|
HC DIPHTHERIA IGG AB
|
Facility
|
IP
|
$420.55
|
|
|
Service Code
|
CPT 86317
|
| Hospital Charge Code |
63001035
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$315.41 |
| Max. Negotiated Rate |
$391.11 |
| Rate for Payer: Aetna Commercial |
$363.36
|
| Rate for Payer: Cash Price |
$252.33
|
| Rate for Payer: Cigna All Commercial |
$362.93
|
| Rate for Payer: CORVEL All Commercial |
$391.11
|
| Rate for Payer: Coventry All Commercial |
$370.08
|
| Rate for Payer: Encore All Commercial |
$387.12
|
| Rate for Payer: Frontpath All Commercial |
$386.91
|
| Rate for Payer: Humana ChoiceCare |
$363.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$378.50
|
| Rate for Payer: PHCS All Commercial |
$315.41
|
| Rate for Payer: PHP All Commercial |
$318.95
|
| Rate for Payer: Sagamore Health Network All Products |
$324.66
|
| Rate for Payer: Signature Care EPO |
$349.06
|
| Rate for Payer: Signature Care PPO |
$370.08
|
| Rate for Payer: United Healthcare Commercial |
$331.39
|
|
|
HC DIRECT ANTIGLOBULIN TEST
|
Facility
|
IP
|
$99.31
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
63001983
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$74.48 |
| Max. Negotiated Rate |
$92.36 |
| Rate for Payer: Aetna Commercial |
$85.80
|
| Rate for Payer: Cash Price |
$59.59
|
| Rate for Payer: Cigna All Commercial |
$85.70
|
| Rate for Payer: CORVEL All Commercial |
$92.36
|
| Rate for Payer: Coventry All Commercial |
$87.39
|
| Rate for Payer: Encore All Commercial |
$91.41
|
| Rate for Payer: Frontpath All Commercial |
$91.37
|
| Rate for Payer: Humana ChoiceCare |
$85.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89.38
|
| Rate for Payer: PHCS All Commercial |
$74.48
|
| Rate for Payer: PHP All Commercial |
$75.32
|
| Rate for Payer: Sagamore Health Network All Products |
$76.67
|
| Rate for Payer: Signature Care EPO |
$82.43
|
| Rate for Payer: Signature Care PPO |
$87.39
|
| Rate for Payer: United Healthcare Commercial |
$78.26
|
|
|
HC DIRECT ANTIGLOBULIN TEST
|
Facility
|
OP
|
$99.31
|
|
|
Service Code
|
CPT 86880
|
| Hospital Charge Code |
63001983
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.39 |
| Max. Negotiated Rate |
$92.36 |
| Rate for Payer: Aetna Commercial |
$83.82
|
| Rate for Payer: Aetna Medicare |
$31.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$5.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$30.79
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$45.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$45.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$5.39
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$34.96
|
| Rate for Payer: Cash Price |
$59.59
|
| Rate for Payer: Cash Price |
$59.59
|
| Rate for Payer: Centivo All Commercial |
$54.02
|
| Rate for Payer: Cigna All Commercial |
$85.70
|
| Rate for Payer: CORVEL All Commercial |
$92.36
|
| Rate for Payer: Coventry All Commercial |
$87.39
|
| Rate for Payer: Encore All Commercial |
$91.41
|
| Rate for Payer: Frontpath All Commercial |
$91.37
|
| Rate for Payer: Humana ChoiceCare |
$85.77
|
| Rate for Payer: Humana Medicare |
$31.78
|
| Rate for Payer: Lucent All Commercial |
$54.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89.38
|
| Rate for Payer: Managed Health Services Medicaid |
$5.39
|
| Rate for Payer: MDWise Medicaid |
$5.39
|
| Rate for Payer: PHCS All Commercial |
$74.48
|
| Rate for Payer: PHP All Commercial |
$75.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$38.73
|
| Rate for Payer: Sagamore Health Network All Products |
$76.67
|
| Rate for Payer: Signature Care EPO |
$82.43
|
| Rate for Payer: Signature Care PPO |
$87.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$84.41
|
| Rate for Payer: United Healthcare Commercial |
$78.26
|
| Rate for Payer: United Healthcare Medicare |
$31.78
|
|
|
HC DISCOVER JAGWIRE
|
Facility
|
IP
|
$901.25
|
|
| Hospital Charge Code |
41608364
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$675.94 |
| Max. Negotiated Rate |
$838.16 |
| Rate for Payer: Aetna Commercial |
$778.68
|
| Rate for Payer: Cash Price |
$540.75
|
| Rate for Payer: Cigna All Commercial |
$777.78
|
| Rate for Payer: CORVEL All Commercial |
$838.16
|
| Rate for Payer: Coventry All Commercial |
$793.10
|
| Rate for Payer: Encore All Commercial |
$829.60
|
| Rate for Payer: Frontpath All Commercial |
$829.15
|
| Rate for Payer: Humana ChoiceCare |
$778.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$811.12
|
| Rate for Payer: PHCS All Commercial |
$675.94
|
| Rate for Payer: PHP All Commercial |
$683.51
|
| Rate for Payer: Sagamore Health Network All Products |
$695.76
|
| Rate for Payer: Signature Care EPO |
$748.04
|
| Rate for Payer: Signature Care PPO |
$793.10
|
| Rate for Payer: United Healthcare Commercial |
$710.18
|
|
|
HC DISCOVER JAGWIRE
|
Facility
|
OP
|
$901.25
|
|
| Hospital Charge Code |
41608364
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$838.16 |
| Rate for Payer: Aetna Commercial |
$760.65
|
| Rate for Payer: Aetna Medicare |
$288.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$279.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$517.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$563.37
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$331.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$317.24
|
| Rate for Payer: Cash Price |
$540.75
|
| Rate for Payer: Cash Price |
$540.75
|
| Rate for Payer: Centivo All Commercial |
$490.28
|
| Rate for Payer: Cigna All Commercial |
$777.78
|
| Rate for Payer: CORVEL All Commercial |
$838.16
|
| Rate for Payer: Coventry All Commercial |
$793.10
|
| Rate for Payer: Encore All Commercial |
$829.60
|
| Rate for Payer: Frontpath All Commercial |
$829.15
|
| Rate for Payer: Humana ChoiceCare |
$778.41
|
| Rate for Payer: Humana Medicare |
$288.40
|
| Rate for Payer: Lucent All Commercial |
$490.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$811.12
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$675.94
|
| Rate for Payer: PHP All Commercial |
$683.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$351.49
|
| Rate for Payer: Sagamore Health Network All Products |
$695.76
|
| Rate for Payer: Signature Care EPO |
$748.04
|
| Rate for Payer: Signature Care PPO |
$793.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$766.06
|
| Rate for Payer: United Healthcare Commercial |
$710.18
|
| Rate for Payer: United Healthcare Medicare |
$288.40
|
|
|
HC DNA ANTIBODY TITER
|
Facility
|
OP
|
$194.36
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
63001894
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$180.75 |
| Rate for Payer: Aetna Commercial |
$164.04
|
| Rate for Payer: Aetna Medicare |
$62.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$12.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$60.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$89.33
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.33
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$12.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$71.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$68.41
|
| Rate for Payer: Cash Price |
$116.62
|
| Rate for Payer: Cash Price |
$116.62
|
| Rate for Payer: Centivo All Commercial |
$105.73
|
| Rate for Payer: Cigna All Commercial |
$167.73
|
| Rate for Payer: CORVEL All Commercial |
$180.75
|
| Rate for Payer: Coventry All Commercial |
$171.04
|
| Rate for Payer: Encore All Commercial |
$178.91
|
| Rate for Payer: Frontpath All Commercial |
$178.81
|
| Rate for Payer: Humana ChoiceCare |
$167.87
|
| Rate for Payer: Humana Medicare |
$62.20
|
| Rate for Payer: Lucent All Commercial |
$105.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$174.92
|
| Rate for Payer: Managed Health Services Medicaid |
$12.05
|
| Rate for Payer: MDWise Medicaid |
$12.05
|
| Rate for Payer: PHCS All Commercial |
$145.77
|
| Rate for Payer: PHP All Commercial |
$147.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$75.80
|
| Rate for Payer: Sagamore Health Network All Products |
$150.05
|
| Rate for Payer: Signature Care EPO |
$161.32
|
| Rate for Payer: Signature Care PPO |
$171.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$165.21
|
| Rate for Payer: United Healthcare Commercial |
$153.16
|
| Rate for Payer: United Healthcare Medicare |
$62.20
|
|
|
HC DNA ANTIBODY TITER
|
Facility
|
IP
|
$194.36
|
|
|
Service Code
|
CPT 86256
|
| Hospital Charge Code |
63001894
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$145.77 |
| Max. Negotiated Rate |
$180.75 |
| Rate for Payer: Aetna Commercial |
$167.93
|
| Rate for Payer: Cash Price |
$116.62
|
| Rate for Payer: Cigna All Commercial |
$167.73
|
| Rate for Payer: CORVEL All Commercial |
$180.75
|
| Rate for Payer: Coventry All Commercial |
$171.04
|
| Rate for Payer: Encore All Commercial |
$178.91
|
| Rate for Payer: Frontpath All Commercial |
$178.81
|
| Rate for Payer: Humana ChoiceCare |
$167.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$174.92
|
| Rate for Payer: PHCS All Commercial |
$145.77
|
| Rate for Payer: PHP All Commercial |
$147.40
|
| Rate for Payer: Sagamore Health Network All Products |
$150.05
|
| Rate for Payer: Signature Care EPO |
$161.32
|
| Rate for Payer: Signature Care PPO |
$171.04
|
| Rate for Payer: United Healthcare Commercial |
$153.16
|
|
|
HC DNA BLOOD DRAW
|
Facility
|
IP
|
$72.96
|
|
| Hospital Charge Code |
63002211
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$54.72 |
| Max. Negotiated Rate |
$67.85 |
| Rate for Payer: Aetna Commercial |
$63.04
|
| Rate for Payer: Cash Price |
$43.78
|
| Rate for Payer: Cigna All Commercial |
$62.96
|
| Rate for Payer: CORVEL All Commercial |
$67.85
|
| Rate for Payer: Coventry All Commercial |
$64.20
|
| Rate for Payer: Encore All Commercial |
$67.16
|
| Rate for Payer: Frontpath All Commercial |
$67.12
|
| Rate for Payer: Humana ChoiceCare |
$63.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.66
|
| Rate for Payer: PHCS All Commercial |
$54.72
|
| Rate for Payer: PHP All Commercial |
$55.33
|
| Rate for Payer: Sagamore Health Network All Products |
$56.33
|
| Rate for Payer: Signature Care EPO |
$60.56
|
| Rate for Payer: Signature Care PPO |
$64.20
|
| Rate for Payer: United Healthcare Commercial |
$57.49
|
|
|
HC DNA BLOOD DRAW
|
Facility
|
OP
|
$72.96
|
|
| Hospital Charge Code |
63002211
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$67.85 |
| Rate for Payer: Aetna Commercial |
$61.58
|
| Rate for Payer: Aetna Medicare |
$23.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$22.62
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$33.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$33.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$26.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$25.68
|
| Rate for Payer: Cash Price |
$43.78
|
| Rate for Payer: Centivo All Commercial |
$39.69
|
| Rate for Payer: Cigna All Commercial |
$62.96
|
| Rate for Payer: CORVEL All Commercial |
$67.85
|
| Rate for Payer: Coventry All Commercial |
$64.20
|
| Rate for Payer: Encore All Commercial |
$67.16
|
| Rate for Payer: Frontpath All Commercial |
$67.12
|
| Rate for Payer: Humana ChoiceCare |
$63.02
|
| Rate for Payer: Humana Medicare |
$23.35
|
| Rate for Payer: Lucent All Commercial |
$39.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$65.66
|
| Rate for Payer: PHCS All Commercial |
$54.72
|
| Rate for Payer: PHP All Commercial |
$55.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$28.45
|
| Rate for Payer: Sagamore Health Network All Products |
$56.33
|
| Rate for Payer: Signature Care EPO |
$60.56
|
| Rate for Payer: Signature Care PPO |
$64.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$62.02
|
| Rate for Payer: United Healthcare Commercial |
$57.49
|
| Rate for Payer: United Healthcare Medicare |
$23.35
|
|
|
HC DNA DOUBLE STRANDED AB EIA
|
Facility
|
IP
|
$57.22
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
63001873
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$42.91 |
| Max. Negotiated Rate |
$53.21 |
| Rate for Payer: Aetna Commercial |
$49.44
|
| Rate for Payer: Cash Price |
$34.33
|
| Rate for Payer: Cigna All Commercial |
$49.38
|
| Rate for Payer: CORVEL All Commercial |
$53.21
|
| Rate for Payer: Coventry All Commercial |
$50.35
|
| Rate for Payer: Encore All Commercial |
$52.67
|
| Rate for Payer: Frontpath All Commercial |
$52.64
|
| Rate for Payer: Humana ChoiceCare |
$49.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.50
|
| Rate for Payer: PHCS All Commercial |
$42.91
|
| Rate for Payer: PHP All Commercial |
$43.40
|
| Rate for Payer: Sagamore Health Network All Products |
$44.17
|
| Rate for Payer: Signature Care EPO |
$47.49
|
| Rate for Payer: Signature Care PPO |
$50.35
|
| Rate for Payer: United Healthcare Commercial |
$45.09
|
|
|
HC DNA DOUBLE STRANDED AB EIA
|
Facility
|
OP
|
$57.22
|
|
|
Service Code
|
CPT 86225
|
| Hospital Charge Code |
63001873
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$13.74 |
| Max. Negotiated Rate |
$53.21 |
| Rate for Payer: Aetna Commercial |
$48.29
|
| Rate for Payer: Aetna Medicare |
$18.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$13.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$17.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$26.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$26.30
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$13.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$21.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$20.14
|
| Rate for Payer: Cash Price |
$34.33
|
| Rate for Payer: Cash Price |
$34.33
|
| Rate for Payer: Centivo All Commercial |
$31.13
|
| Rate for Payer: Cigna All Commercial |
$49.38
|
| Rate for Payer: CORVEL All Commercial |
$53.21
|
| Rate for Payer: Coventry All Commercial |
$50.35
|
| Rate for Payer: Encore All Commercial |
$52.67
|
| Rate for Payer: Frontpath All Commercial |
$52.64
|
| Rate for Payer: Humana ChoiceCare |
$49.42
|
| Rate for Payer: Humana Medicare |
$18.31
|
| Rate for Payer: Lucent All Commercial |
$31.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$51.50
|
| Rate for Payer: Managed Health Services Medicaid |
$13.74
|
| Rate for Payer: MDWise Medicaid |
$13.74
|
| Rate for Payer: PHCS All Commercial |
$42.91
|
| Rate for Payer: PHP All Commercial |
$43.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$22.32
|
| Rate for Payer: Sagamore Health Network All Products |
$44.17
|
| Rate for Payer: Signature Care EPO |
$47.49
|
| Rate for Payer: Signature Care PPO |
$50.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$48.64
|
| Rate for Payer: United Healthcare Commercial |
$45.09
|
| Rate for Payer: United Healthcare Medicare |
$18.31
|
|
|
HC DOSIMETRY-BASIC
|
Facility
|
OP
|
$772.26
|
|
|
Service Code
|
CPT 77300
|
| Hospital Charge Code |
1547300
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$24.19 |
| Max. Negotiated Rate |
$718.20 |
| Rate for Payer: Aetna Commercial |
$651.79
|
| Rate for Payer: Aetna Medicare |
$247.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$24.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$239.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$443.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$482.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$24.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$284.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$271.84
|
| Rate for Payer: Cash Price |
$463.36
|
| Rate for Payer: Cash Price |
$463.36
|
| Rate for Payer: Centivo All Commercial |
$420.11
|
| Rate for Payer: Cigna All Commercial |
$666.46
|
| Rate for Payer: CORVEL All Commercial |
$718.20
|
| Rate for Payer: Coventry All Commercial |
$679.59
|
| Rate for Payer: Encore All Commercial |
$710.87
|
| Rate for Payer: Frontpath All Commercial |
$710.48
|
| Rate for Payer: Humana ChoiceCare |
$667.00
|
| Rate for Payer: Humana Medicare |
$247.12
|
| Rate for Payer: Lucent All Commercial |
$420.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$695.03
|
| Rate for Payer: Managed Health Services Medicaid |
$24.19
|
| Rate for Payer: MDWise Medicaid |
$24.19
|
| Rate for Payer: PHCS All Commercial |
$579.20
|
| Rate for Payer: PHP All Commercial |
$585.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$301.18
|
| Rate for Payer: Sagamore Health Network All Products |
$596.18
|
| Rate for Payer: Signature Care EPO |
$640.98
|
| Rate for Payer: Signature Care PPO |
$679.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$656.42
|
| Rate for Payer: United Healthcare Commercial |
$608.54
|
| Rate for Payer: United Healthcare Medicare |
$247.12
|
|
|
HC DOSIMETRY-BASIC
|
Facility
|
IP
|
$772.26
|
|
|
Service Code
|
CPT 77300
|
| Hospital Charge Code |
1547300
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$579.20 |
| Max. Negotiated Rate |
$718.20 |
| Rate for Payer: Aetna Commercial |
$667.23
|
| Rate for Payer: Cash Price |
$463.36
|
| Rate for Payer: Cigna All Commercial |
$666.46
|
| Rate for Payer: CORVEL All Commercial |
$718.20
|
| Rate for Payer: Coventry All Commercial |
$679.59
|
| Rate for Payer: Encore All Commercial |
$710.87
|
| Rate for Payer: Frontpath All Commercial |
$710.48
|
| Rate for Payer: Humana ChoiceCare |
$667.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$695.03
|
| Rate for Payer: PHCS All Commercial |
$579.20
|
| Rate for Payer: PHP All Commercial |
$585.68
|
| Rate for Payer: Sagamore Health Network All Products |
$596.18
|
| Rate for Payer: Signature Care EPO |
$640.98
|
| Rate for Payer: Signature Care PPO |
$679.59
|
| Rate for Payer: United Healthcare Commercial |
$608.54
|
|
|
HC DOSIMETRY-BASIC 11+
|
Facility
|
IP
|
$772.26
|
|
|
Service Code
|
CPT 77300 59
|
| Hospital Charge Code |
1548300
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$579.20 |
| Max. Negotiated Rate |
$718.20 |
| Rate for Payer: Aetna Commercial |
$667.23
|
| Rate for Payer: Cash Price |
$463.36
|
| Rate for Payer: Cigna All Commercial |
$666.46
|
| Rate for Payer: CORVEL All Commercial |
$718.20
|
| Rate for Payer: Coventry All Commercial |
$679.59
|
| Rate for Payer: Encore All Commercial |
$710.87
|
| Rate for Payer: Frontpath All Commercial |
$710.48
|
| Rate for Payer: Humana ChoiceCare |
$667.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$695.03
|
| Rate for Payer: PHCS All Commercial |
$579.20
|
| Rate for Payer: PHP All Commercial |
$585.68
|
| Rate for Payer: Sagamore Health Network All Products |
$596.18
|
| Rate for Payer: Signature Care EPO |
$640.98
|
| Rate for Payer: Signature Care PPO |
$679.59
|
| Rate for Payer: United Healthcare Commercial |
$608.54
|
|
|
HC DOSIMETRY-BASIC 11+
|
Facility
|
OP
|
$772.26
|
|
|
Service Code
|
CPT 77300 59
|
| Hospital Charge Code |
1548300
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$24.19 |
| Max. Negotiated Rate |
$718.20 |
| Rate for Payer: Aetna Commercial |
$651.79
|
| Rate for Payer: Aetna Medicare |
$247.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$24.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$239.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$443.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$482.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$24.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$284.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$271.84
|
| Rate for Payer: Cash Price |
$463.36
|
| Rate for Payer: Cash Price |
$463.36
|
| Rate for Payer: Centivo All Commercial |
$420.11
|
| Rate for Payer: Cigna All Commercial |
$666.46
|
| Rate for Payer: CORVEL All Commercial |
$718.20
|
| Rate for Payer: Coventry All Commercial |
$679.59
|
| Rate for Payer: Encore All Commercial |
$710.87
|
| Rate for Payer: Frontpath All Commercial |
$710.48
|
| Rate for Payer: Humana ChoiceCare |
$667.00
|
| Rate for Payer: Humana Medicare |
$247.12
|
| Rate for Payer: Lucent All Commercial |
$420.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$695.03
|
| Rate for Payer: Managed Health Services Medicaid |
$24.19
|
| Rate for Payer: MDWise Medicaid |
$24.19
|
| Rate for Payer: PHCS All Commercial |
$579.20
|
| Rate for Payer: PHP All Commercial |
$585.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$301.18
|
| Rate for Payer: Sagamore Health Network All Products |
$596.18
|
| Rate for Payer: Signature Care EPO |
$640.98
|
| Rate for Payer: Signature Care PPO |
$679.59
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$656.42
|
| Rate for Payer: United Healthcare Commercial |
$608.54
|
| Rate for Payer: United Healthcare Medicare |
$247.12
|
|
|
HC DOSIMETRY-SPECIAL
|
Facility
|
IP
|
$901.68
|
|
|
Service Code
|
CPT 77331
|
| Hospital Charge Code |
1547331
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$676.26 |
| Max. Negotiated Rate |
$838.56 |
| Rate for Payer: Aetna Commercial |
$779.05
|
| Rate for Payer: Cash Price |
$541.01
|
| Rate for Payer: Cigna All Commercial |
$778.15
|
| Rate for Payer: CORVEL All Commercial |
$838.56
|
| Rate for Payer: Coventry All Commercial |
$793.48
|
| Rate for Payer: Encore All Commercial |
$830.00
|
| Rate for Payer: Frontpath All Commercial |
$829.55
|
| Rate for Payer: Humana ChoiceCare |
$778.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$811.51
|
| Rate for Payer: PHCS All Commercial |
$676.26
|
| Rate for Payer: PHP All Commercial |
$683.83
|
| Rate for Payer: Sagamore Health Network All Products |
$696.10
|
| Rate for Payer: Signature Care EPO |
$748.39
|
| Rate for Payer: Signature Care PPO |
$793.48
|
| Rate for Payer: United Healthcare Commercial |
$710.52
|
|
|
HC DOSIMETRY-SPECIAL
|
Facility
|
OP
|
$901.68
|
|
|
Service Code
|
CPT 77331
|
| Hospital Charge Code |
1547331
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$12.80 |
| Max. Negotiated Rate |
$838.56 |
| Rate for Payer: Aetna Commercial |
$761.02
|
| Rate for Payer: Aetna Medicare |
$288.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$12.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$279.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$517.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$563.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$12.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$331.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$317.39
|
| Rate for Payer: Cash Price |
$541.01
|
| Rate for Payer: Cash Price |
$541.01
|
| Rate for Payer: Centivo All Commercial |
$490.51
|
| Rate for Payer: Cigna All Commercial |
$778.15
|
| Rate for Payer: CORVEL All Commercial |
$838.56
|
| Rate for Payer: Coventry All Commercial |
$793.48
|
| Rate for Payer: Encore All Commercial |
$830.00
|
| Rate for Payer: Frontpath All Commercial |
$829.55
|
| Rate for Payer: Humana ChoiceCare |
$778.78
|
| Rate for Payer: Humana Medicare |
$288.54
|
| Rate for Payer: Lucent All Commercial |
$490.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$811.51
|
| Rate for Payer: Managed Health Services Medicaid |
$12.80
|
| Rate for Payer: MDWise Medicaid |
$12.80
|
| Rate for Payer: PHCS All Commercial |
$676.26
|
| Rate for Payer: PHP All Commercial |
$683.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$351.66
|
| Rate for Payer: Sagamore Health Network All Products |
$696.10
|
| Rate for Payer: Signature Care EPO |
$748.39
|
| Rate for Payer: Signature Care PPO |
$793.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$766.43
|
| Rate for Payer: United Healthcare Commercial |
$710.52
|
| Rate for Payer: United Healthcare Medicare |
$288.54
|
|
|
HC DRAINABLE POUCH
|
Facility
|
OP
|
$1.74
|
|
| Hospital Charge Code |
41601409
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.54 |
| Max. Negotiated Rate |
$21.01 |
| Rate for Payer: Aetna Commercial |
$1.47
|
| Rate for Payer: Aetna Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$21.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.09
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.61
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Centivo All Commercial |
$0.95
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.62
|
| Rate for Payer: Coventry All Commercial |
$1.53
|
| Rate for Payer: Encore All Commercial |
$1.60
|
| Rate for Payer: Frontpath All Commercial |
$1.60
|
| Rate for Payer: Humana ChoiceCare |
$1.50
|
| Rate for Payer: Humana Medicare |
$0.56
|
| Rate for Payer: Lucent All Commercial |
$0.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.57
|
| Rate for Payer: Managed Health Services Medicaid |
$21.01
|
| Rate for Payer: MDWise Medicaid |
$21.01
|
| Rate for Payer: PHCS All Commercial |
$1.30
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.68
|
| Rate for Payer: Sagamore Health Network All Products |
$1.34
|
| Rate for Payer: Signature Care EPO |
$1.44
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
| Rate for Payer: United Healthcare Medicare |
$0.56
|
|
|
HC DRAINABLE POUCH
|
Facility
|
IP
|
$1.74
|
|
| Hospital Charge Code |
41601409
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$1.62 |
| Rate for Payer: Aetna Commercial |
$1.50
|
| Rate for Payer: Cash Price |
$1.04
|
| Rate for Payer: Cigna All Commercial |
$1.50
|
| Rate for Payer: CORVEL All Commercial |
$1.62
|
| Rate for Payer: Coventry All Commercial |
$1.53
|
| Rate for Payer: Encore All Commercial |
$1.60
|
| Rate for Payer: Frontpath All Commercial |
$1.60
|
| Rate for Payer: Humana ChoiceCare |
$1.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.57
|
| Rate for Payer: PHCS All Commercial |
$1.30
|
| Rate for Payer: PHP All Commercial |
$1.32
|
| Rate for Payer: Sagamore Health Network All Products |
$1.34
|
| Rate for Payer: Signature Care EPO |
$1.44
|
| Rate for Payer: Signature Care PPO |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$1.37
|
|
|
HC DRAINABLE POUCH & BAR
|
Facility
|
IP
|
$5.11
|
|
| Hospital Charge Code |
41601441
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$3.83 |
| Max. Negotiated Rate |
$4.75 |
| Rate for Payer: Aetna Commercial |
$4.42
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Cigna All Commercial |
$4.41
|
| Rate for Payer: CORVEL All Commercial |
$4.75
|
| Rate for Payer: Coventry All Commercial |
$4.50
|
| Rate for Payer: Encore All Commercial |
$4.70
|
| Rate for Payer: Frontpath All Commercial |
$4.70
|
| Rate for Payer: Humana ChoiceCare |
$4.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.60
|
| Rate for Payer: PHCS All Commercial |
$3.83
|
| Rate for Payer: PHP All Commercial |
$3.88
|
| Rate for Payer: Sagamore Health Network All Products |
$3.94
|
| Rate for Payer: Signature Care EPO |
$4.24
|
| Rate for Payer: Signature Care PPO |
$4.50
|
| Rate for Payer: United Healthcare Commercial |
$4.03
|
|
|
HC DRAINABLE POUCH & BAR
|
Facility
|
OP
|
$5.11
|
|
| Hospital Charge Code |
41601441
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$21.01 |
| Rate for Payer: Aetna Commercial |
$4.31
|
| Rate for Payer: Aetna Medicare |
$1.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$21.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.19
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.80
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Cash Price |
$3.07
|
| Rate for Payer: Centivo All Commercial |
$2.78
|
| Rate for Payer: Cigna All Commercial |
$4.41
|
| Rate for Payer: CORVEL All Commercial |
$4.75
|
| Rate for Payer: Coventry All Commercial |
$4.50
|
| Rate for Payer: Encore All Commercial |
$4.70
|
| Rate for Payer: Frontpath All Commercial |
$4.70
|
| Rate for Payer: Humana ChoiceCare |
$4.41
|
| Rate for Payer: Humana Medicare |
$1.64
|
| Rate for Payer: Lucent All Commercial |
$2.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.60
|
| Rate for Payer: Managed Health Services Medicaid |
$21.01
|
| Rate for Payer: MDWise Medicaid |
$21.01
|
| Rate for Payer: PHCS All Commercial |
$3.83
|
| Rate for Payer: PHP All Commercial |
$3.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.99
|
| Rate for Payer: Sagamore Health Network All Products |
$3.94
|
| Rate for Payer: Signature Care EPO |
$4.24
|
| Rate for Payer: Signature Care PPO |
$4.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.34
|
| Rate for Payer: United Healthcare Commercial |
$4.03
|
| Rate for Payer: United Healthcare Medicare |
$1.64
|
|
|
HC DRAIN BLAKE 10FR W/TROCAR
|
Facility
|
IP
|
$506.57
|
|
| Hospital Charge Code |
41601910
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$379.93 |
| Max. Negotiated Rate |
$471.11 |
| Rate for Payer: Aetna Commercial |
$437.68
|
| Rate for Payer: Cash Price |
$303.94
|
| Rate for Payer: Cigna All Commercial |
$437.17
|
| Rate for Payer: CORVEL All Commercial |
$471.11
|
| Rate for Payer: Coventry All Commercial |
$445.78
|
| Rate for Payer: Encore All Commercial |
$466.30
|
| Rate for Payer: Frontpath All Commercial |
$466.04
|
| Rate for Payer: Humana ChoiceCare |
$437.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$455.91
|
| Rate for Payer: PHCS All Commercial |
$379.93
|
| Rate for Payer: PHP All Commercial |
$384.18
|
| Rate for Payer: Sagamore Health Network All Products |
$391.07
|
| Rate for Payer: Signature Care EPO |
$420.45
|
| Rate for Payer: Signature Care PPO |
$445.78
|
| Rate for Payer: United Healthcare Commercial |
$399.18
|
|
|
HC DRAIN BLAKE 10FR W/TROCAR
|
Facility
|
OP
|
$506.57
|
|
| Hospital Charge Code |
41601910
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$471.11 |
| Rate for Payer: Aetna Commercial |
$427.55
|
| Rate for Payer: Aetna Medicare |
$162.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$157.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$290.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$316.66
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$186.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$178.31
|
| Rate for Payer: Cash Price |
$303.94
|
| Rate for Payer: Cash Price |
$303.94
|
| Rate for Payer: Centivo All Commercial |
$275.57
|
| Rate for Payer: Cigna All Commercial |
$437.17
|
| Rate for Payer: CORVEL All Commercial |
$471.11
|
| Rate for Payer: Coventry All Commercial |
$445.78
|
| Rate for Payer: Encore All Commercial |
$466.30
|
| Rate for Payer: Frontpath All Commercial |
$466.04
|
| Rate for Payer: Humana ChoiceCare |
$437.52
|
| Rate for Payer: Humana Medicare |
$162.10
|
| Rate for Payer: Lucent All Commercial |
$275.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$455.91
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$379.93
|
| Rate for Payer: PHP All Commercial |
$384.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$197.56
|
| Rate for Payer: Sagamore Health Network All Products |
$391.07
|
| Rate for Payer: Signature Care EPO |
$420.45
|
| Rate for Payer: Signature Care PPO |
$445.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$430.58
|
| Rate for Payer: United Healthcare Commercial |
$399.18
|
| Rate for Payer: United Healthcare Medicare |
$162.10
|
|
|
HC DRAIN BLAKE 15FR W/TROCAR
|
Facility
|
OP
|
$612.95
|
|
| Hospital Charge Code |
41601199
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$21.01 |
| Max. Negotiated Rate |
$570.04 |
| Rate for Payer: Aetna Commercial |
$517.33
|
| Rate for Payer: Aetna Medicare |
$196.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$21.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$190.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$352.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$383.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$225.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$215.76
|
| Rate for Payer: Cash Price |
$367.77
|
| Rate for Payer: Cash Price |
$367.77
|
| Rate for Payer: Centivo All Commercial |
$333.44
|
| Rate for Payer: Cigna All Commercial |
$528.98
|
| Rate for Payer: CORVEL All Commercial |
$570.04
|
| Rate for Payer: Coventry All Commercial |
$539.40
|
| Rate for Payer: Encore All Commercial |
$564.22
|
| Rate for Payer: Frontpath All Commercial |
$563.91
|
| Rate for Payer: Humana ChoiceCare |
$529.40
|
| Rate for Payer: Humana Medicare |
$196.14
|
| Rate for Payer: Lucent All Commercial |
$333.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$551.65
|
| Rate for Payer: Managed Health Services Medicaid |
$21.01
|
| Rate for Payer: MDWise Medicaid |
$21.01
|
| Rate for Payer: PHCS All Commercial |
$459.71
|
| Rate for Payer: PHP All Commercial |
$464.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$239.05
|
| Rate for Payer: Sagamore Health Network All Products |
$473.20
|
| Rate for Payer: Signature Care EPO |
$508.75
|
| Rate for Payer: Signature Care PPO |
$539.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$521.01
|
| Rate for Payer: United Healthcare Commercial |
$483.00
|
| Rate for Payer: United Healthcare Medicare |
$196.14
|
|
|
HC DRAIN BLAKE 15FR W/TROCAR
|
Facility
|
IP
|
$612.95
|
|
| Hospital Charge Code |
41601199
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$459.71 |
| Max. Negotiated Rate |
$570.04 |
| Rate for Payer: Aetna Commercial |
$529.59
|
| Rate for Payer: Cash Price |
$367.77
|
| Rate for Payer: Cigna All Commercial |
$528.98
|
| Rate for Payer: CORVEL All Commercial |
$570.04
|
| Rate for Payer: Coventry All Commercial |
$539.40
|
| Rate for Payer: Encore All Commercial |
$564.22
|
| Rate for Payer: Frontpath All Commercial |
$563.91
|
| Rate for Payer: Humana ChoiceCare |
$529.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$551.65
|
| Rate for Payer: PHCS All Commercial |
$459.71
|
| Rate for Payer: PHP All Commercial |
$464.86
|
| Rate for Payer: Sagamore Health Network All Products |
$473.20
|
| Rate for Payer: Signature Care EPO |
$508.75
|
| Rate for Payer: Signature Care PPO |
$539.40
|
| Rate for Payer: United Healthcare Commercial |
$483.00
|
|
