|
HC CT SCAN, FACE/JAW CONTRAST - CT SINUS W CONTRAST
|
Facility
|
OP
|
$1,561.00
|
|
|
Service Code
|
HCPCS 70487
|
| Hospital Charge Code |
3517048701
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$845.28 |
| 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 |
$1,030.26
|
| 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 |
$889.77
|
| Rate for Payer: HealthUtah PPO |
$1,561.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,514.17
|
| Rate for Payer: Multiplan Medicare/VA |
$845.28
|
| 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 |
$889.77
|
| Rate for Payer: United Healthcare Commercial |
$1,490.76
|
| Rate for Payer: United Healthcare Medicare |
$889.77
|
| Rate for Payer: WINHealth Partners Commercial |
$1,529.78
|
| Rate for Payer: Wise Provider Network Commercial |
$1,482.95
|
|
|
HC CT SCAN,HEAD/BRAIN,W/O CONTRAST MATL - CT HEAD WO CONTRAST
|
Facility
|
OP
|
$2,175.00
|
|
|
Service Code
|
HCPCS 70450
|
| Hospital Charge Code |
3517045001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,177.76 |
| Max. Negotiated Rate |
$2,175.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,131.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,435.50
|
| Rate for Payer: Altius Commercial |
$2,088.00
|
| Rate for Payer: Beech Street Commercial |
$2,131.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,109.75
|
| Rate for Payer: Cash Price |
$1,522.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,109.75
|
| Rate for Payer: Cigna of WY Commercial |
$2,131.50
|
| Rate for Payer: Entrust Commercial |
$2,066.25
|
| Rate for Payer: First Choice Health Commercial |
$2,066.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,066.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,239.75
|
| Rate for Payer: HealthUtah PPO |
$2,175.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,109.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1,177.76
|
| Rate for Payer: One Health Plan of WY PPO |
$2,131.50
|
| Rate for Payer: PacificSource Commercial |
$1,957.50
|
| Rate for Payer: PHCS PPO |
$2,131.50
|
| Rate for Payer: Three Rivers PPO |
$1,631.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,239.75
|
| Rate for Payer: United Healthcare Commercial |
$2,077.12
|
| Rate for Payer: United Healthcare Medicare |
$1,239.75
|
| Rate for Payer: WINHealth Partners Commercial |
$2,131.50
|
| Rate for Payer: Wise Provider Network Commercial |
$2,066.25
|
|
|
HC CT SCAN,HEAD/BRAIN,W/O CONTRAST MATL - CT HEAD WO CONTRAST
|
Facility
|
IP
|
$2,175.00
|
|
|
Service Code
|
HCPCS 70450
|
| Hospital Charge Code |
3517045001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,260.41 |
| Max. Negotiated Rate |
$2,175.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,131.50
|
| Rate for Payer: Aetna of WY Medicare |
$1,392.00
|
| Rate for Payer: Altius Commercial |
$2,088.00
|
| Rate for Payer: Beech Street Commercial |
$2,131.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,109.75
|
| Rate for Payer: Cash Price |
$1,522.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,109.75
|
| Rate for Payer: Cigna of WY Commercial |
$2,131.50
|
| Rate for Payer: Entrust Commercial |
$2,066.25
|
| Rate for Payer: First Choice Health Commercial |
$2,066.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,066.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,326.75
|
| Rate for Payer: HealthUtah PPO |
$2,175.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,109.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1,260.41
|
| Rate for Payer: One Health Plan of WY PPO |
$2,131.50
|
| Rate for Payer: PacificSource Commercial |
$1,957.50
|
| Rate for Payer: PHCS PPO |
$2,131.50
|
| Rate for Payer: Three Rivers PPO |
$1,631.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,326.75
|
| Rate for Payer: United Healthcare Commercial |
$2,077.12
|
| Rate for Payer: United Healthcare Medicare |
$1,326.75
|
| Rate for Payer: WINHealth Partners Commercial |
$2,066.25
|
| Rate for Payer: Wise Provider Network Commercial |
$2,066.25
|
|
|
HC CT SCAN HEAD COMBO - CT HEAD W WO CONTRAST
|
Facility
|
IP
|
$2,173.00
|
|
|
Service Code
|
HCPCS 70470
|
| Hospital Charge Code |
3517047001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,259.25 |
| Max. Negotiated Rate |
$2,173.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,129.54
|
| Rate for Payer: Aetna of WY Medicare |
$1,390.72
|
| Rate for Payer: Altius Commercial |
$2,086.08
|
| Rate for Payer: Beech Street Commercial |
$2,129.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,107.81
|
| Rate for Payer: Cash Price |
$1,521.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,107.81
|
| Rate for Payer: Cigna of WY Commercial |
$2,129.54
|
| Rate for Payer: Entrust Commercial |
$2,064.35
|
| Rate for Payer: First Choice Health Commercial |
$2,064.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,064.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,325.53
|
| Rate for Payer: HealthUtah PPO |
$2,173.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,107.81
|
| Rate for Payer: Multiplan Medicare/VA |
$1,259.25
|
| Rate for Payer: One Health Plan of WY PPO |
$2,129.54
|
| Rate for Payer: PacificSource Commercial |
$1,955.70
|
| Rate for Payer: PHCS PPO |
$2,129.54
|
| Rate for Payer: Three Rivers PPO |
$1,629.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,325.53
|
| Rate for Payer: United Healthcare Commercial |
$2,075.22
|
| Rate for Payer: United Healthcare Medicare |
$1,325.53
|
| Rate for Payer: WINHealth Partners Commercial |
$2,064.35
|
| Rate for Payer: Wise Provider Network Commercial |
$2,064.35
|
|
|
HC CT SCAN HEAD COMBO - CT HEAD W WO CONTRAST
|
Facility
|
OP
|
$2,173.00
|
|
|
Service Code
|
HCPCS 70470
|
| Hospital Charge Code |
3517047001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$1,176.68 |
| Max. Negotiated Rate |
$2,173.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,129.54
|
| Rate for Payer: Aetna of WY Medicare |
$1,434.18
|
| Rate for Payer: Altius Commercial |
$2,086.08
|
| Rate for Payer: Beech Street Commercial |
$2,129.54
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,107.81
|
| Rate for Payer: Cash Price |
$1,521.10
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,107.81
|
| Rate for Payer: Cigna of WY Commercial |
$2,129.54
|
| Rate for Payer: Entrust Commercial |
$2,064.35
|
| Rate for Payer: First Choice Health Commercial |
$2,064.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,064.35
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,238.61
|
| Rate for Payer: HealthUtah PPO |
$2,173.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,107.81
|
| Rate for Payer: Multiplan Medicare/VA |
$1,176.68
|
| Rate for Payer: One Health Plan of WY PPO |
$2,129.54
|
| Rate for Payer: PacificSource Commercial |
$1,955.70
|
| Rate for Payer: PHCS PPO |
$2,129.54
|
| Rate for Payer: Three Rivers PPO |
$1,629.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,238.61
|
| Rate for Payer: United Healthcare Commercial |
$2,075.22
|
| Rate for Payer: United Healthcare Medicare |
$1,238.61
|
| Rate for Payer: WINHealth Partners Commercial |
$2,129.54
|
| Rate for Payer: Wise Provider Network Commercial |
$2,064.35
|
|
|
HC CT SCAN HEAD CONTRAST - CT HEAD W CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 70460
|
| Hospital Charge Code |
3517046001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$881.56 |
| Max. Negotiated Rate |
$1,628.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,595.44
|
| Rate for Payer: Aetna of WY Medicare |
$1,074.48
|
| Rate for Payer: Altius Commercial |
$1,562.88
|
| Rate for Payer: Beech Street Commercial |
$1,595.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,579.16
|
| Rate for Payer: Cash Price |
$1,139.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,579.16
|
| Rate for Payer: Cigna of WY Commercial |
$1,595.44
|
| Rate for Payer: Entrust Commercial |
$1,546.60
|
| Rate for Payer: First Choice Health Commercial |
$1,546.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,546.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$927.96
|
| Rate for Payer: HealthUtah PPO |
$1,628.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,579.16
|
| Rate for Payer: Multiplan Medicare/VA |
$881.56
|
| Rate for Payer: One Health Plan of WY PPO |
$1,595.44
|
| Rate for Payer: PacificSource Commercial |
$1,465.20
|
| Rate for Payer: PHCS PPO |
$1,595.44
|
| Rate for Payer: Three Rivers PPO |
$1,221.00
|
| Rate for Payer: TriWest Veterans Administration |
$927.96
|
| Rate for Payer: United Healthcare Commercial |
$1,554.74
|
| Rate for Payer: United Healthcare Medicare |
$927.96
|
| Rate for Payer: WINHealth Partners Commercial |
$1,595.44
|
| Rate for Payer: Wise Provider Network Commercial |
$1,546.60
|
|
|
HC CT SCAN HEAD CONTRAST - CT HEAD W CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 70460
|
| Hospital Charge Code |
3517046001
|
|
Hospital Revenue Code
|
351
|
| Min. Negotiated Rate |
$943.43 |
| Max. Negotiated Rate |
$1,628.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,595.44
|
| Rate for Payer: Aetna of WY Medicare |
$1,041.92
|
| Rate for Payer: Altius Commercial |
$1,562.88
|
| Rate for Payer: Beech Street Commercial |
$1,595.44
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,579.16
|
| Rate for Payer: Cash Price |
$1,139.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,579.16
|
| Rate for Payer: Cigna of WY Commercial |
$1,595.44
|
| Rate for Payer: Entrust Commercial |
$1,546.60
|
| Rate for Payer: First Choice Health Commercial |
$1,546.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,546.60
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$993.08
|
| Rate for Payer: HealthUtah PPO |
$1,628.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,579.16
|
| Rate for Payer: Multiplan Medicare/VA |
$943.43
|
| Rate for Payer: One Health Plan of WY PPO |
$1,595.44
|
| Rate for Payer: PacificSource Commercial |
$1,465.20
|
| Rate for Payer: PHCS PPO |
$1,595.44
|
| Rate for Payer: Three Rivers PPO |
$1,221.00
|
| Rate for Payer: TriWest Veterans Administration |
$993.08
|
| Rate for Payer: United Healthcare Commercial |
$1,554.74
|
| Rate for Payer: United Healthcare Medicare |
$993.08
|
| Rate for Payer: WINHealth Partners Commercial |
$1,546.60
|
| Rate for Payer: Wise Provider Network Commercial |
$1,546.60
|
|
|
HC CT SCAN,LIMITED/LOCALIZED F/U STUDY - CT LIMITED FOLLOW UP
|
Facility
|
IP
|
$819.00
|
|
|
Service Code
|
HCPCS 76380
|
| Hospital Charge Code |
3507638001
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$474.61 |
| Max. Negotiated Rate |
$819.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$802.62
|
| Rate for Payer: Aetna of WY Medicare |
$524.16
|
| Rate for Payer: Altius Commercial |
$786.24
|
| Rate for Payer: Beech Street Commercial |
$802.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$794.43
|
| Rate for Payer: Cash Price |
$573.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$794.43
|
| Rate for Payer: Cigna of WY Commercial |
$802.62
|
| Rate for Payer: Entrust Commercial |
$778.05
|
| Rate for Payer: First Choice Health Commercial |
$778.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$778.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$499.59
|
| Rate for Payer: HealthUtah PPO |
$819.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$794.43
|
| Rate for Payer: Multiplan Medicare/VA |
$474.61
|
| Rate for Payer: One Health Plan of WY PPO |
$802.62
|
| Rate for Payer: PacificSource Commercial |
$737.10
|
| Rate for Payer: PHCS PPO |
$802.62
|
| Rate for Payer: Three Rivers PPO |
$614.25
|
| Rate for Payer: TriWest Veterans Administration |
$499.59
|
| Rate for Payer: United Healthcare Commercial |
$782.14
|
| Rate for Payer: United Healthcare Medicare |
$499.59
|
| Rate for Payer: WINHealth Partners Commercial |
$778.05
|
| Rate for Payer: Wise Provider Network Commercial |
$778.05
|
|
|
HC CT SCAN,LIMITED/LOCALIZED F/U STUDY - CT LIMITED FOLLOW UP
|
Facility
|
OP
|
$819.00
|
|
|
Service Code
|
HCPCS 76380
|
| Hospital Charge Code |
3507638001
|
|
Hospital Revenue Code
|
350
|
| Min. Negotiated Rate |
$443.49 |
| Max. Negotiated Rate |
$819.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$802.62
|
| Rate for Payer: Aetna of WY Medicare |
$540.54
|
| Rate for Payer: Altius Commercial |
$786.24
|
| Rate for Payer: Beech Street Commercial |
$802.62
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$794.43
|
| Rate for Payer: Cash Price |
$573.30
|
| Rate for Payer: ChoiceCare Network Commercial |
$794.43
|
| Rate for Payer: Cigna of WY Commercial |
$802.62
|
| Rate for Payer: Entrust Commercial |
$778.05
|
| Rate for Payer: First Choice Health Commercial |
$778.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$778.05
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$466.83
|
| Rate for Payer: HealthUtah PPO |
$819.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$794.43
|
| Rate for Payer: Multiplan Medicare/VA |
$443.49
|
| Rate for Payer: One Health Plan of WY PPO |
$802.62
|
| Rate for Payer: PacificSource Commercial |
$737.10
|
| Rate for Payer: PHCS PPO |
$802.62
|
| Rate for Payer: Three Rivers PPO |
$614.25
|
| Rate for Payer: TriWest Veterans Administration |
$466.83
|
| Rate for Payer: United Healthcare Commercial |
$782.14
|
| Rate for Payer: United Healthcare Medicare |
$466.83
|
| Rate for Payer: WINHealth Partners Commercial |
$802.62
|
| Rate for Payer: Wise Provider Network Commercial |
$778.05
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT ANKLE LEFT WO IV CONTRAST
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370009
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,060.26 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,292.28
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.06
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.06
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,116.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1,918.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT ANKLE LEFT WO IV CONTRAST
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370009
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,134.66 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,253.12
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,194.38
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,134.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,194.38
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,194.38
|
| Rate for Payer: WINHealth Partners Commercial |
$1,860.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT ANKLE RIGHT WO IV CONTRAST
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370010
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,060.26 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,292.28
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.06
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.06
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,116.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1,918.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT ANKLE RIGHT WO IV CONTRAST
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370010
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,134.66 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,253.12
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,194.38
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,134.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,194.38
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,194.38
|
| Rate for Payer: WINHealth Partners Commercial |
$1,860.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT FEMUR LEFT WO IV CONTRAST
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370003
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,134.66 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,253.12
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,194.38
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,134.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,194.38
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,194.38
|
| Rate for Payer: WINHealth Partners Commercial |
$1,860.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT FEMUR LEFT WO IV CONTRAST
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370003
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,060.26 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,292.28
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.06
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.06
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,116.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1,918.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT FEMUR RIGHT WO IV CONTRAST
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370004
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,060.26 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,292.28
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.06
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.06
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,116.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1,918.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT FEMUR RIGHT WO IV CONTRAST
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370004
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,134.66 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,253.12
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,194.38
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,134.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,194.38
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,194.38
|
| Rate for Payer: WINHealth Partners Commercial |
$1,860.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT FOOT LEFT WO IV CONTRAST
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370007
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,060.26 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,292.28
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.06
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.06
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,116.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1,918.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT FOOT LEFT WO IV CONTRAST
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370007
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,134.66 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,253.12
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,194.38
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,134.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,194.38
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,194.38
|
| Rate for Payer: WINHealth Partners Commercial |
$1,860.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT FOOT RIGHT WO IV CONTRAST
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370008
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,060.26 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,292.28
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.06
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.06
|
| Rate for Payer: United Healthcare Medicare |
$1,116.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1,918.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT FOOT RIGHT WO IV CONTRAST
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370008
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,134.66 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,253.12
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,194.38
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,134.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,194.38
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,194.38
|
| Rate for Payer: WINHealth Partners Commercial |
$1,860.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT HIP LEFT WO IV CONTRAST
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,134.66 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,253.12
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,194.38
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,134.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,194.38
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,194.38
|
| Rate for Payer: WINHealth Partners Commercial |
$1,860.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT HIP LEFT WO IV CONTRAST
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370001
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,060.26 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,292.28
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.06
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.06
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,116.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1,918.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT HIP RIGHT WO IV CONTRAST
|
Facility
|
OP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370002
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,060.26 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,292.28
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,116.06
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,060.26
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,116.06
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,116.06
|
| Rate for Payer: WINHealth Partners Commercial |
$1,918.84
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
|
HC CT SCAN,LOWER EXTREMITY,W/O CONTRAST - CT HIP RIGHT WO IV CONTRAST
|
Facility
|
IP
|
$1,958.00
|
|
|
Service Code
|
HCPCS 73700
|
| Hospital Charge Code |
3527370002
|
|
Hospital Revenue Code
|
352
|
| Min. Negotiated Rate |
$1,134.66 |
| Max. Negotiated Rate |
$1,958.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,918.84
|
| Rate for Payer: Aetna of WY Medicare |
$1,253.12
|
| Rate for Payer: Altius Commercial |
$1,879.68
|
| Rate for Payer: Beech Street Commercial |
$1,918.84
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,899.26
|
| Rate for Payer: Cash Price |
$1,370.60
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,899.26
|
| Rate for Payer: Cigna of WY Commercial |
$1,918.84
|
| Rate for Payer: Entrust Commercial |
$1,860.10
|
| Rate for Payer: First Choice Health Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,860.10
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,194.38
|
| Rate for Payer: HealthUtah PPO |
$1,958.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,899.26
|
| Rate for Payer: Multiplan Medicare/VA |
$1,134.66
|
| Rate for Payer: One Health Plan of WY PPO |
$1,918.84
|
| Rate for Payer: PacificSource Commercial |
$1,762.20
|
| Rate for Payer: PHCS PPO |
$1,918.84
|
| Rate for Payer: Three Rivers PPO |
$1,468.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,194.38
|
| Rate for Payer: United Healthcare Commercial |
$1,869.89
|
| Rate for Payer: United Healthcare Medicare |
$1,194.38
|
| Rate for Payer: WINHealth Partners Commercial |
$1,860.10
|
| Rate for Payer: Wise Provider Network Commercial |
$1,860.10
|
|
