|
HC CT SCAN OF LEG COMBO - CT TIBIA FIBULA RIGHT W AND WO IV CONTRAST
|
Facility
|
OP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 73702
|
| Hospital Charge Code |
3527370208
|
|
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 OF LEG COMBO - CT TIBIA FIBULA RIGHT W AND WO IV CONTRAST
|
Facility
|
IP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 73702
|
| Hospital Charge Code |
3527370208
|
|
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 OF LEG CONTRAST - CT FEMUR LEFT W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370108
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT FEMUR LEFT W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370108
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT FEMUR RIGHT W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370103
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT FEMUR RIGHT W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370103
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT FOOT LEFT W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370101
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT FOOT LEFT W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370101
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT FOOT RIGHT W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370109
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT FOOT RIGHT W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370109
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT HIP LEFT W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370110
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT HIP LEFT W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370110
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT HIP RIGHT W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370102
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT HIP RIGHT W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370102
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT KNEE LEFT W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370105
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT KNEE LEFT W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370105
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT KNEE RIGHT W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370111
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT KNEE RIGHT W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370111
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT LOWER EXTREMITY W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370107
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT LOWER EXTREMITY W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370107
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT TIBIA FIBULA LEFT W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370106
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT TIBIA FIBULA LEFT W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370106
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT TIBIA FIBULA RIGHT W IV CONTRAST
|
Facility
|
OP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370104
|
|
Hospital Revenue Code
|
352
|
| 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 OF LEG CONTRAST - CT TIBIA FIBULA RIGHT W IV CONTRAST
|
Facility
|
IP
|
$1,628.00
|
|
|
Service Code
|
HCPCS 73701
|
| Hospital Charge Code |
3527370104
|
|
Hospital Revenue Code
|
352
|
| 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 OF PELVIS COMBO - CT PELVIS W WO CONTRAST
|
Facility
|
IP
|
$1,808.00
|
|
|
Service Code
|
HCPCS 72194
|
| Hospital Charge Code |
3527219401
|
|
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
|
|
