|
HC PORT FILMS - SIX
|
Facility
|
OP
|
$1,734.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
1547422
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$26.05 |
| Max. Negotiated Rate |
$1,612.62 |
| Rate for Payer: Aetna Commercial |
$1,463.50
|
| Rate for Payer: Aetna Medicare |
$554.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$26.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$537.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$995.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,083.92
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$26.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$638.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$610.37
|
| Rate for Payer: Cash Price |
$1,040.40
|
| Rate for Payer: Cash Price |
$1,040.40
|
| Rate for Payer: Centivo All Commercial |
$943.30
|
| Rate for Payer: Cigna All Commercial |
$1,496.44
|
| Rate for Payer: CORVEL All Commercial |
$1,612.62
|
| Rate for Payer: Coventry All Commercial |
$1,525.92
|
| Rate for Payer: Encore All Commercial |
$1,596.15
|
| Rate for Payer: Frontpath All Commercial |
$1,595.28
|
| Rate for Payer: Humana ChoiceCare |
$1,497.66
|
| Rate for Payer: Humana Medicare |
$554.88
|
| Rate for Payer: Lucent All Commercial |
$943.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,560.60
|
| Rate for Payer: Managed Health Services Medicaid |
$26.05
|
| Rate for Payer: MDWise Medicaid |
$26.05
|
| Rate for Payer: PHCS All Commercial |
$1,300.50
|
| Rate for Payer: PHP All Commercial |
$1,315.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$676.26
|
| Rate for Payer: Sagamore Health Network All Products |
$1,338.65
|
| Rate for Payer: Signature Care EPO |
$1,439.22
|
| Rate for Payer: Signature Care PPO |
$1,525.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,473.90
|
| Rate for Payer: United Healthcare Commercial |
$1,366.39
|
| Rate for Payer: United Healthcare Medicare |
$554.88
|
|
|
HC PORT FILMS - SIX
|
Facility
|
IP
|
$1,734.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
1547422
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,300.50 |
| Max. Negotiated Rate |
$1,612.62 |
| Rate for Payer: Aetna Commercial |
$1,498.18
|
| Rate for Payer: Cash Price |
$1,040.40
|
| Rate for Payer: Cigna All Commercial |
$1,496.44
|
| Rate for Payer: CORVEL All Commercial |
$1,612.62
|
| Rate for Payer: Coventry All Commercial |
$1,525.92
|
| Rate for Payer: Encore All Commercial |
$1,596.15
|
| Rate for Payer: Frontpath All Commercial |
$1,595.28
|
| Rate for Payer: Humana ChoiceCare |
$1,497.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,560.60
|
| Rate for Payer: PHCS All Commercial |
$1,300.50
|
| Rate for Payer: PHP All Commercial |
$1,315.07
|
| Rate for Payer: Sagamore Health Network All Products |
$1,338.65
|
| Rate for Payer: Signature Care EPO |
$1,439.22
|
| Rate for Payer: Signature Care PPO |
$1,525.92
|
| Rate for Payer: United Healthcare Commercial |
$1,366.39
|
|
|
HC PORT FILMS - THREE
|
Facility
|
IP
|
$867.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
1547419
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$650.25 |
| Max. Negotiated Rate |
$806.31 |
| Rate for Payer: Aetna Commercial |
$749.09
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Cigna All Commercial |
$748.22
|
| Rate for Payer: CORVEL All Commercial |
$806.31
|
| Rate for Payer: Coventry All Commercial |
$762.96
|
| Rate for Payer: Encore All Commercial |
$798.07
|
| Rate for Payer: Frontpath All Commercial |
$797.64
|
| Rate for Payer: Humana ChoiceCare |
$748.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$780.30
|
| Rate for Payer: PHCS All Commercial |
$650.25
|
| Rate for Payer: PHP All Commercial |
$657.53
|
| Rate for Payer: Sagamore Health Network All Products |
$669.32
|
| Rate for Payer: Signature Care EPO |
$719.61
|
| Rate for Payer: Signature Care PPO |
$762.96
|
| Rate for Payer: United Healthcare Commercial |
$683.20
|
|
|
HC PORT FILMS - THREE
|
Facility
|
OP
|
$867.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
1547419
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$26.05 |
| Max. Negotiated Rate |
$806.31 |
| Rate for Payer: Aetna Commercial |
$731.75
|
| Rate for Payer: Aetna Medicare |
$277.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$26.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$268.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$497.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$541.96
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$26.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$319.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$305.18
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Cash Price |
$520.20
|
| Rate for Payer: Centivo All Commercial |
$471.65
|
| Rate for Payer: Cigna All Commercial |
$748.22
|
| Rate for Payer: CORVEL All Commercial |
$806.31
|
| Rate for Payer: Coventry All Commercial |
$762.96
|
| Rate for Payer: Encore All Commercial |
$798.07
|
| Rate for Payer: Frontpath All Commercial |
$797.64
|
| Rate for Payer: Humana ChoiceCare |
$748.83
|
| Rate for Payer: Humana Medicare |
$277.44
|
| Rate for Payer: Lucent All Commercial |
$471.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$780.30
|
| Rate for Payer: Managed Health Services Medicaid |
$26.05
|
| Rate for Payer: MDWise Medicaid |
$26.05
|
| Rate for Payer: PHCS All Commercial |
$650.25
|
| Rate for Payer: PHP All Commercial |
$657.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$338.13
|
| Rate for Payer: Sagamore Health Network All Products |
$669.32
|
| Rate for Payer: Signature Care EPO |
$719.61
|
| Rate for Payer: Signature Care PPO |
$762.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$736.95
|
| Rate for Payer: United Healthcare Commercial |
$683.20
|
| Rate for Payer: United Healthcare Medicare |
$277.44
|
|
|
HC PORT FILMS - TWO
|
Facility
|
OP
|
$636.48
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
1547418
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$26.05 |
| Max. Negotiated Rate |
$591.93 |
| Rate for Payer: Aetna Commercial |
$537.19
|
| Rate for Payer: Aetna Medicare |
$203.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$26.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$197.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$365.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$397.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$26.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$234.22
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$224.04
|
| Rate for Payer: Cash Price |
$381.89
|
| Rate for Payer: Cash Price |
$381.89
|
| Rate for Payer: Centivo All Commercial |
$346.25
|
| Rate for Payer: Cigna All Commercial |
$549.28
|
| Rate for Payer: CORVEL All Commercial |
$591.93
|
| Rate for Payer: Coventry All Commercial |
$560.10
|
| Rate for Payer: Encore All Commercial |
$585.88
|
| Rate for Payer: Frontpath All Commercial |
$585.56
|
| Rate for Payer: Humana ChoiceCare |
$549.73
|
| Rate for Payer: Humana Medicare |
$203.67
|
| Rate for Payer: Lucent All Commercial |
$346.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$572.83
|
| Rate for Payer: Managed Health Services Medicaid |
$26.05
|
| Rate for Payer: MDWise Medicaid |
$26.05
|
| Rate for Payer: PHCS All Commercial |
$477.36
|
| Rate for Payer: PHP All Commercial |
$482.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$248.23
|
| Rate for Payer: Sagamore Health Network All Products |
$491.36
|
| Rate for Payer: Signature Care EPO |
$528.28
|
| Rate for Payer: Signature Care PPO |
$560.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$541.01
|
| Rate for Payer: United Healthcare Commercial |
$501.55
|
| Rate for Payer: United Healthcare Medicare |
$203.67
|
|
|
HC PORT FILMS - TWO
|
Facility
|
IP
|
$636.48
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
1547418
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$477.36 |
| Max. Negotiated Rate |
$591.93 |
| Rate for Payer: Aetna Commercial |
$549.92
|
| Rate for Payer: Cash Price |
$381.89
|
| Rate for Payer: Cigna All Commercial |
$549.28
|
| Rate for Payer: CORVEL All Commercial |
$591.93
|
| Rate for Payer: Coventry All Commercial |
$560.10
|
| Rate for Payer: Encore All Commercial |
$585.88
|
| Rate for Payer: Frontpath All Commercial |
$585.56
|
| Rate for Payer: Humana ChoiceCare |
$549.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$572.83
|
| Rate for Payer: PHCS All Commercial |
$477.36
|
| Rate for Payer: PHP All Commercial |
$482.71
|
| Rate for Payer: Sagamore Health Network All Products |
$491.36
|
| Rate for Payer: Signature Care EPO |
$528.28
|
| Rate for Payer: Signature Care PPO |
$560.10
|
| Rate for Payer: United Healthcare Commercial |
$501.55
|
|
|
HC PORT IRRIGATION
|
Facility
|
OP
|
$159.12
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
1296523
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$18.90 |
| Max. Negotiated Rate |
$147.98 |
| Rate for Payer: Aetna Commercial |
$134.30
|
| Rate for Payer: Aetna Medicare |
$50.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$18.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$49.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$91.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$99.47
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$18.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$58.56
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$56.01
|
| Rate for Payer: Cash Price |
$95.47
|
| Rate for Payer: Cash Price |
$95.47
|
| Rate for Payer: Centivo All Commercial |
$86.56
|
| Rate for Payer: Cigna All Commercial |
$137.32
|
| Rate for Payer: CORVEL All Commercial |
$147.98
|
| Rate for Payer: Coventry All Commercial |
$140.03
|
| Rate for Payer: Encore All Commercial |
$146.47
|
| Rate for Payer: Frontpath All Commercial |
$146.39
|
| Rate for Payer: Humana ChoiceCare |
$137.43
|
| Rate for Payer: Humana Medicare |
$50.92
|
| Rate for Payer: Lucent All Commercial |
$86.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.21
|
| Rate for Payer: Managed Health Services Medicaid |
$18.90
|
| Rate for Payer: MDWise Medicaid |
$18.90
|
| Rate for Payer: PHCS All Commercial |
$119.34
|
| Rate for Payer: PHP All Commercial |
$120.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$62.06
|
| Rate for Payer: Sagamore Health Network All Products |
$122.84
|
| Rate for Payer: Signature Care EPO |
$132.07
|
| Rate for Payer: Signature Care PPO |
$140.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$135.25
|
| Rate for Payer: United Healthcare Commercial |
$125.39
|
| Rate for Payer: United Healthcare Medicare |
$50.92
|
|
|
HC PORT IRRIGATION
|
Facility
|
IP
|
$159.12
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
1296523
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$119.34 |
| Max. Negotiated Rate |
$147.98 |
| Rate for Payer: Aetna Commercial |
$137.48
|
| Rate for Payer: Cash Price |
$95.47
|
| Rate for Payer: Cigna All Commercial |
$137.32
|
| Rate for Payer: CORVEL All Commercial |
$147.98
|
| Rate for Payer: Coventry All Commercial |
$140.03
|
| Rate for Payer: Encore All Commercial |
$146.47
|
| Rate for Payer: Frontpath All Commercial |
$146.39
|
| Rate for Payer: Humana ChoiceCare |
$137.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.21
|
| Rate for Payer: PHCS All Commercial |
$119.34
|
| Rate for Payer: PHP All Commercial |
$120.68
|
| Rate for Payer: Sagamore Health Network All Products |
$122.84
|
| Rate for Payer: Signature Care EPO |
$132.07
|
| Rate for Payer: Signature Care PPO |
$140.03
|
| Rate for Payer: United Healthcare Commercial |
$125.39
|
|
|
HC POST OP PAIN BLOCK W/IMG GUID
|
Facility
|
IP
|
$1,775.00
|
|
| Hospital Charge Code |
1695555
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$1,331.25 |
| Max. Negotiated Rate |
$1,650.75 |
| Rate for Payer: Aetna Commercial |
$1,533.60
|
| Rate for Payer: Cash Price |
$1,065.00
|
| Rate for Payer: Cigna All Commercial |
$1,531.83
|
| Rate for Payer: CORVEL All Commercial |
$1,650.75
|
| Rate for Payer: Coventry All Commercial |
$1,562.00
|
| Rate for Payer: Encore All Commercial |
$1,633.89
|
| Rate for Payer: Frontpath All Commercial |
$1,633.00
|
| Rate for Payer: Humana ChoiceCare |
$1,533.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,597.50
|
| Rate for Payer: PHCS All Commercial |
$1,331.25
|
| Rate for Payer: PHP All Commercial |
$1,346.16
|
| Rate for Payer: Sagamore Health Network All Products |
$1,370.30
|
| Rate for Payer: Signature Care EPO |
$1,473.25
|
| Rate for Payer: Signature Care PPO |
$1,562.00
|
| Rate for Payer: United Healthcare Commercial |
$1,398.70
|
|
|
HC POST OP PAIN BLOCK W/IMG GUID
|
Facility
|
OP
|
$1,775.00
|
|
| Hospital Charge Code |
1695555
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$550.25 |
| Max. Negotiated Rate |
$1,650.75 |
| Rate for Payer: Aetna Commercial |
$1,498.10
|
| Rate for Payer: Aetna Medicare |
$568.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$550.25
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,019.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,109.55
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$653.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$624.80
|
| Rate for Payer: Cash Price |
$1,065.00
|
| Rate for Payer: Centivo All Commercial |
$965.60
|
| Rate for Payer: Cigna All Commercial |
$1,531.83
|
| Rate for Payer: CORVEL All Commercial |
$1,650.75
|
| Rate for Payer: Coventry All Commercial |
$1,562.00
|
| Rate for Payer: Encore All Commercial |
$1,633.89
|
| Rate for Payer: Frontpath All Commercial |
$1,633.00
|
| Rate for Payer: Humana ChoiceCare |
$1,533.07
|
| Rate for Payer: Humana Medicare |
$568.00
|
| Rate for Payer: Lucent All Commercial |
$965.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,597.50
|
| Rate for Payer: PHCS All Commercial |
$1,331.25
|
| Rate for Payer: PHP All Commercial |
$1,346.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$692.25
|
| Rate for Payer: Sagamore Health Network All Products |
$1,370.30
|
| Rate for Payer: Signature Care EPO |
$1,473.25
|
| Rate for Payer: Signature Care PPO |
$1,562.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,508.75
|
| Rate for Payer: United Healthcare Commercial |
$1,398.70
|
| Rate for Payer: United Healthcare Medicare |
$568.00
|
|
|
HC POST PARTUM ROOM
|
Facility
|
IP
|
$1,644.24
|
|
| Hospital Charge Code |
10010026
|
|
Hospital Revenue Code
|
122
|
| Min. Negotiated Rate |
$1,233.18 |
| Max. Negotiated Rate |
$6,636.80 |
| Rate for Payer: Aetna Commercial |
$1,420.62
|
| Rate for Payer: Aetna Medicare |
$3,904.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,864.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$4,489.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$4,294.40
|
| Rate for Payer: Cash Price |
$986.54
|
| Rate for Payer: Cash Price |
$986.54
|
| Rate for Payer: Centivo All Commercial |
$6,636.80
|
| Rate for Payer: Cigna All Commercial |
$1,418.98
|
| Rate for Payer: CORVEL All Commercial |
$1,529.14
|
| Rate for Payer: Coventry All Commercial |
$1,446.93
|
| Rate for Payer: Encore All Commercial |
$1,513.52
|
| Rate for Payer: Frontpath All Commercial |
$1,512.70
|
| Rate for Payer: Humana ChoiceCare |
$1,420.13
|
| Rate for Payer: Humana Medicare |
$3,904.00
|
| Rate for Payer: Lucent All Commercial |
$6,636.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,479.82
|
| Rate for Payer: PHCS All Commercial |
$1,233.18
|
| Rate for Payer: PHP All Commercial |
$1,246.99
|
| Rate for Payer: Sagamore Health Network All Products |
$1,269.35
|
| Rate for Payer: Signature Care EPO |
$1,364.72
|
| Rate for Payer: Signature Care PPO |
$1,446.93
|
| Rate for Payer: United Healthcare Commercial |
$1,295.66
|
| Rate for Payer: United Healthcare Medicare |
$3,904.00
|
|
|
HC POTASSIUM
|
Facility
|
IP
|
$47.91
|
|
|
Service Code
|
CPT 84132
|
| Hospital Charge Code |
63001110
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.93 |
| Max. Negotiated Rate |
$44.56 |
| Rate for Payer: Aetna Commercial |
$41.39
|
| Rate for Payer: Cash Price |
$28.75
|
| Rate for Payer: Cigna All Commercial |
$41.35
|
| Rate for Payer: CORVEL All Commercial |
$44.56
|
| Rate for Payer: Coventry All Commercial |
$42.16
|
| Rate for Payer: Encore All Commercial |
$44.10
|
| Rate for Payer: Frontpath All Commercial |
$44.08
|
| Rate for Payer: Humana ChoiceCare |
$41.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.12
|
| Rate for Payer: PHCS All Commercial |
$35.93
|
| Rate for Payer: PHP All Commercial |
$36.33
|
| Rate for Payer: Sagamore Health Network All Products |
$36.99
|
| Rate for Payer: Signature Care EPO |
$39.77
|
| Rate for Payer: Signature Care PPO |
$42.16
|
| Rate for Payer: United Healthcare Commercial |
$37.75
|
|
|
HC POTASSIUM
|
Facility
|
OP
|
$47.91
|
|
|
Service Code
|
CPT 84132
|
| Hospital Charge Code |
63001110
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$44.56 |
| Rate for Payer: Aetna Commercial |
$40.44
|
| Rate for Payer: Aetna Medicare |
$15.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$4.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.02
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$4.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.86
|
| Rate for Payer: Cash Price |
$28.75
|
| Rate for Payer: Cash Price |
$28.75
|
| Rate for Payer: Centivo All Commercial |
$26.06
|
| Rate for Payer: Cigna All Commercial |
$41.35
|
| Rate for Payer: CORVEL All Commercial |
$44.56
|
| Rate for Payer: Coventry All Commercial |
$42.16
|
| Rate for Payer: Encore All Commercial |
$44.10
|
| Rate for Payer: Frontpath All Commercial |
$44.08
|
| Rate for Payer: Humana ChoiceCare |
$41.38
|
| Rate for Payer: Humana Medicare |
$15.33
|
| Rate for Payer: Lucent All Commercial |
$26.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.12
|
| Rate for Payer: Managed Health Services Medicaid |
$4.76
|
| Rate for Payer: MDWise Medicaid |
$4.76
|
| Rate for Payer: PHCS All Commercial |
$35.93
|
| Rate for Payer: PHP All Commercial |
$36.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.68
|
| Rate for Payer: Sagamore Health Network All Products |
$36.99
|
| Rate for Payer: Signature Care EPO |
$39.77
|
| Rate for Payer: Signature Care PPO |
$42.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.72
|
| Rate for Payer: United Healthcare Commercial |
$37.75
|
| Rate for Payer: United Healthcare Medicare |
$15.33
|
|
|
HC POTASSIUM URINE
|
Facility
|
IP
|
$100.42
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
63001152
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$75.31 |
| Max. Negotiated Rate |
$93.39 |
| Rate for Payer: Aetna Commercial |
$86.76
|
| Rate for Payer: Cash Price |
$60.25
|
| Rate for Payer: Cigna All Commercial |
$86.66
|
| Rate for Payer: CORVEL All Commercial |
$93.39
|
| Rate for Payer: Coventry All Commercial |
$88.37
|
| Rate for Payer: Encore All Commercial |
$92.44
|
| Rate for Payer: Frontpath All Commercial |
$92.39
|
| Rate for Payer: Humana ChoiceCare |
$86.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.38
|
| Rate for Payer: PHCS All Commercial |
$75.31
|
| Rate for Payer: PHP All Commercial |
$76.16
|
| Rate for Payer: Sagamore Health Network All Products |
$77.52
|
| Rate for Payer: Signature Care EPO |
$83.35
|
| Rate for Payer: Signature Care PPO |
$88.37
|
| Rate for Payer: United Healthcare Commercial |
$79.13
|
|
|
HC POTASSIUM URINE
|
Facility
|
OP
|
$100.42
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
63001152
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.73 |
| Max. Negotiated Rate |
$93.39 |
| Rate for Payer: Aetna Commercial |
$84.75
|
| Rate for Payer: Aetna Medicare |
$32.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$4.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$46.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$46.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$4.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$35.35
|
| Rate for Payer: Cash Price |
$60.25
|
| Rate for Payer: Cash Price |
$60.25
|
| Rate for Payer: Centivo All Commercial |
$54.63
|
| Rate for Payer: Cigna All Commercial |
$86.66
|
| Rate for Payer: CORVEL All Commercial |
$93.39
|
| Rate for Payer: Coventry All Commercial |
$88.37
|
| Rate for Payer: Encore All Commercial |
$92.44
|
| Rate for Payer: Frontpath All Commercial |
$92.39
|
| Rate for Payer: Humana ChoiceCare |
$86.73
|
| Rate for Payer: Humana Medicare |
$32.13
|
| Rate for Payer: Lucent All Commercial |
$54.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.38
|
| Rate for Payer: Managed Health Services Medicaid |
$4.73
|
| Rate for Payer: MDWise Medicaid |
$4.73
|
| Rate for Payer: PHCS All Commercial |
$75.31
|
| Rate for Payer: PHP All Commercial |
$76.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.16
|
| Rate for Payer: Sagamore Health Network All Products |
$77.52
|
| Rate for Payer: Signature Care EPO |
$83.35
|
| Rate for Payer: Signature Care PPO |
$88.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.36
|
| Rate for Payer: United Healthcare Commercial |
$79.13
|
| Rate for Payer: United Healthcare Medicare |
$32.13
|
|
|
HC POUCH CLAMP OSTOMY
|
Facility
|
IP
|
$1.68
|
|
| Hospital Charge Code |
41601034
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$1.56 |
| Rate for Payer: Aetna Commercial |
$1.45
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cigna All Commercial |
$1.45
|
| Rate for Payer: CORVEL All Commercial |
$1.56
|
| Rate for Payer: Coventry All Commercial |
$1.48
|
| Rate for Payer: Encore All Commercial |
$1.55
|
| Rate for Payer: Frontpath All Commercial |
$1.55
|
| Rate for Payer: Humana ChoiceCare |
$1.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.51
|
| Rate for Payer: PHCS All Commercial |
$1.26
|
| Rate for Payer: PHP All Commercial |
$1.27
|
| Rate for Payer: Sagamore Health Network All Products |
$1.30
|
| Rate for Payer: Signature Care EPO |
$1.39
|
| Rate for Payer: Signature Care PPO |
$1.48
|
| Rate for Payer: United Healthcare Commercial |
$1.32
|
|
|
HC POUCH CLAMP OSTOMY
|
Facility
|
OP
|
$1.68
|
|
| Hospital Charge Code |
41601034
|
|
Hospital Revenue Code
|
271
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$21.01 |
| Rate for Payer: Aetna Commercial |
$1.42
|
| Rate for Payer: Aetna Medicare |
$0.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$21.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.05
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Cash Price |
$1.01
|
| Rate for Payer: Centivo All Commercial |
$0.91
|
| Rate for Payer: Cigna All Commercial |
$1.45
|
| Rate for Payer: CORVEL All Commercial |
$1.56
|
| Rate for Payer: Coventry All Commercial |
$1.48
|
| Rate for Payer: Encore All Commercial |
$1.55
|
| Rate for Payer: Frontpath All Commercial |
$1.55
|
| Rate for Payer: Humana ChoiceCare |
$1.45
|
| Rate for Payer: Humana Medicare |
$0.54
|
| Rate for Payer: Lucent All Commercial |
$0.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.51
|
| Rate for Payer: Managed Health Services Medicaid |
$21.01
|
| Rate for Payer: MDWise Medicaid |
$21.01
|
| Rate for Payer: PHCS All Commercial |
$1.26
|
| Rate for Payer: PHP All Commercial |
$1.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.66
|
| Rate for Payer: Sagamore Health Network All Products |
$1.30
|
| Rate for Payer: Signature Care EPO |
$1.39
|
| Rate for Payer: Signature Care PPO |
$1.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.43
|
| Rate for Payer: United Healthcare Commercial |
$1.32
|
| Rate for Payer: United Healthcare Medicare |
$0.54
|
|
|
HC PREALBUMIN
|
Facility
|
IP
|
$169.71
|
|
|
Service Code
|
CPT 84134
|
| Hospital Charge Code |
63001003
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$127.28 |
| Max. Negotiated Rate |
$157.83 |
| Rate for Payer: Aetna Commercial |
$146.63
|
| Rate for Payer: Cash Price |
$101.83
|
| Rate for Payer: Cigna All Commercial |
$146.46
|
| Rate for Payer: CORVEL All Commercial |
$157.83
|
| Rate for Payer: Coventry All Commercial |
$149.34
|
| Rate for Payer: Encore All Commercial |
$156.22
|
| Rate for Payer: Frontpath All Commercial |
$156.13
|
| Rate for Payer: Humana ChoiceCare |
$146.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$152.74
|
| Rate for Payer: PHCS All Commercial |
$127.28
|
| Rate for Payer: PHP All Commercial |
$128.71
|
| Rate for Payer: Sagamore Health Network All Products |
$131.02
|
| Rate for Payer: Signature Care EPO |
$140.86
|
| Rate for Payer: Signature Care PPO |
$149.34
|
| Rate for Payer: United Healthcare Commercial |
$133.73
|
|
|
HC PREALBUMIN
|
Facility
|
OP
|
$169.71
|
|
|
Service Code
|
CPT 84134
|
| Hospital Charge Code |
63001003
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.59 |
| Max. Negotiated Rate |
$157.83 |
| Rate for Payer: Aetna Commercial |
$143.24
|
| Rate for Payer: Aetna Medicare |
$54.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$14.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$52.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$78.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$78.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$14.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$62.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$59.74
|
| Rate for Payer: Cash Price |
$101.83
|
| Rate for Payer: Cash Price |
$101.83
|
| Rate for Payer: Centivo All Commercial |
$92.32
|
| Rate for Payer: Cigna All Commercial |
$146.46
|
| Rate for Payer: CORVEL All Commercial |
$157.83
|
| Rate for Payer: Coventry All Commercial |
$149.34
|
| Rate for Payer: Encore All Commercial |
$156.22
|
| Rate for Payer: Frontpath All Commercial |
$156.13
|
| Rate for Payer: Humana ChoiceCare |
$146.58
|
| Rate for Payer: Humana Medicare |
$54.31
|
| Rate for Payer: Lucent All Commercial |
$92.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$152.74
|
| Rate for Payer: Managed Health Services Medicaid |
$14.59
|
| Rate for Payer: MDWise Medicaid |
$14.59
|
| Rate for Payer: PHCS All Commercial |
$127.28
|
| Rate for Payer: PHP All Commercial |
$128.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$66.19
|
| Rate for Payer: Sagamore Health Network All Products |
$131.02
|
| Rate for Payer: Signature Care EPO |
$140.86
|
| Rate for Payer: Signature Care PPO |
$149.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$144.25
|
| Rate for Payer: United Healthcare Commercial |
$133.73
|
| Rate for Payer: United Healthcare Medicare |
$54.31
|
|
|
HC PREGNENOLONE-SERUM
|
Facility
|
IP
|
$192.98
|
|
|
Service Code
|
CPT 84140
|
| Hospital Charge Code |
63001356
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$144.74 |
| Max. Negotiated Rate |
$179.47 |
| Rate for Payer: Aetna Commercial |
$166.73
|
| Rate for Payer: Cash Price |
$115.79
|
| Rate for Payer: Cigna All Commercial |
$166.54
|
| Rate for Payer: CORVEL All Commercial |
$179.47
|
| Rate for Payer: Coventry All Commercial |
$169.82
|
| Rate for Payer: Encore All Commercial |
$177.64
|
| Rate for Payer: Frontpath All Commercial |
$177.54
|
| Rate for Payer: Humana ChoiceCare |
$166.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$173.68
|
| Rate for Payer: PHCS All Commercial |
$144.74
|
| Rate for Payer: PHP All Commercial |
$146.36
|
| Rate for Payer: Sagamore Health Network All Products |
$148.98
|
| Rate for Payer: Signature Care EPO |
$160.17
|
| Rate for Payer: Signature Care PPO |
$169.82
|
| Rate for Payer: United Healthcare Commercial |
$152.07
|
|
|
HC PREGNENOLONE-SERUM
|
Facility
|
OP
|
$192.98
|
|
|
Service Code
|
CPT 84140
|
| Hospital Charge Code |
63001356
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.67 |
| Max. Negotiated Rate |
$179.47 |
| Rate for Payer: Aetna Commercial |
$162.88
|
| Rate for Payer: Aetna Medicare |
$61.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$20.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$59.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$88.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$88.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$20.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$71.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$67.93
|
| Rate for Payer: Cash Price |
$115.79
|
| Rate for Payer: Cash Price |
$115.79
|
| Rate for Payer: Centivo All Commercial |
$104.98
|
| Rate for Payer: Cigna All Commercial |
$166.54
|
| Rate for Payer: CORVEL All Commercial |
$179.47
|
| Rate for Payer: Coventry All Commercial |
$169.82
|
| Rate for Payer: Encore All Commercial |
$177.64
|
| Rate for Payer: Frontpath All Commercial |
$177.54
|
| Rate for Payer: Humana ChoiceCare |
$166.68
|
| Rate for Payer: Humana Medicare |
$61.75
|
| Rate for Payer: Lucent All Commercial |
$104.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$173.68
|
| Rate for Payer: Managed Health Services Medicaid |
$20.67
|
| Rate for Payer: MDWise Medicaid |
$20.67
|
| Rate for Payer: PHCS All Commercial |
$144.74
|
| Rate for Payer: PHP All Commercial |
$146.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$75.26
|
| Rate for Payer: Sagamore Health Network All Products |
$148.98
|
| Rate for Payer: Signature Care EPO |
$160.17
|
| Rate for Payer: Signature Care PPO |
$169.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$164.03
|
| Rate for Payer: United Healthcare Commercial |
$152.07
|
| Rate for Payer: United Healthcare Medicare |
$61.75
|
|
|
HC PREMIUM POWDER
|
Facility
|
OP
|
$5.95
|
|
| Hospital Charge Code |
41601088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$31.20 |
| Rate for Payer: Aetna Commercial |
$5.02
|
| Rate for Payer: Aetna Medicare |
$1.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.72
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.09
|
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: Centivo All Commercial |
$3.24
|
| Rate for Payer: Cigna All Commercial |
$5.13
|
| Rate for Payer: CORVEL All Commercial |
$5.53
|
| Rate for Payer: Coventry All Commercial |
$5.24
|
| Rate for Payer: Encore All Commercial |
$5.48
|
| Rate for Payer: Frontpath All Commercial |
$5.47
|
| Rate for Payer: Humana ChoiceCare |
$5.14
|
| Rate for Payer: Humana Medicare |
$1.90
|
| Rate for Payer: Lucent All Commercial |
$3.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.36
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$4.46
|
| Rate for Payer: PHP All Commercial |
$4.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.32
|
| Rate for Payer: Sagamore Health Network All Products |
$4.59
|
| Rate for Payer: Signature Care EPO |
$4.94
|
| Rate for Payer: Signature Care PPO |
$5.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.06
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$1.90
|
|
|
HC PREMIUM POWDER
|
Facility
|
IP
|
$5.95
|
|
| Hospital Charge Code |
41601088
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$5.53 |
| Rate for Payer: Aetna Commercial |
$5.14
|
| Rate for Payer: Cash Price |
$3.57
|
| Rate for Payer: Cigna All Commercial |
$5.13
|
| Rate for Payer: CORVEL All Commercial |
$5.53
|
| Rate for Payer: Coventry All Commercial |
$5.24
|
| Rate for Payer: Encore All Commercial |
$5.48
|
| Rate for Payer: Frontpath All Commercial |
$5.47
|
| Rate for Payer: Humana ChoiceCare |
$5.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.36
|
| Rate for Payer: PHCS All Commercial |
$4.46
|
| Rate for Payer: PHP All Commercial |
$4.51
|
| Rate for Payer: Sagamore Health Network All Products |
$4.59
|
| Rate for Payer: Signature Care EPO |
$4.94
|
| Rate for Payer: Signature Care PPO |
$5.24
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
|
|
HC PRESSURE TRANSDUCER KIT
|
Facility
|
IP
|
$113.33
|
|
| Hospital Charge Code |
41601224
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$85.00 |
| Max. Negotiated Rate |
$105.40 |
| Rate for Payer: Aetna Commercial |
$97.92
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cigna All Commercial |
$97.80
|
| Rate for Payer: CORVEL All Commercial |
$105.40
|
| Rate for Payer: Coventry All Commercial |
$99.73
|
| Rate for Payer: Encore All Commercial |
$104.32
|
| Rate for Payer: Frontpath All Commercial |
$104.26
|
| Rate for Payer: Humana ChoiceCare |
$97.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$102.00
|
| Rate for Payer: PHCS All Commercial |
$85.00
|
| Rate for Payer: PHP All Commercial |
$85.95
|
| Rate for Payer: Sagamore Health Network All Products |
$87.49
|
| Rate for Payer: Signature Care EPO |
$94.06
|
| Rate for Payer: Signature Care PPO |
$99.73
|
| Rate for Payer: United Healthcare Commercial |
$89.30
|
|
|
HC PRESSURE TRANSDUCER KIT
|
Facility
|
OP
|
$113.33
|
|
| Hospital Charge Code |
41601224
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$105.40 |
| Rate for Payer: Aetna Commercial |
$95.65
|
| Rate for Payer: Aetna Medicare |
$36.27
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$65.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.84
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$41.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$39.89
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Cash Price |
$68.00
|
| Rate for Payer: Centivo All Commercial |
$61.65
|
| Rate for Payer: Cigna All Commercial |
$97.80
|
| Rate for Payer: CORVEL All Commercial |
$105.40
|
| Rate for Payer: Coventry All Commercial |
$99.73
|
| Rate for Payer: Encore All Commercial |
$104.32
|
| Rate for Payer: Frontpath All Commercial |
$104.26
|
| Rate for Payer: Humana ChoiceCare |
$97.88
|
| Rate for Payer: Humana Medicare |
$36.27
|
| Rate for Payer: Lucent All Commercial |
$61.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$102.00
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$85.00
|
| Rate for Payer: PHP All Commercial |
$85.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$44.20
|
| Rate for Payer: Sagamore Health Network All Products |
$87.49
|
| Rate for Payer: Signature Care EPO |
$94.06
|
| Rate for Payer: Signature Care PPO |
$99.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$96.33
|
| Rate for Payer: United Healthcare Commercial |
$89.30
|
| Rate for Payer: United Healthcare Medicare |
$36.27
|
|
