|
HC PLATELET COUNT - PLATELET COUNT
|
Facility
|
OP
|
$115.00
|
|
|
Service Code
|
HCPCS 85049
|
| Hospital Charge Code |
3058504902
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$63.36 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$112.70
|
| Rate for Payer: Aetna of WY Medicare |
$75.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$110.40
|
| Rate for Payer: Altius Commercial |
$110.40
|
| Rate for Payer: Beech Street Commercial |
$112.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$94.42
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$111.55
|
| Rate for Payer: Cigna of WY Commercial |
$112.70
|
| Rate for Payer: Entrust Commercial |
$109.25
|
| Rate for Payer: First Choice Health Commercial |
$109.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$109.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$66.70
|
| Rate for Payer: HealthUtah PPO |
$115.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$111.55
|
| Rate for Payer: Multiplan Medicare/VA |
$63.36
|
| Rate for Payer: One Health Plan of WY PPO |
$112.70
|
| Rate for Payer: PacificSource Commercial |
$103.50
|
| Rate for Payer: PHCS PPO |
$112.70
|
| Rate for Payer: Three Rivers PPO |
$86.25
|
| Rate for Payer: TriWest Veterans Administration |
$66.70
|
| Rate for Payer: United Healthcare Commercial |
$100.05
|
| Rate for Payer: United Healthcare Medicare |
$66.70
|
| Rate for Payer: WINHealth Partners Commercial |
$112.70
|
| Rate for Payer: Wise Provider Network Commercial |
$109.25
|
|
|
HC PLATELET COUNT - PLATELET COUNT
|
Facility
|
IP
|
$115.00
|
|
|
Service Code
|
HCPCS 85049
|
| Hospital Charge Code |
3058504902
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$72.10 |
| Max. Negotiated Rate |
$115.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$112.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$110.40
|
| Rate for Payer: Altius Commercial |
$110.40
|
| Rate for Payer: Beech Street Commercial |
$112.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$94.42
|
| Rate for Payer: Cash Price |
$80.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$111.55
|
| Rate for Payer: Cigna of WY Commercial |
$112.70
|
| Rate for Payer: Entrust Commercial |
$109.25
|
| Rate for Payer: First Choice Health Commercial |
$109.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$109.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$75.90
|
| Rate for Payer: HealthUtah PPO |
$115.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$111.55
|
| Rate for Payer: Multiplan Medicare/VA |
$72.10
|
| Rate for Payer: One Health Plan of WY PPO |
$112.70
|
| Rate for Payer: PacificSource Commercial |
$103.50
|
| Rate for Payer: PHCS PPO |
$112.70
|
| Rate for Payer: Three Rivers PPO |
$86.25
|
| Rate for Payer: TriWest Veterans Administration |
$75.90
|
| Rate for Payer: United Healthcare Commercial |
$100.05
|
| Rate for Payer: United Healthcare Medicare |
$75.90
|
| Rate for Payer: WINHealth Partners Commercial |
$109.25
|
| Rate for Payer: Wise Provider Network Commercial |
$109.25
|
|
|
HC PLATELETS, PHERESIS, PATHOGEN-REDUCED, EA UNIT
|
Facility
|
OP
|
$2,065.00
|
|
|
Service Code
|
HCPCS P9073
|
| Hospital Charge Code |
390P907301
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$1,137.82 |
| Max. Negotiated Rate |
$2,065.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,023.70
|
| Rate for Payer: Aetna of WY Medicare |
$1,362.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,982.40
|
| Rate for Payer: Altius Commercial |
$1,982.40
|
| Rate for Payer: Beech Street Commercial |
$2,023.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,695.36
|
| Rate for Payer: Cash Price |
$1,445.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,003.05
|
| Rate for Payer: Cigna of WY Commercial |
$2,023.70
|
| Rate for Payer: Entrust Commercial |
$1,961.75
|
| Rate for Payer: First Choice Health Commercial |
$1,961.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,961.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,197.70
|
| Rate for Payer: HealthUtah PPO |
$2,065.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,003.05
|
| Rate for Payer: Multiplan Medicare/VA |
$1,137.82
|
| Rate for Payer: One Health Plan of WY PPO |
$2,023.70
|
| Rate for Payer: PacificSource Commercial |
$1,858.50
|
| Rate for Payer: PHCS PPO |
$2,023.70
|
| Rate for Payer: Three Rivers PPO |
$1,548.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,197.70
|
| Rate for Payer: United Healthcare Commercial |
$1,796.55
|
| Rate for Payer: United Healthcare Medicare |
$1,197.70
|
| Rate for Payer: WINHealth Partners Commercial |
$2,023.70
|
| Rate for Payer: Wise Provider Network Commercial |
$1,961.75
|
|
|
HC PLATELETS, PHERESIS, PATHOGEN-REDUCED, EA UNIT
|
Facility
|
IP
|
$2,065.00
|
|
|
Service Code
|
HCPCS P9073
|
| Hospital Charge Code |
390P907301
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$1,294.76 |
| Max. Negotiated Rate |
$2,065.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,023.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,982.40
|
| Rate for Payer: Altius Commercial |
$1,982.40
|
| Rate for Payer: Beech Street Commercial |
$2,023.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,695.36
|
| Rate for Payer: Cash Price |
$1,445.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,003.05
|
| Rate for Payer: Cigna of WY Commercial |
$2,023.70
|
| Rate for Payer: Entrust Commercial |
$1,961.75
|
| Rate for Payer: First Choice Health Commercial |
$1,961.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,961.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,362.90
|
| Rate for Payer: HealthUtah PPO |
$2,065.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,003.05
|
| Rate for Payer: Multiplan Medicare/VA |
$1,294.76
|
| Rate for Payer: One Health Plan of WY PPO |
$2,023.70
|
| Rate for Payer: PacificSource Commercial |
$1,858.50
|
| Rate for Payer: PHCS PPO |
$2,023.70
|
| Rate for Payer: Three Rivers PPO |
$1,548.75
|
| Rate for Payer: TriWest Veterans Administration |
$1,362.90
|
| Rate for Payer: United Healthcare Commercial |
$1,796.55
|
| Rate for Payer: United Healthcare Medicare |
$1,362.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,961.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1,961.75
|
|
|
HC PMS2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS
|
Facility
|
OP
|
$1,815.00
|
|
|
Service Code
|
HCPCS 81319
|
| Hospital Charge Code |
3108131901
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$1,000.06 |
| Max. Negotiated Rate |
$1,815.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,778.70
|
| Rate for Payer: Aetna of WY Medicare |
$1,197.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,742.40
|
| Rate for Payer: Altius Commercial |
$1,742.40
|
| Rate for Payer: Beech Street Commercial |
$1,778.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,490.12
|
| Rate for Payer: Cash Price |
$1,270.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,760.55
|
| Rate for Payer: Cigna of WY Commercial |
$1,778.70
|
| Rate for Payer: Entrust Commercial |
$1,724.25
|
| Rate for Payer: First Choice Health Commercial |
$1,724.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,724.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,052.70
|
| Rate for Payer: HealthUtah PPO |
$1,815.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,760.55
|
| Rate for Payer: Multiplan Medicare/VA |
$1,000.06
|
| Rate for Payer: One Health Plan of WY PPO |
$1,778.70
|
| Rate for Payer: PacificSource Commercial |
$1,633.50
|
| Rate for Payer: PHCS PPO |
$1,778.70
|
| Rate for Payer: Three Rivers PPO |
$1,361.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,052.70
|
| Rate for Payer: United Healthcare Commercial |
$1,579.05
|
| Rate for Payer: United Healthcare Medicare |
$1,052.70
|
| Rate for Payer: WINHealth Partners Commercial |
$1,778.70
|
| Rate for Payer: Wise Provider Network Commercial |
$1,724.25
|
|
|
HC PMS2 GENE ANALYSIS DUPLICATION/DELETION VARIANTS
|
Facility
|
IP
|
$1,815.00
|
|
|
Service Code
|
HCPCS 81319
|
| Hospital Charge Code |
3108131901
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$1,138.00 |
| Max. Negotiated Rate |
$1,815.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,778.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,742.40
|
| Rate for Payer: Altius Commercial |
$1,742.40
|
| Rate for Payer: Beech Street Commercial |
$1,778.70
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,490.12
|
| Rate for Payer: Cash Price |
$1,270.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,760.55
|
| Rate for Payer: Cigna of WY Commercial |
$1,778.70
|
| Rate for Payer: Entrust Commercial |
$1,724.25
|
| Rate for Payer: First Choice Health Commercial |
$1,724.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,724.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,197.90
|
| Rate for Payer: HealthUtah PPO |
$1,815.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,760.55
|
| Rate for Payer: Multiplan Medicare/VA |
$1,138.00
|
| Rate for Payer: One Health Plan of WY PPO |
$1,778.70
|
| Rate for Payer: PacificSource Commercial |
$1,633.50
|
| Rate for Payer: PHCS PPO |
$1,778.70
|
| Rate for Payer: Three Rivers PPO |
$1,361.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,197.90
|
| Rate for Payer: United Healthcare Commercial |
$1,579.05
|
| Rate for Payer: United Healthcare Medicare |
$1,197.90
|
| Rate for Payer: WINHealth Partners Commercial |
$1,724.25
|
| Rate for Payer: Wise Provider Network Commercial |
$1,724.25
|
|
|
HC PMS2 GENE ANALYSIS FULL SEQUENCE
|
Facility
|
OP
|
$3,020.00
|
|
|
Service Code
|
HCPCS 81317
|
| Hospital Charge Code |
3108131701
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$1,664.02 |
| Max. Negotiated Rate |
$3,020.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,959.60
|
| Rate for Payer: Aetna of WY Medicare |
$1,993.20
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,899.20
|
| Rate for Payer: Altius Commercial |
$2,899.20
|
| Rate for Payer: Beech Street Commercial |
$2,959.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,479.42
|
| Rate for Payer: Cash Price |
$2,114.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,929.40
|
| Rate for Payer: Cigna of WY Commercial |
$2,959.60
|
| Rate for Payer: Entrust Commercial |
$2,869.00
|
| Rate for Payer: First Choice Health Commercial |
$2,869.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,869.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,751.60
|
| Rate for Payer: HealthUtah PPO |
$3,020.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,929.40
|
| Rate for Payer: Multiplan Medicare/VA |
$1,664.02
|
| Rate for Payer: One Health Plan of WY PPO |
$2,959.60
|
| Rate for Payer: PacificSource Commercial |
$2,718.00
|
| Rate for Payer: PHCS PPO |
$2,959.60
|
| Rate for Payer: Three Rivers PPO |
$2,265.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,751.60
|
| Rate for Payer: United Healthcare Commercial |
$2,627.40
|
| Rate for Payer: United Healthcare Medicare |
$1,751.60
|
| Rate for Payer: WINHealth Partners Commercial |
$2,959.60
|
| Rate for Payer: Wise Provider Network Commercial |
$2,869.00
|
|
|
HC PMS2 GENE ANALYSIS FULL SEQUENCE
|
Facility
|
IP
|
$3,020.00
|
|
|
Service Code
|
HCPCS 81317
|
| Hospital Charge Code |
3108131701
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$1,893.54 |
| Max. Negotiated Rate |
$3,020.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$2,959.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$2,899.20
|
| Rate for Payer: Altius Commercial |
$2,899.20
|
| Rate for Payer: Beech Street Commercial |
$2,959.60
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$2,479.42
|
| Rate for Payer: Cash Price |
$2,114.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$2,929.40
|
| Rate for Payer: Cigna of WY Commercial |
$2,959.60
|
| Rate for Payer: Entrust Commercial |
$2,869.00
|
| Rate for Payer: First Choice Health Commercial |
$2,869.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$2,869.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,993.20
|
| Rate for Payer: HealthUtah PPO |
$3,020.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$2,929.40
|
| Rate for Payer: Multiplan Medicare/VA |
$1,893.54
|
| Rate for Payer: One Health Plan of WY PPO |
$2,959.60
|
| Rate for Payer: PacificSource Commercial |
$2,718.00
|
| Rate for Payer: PHCS PPO |
$2,959.60
|
| Rate for Payer: Three Rivers PPO |
$2,265.00
|
| Rate for Payer: TriWest Veterans Administration |
$1,993.20
|
| Rate for Payer: United Healthcare Commercial |
$2,627.40
|
| Rate for Payer: United Healthcare Medicare |
$1,993.20
|
| Rate for Payer: WINHealth Partners Commercial |
$2,869.00
|
| Rate for Payer: Wise Provider Network Commercial |
$2,869.00
|
|
|
HC PNEUMOCYSTIS CARINII AG, DFA - PNEUMOCYSTIS SMEAR BY DFA
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
HCPCS 87281
|
| Hospital Charge Code |
3068728101
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$74.38 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$132.30
|
| Rate for Payer: Aetna of WY Medicare |
$89.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$129.60
|
| Rate for Payer: Altius Commercial |
$129.60
|
| Rate for Payer: Beech Street Commercial |
$132.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$110.84
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.95
|
| Rate for Payer: Cigna of WY Commercial |
$132.30
|
| Rate for Payer: Entrust Commercial |
$128.25
|
| Rate for Payer: First Choice Health Commercial |
$128.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$128.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.30
|
| Rate for Payer: HealthUtah PPO |
$135.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.95
|
| Rate for Payer: Multiplan Medicare/VA |
$74.38
|
| Rate for Payer: One Health Plan of WY PPO |
$132.30
|
| Rate for Payer: PacificSource Commercial |
$121.50
|
| Rate for Payer: PHCS PPO |
$132.30
|
| Rate for Payer: Three Rivers PPO |
$101.25
|
| Rate for Payer: TriWest Veterans Administration |
$78.30
|
| Rate for Payer: United Healthcare Commercial |
$117.45
|
| Rate for Payer: United Healthcare Medicare |
$78.30
|
| Rate for Payer: WINHealth Partners Commercial |
$132.30
|
| Rate for Payer: Wise Provider Network Commercial |
$128.25
|
|
|
HC PNEUMOCYSTIS CARINII AG, DFA - PNEUMOCYSTIS SMEAR BY DFA
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
HCPCS 87281
|
| Hospital Charge Code |
3068728101
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$84.64 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$132.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$129.60
|
| Rate for Payer: Altius Commercial |
$129.60
|
| Rate for Payer: Beech Street Commercial |
$132.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$110.84
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.95
|
| Rate for Payer: Cigna of WY Commercial |
$132.30
|
| Rate for Payer: Entrust Commercial |
$128.25
|
| Rate for Payer: First Choice Health Commercial |
$128.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$128.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$89.10
|
| Rate for Payer: HealthUtah PPO |
$135.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.95
|
| Rate for Payer: Multiplan Medicare/VA |
$84.64
|
| Rate for Payer: One Health Plan of WY PPO |
$132.30
|
| Rate for Payer: PacificSource Commercial |
$121.50
|
| Rate for Payer: PHCS PPO |
$132.30
|
| Rate for Payer: Three Rivers PPO |
$101.25
|
| Rate for Payer: TriWest Veterans Administration |
$89.10
|
| Rate for Payer: United Healthcare Commercial |
$117.45
|
| Rate for Payer: United Healthcare Medicare |
$89.10
|
| Rate for Payer: WINHealth Partners Commercial |
$128.25
|
| Rate for Payer: Wise Provider Network Commercial |
$128.25
|
|
|
HC POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND
|
Facility
|
IP
|
$5,400.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
7409581001
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$3,385.80 |
| Max. Negotiated Rate |
$5,400.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,292.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,184.00
|
| Rate for Payer: Altius Commercial |
$5,184.00
|
| Rate for Payer: Beech Street Commercial |
$5,292.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,433.40
|
| Rate for Payer: Cash Price |
$3,780.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,238.00
|
| Rate for Payer: Cigna of WY Commercial |
$5,292.00
|
| Rate for Payer: Entrust Commercial |
$5,130.00
|
| Rate for Payer: First Choice Health Commercial |
$5,130.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,130.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,564.00
|
| Rate for Payer: HealthUtah PPO |
$5,400.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,238.00
|
| Rate for Payer: Multiplan Medicare/VA |
$3,385.80
|
| Rate for Payer: One Health Plan of WY PPO |
$5,292.00
|
| Rate for Payer: PacificSource Commercial |
$4,860.00
|
| Rate for Payer: PHCS PPO |
$5,292.00
|
| Rate for Payer: Three Rivers PPO |
$4,050.00
|
| Rate for Payer: TriWest Veterans Administration |
$3,564.00
|
| Rate for Payer: United Healthcare Commercial |
$4,698.00
|
| Rate for Payer: United Healthcare Medicare |
$3,564.00
|
| Rate for Payer: WINHealth Partners Commercial |
$5,130.00
|
| Rate for Payer: Wise Provider Network Commercial |
$5,130.00
|
|
|
HC POLYSOM 6/>YRS SLEEP 4/> ADDL PARAM ATTND
|
Facility
|
OP
|
$5,400.00
|
|
|
Service Code
|
HCPCS 95810
|
| Hospital Charge Code |
7409581001
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$2,975.40 |
| Max. Negotiated Rate |
$5,400.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,292.00
|
| Rate for Payer: Aetna of WY Medicare |
$3,564.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,184.00
|
| Rate for Payer: Altius Commercial |
$5,184.00
|
| Rate for Payer: Beech Street Commercial |
$5,292.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,433.40
|
| Rate for Payer: Cash Price |
$3,780.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,238.00
|
| Rate for Payer: Cigna of WY Commercial |
$5,292.00
|
| Rate for Payer: Entrust Commercial |
$5,130.00
|
| Rate for Payer: First Choice Health Commercial |
$5,130.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,130.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,132.00
|
| Rate for Payer: HealthUtah PPO |
$5,400.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,238.00
|
| Rate for Payer: Multiplan Medicare/VA |
$2,975.40
|
| Rate for Payer: One Health Plan of WY PPO |
$5,292.00
|
| Rate for Payer: PacificSource Commercial |
$4,860.00
|
| Rate for Payer: PHCS PPO |
$5,292.00
|
| Rate for Payer: Three Rivers PPO |
$4,050.00
|
| Rate for Payer: TriWest Veterans Administration |
$3,132.00
|
| Rate for Payer: United Healthcare Commercial |
$4,698.00
|
| Rate for Payer: United Healthcare Medicare |
$3,132.00
|
| Rate for Payer: WINHealth Partners Commercial |
$5,292.00
|
| Rate for Payer: Wise Provider Network Commercial |
$5,130.00
|
|
|
HC POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND
|
Facility
|
OP
|
$5,950.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
7409581101
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$3,278.45 |
| Max. Negotiated Rate |
$5,950.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,831.00
|
| Rate for Payer: Aetna of WY Medicare |
$3,927.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,712.00
|
| Rate for Payer: Altius Commercial |
$5,712.00
|
| Rate for Payer: Beech Street Commercial |
$5,831.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,884.95
|
| Rate for Payer: Cash Price |
$4,165.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,771.50
|
| Rate for Payer: Cigna of WY Commercial |
$5,831.00
|
| Rate for Payer: Entrust Commercial |
$5,652.50
|
| Rate for Payer: First Choice Health Commercial |
$5,652.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,652.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,451.00
|
| Rate for Payer: HealthUtah PPO |
$5,950.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,771.50
|
| Rate for Payer: Multiplan Medicare/VA |
$3,278.45
|
| Rate for Payer: One Health Plan of WY PPO |
$5,831.00
|
| Rate for Payer: PacificSource Commercial |
$5,355.00
|
| Rate for Payer: PHCS PPO |
$5,831.00
|
| Rate for Payer: Three Rivers PPO |
$4,462.50
|
| Rate for Payer: TriWest Veterans Administration |
$3,451.00
|
| Rate for Payer: United Healthcare Commercial |
$5,176.50
|
| Rate for Payer: United Healthcare Medicare |
$3,451.00
|
| Rate for Payer: WINHealth Partners Commercial |
$5,831.00
|
| Rate for Payer: Wise Provider Network Commercial |
$5,652.50
|
|
|
HC POLYSOM 6/>YRS SLEEP W/CPAP 4/> ADDL PARAM ATTND
|
Facility
|
IP
|
$5,950.00
|
|
|
Service Code
|
HCPCS 95811
|
| Hospital Charge Code |
7409581101
|
|
Hospital Revenue Code
|
740
|
| Min. Negotiated Rate |
$3,730.65 |
| Max. Negotiated Rate |
$5,950.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,831.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$5,712.00
|
| Rate for Payer: Altius Commercial |
$5,712.00
|
| Rate for Payer: Beech Street Commercial |
$5,831.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,884.95
|
| Rate for Payer: Cash Price |
$4,165.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$5,771.50
|
| Rate for Payer: Cigna of WY Commercial |
$5,831.00
|
| Rate for Payer: Entrust Commercial |
$5,652.50
|
| Rate for Payer: First Choice Health Commercial |
$5,652.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$5,652.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,927.00
|
| Rate for Payer: HealthUtah PPO |
$5,950.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$5,771.50
|
| Rate for Payer: Multiplan Medicare/VA |
$3,730.65
|
| Rate for Payer: One Health Plan of WY PPO |
$5,831.00
|
| Rate for Payer: PacificSource Commercial |
$5,355.00
|
| Rate for Payer: PHCS PPO |
$5,831.00
|
| Rate for Payer: Three Rivers PPO |
$4,462.50
|
| Rate for Payer: TriWest Veterans Administration |
$3,927.00
|
| Rate for Payer: United Healthcare Commercial |
$5,176.50
|
| Rate for Payer: United Healthcare Medicare |
$3,927.00
|
| Rate for Payer: WINHealth Partners Commercial |
$5,652.50
|
| Rate for Payer: Wise Provider Network Commercial |
$5,652.50
|
|
|
HC PORPHYRINS URINE QUANTITATIVE/FRACTIONATED
|
Facility
|
OP
|
$205.00
|
|
|
Service Code
|
HCPCS 84120
|
| Hospital Charge Code |
3018412001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$112.96 |
| Max. Negotiated Rate |
$205.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$200.90
|
| Rate for Payer: Aetna of WY Medicare |
$135.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$196.80
|
| Rate for Payer: Altius Commercial |
$196.80
|
| Rate for Payer: Beech Street Commercial |
$200.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$168.30
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$198.85
|
| Rate for Payer: Cigna of WY Commercial |
$200.90
|
| Rate for Payer: Entrust Commercial |
$194.75
|
| Rate for Payer: First Choice Health Commercial |
$194.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$194.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$118.90
|
| Rate for Payer: HealthUtah PPO |
$205.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$198.85
|
| Rate for Payer: Multiplan Medicare/VA |
$112.96
|
| Rate for Payer: One Health Plan of WY PPO |
$200.90
|
| Rate for Payer: PacificSource Commercial |
$184.50
|
| Rate for Payer: PHCS PPO |
$200.90
|
| Rate for Payer: Three Rivers PPO |
$153.75
|
| Rate for Payer: TriWest Veterans Administration |
$118.90
|
| Rate for Payer: United Healthcare Commercial |
$178.35
|
| Rate for Payer: United Healthcare Medicare |
$118.90
|
| Rate for Payer: WINHealth Partners Commercial |
$200.90
|
| Rate for Payer: Wise Provider Network Commercial |
$194.75
|
|
|
HC PORPHYRINS URINE QUANTITATIVE/FRACTIONATED
|
Facility
|
IP
|
$205.00
|
|
|
Service Code
|
HCPCS 84120
|
| Hospital Charge Code |
3018412001
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$128.54 |
| Max. Negotiated Rate |
$205.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$200.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$196.80
|
| Rate for Payer: Altius Commercial |
$196.80
|
| Rate for Payer: Beech Street Commercial |
$200.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$168.30
|
| Rate for Payer: Cash Price |
$143.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$198.85
|
| Rate for Payer: Cigna of WY Commercial |
$200.90
|
| Rate for Payer: Entrust Commercial |
$194.75
|
| Rate for Payer: First Choice Health Commercial |
$194.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$194.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$135.30
|
| Rate for Payer: HealthUtah PPO |
$205.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$198.85
|
| Rate for Payer: Multiplan Medicare/VA |
$128.54
|
| Rate for Payer: One Health Plan of WY PPO |
$200.90
|
| Rate for Payer: PacificSource Commercial |
$184.50
|
| Rate for Payer: PHCS PPO |
$200.90
|
| Rate for Payer: Three Rivers PPO |
$153.75
|
| Rate for Payer: TriWest Veterans Administration |
$135.30
|
| Rate for Payer: United Healthcare Commercial |
$178.35
|
| Rate for Payer: United Healthcare Medicare |
$135.30
|
| Rate for Payer: WINHealth Partners Commercial |
$194.75
|
| Rate for Payer: Wise Provider Network Commercial |
$194.75
|
|
|
HC POSTPARTUM CARE ONLY SEPARATE PROCEDURE
|
Facility
|
IP
|
$81.00
|
|
|
Service Code
|
HCPCS 59430
|
| Hospital Charge Code |
5105943001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$50.79 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$79.38
|
| Rate for Payer: Altius Auto/Workers Compensation |
$77.76
|
| Rate for Payer: Altius Commercial |
$77.76
|
| Rate for Payer: Beech Street Commercial |
$79.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$66.50
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$78.57
|
| Rate for Payer: Cigna of WY Commercial |
$79.38
|
| Rate for Payer: Entrust Commercial |
$76.95
|
| Rate for Payer: First Choice Health Commercial |
$76.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$76.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$53.46
|
| Rate for Payer: HealthUtah PPO |
$81.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$78.57
|
| Rate for Payer: Multiplan Medicare/VA |
$50.79
|
| Rate for Payer: One Health Plan of WY PPO |
$79.38
|
| Rate for Payer: PacificSource Commercial |
$72.90
|
| Rate for Payer: PHCS PPO |
$79.38
|
| Rate for Payer: Three Rivers PPO |
$60.75
|
| Rate for Payer: TriWest Veterans Administration |
$53.46
|
| Rate for Payer: United Healthcare Commercial |
$70.47
|
| Rate for Payer: United Healthcare Medicare |
$53.46
|
| Rate for Payer: WINHealth Partners Commercial |
$76.95
|
| Rate for Payer: Wise Provider Network Commercial |
$76.95
|
|
|
HC POSTPARTUM CARE ONLY SEPARATE PROCEDURE
|
Facility
|
OP
|
$81.00
|
|
|
Service Code
|
HCPCS 59430
|
| Hospital Charge Code |
5105943001
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$44.63 |
| Max. Negotiated Rate |
$81.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$79.38
|
| Rate for Payer: Aetna of WY Medicare |
$53.46
|
| Rate for Payer: Altius Auto/Workers Compensation |
$77.76
|
| Rate for Payer: Altius Commercial |
$77.76
|
| Rate for Payer: Beech Street Commercial |
$79.38
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$66.50
|
| Rate for Payer: Cash Price |
$56.70
|
| Rate for Payer: ChoiceCare Network Commercial |
$78.57
|
| Rate for Payer: Cigna of WY Commercial |
$79.38
|
| Rate for Payer: Entrust Commercial |
$76.95
|
| Rate for Payer: First Choice Health Commercial |
$76.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$76.95
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$46.98
|
| Rate for Payer: HealthUtah PPO |
$81.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$78.57
|
| Rate for Payer: Multiplan Medicare/VA |
$44.63
|
| Rate for Payer: One Health Plan of WY PPO |
$79.38
|
| Rate for Payer: PacificSource Commercial |
$72.90
|
| Rate for Payer: PHCS PPO |
$79.38
|
| Rate for Payer: Three Rivers PPO |
$60.75
|
| Rate for Payer: TriWest Veterans Administration |
$46.98
|
| Rate for Payer: United Healthcare Commercial |
$70.47
|
| Rate for Payer: United Healthcare Medicare |
$46.98
|
| Rate for Payer: WINHealth Partners Commercial |
$79.38
|
| Rate for Payer: Wise Provider Network Commercial |
$76.95
|
|
|
HC PR0 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK
|
Facility
|
IP
|
$5,107.00
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
9831573401
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$3,202.09 |
| Max. Negotiated Rate |
$5,107.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,004.86
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,902.72
|
| Rate for Payer: Altius Commercial |
$4,902.72
|
| Rate for Payer: Beech Street Commercial |
$5,004.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,192.85
|
| Rate for Payer: Cash Price |
$3,574.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,953.79
|
| Rate for Payer: Cigna of WY Commercial |
$5,004.86
|
| Rate for Payer: Entrust Commercial |
$4,851.65
|
| Rate for Payer: First Choice Health Commercial |
$4,851.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,851.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$3,370.62
|
| Rate for Payer: HealthUtah PPO |
$5,107.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,953.79
|
| Rate for Payer: Multiplan Medicare/VA |
$3,202.09
|
| Rate for Payer: One Health Plan of WY PPO |
$5,004.86
|
| Rate for Payer: PacificSource Commercial |
$4,596.30
|
| Rate for Payer: PHCS PPO |
$5,004.86
|
| Rate for Payer: Three Rivers PPO |
$3,830.25
|
| Rate for Payer: TriWest Veterans Administration |
$3,370.62
|
| Rate for Payer: United Healthcare Commercial |
$4,443.09
|
| Rate for Payer: United Healthcare Medicare |
$3,370.62
|
| Rate for Payer: WINHealth Partners Commercial |
$4,851.65
|
| Rate for Payer: Wise Provider Network Commercial |
$4,851.65
|
|
|
HC PR0 MUSC MYOCUTANEOUS/FASCIOCUTANEOUS FLAP TRUNK
|
Facility
|
OP
|
$5,107.00
|
|
|
Service Code
|
HCPCS 15734
|
| Hospital Charge Code |
9831573401
|
|
Hospital Revenue Code
|
983
|
| Min. Negotiated Rate |
$2,813.96 |
| Max. Negotiated Rate |
$5,107.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$5,004.86
|
| Rate for Payer: Aetna of WY Medicare |
$3,370.62
|
| Rate for Payer: Altius Auto/Workers Compensation |
$4,902.72
|
| Rate for Payer: Altius Commercial |
$4,902.72
|
| Rate for Payer: Beech Street Commercial |
$5,004.86
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$4,192.85
|
| Rate for Payer: Cash Price |
$3,574.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$4,953.79
|
| Rate for Payer: Cigna of WY Commercial |
$5,004.86
|
| Rate for Payer: Entrust Commercial |
$4,851.65
|
| Rate for Payer: First Choice Health Commercial |
$4,851.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$4,851.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$2,962.06
|
| Rate for Payer: HealthUtah PPO |
$5,107.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$4,953.79
|
| Rate for Payer: Multiplan Medicare/VA |
$2,813.96
|
| Rate for Payer: One Health Plan of WY PPO |
$5,004.86
|
| Rate for Payer: PacificSource Commercial |
$4,596.30
|
| Rate for Payer: PHCS PPO |
$5,004.86
|
| Rate for Payer: Three Rivers PPO |
$3,830.25
|
| Rate for Payer: TriWest Veterans Administration |
$2,962.06
|
| Rate for Payer: United Healthcare Commercial |
$4,443.09
|
| Rate for Payer: United Healthcare Medicare |
$2,962.06
|
| Rate for Payer: WINHealth Partners Commercial |
$5,004.86
|
| Rate for Payer: Wise Provider Network Commercial |
$4,851.65
|
|
|
HC PR ED MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP
|
Facility
|
OP
|
$1,587.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
9821902002
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$874.44 |
| Max. Negotiated Rate |
$1,587.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,555.26
|
| Rate for Payer: Aetna of WY Medicare |
$1,047.42
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,523.52
|
| Rate for Payer: Altius Commercial |
$1,523.52
|
| Rate for Payer: Beech Street Commercial |
$1,555.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,302.93
|
| Rate for Payer: Cash Price |
$1,110.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,539.39
|
| Rate for Payer: Cigna of WY Commercial |
$1,555.26
|
| Rate for Payer: Entrust Commercial |
$1,507.65
|
| Rate for Payer: First Choice Health Commercial |
$1,507.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,507.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$920.46
|
| Rate for Payer: HealthUtah PPO |
$1,587.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,539.39
|
| Rate for Payer: Multiplan Medicare/VA |
$874.44
|
| Rate for Payer: One Health Plan of WY PPO |
$1,555.26
|
| Rate for Payer: PacificSource Commercial |
$1,428.30
|
| Rate for Payer: PHCS PPO |
$1,555.26
|
| Rate for Payer: Three Rivers PPO |
$1,190.25
|
| Rate for Payer: TriWest Veterans Administration |
$920.46
|
| Rate for Payer: United Healthcare Commercial |
$1,380.69
|
| Rate for Payer: United Healthcare Medicare |
$920.46
|
| Rate for Payer: WINHealth Partners Commercial |
$1,555.26
|
| Rate for Payer: Wise Provider Network Commercial |
$1,507.65
|
|
|
HC PR ED MASTOTOMY W/EXPLORATION/DRAINAGE ABSCESS DEEP
|
Facility
|
IP
|
$1,587.00
|
|
|
Service Code
|
HCPCS 19020
|
| Hospital Charge Code |
9821902002
|
|
Hospital Revenue Code
|
982
|
| Min. Negotiated Rate |
$995.05 |
| Max. Negotiated Rate |
$1,587.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,555.26
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,523.52
|
| Rate for Payer: Altius Commercial |
$1,523.52
|
| Rate for Payer: Beech Street Commercial |
$1,555.26
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,302.93
|
| Rate for Payer: Cash Price |
$1,110.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,539.39
|
| Rate for Payer: Cigna of WY Commercial |
$1,555.26
|
| Rate for Payer: Entrust Commercial |
$1,507.65
|
| Rate for Payer: First Choice Health Commercial |
$1,507.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,507.65
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$1,047.42
|
| Rate for Payer: HealthUtah PPO |
$1,587.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,539.39
|
| Rate for Payer: Multiplan Medicare/VA |
$995.05
|
| Rate for Payer: One Health Plan of WY PPO |
$1,555.26
|
| Rate for Payer: PacificSource Commercial |
$1,428.30
|
| Rate for Payer: PHCS PPO |
$1,555.26
|
| Rate for Payer: Three Rivers PPO |
$1,190.25
|
| Rate for Payer: TriWest Veterans Administration |
$1,047.42
|
| Rate for Payer: United Healthcare Commercial |
$1,380.69
|
| Rate for Payer: United Healthcare Medicare |
$1,047.42
|
| Rate for Payer: WINHealth Partners Commercial |
$1,507.65
|
| Rate for Payer: Wise Provider Network Commercial |
$1,507.65
|
|
|
HC PREG ASSOC PLAS PRO-A(PAPP-A), SERUM - PREGNANCY-ASSOCIATED PLASMA
|
Facility
|
OP
|
$135.00
|
|
|
Service Code
|
HCPCS 84163
|
| Hospital Charge Code |
3018416301
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$74.38 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$132.30
|
| Rate for Payer: Aetna of WY Medicare |
$89.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$129.60
|
| Rate for Payer: Altius Commercial |
$129.60
|
| Rate for Payer: Beech Street Commercial |
$132.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$110.84
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.95
|
| Rate for Payer: Cigna of WY Commercial |
$132.30
|
| Rate for Payer: Entrust Commercial |
$128.25
|
| Rate for Payer: First Choice Health Commercial |
$128.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$128.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$78.30
|
| Rate for Payer: HealthUtah PPO |
$135.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.95
|
| Rate for Payer: Multiplan Medicare/VA |
$74.38
|
| Rate for Payer: One Health Plan of WY PPO |
$132.30
|
| Rate for Payer: PacificSource Commercial |
$121.50
|
| Rate for Payer: PHCS PPO |
$132.30
|
| Rate for Payer: Three Rivers PPO |
$101.25
|
| Rate for Payer: TriWest Veterans Administration |
$78.30
|
| Rate for Payer: United Healthcare Commercial |
$117.45
|
| Rate for Payer: United Healthcare Medicare |
$78.30
|
| Rate for Payer: WINHealth Partners Commercial |
$132.30
|
| Rate for Payer: Wise Provider Network Commercial |
$128.25
|
|
|
HC PREG ASSOC PLAS PRO-A(PAPP-A), SERUM - PREGNANCY-ASSOCIATED PLASMA
|
Facility
|
IP
|
$135.00
|
|
|
Service Code
|
HCPCS 84163
|
| Hospital Charge Code |
3018416301
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$84.64 |
| Max. Negotiated Rate |
$135.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$132.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$129.60
|
| Rate for Payer: Altius Commercial |
$129.60
|
| Rate for Payer: Beech Street Commercial |
$132.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$110.84
|
| Rate for Payer: Cash Price |
$94.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$130.95
|
| Rate for Payer: Cigna of WY Commercial |
$132.30
|
| Rate for Payer: Entrust Commercial |
$128.25
|
| Rate for Payer: First Choice Health Commercial |
$128.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$128.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$89.10
|
| Rate for Payer: HealthUtah PPO |
$135.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$130.95
|
| Rate for Payer: Multiplan Medicare/VA |
$84.64
|
| Rate for Payer: One Health Plan of WY PPO |
$132.30
|
| Rate for Payer: PacificSource Commercial |
$121.50
|
| Rate for Payer: PHCS PPO |
$132.30
|
| Rate for Payer: Three Rivers PPO |
$101.25
|
| Rate for Payer: TriWest Veterans Administration |
$89.10
|
| Rate for Payer: United Healthcare Commercial |
$117.45
|
| Rate for Payer: United Healthcare Medicare |
$89.10
|
| Rate for Payer: WINHealth Partners Commercial |
$128.25
|
| Rate for Payer: Wise Provider Network Commercial |
$128.25
|
|
|
HC PREVENTIVE VISIT,EST,18-39
|
Facility
|
OP
|
$277.00
|
|
|
Service Code
|
HCPCS 99395
|
| Hospital Charge Code |
5109939501
|
|
Hospital Revenue Code
|
510
|
| Min. Negotiated Rate |
$152.63 |
| Max. Negotiated Rate |
$277.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$271.46
|
| Rate for Payer: Aetna of WY Medicare |
$182.82
|
| Rate for Payer: Altius Auto/Workers Compensation |
$265.92
|
| Rate for Payer: Altius Commercial |
$265.92
|
| Rate for Payer: Beech Street Commercial |
$271.46
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$227.42
|
| Rate for Payer: Cash Price |
$193.90
|
| Rate for Payer: ChoiceCare Network Commercial |
$268.69
|
| Rate for Payer: Cigna of WY Commercial |
$271.46
|
| Rate for Payer: Entrust Commercial |
$263.15
|
| Rate for Payer: First Choice Health Commercial |
$263.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$263.15
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$160.66
|
| Rate for Payer: HealthUtah PPO |
$277.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$268.69
|
| Rate for Payer: Multiplan Medicare/VA |
$152.63
|
| Rate for Payer: One Health Plan of WY PPO |
$271.46
|
| Rate for Payer: PacificSource Commercial |
$249.30
|
| Rate for Payer: PHCS PPO |
$271.46
|
| Rate for Payer: Three Rivers PPO |
$207.75
|
| Rate for Payer: TriWest Veterans Administration |
$160.66
|
| Rate for Payer: United Healthcare Commercial |
$240.99
|
| Rate for Payer: United Healthcare Medicare |
$160.66
|
| Rate for Payer: WINHealth Partners Commercial |
$271.46
|
| Rate for Payer: Wise Provider Network Commercial |
$263.15
|
|
