|
HC MRI, ABDOMEN W/CONTRAST - MRI ABDOMEN W CONTRAST
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 74182
|
| Hospital Charge Code |
6147418202
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,881.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,940.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,880.00
|
| Rate for Payer: Altius Commercial |
$2,880.00
|
| Rate for Payer: Beech Street Commercial |
$2,940.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,463.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,910.00
|
| Rate for Payer: Cigna of WY Commercial |
$2,940.00
|
| Rate for Payer: Entrust Commercial |
$2,850.00
|
| Rate for Payer: First Choice Health Commercial |
$2,850.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,850.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,980.00
|
| Rate for Payer: HealthUtah PPO |
$3,000.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,910.00
|
| Rate for Payer: Multiplan Medicare/VA |
$1,881.00
|
| Rate for Payer: One Health Plan of WY PPO |
$2,940.00
|
| Rate for Payer: PacificSource Commercial |
$2,700.00
|
| Rate for Payer: PHCS PPO |
$2,940.00
|
| Rate for Payer: Three Rivers PPO |
$2,250.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,980.00
|
| Rate for Payer: United Healthcare Commercial |
$2,610.00
|
| Rate for Payer: United Healthcare Medicare |
$1,980.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,850.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,850.00
|
|
|
HC MRI, ABDOMEN W/CONTRAST - MRI ABDOMEN W CONTRAST
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS 74182
|
| Hospital Charge Code |
6147418202
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,653.00 |
| Max. Negotiated Rate |
$3,000.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,940.00
|
| Rate for Payer: Aetna of WY Medicare |
$1,980.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,880.00
|
| Rate for Payer: Altius Commercial |
$2,880.00
|
| Rate for Payer: Beech Street Commercial |
$2,940.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,463.00
|
| Rate for Payer: Cash Price |
$2,100.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,910.00
|
| Rate for Payer: Cigna of WY Commercial |
$2,940.00
|
| Rate for Payer: Entrust Commercial |
$2,850.00
|
| Rate for Payer: First Choice Health Commercial |
$2,850.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,850.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,740.00
|
| Rate for Payer: HealthUtah PPO |
$3,000.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,910.00
|
| Rate for Payer: Multiplan Medicare/VA |
$1,653.00
|
| Rate for Payer: One Health Plan of WY PPO |
$2,940.00
|
| Rate for Payer: PacificSource Commercial |
$2,700.00
|
| Rate for Payer: PHCS PPO |
$2,940.00
|
| Rate for Payer: Three Rivers PPO |
$2,250.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,740.00
|
| Rate for Payer: United Healthcare Commercial |
$2,610.00
|
| Rate for Payer: United Healthcare Medicare |
$1,740.00
|
| Rate for Payer: WINHealth Partners Commercial |
$2,940.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,850.00
|
|
|
HC MRI BRAIN COMBO - MRI BRAIN W WO CONTRAST
|
Facility
|
IP
|
$3,655.00
|
|
|
Service Code
|
HCPCS 70553
|
| Hospital Charge Code |
6117055302
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$2,291.68 |
| Max. Negotiated Rate |
$3,655.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,581.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,508.80
|
| Rate for Payer: Altius Commercial |
$3,508.80
|
| Rate for Payer: Beech Street Commercial |
$3,581.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,000.76
|
| Rate for Payer: Cash Price |
$2,558.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,545.35
|
| Rate for Payer: Cigna of WY Commercial |
$3,581.90
|
| Rate for Payer: Entrust Commercial |
$3,472.25
|
| Rate for Payer: First Choice Health Commercial |
$3,472.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,472.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,412.30
|
| Rate for Payer: HealthUtah PPO |
$3,655.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,545.35
|
| Rate for Payer: Multiplan Medicare/VA |
$2,291.68
|
| Rate for Payer: One Health Plan of WY PPO |
$3,581.90
|
| Rate for Payer: PacificSource Commercial |
$3,289.50
|
| Rate for Payer: PHCS PPO |
$3,581.90
|
| Rate for Payer: Three Rivers PPO |
$2,741.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,412.30
|
| Rate for Payer: United Healthcare Commercial |
$3,179.85
|
| Rate for Payer: United Healthcare Medicare |
$2,412.30
|
| Rate for Payer: WINHealth Partners Commercial |
$3,472.25
|
| Rate for Payer: Wise Provider Network Commercial |
$3,472.25
|
|
|
HC MRI BRAIN COMBO - MRI BRAIN W WO CONTRAST
|
Facility
|
OP
|
$3,655.00
|
|
|
Service Code
|
HCPCS 70553
|
| Hospital Charge Code |
6117055302
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$2,013.90 |
| Max. Negotiated Rate |
$3,655.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,581.90
|
| Rate for Payer: Aetna of WY Medicare |
$2,412.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,508.80
|
| Rate for Payer: Altius Commercial |
$3,508.80
|
| Rate for Payer: Beech Street Commercial |
$3,581.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,000.76
|
| Rate for Payer: Cash Price |
$2,558.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,545.35
|
| Rate for Payer: Cigna of WY Commercial |
$3,581.90
|
| Rate for Payer: Entrust Commercial |
$3,472.25
|
| Rate for Payer: First Choice Health Commercial |
$3,472.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,472.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,119.90
|
| Rate for Payer: HealthUtah PPO |
$3,655.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,545.35
|
| Rate for Payer: Multiplan Medicare/VA |
$2,013.90
|
| Rate for Payer: One Health Plan of WY PPO |
$3,581.90
|
| Rate for Payer: PacificSource Commercial |
$3,289.50
|
| Rate for Payer: PHCS PPO |
$3,581.90
|
| Rate for Payer: Three Rivers PPO |
$2,741.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,119.90
|
| Rate for Payer: United Healthcare Commercial |
$3,179.85
|
| Rate for Payer: United Healthcare Medicare |
$2,119.90
|
| Rate for Payer: WINHealth Partners Commercial |
$3,581.90
|
| Rate for Payer: Wise Provider Network Commercial |
$3,472.25
|
|
|
HC MRI BRAIN COMBO - MR PITUITARY W/WO IV CONTRAST
|
Facility
|
IP
|
$3,655.00
|
|
|
Service Code
|
HCPCS 70553
|
| Hospital Charge Code |
6117055301
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$2,291.68 |
| Max. Negotiated Rate |
$3,655.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,581.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,508.80
|
| Rate for Payer: Altius Commercial |
$3,508.80
|
| Rate for Payer: Beech Street Commercial |
$3,581.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,000.76
|
| Rate for Payer: Cash Price |
$2,558.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,545.35
|
| Rate for Payer: Cigna of WY Commercial |
$3,581.90
|
| Rate for Payer: Entrust Commercial |
$3,472.25
|
| Rate for Payer: First Choice Health Commercial |
$3,472.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,472.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,412.30
|
| Rate for Payer: HealthUtah PPO |
$3,655.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,545.35
|
| Rate for Payer: Multiplan Medicare/VA |
$2,291.68
|
| Rate for Payer: One Health Plan of WY PPO |
$3,581.90
|
| Rate for Payer: PacificSource Commercial |
$3,289.50
|
| Rate for Payer: PHCS PPO |
$3,581.90
|
| Rate for Payer: Three Rivers PPO |
$2,741.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,412.30
|
| Rate for Payer: United Healthcare Commercial |
$3,179.85
|
| Rate for Payer: United Healthcare Medicare |
$2,412.30
|
| Rate for Payer: WINHealth Partners Commercial |
$3,472.25
|
| Rate for Payer: Wise Provider Network Commercial |
$3,472.25
|
|
|
HC MRI BRAIN COMBO - MR PITUITARY W/WO IV CONTRAST
|
Facility
|
OP
|
$3,655.00
|
|
|
Service Code
|
HCPCS 70553
|
| Hospital Charge Code |
6117055301
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$2,013.90 |
| Max. Negotiated Rate |
$3,655.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,581.90
|
| Rate for Payer: Aetna of WY Medicare |
$2,412.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,508.80
|
| Rate for Payer: Altius Commercial |
$3,508.80
|
| Rate for Payer: Beech Street Commercial |
$3,581.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,000.76
|
| Rate for Payer: Cash Price |
$2,558.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,545.35
|
| Rate for Payer: Cigna of WY Commercial |
$3,581.90
|
| Rate for Payer: Entrust Commercial |
$3,472.25
|
| Rate for Payer: First Choice Health Commercial |
$3,472.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,472.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,119.90
|
| Rate for Payer: HealthUtah PPO |
$3,655.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,545.35
|
| Rate for Payer: Multiplan Medicare/VA |
$2,013.90
|
| Rate for Payer: One Health Plan of WY PPO |
$3,581.90
|
| Rate for Payer: PacificSource Commercial |
$3,289.50
|
| Rate for Payer: PHCS PPO |
$3,581.90
|
| Rate for Payer: Three Rivers PPO |
$2,741.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,119.90
|
| Rate for Payer: United Healthcare Commercial |
$3,179.85
|
| Rate for Payer: United Healthcare Medicare |
$2,119.90
|
| Rate for Payer: WINHealth Partners Commercial |
$3,581.90
|
| Rate for Payer: Wise Provider Network Commercial |
$3,472.25
|
|
|
HC MRI BRAIN CONTRAST - MRI BRAIN W CONTRAST
|
Facility
|
IP
|
$2,940.00
|
|
|
Service Code
|
HCPCS 70552
|
| Hospital Charge Code |
6117055202
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$1,843.38 |
| Max. Negotiated Rate |
$2,940.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,881.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,822.40
|
| Rate for Payer: Altius Commercial |
$2,822.40
|
| Rate for Payer: Beech Street Commercial |
$2,881.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,413.74
|
| Rate for Payer: Cash Price |
$2,058.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,851.80
|
| Rate for Payer: Cigna of WY Commercial |
$2,881.20
|
| Rate for Payer: Entrust Commercial |
$2,793.00
|
| Rate for Payer: First Choice Health Commercial |
$2,793.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,793.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,940.40
|
| Rate for Payer: HealthUtah PPO |
$2,940.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,851.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1,843.38
|
| Rate for Payer: One Health Plan of WY PPO |
$2,881.20
|
| Rate for Payer: PacificSource Commercial |
$2,646.00
|
| Rate for Payer: PHCS PPO |
$2,881.20
|
| Rate for Payer: Three Rivers PPO |
$2,205.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,940.40
|
| Rate for Payer: United Healthcare Commercial |
$2,557.80
|
| Rate for Payer: United Healthcare Medicare |
$1,940.40
|
| Rate for Payer: WINHealth Partners Commercial |
$2,793.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,793.00
|
|
|
HC MRI BRAIN CONTRAST - MRI BRAIN W CONTRAST
|
Facility
|
OP
|
$2,940.00
|
|
|
Service Code
|
HCPCS 70552
|
| Hospital Charge Code |
6117055202
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$1,619.94 |
| Max. Negotiated Rate |
$2,940.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,881.20
|
| Rate for Payer: Aetna of WY Medicare |
$1,940.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,822.40
|
| Rate for Payer: Altius Commercial |
$2,822.40
|
| Rate for Payer: Beech Street Commercial |
$2,881.20
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,413.74
|
| Rate for Payer: Cash Price |
$2,058.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,851.80
|
| Rate for Payer: Cigna of WY Commercial |
$2,881.20
|
| Rate for Payer: Entrust Commercial |
$2,793.00
|
| Rate for Payer: First Choice Health Commercial |
$2,793.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,793.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,705.20
|
| Rate for Payer: HealthUtah PPO |
$2,940.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,851.80
|
| Rate for Payer: Multiplan Medicare/VA |
$1,619.94
|
| Rate for Payer: One Health Plan of WY PPO |
$2,881.20
|
| Rate for Payer: PacificSource Commercial |
$2,646.00
|
| Rate for Payer: PHCS PPO |
$2,881.20
|
| Rate for Payer: Three Rivers PPO |
$2,205.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,705.20
|
| Rate for Payer: United Healthcare Commercial |
$2,557.80
|
| Rate for Payer: United Healthcare Medicare |
$1,705.20
|
| Rate for Payer: WINHealth Partners Commercial |
$2,881.20
|
| Rate for Payer: Wise Provider Network Commercial |
$2,793.00
|
|
|
HC MRI BRAIN - MRI BRAIN WO CONTRAST
|
Facility
|
OP
|
$3,145.00
|
|
|
Service Code
|
HCPCS 70551
|
| Hospital Charge Code |
6117055102
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$1,732.90 |
| Max. Negotiated Rate |
$3,145.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,082.10
|
| Rate for Payer: Aetna of WY Medicare |
$2,075.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,019.20
|
| Rate for Payer: Altius Commercial |
$3,019.20
|
| Rate for Payer: Beech Street Commercial |
$3,082.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,582.04
|
| Rate for Payer: Cash Price |
$2,201.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,050.65
|
| Rate for Payer: Cigna of WY Commercial |
$3,082.10
|
| Rate for Payer: Entrust Commercial |
$2,987.75
|
| Rate for Payer: First Choice Health Commercial |
$2,987.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,987.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,824.10
|
| Rate for Payer: HealthUtah PPO |
$3,145.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,050.65
|
| Rate for Payer: Multiplan Medicare/VA |
$1,732.90
|
| Rate for Payer: One Health Plan of WY PPO |
$3,082.10
|
| Rate for Payer: PacificSource Commercial |
$2,830.50
|
| Rate for Payer: PHCS PPO |
$3,082.10
|
| Rate for Payer: Three Rivers PPO |
$2,358.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,824.10
|
| Rate for Payer: United Healthcare Commercial |
$2,736.15
|
| Rate for Payer: United Healthcare Medicare |
$1,824.10
|
| Rate for Payer: WINHealth Partners Commercial |
$3,082.10
|
| Rate for Payer: Wise Provider Network Commercial |
$2,987.75
|
|
|
HC MRI BRAIN - MRI BRAIN WO CONTRAST
|
Facility
|
IP
|
$3,145.00
|
|
|
Service Code
|
HCPCS 70551
|
| Hospital Charge Code |
6117055102
|
|
Hospital Revenue Code
|
611
|
| Min. Negotiated Rate |
$1,971.92 |
| Max. Negotiated Rate |
$3,145.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,082.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,019.20
|
| Rate for Payer: Altius Commercial |
$3,019.20
|
| Rate for Payer: Beech Street Commercial |
$3,082.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,582.04
|
| Rate for Payer: Cash Price |
$2,201.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,050.65
|
| Rate for Payer: Cigna of WY Commercial |
$3,082.10
|
| Rate for Payer: Entrust Commercial |
$2,987.75
|
| Rate for Payer: First Choice Health Commercial |
$2,987.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,987.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,075.70
|
| Rate for Payer: HealthUtah PPO |
$3,145.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,050.65
|
| Rate for Payer: Multiplan Medicare/VA |
$1,971.92
|
| Rate for Payer: One Health Plan of WY PPO |
$3,082.10
|
| Rate for Payer: PacificSource Commercial |
$2,830.50
|
| Rate for Payer: PHCS PPO |
$3,082.10
|
| Rate for Payer: Three Rivers PPO |
$2,358.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,075.70
|
| Rate for Payer: United Healthcare Commercial |
$2,736.15
|
| Rate for Payer: United Healthcare Medicare |
$2,075.70
|
| Rate for Payer: WINHealth Partners Commercial |
$2,987.75
|
| Rate for Payer: Wise Provider Network Commercial |
$2,987.75
|
|
|
HC MRI BREAST W/OUT&WITH CONTRAST W/CAD BILATERAL
|
Facility
|
IP
|
$1,950.00
|
|
|
Service Code
|
HCPCS 77049
|
| Hospital Charge Code |
6147704901
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,222.65 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,911.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,872.00
|
| Rate for Payer: Altius Commercial |
$1,872.00
|
| Rate for Payer: Beech Street Commercial |
$1,911.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,600.95
|
| Rate for Payer: Cash Price |
$1,365.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,891.50
|
| Rate for Payer: Cigna of WY Commercial |
$1,911.00
|
| Rate for Payer: Entrust Commercial |
$1,852.50
|
| Rate for Payer: First Choice Health Commercial |
$1,852.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,852.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,287.00
|
| Rate for Payer: HealthUtah PPO |
$1,950.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,891.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,222.65
|
| Rate for Payer: One Health Plan of WY PPO |
$1,911.00
|
| Rate for Payer: PacificSource Commercial |
$1,755.00
|
| Rate for Payer: PHCS PPO |
$1,911.00
|
| Rate for Payer: Three Rivers PPO |
$1,462.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,287.00
|
| Rate for Payer: United Healthcare Commercial |
$1,696.50
|
| Rate for Payer: United Healthcare Medicare |
$1,287.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,852.50
|
| Rate for Payer: Wise Provider Network Commercial |
$1,852.50
|
|
|
HC MRI BREAST W/OUT&WITH CONTRAST W/CAD BILATERAL
|
Facility
|
OP
|
$1,950.00
|
|
|
Service Code
|
HCPCS 77049
|
| Hospital Charge Code |
6147704901
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,074.45 |
| Max. Negotiated Rate |
$1,950.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,911.00
|
| Rate for Payer: Aetna of WY Medicare |
$1,287.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,872.00
|
| Rate for Payer: Altius Commercial |
$1,872.00
|
| Rate for Payer: Beech Street Commercial |
$1,911.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,600.95
|
| Rate for Payer: Cash Price |
$1,365.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,891.50
|
| Rate for Payer: Cigna of WY Commercial |
$1,911.00
|
| Rate for Payer: Entrust Commercial |
$1,852.50
|
| Rate for Payer: First Choice Health Commercial |
$1,852.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,852.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,131.00
|
| Rate for Payer: HealthUtah PPO |
$1,950.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,891.50
|
| Rate for Payer: Multiplan Medicare/VA |
$1,074.45
|
| Rate for Payer: One Health Plan of WY PPO |
$1,911.00
|
| Rate for Payer: PacificSource Commercial |
$1,755.00
|
| Rate for Payer: PHCS PPO |
$1,911.00
|
| Rate for Payer: Three Rivers PPO |
$1,462.50
|
| Rate for Payer: TriWest Veterans Administration |
$1,131.00
|
| Rate for Payer: United Healthcare Commercial |
$1,696.50
|
| Rate for Payer: United Healthcare Medicare |
$1,131.00
|
| Rate for Payer: WINHealth Partners Commercial |
$1,911.00
|
| Rate for Payer: Wise Provider Network Commercial |
$1,852.50
|
|
|
HC MRI, CERV SPINE COMBO - MRI CERVICAL SPINE W WO CONTRAST
|
Facility
|
OP
|
$4,170.00
|
|
|
Service Code
|
HCPCS 72156
|
| Hospital Charge Code |
6127215601
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,297.67 |
| Max. Negotiated Rate |
$4,170.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,086.60
|
| Rate for Payer: Aetna of WY Medicare |
$2,752.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,003.20
|
| Rate for Payer: Altius Commercial |
$4,003.20
|
| Rate for Payer: Beech Street Commercial |
$4,086.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,423.57
|
| Rate for Payer: Cash Price |
$2,919.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,044.90
|
| Rate for Payer: Cigna of WY Commercial |
$4,086.60
|
| Rate for Payer: Entrust Commercial |
$3,961.50
|
| Rate for Payer: First Choice Health Commercial |
$3,961.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,961.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,418.60
|
| Rate for Payer: HealthUtah PPO |
$4,170.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,044.90
|
| Rate for Payer: Multiplan Medicare/VA |
$2,297.67
|
| Rate for Payer: One Health Plan of WY PPO |
$4,086.60
|
| Rate for Payer: PacificSource Commercial |
$3,753.00
|
| Rate for Payer: PHCS PPO |
$4,086.60
|
| Rate for Payer: Three Rivers PPO |
$3,127.50
|
| Rate for Payer: TriWest Veterans Administration |
$2,418.60
|
| Rate for Payer: United Healthcare Commercial |
$3,627.90
|
| Rate for Payer: United Healthcare Medicare |
$2,418.60
|
| Rate for Payer: WINHealth Partners Commercial |
$4,086.60
|
| Rate for Payer: Wise Provider Network Commercial |
$3,961.50
|
|
|
HC MRI, CERV SPINE COMBO - MRI CERVICAL SPINE W WO CONTRAST
|
Facility
|
IP
|
$4,170.00
|
|
|
Service Code
|
HCPCS 72156
|
| Hospital Charge Code |
6127215601
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,614.59 |
| Max. Negotiated Rate |
$4,170.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,086.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,003.20
|
| Rate for Payer: Altius Commercial |
$4,003.20
|
| Rate for Payer: Beech Street Commercial |
$4,086.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,423.57
|
| Rate for Payer: Cash Price |
$2,919.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,044.90
|
| Rate for Payer: Cigna of WY Commercial |
$4,086.60
|
| Rate for Payer: Entrust Commercial |
$3,961.50
|
| Rate for Payer: First Choice Health Commercial |
$3,961.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,961.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,752.20
|
| Rate for Payer: HealthUtah PPO |
$4,170.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,044.90
|
| Rate for Payer: Multiplan Medicare/VA |
$2,614.59
|
| Rate for Payer: One Health Plan of WY PPO |
$4,086.60
|
| Rate for Payer: PacificSource Commercial |
$3,753.00
|
| Rate for Payer: PHCS PPO |
$4,086.60
|
| Rate for Payer: Three Rivers PPO |
$3,127.50
|
| Rate for Payer: TriWest Veterans Administration |
$2,752.20
|
| Rate for Payer: United Healthcare Commercial |
$3,627.90
|
| Rate for Payer: United Healthcare Medicare |
$2,752.20
|
| Rate for Payer: WINHealth Partners Commercial |
$3,961.50
|
| Rate for Payer: Wise Provider Network Commercial |
$3,961.50
|
|
|
HC MRI, CERV SPINE CONTRAST - MRI CERVICAL SPINE W CONTRAST
|
Facility
|
OP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 72142
|
| Hospital Charge Code |
6127214201
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,245.26 |
| Max. Negotiated Rate |
$2,260.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,214.80
|
| Rate for Payer: Aetna of WY Medicare |
$1,491.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,169.60
|
| Rate for Payer: Altius Commercial |
$2,169.60
|
| Rate for Payer: Beech Street Commercial |
$2,214.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,855.46
|
| Rate for Payer: Cash Price |
$1,582.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,192.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,214.80
|
| Rate for Payer: Entrust Commercial |
$2,147.00
|
| Rate for Payer: First Choice Health Commercial |
$2,147.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,147.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,310.80
|
| Rate for Payer: HealthUtah PPO |
$2,260.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,192.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,245.26
|
| Rate for Payer: One Health Plan of WY PPO |
$2,214.80
|
| Rate for Payer: PacificSource Commercial |
$2,034.00
|
| Rate for Payer: PHCS PPO |
$2,214.80
|
| Rate for Payer: Three Rivers PPO |
$1,695.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,310.80
|
| Rate for Payer: United Healthcare Commercial |
$1,966.20
|
| Rate for Payer: United Healthcare Medicare |
$1,310.80
|
| Rate for Payer: WINHealth Partners Commercial |
$2,214.80
|
| Rate for Payer: Wise Provider Network Commercial |
$2,147.00
|
|
|
HC MRI, CERV SPINE CONTRAST - MRI CERVICAL SPINE W CONTRAST
|
Facility
|
IP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 72142
|
| Hospital Charge Code |
6127214201
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,417.02 |
| Max. Negotiated Rate |
$2,260.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,214.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,169.60
|
| Rate for Payer: Altius Commercial |
$2,169.60
|
| Rate for Payer: Beech Street Commercial |
$2,214.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,855.46
|
| Rate for Payer: Cash Price |
$1,582.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,192.20
|
| Rate for Payer: Cigna of WY Commercial |
$2,214.80
|
| Rate for Payer: Entrust Commercial |
$2,147.00
|
| Rate for Payer: First Choice Health Commercial |
$2,147.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,147.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,491.60
|
| Rate for Payer: HealthUtah PPO |
$2,260.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,192.20
|
| Rate for Payer: Multiplan Medicare/VA |
$1,417.02
|
| Rate for Payer: One Health Plan of WY PPO |
$2,214.80
|
| Rate for Payer: PacificSource Commercial |
$2,034.00
|
| Rate for Payer: PHCS PPO |
$2,214.80
|
| Rate for Payer: Three Rivers PPO |
$1,695.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,491.60
|
| Rate for Payer: United Healthcare Commercial |
$1,966.20
|
| Rate for Payer: United Healthcare Medicare |
$1,491.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2,147.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,147.00
|
|
|
HC MRI, CERV SPINE - MRI CERVICAL SPINE WO CONTRAST
|
Facility
|
OP
|
$3,015.00
|
|
|
Service Code
|
HCPCS 72141
|
| Hospital Charge Code |
6127214102
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,661.26 |
| Max. Negotiated Rate |
$3,015.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,954.70
|
| Rate for Payer: Aetna of WY Medicare |
$1,989.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,894.40
|
| Rate for Payer: Altius Commercial |
$2,894.40
|
| Rate for Payer: Beech Street Commercial |
$2,954.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,475.32
|
| Rate for Payer: Cash Price |
$2,110.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,924.55
|
| Rate for Payer: Cigna of WY Commercial |
$2,954.70
|
| Rate for Payer: Entrust Commercial |
$2,864.25
|
| Rate for Payer: First Choice Health Commercial |
$2,864.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,864.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,748.70
|
| Rate for Payer: HealthUtah PPO |
$3,015.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,924.55
|
| Rate for Payer: Multiplan Medicare/VA |
$1,661.26
|
| Rate for Payer: One Health Plan of WY PPO |
$2,954.70
|
| Rate for Payer: PacificSource Commercial |
$2,713.50
|
| Rate for Payer: PHCS PPO |
$2,954.70
|
| Rate for Payer: Three Rivers PPO |
$2,261.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,748.70
|
| Rate for Payer: United Healthcare Commercial |
$2,623.05
|
| Rate for Payer: United Healthcare Medicare |
$1,748.70
|
| Rate for Payer: WINHealth Partners Commercial |
$2,954.70
|
| Rate for Payer: Wise Provider Network Commercial |
$2,864.25
|
|
|
HC MRI, CERV SPINE - MRI CERVICAL SPINE WO CONTRAST
|
Facility
|
IP
|
$3,015.00
|
|
|
Service Code
|
HCPCS 72141
|
| Hospital Charge Code |
6127214102
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,890.40 |
| Max. Negotiated Rate |
$3,015.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,954.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,894.40
|
| Rate for Payer: Altius Commercial |
$2,894.40
|
| Rate for Payer: Beech Street Commercial |
$2,954.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,475.32
|
| Rate for Payer: Cash Price |
$2,110.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,924.55
|
| Rate for Payer: Cigna of WY Commercial |
$2,954.70
|
| Rate for Payer: Entrust Commercial |
$2,864.25
|
| Rate for Payer: First Choice Health Commercial |
$2,864.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,864.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,989.90
|
| Rate for Payer: HealthUtah PPO |
$3,015.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,924.55
|
| Rate for Payer: Multiplan Medicare/VA |
$1,890.40
|
| Rate for Payer: One Health Plan of WY PPO |
$2,954.70
|
| Rate for Payer: PacificSource Commercial |
$2,713.50
|
| Rate for Payer: PHCS PPO |
$2,954.70
|
| Rate for Payer: Three Rivers PPO |
$2,261.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,989.90
|
| Rate for Payer: United Healthcare Commercial |
$2,623.05
|
| Rate for Payer: United Healthcare Medicare |
$1,989.90
|
| Rate for Payer: WINHealth Partners Commercial |
$2,864.25
|
| Rate for Payer: Wise Provider Network Commercial |
$2,864.25
|
|
|
HC MRI, CHEST, COMBO - MRI CHEST W WO CONTRAST
|
Facility
|
IP
|
$3,800.00
|
|
|
Service Code
|
HCPCS 71552
|
| Hospital Charge Code |
6107155202
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,382.60 |
| Max. Negotiated Rate |
$3,800.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,724.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,648.00
|
| Rate for Payer: Altius Commercial |
$3,648.00
|
| Rate for Payer: Beech Street Commercial |
$3,724.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,119.80
|
| Rate for Payer: Cash Price |
$2,660.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,686.00
|
| Rate for Payer: Cigna of WY Commercial |
$3,724.00
|
| Rate for Payer: Entrust Commercial |
$3,610.00
|
| Rate for Payer: First Choice Health Commercial |
$3,610.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,610.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,508.00
|
| Rate for Payer: HealthUtah PPO |
$3,800.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,686.00
|
| Rate for Payer: Multiplan Medicare/VA |
$2,382.60
|
| Rate for Payer: One Health Plan of WY PPO |
$3,724.00
|
| Rate for Payer: PacificSource Commercial |
$3,420.00
|
| Rate for Payer: PHCS PPO |
$3,724.00
|
| Rate for Payer: Three Rivers PPO |
$2,850.00
|
| Rate for Payer: TriWest Veterans Administration |
$2,508.00
|
| Rate for Payer: United Healthcare Commercial |
$3,306.00
|
| Rate for Payer: United Healthcare Medicare |
$2,508.00
|
| Rate for Payer: WINHealth Partners Commercial |
$3,610.00
|
| Rate for Payer: Wise Provider Network Commercial |
$3,610.00
|
|
|
HC MRI, CHEST, COMBO - MRI CHEST W WO CONTRAST
|
Facility
|
OP
|
$3,800.00
|
|
|
Service Code
|
HCPCS 71552
|
| Hospital Charge Code |
6107155202
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,093.80 |
| Max. Negotiated Rate |
$3,800.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,724.00
|
| Rate for Payer: Aetna of WY Medicare |
$2,508.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,648.00
|
| Rate for Payer: Altius Commercial |
$3,648.00
|
| Rate for Payer: Beech Street Commercial |
$3,724.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,119.80
|
| Rate for Payer: Cash Price |
$2,660.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,686.00
|
| Rate for Payer: Cigna of WY Commercial |
$3,724.00
|
| Rate for Payer: Entrust Commercial |
$3,610.00
|
| Rate for Payer: First Choice Health Commercial |
$3,610.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,610.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,204.00
|
| Rate for Payer: HealthUtah PPO |
$3,800.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,686.00
|
| Rate for Payer: Multiplan Medicare/VA |
$2,093.80
|
| Rate for Payer: One Health Plan of WY PPO |
$3,724.00
|
| Rate for Payer: PacificSource Commercial |
$3,420.00
|
| Rate for Payer: PHCS PPO |
$3,724.00
|
| Rate for Payer: Three Rivers PPO |
$2,850.00
|
| Rate for Payer: TriWest Veterans Administration |
$2,204.00
|
| Rate for Payer: United Healthcare Commercial |
$3,306.00
|
| Rate for Payer: United Healthcare Medicare |
$2,204.00
|
| Rate for Payer: WINHealth Partners Commercial |
$3,724.00
|
| Rate for Payer: Wise Provider Network Commercial |
$3,610.00
|
|
|
HC MRI, CHEST - MRI CHEST WO CONTRAST
|
Facility
|
IP
|
$1,555.00
|
|
|
Service Code
|
HCPCS 71550
|
| Hospital Charge Code |
6107155001
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$974.98 |
| Max. Negotiated Rate |
$1,555.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,523.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,492.80
|
| Rate for Payer: Altius Commercial |
$1,492.80
|
| Rate for Payer: Beech Street Commercial |
$1,523.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,276.66
|
| Rate for Payer: Cash Price |
$1,088.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,508.35
|
| Rate for Payer: Cigna of WY Commercial |
$1,523.90
|
| Rate for Payer: Entrust Commercial |
$1,477.25
|
| Rate for Payer: First Choice Health Commercial |
$1,477.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,477.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,026.30
|
| Rate for Payer: HealthUtah PPO |
$1,555.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,508.35
|
| Rate for Payer: Multiplan Medicare/VA |
$974.98
|
| Rate for Payer: One Health Plan of WY PPO |
$1,523.90
|
| Rate for Payer: PacificSource Commercial |
$1,399.50
|
| Rate for Payer: PHCS PPO |
$1,523.90
|
| Rate for Payer: Three Rivers PPO |
$1,166.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,026.30
|
| Rate for Payer: United Healthcare Commercial |
$1,352.85
|
| Rate for Payer: United Healthcare Medicare |
$1,026.30
|
| Rate for Payer: WINHealth Partners Commercial |
$1,477.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,477.25
|
|
|
HC MRI, CHEST - MRI CHEST WO CONTRAST
|
Facility
|
OP
|
$1,555.00
|
|
|
Service Code
|
HCPCS 71550
|
| Hospital Charge Code |
6107155001
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$856.80 |
| Max. Negotiated Rate |
$1,555.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,523.90
|
| Rate for Payer: Aetna of WY Medicare |
$1,026.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,492.80
|
| Rate for Payer: Altius Commercial |
$1,492.80
|
| Rate for Payer: Beech Street Commercial |
$1,523.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,276.66
|
| Rate for Payer: Cash Price |
$1,088.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,508.35
|
| Rate for Payer: Cigna of WY Commercial |
$1,523.90
|
| Rate for Payer: Entrust Commercial |
$1,477.25
|
| Rate for Payer: First Choice Health Commercial |
$1,477.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,477.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$901.90
|
| Rate for Payer: HealthUtah PPO |
$1,555.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,508.35
|
| Rate for Payer: Multiplan Medicare/VA |
$856.80
|
| Rate for Payer: One Health Plan of WY PPO |
$1,523.90
|
| Rate for Payer: PacificSource Commercial |
$1,399.50
|
| Rate for Payer: PHCS PPO |
$1,523.90
|
| Rate for Payer: Three Rivers PPO |
$1,166.25
|
| Rate for Payer: TriWest Veterans Administration |
$901.90
|
| Rate for Payer: United Healthcare Commercial |
$1,352.85
|
| Rate for Payer: United Healthcare Medicare |
$901.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,523.90
|
| Rate for Payer: Wise Provider Network Commercial |
$1,477.25
|
|
|
HC MRI, CHEST, W/CONTRAST - MRI CHEST W CONTRAST
|
Facility
|
IP
|
$4,385.00
|
|
|
Service Code
|
HCPCS 71551
|
| Hospital Charge Code |
6107155101
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,749.40 |
| Max. Negotiated Rate |
$4,385.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,297.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,209.60
|
| Rate for Payer: Altius Commercial |
$4,209.60
|
| Rate for Payer: Beech Street Commercial |
$4,297.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,600.08
|
| Rate for Payer: Cash Price |
$3,069.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,253.45
|
| Rate for Payer: Cigna of WY Commercial |
$4,297.30
|
| Rate for Payer: Entrust Commercial |
$4,165.75
|
| Rate for Payer: First Choice Health Commercial |
$4,165.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,165.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,894.10
|
| Rate for Payer: HealthUtah PPO |
$4,385.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,253.45
|
| Rate for Payer: Multiplan Medicare/VA |
$2,749.40
|
| Rate for Payer: One Health Plan of WY PPO |
$4,297.30
|
| Rate for Payer: PacificSource Commercial |
$3,946.50
|
| Rate for Payer: PHCS PPO |
$4,297.30
|
| Rate for Payer: Three Rivers PPO |
$3,288.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,894.10
|
| Rate for Payer: United Healthcare Commercial |
$3,814.95
|
| Rate for Payer: United Healthcare Medicare |
$2,894.10
|
| Rate for Payer: WINHealth Partners Commercial |
$4,165.75
|
| Rate for Payer: Wise Provider Network Commercial |
$4,165.75
|
|
|
HC MRI, CHEST, W/CONTRAST - MRI CHEST W CONTRAST
|
Facility
|
OP
|
$4,385.00
|
|
|
Service Code
|
HCPCS 71551
|
| Hospital Charge Code |
6107155101
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,416.14 |
| Max. Negotiated Rate |
$4,385.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,297.30
|
| Rate for Payer: Aetna of WY Medicare |
$2,894.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,209.60
|
| Rate for Payer: Altius Commercial |
$4,209.60
|
| Rate for Payer: Beech Street Commercial |
$4,297.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,600.08
|
| Rate for Payer: Cash Price |
$3,069.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,253.45
|
| Rate for Payer: Cigna of WY Commercial |
$4,297.30
|
| Rate for Payer: Entrust Commercial |
$4,165.75
|
| Rate for Payer: First Choice Health Commercial |
$4,165.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,165.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,543.30
|
| Rate for Payer: HealthUtah PPO |
$4,385.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,253.45
|
| Rate for Payer: Multiplan Medicare/VA |
$2,416.14
|
| Rate for Payer: One Health Plan of WY PPO |
$4,297.30
|
| Rate for Payer: PacificSource Commercial |
$3,946.50
|
| Rate for Payer: PHCS PPO |
$4,297.30
|
| Rate for Payer: Three Rivers PPO |
$3,288.75
|
| Rate for Payer: TriWest Veterans Administration |
$2,543.30
|
| Rate for Payer: United Healthcare Commercial |
$3,814.95
|
| Rate for Payer: United Healthcare Medicare |
$2,543.30
|
| Rate for Payer: WINHealth Partners Commercial |
$4,297.30
|
| Rate for Payer: Wise Provider Network Commercial |
$4,165.75
|
|
|
HC MRI, DORSAL SPINE COMBO - MRI THORACIC SPINE W WO CONTRAST
|
Facility
|
IP
|
$4,000.00
|
|
|
Service Code
|
HCPCS 72157
|
| Hospital Charge Code |
6127215701
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,508.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,920.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,840.00
|
| Rate for Payer: Altius Commercial |
$3,840.00
|
| Rate for Payer: Beech Street Commercial |
$3,920.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,284.00
|
| Rate for Payer: Cash Price |
$2,800.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,880.00
|
| Rate for Payer: Cigna of WY Commercial |
$3,920.00
|
| Rate for Payer: Entrust Commercial |
$3,800.00
|
| Rate for Payer: First Choice Health Commercial |
$3,800.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,800.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,640.00
|
| Rate for Payer: HealthUtah PPO |
$4,000.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,880.00
|
| Rate for Payer: Multiplan Medicare/VA |
$2,508.00
|
| Rate for Payer: One Health Plan of WY PPO |
$3,920.00
|
| Rate for Payer: PacificSource Commercial |
$3,600.00
|
| Rate for Payer: PHCS PPO |
$3,920.00
|
| Rate for Payer: Three Rivers PPO |
$3,000.00
|
| Rate for Payer: TriWest Veterans Administration |
$2,640.00
|
| Rate for Payer: United Healthcare Commercial |
$3,480.00
|
| Rate for Payer: United Healthcare Medicare |
$2,640.00
|
| Rate for Payer: WINHealth Partners Commercial |
$3,800.00
|
| Rate for Payer: Wise Provider Network Commercial |
$3,800.00
|
|
