|
HC MRI UP EXTR; NOT JOINT W&WO CONTR LT LTD
|
Facility
IP
|
$1,734.00
|
|
|
Service Code
|
CPT 73220 LT,52
|
| Hospital Charge Code |
01579921
|
|
Hospital Revenue Code
|
614
|
| 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 |
$1,075.08
|
| 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 MRI UP EXTR; NOT JOINT W&WO CONTR LT LTD
|
Facility
OP
|
$1,734.00
|
|
|
Service Code
|
CPT 73220 LT,52
|
| Hospital Charge Code |
01579921
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$572.22 |
| Max. Negotiated Rate |
$1,612.62 |
| Rate for Payer: Aetna Commercial |
$1,463.50
|
| Rate for Payer: Aetna Medicare |
$572.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$572.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,583.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,583.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$658.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$629.44
|
| Rate for Payer: Cash Price |
$1,075.08
|
| Rate for Payer: Cash Price |
$1,075.08
|
| Rate for Payer: Centivo All Commercial |
$884.34
|
| 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 |
$884.34
|
| Rate for Payer: Lucent All Commercial |
$884.34
|
| 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: 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 |
$572.22
|
|
|
HC MRI UP EXTR; NOT JOINT W&WO CONTR RT LTD
|
Facility
IP
|
$1,734.00
|
|
|
Service Code
|
CPT 73220 RT,52
|
| Hospital Charge Code |
01579922
|
|
Hospital Revenue Code
|
614
|
| 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 |
$1,075.08
|
| 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 MRI UP EXTR; NOT JOINT W&WO CONTR RT LTD
|
Facility
OP
|
$1,734.00
|
|
|
Service Code
|
CPT 73220 RT,52
|
| Hospital Charge Code |
01579922
|
|
Hospital Revenue Code
|
614
|
| Min. Negotiated Rate |
$572.22 |
| Max. Negotiated Rate |
$1,612.62 |
| Rate for Payer: Aetna Commercial |
$1,463.50
|
| Rate for Payer: Aetna Medicare |
$572.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$572.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,583.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,583.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$658.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$629.44
|
| Rate for Payer: Cash Price |
$1,075.08
|
| Rate for Payer: Cash Price |
$1,075.08
|
| Rate for Payer: Centivo All Commercial |
$884.34
|
| 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 |
$884.34
|
| Rate for Payer: Lucent All Commercial |
$884.34
|
| 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: 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 |
$572.22
|
|
|
HC MRI-UPPER EXT JOINT W/CON BI
|
Facility
IP
|
$4,335.00
|
|
|
Service Code
|
CPT 73222 50
|
| Hospital Charge Code |
21574222
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,251.25 |
| Max. Negotiated Rate |
$4,031.55 |
| Rate for Payer: Aetna Commercial |
$3,745.44
|
| Rate for Payer: Cash Price |
$2,687.70
|
| Rate for Payer: Cigna All Commercial |
$3,741.10
|
| Rate for Payer: CORVEL All Commercial |
$4,031.55
|
| Rate for Payer: Coventry All Commercial |
$3,814.80
|
| Rate for Payer: Encore All Commercial |
$3,990.37
|
| Rate for Payer: Frontpath All Commercial |
$3,988.20
|
| Rate for Payer: Humana ChoiceCare |
$3,744.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,901.50
|
| Rate for Payer: PHCS All Commercial |
$3,251.25
|
| Rate for Payer: PHP All Commercial |
$3,287.66
|
| Rate for Payer: Sagamore Health Network All Products |
$3,346.62
|
| Rate for Payer: Signature Care EPO |
$3,598.05
|
| Rate for Payer: Signature Care PPO |
$3,814.80
|
| Rate for Payer: United Healthcare Commercial |
$3,415.98
|
|
|
HC MRI-UPPER EXT JOINT W/CON BI
|
Facility
OP
|
$4,335.00
|
|
|
Service Code
|
CPT 73222 50
|
| Hospital Charge Code |
21574222
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,430.55 |
| Max. Negotiated Rate |
$4,031.55 |
| Rate for Payer: Aetna Commercial |
$3,658.74
|
| Rate for Payer: Aetna Medicare |
$1,430.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,430.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,583.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,583.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,645.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,573.60
|
| Rate for Payer: Cash Price |
$2,687.70
|
| Rate for Payer: Cash Price |
$2,687.70
|
| Rate for Payer: Centivo All Commercial |
$2,210.85
|
| Rate for Payer: Cigna All Commercial |
$3,741.10
|
| Rate for Payer: CORVEL All Commercial |
$4,031.55
|
| Rate for Payer: Coventry All Commercial |
$3,814.80
|
| Rate for Payer: Encore All Commercial |
$3,990.37
|
| Rate for Payer: Frontpath All Commercial |
$3,988.20
|
| Rate for Payer: Humana ChoiceCare |
$3,744.14
|
| Rate for Payer: Humana Medicare |
$2,210.85
|
| Rate for Payer: Lucent All Commercial |
$2,210.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,901.50
|
| Rate for Payer: PHCS All Commercial |
$3,251.25
|
| Rate for Payer: PHP All Commercial |
$3,287.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,690.65
|
| Rate for Payer: Sagamore Health Network All Products |
$3,346.62
|
| Rate for Payer: Signature Care EPO |
$3,598.05
|
| Rate for Payer: Signature Care PPO |
$3,814.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,684.75
|
| Rate for Payer: United Healthcare Commercial |
$3,415.98
|
| Rate for Payer: United Healthcare Medicare |
$1,430.55
|
|
|
HC MRI-UPPER EXT JOINT W/CON LT
|
Facility
IP
|
$2,244.00
|
|
|
Service Code
|
CPT 73222 LT
|
| Hospital Charge Code |
01574222
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,683.00 |
| Max. Negotiated Rate |
$2,086.92 |
| Rate for Payer: Aetna Commercial |
$1,938.82
|
| Rate for Payer: Cash Price |
$1,391.28
|
| Rate for Payer: Cigna All Commercial |
$1,936.57
|
| Rate for Payer: CORVEL All Commercial |
$2,086.92
|
| Rate for Payer: Coventry All Commercial |
$1,974.72
|
| Rate for Payer: Encore All Commercial |
$2,065.60
|
| Rate for Payer: Frontpath All Commercial |
$2,064.48
|
| Rate for Payer: Humana ChoiceCare |
$1,938.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,019.60
|
| Rate for Payer: PHCS All Commercial |
$1,683.00
|
| Rate for Payer: PHP All Commercial |
$1,701.85
|
| Rate for Payer: Sagamore Health Network All Products |
$1,732.37
|
| Rate for Payer: Signature Care EPO |
$1,862.52
|
| Rate for Payer: Signature Care PPO |
$1,974.72
|
| Rate for Payer: United Healthcare Commercial |
$1,768.27
|
|
|
HC MRI-UPPER EXT JOINT W/CON LT
|
Facility
OP
|
$2,244.00
|
|
|
Service Code
|
CPT 73222 LT
|
| Hospital Charge Code |
01574222
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$740.52 |
| Max. Negotiated Rate |
$2,086.92 |
| Rate for Payer: Aetna Commercial |
$1,893.94
|
| Rate for Payer: Aetna Medicare |
$740.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$740.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,583.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,583.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$851.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$814.57
|
| Rate for Payer: Cash Price |
$1,391.28
|
| Rate for Payer: Cash Price |
$1,391.28
|
| Rate for Payer: Centivo All Commercial |
$1,144.44
|
| Rate for Payer: Cigna All Commercial |
$1,936.57
|
| Rate for Payer: CORVEL All Commercial |
$2,086.92
|
| Rate for Payer: Coventry All Commercial |
$1,974.72
|
| Rate for Payer: Encore All Commercial |
$2,065.60
|
| Rate for Payer: Frontpath All Commercial |
$2,064.48
|
| Rate for Payer: Humana ChoiceCare |
$1,938.14
|
| Rate for Payer: Humana Medicare |
$1,144.44
|
| Rate for Payer: Lucent All Commercial |
$1,144.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,019.60
|
| Rate for Payer: PHCS All Commercial |
$1,683.00
|
| Rate for Payer: PHP All Commercial |
$1,701.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$875.16
|
| Rate for Payer: Sagamore Health Network All Products |
$1,732.37
|
| Rate for Payer: Signature Care EPO |
$1,862.52
|
| Rate for Payer: Signature Care PPO |
$1,974.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,907.40
|
| Rate for Payer: United Healthcare Commercial |
$1,768.27
|
| Rate for Payer: United Healthcare Medicare |
$740.52
|
|
|
HC MRI-UPPER EXT JOINT W/CON RT
|
Facility
OP
|
$2,244.00
|
|
|
Service Code
|
CPT 73222 RT
|
| Hospital Charge Code |
11574222
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$740.52 |
| Max. Negotiated Rate |
$2,086.92 |
| Rate for Payer: Aetna Commercial |
$1,893.94
|
| Rate for Payer: Aetna Medicare |
$740.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$740.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,583.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,583.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$851.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$814.57
|
| Rate for Payer: Cash Price |
$1,391.28
|
| Rate for Payer: Cash Price |
$1,391.28
|
| Rate for Payer: Centivo All Commercial |
$1,144.44
|
| Rate for Payer: Cigna All Commercial |
$1,936.57
|
| Rate for Payer: CORVEL All Commercial |
$2,086.92
|
| Rate for Payer: Coventry All Commercial |
$1,974.72
|
| Rate for Payer: Encore All Commercial |
$2,065.60
|
| Rate for Payer: Frontpath All Commercial |
$2,064.48
|
| Rate for Payer: Humana ChoiceCare |
$1,938.14
|
| Rate for Payer: Humana Medicare |
$1,144.44
|
| Rate for Payer: Lucent All Commercial |
$1,144.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,019.60
|
| Rate for Payer: PHCS All Commercial |
$1,683.00
|
| Rate for Payer: PHP All Commercial |
$1,701.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$875.16
|
| Rate for Payer: Sagamore Health Network All Products |
$1,732.37
|
| Rate for Payer: Signature Care EPO |
$1,862.52
|
| Rate for Payer: Signature Care PPO |
$1,974.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,907.40
|
| Rate for Payer: United Healthcare Commercial |
$1,768.27
|
| Rate for Payer: United Healthcare Medicare |
$740.52
|
|
|
HC MRI-UPPER EXT JOINT W/CON RT
|
Facility
IP
|
$2,244.00
|
|
|
Service Code
|
CPT 73222 RT
|
| Hospital Charge Code |
11574222
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,683.00 |
| Max. Negotiated Rate |
$2,086.92 |
| Rate for Payer: Aetna Commercial |
$1,938.82
|
| Rate for Payer: Cash Price |
$1,391.28
|
| Rate for Payer: Cigna All Commercial |
$1,936.57
|
| Rate for Payer: CORVEL All Commercial |
$2,086.92
|
| Rate for Payer: Coventry All Commercial |
$1,974.72
|
| Rate for Payer: Encore All Commercial |
$2,065.60
|
| Rate for Payer: Frontpath All Commercial |
$2,064.48
|
| Rate for Payer: Humana ChoiceCare |
$1,938.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,019.60
|
| Rate for Payer: PHCS All Commercial |
$1,683.00
|
| Rate for Payer: PHP All Commercial |
$1,701.85
|
| Rate for Payer: Sagamore Health Network All Products |
$1,732.37
|
| Rate for Payer: Signature Care EPO |
$1,862.52
|
| Rate for Payer: Signature Care PPO |
$1,974.72
|
| Rate for Payer: United Healthcare Commercial |
$1,768.27
|
|
|
HC MRI-UPPER EXT JOINT W/O CON BI
|
Facility
IP
|
$2,754.00
|
|
|
Service Code
|
CPT 73221 50
|
| Hospital Charge Code |
21573221
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$2,065.50 |
| Max. Negotiated Rate |
$2,561.22 |
| Rate for Payer: Aetna Commercial |
$2,379.46
|
| Rate for Payer: Cash Price |
$1,707.48
|
| Rate for Payer: Cigna All Commercial |
$2,376.70
|
| Rate for Payer: CORVEL All Commercial |
$2,561.22
|
| Rate for Payer: Coventry All Commercial |
$2,423.52
|
| Rate for Payer: Encore All Commercial |
$2,535.06
|
| Rate for Payer: Frontpath All Commercial |
$2,533.68
|
| Rate for Payer: Humana ChoiceCare |
$2,378.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,478.60
|
| Rate for Payer: PHCS All Commercial |
$2,065.50
|
| Rate for Payer: PHP All Commercial |
$2,088.63
|
| Rate for Payer: Sagamore Health Network All Products |
$2,126.09
|
| Rate for Payer: Signature Care EPO |
$2,285.82
|
| Rate for Payer: Signature Care PPO |
$2,423.52
|
| Rate for Payer: United Healthcare Commercial |
$2,170.15
|
|
|
HC MRI-UPPER EXT JOINT W/O CON BI
|
Facility
OP
|
$2,754.00
|
|
|
Service Code
|
CPT 73221 50
|
| Hospital Charge Code |
21573221
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$908.82 |
| Max. Negotiated Rate |
$2,561.22 |
| Rate for Payer: Aetna Commercial |
$2,324.38
|
| Rate for Payer: Aetna Medicare |
$908.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$908.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,583.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,583.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,045.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$999.70
|
| Rate for Payer: Cash Price |
$1,707.48
|
| Rate for Payer: Cash Price |
$1,707.48
|
| Rate for Payer: Centivo All Commercial |
$1,404.54
|
| Rate for Payer: Cigna All Commercial |
$2,376.70
|
| Rate for Payer: CORVEL All Commercial |
$2,561.22
|
| Rate for Payer: Coventry All Commercial |
$2,423.52
|
| Rate for Payer: Encore All Commercial |
$2,535.06
|
| Rate for Payer: Frontpath All Commercial |
$2,533.68
|
| Rate for Payer: Humana ChoiceCare |
$2,378.63
|
| Rate for Payer: Humana Medicare |
$1,404.54
|
| Rate for Payer: Lucent All Commercial |
$1,404.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,478.60
|
| Rate for Payer: PHCS All Commercial |
$2,065.50
|
| Rate for Payer: PHP All Commercial |
$2,088.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,074.06
|
| Rate for Payer: Sagamore Health Network All Products |
$2,126.09
|
| Rate for Payer: Signature Care EPO |
$2,285.82
|
| Rate for Payer: Signature Care PPO |
$2,423.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,340.90
|
| Rate for Payer: United Healthcare Commercial |
$2,170.15
|
| Rate for Payer: United Healthcare Medicare |
$908.82
|
|
|
HC MRI-UPPER EXT JOINT W/O CON LT
|
Facility
IP
|
$2,038.98
|
|
|
Service Code
|
CPT 73221 LT
|
| Hospital Charge Code |
01573221
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,529.24 |
| Max. Negotiated Rate |
$1,896.25 |
| Rate for Payer: Aetna Commercial |
$1,761.68
|
| Rate for Payer: Cash Price |
$1,264.17
|
| Rate for Payer: Cigna All Commercial |
$1,759.64
|
| Rate for Payer: CORVEL All Commercial |
$1,896.25
|
| Rate for Payer: Coventry All Commercial |
$1,794.30
|
| Rate for Payer: Encore All Commercial |
$1,876.88
|
| Rate for Payer: Frontpath All Commercial |
$1,875.86
|
| Rate for Payer: Humana ChoiceCare |
$1,761.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,835.08
|
| Rate for Payer: PHCS All Commercial |
$1,529.24
|
| Rate for Payer: PHP All Commercial |
$1,546.36
|
| Rate for Payer: Sagamore Health Network All Products |
$1,574.09
|
| Rate for Payer: Signature Care EPO |
$1,692.35
|
| Rate for Payer: Signature Care PPO |
$1,794.30
|
| Rate for Payer: United Healthcare Commercial |
$1,606.72
|
|
|
HC MRI-UPPER EXT JOINT W/O CON LT
|
Facility
OP
|
$2,038.98
|
|
|
Service Code
|
CPT 73221 LT
|
| Hospital Charge Code |
01573221
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$672.86 |
| Max. Negotiated Rate |
$1,896.25 |
| Rate for Payer: Aetna Commercial |
$1,720.90
|
| Rate for Payer: Aetna Medicare |
$672.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$672.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,583.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,583.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$773.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$740.15
|
| Rate for Payer: Cash Price |
$1,264.17
|
| Rate for Payer: Cash Price |
$1,264.17
|
| Rate for Payer: Centivo All Commercial |
$1,039.88
|
| Rate for Payer: Cigna All Commercial |
$1,759.64
|
| Rate for Payer: CORVEL All Commercial |
$1,896.25
|
| Rate for Payer: Coventry All Commercial |
$1,794.30
|
| Rate for Payer: Encore All Commercial |
$1,876.88
|
| Rate for Payer: Frontpath All Commercial |
$1,875.86
|
| Rate for Payer: Humana ChoiceCare |
$1,761.07
|
| Rate for Payer: Humana Medicare |
$1,039.88
|
| Rate for Payer: Lucent All Commercial |
$1,039.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,835.08
|
| Rate for Payer: PHCS All Commercial |
$1,529.24
|
| Rate for Payer: PHP All Commercial |
$1,546.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$795.20
|
| Rate for Payer: Sagamore Health Network All Products |
$1,574.09
|
| Rate for Payer: Signature Care EPO |
$1,692.35
|
| Rate for Payer: Signature Care PPO |
$1,794.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,733.13
|
| Rate for Payer: United Healthcare Commercial |
$1,606.72
|
| Rate for Payer: United Healthcare Medicare |
$672.86
|
|
|
HC MRI-UPPER EXT JOINT W/O CON RT
|
Facility
IP
|
$2,038.98
|
|
|
Service Code
|
CPT 73221 RT
|
| Hospital Charge Code |
11573221
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,529.24 |
| Max. Negotiated Rate |
$1,896.25 |
| Rate for Payer: Aetna Commercial |
$1,761.68
|
| Rate for Payer: Cash Price |
$1,264.17
|
| Rate for Payer: Cigna All Commercial |
$1,759.64
|
| Rate for Payer: CORVEL All Commercial |
$1,896.25
|
| Rate for Payer: Coventry All Commercial |
$1,794.30
|
| Rate for Payer: Encore All Commercial |
$1,876.88
|
| Rate for Payer: Frontpath All Commercial |
$1,875.86
|
| Rate for Payer: Humana ChoiceCare |
$1,761.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,835.08
|
| Rate for Payer: PHCS All Commercial |
$1,529.24
|
| Rate for Payer: PHP All Commercial |
$1,546.36
|
| Rate for Payer: Sagamore Health Network All Products |
$1,574.09
|
| Rate for Payer: Signature Care EPO |
$1,692.35
|
| Rate for Payer: Signature Care PPO |
$1,794.30
|
| Rate for Payer: United Healthcare Commercial |
$1,606.72
|
|
|
HC MRI-UPPER EXT JOINT W/O CON RT
|
Facility
OP
|
$2,038.98
|
|
|
Service Code
|
CPT 73221 RT
|
| Hospital Charge Code |
11573221
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$672.86 |
| Max. Negotiated Rate |
$1,896.25 |
| Rate for Payer: Aetna Commercial |
$1,720.90
|
| Rate for Payer: Aetna Medicare |
$672.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$672.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,583.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,583.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$773.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$740.15
|
| Rate for Payer: Cash Price |
$1,264.17
|
| Rate for Payer: Cash Price |
$1,264.17
|
| Rate for Payer: Centivo All Commercial |
$1,039.88
|
| Rate for Payer: Cigna All Commercial |
$1,759.64
|
| Rate for Payer: CORVEL All Commercial |
$1,896.25
|
| Rate for Payer: Coventry All Commercial |
$1,794.30
|
| Rate for Payer: Encore All Commercial |
$1,876.88
|
| Rate for Payer: Frontpath All Commercial |
$1,875.86
|
| Rate for Payer: Humana ChoiceCare |
$1,761.07
|
| Rate for Payer: Humana Medicare |
$1,039.88
|
| Rate for Payer: Lucent All Commercial |
$1,039.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,835.08
|
| Rate for Payer: PHCS All Commercial |
$1,529.24
|
| Rate for Payer: PHP All Commercial |
$1,546.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$795.20
|
| Rate for Payer: Sagamore Health Network All Products |
$1,574.09
|
| Rate for Payer: Signature Care EPO |
$1,692.35
|
| Rate for Payer: Signature Care PPO |
$1,794.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,733.13
|
| Rate for Payer: United Healthcare Commercial |
$1,606.72
|
| Rate for Payer: United Healthcare Medicare |
$672.86
|
|
|
HC MRI-UPPER EXT JOINT W/WO CON B
|
Facility
OP
|
$4,335.00
|
|
|
Service Code
|
CPT 73223 50
|
| Hospital Charge Code |
21573223
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,430.55 |
| Max. Negotiated Rate |
$4,031.55 |
| Rate for Payer: Aetna Commercial |
$3,658.74
|
| Rate for Payer: Aetna Medicare |
$1,430.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,430.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,489.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,709.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,645.13
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,573.60
|
| Rate for Payer: Cash Price |
$2,687.70
|
| Rate for Payer: Centivo All Commercial |
$2,210.85
|
| Rate for Payer: Cigna All Commercial |
$3,741.10
|
| Rate for Payer: CORVEL All Commercial |
$4,031.55
|
| Rate for Payer: Coventry All Commercial |
$3,814.80
|
| Rate for Payer: Encore All Commercial |
$3,990.37
|
| Rate for Payer: Frontpath All Commercial |
$3,988.20
|
| Rate for Payer: Humana ChoiceCare |
$3,744.14
|
| Rate for Payer: Humana Medicare |
$2,210.85
|
| Rate for Payer: Lucent All Commercial |
$2,210.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,901.50
|
| Rate for Payer: PHCS All Commercial |
$3,251.25
|
| Rate for Payer: PHP All Commercial |
$3,287.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,690.65
|
| Rate for Payer: Sagamore Health Network All Products |
$3,346.62
|
| Rate for Payer: Signature Care EPO |
$3,598.05
|
| Rate for Payer: Signature Care PPO |
$3,814.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,684.75
|
| Rate for Payer: United Healthcare Commercial |
$3,415.98
|
| Rate for Payer: United Healthcare Medicare |
$1,430.55
|
|
|
HC MRI-UPPER EXT JOINT W/WO CON B
|
Facility
IP
|
$4,335.00
|
|
|
Service Code
|
CPT 73223 50
|
| Hospital Charge Code |
21573223
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$3,251.25 |
| Max. Negotiated Rate |
$4,031.55 |
| Rate for Payer: Aetna Commercial |
$3,745.44
|
| Rate for Payer: Cash Price |
$2,687.70
|
| Rate for Payer: Cigna All Commercial |
$3,741.10
|
| Rate for Payer: CORVEL All Commercial |
$4,031.55
|
| Rate for Payer: Coventry All Commercial |
$3,814.80
|
| Rate for Payer: Encore All Commercial |
$3,990.37
|
| Rate for Payer: Frontpath All Commercial |
$3,988.20
|
| Rate for Payer: Humana ChoiceCare |
$3,744.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,901.50
|
| Rate for Payer: PHCS All Commercial |
$3,251.25
|
| Rate for Payer: PHP All Commercial |
$3,287.66
|
| Rate for Payer: Sagamore Health Network All Products |
$3,346.62
|
| Rate for Payer: Signature Care EPO |
$3,598.05
|
| Rate for Payer: Signature Care PPO |
$3,814.80
|
| Rate for Payer: United Healthcare Commercial |
$3,415.98
|
|
|
HC MRI-UPPER EXT JOINT W/WO CON L
|
Facility
OP
|
$2,652.00
|
|
|
Service Code
|
CPT 73223 LT
|
| Hospital Charge Code |
01573223
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$875.16 |
| Max. Negotiated Rate |
$2,466.36 |
| Rate for Payer: Aetna Commercial |
$2,238.29
|
| Rate for Payer: Aetna Medicare |
$875.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$875.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,523.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,657.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,006.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$962.68
|
| Rate for Payer: Cash Price |
$1,644.24
|
| Rate for Payer: Centivo All Commercial |
$1,352.52
|
| Rate for Payer: Cigna All Commercial |
$2,288.68
|
| Rate for Payer: CORVEL All Commercial |
$2,466.36
|
| Rate for Payer: Coventry All Commercial |
$2,333.76
|
| Rate for Payer: Encore All Commercial |
$2,441.17
|
| Rate for Payer: Frontpath All Commercial |
$2,439.84
|
| Rate for Payer: Humana ChoiceCare |
$2,290.53
|
| Rate for Payer: Humana Medicare |
$1,352.52
|
| Rate for Payer: Lucent All Commercial |
$1,352.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,386.80
|
| Rate for Payer: PHCS All Commercial |
$1,989.00
|
| Rate for Payer: PHP All Commercial |
$2,011.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,034.28
|
| Rate for Payer: Sagamore Health Network All Products |
$2,047.34
|
| Rate for Payer: Signature Care EPO |
$2,201.16
|
| Rate for Payer: Signature Care PPO |
$2,333.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,254.20
|
| Rate for Payer: United Healthcare Commercial |
$2,089.78
|
| Rate for Payer: United Healthcare Medicare |
$875.16
|
|
|
HC MRI-UPPER EXT JOINT W/WO CON L
|
Facility
IP
|
$2,652.00
|
|
|
Service Code
|
CPT 73223 LT
|
| Hospital Charge Code |
01573223
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,989.00 |
| Max. Negotiated Rate |
$2,466.36 |
| Rate for Payer: Aetna Commercial |
$2,291.33
|
| Rate for Payer: Cash Price |
$1,644.24
|
| Rate for Payer: Cigna All Commercial |
$2,288.68
|
| Rate for Payer: CORVEL All Commercial |
$2,466.36
|
| Rate for Payer: Coventry All Commercial |
$2,333.76
|
| Rate for Payer: Encore All Commercial |
$2,441.17
|
| Rate for Payer: Frontpath All Commercial |
$2,439.84
|
| Rate for Payer: Humana ChoiceCare |
$2,290.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,386.80
|
| Rate for Payer: PHCS All Commercial |
$1,989.00
|
| Rate for Payer: PHP All Commercial |
$2,011.28
|
| Rate for Payer: Sagamore Health Network All Products |
$2,047.34
|
| Rate for Payer: Signature Care EPO |
$2,201.16
|
| Rate for Payer: Signature Care PPO |
$2,333.76
|
| Rate for Payer: United Healthcare Commercial |
$2,089.78
|
|
|
HC MRI-UPPER EXT JOINT W/WO CON R
|
Facility
IP
|
$2,652.00
|
|
|
Service Code
|
CPT 73223 RT
|
| Hospital Charge Code |
11573223
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,989.00 |
| Max. Negotiated Rate |
$2,466.36 |
| Rate for Payer: Aetna Commercial |
$2,291.33
|
| Rate for Payer: Cash Price |
$1,644.24
|
| Rate for Payer: Cigna All Commercial |
$2,288.68
|
| Rate for Payer: CORVEL All Commercial |
$2,466.36
|
| Rate for Payer: Coventry All Commercial |
$2,333.76
|
| Rate for Payer: Encore All Commercial |
$2,441.17
|
| Rate for Payer: Frontpath All Commercial |
$2,439.84
|
| Rate for Payer: Humana ChoiceCare |
$2,290.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,386.80
|
| Rate for Payer: PHCS All Commercial |
$1,989.00
|
| Rate for Payer: PHP All Commercial |
$2,011.28
|
| Rate for Payer: Sagamore Health Network All Products |
$2,047.34
|
| Rate for Payer: Signature Care EPO |
$2,201.16
|
| Rate for Payer: Signature Care PPO |
$2,333.76
|
| Rate for Payer: United Healthcare Commercial |
$2,089.78
|
|
|
HC MRI-UPPER EXT JOINT W/WO CON R
|
Facility
OP
|
$2,652.00
|
|
|
Service Code
|
CPT 73223 RT
|
| Hospital Charge Code |
11573223
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$875.16 |
| Max. Negotiated Rate |
$2,466.36 |
| Rate for Payer: Aetna Commercial |
$2,238.29
|
| Rate for Payer: Aetna Medicare |
$875.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$875.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,523.04
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,657.77
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,006.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$962.68
|
| Rate for Payer: Cash Price |
$1,644.24
|
| Rate for Payer: Centivo All Commercial |
$1,352.52
|
| Rate for Payer: Cigna All Commercial |
$2,288.68
|
| Rate for Payer: CORVEL All Commercial |
$2,466.36
|
| Rate for Payer: Coventry All Commercial |
$2,333.76
|
| Rate for Payer: Encore All Commercial |
$2,441.17
|
| Rate for Payer: Frontpath All Commercial |
$2,439.84
|
| Rate for Payer: Humana ChoiceCare |
$2,290.53
|
| Rate for Payer: Humana Medicare |
$1,352.52
|
| Rate for Payer: Lucent All Commercial |
$1,352.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,386.80
|
| Rate for Payer: PHCS All Commercial |
$1,989.00
|
| Rate for Payer: PHP All Commercial |
$2,011.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,034.28
|
| Rate for Payer: Sagamore Health Network All Products |
$2,047.34
|
| Rate for Payer: Signature Care EPO |
$2,201.16
|
| Rate for Payer: Signature Care PPO |
$2,333.76
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,254.20
|
| Rate for Payer: United Healthcare Commercial |
$2,089.78
|
| Rate for Payer: United Healthcare Medicare |
$875.16
|
|
|
HC MRI-UPPER EXTREMITY W/CON BI
|
Facility
IP
|
$2,550.00
|
|
|
Service Code
|
CPT 73219 50
|
| Hospital Charge Code |
21573219
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$1,912.50 |
| Max. Negotiated Rate |
$2,371.50 |
| Rate for Payer: Aetna Commercial |
$2,203.20
|
| Rate for Payer: Cash Price |
$1,581.00
|
| Rate for Payer: Cigna All Commercial |
$2,200.65
|
| Rate for Payer: CORVEL All Commercial |
$2,371.50
|
| Rate for Payer: Coventry All Commercial |
$2,244.00
|
| Rate for Payer: Encore All Commercial |
$2,347.28
|
| Rate for Payer: Frontpath All Commercial |
$2,346.00
|
| Rate for Payer: Humana ChoiceCare |
$2,202.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,295.00
|
| Rate for Payer: PHCS All Commercial |
$1,912.50
|
| Rate for Payer: PHP All Commercial |
$1,933.92
|
| Rate for Payer: Sagamore Health Network All Products |
$1,968.60
|
| Rate for Payer: Signature Care EPO |
$2,116.50
|
| Rate for Payer: Signature Care PPO |
$2,244.00
|
| Rate for Payer: United Healthcare Commercial |
$2,009.40
|
|
|
HC MRI-UPPER EXTREMITY W/CON BI
|
Facility
OP
|
$2,550.00
|
|
|
Service Code
|
CPT 73219 50
|
| Hospital Charge Code |
21573219
|
|
Hospital Revenue Code
|
610
|
| Min. Negotiated Rate |
$841.50 |
| Max. Negotiated Rate |
$2,371.50 |
| Rate for Payer: Aetna Commercial |
$2,152.20
|
| Rate for Payer: Aetna Medicare |
$841.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$841.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,464.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,594.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$967.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$925.65
|
| Rate for Payer: Cash Price |
$1,581.00
|
| Rate for Payer: Centivo All Commercial |
$1,300.50
|
| Rate for Payer: Cigna All Commercial |
$2,200.65
|
| Rate for Payer: CORVEL All Commercial |
$2,371.50
|
| Rate for Payer: Coventry All Commercial |
$2,244.00
|
| Rate for Payer: Encore All Commercial |
$2,347.28
|
| Rate for Payer: Frontpath All Commercial |
$2,346.00
|
| Rate for Payer: Humana ChoiceCare |
$2,202.44
|
| Rate for Payer: Humana Medicare |
$1,300.50
|
| Rate for Payer: Lucent All Commercial |
$1,300.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,295.00
|
| Rate for Payer: PHCS All Commercial |
$1,912.50
|
| Rate for Payer: PHP All Commercial |
$1,933.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$994.50
|
| Rate for Payer: Sagamore Health Network All Products |
$1,968.60
|
| Rate for Payer: Signature Care EPO |
$2,116.50
|
| Rate for Payer: Signature Care PPO |
$2,244.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,167.50
|
| Rate for Payer: United Healthcare Commercial |
$2,009.40
|
| Rate for Payer: United Healthcare Medicare |
$841.50
|
|
|
HC MRI-UPPER EXTREMITY W/CON BI LTD
|
Facility
IP
|
$1,734.00
|
|
|
Service Code
|
CPT 73219 52,50
|
| Hospital Charge Code |
01579610
|
|
Hospital Revenue Code
|
614
|
| 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 |
$1,075.08
|
| 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
|
|
