|
HC MAMMOGRAM DX INCL CAD BILATERAL
|
Facility
|
OP
|
$381.48
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
1610204
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$83.89 |
| Max. Negotiated Rate |
$354.78 |
| Rate for Payer: Aetna Commercial |
$321.97
|
| Rate for Payer: Aetna Medicare |
$122.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$83.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$118.26
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$100.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$109.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$83.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$140.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$134.28
|
| Rate for Payer: Cash Price |
$228.89
|
| Rate for Payer: Cash Price |
$228.89
|
| Rate for Payer: Centivo All Commercial |
$207.53
|
| Rate for Payer: Cigna All Commercial |
$329.22
|
| Rate for Payer: CORVEL All Commercial |
$354.78
|
| Rate for Payer: Coventry All Commercial |
$335.70
|
| Rate for Payer: Encore All Commercial |
$351.15
|
| Rate for Payer: Frontpath All Commercial |
$350.96
|
| Rate for Payer: Humana ChoiceCare |
$329.48
|
| Rate for Payer: Humana Medicare |
$122.07
|
| Rate for Payer: Lucent All Commercial |
$207.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$343.33
|
| Rate for Payer: Managed Health Services Medicaid |
$83.89
|
| Rate for Payer: MDWise Medicaid |
$83.89
|
| Rate for Payer: PHCS All Commercial |
$286.11
|
| Rate for Payer: PHP All Commercial |
$289.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$148.78
|
| Rate for Payer: Sagamore Health Network All Products |
$294.50
|
| Rate for Payer: Signature Care EPO |
$316.63
|
| Rate for Payer: Signature Care PPO |
$335.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$324.26
|
| Rate for Payer: United Healthcare Commercial |
$300.61
|
| Rate for Payer: United Healthcare Medicare |
$122.07
|
|
|
HC MAMMOGRAM DX INCL CAD BILATERAL
|
Facility
|
IP
|
$381.48
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
1610204
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$286.11 |
| Max. Negotiated Rate |
$354.78 |
| Rate for Payer: Aetna Commercial |
$329.60
|
| Rate for Payer: Cash Price |
$228.89
|
| Rate for Payer: Cigna All Commercial |
$329.22
|
| Rate for Payer: CORVEL All Commercial |
$354.78
|
| Rate for Payer: Coventry All Commercial |
$335.70
|
| Rate for Payer: Encore All Commercial |
$351.15
|
| Rate for Payer: Frontpath All Commercial |
$350.96
|
| Rate for Payer: Humana ChoiceCare |
$329.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$343.33
|
| Rate for Payer: PHCS All Commercial |
$286.11
|
| Rate for Payer: PHP All Commercial |
$289.31
|
| Rate for Payer: Sagamore Health Network All Products |
$294.50
|
| Rate for Payer: Signature Care EPO |
$316.63
|
| Rate for Payer: Signature Care PPO |
$335.70
|
| Rate for Payer: United Healthcare Commercial |
$300.61
|
|
|
HC MAMMOGRAM DX INCL CAD UNILATERAL
|
Facility
|
OP
|
$319.92
|
|
|
Service Code
|
CPT 77065
|
| Hospital Charge Code |
1610206
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$65.56 |
| Max. Negotiated Rate |
$297.53 |
| Rate for Payer: Aetna Commercial |
$270.01
|
| Rate for Payer: Aetna Medicare |
$102.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$65.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$99.18
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$100.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$109.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$65.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$117.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$112.61
|
| Rate for Payer: Cash Price |
$191.95
|
| Rate for Payer: Cash Price |
$191.95
|
| Rate for Payer: Centivo All Commercial |
$174.04
|
| Rate for Payer: Cigna All Commercial |
$276.09
|
| Rate for Payer: CORVEL All Commercial |
$297.53
|
| Rate for Payer: Coventry All Commercial |
$281.53
|
| Rate for Payer: Encore All Commercial |
$294.49
|
| Rate for Payer: Frontpath All Commercial |
$294.33
|
| Rate for Payer: Humana ChoiceCare |
$276.31
|
| Rate for Payer: Humana Medicare |
$102.37
|
| Rate for Payer: Lucent All Commercial |
$174.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$287.93
|
| Rate for Payer: Managed Health Services Medicaid |
$65.56
|
| Rate for Payer: MDWise Medicaid |
$65.56
|
| Rate for Payer: PHCS All Commercial |
$239.94
|
| Rate for Payer: PHP All Commercial |
$242.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$124.77
|
| Rate for Payer: Sagamore Health Network All Products |
$246.98
|
| Rate for Payer: Signature Care EPO |
$265.53
|
| Rate for Payer: Signature Care PPO |
$281.53
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$271.93
|
| Rate for Payer: United Healthcare Commercial |
$252.10
|
| Rate for Payer: United Healthcare Medicare |
$102.37
|
|
|
HC MAMMOGRAM DX INCL CAD UNILATERAL
|
Facility
|
IP
|
$319.92
|
|
|
Service Code
|
CPT 77065
|
| Hospital Charge Code |
1610206
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$239.94 |
| Max. Negotiated Rate |
$297.53 |
| Rate for Payer: Aetna Commercial |
$276.41
|
| Rate for Payer: Cash Price |
$191.95
|
| Rate for Payer: Cigna All Commercial |
$276.09
|
| Rate for Payer: CORVEL All Commercial |
$297.53
|
| Rate for Payer: Coventry All Commercial |
$281.53
|
| Rate for Payer: Encore All Commercial |
$294.49
|
| Rate for Payer: Frontpath All Commercial |
$294.33
|
| Rate for Payer: Humana ChoiceCare |
$276.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$287.93
|
| Rate for Payer: PHCS All Commercial |
$239.94
|
| Rate for Payer: PHP All Commercial |
$242.63
|
| Rate for Payer: Sagamore Health Network All Products |
$246.98
|
| Rate for Payer: Signature Care EPO |
$265.53
|
| Rate for Payer: Signature Care PPO |
$281.53
|
| Rate for Payer: United Healthcare Commercial |
$252.10
|
|
|
HC MAMMOGRAM SCREENING INCL CAD BILATERAL
|
Facility
|
IP
|
$268.52
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
1610202
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$201.39 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$232.00
|
| Rate for Payer: Cash Price |
$161.11
|
| Rate for Payer: Cigna All Commercial |
$231.73
|
| Rate for Payer: CORVEL All Commercial |
$249.72
|
| Rate for Payer: Coventry All Commercial |
$236.30
|
| Rate for Payer: Encore All Commercial |
$247.17
|
| Rate for Payer: Frontpath All Commercial |
$247.04
|
| Rate for Payer: Humana ChoiceCare |
$231.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$241.67
|
| Rate for Payer: PHCS All Commercial |
$201.39
|
| Rate for Payer: PHP All Commercial |
$203.65
|
| Rate for Payer: Sagamore Health Network All Products |
$207.30
|
| Rate for Payer: Signature Care EPO |
$222.87
|
| Rate for Payer: Signature Care PPO |
$236.30
|
| Rate for Payer: United Healthcare Commercial |
$211.59
|
|
|
HC MAMMOGRAM SCREENING INCL CAD BILATERAL
|
Facility
|
OP
|
$268.52
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
1610202
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$69.28 |
| Max. Negotiated Rate |
$249.72 |
| Rate for Payer: Aetna Commercial |
$226.63
|
| Rate for Payer: Aetna Medicare |
$85.93
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$69.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$83.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$100.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$109.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$69.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$98.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$94.52
|
| Rate for Payer: Cash Price |
$161.11
|
| Rate for Payer: Cash Price |
$161.11
|
| Rate for Payer: Centivo All Commercial |
$146.07
|
| Rate for Payer: Cigna All Commercial |
$231.73
|
| Rate for Payer: CORVEL All Commercial |
$249.72
|
| Rate for Payer: Coventry All Commercial |
$236.30
|
| Rate for Payer: Encore All Commercial |
$247.17
|
| Rate for Payer: Frontpath All Commercial |
$247.04
|
| Rate for Payer: Humana ChoiceCare |
$231.92
|
| Rate for Payer: Humana Medicare |
$85.93
|
| Rate for Payer: Lucent All Commercial |
$146.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$241.67
|
| Rate for Payer: Managed Health Services Medicaid |
$69.28
|
| Rate for Payer: MDWise Medicaid |
$69.28
|
| Rate for Payer: PHCS All Commercial |
$201.39
|
| Rate for Payer: PHP All Commercial |
$203.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$104.72
|
| Rate for Payer: Sagamore Health Network All Products |
$207.30
|
| Rate for Payer: Signature Care EPO |
$222.87
|
| Rate for Payer: Signature Care PPO |
$236.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$228.24
|
| Rate for Payer: United Healthcare Commercial |
$211.59
|
| Rate for Payer: United Healthcare Medicare |
$85.93
|
|
|
HC MAMMOGRAM SCREENING INCL CAD UNILATERAL
|
Facility
|
OP
|
$269.01
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
1613202
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$69.28 |
| Max. Negotiated Rate |
$250.18 |
| Rate for Payer: Aetna Commercial |
$227.04
|
| Rate for Payer: Aetna Medicare |
$86.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$69.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$83.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$100.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$109.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$69.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$99.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$94.69
|
| Rate for Payer: Cash Price |
$161.41
|
| Rate for Payer: Cash Price |
$161.41
|
| Rate for Payer: Centivo All Commercial |
$146.34
|
| Rate for Payer: Cigna All Commercial |
$232.16
|
| Rate for Payer: CORVEL All Commercial |
$250.18
|
| Rate for Payer: Coventry All Commercial |
$236.73
|
| Rate for Payer: Encore All Commercial |
$247.62
|
| Rate for Payer: Frontpath All Commercial |
$247.49
|
| Rate for Payer: Humana ChoiceCare |
$232.34
|
| Rate for Payer: Humana Medicare |
$86.08
|
| Rate for Payer: Lucent All Commercial |
$146.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$242.11
|
| Rate for Payer: Managed Health Services Medicaid |
$69.28
|
| Rate for Payer: MDWise Medicaid |
$69.28
|
| Rate for Payer: PHCS All Commercial |
$201.76
|
| Rate for Payer: PHP All Commercial |
$204.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$104.91
|
| Rate for Payer: Sagamore Health Network All Products |
$207.68
|
| Rate for Payer: Signature Care EPO |
$223.28
|
| Rate for Payer: Signature Care PPO |
$236.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$228.66
|
| Rate for Payer: United Healthcare Commercial |
$211.98
|
| Rate for Payer: United Healthcare Medicare |
$86.08
|
|
|
HC MAMMOGRAM SCREENING INCL CAD UNILATERAL
|
Facility
|
IP
|
$269.01
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
1613202
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$201.76 |
| Max. Negotiated Rate |
$250.18 |
| Rate for Payer: Aetna Commercial |
$232.42
|
| Rate for Payer: Cash Price |
$161.41
|
| Rate for Payer: Cigna All Commercial |
$232.16
|
| Rate for Payer: CORVEL All Commercial |
$250.18
|
| Rate for Payer: Coventry All Commercial |
$236.73
|
| Rate for Payer: Encore All Commercial |
$247.62
|
| Rate for Payer: Frontpath All Commercial |
$247.49
|
| Rate for Payer: Humana ChoiceCare |
$232.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$242.11
|
| Rate for Payer: PHCS All Commercial |
$201.76
|
| Rate for Payer: PHP All Commercial |
$204.02
|
| Rate for Payer: Sagamore Health Network All Products |
$207.68
|
| Rate for Payer: Signature Care EPO |
$223.28
|
| Rate for Payer: Signature Care PPO |
$236.73
|
| Rate for Payer: United Healthcare Commercial |
$211.98
|
|
|
HC MANTIS CLIP
|
Facility
|
IP
|
$1,890.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41608368
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,417.50 |
| Max. Negotiated Rate |
$1,757.70 |
| Rate for Payer: Aetna Commercial |
$1,632.96
|
| Rate for Payer: Cash Price |
$1,134.00
|
| Rate for Payer: Cigna All Commercial |
$1,631.07
|
| Rate for Payer: CORVEL All Commercial |
$1,757.70
|
| Rate for Payer: Coventry All Commercial |
$1,663.20
|
| Rate for Payer: Encore All Commercial |
$1,739.74
|
| Rate for Payer: Frontpath All Commercial |
$1,738.80
|
| Rate for Payer: Humana ChoiceCare |
$1,632.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,701.00
|
| Rate for Payer: PHCS All Commercial |
$1,417.50
|
| Rate for Payer: PHP All Commercial |
$1,433.38
|
| Rate for Payer: Sagamore Health Network All Products |
$1,459.08
|
| Rate for Payer: Signature Care EPO |
$1,568.70
|
| Rate for Payer: Signature Care PPO |
$1,663.20
|
| Rate for Payer: United Healthcare Commercial |
$1,489.32
|
|
|
HC MANTIS CLIP
|
Facility
|
OP
|
$1,890.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41608368
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$134.40 |
| Max. Negotiated Rate |
$1,757.70 |
| Rate for Payer: Aetna Commercial |
$1,595.16
|
| Rate for Payer: Aetna Medicare |
$604.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$134.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$585.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,085.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,181.44
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$134.40
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$695.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$665.28
|
| Rate for Payer: Cash Price |
$1,134.00
|
| Rate for Payer: Cash Price |
$1,134.00
|
| Rate for Payer: Centivo All Commercial |
$1,028.16
|
| Rate for Payer: Cigna All Commercial |
$1,631.07
|
| Rate for Payer: CORVEL All Commercial |
$1,757.70
|
| Rate for Payer: Coventry All Commercial |
$1,663.20
|
| Rate for Payer: Encore All Commercial |
$1,739.74
|
| Rate for Payer: Frontpath All Commercial |
$1,738.80
|
| Rate for Payer: Humana ChoiceCare |
$1,632.39
|
| Rate for Payer: Humana Medicare |
$604.80
|
| Rate for Payer: Lucent All Commercial |
$1,028.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,701.00
|
| Rate for Payer: Managed Health Services Medicaid |
$134.40
|
| Rate for Payer: MDWise Medicaid |
$134.40
|
| Rate for Payer: PHCS All Commercial |
$1,417.50
|
| Rate for Payer: PHP All Commercial |
$1,433.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$737.10
|
| Rate for Payer: Sagamore Health Network All Products |
$1,459.08
|
| Rate for Payer: Signature Care EPO |
$1,568.70
|
| Rate for Payer: Signature Care PPO |
$1,663.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,606.50
|
| Rate for Payer: United Healthcare Commercial |
$1,489.32
|
| Rate for Payer: United Healthcare Medicare |
$604.80
|
|
|
HC MANUAL THERAPY/15 MIN-OT
|
Facility
|
OP
|
$140.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
1738033
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$43.40 |
| Max. Negotiated Rate |
$130.20 |
| Rate for Payer: Aetna Commercial |
$118.16
|
| Rate for Payer: Aetna Medicare |
$44.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$43.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$80.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$87.51
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$51.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$49.28
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Centivo All Commercial |
$76.16
|
| Rate for Payer: Cigna All Commercial |
$120.82
|
| Rate for Payer: CORVEL All Commercial |
$130.20
|
| Rate for Payer: Coventry All Commercial |
$123.20
|
| Rate for Payer: Encore All Commercial |
$128.87
|
| Rate for Payer: Frontpath All Commercial |
$128.80
|
| Rate for Payer: Humana ChoiceCare |
$120.92
|
| Rate for Payer: Humana Medicare |
$44.80
|
| Rate for Payer: Lucent All Commercial |
$76.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$126.00
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$105.00
|
| Rate for Payer: PHP All Commercial |
$106.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$54.60
|
| Rate for Payer: Sagamore Health Network All Products |
$108.08
|
| Rate for Payer: Signature Care EPO |
$116.20
|
| Rate for Payer: Signature Care PPO |
$123.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$119.00
|
| Rate for Payer: United Healthcare Commercial |
$110.32
|
| Rate for Payer: United Healthcare Medicare |
$44.80
|
|
|
HC MANUAL THERAPY/15 MIN-OT
|
Facility
|
IP
|
$140.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
1738033
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$105.00 |
| Max. Negotiated Rate |
$130.20 |
| Rate for Payer: Aetna Commercial |
$120.96
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna All Commercial |
$120.82
|
| Rate for Payer: CORVEL All Commercial |
$130.20
|
| Rate for Payer: Coventry All Commercial |
$123.20
|
| Rate for Payer: Encore All Commercial |
$128.87
|
| Rate for Payer: Frontpath All Commercial |
$128.80
|
| Rate for Payer: Humana ChoiceCare |
$120.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$126.00
|
| Rate for Payer: PHCS All Commercial |
$105.00
|
| Rate for Payer: PHP All Commercial |
$106.18
|
| Rate for Payer: Sagamore Health Network All Products |
$108.08
|
| Rate for Payer: Signature Care EPO |
$116.20
|
| Rate for Payer: Signature Care PPO |
$123.20
|
| Rate for Payer: United Healthcare Commercial |
$110.32
|
|
|
HC MANUAL THERAPY/15 MIN-PT
|
Facility
|
OP
|
$137.53
|
|
|
Service Code
|
CPT 97140 GP
|
| Hospital Charge Code |
1728046
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$42.63 |
| Max. Negotiated Rate |
$127.90 |
| Rate for Payer: Aetna Commercial |
$116.08
|
| Rate for Payer: Aetna Medicare |
$44.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$42.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$78.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$85.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$50.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$48.41
|
| Rate for Payer: Cash Price |
$82.52
|
| Rate for Payer: Cash Price |
$82.52
|
| Rate for Payer: Centivo All Commercial |
$74.82
|
| Rate for Payer: Cigna All Commercial |
$118.69
|
| Rate for Payer: CORVEL All Commercial |
$127.90
|
| Rate for Payer: Coventry All Commercial |
$121.03
|
| Rate for Payer: Encore All Commercial |
$126.60
|
| Rate for Payer: Frontpath All Commercial |
$126.53
|
| Rate for Payer: Humana ChoiceCare |
$118.78
|
| Rate for Payer: Humana Medicare |
$44.01
|
| Rate for Payer: Lucent All Commercial |
$74.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.78
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$103.15
|
| Rate for Payer: PHP All Commercial |
$104.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$53.64
|
| Rate for Payer: Sagamore Health Network All Products |
$106.17
|
| Rate for Payer: Signature Care EPO |
$114.15
|
| Rate for Payer: Signature Care PPO |
$121.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$116.90
|
| Rate for Payer: United Healthcare Commercial |
$108.37
|
| Rate for Payer: United Healthcare Medicare |
$44.01
|
|
|
HC MANUAL THERAPY/15 MIN-PT
|
Facility
|
IP
|
$137.53
|
|
|
Service Code
|
CPT 97140 GP
|
| Hospital Charge Code |
1728046
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$103.15 |
| Max. Negotiated Rate |
$127.90 |
| Rate for Payer: Aetna Commercial |
$118.83
|
| Rate for Payer: Cash Price |
$82.52
|
| Rate for Payer: Cigna All Commercial |
$118.69
|
| Rate for Payer: CORVEL All Commercial |
$127.90
|
| Rate for Payer: Coventry All Commercial |
$121.03
|
| Rate for Payer: Encore All Commercial |
$126.60
|
| Rate for Payer: Frontpath All Commercial |
$126.53
|
| Rate for Payer: Humana ChoiceCare |
$118.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.78
|
| Rate for Payer: PHCS All Commercial |
$103.15
|
| Rate for Payer: PHP All Commercial |
$104.30
|
| Rate for Payer: Sagamore Health Network All Products |
$106.17
|
| Rate for Payer: Signature Care EPO |
$114.15
|
| Rate for Payer: Signature Care PPO |
$121.03
|
| Rate for Payer: United Healthcare Commercial |
$108.37
|
|
|
HC MARGIN MAP 10MM
|
Facility
|
IP
|
$142.33
|
|
| Hospital Charge Code |
41601348
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.75 |
| Max. Negotiated Rate |
$132.37 |
| Rate for Payer: Aetna Commercial |
$122.97
|
| Rate for Payer: Cash Price |
$85.40
|
| Rate for Payer: Cigna All Commercial |
$122.83
|
| Rate for Payer: CORVEL All Commercial |
$132.37
|
| Rate for Payer: Coventry All Commercial |
$125.25
|
| Rate for Payer: Encore All Commercial |
$131.01
|
| Rate for Payer: Frontpath All Commercial |
$130.94
|
| Rate for Payer: Humana ChoiceCare |
$122.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.10
|
| Rate for Payer: PHCS All Commercial |
$106.75
|
| Rate for Payer: PHP All Commercial |
$107.94
|
| Rate for Payer: Sagamore Health Network All Products |
$109.88
|
| Rate for Payer: Signature Care EPO |
$118.13
|
| Rate for Payer: Signature Care PPO |
$125.25
|
| Rate for Payer: United Healthcare Commercial |
$112.16
|
|
|
HC MARGIN MAP 10MM
|
Facility
|
OP
|
$142.33
|
|
| Hospital Charge Code |
41601348
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$132.37 |
| Rate for Payer: Aetna Commercial |
$120.13
|
| Rate for Payer: Aetna Medicare |
$45.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$44.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$81.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$88.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.10
|
| Rate for Payer: Cash Price |
$85.40
|
| Rate for Payer: Cash Price |
$85.40
|
| Rate for Payer: Centivo All Commercial |
$77.43
|
| Rate for Payer: Cigna All Commercial |
$122.83
|
| Rate for Payer: CORVEL All Commercial |
$132.37
|
| Rate for Payer: Coventry All Commercial |
$125.25
|
| Rate for Payer: Encore All Commercial |
$131.01
|
| Rate for Payer: Frontpath All Commercial |
$130.94
|
| Rate for Payer: Humana ChoiceCare |
$122.93
|
| Rate for Payer: Humana Medicare |
$45.55
|
| Rate for Payer: Lucent All Commercial |
$77.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.10
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$106.75
|
| Rate for Payer: PHP All Commercial |
$107.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.51
|
| Rate for Payer: Sagamore Health Network All Products |
$109.88
|
| Rate for Payer: Signature Care EPO |
$118.13
|
| Rate for Payer: Signature Care PPO |
$125.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$120.98
|
| Rate for Payer: United Healthcare Commercial |
$112.16
|
| Rate for Payer: United Healthcare Medicare |
$45.55
|
|
|
HC MARGIN MAP 5MM
|
Facility
|
IP
|
$142.33
|
|
| Hospital Charge Code |
41601349
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$106.75 |
| Max. Negotiated Rate |
$132.37 |
| Rate for Payer: Aetna Commercial |
$122.97
|
| Rate for Payer: Cash Price |
$85.40
|
| Rate for Payer: Cigna All Commercial |
$122.83
|
| Rate for Payer: CORVEL All Commercial |
$132.37
|
| Rate for Payer: Coventry All Commercial |
$125.25
|
| Rate for Payer: Encore All Commercial |
$131.01
|
| Rate for Payer: Frontpath All Commercial |
$130.94
|
| Rate for Payer: Humana ChoiceCare |
$122.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.10
|
| Rate for Payer: PHCS All Commercial |
$106.75
|
| Rate for Payer: PHP All Commercial |
$107.94
|
| Rate for Payer: Sagamore Health Network All Products |
$109.88
|
| Rate for Payer: Signature Care EPO |
$118.13
|
| Rate for Payer: Signature Care PPO |
$125.25
|
| Rate for Payer: United Healthcare Commercial |
$112.16
|
|
|
HC MARGIN MAP 5MM
|
Facility
|
OP
|
$142.33
|
|
| Hospital Charge Code |
41601349
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$132.37 |
| Rate for Payer: Aetna Commercial |
$120.13
|
| Rate for Payer: Aetna Medicare |
$45.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$44.12
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$81.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$88.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.10
|
| Rate for Payer: Cash Price |
$85.40
|
| Rate for Payer: Cash Price |
$85.40
|
| Rate for Payer: Centivo All Commercial |
$77.43
|
| Rate for Payer: Cigna All Commercial |
$122.83
|
| Rate for Payer: CORVEL All Commercial |
$132.37
|
| Rate for Payer: Coventry All Commercial |
$125.25
|
| Rate for Payer: Encore All Commercial |
$131.01
|
| Rate for Payer: Frontpath All Commercial |
$130.94
|
| Rate for Payer: Humana ChoiceCare |
$122.93
|
| Rate for Payer: Humana Medicare |
$45.55
|
| Rate for Payer: Lucent All Commercial |
$77.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.10
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$106.75
|
| Rate for Payer: PHP All Commercial |
$107.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.51
|
| Rate for Payer: Sagamore Health Network All Products |
$109.88
|
| Rate for Payer: Signature Care EPO |
$118.13
|
| Rate for Payer: Signature Care PPO |
$125.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$120.98
|
| Rate for Payer: United Healthcare Commercial |
$112.16
|
| Rate for Payer: United Healthcare Medicare |
$45.55
|
|
|
HC MARIJUANA(THC) MS
|
Facility
|
OP
|
$314.66
|
|
|
Service Code
|
CPT 80349
|
| Hospital Charge Code |
63001415
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$97.54 |
| Max. Negotiated Rate |
$292.63 |
| Rate for Payer: Aetna Commercial |
$265.57
|
| Rate for Payer: Aetna Medicare |
$100.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$144.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$144.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$115.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$110.76
|
| Rate for Payer: Cash Price |
$188.80
|
| Rate for Payer: Centivo All Commercial |
$171.18
|
| Rate for Payer: Cigna All Commercial |
$271.55
|
| Rate for Payer: CORVEL All Commercial |
$292.63
|
| Rate for Payer: Coventry All Commercial |
$276.90
|
| Rate for Payer: Encore All Commercial |
$289.64
|
| Rate for Payer: Frontpath All Commercial |
$289.49
|
| Rate for Payer: Humana ChoiceCare |
$271.77
|
| Rate for Payer: Humana Medicare |
$100.69
|
| Rate for Payer: Lucent All Commercial |
$171.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.19
|
| Rate for Payer: PHCS All Commercial |
$236.00
|
| Rate for Payer: PHP All Commercial |
$238.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$122.72
|
| Rate for Payer: Sagamore Health Network All Products |
$242.92
|
| Rate for Payer: Signature Care EPO |
$261.17
|
| Rate for Payer: Signature Care PPO |
$276.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$267.46
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$100.69
|
|
|
HC MARIJUANA(THC) MS
|
Facility
|
IP
|
$314.66
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
63001415
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$236.00 |
| Max. Negotiated Rate |
$292.63 |
| Rate for Payer: Aetna Commercial |
$271.87
|
| Rate for Payer: Cash Price |
$188.80
|
| Rate for Payer: Cigna All Commercial |
$271.55
|
| Rate for Payer: CORVEL All Commercial |
$292.63
|
| Rate for Payer: Coventry All Commercial |
$276.90
|
| Rate for Payer: Encore All Commercial |
$289.64
|
| Rate for Payer: Frontpath All Commercial |
$289.49
|
| Rate for Payer: Humana ChoiceCare |
$271.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.19
|
| Rate for Payer: PHCS All Commercial |
$236.00
|
| Rate for Payer: PHP All Commercial |
$238.64
|
| Rate for Payer: Sagamore Health Network All Products |
$242.92
|
| Rate for Payer: Signature Care EPO |
$261.17
|
| Rate for Payer: Signature Care PPO |
$276.90
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
|
|
HC MARIJUANA(THC) MS
|
Facility
|
OP
|
$314.66
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
63001415
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$97.54 |
| Max. Negotiated Rate |
$292.63 |
| Rate for Payer: Aetna Commercial |
$265.57
|
| Rate for Payer: Aetna Medicare |
$100.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$114.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$144.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$144.62
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$114.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$115.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$110.76
|
| Rate for Payer: Cash Price |
$188.80
|
| Rate for Payer: Cash Price |
$188.80
|
| Rate for Payer: Centivo All Commercial |
$171.18
|
| Rate for Payer: Cigna All Commercial |
$271.55
|
| Rate for Payer: CORVEL All Commercial |
$292.63
|
| Rate for Payer: Coventry All Commercial |
$276.90
|
| Rate for Payer: Encore All Commercial |
$289.64
|
| Rate for Payer: Frontpath All Commercial |
$289.49
|
| Rate for Payer: Humana ChoiceCare |
$271.77
|
| Rate for Payer: Humana Medicare |
$100.69
|
| Rate for Payer: Lucent All Commercial |
$171.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.19
|
| Rate for Payer: Managed Health Services Medicaid |
$114.43
|
| Rate for Payer: MDWise Medicaid |
$114.43
|
| Rate for Payer: PHCS All Commercial |
$236.00
|
| Rate for Payer: PHP All Commercial |
$238.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$122.72
|
| Rate for Payer: Sagamore Health Network All Products |
$242.92
|
| Rate for Payer: Signature Care EPO |
$261.17
|
| Rate for Payer: Signature Care PPO |
$276.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$267.46
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
| Rate for Payer: United Healthcare Medicare |
$100.69
|
|
|
HC MARIJUANA(THC) MS
|
Facility
|
IP
|
$314.66
|
|
|
Service Code
|
CPT 80349
|
| Hospital Charge Code |
63001415
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$236.00 |
| Max. Negotiated Rate |
$292.63 |
| Rate for Payer: Aetna Commercial |
$271.87
|
| Rate for Payer: Cash Price |
$188.80
|
| Rate for Payer: Cigna All Commercial |
$271.55
|
| Rate for Payer: CORVEL All Commercial |
$292.63
|
| Rate for Payer: Coventry All Commercial |
$276.90
|
| Rate for Payer: Encore All Commercial |
$289.64
|
| Rate for Payer: Frontpath All Commercial |
$289.49
|
| Rate for Payer: Humana ChoiceCare |
$271.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$283.19
|
| Rate for Payer: PHCS All Commercial |
$236.00
|
| Rate for Payer: PHP All Commercial |
$238.64
|
| Rate for Payer: Sagamore Health Network All Products |
$242.92
|
| Rate for Payer: Signature Care EPO |
$261.17
|
| Rate for Payer: Signature Care PPO |
$276.90
|
| Rate for Payer: United Healthcare Commercial |
$247.95
|
|
|
HC MASK AEROSOL ADULT
|
Facility
|
OP
|
$2.50
|
|
| Hospital Charge Code |
41601074
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$21.01 |
| Rate for Payer: Aetna Commercial |
$2.11
|
| Rate for Payer: Aetna Medicare |
$0.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$21.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.88
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Centivo All Commercial |
$1.36
|
| Rate for Payer: Cigna All Commercial |
$2.16
|
| Rate for Payer: CORVEL All Commercial |
$2.33
|
| Rate for Payer: Coventry All Commercial |
$2.20
|
| Rate for Payer: Encore All Commercial |
$2.30
|
| Rate for Payer: Frontpath All Commercial |
$2.30
|
| Rate for Payer: Humana ChoiceCare |
$2.16
|
| Rate for Payer: Humana Medicare |
$0.80
|
| Rate for Payer: Lucent All Commercial |
$1.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.25
|
| Rate for Payer: Managed Health Services Medicaid |
$21.01
|
| Rate for Payer: MDWise Medicaid |
$21.01
|
| Rate for Payer: PHCS All Commercial |
$1.88
|
| Rate for Payer: PHP All Commercial |
$1.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.98
|
| Rate for Payer: Sagamore Health Network All Products |
$1.93
|
| Rate for Payer: Signature Care EPO |
$2.08
|
| Rate for Payer: Signature Care PPO |
$2.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.12
|
| Rate for Payer: United Healthcare Commercial |
$1.97
|
| Rate for Payer: United Healthcare Medicare |
$0.80
|
|
|
HC MASK AEROSOL ADULT
|
Facility
|
IP
|
$2.50
|
|
| Hospital Charge Code |
41601074
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna Commercial |
$2.16
|
| Rate for Payer: Cash Price |
$1.50
|
| Rate for Payer: Cigna All Commercial |
$2.16
|
| Rate for Payer: CORVEL All Commercial |
$2.33
|
| Rate for Payer: Coventry All Commercial |
$2.20
|
| Rate for Payer: Encore All Commercial |
$2.30
|
| Rate for Payer: Frontpath All Commercial |
$2.30
|
| Rate for Payer: Humana ChoiceCare |
$2.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.25
|
| Rate for Payer: PHCS All Commercial |
$1.88
|
| Rate for Payer: PHP All Commercial |
$1.90
|
| Rate for Payer: Sagamore Health Network All Products |
$1.93
|
| Rate for Payer: Signature Care EPO |
$2.08
|
| Rate for Payer: Signature Care PPO |
$2.20
|
| Rate for Payer: United Healthcare Commercial |
$1.97
|
|
|
HC MASK AEROSOL PEDIATRIC
|
Facility
|
IP
|
$3.18
|
|
| Hospital Charge Code |
41601075
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$2.38 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna Commercial |
$2.75
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cigna All Commercial |
$2.74
|
| Rate for Payer: CORVEL All Commercial |
$2.96
|
| Rate for Payer: Coventry All Commercial |
$2.80
|
| Rate for Payer: Encore All Commercial |
$2.93
|
| Rate for Payer: Frontpath All Commercial |
$2.93
|
| Rate for Payer: Humana ChoiceCare |
$2.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.86
|
| Rate for Payer: PHCS All Commercial |
$2.38
|
| Rate for Payer: PHP All Commercial |
$2.41
|
| Rate for Payer: Sagamore Health Network All Products |
$2.45
|
| Rate for Payer: Signature Care EPO |
$2.64
|
| Rate for Payer: Signature Care PPO |
$2.80
|
| Rate for Payer: United Healthcare Commercial |
$2.51
|
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