|
HC MAGNESIUM 24HR URINE
|
Facility
OP
|
$108.49
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
63001627
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$100.89 |
| Rate for Payer: Aetna Commercial |
$91.56
|
| Rate for Payer: Aetna Medicare |
$35.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$49.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$6.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.38
|
| Rate for Payer: Cash Price |
$67.26
|
| Rate for Payer: Cash Price |
$67.26
|
| Rate for Payer: Centivo All Commercial |
$55.33
|
| Rate for Payer: Cigna All Commercial |
$93.62
|
| Rate for Payer: CORVEL All Commercial |
$100.89
|
| Rate for Payer: Coventry All Commercial |
$95.47
|
| Rate for Payer: Encore All Commercial |
$99.86
|
| Rate for Payer: Frontpath All Commercial |
$99.81
|
| Rate for Payer: Humana ChoiceCare |
$93.70
|
| Rate for Payer: Humana Medicare |
$55.33
|
| Rate for Payer: Lucent All Commercial |
$55.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.64
|
| Rate for Payer: Managed Health Services Medicaid |
$6.70
|
| Rate for Payer: MDWise Medicaid |
$6.70
|
| Rate for Payer: PHCS All Commercial |
$81.37
|
| Rate for Payer: PHP All Commercial |
$82.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.31
|
| Rate for Payer: Sagamore Health Network All Products |
$83.75
|
| Rate for Payer: Signature Care EPO |
$90.04
|
| Rate for Payer: Signature Care PPO |
$95.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$92.21
|
| Rate for Payer: United Healthcare Commercial |
$85.49
|
| Rate for Payer: United Healthcare Medicare |
$35.80
|
|
|
HC MAGNESIUM 24HR URINE
|
Facility
IP
|
$108.49
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
63001627
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$81.37 |
| Max. Negotiated Rate |
$100.89 |
| Rate for Payer: Aetna Commercial |
$93.73
|
| Rate for Payer: Cash Price |
$67.26
|
| Rate for Payer: Cigna All Commercial |
$93.62
|
| Rate for Payer: CORVEL All Commercial |
$100.89
|
| Rate for Payer: Coventry All Commercial |
$95.47
|
| Rate for Payer: Encore All Commercial |
$99.86
|
| Rate for Payer: Frontpath All Commercial |
$99.81
|
| Rate for Payer: Humana ChoiceCare |
$93.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.64
|
| Rate for Payer: PHCS All Commercial |
$81.37
|
| Rate for Payer: PHP All Commercial |
$82.28
|
| Rate for Payer: Sagamore Health Network All Products |
$83.75
|
| Rate for Payer: Signature Care EPO |
$90.04
|
| Rate for Payer: Signature Care PPO |
$95.47
|
| Rate for Payer: United Healthcare Commercial |
$85.49
|
|
|
HC MAGNESIUM, RBCS
|
Facility
OP
|
$108.49
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
63001629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$100.89 |
| Rate for Payer: Aetna Commercial |
$91.56
|
| Rate for Payer: Aetna Medicare |
$35.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$49.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$6.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.38
|
| Rate for Payer: Cash Price |
$67.26
|
| Rate for Payer: Cash Price |
$67.26
|
| Rate for Payer: Centivo All Commercial |
$55.33
|
| Rate for Payer: Cigna All Commercial |
$93.62
|
| Rate for Payer: CORVEL All Commercial |
$100.89
|
| Rate for Payer: Coventry All Commercial |
$95.47
|
| Rate for Payer: Encore All Commercial |
$99.86
|
| Rate for Payer: Frontpath All Commercial |
$99.81
|
| Rate for Payer: Humana ChoiceCare |
$93.70
|
| Rate for Payer: Humana Medicare |
$55.33
|
| Rate for Payer: Lucent All Commercial |
$55.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.64
|
| Rate for Payer: Managed Health Services Medicaid |
$6.70
|
| Rate for Payer: MDWise Medicaid |
$6.70
|
| Rate for Payer: PHCS All Commercial |
$81.37
|
| Rate for Payer: PHP All Commercial |
$82.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$42.31
|
| Rate for Payer: Sagamore Health Network All Products |
$83.75
|
| Rate for Payer: Signature Care EPO |
$90.04
|
| Rate for Payer: Signature Care PPO |
$95.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$92.21
|
| Rate for Payer: United Healthcare Commercial |
$85.49
|
| Rate for Payer: United Healthcare Medicare |
$35.80
|
|
|
HC MAGNESIUM, RBCS
|
Facility
IP
|
$108.49
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
63001629
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$81.37 |
| Max. Negotiated Rate |
$100.89 |
| Rate for Payer: Aetna Commercial |
$93.73
|
| Rate for Payer: Cash Price |
$67.26
|
| Rate for Payer: Cigna All Commercial |
$93.62
|
| Rate for Payer: CORVEL All Commercial |
$100.89
|
| Rate for Payer: Coventry All Commercial |
$95.47
|
| Rate for Payer: Encore All Commercial |
$99.86
|
| Rate for Payer: Frontpath All Commercial |
$99.81
|
| Rate for Payer: Humana ChoiceCare |
$93.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.64
|
| Rate for Payer: PHCS All Commercial |
$81.37
|
| Rate for Payer: PHP All Commercial |
$82.28
|
| Rate for Payer: Sagamore Health Network All Products |
$83.75
|
| Rate for Payer: Signature Care EPO |
$90.04
|
| Rate for Payer: Signature Care PPO |
$95.47
|
| Rate for Payer: United Healthcare Commercial |
$85.49
|
|
|
HC MAGNESIUM UR
|
Facility
IP
|
$84.26
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
63001628
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$63.20 |
| Max. Negotiated Rate |
$78.36 |
| Rate for Payer: Aetna Commercial |
$72.80
|
| Rate for Payer: Cash Price |
$52.24
|
| Rate for Payer: Cigna All Commercial |
$72.72
|
| Rate for Payer: CORVEL All Commercial |
$78.36
|
| Rate for Payer: Coventry All Commercial |
$74.15
|
| Rate for Payer: Encore All Commercial |
$77.56
|
| Rate for Payer: Frontpath All Commercial |
$77.52
|
| Rate for Payer: Humana ChoiceCare |
$72.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.84
|
| Rate for Payer: PHCS All Commercial |
$63.20
|
| Rate for Payer: PHP All Commercial |
$63.90
|
| Rate for Payer: Sagamore Health Network All Products |
$65.05
|
| Rate for Payer: Signature Care EPO |
$69.94
|
| Rate for Payer: Signature Care PPO |
$74.15
|
| Rate for Payer: United Healthcare Commercial |
$66.40
|
|
|
HC MAGNESIUM UR
|
Facility
OP
|
$84.26
|
|
|
Service Code
|
CPT 83735
|
| Hospital Charge Code |
63001628
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$6.70 |
| Max. Negotiated Rate |
$78.36 |
| Rate for Payer: Aetna Commercial |
$71.12
|
| Rate for Payer: Aetna Medicare |
$27.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$38.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$38.73
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$6.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$31.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$30.59
|
| Rate for Payer: Cash Price |
$52.24
|
| Rate for Payer: Cash Price |
$52.24
|
| Rate for Payer: Centivo All Commercial |
$42.97
|
| Rate for Payer: Cigna All Commercial |
$72.72
|
| Rate for Payer: CORVEL All Commercial |
$78.36
|
| Rate for Payer: Coventry All Commercial |
$74.15
|
| Rate for Payer: Encore All Commercial |
$77.56
|
| Rate for Payer: Frontpath All Commercial |
$77.52
|
| Rate for Payer: Humana ChoiceCare |
$72.78
|
| Rate for Payer: Humana Medicare |
$42.97
|
| Rate for Payer: Lucent All Commercial |
$42.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.84
|
| Rate for Payer: Managed Health Services Medicaid |
$6.70
|
| Rate for Payer: MDWise Medicaid |
$6.70
|
| Rate for Payer: PHCS All Commercial |
$63.20
|
| Rate for Payer: PHP All Commercial |
$63.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.86
|
| Rate for Payer: Sagamore Health Network All Products |
$65.05
|
| Rate for Payer: Signature Care EPO |
$69.94
|
| Rate for Payer: Signature Care PPO |
$74.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$71.62
|
| Rate for Payer: United Healthcare Commercial |
$66.40
|
| Rate for Payer: United Healthcare Medicare |
$27.81
|
|
|
HC MAGNET CRM
|
Facility
IP
|
$75.00
|
|
| Hospital Charge Code |
41607302
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.25 |
| Max. Negotiated Rate |
$69.75 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna All Commercial |
$64.72
|
| Rate for Payer: CORVEL All Commercial |
$69.75
|
| Rate for Payer: Coventry All Commercial |
$66.00
|
| Rate for Payer: Encore All Commercial |
$69.04
|
| Rate for Payer: Frontpath All Commercial |
$69.00
|
| Rate for Payer: Humana ChoiceCare |
$64.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.50
|
| Rate for Payer: PHCS All Commercial |
$56.25
|
| Rate for Payer: PHP All Commercial |
$56.88
|
| Rate for Payer: Sagamore Health Network All Products |
$57.90
|
| Rate for Payer: Signature Care EPO |
$62.25
|
| Rate for Payer: Signature Care PPO |
$66.00
|
| Rate for Payer: United Healthcare Commercial |
$59.10
|
|
|
HC MAGNET CRM
|
Facility
OP
|
$75.00
|
|
| Hospital Charge Code |
41607302
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$63.30
|
| Rate for Payer: Aetna Medicare |
$24.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$43.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$46.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.22
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Centivo All Commercial |
$38.25
|
| Rate for Payer: Cigna All Commercial |
$64.72
|
| Rate for Payer: CORVEL All Commercial |
$69.75
|
| Rate for Payer: Coventry All Commercial |
$66.00
|
| Rate for Payer: Encore All Commercial |
$69.04
|
| Rate for Payer: Frontpath All Commercial |
$69.00
|
| Rate for Payer: Humana ChoiceCare |
$64.78
|
| Rate for Payer: Humana Medicare |
$38.25
|
| Rate for Payer: Lucent All Commercial |
$38.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.50
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$56.25
|
| Rate for Payer: PHP All Commercial |
$56.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$29.25
|
| Rate for Payer: Sagamore Health Network All Products |
$57.90
|
| Rate for Payer: Signature Care EPO |
$62.25
|
| Rate for Payer: Signature Care PPO |
$66.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$63.75
|
| Rate for Payer: United Healthcare Commercial |
$59.10
|
| Rate for Payer: United Healthcare Medicare |
$24.75
|
|
|
HC MAGNET ICM
|
Facility
IP
|
$75.00
|
|
| Hospital Charge Code |
41607246
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$56.25 |
| Max. Negotiated Rate |
$69.75 |
| Rate for Payer: Aetna Commercial |
$64.80
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cigna All Commercial |
$64.72
|
| Rate for Payer: CORVEL All Commercial |
$69.75
|
| Rate for Payer: Coventry All Commercial |
$66.00
|
| Rate for Payer: Encore All Commercial |
$69.04
|
| Rate for Payer: Frontpath All Commercial |
$69.00
|
| Rate for Payer: Humana ChoiceCare |
$64.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.50
|
| Rate for Payer: PHCS All Commercial |
$56.25
|
| Rate for Payer: PHP All Commercial |
$56.88
|
| Rate for Payer: Sagamore Health Network All Products |
$57.90
|
| Rate for Payer: Signature Care EPO |
$62.25
|
| Rate for Payer: Signature Care PPO |
$66.00
|
| Rate for Payer: United Healthcare Commercial |
$59.10
|
|
|
HC MAGNET ICM
|
Facility
OP
|
$75.00
|
|
| Hospital Charge Code |
41607246
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$63.30
|
| Rate for Payer: Aetna Medicare |
$24.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$43.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$46.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.22
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Cash Price |
$46.50
|
| Rate for Payer: Centivo All Commercial |
$38.25
|
| Rate for Payer: Cigna All Commercial |
$64.72
|
| Rate for Payer: CORVEL All Commercial |
$69.75
|
| Rate for Payer: Coventry All Commercial |
$66.00
|
| Rate for Payer: Encore All Commercial |
$69.04
|
| Rate for Payer: Frontpath All Commercial |
$69.00
|
| Rate for Payer: Humana ChoiceCare |
$64.78
|
| Rate for Payer: Humana Medicare |
$38.25
|
| Rate for Payer: Lucent All Commercial |
$38.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$67.50
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$56.25
|
| Rate for Payer: PHP All Commercial |
$56.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$29.25
|
| Rate for Payer: Sagamore Health Network All Products |
$57.90
|
| Rate for Payer: Signature Care EPO |
$62.25
|
| Rate for Payer: Signature Care PPO |
$66.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$63.75
|
| Rate for Payer: United Healthcare Commercial |
$59.10
|
| Rate for Payer: United Healthcare Medicare |
$24.75
|
|
|
HC MAMMOGRAM DX INCL CAD BILATERAL
|
Facility
IP
|
$381.48
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
01610204
|
|
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 |
$236.52
|
| 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 BILATERAL
|
Facility
OP
|
$381.48
|
|
|
Service Code
|
CPT 77066
|
| Hospital Charge Code |
01610204
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$94.00 |
| Max. Negotiated Rate |
$354.78 |
| Rate for Payer: Aetna Commercial |
$321.97
|
| Rate for Payer: Aetna Medicare |
$125.89
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$125.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$94.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$100.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$327.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$144.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$138.48
|
| Rate for Payer: Cash Price |
$236.52
|
| Rate for Payer: Cash Price |
$236.52
|
| Rate for Payer: Centivo All Commercial |
$194.55
|
| 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 |
$194.55
|
| Rate for Payer: Lucent All Commercial |
$194.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$343.33
|
| Rate for Payer: Managed Health Services Medicaid |
$327.17
|
| Rate for Payer: MDWise Medicaid |
$327.17
|
| 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 |
$125.89
|
|
|
HC MAMMOGRAM DX INCL CAD UNILATERAL
|
Facility
OP
|
$319.92
|
|
|
Service Code
|
CPT 77065
|
| Hospital Charge Code |
01610206
|
|
Hospital Revenue Code
|
401
|
| Min. Negotiated Rate |
$94.00 |
| Max. Negotiated Rate |
$297.53 |
| Rate for Payer: Aetna Commercial |
$270.02
|
| Rate for Payer: Aetna Medicare |
$105.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$105.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$94.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$100.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$255.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$121.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$116.13
|
| Rate for Payer: Cash Price |
$198.35
|
| Rate for Payer: Cash Price |
$198.35
|
| Rate for Payer: Centivo All Commercial |
$163.16
|
| 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 |
$276.32
|
| Rate for Payer: Humana Medicare |
$163.16
|
| Rate for Payer: Lucent All Commercial |
$163.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$287.93
|
| Rate for Payer: Managed Health Services Medicaid |
$255.68
|
| Rate for Payer: MDWise Medicaid |
$255.68
|
| 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 |
$265.54
|
| 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 |
$105.57
|
|
|
HC MAMMOGRAM DX INCL CAD UNILATERAL
|
Facility
IP
|
$319.92
|
|
|
Service Code
|
CPT 77065
|
| Hospital Charge Code |
01610206
|
|
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 |
$198.35
|
| 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 |
$276.32
|
| 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 |
$265.54
|
| Rate for Payer: Signature Care PPO |
$281.53
|
| Rate for Payer: United Healthcare Commercial |
$252.10
|
|
|
HC MAMMOGRAM SCREENING INCL CAD BILATERAL
|
Facility
OP
|
$268.52
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
01610202
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$88.61 |
| Max. Negotiated Rate |
$270.19 |
| Rate for Payer: Aetna Commercial |
$226.63
|
| Rate for Payer: Aetna Medicare |
$88.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$88.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$94.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$100.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$270.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$101.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$97.47
|
| Rate for Payer: Cash Price |
$166.48
|
| Rate for Payer: Cash Price |
$166.48
|
| Rate for Payer: Centivo All Commercial |
$136.94
|
| Rate for Payer: Cigna All Commercial |
$231.73
|
| Rate for Payer: CORVEL All Commercial |
$249.72
|
| Rate for Payer: Coventry All Commercial |
$236.29
|
| Rate for Payer: Encore All Commercial |
$247.17
|
| Rate for Payer: Frontpath All Commercial |
$247.03
|
| Rate for Payer: Humana ChoiceCare |
$231.92
|
| Rate for Payer: Humana Medicare |
$136.94
|
| Rate for Payer: Lucent All Commercial |
$136.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$241.66
|
| Rate for Payer: Managed Health Services Medicaid |
$270.19
|
| Rate for Payer: MDWise Medicaid |
$270.19
|
| Rate for Payer: PHCS All Commercial |
$201.39
|
| Rate for Payer: PHP All Commercial |
$203.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$104.72
|
| Rate for Payer: Sagamore Health Network All Products |
$207.29
|
| Rate for Payer: Signature Care EPO |
$222.87
|
| Rate for Payer: Signature Care PPO |
$236.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$228.24
|
| Rate for Payer: United Healthcare Commercial |
$211.59
|
| Rate for Payer: United Healthcare Medicare |
$88.61
|
|
|
HC MAMMOGRAM SCREENING INCL CAD BILATERAL
|
Facility
IP
|
$268.52
|
|
|
Service Code
|
CPT 77067
|
| Hospital Charge Code |
01610202
|
|
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 |
$166.48
|
| Rate for Payer: Cigna All Commercial |
$231.73
|
| Rate for Payer: CORVEL All Commercial |
$249.72
|
| Rate for Payer: Coventry All Commercial |
$236.29
|
| Rate for Payer: Encore All Commercial |
$247.17
|
| Rate for Payer: Frontpath All Commercial |
$247.03
|
| Rate for Payer: Humana ChoiceCare |
$231.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$241.66
|
| Rate for Payer: PHCS All Commercial |
$201.39
|
| Rate for Payer: PHP All Commercial |
$203.64
|
| Rate for Payer: Sagamore Health Network All Products |
$207.29
|
| Rate for Payer: Signature Care EPO |
$222.87
|
| Rate for Payer: Signature Care PPO |
$236.29
|
| Rate for Payer: United Healthcare Commercial |
$211.59
|
|
|
HC MAMMOGRAM SCREENING INCL CAD UNILATERAL
|
Facility
OP
|
$269.01
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
01613202
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$88.77 |
| Max. Negotiated Rate |
$250.18 |
| Rate for Payer: Aetna Commercial |
$227.05
|
| Rate for Payer: Aetna Medicare |
$88.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$88.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$94.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$100.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$102.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$97.65
|
| Rate for Payer: Cash Price |
$166.79
|
| Rate for Payer: Cash Price |
$166.79
|
| Rate for Payer: Centivo All Commercial |
$137.20
|
| 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 |
$247.63
|
| Rate for Payer: Frontpath All Commercial |
$247.49
|
| Rate for Payer: Humana ChoiceCare |
$232.35
|
| Rate for Payer: Humana Medicare |
$137.20
|
| Rate for Payer: Lucent All Commercial |
$137.20
|
| 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: Plain Church Group Ministry All Commercial |
$104.92
|
| 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 |
$88.77
|
|
|
HC MAMMOGRAM SCREENING INCL CAD UNILATERAL
|
Facility
IP
|
$269.01
|
|
|
Service Code
|
CPT 77067 52
|
| Hospital Charge Code |
01613202
|
|
Hospital Revenue Code
|
403
|
| Min. Negotiated Rate |
$201.76 |
| Max. Negotiated Rate |
$250.18 |
| Rate for Payer: Aetna Commercial |
$232.43
|
| Rate for Payer: Cash Price |
$166.79
|
| 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 |
$247.63
|
| Rate for Payer: Frontpath All Commercial |
$247.49
|
| Rate for Payer: Humana ChoiceCare |
$232.35
|
| 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 MANUAL THERAPY/15 MIN-OT
|
Facility
OP
|
$140.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
01738033
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$46.20 |
| Max. Negotiated Rate |
$130.20 |
| Rate for Payer: Aetna Commercial |
$118.16
|
| Rate for Payer: Aetna Medicare |
$46.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$46.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$80.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$87.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$53.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.82
|
| Rate for Payer: Cash Price |
$86.80
|
| Rate for Payer: Centivo All Commercial |
$71.40
|
| 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 |
$120.91
|
| Rate for Payer: Humana Medicare |
$71.40
|
| Rate for Payer: Lucent All Commercial |
$71.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$126.00
|
| Rate for Payer: PHCS All Commercial |
$105.00
|
| Rate for Payer: PHP All Commercial |
$106.17
|
| 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 |
$46.20
|
|
|
HC MANUAL THERAPY/15 MIN-OT
|
Facility
IP
|
$140.00
|
|
|
Service Code
|
CPT 97140 GO
|
| Hospital Charge Code |
01738033
|
|
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 |
$86.80
|
| 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 |
$120.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$126.00
|
| Rate for Payer: PHCS All Commercial |
$105.00
|
| Rate for Payer: PHP All Commercial |
$106.17
|
| 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
IP
|
$137.53
|
|
|
Service Code
|
CPT 97140 GP
|
| Hospital Charge Code |
01728046
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$103.14 |
| Max. Negotiated Rate |
$127.90 |
| Rate for Payer: Aetna Commercial |
$118.82
|
| Rate for Payer: Cash Price |
$85.27
|
| Rate for Payer: Cigna All Commercial |
$118.69
|
| Rate for Payer: CORVEL All Commercial |
$127.90
|
| Rate for Payer: Coventry All Commercial |
$121.02
|
| Rate for Payer: Encore All Commercial |
$126.59
|
| Rate for Payer: Frontpath All Commercial |
$126.52
|
| Rate for Payer: Humana ChoiceCare |
$118.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.77
|
| Rate for Payer: PHCS All Commercial |
$103.14
|
| 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 |
$121.02
|
| Rate for Payer: United Healthcare Commercial |
$108.37
|
|
|
HC MANUAL THERAPY/15 MIN-PT
|
Facility
OP
|
$137.53
|
|
|
Service Code
|
CPT 97140 GP
|
| Hospital Charge Code |
01728046
|
|
Hospital Revenue Code
|
420
|
| Min. Negotiated Rate |
$45.38 |
| Max. Negotiated Rate |
$127.90 |
| Rate for Payer: Aetna Commercial |
$116.07
|
| Rate for Payer: Aetna Medicare |
$45.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$45.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$78.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$85.97
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$49.92
|
| Rate for Payer: Cash Price |
$85.27
|
| Rate for Payer: Centivo All Commercial |
$70.14
|
| Rate for Payer: Cigna All Commercial |
$118.69
|
| Rate for Payer: CORVEL All Commercial |
$127.90
|
| Rate for Payer: Coventry All Commercial |
$121.02
|
| Rate for Payer: Encore All Commercial |
$126.59
|
| Rate for Payer: Frontpath All Commercial |
$126.52
|
| Rate for Payer: Humana ChoiceCare |
$118.78
|
| Rate for Payer: Humana Medicare |
$70.14
|
| Rate for Payer: Lucent All Commercial |
$70.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$123.77
|
| Rate for Payer: PHCS All Commercial |
$103.14
|
| 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 |
$121.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$116.90
|
| Rate for Payer: United Healthcare Commercial |
$108.37
|
| Rate for Payer: United Healthcare Medicare |
$45.38
|
|
|
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 |
$88.25
|
| 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 |
$46.97 |
| Max. Negotiated Rate |
$132.37 |
| Rate for Payer: Aetna Commercial |
$120.13
|
| Rate for Payer: Aetna Medicare |
$46.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$46.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$81.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$88.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$51.67
|
| Rate for Payer: Cash Price |
$88.25
|
| Rate for Payer: Cash Price |
$88.25
|
| Rate for Payer: Centivo All Commercial |
$72.59
|
| 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 |
$72.59
|
| Rate for Payer: Lucent All Commercial |
$72.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.10
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| 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 |
$46.97
|
|
|
HC MARGIN MAP 5MM
|
Facility
OP
|
$142.33
|
|
| Hospital Charge Code |
41601349
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.97 |
| Max. Negotiated Rate |
$132.37 |
| Rate for Payer: Aetna Commercial |
$120.13
|
| Rate for Payer: Aetna Medicare |
$46.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$46.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$81.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$88.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$51.67
|
| Rate for Payer: Cash Price |
$88.25
|
| Rate for Payer: Cash Price |
$88.25
|
| Rate for Payer: Centivo All Commercial |
$72.59
|
| 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 |
$72.59
|
| Rate for Payer: Lucent All Commercial |
$72.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.10
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| 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 |
$46.97
|
|
