|
HC MRI, DORSAL SPINE COMBO - MRI THORACIC SPINE W WO CONTRAST
|
Facility
|
OP
|
$4,000.00
|
|
|
Service Code
|
HCPCS 72157
|
| Hospital Charge Code |
6127215701
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$2,204.00 |
| Max. Negotiated Rate |
$4,000.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,920.00
|
| Rate for Payer: Aetna of WY Medicare |
$2,640.00
|
| 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 |
$2,320.00
|
| Rate for Payer: HealthUtah PPO |
$4,000.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,880.00
|
| Rate for Payer: Multiplan Medicare/VA |
$2,204.00
|
| 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 |
$2,320.00
|
| Rate for Payer: United Healthcare Commercial |
$3,480.00
|
| Rate for Payer: United Healthcare Medicare |
$2,320.00
|
| Rate for Payer: WINHealth Partners Commercial |
$3,920.00
|
| Rate for Payer: Wise Provider Network Commercial |
$3,800.00
|
|
|
HC MRI, DORSAL SPINE CONTRAST - MRI THORACIC SPINE W CONTRAST
|
Facility
|
IP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 72147
|
| Hospital Charge Code |
6127214701
|
|
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, DORSAL SPINE CONTRAST - MRI THORACIC SPINE W CONTRAST
|
Facility
|
OP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 72147
|
| Hospital Charge Code |
6127214701
|
|
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, DORSAL SPINE - MRI THORACIC SPINE WO CONTRAST
|
Facility
|
IP
|
$2,780.00
|
|
|
Service Code
|
HCPCS 72146
|
| Hospital Charge Code |
6127214602
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,743.06 |
| Max. Negotiated Rate |
$2,780.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,724.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,668.80
|
| Rate for Payer: Altius Commercial |
$2,668.80
|
| Rate for Payer: Beech Street Commercial |
$2,724.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,282.38
|
| Rate for Payer: Cash Price |
$1,946.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,696.60
|
| Rate for Payer: Cigna of WY Commercial |
$2,724.40
|
| Rate for Payer: Entrust Commercial |
$2,641.00
|
| Rate for Payer: First Choice Health Commercial |
$2,641.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,641.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,834.80
|
| Rate for Payer: HealthUtah PPO |
$2,780.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,696.60
|
| Rate for Payer: Multiplan Medicare/VA |
$1,743.06
|
| Rate for Payer: One Health Plan of WY PPO |
$2,724.40
|
| Rate for Payer: PacificSource Commercial |
$2,502.00
|
| Rate for Payer: PHCS PPO |
$2,724.40
|
| Rate for Payer: Three Rivers PPO |
$2,085.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,834.80
|
| Rate for Payer: United Healthcare Commercial |
$2,418.60
|
| Rate for Payer: United Healthcare Medicare |
$1,834.80
|
| Rate for Payer: WINHealth Partners Commercial |
$2,641.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,641.00
|
|
|
HC MRI, DORSAL SPINE - MRI THORACIC SPINE WO CONTRAST
|
Facility
|
OP
|
$2,780.00
|
|
|
Service Code
|
HCPCS 72146
|
| Hospital Charge Code |
6127214602
|
|
Hospital Revenue Code
|
612
|
| Min. Negotiated Rate |
$1,531.78 |
| Max. Negotiated Rate |
$2,780.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,724.40
|
| Rate for Payer: Aetna of WY Medicare |
$1,834.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,668.80
|
| Rate for Payer: Altius Commercial |
$2,668.80
|
| Rate for Payer: Beech Street Commercial |
$2,724.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,282.38
|
| Rate for Payer: Cash Price |
$1,946.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,696.60
|
| Rate for Payer: Cigna of WY Commercial |
$2,724.40
|
| Rate for Payer: Entrust Commercial |
$2,641.00
|
| Rate for Payer: First Choice Health Commercial |
$2,641.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,641.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,612.40
|
| Rate for Payer: HealthUtah PPO |
$2,780.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,696.60
|
| Rate for Payer: Multiplan Medicare/VA |
$1,531.78
|
| Rate for Payer: One Health Plan of WY PPO |
$2,724.40
|
| Rate for Payer: PacificSource Commercial |
$2,502.00
|
| Rate for Payer: PHCS PPO |
$2,724.40
|
| Rate for Payer: Three Rivers PPO |
$2,085.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,612.40
|
| Rate for Payer: United Healthcare Commercial |
$2,418.60
|
| Rate for Payer: United Healthcare Medicare |
$1,612.40
|
| Rate for Payer: WINHealth Partners Commercial |
$2,724.40
|
| Rate for Payer: Wise Provider Network Commercial |
$2,641.00
|
|
|
HC MRI, FACE, NECK, COMBO - MR ORBIT FACE NECK W AND WO IV CONTRAST
|
Facility
|
OP
|
$4,150.00
|
|
|
Service Code
|
HCPCS 70543
|
| Hospital Charge Code |
6157054302
|
|
Hospital Revenue Code
|
615
|
| Min. Negotiated Rate |
$2,286.65 |
| Max. Negotiated Rate |
$4,150.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,067.00
|
| Rate for Payer: Aetna of WY Medicare |
$2,739.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,984.00
|
| Rate for Payer: Altius Commercial |
$3,984.00
|
| Rate for Payer: Beech Street Commercial |
$4,067.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,407.15
|
| Rate for Payer: Cash Price |
$2,905.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,025.50
|
| Rate for Payer: Cigna of WY Commercial |
$4,067.00
|
| Rate for Payer: Entrust Commercial |
$3,942.50
|
| Rate for Payer: First Choice Health Commercial |
$3,942.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,942.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,407.00
|
| Rate for Payer: HealthUtah PPO |
$4,150.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,025.50
|
| Rate for Payer: Multiplan Medicare/VA |
$2,286.65
|
| Rate for Payer: One Health Plan of WY PPO |
$4,067.00
|
| Rate for Payer: PacificSource Commercial |
$3,735.00
|
| Rate for Payer: PHCS PPO |
$4,067.00
|
| Rate for Payer: Three Rivers PPO |
$3,112.50
|
| Rate for Payer: TriWest Veterans Administration |
$2,407.00
|
| Rate for Payer: United Healthcare Commercial |
$3,610.50
|
| Rate for Payer: United Healthcare Medicare |
$2,407.00
|
| Rate for Payer: WINHealth Partners Commercial |
$4,067.00
|
| Rate for Payer: Wise Provider Network Commercial |
$3,942.50
|
|
|
HC MRI, FACE, NECK, COMBO - MR ORBIT FACE NECK W AND WO IV CONTRAST
|
Facility
|
IP
|
$4,150.00
|
|
|
Service Code
|
HCPCS 70543
|
| Hospital Charge Code |
6157054302
|
|
Hospital Revenue Code
|
615
|
| Min. Negotiated Rate |
$2,602.05 |
| Max. Negotiated Rate |
$4,150.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$4,067.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,984.00
|
| Rate for Payer: Altius Commercial |
$3,984.00
|
| Rate for Payer: Beech Street Commercial |
$4,067.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$3,407.15
|
| Rate for Payer: Cash Price |
$2,905.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,025.50
|
| Rate for Payer: Cigna of WY Commercial |
$4,067.00
|
| Rate for Payer: Entrust Commercial |
$3,942.50
|
| Rate for Payer: First Choice Health Commercial |
$3,942.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,942.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,739.00
|
| Rate for Payer: HealthUtah PPO |
$4,150.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,025.50
|
| Rate for Payer: Multiplan Medicare/VA |
$2,602.05
|
| Rate for Payer: One Health Plan of WY PPO |
$4,067.00
|
| Rate for Payer: PacificSource Commercial |
$3,735.00
|
| Rate for Payer: PHCS PPO |
$4,067.00
|
| Rate for Payer: Three Rivers PPO |
$3,112.50
|
| Rate for Payer: TriWest Veterans Administration |
$2,739.00
|
| Rate for Payer: United Healthcare Commercial |
$3,610.50
|
| Rate for Payer: United Healthcare Medicare |
$2,739.00
|
| Rate for Payer: WINHealth Partners Commercial |
$3,942.50
|
| Rate for Payer: Wise Provider Network Commercial |
$3,942.50
|
|
|
HC MRI, FACE, NECK - MR ORBIT FACE NECK WO IV CONTRAST
|
Facility
|
IP
|
$1,270.00
|
|
|
Service Code
|
HCPCS 70540
|
| Hospital Charge Code |
6157054002
|
|
Hospital Revenue Code
|
615
|
| Min. Negotiated Rate |
$796.29 |
| Max. Negotiated Rate |
$1,270.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,244.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,219.20
|
| Rate for Payer: Altius Commercial |
$1,219.20
|
| Rate for Payer: Beech Street Commercial |
$1,244.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,042.67
|
| Rate for Payer: Cash Price |
$889.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,231.90
|
| Rate for Payer: Cigna of WY Commercial |
$1,244.60
|
| Rate for Payer: Entrust Commercial |
$1,206.50
|
| Rate for Payer: First Choice Health Commercial |
$1,206.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,206.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$838.20
|
| Rate for Payer: HealthUtah PPO |
$1,270.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,231.90
|
| Rate for Payer: Multiplan Medicare/VA |
$796.29
|
| Rate for Payer: One Health Plan of WY PPO |
$1,244.60
|
| Rate for Payer: PacificSource Commercial |
$1,143.00
|
| Rate for Payer: PHCS PPO |
$1,244.60
|
| Rate for Payer: Three Rivers PPO |
$952.50
|
| Rate for Payer: TriWest Veterans Administration |
$838.20
|
| Rate for Payer: United Healthcare Commercial |
$1,104.90
|
| Rate for Payer: United Healthcare Medicare |
$838.20
|
| Rate for Payer: WINHealth Partners Commercial |
$1,206.50
|
| Rate for Payer: Wise Provider Network Commercial |
$1,206.50
|
|
|
HC MRI, FACE, NECK - MR ORBIT FACE NECK WO IV CONTRAST
|
Facility
|
OP
|
$1,270.00
|
|
|
Service Code
|
HCPCS 70540
|
| Hospital Charge Code |
6157054002
|
|
Hospital Revenue Code
|
615
|
| Min. Negotiated Rate |
$699.77 |
| Max. Negotiated Rate |
$1,270.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,244.60
|
| Rate for Payer: Aetna of WY Medicare |
$838.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,219.20
|
| Rate for Payer: Altius Commercial |
$1,219.20
|
| Rate for Payer: Beech Street Commercial |
$1,244.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,042.67
|
| Rate for Payer: Cash Price |
$889.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,231.90
|
| Rate for Payer: Cigna of WY Commercial |
$1,244.60
|
| Rate for Payer: Entrust Commercial |
$1,206.50
|
| Rate for Payer: First Choice Health Commercial |
$1,206.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,206.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$736.60
|
| Rate for Payer: HealthUtah PPO |
$1,270.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,231.90
|
| Rate for Payer: Multiplan Medicare/VA |
$699.77
|
| Rate for Payer: One Health Plan of WY PPO |
$1,244.60
|
| Rate for Payer: PacificSource Commercial |
$1,143.00
|
| Rate for Payer: PHCS PPO |
$1,244.60
|
| Rate for Payer: Three Rivers PPO |
$952.50
|
| Rate for Payer: TriWest Veterans Administration |
$736.60
|
| Rate for Payer: United Healthcare Commercial |
$1,104.90
|
| Rate for Payer: United Healthcare Medicare |
$736.60
|
| Rate for Payer: WINHealth Partners Commercial |
$1,244.60
|
| Rate for Payer: Wise Provider Network Commercial |
$1,206.50
|
|
|
HC MRI, FACE, NECK W/CONTRAST - MR ORBIT FACE NECK W IV CONTRAST
|
Facility
|
IP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 70542
|
| Hospital Charge Code |
6157054202
|
|
Hospital Revenue Code
|
615
|
| 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, FACE, NECK W/CONTRAST - MR ORBIT FACE NECK W IV CONTRAST
|
Facility
|
OP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 70542
|
| Hospital Charge Code |
6157054202
|
|
Hospital Revenue Code
|
615
|
| 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 JNT OF LWR EXTRE W/O DYE - MRI ANKLE LT WO CONT
|
Facility
|
IP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6147372101
|
|
Hospital Revenue Code
|
614
|
| 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 JNT OF LWR EXTRE W/O DYE - MRI ANKLE LT WO CONT
|
Facility
|
OP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6147372101
|
|
Hospital Revenue Code
|
614
|
| 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 JNT OF LWR EXTRE W/O DYE - MRI ANKLE RT WO CONT
|
Facility
|
IP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6147372102
|
|
Hospital Revenue Code
|
614
|
| 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 JNT OF LWR EXTRE W/O DYE - MRI ANKLE RT WO CONT
|
Facility
|
OP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6147372102
|
|
Hospital Revenue Code
|
614
|
| 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 JNT OF LWR EXTRE W/O DYE - MRI HIP LT WO CONT
|
Facility
|
OP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6167372106
|
|
Hospital Revenue Code
|
616
|
| 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 JNT OF LWR EXTRE W/O DYE - MRI HIP LT WO CONT
|
Facility
|
IP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6167372106
|
|
Hospital Revenue Code
|
616
|
| 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 JNT OF LWR EXTRE W/O DYE - MRI HIP RT WO CONT
|
Facility
|
OP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6167372105
|
|
Hospital Revenue Code
|
616
|
| 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 JNT OF LWR EXTRE W/O DYE - MRI HIP RT WO CONT
|
Facility
|
IP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6167372105
|
|
Hospital Revenue Code
|
616
|
| 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 JNT OF LWR EXTRE W/O DYE - MR LOWER EXT JOINT LT WO IV CONT
|
Facility
|
IP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6167372102
|
|
Hospital Revenue Code
|
616
|
| 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 JNT OF LWR EXTRE W/O DYE - MR LOWER EXT JOINT LT WO IV CONT
|
Facility
|
OP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6167372102
|
|
Hospital Revenue Code
|
616
|
| 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 JNT OF LWR EXTRE W/O DYE - MR LOWER EXT JOINT RT WO IV CONT
|
Facility
|
OP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6167372101
|
|
Hospital Revenue Code
|
616
|
| 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 JNT OF LWR EXTRE W/O DYE - MR LOWER EXT JOINT RT WO IV CONT
|
Facility
|
IP
|
$2,260.00
|
|
|
Service Code
|
HCPCS 73721
|
| Hospital Charge Code |
6167372101
|
|
Hospital Revenue Code
|
616
|
| 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, JOINT OF LEG. COMBO - MR ANKLE LEFT W AND WO IV CONTRAST
|
Facility
|
IP
|
$3,375.00
|
|
|
Service Code
|
HCPCS 73723
|
| Hospital Charge Code |
6147372306
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$2,116.12 |
| Max. Negotiated Rate |
$3,375.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,307.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,240.00
|
| Rate for Payer: Altius Commercial |
$3,240.00
|
| Rate for Payer: Beech Street Commercial |
$3,307.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,770.88
|
| Rate for Payer: Cash Price |
$2,362.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,273.75
|
| Rate for Payer: Cigna of WY Commercial |
$3,307.50
|
| Rate for Payer: Entrust Commercial |
$3,206.25
|
| Rate for Payer: First Choice Health Commercial |
$3,206.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,206.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,227.50
|
| Rate for Payer: HealthUtah PPO |
$3,375.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,273.75
|
| Rate for Payer: Multiplan Medicare/VA |
$2,116.12
|
| Rate for Payer: One Health Plan of WY PPO |
$3,307.50
|
| Rate for Payer: PacificSource Commercial |
$3,037.50
|
| Rate for Payer: PHCS PPO |
$3,307.50
|
| Rate for Payer: Three Rivers PPO |
$2,531.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,227.50
|
| Rate for Payer: United Healthcare Commercial |
$2,936.25
|
| Rate for Payer: United Healthcare Medicare |
$2,227.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,206.25
|
| Rate for Payer: Wise Provider Network Commercial |
$3,206.25
|
|
|
HC MRI, JOINT OF LEG. COMBO - MR ANKLE LEFT W AND WO IV CONTRAST
|
Facility
|
OP
|
$3,375.00
|
|
|
Service Code
|
HCPCS 73723
|
| Hospital Charge Code |
6147372306
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$1,859.62 |
| Max. Negotiated Rate |
$3,375.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$3,307.50
|
| Rate for Payer: Aetna of WY Medicare |
$2,227.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$3,240.00
|
| Rate for Payer: Altius Commercial |
$3,240.00
|
| Rate for Payer: Beech Street Commercial |
$3,307.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,770.88
|
| Rate for Payer: Cash Price |
$2,362.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$3,273.75
|
| Rate for Payer: Cigna of WY Commercial |
$3,307.50
|
| Rate for Payer: Entrust Commercial |
$3,206.25
|
| Rate for Payer: First Choice Health Commercial |
$3,206.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$3,206.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,957.50
|
| Rate for Payer: HealthUtah PPO |
$3,375.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$3,273.75
|
| Rate for Payer: Multiplan Medicare/VA |
$1,859.62
|
| Rate for Payer: One Health Plan of WY PPO |
$3,307.50
|
| Rate for Payer: PacificSource Commercial |
$3,037.50
|
| Rate for Payer: PHCS PPO |
$3,307.50
|
| Rate for Payer: Three Rivers PPO |
$2,531.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,957.50
|
| Rate for Payer: United Healthcare Commercial |
$2,936.25
|
| Rate for Payer: United Healthcare Medicare |
$1,957.50
|
| Rate for Payer: WINHealth Partners Commercial |
$3,307.50
|
| Rate for Payer: Wise Provider Network Commercial |
$3,206.25
|
|
