|
CEPHALEXIN 250 MG ORAL CAP
|
Facility
|
IP
|
$1.98
|
|
|
Service Code
|
NDC 60687015201
|
| Hospital Charge Code |
9499
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.71
|
| Rate for Payer: Cash Price |
$1.23
|
| Rate for Payer: Cigna All Commercial |
$1.71
|
| Rate for Payer: CORVEL All Commercial |
$1.84
|
| Rate for Payer: Coventry All Commercial |
$1.74
|
| Rate for Payer: Encore All Commercial |
$1.82
|
| Rate for Payer: Frontpath All Commercial |
$1.82
|
| Rate for Payer: Humana ChoiceCare |
$1.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.78
|
| Rate for Payer: PHCS All Commercial |
$1.49
|
| Rate for Payer: PHP All Commercial |
$1.50
|
| Rate for Payer: Sagamore Health Network All Products |
$1.53
|
| Rate for Payer: Signature Care EPO |
$1.64
|
| Rate for Payer: Signature Care PPO |
$1.74
|
| Rate for Payer: United Healthcare Commercial |
$1.56
|
|
|
CEPHALEXIN 500 MG ORAL CAP
|
Facility
|
OP
|
$2.32
|
|
|
Service Code
|
NDC 60687016301
|
| Hospital Charge Code |
9500
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna Commercial |
$1.96
|
| Rate for Payer: Aetna Medicare |
$0.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.84
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Centivo All Commercial |
$1.19
|
| Rate for Payer: Cigna All Commercial |
$2.01
|
| Rate for Payer: CORVEL All Commercial |
$2.16
|
| Rate for Payer: Coventry All Commercial |
$2.05
|
| Rate for Payer: Encore All Commercial |
$2.14
|
| Rate for Payer: Frontpath All Commercial |
$2.14
|
| Rate for Payer: Humana ChoiceCare |
$2.01
|
| Rate for Payer: Humana Medicare |
$1.19
|
| Rate for Payer: Lucent All Commercial |
$1.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.09
|
| Rate for Payer: PHCS All Commercial |
$1.74
|
| Rate for Payer: PHP All Commercial |
$1.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.91
|
| Rate for Payer: Sagamore Health Network All Products |
$1.79
|
| Rate for Payer: Signature Care EPO |
$1.93
|
| Rate for Payer: Signature Care PPO |
$2.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.98
|
| Rate for Payer: United Healthcare Commercial |
$1.83
|
| Rate for Payer: United Healthcare Medicare |
$0.77
|
|
|
CEPHALEXIN 500 MG ORAL CAP
|
Facility
|
IP
|
$2.32
|
|
|
Service Code
|
NDC 60687016301
|
| Hospital Charge Code |
9500
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.74 |
| Max. Negotiated Rate |
$2.16 |
| Rate for Payer: Aetna Commercial |
$2.01
|
| Rate for Payer: Cash Price |
$1.44
|
| Rate for Payer: Cigna All Commercial |
$2.01
|
| Rate for Payer: CORVEL All Commercial |
$2.16
|
| Rate for Payer: Coventry All Commercial |
$2.05
|
| Rate for Payer: Encore All Commercial |
$2.14
|
| Rate for Payer: Frontpath All Commercial |
$2.14
|
| Rate for Payer: Humana ChoiceCare |
$2.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.09
|
| Rate for Payer: PHCS All Commercial |
$1.74
|
| Rate for Payer: PHP All Commercial |
$1.76
|
| Rate for Payer: Sagamore Health Network All Products |
$1.79
|
| Rate for Payer: Signature Care EPO |
$1.93
|
| Rate for Payer: Signature Care PPO |
$2.05
|
| Rate for Payer: United Healthcare Commercial |
$1.83
|
|
|
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SUBQ SYKT
|
Facility
|
IP
|
$19,224.00
|
|
|
Service Code
|
HCPCS J0717
|
| Hospital Charge Code |
97853
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14,418.00 |
| Max. Negotiated Rate |
$17,878.32 |
| Rate for Payer: Aetna Commercial |
$16,609.53
|
| Rate for Payer: Cash Price |
$11,918.88
|
| Rate for Payer: Cigna All Commercial |
$16,590.31
|
| Rate for Payer: CORVEL All Commercial |
$17,878.32
|
| Rate for Payer: Coventry All Commercial |
$16,917.12
|
| Rate for Payer: Encore All Commercial |
$17,695.69
|
| Rate for Payer: Frontpath All Commercial |
$17,686.08
|
| Rate for Payer: Humana ChoiceCare |
$16,603.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17,301.60
|
| Rate for Payer: PHCS All Commercial |
$14,418.00
|
| Rate for Payer: PHP All Commercial |
$14,579.48
|
| Rate for Payer: Sagamore Health Network All Products |
$14,840.92
|
| Rate for Payer: Signature Care EPO |
$15,955.92
|
| Rate for Payer: Signature Care PPO |
$16,917.12
|
| Rate for Payer: United Healthcare Commercial |
$15,148.51
|
|
|
CERTOLIZUMAB PEGOL 400 MG/2 ML (200 MG/ML X 2) SUBQ SYKT
|
Facility
|
OP
|
$19,224.00
|
|
|
Service Code
|
HCPCS J0717
|
| Hospital Charge Code |
97853
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.18 |
| Max. Negotiated Rate |
$17,878.32 |
| Rate for Payer: Aetna Commercial |
$16,225.05
|
| Rate for Payer: Aetna Medicare |
$6,343.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6,343.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11,040.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12,016.92
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$14.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7,295.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6,978.31
|
| Rate for Payer: Cash Price |
$11,918.88
|
| Rate for Payer: Cash Price |
$11,918.88
|
| Rate for Payer: Centivo All Commercial |
$9,804.24
|
| Rate for Payer: Cigna All Commercial |
$16,590.31
|
| Rate for Payer: CORVEL All Commercial |
$17,878.32
|
| Rate for Payer: Coventry All Commercial |
$16,917.12
|
| Rate for Payer: Encore All Commercial |
$17,695.69
|
| Rate for Payer: Frontpath All Commercial |
$17,686.08
|
| Rate for Payer: Humana ChoiceCare |
$16,603.76
|
| Rate for Payer: Humana Medicare |
$9,804.24
|
| Rate for Payer: Lucent All Commercial |
$9,804.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17,301.60
|
| Rate for Payer: Managed Health Services Medicaid |
$14.18
|
| Rate for Payer: MDWise Medicaid |
$14.18
|
| Rate for Payer: PHCS All Commercial |
$14,418.00
|
| Rate for Payer: PHP All Commercial |
$14,579.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7,497.36
|
| Rate for Payer: Sagamore Health Network All Products |
$14,840.92
|
| Rate for Payer: Signature Care EPO |
$15,955.92
|
| Rate for Payer: Signature Care PPO |
$16,917.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16,340.40
|
| Rate for Payer: United Healthcare Commercial |
$15,148.51
|
| Rate for Payer: United Healthcare Medicare |
$6,343.92
|
|
|
CETIRIZINE 10 MG ORAL TAB
|
Facility
|
OP
|
$0.84
|
|
|
Service Code
|
NDC 00904671761
|
| Hospital Charge Code |
9506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna Commercial |
$0.71
|
| Rate for Payer: Aetna Medicare |
$0.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.30
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Centivo All Commercial |
$0.43
|
| Rate for Payer: Cigna All Commercial |
$0.72
|
| Rate for Payer: CORVEL All Commercial |
$0.78
|
| Rate for Payer: Coventry All Commercial |
$0.74
|
| Rate for Payer: Encore All Commercial |
$0.77
|
| Rate for Payer: Frontpath All Commercial |
$0.77
|
| Rate for Payer: Humana ChoiceCare |
$0.73
|
| Rate for Payer: Humana Medicare |
$0.43
|
| Rate for Payer: Lucent All Commercial |
$0.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.76
|
| Rate for Payer: PHCS All Commercial |
$0.63
|
| Rate for Payer: PHP All Commercial |
$0.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.33
|
| Rate for Payer: Sagamore Health Network All Products |
$0.65
|
| Rate for Payer: Signature Care EPO |
$0.70
|
| Rate for Payer: Signature Care PPO |
$0.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.71
|
| Rate for Payer: United Healthcare Commercial |
$0.66
|
| Rate for Payer: United Healthcare Medicare |
$0.28
|
|
|
CETIRIZINE 10 MG ORAL TAB
|
Facility
|
IP
|
$1.14
|
|
|
Service Code
|
NDC 51079059720
|
| Hospital Charge Code |
9506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna Commercial |
$0.99
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Cigna All Commercial |
$0.98
|
| Rate for Payer: CORVEL All Commercial |
$1.06
|
| Rate for Payer: Coventry All Commercial |
$1.00
|
| Rate for Payer: Encore All Commercial |
$1.05
|
| Rate for Payer: Frontpath All Commercial |
$1.05
|
| Rate for Payer: Humana ChoiceCare |
$0.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.03
|
| Rate for Payer: PHCS All Commercial |
$0.86
|
| Rate for Payer: PHP All Commercial |
$0.87
|
| Rate for Payer: Sagamore Health Network All Products |
$0.88
|
| Rate for Payer: Signature Care EPO |
$0.95
|
| Rate for Payer: Signature Care PPO |
$1.00
|
| Rate for Payer: United Healthcare Commercial |
$0.90
|
|
|
CETIRIZINE 10 MG ORAL TAB
|
Facility
|
IP
|
$0.84
|
|
|
Service Code
|
NDC 00904671761
|
| Hospital Charge Code |
9506
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna Commercial |
$0.73
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna All Commercial |
$0.72
|
| Rate for Payer: CORVEL All Commercial |
$0.78
|
| Rate for Payer: Coventry All Commercial |
$0.74
|
| Rate for Payer: Encore All Commercial |
$0.77
|
| Rate for Payer: Frontpath All Commercial |
$0.77
|
| Rate for Payer: Humana ChoiceCare |
$0.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.76
|
| Rate for Payer: PHCS All Commercial |
$0.63
|
| Rate for Payer: PHP All Commercial |
$0.64
|
| Rate for Payer: Sagamore Health Network All Products |
$0.65
|
| Rate for Payer: Signature Care EPO |
$0.70
|
| Rate for Payer: Signature Care PPO |
$0.74
|
| Rate for Payer: United Healthcare Commercial |
$0.66
|
|
|
CETIRIZINE 10 MG ORAL TAB
|
Facility
|
OP
|
$1.14
|
|
|
Service Code
|
NDC 51079059720
|
| Hospital Charge Code |
9506
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna Commercial |
$0.96
|
| Rate for Payer: Aetna Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.41
|
| Rate for Payer: Cash Price |
$0.71
|
| Rate for Payer: Centivo All Commercial |
$0.58
|
| Rate for Payer: Cigna All Commercial |
$0.98
|
| Rate for Payer: CORVEL All Commercial |
$1.06
|
| Rate for Payer: Coventry All Commercial |
$1.00
|
| Rate for Payer: Encore All Commercial |
$1.05
|
| Rate for Payer: Frontpath All Commercial |
$1.05
|
| Rate for Payer: Humana ChoiceCare |
$0.99
|
| Rate for Payer: Humana Medicare |
$0.58
|
| Rate for Payer: Lucent All Commercial |
$0.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.03
|
| Rate for Payer: PHCS All Commercial |
$0.86
|
| Rate for Payer: PHP All Commercial |
$0.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.44
|
| Rate for Payer: Sagamore Health Network All Products |
$0.88
|
| Rate for Payer: Signature Care EPO |
$0.95
|
| Rate for Payer: Signature Care PPO |
$1.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.97
|
| Rate for Payer: United Healthcare Commercial |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$0.38
|
|
|
CHEMO IV INFUSION 1 HR
|
Professional
|
Both
|
$237.58
|
|
|
Service Code
|
CPT 96413
|
| Hospital Charge Code |
z96413
|
| Min. Negotiated Rate |
$120.21 |
| Max. Negotiated Rate |
$224.84 |
| Rate for Payer: Aetna Medicare |
$120.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$138.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$132.23
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Cash Price |
$147.30
|
| Rate for Payer: Coventry All Commercial |
$144.25
|
| Rate for Payer: Frontpath All Commercial |
$142.31
|
| Rate for Payer: Humana ChoiceCare |
$224.84
|
| Rate for Payer: Humana Medicare |
$120.21
|
| Rate for Payer: Lucent All Commercial |
$204.36
|
| Rate for Payer: PHCS All Commercial |
$178.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$120.21
|
| Rate for Payer: United Healthcare Commercial |
$169.15
|
| Rate for Payer: United Healthcare Medicare |
$120.21
|
|
|
CHEMO IV INFUSION ADDL HR
|
Professional
|
Both
|
$51.36
|
|
|
Service Code
|
CPT 96415
|
| Hospital Charge Code |
z96415
|
| Min. Negotiated Rate |
$26.21 |
| Max. Negotiated Rate |
$50.11 |
| Rate for Payer: Aetna Medicare |
$26.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$28.83
|
| Rate for Payer: Cash Price |
$31.84
|
| Rate for Payer: Cash Price |
$31.84
|
| Rate for Payer: Coventry All Commercial |
$31.45
|
| Rate for Payer: Frontpath All Commercial |
$30.66
|
| Rate for Payer: Humana ChoiceCare |
$50.11
|
| Rate for Payer: Humana Medicare |
$26.21
|
| Rate for Payer: Lucent All Commercial |
$44.56
|
| Rate for Payer: PHCS All Commercial |
$38.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$26.21
|
| Rate for Payer: United Healthcare Commercial |
$38.19
|
| Rate for Payer: United Healthcare Medicare |
$26.21
|
|
|
CHG 3D RENDERING W/INTERP & POSTPROCESS SUPERVISION
|
Professional
|
Both
|
$26.22
|
|
|
Service Code
|
CPT 76376
|
| Hospital Charge Code |
z76376
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$163.04 |
| Rate for Payer: Aetna Medicare |
$22.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.78
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Cash Price |
$16.26
|
| Rate for Payer: Coventry All Commercial |
$27.04
|
| Rate for Payer: Frontpath All Commercial |
$37.76
|
| Rate for Payer: Humana ChoiceCare |
$163.04
|
| Rate for Payer: Humana Medicare |
$22.53
|
| Rate for Payer: Lucent All Commercial |
$38.30
|
| Rate for Payer: PHCS All Commercial |
$19.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.53
|
| Rate for Payer: United Healthcare Commercial |
$69.29
|
| Rate for Payer: United Healthcare Medicare |
$22.53
|
|
|
CHG ASSAY OF ALCOHOL (ETHANOL) BREATH
|
Professional
|
Both
|
$60.00
|
|
|
Service Code
|
CPT 82075
|
| Hospital Charge Code |
z82075
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Cash Price |
$37.20
|
| Rate for Payer: Frontpath All Commercial |
$30.00
|
| Rate for Payer: PHCS All Commercial |
$45.00
|
| Rate for Payer: PHP All Commercial |
$26.40
|
| Rate for Payer: Signature Care EPO |
$15.30
|
| Rate for Payer: Signature Care PPO |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$10.56
|
|
|
CHG ASSAY OF LEAD
|
Professional
|
Both
|
$24.22
|
|
|
Service Code
|
CPT 83655
|
| Hospital Charge Code |
z83655
|
| Min. Negotiated Rate |
$10.60 |
| Max. Negotiated Rate |
$18.16 |
| Rate for Payer: Cash Price |
$15.02
|
| Rate for Payer: Cash Price |
$15.02
|
| Rate for Payer: Frontpath All Commercial |
$12.11
|
| Rate for Payer: PHCS All Commercial |
$18.16
|
| Rate for Payer: PHP All Commercial |
$10.66
|
| Rate for Payer: United Healthcare Commercial |
$10.60
|
|
|
CHG BILIRUBIN TOTAL TRANSCUTANEOUS
|
Professional
|
Both
|
$10.04
|
|
|
Service Code
|
CPT 88720
|
| Hospital Charge Code |
z88720
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$8.53 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.82
|
| Rate for Payer: Cash Price |
$6.22
|
| Rate for Payer: Cash Price |
$6.22
|
| Rate for Payer: Frontpath All Commercial |
$5.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.00
|
| Rate for Payer: PHCS All Commercial |
$7.53
|
| Rate for Payer: PHP All Commercial |
$4.42
|
| Rate for Payer: Signature Care EPO |
$8.53
|
| Rate for Payer: Signature Care PPO |
$8.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.00
|
| Rate for Payer: United Healthcare Commercial |
$7.33
|
|
|
CHG BLOOD,OCCULT,FECAL HGB,FECES,1-3 SIMULT
|
Professional
|
Both
|
$31.84
|
|
|
Service Code
|
CPT 82274
|
| Hospital Charge Code |
z82274
|
| Min. Negotiated Rate |
$14.01 |
| Max. Negotiated Rate |
$23.88 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$21.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.65
|
| Rate for Payer: Cash Price |
$19.74
|
| Rate for Payer: Cash Price |
$19.74
|
| Rate for Payer: Frontpath All Commercial |
$15.92
|
| Rate for Payer: Humana ChoiceCare |
$15.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.00
|
| Rate for Payer: PHCS All Commercial |
$23.88
|
| Rate for Payer: PHP All Commercial |
$14.01
|
| Rate for Payer: Signature Care EPO |
$18.40
|
| Rate for Payer: Signature Care PPO |
$18.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.00
|
| Rate for Payer: United Healthcare Commercial |
$23.22
|
|
|
CHG CYTOPAT,CER/VAG,THIN LAYER,MAN RES,INTER
|
Professional
|
Both
|
$53.22
|
|
|
Service Code
|
CPT 88175
|
| Hospital Charge Code |
z88175
|
| Min. Negotiated Rate |
$15.01 |
| Max. Negotiated Rate |
$45.24 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.01
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Cash Price |
$33.00
|
| Rate for Payer: Frontpath All Commercial |
$26.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$37.00
|
| Rate for Payer: PHCS All Commercial |
$39.92
|
| Rate for Payer: PHP All Commercial |
$23.42
|
| Rate for Payer: Signature Care EPO |
$45.24
|
| Rate for Payer: Signature Care PPO |
$45.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.00
|
| Rate for Payer: United Healthcare Commercial |
$37.49
|
|
|
CHG DETECT AGENT, MULT ORGS, DNA, AMP
|
Professional
|
Both
|
$140.40
|
|
|
Service Code
|
CPT 87801
|
| Hospital Charge Code |
z87801
|
| Min. Negotiated Rate |
$33.20 |
| Max. Negotiated Rate |
$105.30 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$33.20
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.20
|
| Rate for Payer: Cash Price |
$87.05
|
| Rate for Payer: Cash Price |
$87.05
|
| Rate for Payer: Frontpath All Commercial |
$70.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$98.00
|
| Rate for Payer: PHCS All Commercial |
$105.30
|
| Rate for Payer: PHP All Commercial |
$61.78
|
| Rate for Payer: Signature Care EPO |
$91.80
|
| Rate for Payer: Signature Care PPO |
$91.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$91.00
|
| Rate for Payer: United Healthcare Commercial |
$61.49
|
|
|
CHG DOPPLER FETAL UMBILICAL ARTERY
|
Professional
|
Both
|
$83.08
|
|
|
Service Code
|
CPT 76820
|
| Hospital Charge Code |
z76820
|
| Min. Negotiated Rate |
$42.58 |
| Max. Negotiated Rate |
$79.86 |
| Rate for Payer: Aetna Medicare |
$42.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$79.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$79.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$48.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$46.84
|
| Rate for Payer: Cash Price |
$51.51
|
| Rate for Payer: Cash Price |
$51.51
|
| Rate for Payer: Coventry All Commercial |
$51.10
|
| Rate for Payer: Frontpath All Commercial |
$75.40
|
| Rate for Payer: Humana ChoiceCare |
$48.87
|
| Rate for Payer: Humana Medicare |
$42.58
|
| Rate for Payer: Lucent All Commercial |
$72.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.00
|
| Rate for Payer: PHCS All Commercial |
$62.31
|
| Rate for Payer: PHP All Commercial |
$54.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.58
|
| Rate for Payer: Signature Care EPO |
$73.66
|
| Rate for Payer: Signature Care PPO |
$73.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$62.00
|
| Rate for Payer: United Healthcare Commercial |
$50.08
|
| Rate for Payer: United Healthcare Medicare |
$42.58
|
|
|
CHG DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE
|
Professional
|
Both
|
$25.20
|
|
|
Service Code
|
CPT 80305
|
| Hospital Charge Code |
z80305
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$18.90 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.94
|
| Rate for Payer: Cash Price |
$15.62
|
| Rate for Payer: Cash Price |
$15.62
|
| Rate for Payer: Frontpath All Commercial |
$12.60
|
| Rate for Payer: Humana ChoiceCare |
$12.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.00
|
| Rate for Payer: PHCS All Commercial |
$18.90
|
| Rate for Payer: PHP All Commercial |
$11.09
|
| Rate for Payer: Signature Care EPO |
$16.92
|
| Rate for Payer: Signature Care PPO |
$16.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.00
|
| Rate for Payer: United Healthcare Commercial |
$8.98
|
|
|
CHG FETAL BIOPHYSICAL PROFILE
|
Professional
|
Both
|
$215.28
|
|
|
Service Code
|
CPT 76818
|
| Hospital Charge Code |
z76818
|
| Min. Negotiated Rate |
$110.19 |
| Max. Negotiated Rate |
$189.70 |
| Rate for Payer: Aetna Medicare |
$110.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$110.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$110.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$126.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$121.36
|
| Rate for Payer: Cash Price |
$133.47
|
| Rate for Payer: Cash Price |
$133.47
|
| Rate for Payer: Coventry All Commercial |
$132.40
|
| Rate for Payer: Frontpath All Commercial |
$189.70
|
| Rate for Payer: Humana ChoiceCare |
$122.91
|
| Rate for Payer: Humana Medicare |
$110.33
|
| Rate for Payer: Lucent All Commercial |
$187.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$171.00
|
| Rate for Payer: PHCS All Commercial |
$161.46
|
| Rate for Payer: PHP All Commercial |
$139.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$110.33
|
| Rate for Payer: Signature Care EPO |
$141.10
|
| Rate for Payer: Signature Care PPO |
$141.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$160.00
|
| Rate for Payer: United Healthcare Commercial |
$111.96
|
| Rate for Payer: United Healthcare Medicare |
$110.33
|
|
|
CHG FETAL BIOPHYS PROF,W/O NST
|
Professional
|
Both
|
$155.46
|
|
|
Service Code
|
CPT 76819
|
| Hospital Charge Code |
z76819
|
| Min. Negotiated Rate |
$79.67 |
| Max. Negotiated Rate |
$138.75 |
| Rate for Payer: Aetna Medicare |
$79.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$95.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$95.96
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$91.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$87.64
|
| Rate for Payer: Cash Price |
$96.39
|
| Rate for Payer: Cash Price |
$96.39
|
| Rate for Payer: Coventry All Commercial |
$95.60
|
| Rate for Payer: Frontpath All Commercial |
$138.75
|
| Rate for Payer: Humana ChoiceCare |
$90.93
|
| Rate for Payer: Humana Medicare |
$79.67
|
| Rate for Payer: Lucent All Commercial |
$135.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.00
|
| Rate for Payer: PHCS All Commercial |
$116.60
|
| Rate for Payer: PHP All Commercial |
$101.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$79.67
|
| Rate for Payer: Signature Care EPO |
$122.40
|
| Rate for Payer: Signature Care PPO |
$122.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$116.00
|
| Rate for Payer: United Healthcare Commercial |
$86.53
|
| Rate for Payer: United Healthcare Medicare |
$79.67
|
|
|
CHG FLUOROSCOPY UP TO 1 HOUR PHYSICIAN/QHP TIME
|
Professional
|
Both
|
$78.64
|
|
|
Service Code
|
CPT 76000
|
| Hospital Charge Code |
z76000
|
| Min. Negotiated Rate |
$40.30 |
| Max. Negotiated Rate |
$86.99 |
| Rate for Payer: Aetna Medicare |
$40.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$46.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$44.33
|
| Rate for Payer: Cash Price |
$48.76
|
| Rate for Payer: Cash Price |
$48.76
|
| Rate for Payer: Coventry All Commercial |
$48.36
|
| Rate for Payer: Frontpath All Commercial |
$70.82
|
| Rate for Payer: Humana ChoiceCare |
$44.93
|
| Rate for Payer: Humana Medicare |
$40.30
|
| Rate for Payer: Lucent All Commercial |
$68.51
|
| Rate for Payer: PHCS All Commercial |
$58.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.30
|
| Rate for Payer: United Healthcare Commercial |
$86.99
|
| Rate for Payer: United Healthcare Medicare |
$40.30
|
|
|
CHG GLUCOSE BLOOD TEST
|
Professional
|
Both
|
$6.56
|
|
|
Service Code
|
CPT 82962
|
| Hospital Charge Code |
z82962
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$5.00 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.97
|
| Rate for Payer: Cash Price |
$4.07
|
| Rate for Payer: Cash Price |
$4.07
|
| Rate for Payer: Frontpath All Commercial |
$3.28
|
| Rate for Payer: Humana ChoiceCare |
$3.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.00
|
| Rate for Payer: PHCS All Commercial |
$4.92
|
| Rate for Payer: PHP All Commercial |
$2.89
|
| Rate for Payer: Signature Care EPO |
$3.40
|
| Rate for Payer: Signature Care PPO |
$3.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.00
|
| Rate for Payer: United Healthcare Commercial |
$3.42
|
|
|
CHG GLYCOSYLATED HEMOGLOBIN, HOME DEVICE
|
Professional
|
Both
|
$19.42
|
|
|
Service Code
|
CPT 83037
|
| Hospital Charge Code |
z83037
|
| Min. Negotiated Rate |
$6.98 |
| Max. Negotiated Rate |
$16.51 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$6.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6.98
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Frontpath All Commercial |
$9.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.00
|
| Rate for Payer: PHCS All Commercial |
$14.56
|
| Rate for Payer: PHP All Commercial |
$8.54
|
| Rate for Payer: Signature Care EPO |
$16.51
|
| Rate for Payer: Signature Care PPO |
$16.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.00
|
| Rate for Payer: United Healthcare Commercial |
$14.17
|
|
