|
HC TC99M MEBROFENIN TO 15 MIC
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
343A953701
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$413.82 |
| Max. Negotiated Rate |
$660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$646.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$633.60
|
| Rate for Payer: Altius Commercial |
$633.60
|
| Rate for Payer: Beech Street Commercial |
$646.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$541.86
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$640.20
|
| Rate for Payer: Cigna of WY Commercial |
$646.80
|
| Rate for Payer: Entrust Commercial |
$627.00
|
| Rate for Payer: First Choice Health Commercial |
$627.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$627.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$435.60
|
| Rate for Payer: HealthUtah PPO |
$660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$640.20
|
| Rate for Payer: Multiplan Medicare/VA |
$413.82
|
| Rate for Payer: One Health Plan of WY PPO |
$646.80
|
| Rate for Payer: PacificSource Commercial |
$594.00
|
| Rate for Payer: PHCS PPO |
$646.80
|
| Rate for Payer: Three Rivers PPO |
$495.00
|
| Rate for Payer: TriWest Veterans Administration |
$435.60
|
| Rate for Payer: United Healthcare Commercial |
$574.20
|
| Rate for Payer: United Healthcare Medicare |
$435.60
|
| Rate for Payer: WINHealth Partners Commercial |
$627.00
|
| Rate for Payer: Wise Provider Network Commercial |
$627.00
|
|
|
HC TC99M MEBROFENIN TO 15 MIC
|
Facility
|
OP
|
$660.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
343A953702
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$363.66 |
| Max. Negotiated Rate |
$660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$646.80
|
| Rate for Payer: Aetna of WY Medicare |
$435.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$633.60
|
| Rate for Payer: Altius Commercial |
$633.60
|
| Rate for Payer: Beech Street Commercial |
$646.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$541.86
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$640.20
|
| Rate for Payer: Cigna of WY Commercial |
$646.80
|
| Rate for Payer: Entrust Commercial |
$627.00
|
| Rate for Payer: First Choice Health Commercial |
$627.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$627.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$382.80
|
| Rate for Payer: HealthUtah PPO |
$660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$640.20
|
| Rate for Payer: Multiplan Medicare/VA |
$363.66
|
| Rate for Payer: One Health Plan of WY PPO |
$646.80
|
| Rate for Payer: PacificSource Commercial |
$594.00
|
| Rate for Payer: PHCS PPO |
$646.80
|
| Rate for Payer: Three Rivers PPO |
$495.00
|
| Rate for Payer: TriWest Veterans Administration |
$382.80
|
| Rate for Payer: United Healthcare Commercial |
$574.20
|
| Rate for Payer: United Healthcare Medicare |
$382.80
|
| Rate for Payer: WINHealth Partners Commercial |
$646.80
|
| Rate for Payer: Wise Provider Network Commercial |
$627.00
|
|
|
HC TC99M MEBROFENIN TO 15 MIC
|
Facility
|
IP
|
$660.00
|
|
|
Service Code
|
HCPCS A9537
|
| Hospital Charge Code |
343A953702
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$413.82 |
| Max. Negotiated Rate |
$660.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$646.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$633.60
|
| Rate for Payer: Altius Commercial |
$633.60
|
| Rate for Payer: Beech Street Commercial |
$646.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$541.86
|
| Rate for Payer: Cash Price |
$462.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$640.20
|
| Rate for Payer: Cigna of WY Commercial |
$646.80
|
| Rate for Payer: Entrust Commercial |
$627.00
|
| Rate for Payer: First Choice Health Commercial |
$627.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$627.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$435.60
|
| Rate for Payer: HealthUtah PPO |
$660.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$640.20
|
| Rate for Payer: Multiplan Medicare/VA |
$413.82
|
| Rate for Payer: One Health Plan of WY PPO |
$646.80
|
| Rate for Payer: PacificSource Commercial |
$594.00
|
| Rate for Payer: PHCS PPO |
$646.80
|
| Rate for Payer: Three Rivers PPO |
$495.00
|
| Rate for Payer: TriWest Veterans Administration |
$435.60
|
| Rate for Payer: United Healthcare Commercial |
$574.20
|
| Rate for Payer: United Healthcare Medicare |
$435.60
|
| Rate for Payer: WINHealth Partners Commercial |
$627.00
|
| Rate for Payer: Wise Provider Network Commercial |
$627.00
|
|
|
HC TC99M MEDRONATE
|
Facility
|
OP
|
$210.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
343A950301
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$115.71 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$205.80
|
| Rate for Payer: Aetna of WY Medicare |
$138.60
|
| Rate for Payer: Altius Auto/Workers Compensation |
$201.60
|
| Rate for Payer: Altius Commercial |
$201.60
|
| Rate for Payer: Beech Street Commercial |
$205.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$172.41
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$203.70
|
| Rate for Payer: Cigna of WY Commercial |
$205.80
|
| Rate for Payer: Entrust Commercial |
$199.50
|
| Rate for Payer: First Choice Health Commercial |
$199.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$199.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$121.80
|
| Rate for Payer: HealthUtah PPO |
$210.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$203.70
|
| Rate for Payer: Multiplan Medicare/VA |
$115.71
|
| Rate for Payer: One Health Plan of WY PPO |
$205.80
|
| Rate for Payer: PacificSource Commercial |
$189.00
|
| Rate for Payer: PHCS PPO |
$205.80
|
| Rate for Payer: Three Rivers PPO |
$157.50
|
| Rate for Payer: TriWest Veterans Administration |
$121.80
|
| Rate for Payer: United Healthcare Commercial |
$182.70
|
| Rate for Payer: United Healthcare Medicare |
$121.80
|
| Rate for Payer: WINHealth Partners Commercial |
$205.80
|
| Rate for Payer: Wise Provider Network Commercial |
$199.50
|
|
|
HC TC99M MEDRONATE
|
Facility
|
IP
|
$210.00
|
|
|
Service Code
|
HCPCS A9503
|
| Hospital Charge Code |
343A950301
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$131.67 |
| Max. Negotiated Rate |
$210.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$205.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$201.60
|
| Rate for Payer: Altius Commercial |
$201.60
|
| Rate for Payer: Beech Street Commercial |
$205.80
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$172.41
|
| Rate for Payer: Cash Price |
$147.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$203.70
|
| Rate for Payer: Cigna of WY Commercial |
$205.80
|
| Rate for Payer: Entrust Commercial |
$199.50
|
| Rate for Payer: First Choice Health Commercial |
$199.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$199.50
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$138.60
|
| Rate for Payer: HealthUtah PPO |
$210.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$203.70
|
| Rate for Payer: Multiplan Medicare/VA |
$131.67
|
| Rate for Payer: One Health Plan of WY PPO |
$205.80
|
| Rate for Payer: PacificSource Commercial |
$189.00
|
| Rate for Payer: PHCS PPO |
$205.80
|
| Rate for Payer: Three Rivers PPO |
$157.50
|
| Rate for Payer: TriWest Veterans Administration |
$138.60
|
| Rate for Payer: United Healthcare Commercial |
$182.70
|
| Rate for Payer: United Healthcare Medicare |
$138.60
|
| Rate for Payer: WINHealth Partners Commercial |
$199.50
|
| Rate for Payer: Wise Provider Network Commercial |
$199.50
|
|
|
HC TC99M MERTIATIDE TO 15 MIC
|
Facility
|
OP
|
$1,285.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
364A956201
|
|
Hospital Revenue Code
|
364
|
| Min. Negotiated Rate |
$708.04 |
| Max. Negotiated Rate |
$1,285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,259.30
|
| Rate for Payer: Aetna of WY Medicare |
$848.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,233.60
|
| Rate for Payer: Altius Commercial |
$1,233.60
|
| Rate for Payer: Beech Street Commercial |
$1,259.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,054.98
|
| Rate for Payer: Cash Price |
$899.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,246.45
|
| Rate for Payer: Cigna of WY Commercial |
$1,259.30
|
| Rate for Payer: Entrust Commercial |
$1,220.75
|
| Rate for Payer: First Choice Health Commercial |
$1,220.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,220.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$745.30
|
| Rate for Payer: HealthUtah PPO |
$1,285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,246.45
|
| Rate for Payer: Multiplan Medicare/VA |
$708.04
|
| Rate for Payer: One Health Plan of WY PPO |
$1,259.30
|
| Rate for Payer: PacificSource Commercial |
$1,156.50
|
| Rate for Payer: PHCS PPO |
$1,259.30
|
| Rate for Payer: Three Rivers PPO |
$963.75
|
| Rate for Payer: TriWest Veterans Administration |
$745.30
|
| Rate for Payer: United Healthcare Commercial |
$1,117.95
|
| Rate for Payer: United Healthcare Medicare |
$745.30
|
| Rate for Payer: WINHealth Partners Commercial |
$1,259.30
|
| Rate for Payer: Wise Provider Network Commercial |
$1,220.75
|
|
|
HC TC99M MERTIATIDE TO 15 MIC
|
Facility
|
IP
|
$1,285.00
|
|
|
Service Code
|
HCPCS A9562
|
| Hospital Charge Code |
364A956201
|
|
Hospital Revenue Code
|
364
|
| Min. Negotiated Rate |
$805.70 |
| Max. Negotiated Rate |
$1,285.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$1,259.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$1,233.60
|
| Rate for Payer: Altius Commercial |
$1,233.60
|
| Rate for Payer: Beech Street Commercial |
$1,259.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$1,054.98
|
| Rate for Payer: Cash Price |
$899.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$1,246.45
|
| Rate for Payer: Cigna of WY Commercial |
$1,259.30
|
| Rate for Payer: Entrust Commercial |
$1,220.75
|
| Rate for Payer: First Choice Health Commercial |
$1,220.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$1,220.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$848.10
|
| Rate for Payer: HealthUtah PPO |
$1,285.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$1,246.45
|
| Rate for Payer: Multiplan Medicare/VA |
$805.70
|
| Rate for Payer: One Health Plan of WY PPO |
$1,259.30
|
| Rate for Payer: PacificSource Commercial |
$1,156.50
|
| Rate for Payer: PHCS PPO |
$1,259.30
|
| Rate for Payer: Three Rivers PPO |
$963.75
|
| Rate for Payer: TriWest Veterans Administration |
$848.10
|
| Rate for Payer: United Healthcare Commercial |
$1,117.95
|
| Rate for Payer: United Healthcare Medicare |
$848.10
|
| Rate for Payer: WINHealth Partners Commercial |
$1,220.75
|
| Rate for Payer: Wise Provider Network Commercial |
$1,220.75
|
|
|
HC TC99M OXIDRONATE TO 30 MIC
|
Facility
|
OP
|
$535.00
|
|
|
Service Code
|
HCPCS A9561
|
| Hospital Charge Code |
343A956101
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$294.78 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$524.30
|
| Rate for Payer: Aetna of WY Medicare |
$353.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$513.60
|
| Rate for Payer: Altius Commercial |
$513.60
|
| Rate for Payer: Beech Street Commercial |
$524.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$439.24
|
| Rate for Payer: Cash Price |
$374.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$518.95
|
| Rate for Payer: Cigna of WY Commercial |
$524.30
|
| Rate for Payer: Entrust Commercial |
$508.25
|
| Rate for Payer: First Choice Health Commercial |
$508.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$508.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$310.30
|
| Rate for Payer: HealthUtah PPO |
$535.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$518.95
|
| Rate for Payer: Multiplan Medicare/VA |
$294.78
|
| Rate for Payer: One Health Plan of WY PPO |
$524.30
|
| Rate for Payer: PacificSource Commercial |
$481.50
|
| Rate for Payer: PHCS PPO |
$524.30
|
| Rate for Payer: Three Rivers PPO |
$401.25
|
| Rate for Payer: TriWest Veterans Administration |
$310.30
|
| Rate for Payer: United Healthcare Commercial |
$465.45
|
| Rate for Payer: United Healthcare Medicare |
$310.30
|
| Rate for Payer: WINHealth Partners Commercial |
$524.30
|
| Rate for Payer: Wise Provider Network Commercial |
$508.25
|
|
|
HC TC99M OXIDRONATE TO 30 MIC
|
Facility
|
IP
|
$535.00
|
|
|
Service Code
|
HCPCS A9561
|
| Hospital Charge Code |
343A956101
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$335.44 |
| Max. Negotiated Rate |
$535.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$524.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$513.60
|
| Rate for Payer: Altius Commercial |
$513.60
|
| Rate for Payer: Beech Street Commercial |
$524.30
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$439.24
|
| Rate for Payer: Cash Price |
$374.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$518.95
|
| Rate for Payer: Cigna of WY Commercial |
$524.30
|
| Rate for Payer: Entrust Commercial |
$508.25
|
| Rate for Payer: First Choice Health Commercial |
$508.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$508.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$353.10
|
| Rate for Payer: HealthUtah PPO |
$535.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$518.95
|
| Rate for Payer: Multiplan Medicare/VA |
$335.44
|
| Rate for Payer: One Health Plan of WY PPO |
$524.30
|
| Rate for Payer: PacificSource Commercial |
$481.50
|
| Rate for Payer: PHCS PPO |
$524.30
|
| Rate for Payer: Three Rivers PPO |
$401.25
|
| Rate for Payer: TriWest Veterans Administration |
$353.10
|
| Rate for Payer: United Healthcare Commercial |
$465.45
|
| Rate for Payer: United Healthcare Medicare |
$353.10
|
| Rate for Payer: WINHealth Partners Commercial |
$508.25
|
| Rate for Payer: Wise Provider Network Commercial |
$508.25
|
|
|
HC TC99M PENTETATE TO 25 MIC
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
343A953901
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$165.30 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$294.00
|
| Rate for Payer: Aetna of WY Medicare |
$198.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$288.00
|
| Rate for Payer: Altius Commercial |
$288.00
|
| Rate for Payer: Beech Street Commercial |
$294.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$246.30
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$291.00
|
| Rate for Payer: Cigna of WY Commercial |
$294.00
|
| Rate for Payer: Entrust Commercial |
$285.00
|
| Rate for Payer: First Choice Health Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$174.00
|
| Rate for Payer: HealthUtah PPO |
$300.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$291.00
|
| Rate for Payer: Multiplan Medicare/VA |
$165.30
|
| Rate for Payer: One Health Plan of WY PPO |
$294.00
|
| Rate for Payer: PacificSource Commercial |
$270.00
|
| Rate for Payer: PHCS PPO |
$294.00
|
| Rate for Payer: Three Rivers PPO |
$225.00
|
| Rate for Payer: TriWest Veterans Administration |
$174.00
|
| Rate for Payer: United Healthcare Commercial |
$261.00
|
| Rate for Payer: United Healthcare Medicare |
$174.00
|
| Rate for Payer: WINHealth Partners Commercial |
$294.00
|
| Rate for Payer: Wise Provider Network Commercial |
$285.00
|
|
|
HC TC99M PENTETATE TO 25 MIC
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
HCPCS A9539
|
| Hospital Charge Code |
343A953901
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$188.10 |
| Max. Negotiated Rate |
$300.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$294.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$288.00
|
| Rate for Payer: Altius Commercial |
$288.00
|
| Rate for Payer: Beech Street Commercial |
$294.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$246.30
|
| Rate for Payer: Cash Price |
$210.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$291.00
|
| Rate for Payer: Cigna of WY Commercial |
$294.00
|
| Rate for Payer: Entrust Commercial |
$285.00
|
| Rate for Payer: First Choice Health Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$285.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$198.00
|
| Rate for Payer: HealthUtah PPO |
$300.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$291.00
|
| Rate for Payer: Multiplan Medicare/VA |
$188.10
|
| Rate for Payer: One Health Plan of WY PPO |
$294.00
|
| Rate for Payer: PacificSource Commercial |
$270.00
|
| Rate for Payer: PHCS PPO |
$294.00
|
| Rate for Payer: Three Rivers PPO |
$225.00
|
| Rate for Payer: TriWest Veterans Administration |
$198.00
|
| Rate for Payer: United Healthcare Commercial |
$261.00
|
| Rate for Payer: United Healthcare Medicare |
$198.00
|
| Rate for Payer: WINHealth Partners Commercial |
$285.00
|
| Rate for Payer: Wise Provider Network Commercial |
$285.00
|
|
|
HC TC99M PERTECHNETATE
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
343A951201
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$68.88 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$122.50
|
| Rate for Payer: Aetna of WY Medicare |
$82.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$120.00
|
| Rate for Payer: Altius Commercial |
$120.00
|
| Rate for Payer: Beech Street Commercial |
$122.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$102.62
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$121.25
|
| Rate for Payer: Cigna of WY Commercial |
$122.50
|
| Rate for Payer: Entrust Commercial |
$118.75
|
| Rate for Payer: First Choice Health Commercial |
$118.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$118.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$72.50
|
| Rate for Payer: HealthUtah PPO |
$125.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$121.25
|
| Rate for Payer: Multiplan Medicare/VA |
$68.88
|
| Rate for Payer: One Health Plan of WY PPO |
$122.50
|
| Rate for Payer: PacificSource Commercial |
$112.50
|
| Rate for Payer: PHCS PPO |
$122.50
|
| Rate for Payer: Three Rivers PPO |
$93.75
|
| Rate for Payer: TriWest Veterans Administration |
$72.50
|
| Rate for Payer: United Healthcare Commercial |
$108.75
|
| Rate for Payer: United Healthcare Medicare |
$72.50
|
| Rate for Payer: WINHealth Partners Commercial |
$122.50
|
| Rate for Payer: Wise Provider Network Commercial |
$118.75
|
|
|
HC TC99M PERTECHNETATE
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
HCPCS A9512
|
| Hospital Charge Code |
343A951201
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$78.38 |
| Max. Negotiated Rate |
$125.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$122.50
|
| Rate for Payer: Altius Auto/Workers Compensation |
$120.00
|
| Rate for Payer: Altius Commercial |
$120.00
|
| Rate for Payer: Beech Street Commercial |
$122.50
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$102.62
|
| Rate for Payer: Cash Price |
$87.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$121.25
|
| Rate for Payer: Cigna of WY Commercial |
$122.50
|
| Rate for Payer: Entrust Commercial |
$118.75
|
| Rate for Payer: First Choice Health Commercial |
$118.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$118.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$82.50
|
| Rate for Payer: HealthUtah PPO |
$125.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$121.25
|
| Rate for Payer: Multiplan Medicare/VA |
$78.38
|
| Rate for Payer: One Health Plan of WY PPO |
$122.50
|
| Rate for Payer: PacificSource Commercial |
$112.50
|
| Rate for Payer: PHCS PPO |
$122.50
|
| Rate for Payer: Three Rivers PPO |
$93.75
|
| Rate for Payer: TriWest Veterans Administration |
$82.50
|
| Rate for Payer: United Healthcare Commercial |
$108.75
|
| Rate for Payer: United Healthcare Medicare |
$82.50
|
| Rate for Payer: WINHealth Partners Commercial |
$118.75
|
| Rate for Payer: Wise Provider Network Commercial |
$118.75
|
|
|
HC TC99M SULFUR COLLOID 20 MIC
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
343A954102
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$330.60 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$588.00
|
| Rate for Payer: Aetna of WY Medicare |
$396.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$576.00
|
| Rate for Payer: Altius Commercial |
$576.00
|
| Rate for Payer: Beech Street Commercial |
$588.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$492.60
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$582.00
|
| Rate for Payer: Cigna of WY Commercial |
$588.00
|
| Rate for Payer: Entrust Commercial |
$570.00
|
| Rate for Payer: First Choice Health Commercial |
$570.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$570.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$348.00
|
| Rate for Payer: HealthUtah PPO |
$600.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$582.00
|
| Rate for Payer: Multiplan Medicare/VA |
$330.60
|
| Rate for Payer: One Health Plan of WY PPO |
$588.00
|
| Rate for Payer: PacificSource Commercial |
$540.00
|
| Rate for Payer: PHCS PPO |
$588.00
|
| Rate for Payer: Three Rivers PPO |
$450.00
|
| Rate for Payer: TriWest Veterans Administration |
$348.00
|
| Rate for Payer: United Healthcare Commercial |
$522.00
|
| Rate for Payer: United Healthcare Medicare |
$348.00
|
| Rate for Payer: WINHealth Partners Commercial |
$588.00
|
| Rate for Payer: Wise Provider Network Commercial |
$570.00
|
|
|
HC TC99M SULFUR COLLOID 20 MIC
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
343A954102
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$376.20 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$588.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$576.00
|
| Rate for Payer: Altius Commercial |
$576.00
|
| Rate for Payer: Beech Street Commercial |
$588.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$492.60
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$582.00
|
| Rate for Payer: Cigna of WY Commercial |
$588.00
|
| Rate for Payer: Entrust Commercial |
$570.00
|
| Rate for Payer: First Choice Health Commercial |
$570.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$570.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$396.00
|
| Rate for Payer: HealthUtah PPO |
$600.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$582.00
|
| Rate for Payer: Multiplan Medicare/VA |
$376.20
|
| Rate for Payer: One Health Plan of WY PPO |
$588.00
|
| Rate for Payer: PacificSource Commercial |
$540.00
|
| Rate for Payer: PHCS PPO |
$588.00
|
| Rate for Payer: Three Rivers PPO |
$450.00
|
| Rate for Payer: TriWest Veterans Administration |
$396.00
|
| Rate for Payer: United Healthcare Commercial |
$522.00
|
| Rate for Payer: United Healthcare Medicare |
$396.00
|
| Rate for Payer: WINHealth Partners Commercial |
$570.00
|
| Rate for Payer: Wise Provider Network Commercial |
$570.00
|
|
|
HC TC99M SULFUR COLLOID 20 MIC
|
Facility
|
OP
|
$600.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
343A954101
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$330.60 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$588.00
|
| Rate for Payer: Aetna of WY Medicare |
$396.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$576.00
|
| Rate for Payer: Altius Commercial |
$576.00
|
| Rate for Payer: Beech Street Commercial |
$588.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$492.60
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$582.00
|
| Rate for Payer: Cigna of WY Commercial |
$588.00
|
| Rate for Payer: Entrust Commercial |
$570.00
|
| Rate for Payer: First Choice Health Commercial |
$570.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$570.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$348.00
|
| Rate for Payer: HealthUtah PPO |
$600.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$582.00
|
| Rate for Payer: Multiplan Medicare/VA |
$330.60
|
| Rate for Payer: One Health Plan of WY PPO |
$588.00
|
| Rate for Payer: PacificSource Commercial |
$540.00
|
| Rate for Payer: PHCS PPO |
$588.00
|
| Rate for Payer: Three Rivers PPO |
$450.00
|
| Rate for Payer: TriWest Veterans Administration |
$348.00
|
| Rate for Payer: United Healthcare Commercial |
$522.00
|
| Rate for Payer: United Healthcare Medicare |
$348.00
|
| Rate for Payer: WINHealth Partners Commercial |
$588.00
|
| Rate for Payer: Wise Provider Network Commercial |
$570.00
|
|
|
HC TC99M SULFUR COLLOID 20 MIC
|
Facility
|
IP
|
$600.00
|
|
|
Service Code
|
HCPCS A9541
|
| Hospital Charge Code |
343A954101
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$376.20 |
| Max. Negotiated Rate |
$600.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$588.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$576.00
|
| Rate for Payer: Altius Commercial |
$576.00
|
| Rate for Payer: Beech Street Commercial |
$588.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$492.60
|
| Rate for Payer: Cash Price |
$420.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$582.00
|
| Rate for Payer: Cigna of WY Commercial |
$588.00
|
| Rate for Payer: Entrust Commercial |
$570.00
|
| Rate for Payer: First Choice Health Commercial |
$570.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$570.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$396.00
|
| Rate for Payer: HealthUtah PPO |
$600.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$582.00
|
| Rate for Payer: Multiplan Medicare/VA |
$376.20
|
| Rate for Payer: One Health Plan of WY PPO |
$588.00
|
| Rate for Payer: PacificSource Commercial |
$540.00
|
| Rate for Payer: PHCS PPO |
$588.00
|
| Rate for Payer: Three Rivers PPO |
$450.00
|
| Rate for Payer: TriWest Veterans Administration |
$396.00
|
| Rate for Payer: United Healthcare Commercial |
$522.00
|
| Rate for Payer: United Healthcare Medicare |
$396.00
|
| Rate for Payer: WINHealth Partners Commercial |
$570.00
|
| Rate for Payer: Wise Provider Network Commercial |
$570.00
|
|
|
HC T CELL ABSOLUTE COUNT/RATIO - T-HELPER CELLS CD4/CD8 %
|
Facility
|
OP
|
$305.00
|
|
|
Service Code
|
HCPCS 86360
|
| Hospital Charge Code |
3028636001
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$168.06 |
| Max. Negotiated Rate |
$305.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$298.90
|
| Rate for Payer: Aetna of WY Medicare |
$201.30
|
| Rate for Payer: Altius Auto/Workers Compensation |
$292.80
|
| Rate for Payer: Altius Commercial |
$292.80
|
| Rate for Payer: Beech Street Commercial |
$298.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$250.40
|
| Rate for Payer: Cash Price |
$213.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$295.85
|
| Rate for Payer: Cigna of WY Commercial |
$298.90
|
| Rate for Payer: Entrust Commercial |
$289.75
|
| Rate for Payer: First Choice Health Commercial |
$289.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$289.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$176.90
|
| Rate for Payer: HealthUtah PPO |
$305.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$295.85
|
| Rate for Payer: Multiplan Medicare/VA |
$168.06
|
| Rate for Payer: One Health Plan of WY PPO |
$298.90
|
| Rate for Payer: PacificSource Commercial |
$274.50
|
| Rate for Payer: PHCS PPO |
$298.90
|
| Rate for Payer: Three Rivers PPO |
$228.75
|
| Rate for Payer: TriWest Veterans Administration |
$176.90
|
| Rate for Payer: United Healthcare Commercial |
$265.35
|
| Rate for Payer: United Healthcare Medicare |
$176.90
|
| Rate for Payer: WINHealth Partners Commercial |
$298.90
|
| Rate for Payer: Wise Provider Network Commercial |
$289.75
|
|
|
HC T CELL ABSOLUTE COUNT/RATIO - T-HELPER CELLS CD4/CD8 %
|
Facility
|
IP
|
$305.00
|
|
|
Service Code
|
HCPCS 86360
|
| Hospital Charge Code |
3028636001
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$191.24 |
| Max. Negotiated Rate |
$305.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$298.90
|
| Rate for Payer: Altius Auto/Workers Compensation |
$292.80
|
| Rate for Payer: Altius Commercial |
$292.80
|
| Rate for Payer: Beech Street Commercial |
$298.90
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$250.40
|
| Rate for Payer: Cash Price |
$213.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$295.85
|
| Rate for Payer: Cigna of WY Commercial |
$298.90
|
| Rate for Payer: Entrust Commercial |
$289.75
|
| Rate for Payer: First Choice Health Commercial |
$289.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$289.75
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$201.30
|
| Rate for Payer: HealthUtah PPO |
$305.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$295.85
|
| Rate for Payer: Multiplan Medicare/VA |
$191.24
|
| Rate for Payer: One Health Plan of WY PPO |
$298.90
|
| Rate for Payer: PacificSource Commercial |
$274.50
|
| Rate for Payer: PHCS PPO |
$298.90
|
| Rate for Payer: Three Rivers PPO |
$228.75
|
| Rate for Payer: TriWest Veterans Administration |
$201.30
|
| Rate for Payer: United Healthcare Commercial |
$265.35
|
| Rate for Payer: United Healthcare Medicare |
$201.30
|
| Rate for Payer: WINHealth Partners Commercial |
$289.75
|
| Rate for Payer: Wise Provider Network Commercial |
$289.75
|
|
|
HC T CELL ABSOLUTE COUNT - T-HELPER CELLS (CD4) COUNT
|
Facility
|
OP
|
$195.00
|
|
|
Service Code
|
HCPCS 86361
|
| Hospital Charge Code |
3028636101
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$107.44 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$191.10
|
| Rate for Payer: Aetna of WY Medicare |
$128.70
|
| Rate for Payer: Altius Auto/Workers Compensation |
$187.20
|
| Rate for Payer: Altius Commercial |
$187.20
|
| Rate for Payer: Beech Street Commercial |
$191.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$160.10
|
| Rate for Payer: Cash Price |
$136.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$189.15
|
| Rate for Payer: Cigna of WY Commercial |
$191.10
|
| Rate for Payer: Entrust Commercial |
$185.25
|
| Rate for Payer: First Choice Health Commercial |
$185.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$185.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$113.10
|
| Rate for Payer: HealthUtah PPO |
$195.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$189.15
|
| Rate for Payer: Multiplan Medicare/VA |
$107.44
|
| Rate for Payer: One Health Plan of WY PPO |
$191.10
|
| Rate for Payer: PacificSource Commercial |
$175.50
|
| Rate for Payer: PHCS PPO |
$191.10
|
| Rate for Payer: Three Rivers PPO |
$146.25
|
| Rate for Payer: TriWest Veterans Administration |
$113.10
|
| Rate for Payer: United Healthcare Commercial |
$169.65
|
| Rate for Payer: United Healthcare Medicare |
$113.10
|
| Rate for Payer: WINHealth Partners Commercial |
$191.10
|
| Rate for Payer: Wise Provider Network Commercial |
$185.25
|
|
|
HC T CELL ABSOLUTE COUNT - T-HELPER CELLS (CD4) COUNT
|
Facility
|
IP
|
$195.00
|
|
|
Service Code
|
HCPCS 86361
|
| Hospital Charge Code |
3028636101
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$122.26 |
| Max. Negotiated Rate |
$195.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$191.10
|
| Rate for Payer: Altius Auto/Workers Compensation |
$187.20
|
| Rate for Payer: Altius Commercial |
$187.20
|
| Rate for Payer: Beech Street Commercial |
$191.10
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$160.10
|
| Rate for Payer: Cash Price |
$136.50
|
| Rate for Payer: ChoiceCare Network Commercial |
$189.15
|
| Rate for Payer: Cigna of WY Commercial |
$191.10
|
| Rate for Payer: Entrust Commercial |
$185.25
|
| Rate for Payer: First Choice Health Commercial |
$185.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$185.25
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$128.70
|
| Rate for Payer: HealthUtah PPO |
$195.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$189.15
|
| Rate for Payer: Multiplan Medicare/VA |
$122.26
|
| Rate for Payer: One Health Plan of WY PPO |
$191.10
|
| Rate for Payer: PacificSource Commercial |
$175.50
|
| Rate for Payer: PHCS PPO |
$191.10
|
| Rate for Payer: Three Rivers PPO |
$146.25
|
| Rate for Payer: TriWest Veterans Administration |
$128.70
|
| Rate for Payer: United Healthcare Commercial |
$169.65
|
| Rate for Payer: United Healthcare Medicare |
$128.70
|
| Rate for Payer: WINHealth Partners Commercial |
$185.25
|
| Rate for Payer: Wise Provider Network Commercial |
$185.25
|
|
|
HC T CELLS, TOTAL COUNT - T CELLS, TOTAL COUNT
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
HCPCS 86359
|
| Hospital Charge Code |
3028635901
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$238.26 |
| Max. Negotiated Rate |
$380.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$372.40
|
| Rate for Payer: Altius Auto/Workers Compensation |
$364.80
|
| Rate for Payer: Altius Commercial |
$364.80
|
| Rate for Payer: Beech Street Commercial |
$372.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$311.98
|
| Rate for Payer: Cash Price |
$266.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$368.60
|
| Rate for Payer: Cigna of WY Commercial |
$372.40
|
| Rate for Payer: Entrust Commercial |
$361.00
|
| Rate for Payer: First Choice Health Commercial |
$361.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$361.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$250.80
|
| Rate for Payer: HealthUtah PPO |
$380.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$368.60
|
| Rate for Payer: Multiplan Medicare/VA |
$238.26
|
| Rate for Payer: One Health Plan of WY PPO |
$372.40
|
| Rate for Payer: PacificSource Commercial |
$342.00
|
| Rate for Payer: PHCS PPO |
$372.40
|
| Rate for Payer: Three Rivers PPO |
$285.00
|
| Rate for Payer: TriWest Veterans Administration |
$250.80
|
| Rate for Payer: United Healthcare Commercial |
$330.60
|
| Rate for Payer: United Healthcare Medicare |
$250.80
|
| Rate for Payer: WINHealth Partners Commercial |
$361.00
|
| Rate for Payer: Wise Provider Network Commercial |
$361.00
|
|
|
HC T CELLS, TOTAL COUNT - T CELLS, TOTAL COUNT
|
Facility
|
OP
|
$380.00
|
|
|
Service Code
|
HCPCS 86359
|
| Hospital Charge Code |
3028635901
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$209.38 |
| Max. Negotiated Rate |
$380.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$372.40
|
| Rate for Payer: Aetna of WY Medicare |
$250.80
|
| Rate for Payer: Altius Auto/Workers Compensation |
$364.80
|
| Rate for Payer: Altius Commercial |
$364.80
|
| Rate for Payer: Beech Street Commercial |
$372.40
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$311.98
|
| Rate for Payer: Cash Price |
$266.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$368.60
|
| Rate for Payer: Cigna of WY Commercial |
$372.40
|
| Rate for Payer: Entrust Commercial |
$361.00
|
| Rate for Payer: First Choice Health Commercial |
$361.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$361.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$220.40
|
| Rate for Payer: HealthUtah PPO |
$380.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$368.60
|
| Rate for Payer: Multiplan Medicare/VA |
$209.38
|
| Rate for Payer: One Health Plan of WY PPO |
$372.40
|
| Rate for Payer: PacificSource Commercial |
$342.00
|
| Rate for Payer: PHCS PPO |
$372.40
|
| Rate for Payer: Three Rivers PPO |
$285.00
|
| Rate for Payer: TriWest Veterans Administration |
$220.40
|
| Rate for Payer: United Healthcare Commercial |
$330.60
|
| Rate for Payer: United Healthcare Medicare |
$220.40
|
| Rate for Payer: WINHealth Partners Commercial |
$372.40
|
| Rate for Payer: Wise Provider Network Commercial |
$361.00
|
|
|
HC TECHNETIUM TC-99M TETROFOSMIN
|
Facility
|
OP
|
$900.00
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
343A950201
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$495.90 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$882.00
|
| Rate for Payer: Aetna of WY Medicare |
$594.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$864.00
|
| Rate for Payer: Altius Commercial |
$864.00
|
| Rate for Payer: Beech Street Commercial |
$882.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$738.90
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$873.00
|
| Rate for Payer: Cigna of WY Commercial |
$882.00
|
| Rate for Payer: Entrust Commercial |
$855.00
|
| Rate for Payer: First Choice Health Commercial |
$855.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$855.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$522.00
|
| Rate for Payer: HealthUtah PPO |
$900.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$873.00
|
| Rate for Payer: Multiplan Medicare/VA |
$495.90
|
| Rate for Payer: One Health Plan of WY PPO |
$882.00
|
| Rate for Payer: PacificSource Commercial |
$810.00
|
| Rate for Payer: PHCS PPO |
$882.00
|
| Rate for Payer: Three Rivers PPO |
$675.00
|
| Rate for Payer: TriWest Veterans Administration |
$522.00
|
| Rate for Payer: United Healthcare Commercial |
$783.00
|
| Rate for Payer: United Healthcare Medicare |
$522.00
|
| Rate for Payer: WINHealth Partners Commercial |
$882.00
|
| Rate for Payer: Wise Provider Network Commercial |
$855.00
|
|
|
HC TECHNETIUM TC-99M TETROFOSMIN
|
Facility
|
IP
|
$900.00
|
|
|
Service Code
|
HCPCS A9502
|
| Hospital Charge Code |
343A950201
|
|
Hospital Revenue Code
|
343
|
| Min. Negotiated Rate |
$564.30 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna of WY Commercial/Medical Rental |
$882.00
|
| Rate for Payer: Altius Auto/Workers Compensation |
$864.00
|
| Rate for Payer: Altius Commercial |
$864.00
|
| Rate for Payer: Beech Street Commercial |
$882.00
|
| Rate for Payer: Blue Cross Blue Shield of Wyoming Commercial |
$738.90
|
| Rate for Payer: Cash Price |
$630.00
|
| Rate for Payer: ChoiceCare Network Commercial |
$873.00
|
| Rate for Payer: Cigna of WY Commercial |
$882.00
|
| Rate for Payer: Entrust Commercial |
$855.00
|
| Rate for Payer: First Choice Health Commercial |
$855.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Commercial |
$855.00
|
| Rate for Payer: Government Employees Health Association (GEHA) Medicare |
$594.00
|
| Rate for Payer: HealthUtah PPO |
$900.00
|
| Rate for Payer: Idaho Integrated Healthcare Commercial |
$873.00
|
| Rate for Payer: Multiplan Medicare/VA |
$564.30
|
| Rate for Payer: One Health Plan of WY PPO |
$882.00
|
| Rate for Payer: PacificSource Commercial |
$810.00
|
| Rate for Payer: PHCS PPO |
$882.00
|
| Rate for Payer: Three Rivers PPO |
$675.00
|
| Rate for Payer: TriWest Veterans Administration |
$594.00
|
| Rate for Payer: United Healthcare Commercial |
$783.00
|
| Rate for Payer: United Healthcare Medicare |
$594.00
|
| Rate for Payer: WINHealth Partners Commercial |
$855.00
|
| Rate for Payer: Wise Provider Network Commercial |
$855.00
|
|
