial |
$42.75
|
| Rate for Payer: Wise Provider Network Commercial |
$42.75
|
|
|
HC CTRL NOSEBLEED,ANTER,SIMPLE
|
Facility
|
OP
|
$456.00
|
|
|
Service Code
|
HCPCS 30901
|
| Hospital Charge Code |
7613090101
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$246.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$446.88
|
| Rate for Payer: Aetna of WY Medicare |
$300.96
|
| Rate for Payer: Altius Commercial |
$437.76
|
| Rate for Payer: Beech Street Commercial |
$446.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$442.32
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$442.32
|
| Rate for Payer: Cigna of WY Commercial |
$446.88
|
| Rate for Payer: Entrust Commercial |
$433.20
|
| Rate for Payer: First Choice Health Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$259.92
|
| Rate for Payer: HealthUtah PPO |
$456.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$442.32
|
| Rate for Payer: Multiplan Medicare/VA |
$246.92
|
| Rate for Payer: One Health Plan of WY PPO |
$446.88
|
| Rate for Payer: PacificSource Commercial |
$410.40
|
| Rate for Payer: PHCS PPO |
$446.88
|
| Rate for Payer: Three Rivers PPO |
$342.00
|
| Rate for Payer: TriWest Veterans Administration |
$259.92
|
| Rate for Payer: United Healthcare Commercial |
$435.48
|
| Rate for Payer: United Healthcare Medicare |
$259.92
|
| Rate for Payer: WINHealth Partners Commercial |
$446.88
|
| Rate for Payer: Wise Provider Network Commercial |
$433.20
|
|
|
HC CTRL NOSEBLEED,POST,W/PACKS &/OR CAUT
|
Facility
|
IP
|
$456.00
|
|
|
Service Code
|
HCPCS 30905
|
| Hospital Charge Code |
7613090501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$264.25 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$446.88
|
| Rate for Payer: Aetna of WY Medicare |
$291.84
|
| Rate for Payer: Altius Commercial |
$437.76
|
| Rate for Payer: Beech Street Commercial |
$446.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$442.32
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$442.32
|
| Rate for Payer: Cigna of WY Commercial |
$446.88
|
| Rate for Payer: Entrust Commercial |
$433.20
|
| Rate for Payer: First Choice Health Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$278.16
|
| Rate for Payer: HealthUtah PPO |
$456.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$442.32
|
| Rate for Payer: Multiplan Medicare/VA |
$264.25
|
| Rate for Payer: One Health Plan of WY PPO |
$446.88
|
| Rate for Payer: PacificSource Commercial |
$410.40
|
| Rate for Payer: PHCS PPO |
$446.88
|
| Rate for Payer: Three Rivers PPO |
$342.00
|
| Rate for Payer: TriWest Veterans Administration |
$278.16
|
| Rate for Payer: United Healthcare Commercial |
$435.48
|
| Rate for Payer: United Healthcare Medicare |
$278.16
|
| Rate for Payer: WINHealth Partners Commercial |
$433.20
|
| Rate for Payer: Wise Provider Network Commercial |
$433.20
|
|
|
HC CTRL NOSEBLEED,POST,W/PACKS &/OR CAUT
|
Facility
|
OP
|
$456.00
|
|
|
Service Code
|
HCPCS 30905
|
| Hospital Charge Code |
7613090501
|
|
Hospital Revenue Code
|
761
|
| Min. Negotiated Rate |
$246.92 |
| Max. Negotiated Rate |
$456.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$446.88
|
| Rate for Payer: Aetna of WY Medicare |
$300.96
|
| Rate for Payer: Altius Commercial |
$437.76
|
| Rate for Payer: Beech Street Commercial |
$446.88
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$442.32
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: ChoiceCare Network Commercial |
$442.32
|
| Rate for Payer: Cigna of WY Commercial |
$446.88
|
| Rate for Payer: Entrust Commercial |
$433.20
|
| Rate for Payer: First Choice Health Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$433.20
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$259.92
|
| Rate for Payer: HealthUtah PPO |
$456.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$442.32
|
| Rate for Payer: Multiplan Medicare/VA |
$246.92
|
| Rate for Payer: One Health Plan of WY PPO |
$446.88
|
| Rate for Payer: PacificSource Commercial |
$410.40
|
| Rate for Payer: PHCS PPO |
$446.88
|
| Rate for Payer: Three Rivers PPO |
$342.00
|
| Rate for Payer: TriWest Veterans Administration |
$259.92
|
| Rate for Payer: United Healthcare Commercial |
$435.48
|
| Rate for Payer: United Healthcare Medicare |
$259.92
|
| Rate for Payer: WINHealth Partners Commercial |
$446.88
|
| Rate for Payer: Wise Provider Network Commercial |
$433.20
|
|
|
HC CTR MOTR EP STD TRANSCRNL MOTR STIM UPR&LOW LI
|
Facility
|
IP
|
$1,069.00
|
|
|
Service Code
|
HCPCS 95939
|
| Hospital Charge Code |
9229593901
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$619.49 |
| Max. Negotiated Rate |
$1,069.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,047.62
|
| Rate for Payer: Aetna of WY Medicare |
$684.16
|
| Rate for Payer: Altius Commercial |
$1,026.24
|
| Rate for Payer: Beech Street Commercial |
$1,047.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,036.93
|
| Rate for Payer: Cash Price |
$748.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,036.93
|
| Rate for Payer: Cigna of WY Commercial |
$1,047.62
|
| Rate for Payer: Entrust Commercial |
$1,015.55
|
| Rate for Payer: First Choice Health Commercial |
$1,015.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,015.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$652.09
|
| Rate for Payer: HealthUtah PPO |
$1,069.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,036.93
|
| Rate for Payer: Multiplan Medicare/VA |
$619.49
|
| Rate for Payer: One Health Plan of WY PPO |
$1,047.62
|
| Rate for Payer: PacificSource Commercial |
$962.10
|
| Rate for Payer: PHCS PPO |
$1,047.62
|
| Rate for Payer: Three Rivers PPO |
$801.75
|
| Rate for Payer: TriWest Veterans Administration |
$652.09
|
| Rate for Payer: United Healthcare Commercial |
$1,020.90
|
| Rate for Payer: United Healthcare Medicare |
$652.09
|
| Rate for Payer: WINHealth Partners Commercial |
$1,015.55
|
| Rate for Payer: Wise Provider Network Commercial |
$1,015.55
|
|
|
HC CTR MOTR EP STD TRANSCRNL MOTR STIM UPR&LOW LI
|
Facility
|
OP
|
$1,069.00
|
|
|
Service Code
|
HCPCS 95939
|
| Hospital Charge Code |
9229593901
|
|
Hospital Revenue Code
|
922
|
| Min. Negotiated Rate |
$578.86 |
| Max. Negotiated Rate |
$1,069.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,047.62
|
| Rate for Payer: Aetna of WY Medicare |
$705.54
|
| Rate for Payer: Altius Commercial |
$1,026.24
|
| Rate for Payer: Beech Street Commercial |
$1,047.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,036.93
|
| Rate for Payer: Cash Price |
$748.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,036.93
|
| Rate for Payer: Cigna of WY Commercial |
$1,047.62
|
| Rate for Payer: Entrust Commercial |
$1,015.55
|
| Rate for Payer: First Choice Health Commercial |
$1,015.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,015.55
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$609.33
|
| Rate for Payer: HealthUtah PPO |
$1,069.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,036.93
|
| Rate for Payer: Multiplan Medicare/VA |
$578.86
|
| Rate for Payer: One Health Plan of WY PPO |
$1,047.62
|
| Rate for Payer: PacificSource Commercial |
$962.10
|
| Rate for Payer: PHCS PPO |
$1,047.62
|
| Rate for Payer: Three Rivers PPO |
$801.75
|
| Rate for Payer: TriWest Veterans Administration |
$609.33
|
| Rate for Payer: United Healthcare Commercial |
$1,020.90
|
| Rate for Payer: United Healthcare Medicare |
$609.33
|
| Rate for Payer: WINHealth Partners Commercial |
$1,047.62
|
| Rate for Payer: Wise Provider Network Commercial |
$1,015.55
|
|
|
HC CT SCAN,CERVICAL SPINE,W/O CONTRAST - CT CERVICAL SPINE WO CONTRAST
|
Facility
|
IP
|
$2,374.00
|
|
|
Service Code
|
HCPCS 72125
|
| Hospital Charge Code |
3527212501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,375.73 |
| Max. Negotiated Rate |
$2,374.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,326.52
|
| Rate for Payer: Aetna of WY Medicare |
$1,519.36
|
| Rate for Payer: Altius Commercial |
$2,279.04
|
| Rate for Payer: Beech Street Commercial |
$2,326.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,302.78
|
| Rate for Payer: Cash Price |
$1,661.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,302.78
|
| Rate for Payer: Cigna of WY Commercial |
$2,326.52
|
| Rate for Payer: Entrust Commercial |
$2,255.30
|
| Rate for Payer: First Choice Health Commercial |
$2,255.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,255.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,448.14
|
| Rate for Payer: HealthUtah PPO |
$2,374.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,302.78
|
| Rate for Payer: Multiplan Medicare/VA |
$1,375.73
|
| Rate for Payer: One Health Plan of WY PPO |
$2,326.52
|
| Rate for Payer: PacificSource Commercial |
$2,136.60
|
| Rate for Payer: PHCS PPO |
$2,326.52
|
| Rate for Payer: Three Rivers PPO |
$1,780.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,448.14
|
| Rate for Payer: United Healthcare Commercial |
$2,267.17
|
| Rate for Payer: United Healthcare Medicare |
$1,448.14
|
| Rate for Payer: WINHealth Partners Commercial |
$2,255.30
|
| Rate for Payer: Wise Provider Network Commercial |
$2,255.30
|
|
|
HC CT SCAN,CERVICAL SPINE,W/O CONTRAST - CT CERVICAL SPINE WO CONTRAST
|
Facility
|
OP
|
$2,374.00
|
|
|
Service Code
|
HCPCS 72125
|
| Hospital Charge Code |
3527212501
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,285.52 |
| Max. Negotiated Rate |
$2,374.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,326.52
|
| Rate for Payer: Aetna of WY Medicare |
$1,566.84
|
| Rate for Payer: Altius Commercial |
$2,279.04
|
| Rate for Payer: Beech Street Commercial |
$2,326.52
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,302.78
|
| Rate for Payer: Cash Price |
$1,661.80
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,302.78
|
| Rate for Payer: Cigna of WY Commercial |
$2,326.52
|
| Rate for Payer: Entrust Commercial |
$2,255.30
|
| Rate for Payer: First Choice Health Commercial |
$2,255.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,255.30
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,353.18
|
| Rate for Payer: HealthUtah PPO |
$2,374.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,302.78
|
| Rate for Payer: Multiplan Medicare/VA |
$1,285.52
|
| Rate for Payer: One Health Plan of WY PPO |
$2,326.52
|
| Rate for Payer: PacificSource Commercial |
$2,136.60
|
| Rate for Payer: PHCS PPO |
$2,326.52
|
| Rate for Payer: Three Rivers PPO |
$1,780.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,353.18
|
| Rate for Payer: United Healthcare Commercial |
$2,267.17
|
| Rate for Payer: United Healthcare Medicare |
$1,353.18
|
| Rate for Payer: WINHealth Partners Commercial |
$2,326.52
|
| Rate for Payer: Wise Provider Network Commercial |
$2,255.30
|
|
|
HC CT SCAN CERV SP COMBO - CT CERVICAL SPINE W WO CONTRAST
|
Facility
|
OP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 72127
|
| Hospital Charge Code |
3527212701
|
|
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 SCAN CERV SP COMBO - CT CERVICAL SPINE W WO CONTRAST
|
Facility
|
IP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 72127
|
| Hospital Charge Code |
3527212701
|
|
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 SCAN CERV SPINE CONTRAST - CT CERVICAL SPINE W CONTRAST
|
Facility
|
IP
|
$1,740.00
|
|
|
Service Code
|
HCPCS 72126
|
| Hospital Charge Code |
3527212601
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,008.33 |
| Max. Negotiated Rate |
$1,740.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,705.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,113.60
|
| Rate for Payer: Altius Commercial |
$1,670.40
|
| Rate for Payer: Beech Street Commercial |
$1,705.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,687.80
|
| Rate for Payer: Cash Price |
$1,218.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,687.80
|
| Rate for Payer: Cigna of WY Commercial |
$1,705.20
|
| Rate for Payer: Entrust Commercial |
$1,653.00
|
| Rate for Payer: First Choice Health Commercial |
$1,653.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,653.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,061.40
|
| Rate for Payer: HealthUtah PPO |
$1,740.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,687.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1,008.33
|
| Rate for Payer: One Health Plan of WY PPO |
$1,705.20
|
| Rate for Payer: PacificSource Commercial |
$1,566.00
|
| Rate for Payer: PHCS PPO |
$1,705.20
|
| Rate for Payer: Three Rivers PPO |
$1,305.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,061.40
|
| Rate for Payer: United Healthcare Commercial |
$1,661.70
|
| Rate for Payer: United Healthcare Medicare |
$1,061.40
|
| Rate for Payer: WINHealth Partners Commercial |
$1,653.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,653.00
|
|
|
HC CT SCAN CERV SPINE CONTRAST - CT CERVICAL SPINE W CONTRAST
|
Facility
|
OP
|
$1,740.00
|
|
|
Service Code
|
HCPCS 72126
|
| Hospital Charge Code |
3527212601
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$942.21 |
| Max. Negotiated Rate |
$1,740.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,705.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,148.40
|
| Rate for Payer: Altius Commercial |
$1,670.40
|
| Rate for Payer: Beech Street Commercial |
$1,705.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,687.80
|
| Rate for Payer: Cash Price |
$1,218.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,687.80
|
| Rate for Payer: Cigna of WY Commercial |
$1,705.20
|
| Rate for Payer: Entrust Commercial |
$1,653.00
|
| Rate for Payer: First Choice Health Commercial |
$1,653.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,653.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$991.80
|
| Rate for Payer: HealthUtah PPO |
$1,740.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,687.80
|
| Rate for Payer: Multiplan Medicare/VA |
$942.21
|
| Rate for Payer: One Health Plan of WY PPO |
$1,705.20
|
| Rate for Payer: PacificSource Commercial |
$1,566.00
|
| Rate for Payer: PHCS PPO |
$1,705.20
|
| Rate for Payer: Three Rivers PPO |
$1,305.00
|
| Rate for Payer: TriWest Veterans Administration |
$991.80
|
| Rate for Payer: United Healthcare Commercial |
$1,661.70
|
| Rate for Payer: United Healthcare Medicare |
$991.80
|
| Rate for Payer: WINHealth Partners Commercial |
$1,705.20
|
| Rate for Payer: Wise Provider Network Commercial |
$1,653.00
|
|
|
HC CT SCAN DORSAL SP COMBO - CT THORACIC SPINE W WO CONTRAST
|
Facility
|
IP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 72130
|
| Hospital Charge Code |
3527213001
|
|
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 SCAN DORSAL SP COMBO - CT THORACIC SPINE W WO CONTRAST
|
Facility
|
OP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 72130
|
| Hospital Charge Code |
3527213001
|
|
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 SCAN DORSAL SP CONTRAST - CT THORACIC SPINE W CONTRAST
|
Facility
|
IP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 72129
|
| Hospital Charge Code |
3527212901
|
|
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 SCAN DORSAL SP CONTRAST - CT THORACIC SPINE W CONTRAST
|
Facility
|
OP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 72129
|
| Hospital Charge Code |
3527212901
|
|
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 SCAN, FACE/JAW CONTRAST - CT SINUS FACIAL BONES W CONTRAST
|
Facility
|
OP
|
$1,271.00
|
|
|
Service Code
|
HCPCS 70487
|
| Hospital Charge Code |
3517048702
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$688.25 |
| Max. Negotiated Rate |
$1,271.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,245.58
|
| Rate for Payer: Aetna of WY Medicare |
$838.86
|
| Rate for Payer: Altius Commercial |
$1,220.16
|
| Rate for Payer: Beech Street Commercial |
$1,245.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,232.87
|
| Rate for Payer: Cash Price |
$889.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,232.87
|
| Rate for Payer: Cigna of WY Commercial |
$1,245.58
|
| Rate for Payer: Entrust Commercial |
$1,207.45
|
| Rate for Payer: First Choice Health Commercial |
$1,207.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,207.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$724.47
|
| Rate for Payer: HealthUtah PPO |
$1,271.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,232.87
|
| Rate for Payer: Multiplan Medicare/VA |
$688.25
|
| Rate for Payer: One Health Plan of WY PPO |
$1,245.58
|
| Rate for Payer: PacificSource Commercial |
$1,143.90
|
| Rate for Payer: PHCS PPO |
$1,245.58
|
| Rate for Payer: Three Rivers PPO |
$953.25
|
| Rate for Payer: TriWest Veterans Administration |
$724.47
|
| Rate for Payer: United Healthcare Commercial |
$1,213.80
|
| Rate for Payer: United Healthcare Medicare |
$724.47
|
| Rate for Payer: WINHealth Partners Commercial |
$1,245.58
|
| Rate for Payer: Wise Provider Network Commercial |
$1,207.45
|
|
|
HC CT SCAN, FACE/JAW CONTRAST - CT SINUS FACIAL BONES W CONTRAST
|
Facility
|
IP
|
$1,271.00
|
|
|
Service Code
|
HCPCS 70487
|
| Hospital Charge Code |
3517048702
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$736.54 |
| Max. Negotiated Rate |
$1,271.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,245.58
|
| Rate for Payer: Aetna of WY Medicare |
$813.44
|
| Rate for Payer: Altius Commercial |
$1,220.16
|
| Rate for Payer: Beech Street Commercial |
$1,245.58
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,232.87
|
| Rate for Payer: Cash Price |
$889.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,232.87
|
| Rate for Payer: Cigna of WY Commercial |
$1,245.58
|
| Rate for Payer: Entrust Commercial |
$1,207.45
|
| Rate for Payer: First Choice Health Commercial |
$1,207.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,207.45
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$775.31
|
| Rate for Payer: HealthUtah PPO |
$1,271.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,232.87
|
| Rate for Payer: Multiplan Medicare/VA |
$736.54
|
| Rate for Payer: One Health Plan of WY PPO |
$1,245.58
|
| Rate for Payer: PacificSource Commercial |
$1,143.90
|
| Rate for Payer: PHCS PPO |
$1,245.58
|
| Rate for Payer: Three Rivers PPO |
$953.25
|
| Rate for Payer: TriWest Veterans Administration |
$775.31
|
| Rate for Payer: United Healthcare Commercial |
$1,213.80
|
| Rate for Payer: United Healthcare Medicare |
$775.31
|
| Rate for Payer: WINHealth Partners Commercial |
$1,207.45
|
| Rate for Payer: Wise Provider Network Commercial |
$1,207.45
|
|
|
HC CT SCAN, FACE/JAW CONTRAST - CT SINUS W CONTRAST
|
Facility
|
IP
|
$1,561.00
|
|
|
Service Code
|
HCPCS 70487
|
| Hospital Charge Code |
3517048701
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$904.60 |
| Max. Negotiated Rate |
$1,561.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,529.78
|
| Rate for Payer: Aetna of WY Medicare |
$999.04
|
| Rate for Payer: Altius Commercial |
$1,498.56
|
| Rate for Payer: Beech Street Commercial |
$1,529.78
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,514.17
|
| Rate for Payer: Cash Price |
$1,092.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,514.17
|
| Rate for Payer: Cigna of WY Commercial |
$1,529.78
|
| Rate for Payer: Entrust Commercial |
$1,482.95
|
| Rate for Payer: First Choice Health Commercial |
$1,482.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,482.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$952.21
|
| Rate for Payer: HealthUtah PPO |
$1,561.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,514.17
|
| Rate for Payer: Multiplan Medicare/VA |
$904.60
|
| Rate for Payer: One Health Plan of WY PPO |
$1,529.78
|
| Rate for Payer: PacificSource Commercial |
$1,404.90
|
| Rate for Payer: PHCS PPO |
$1,529.78
|
| Rate for Payer: Three Rivers PPO |
$1,170.75
|
| Rate for Payer: TriWest Veterans Administration |
$952.21
|
| Rate for Payer: United Healthcare Commercial |
$1,490.76
|
| Rate for Payer: United Healthcare Medicare |
$952.21
|
| Rate for Payer: WINHealth Partners Commercial |
$1,482.95
|
| Rate for Payer: Wise Provider Network Commercial |
$1,482.95
|
|
