|
HC RETICULOCYTE COUNT
|
Facility
|
OP
|
$103.20
|
|
|
Service Code
|
CPT 85045
|
| Hospital Charge Code |
63001045
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.99 |
| Max. Negotiated Rate |
$95.98 |
| Rate for Payer: Aetna Commercial |
$87.10
|
| Rate for Payer: Aetna Medicare |
$33.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$3.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$47.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$47.43
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$3.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.33
|
| Rate for Payer: Cash Price |
$61.92
|
| Rate for Payer: Cash Price |
$61.92
|
| Rate for Payer: Centivo All Commercial |
$56.14
|
| Rate for Payer: Cigna All Commercial |
$89.06
|
| Rate for Payer: CORVEL All Commercial |
$95.98
|
| Rate for Payer: Coventry All Commercial |
$90.82
|
| Rate for Payer: Encore All Commercial |
$95.00
|
| Rate for Payer: Frontpath All Commercial |
$94.94
|
| Rate for Payer: Humana ChoiceCare |
$89.13
|
| Rate for Payer: Humana Medicare |
$33.02
|
| Rate for Payer: Lucent All Commercial |
$56.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$92.88
|
| Rate for Payer: Managed Health Services Medicaid |
$3.99
|
| Rate for Payer: MDWise Medicaid |
$3.99
|
| Rate for Payer: PHCS All Commercial |
$77.40
|
| Rate for Payer: PHP All Commercial |
$78.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.25
|
| Rate for Payer: Sagamore Health Network All Products |
$79.67
|
| Rate for Payer: Signature Care EPO |
$85.66
|
| Rate for Payer: Signature Care PPO |
$90.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$87.72
|
| Rate for Payer: United Healthcare Commercial |
$81.32
|
| Rate for Payer: United Healthcare Medicare |
$33.02
|
|
|
HC RETRACTOR ALEXIS
|
Facility
|
IP
|
$630.00
|
|
| Hospital Charge Code |
41601983
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$472.50 |
| Max. Negotiated Rate |
$585.90 |
| Rate for Payer: Aetna Commercial |
$544.32
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Cigna All Commercial |
$543.69
|
| Rate for Payer: CORVEL All Commercial |
$585.90
|
| Rate for Payer: Coventry All Commercial |
$554.40
|
| Rate for Payer: Encore All Commercial |
$579.91
|
| Rate for Payer: Frontpath All Commercial |
$579.60
|
| Rate for Payer: Humana ChoiceCare |
$544.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$567.00
|
| Rate for Payer: PHCS All Commercial |
$472.50
|
| Rate for Payer: PHP All Commercial |
$477.79
|
| Rate for Payer: Sagamore Health Network All Products |
$486.36
|
| Rate for Payer: Signature Care EPO |
$522.90
|
| Rate for Payer: Signature Care PPO |
$554.40
|
| Rate for Payer: United Healthcare Commercial |
$496.44
|
|
|
HC RETRACTOR ALEXIS
|
Facility
|
OP
|
$630.00
|
|
| Hospital Charge Code |
41601983
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$585.90 |
| Rate for Payer: Aetna Commercial |
$531.72
|
| Rate for Payer: Aetna Medicare |
$201.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$195.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$361.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$393.81
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$231.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$221.76
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Cash Price |
$378.00
|
| Rate for Payer: Centivo All Commercial |
$342.72
|
| Rate for Payer: Cigna All Commercial |
$543.69
|
| Rate for Payer: CORVEL All Commercial |
$585.90
|
| Rate for Payer: Coventry All Commercial |
$554.40
|
| Rate for Payer: Encore All Commercial |
$579.91
|
| Rate for Payer: Frontpath All Commercial |
$579.60
|
| Rate for Payer: Humana ChoiceCare |
$544.13
|
| Rate for Payer: Humana Medicare |
$201.60
|
| Rate for Payer: Lucent All Commercial |
$342.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$567.00
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$472.50
|
| Rate for Payer: PHP All Commercial |
$477.79
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$245.70
|
| Rate for Payer: Sagamore Health Network All Products |
$486.36
|
| Rate for Payer: Signature Care EPO |
$522.90
|
| Rate for Payer: Signature Care PPO |
$554.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$535.50
|
| Rate for Payer: United Healthcare Commercial |
$496.44
|
| Rate for Payer: United Healthcare Medicare |
$201.60
|
|
|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
|
IP
|
$610.86
|
|
| Hospital Charge Code |
41602382
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$458.14 |
| Max. Negotiated Rate |
$568.10 |
| Rate for Payer: Aetna Commercial |
$527.78
|
| Rate for Payer: Cash Price |
$366.52
|
| Rate for Payer: Cigna All Commercial |
$527.17
|
| Rate for Payer: CORVEL All Commercial |
$568.10
|
| Rate for Payer: Coventry All Commercial |
$537.56
|
| Rate for Payer: Encore All Commercial |
$562.30
|
| Rate for Payer: Frontpath All Commercial |
$561.99
|
| Rate for Payer: Humana ChoiceCare |
$527.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$549.77
|
| Rate for Payer: PHCS All Commercial |
$458.14
|
| Rate for Payer: PHP All Commercial |
$463.28
|
| Rate for Payer: Sagamore Health Network All Products |
$471.58
|
| Rate for Payer: Signature Care EPO |
$507.01
|
| Rate for Payer: Signature Care PPO |
$537.56
|
| Rate for Payer: United Healthcare Commercial |
$481.36
|
|
|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
|
IP
|
$291.49
|
|
| Hospital Charge Code |
41602384
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$218.62 |
| Max. Negotiated Rate |
$271.09 |
| Rate for Payer: Aetna Commercial |
$251.85
|
| Rate for Payer: Cash Price |
$174.89
|
| Rate for Payer: Cigna All Commercial |
$251.56
|
| Rate for Payer: CORVEL All Commercial |
$271.09
|
| Rate for Payer: Coventry All Commercial |
$256.51
|
| Rate for Payer: Encore All Commercial |
$268.32
|
| Rate for Payer: Frontpath All Commercial |
$268.17
|
| Rate for Payer: Humana ChoiceCare |
$251.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$262.34
|
| Rate for Payer: PHCS All Commercial |
$218.62
|
| Rate for Payer: PHP All Commercial |
$221.07
|
| Rate for Payer: Sagamore Health Network All Products |
$225.03
|
| Rate for Payer: Signature Care EPO |
$241.94
|
| Rate for Payer: Signature Care PPO |
$256.51
|
| Rate for Payer: United Healthcare Commercial |
$229.69
|
|
|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
|
OP
|
$291.49
|
|
| Hospital Charge Code |
41602384
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$271.09 |
| Rate for Payer: Aetna Commercial |
$246.02
|
| Rate for Payer: Aetna Medicare |
$93.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$90.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$167.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$182.21
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$107.27
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$102.60
|
| Rate for Payer: Cash Price |
$174.89
|
| Rate for Payer: Cash Price |
$174.89
|
| Rate for Payer: Centivo All Commercial |
$158.57
|
| Rate for Payer: Cigna All Commercial |
$251.56
|
| Rate for Payer: CORVEL All Commercial |
$271.09
|
| Rate for Payer: Coventry All Commercial |
$256.51
|
| Rate for Payer: Encore All Commercial |
$268.32
|
| Rate for Payer: Frontpath All Commercial |
$268.17
|
| Rate for Payer: Humana ChoiceCare |
$251.76
|
| Rate for Payer: Humana Medicare |
$93.28
|
| Rate for Payer: Lucent All Commercial |
$158.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$262.34
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$218.62
|
| Rate for Payer: PHP All Commercial |
$221.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$113.68
|
| Rate for Payer: Sagamore Health Network All Products |
$225.03
|
| Rate for Payer: Signature Care EPO |
$241.94
|
| Rate for Payer: Signature Care PPO |
$256.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$247.77
|
| Rate for Payer: United Healthcare Commercial |
$229.69
|
| Rate for Payer: United Healthcare Medicare |
$93.28
|
|
|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
|
OP
|
$610.86
|
|
| Hospital Charge Code |
41602382
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$568.10 |
| Rate for Payer: Aetna Commercial |
$515.57
|
| Rate for Payer: Aetna Medicare |
$195.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$189.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$350.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$381.85
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$224.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$215.02
|
| Rate for Payer: Cash Price |
$366.52
|
| Rate for Payer: Cash Price |
$366.52
|
| Rate for Payer: Centivo All Commercial |
$332.31
|
| Rate for Payer: Cigna All Commercial |
$527.17
|
| Rate for Payer: CORVEL All Commercial |
$568.10
|
| Rate for Payer: Coventry All Commercial |
$537.56
|
| Rate for Payer: Encore All Commercial |
$562.30
|
| Rate for Payer: Frontpath All Commercial |
$561.99
|
| Rate for Payer: Humana ChoiceCare |
$527.60
|
| Rate for Payer: Humana Medicare |
$195.48
|
| Rate for Payer: Lucent All Commercial |
$332.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$549.77
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$458.14
|
| Rate for Payer: PHP All Commercial |
$463.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$238.24
|
| Rate for Payer: Sagamore Health Network All Products |
$471.58
|
| Rate for Payer: Signature Care EPO |
$507.01
|
| Rate for Payer: Signature Care PPO |
$537.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$519.23
|
| Rate for Payer: United Healthcare Commercial |
$481.36
|
| Rate for Payer: United Healthcare Medicare |
$195.48
|
|
|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
|
OP
|
$661.10
|
|
| Hospital Charge Code |
41602383
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$614.82 |
| Rate for Payer: Aetna Commercial |
$557.97
|
| Rate for Payer: Aetna Medicare |
$211.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$204.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$379.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$413.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$243.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$232.71
|
| Rate for Payer: Cash Price |
$396.66
|
| Rate for Payer: Cash Price |
$396.66
|
| Rate for Payer: Centivo All Commercial |
$359.64
|
| Rate for Payer: Cigna All Commercial |
$570.53
|
| Rate for Payer: CORVEL All Commercial |
$614.82
|
| Rate for Payer: Coventry All Commercial |
$581.77
|
| Rate for Payer: Encore All Commercial |
$608.54
|
| Rate for Payer: Frontpath All Commercial |
$608.21
|
| Rate for Payer: Humana ChoiceCare |
$570.99
|
| Rate for Payer: Humana Medicare |
$211.55
|
| Rate for Payer: Lucent All Commercial |
$359.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$594.99
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$495.82
|
| Rate for Payer: PHP All Commercial |
$501.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$257.83
|
| Rate for Payer: Sagamore Health Network All Products |
$510.37
|
| Rate for Payer: Signature Care EPO |
$548.71
|
| Rate for Payer: Signature Care PPO |
$581.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$561.93
|
| Rate for Payer: United Healthcare Commercial |
$520.95
|
| Rate for Payer: United Healthcare Medicare |
$211.55
|
|
|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
|
IP
|
$661.10
|
|
| Hospital Charge Code |
41602383
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$495.82 |
| Max. Negotiated Rate |
$614.82 |
| Rate for Payer: Aetna Commercial |
$571.19
|
| Rate for Payer: Cash Price |
$396.66
|
| Rate for Payer: Cigna All Commercial |
$570.53
|
| Rate for Payer: CORVEL All Commercial |
$614.82
|
| Rate for Payer: Coventry All Commercial |
$581.77
|
| Rate for Payer: Encore All Commercial |
$608.54
|
| Rate for Payer: Frontpath All Commercial |
$608.21
|
| Rate for Payer: Humana ChoiceCare |
$570.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$594.99
|
| Rate for Payer: PHCS All Commercial |
$495.82
|
| Rate for Payer: PHP All Commercial |
$501.38
|
| Rate for Payer: Sagamore Health Network All Products |
$510.37
|
| Rate for Payer: Signature Care EPO |
$548.71
|
| Rate for Payer: Signature Care PPO |
$581.77
|
| Rate for Payer: United Healthcare Commercial |
$520.95
|
|
|
HC RETROBULBAR ATKINSON
|
Facility
|
IP
|
$34.46
|
|
| Hospital Charge Code |
41601799
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.84 |
| Max. Negotiated Rate |
$32.05 |
| Rate for Payer: Aetna Commercial |
$29.77
|
| Rate for Payer: Cash Price |
$20.68
|
| Rate for Payer: Cigna All Commercial |
$29.74
|
| Rate for Payer: CORVEL All Commercial |
$32.05
|
| Rate for Payer: Coventry All Commercial |
$30.32
|
| Rate for Payer: Encore All Commercial |
$31.72
|
| Rate for Payer: Frontpath All Commercial |
$31.70
|
| Rate for Payer: Humana ChoiceCare |
$29.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.01
|
| Rate for Payer: PHCS All Commercial |
$25.84
|
| Rate for Payer: PHP All Commercial |
$26.13
|
| Rate for Payer: Sagamore Health Network All Products |
$26.60
|
| Rate for Payer: Signature Care EPO |
$28.60
|
| Rate for Payer: Signature Care PPO |
$30.32
|
| Rate for Payer: United Healthcare Commercial |
$27.15
|
|
|
HC RETROBULBAR ATKINSON
|
Facility
|
OP
|
$34.46
|
|
| Hospital Charge Code |
41601799
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$10.68 |
| Max. Negotiated Rate |
$32.05 |
| Rate for Payer: Aetna Commercial |
$29.08
|
| Rate for Payer: Aetna Medicare |
$11.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$24.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$24.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.13
|
| Rate for Payer: Cash Price |
$20.68
|
| Rate for Payer: Cash Price |
$20.68
|
| Rate for Payer: Centivo All Commercial |
$18.75
|
| Rate for Payer: Cigna All Commercial |
$29.74
|
| Rate for Payer: CORVEL All Commercial |
$32.05
|
| Rate for Payer: Coventry All Commercial |
$30.32
|
| Rate for Payer: Encore All Commercial |
$31.72
|
| Rate for Payer: Frontpath All Commercial |
$31.70
|
| Rate for Payer: Humana ChoiceCare |
$29.76
|
| Rate for Payer: Humana Medicare |
$11.03
|
| Rate for Payer: Lucent All Commercial |
$18.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.01
|
| Rate for Payer: Managed Health Services Medicaid |
$24.83
|
| Rate for Payer: MDWise Medicaid |
$24.83
|
| Rate for Payer: PHCS All Commercial |
$25.84
|
| Rate for Payer: PHP All Commercial |
$26.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.44
|
| Rate for Payer: Sagamore Health Network All Products |
$26.60
|
| Rate for Payer: Signature Care EPO |
$28.60
|
| Rate for Payer: Signature Care PPO |
$30.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.29
|
| Rate for Payer: United Healthcare Commercial |
$27.15
|
| Rate for Payer: United Healthcare Medicare |
$11.03
|
|
|
HC RETROGRADE PYLOGRAM
|
Facility
|
OP
|
$948.29
|
|
|
Service Code
|
CPT 74420
|
| Hospital Charge Code |
1614431
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$65.48 |
| Max. Negotiated Rate |
$881.91 |
| Rate for Payer: Aetna Commercial |
$800.36
|
| Rate for Payer: Aetna Medicare |
$303.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$65.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$293.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$544.60
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$592.78
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$65.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$348.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$333.80
|
| Rate for Payer: Cash Price |
$568.97
|
| Rate for Payer: Cash Price |
$568.97
|
| Rate for Payer: Centivo All Commercial |
$515.87
|
| Rate for Payer: Cigna All Commercial |
$818.37
|
| Rate for Payer: CORVEL All Commercial |
$881.91
|
| Rate for Payer: Coventry All Commercial |
$834.50
|
| Rate for Payer: Encore All Commercial |
$872.90
|
| Rate for Payer: Frontpath All Commercial |
$872.43
|
| Rate for Payer: Humana ChoiceCare |
$819.04
|
| Rate for Payer: Humana Medicare |
$303.45
|
| Rate for Payer: Lucent All Commercial |
$515.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$853.46
|
| Rate for Payer: Managed Health Services Medicaid |
$65.48
|
| Rate for Payer: MDWise Medicaid |
$65.48
|
| Rate for Payer: PHCS All Commercial |
$711.22
|
| Rate for Payer: PHP All Commercial |
$719.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$369.83
|
| Rate for Payer: Sagamore Health Network All Products |
$732.08
|
| Rate for Payer: Signature Care EPO |
$787.08
|
| Rate for Payer: Signature Care PPO |
$834.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$806.05
|
| Rate for Payer: United Healthcare Commercial |
$747.25
|
| Rate for Payer: United Healthcare Medicare |
$303.45
|
|
|
HC RETROGRADE PYLOGRAM
|
Facility
|
IP
|
$948.29
|
|
|
Service Code
|
CPT 74420
|
| Hospital Charge Code |
1614431
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$711.22 |
| Max. Negotiated Rate |
$881.91 |
| Rate for Payer: Aetna Commercial |
$819.32
|
| Rate for Payer: Cash Price |
$568.97
|
| Rate for Payer: Cigna All Commercial |
$818.37
|
| Rate for Payer: CORVEL All Commercial |
$881.91
|
| Rate for Payer: Coventry All Commercial |
$834.50
|
| Rate for Payer: Encore All Commercial |
$872.90
|
| Rate for Payer: Frontpath All Commercial |
$872.43
|
| Rate for Payer: Humana ChoiceCare |
$819.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$853.46
|
| Rate for Payer: PHCS All Commercial |
$711.22
|
| Rate for Payer: PHP All Commercial |
$719.18
|
| Rate for Payer: Sagamore Health Network All Products |
$732.08
|
| Rate for Payer: Signature Care EPO |
$787.08
|
| Rate for Payer: Signature Care PPO |
$834.50
|
| Rate for Payer: United Healthcare Commercial |
$747.25
|
|
|
HC RETROGRADE URETHROGRAM
|
Facility
|
OP
|
$1,384.08
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1614450
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$36.41 |
| Max. Negotiated Rate |
$1,287.19 |
| Rate for Payer: Aetna Commercial |
$1,168.16
|
| Rate for Payer: Aetna Medicare |
$442.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$36.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$429.06
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$794.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$865.19
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$36.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$509.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$487.20
|
| Rate for Payer: Cash Price |
$830.45
|
| Rate for Payer: Cash Price |
$830.45
|
| Rate for Payer: Centivo All Commercial |
$752.94
|
| Rate for Payer: Cigna All Commercial |
$1,194.46
|
| Rate for Payer: CORVEL All Commercial |
$1,287.19
|
| Rate for Payer: Coventry All Commercial |
$1,217.99
|
| Rate for Payer: Encore All Commercial |
$1,274.05
|
| Rate for Payer: Frontpath All Commercial |
$1,273.35
|
| Rate for Payer: Humana ChoiceCare |
$1,195.43
|
| Rate for Payer: Humana Medicare |
$442.91
|
| Rate for Payer: Lucent All Commercial |
$752.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,245.67
|
| Rate for Payer: Managed Health Services Medicaid |
$36.41
|
| Rate for Payer: MDWise Medicaid |
$36.41
|
| Rate for Payer: PHCS All Commercial |
$1,038.06
|
| Rate for Payer: PHP All Commercial |
$1,049.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$539.79
|
| Rate for Payer: Sagamore Health Network All Products |
$1,068.51
|
| Rate for Payer: Signature Care EPO |
$1,148.79
|
| Rate for Payer: Signature Care PPO |
$1,217.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,176.47
|
| Rate for Payer: United Healthcare Commercial |
$1,090.66
|
| Rate for Payer: United Healthcare Medicare |
$442.91
|
|
|
HC RETROGRADE URETHROGRAM
|
Facility
|
IP
|
$1,384.08
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
1614450
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,038.06 |
| Max. Negotiated Rate |
$1,287.19 |
| Rate for Payer: Aetna Commercial |
$1,195.85
|
| Rate for Payer: Cash Price |
$830.45
|
| Rate for Payer: Cigna All Commercial |
$1,194.46
|
| Rate for Payer: CORVEL All Commercial |
$1,287.19
|
| Rate for Payer: Coventry All Commercial |
$1,217.99
|
| Rate for Payer: Encore All Commercial |
$1,274.05
|
| Rate for Payer: Frontpath All Commercial |
$1,273.35
|
| Rate for Payer: Humana ChoiceCare |
$1,195.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,245.67
|
| Rate for Payer: PHCS All Commercial |
$1,038.06
|
| Rate for Payer: PHP All Commercial |
$1,049.69
|
| Rate for Payer: Sagamore Health Network All Products |
$1,068.51
|
| Rate for Payer: Signature Care EPO |
$1,148.79
|
| Rate for Payer: Signature Care PPO |
$1,217.99
|
| Rate for Payer: United Healthcare Commercial |
$1,090.66
|
|
|
HC RETRO INJ URETHRA
|
Facility
|
IP
|
$95.15
|
|
| Hospital Charge Code |
1611610
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$71.36 |
| Max. Negotiated Rate |
$88.49 |
| Rate for Payer: Aetna Commercial |
$82.21
|
| Rate for Payer: Cash Price |
$57.09
|
| Rate for Payer: Cigna All Commercial |
$82.11
|
| Rate for Payer: CORVEL All Commercial |
$88.49
|
| Rate for Payer: Coventry All Commercial |
$83.73
|
| Rate for Payer: Encore All Commercial |
$87.59
|
| Rate for Payer: Frontpath All Commercial |
$87.54
|
| Rate for Payer: Humana ChoiceCare |
$82.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$85.64
|
| Rate for Payer: PHCS All Commercial |
$71.36
|
| Rate for Payer: PHP All Commercial |
$72.16
|
| Rate for Payer: Sagamore Health Network All Products |
$73.46
|
| Rate for Payer: Signature Care EPO |
$78.97
|
| Rate for Payer: Signature Care PPO |
$83.73
|
| Rate for Payer: United Healthcare Commercial |
$74.98
|
|
|
HC RETRO INJ URETHRA
|
Facility
|
OP
|
$528.88
|
|
|
Service Code
|
CPT 51610
|
| Hospital Charge Code |
1619610
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$163.95 |
| Max. Negotiated Rate |
$491.86 |
| Rate for Payer: Aetna Commercial |
$446.37
|
| Rate for Payer: Aetna Medicare |
$169.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$318.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$163.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$303.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$330.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$318.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$194.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$186.17
|
| Rate for Payer: Cash Price |
$317.33
|
| Rate for Payer: Cash Price |
$317.33
|
| Rate for Payer: Centivo All Commercial |
$287.71
|
| Rate for Payer: Cigna All Commercial |
$456.42
|
| Rate for Payer: CORVEL All Commercial |
$491.86
|
| Rate for Payer: Coventry All Commercial |
$465.41
|
| Rate for Payer: Encore All Commercial |
$486.83
|
| Rate for Payer: Frontpath All Commercial |
$486.57
|
| Rate for Payer: Humana ChoiceCare |
$456.79
|
| Rate for Payer: Humana Medicare |
$169.24
|
| Rate for Payer: Lucent All Commercial |
$287.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$475.99
|
| Rate for Payer: Managed Health Services Medicaid |
$318.54
|
| Rate for Payer: MDWise Medicaid |
$318.54
|
| Rate for Payer: PHCS All Commercial |
$396.66
|
| Rate for Payer: PHP All Commercial |
$401.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$206.26
|
| Rate for Payer: Sagamore Health Network All Products |
$408.30
|
| Rate for Payer: Signature Care EPO |
$438.97
|
| Rate for Payer: Signature Care PPO |
$465.41
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$449.55
|
| Rate for Payer: United Healthcare Commercial |
$416.76
|
| Rate for Payer: United Healthcare Medicare |
$169.24
|
|
|
HC RETRO INJ URETHRA
|
Facility
|
IP
|
$528.88
|
|
|
Service Code
|
CPT 51610
|
| Hospital Charge Code |
1619610
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$396.66 |
| Max. Negotiated Rate |
$491.86 |
| Rate for Payer: Aetna Commercial |
$456.95
|
| Rate for Payer: Cash Price |
$317.33
|
| Rate for Payer: Cigna All Commercial |
$456.42
|
| Rate for Payer: CORVEL All Commercial |
$491.86
|
| Rate for Payer: Coventry All Commercial |
$465.41
|
| Rate for Payer: Encore All Commercial |
$486.83
|
| Rate for Payer: Frontpath All Commercial |
$486.57
|
| Rate for Payer: Humana ChoiceCare |
$456.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$475.99
|
| Rate for Payer: PHCS All Commercial |
$396.66
|
| Rate for Payer: PHP All Commercial |
$401.10
|
| Rate for Payer: Sagamore Health Network All Products |
$408.30
|
| Rate for Payer: Signature Care EPO |
$438.97
|
| Rate for Payer: Signature Care PPO |
$465.41
|
| Rate for Payer: United Healthcare Commercial |
$416.76
|
|
|
HC RETRO INJ URETHRA
|
Facility
|
OP
|
$95.15
|
|
| Hospital Charge Code |
1611610
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$29.50 |
| Max. Negotiated Rate |
$88.49 |
| Rate for Payer: Aetna Commercial |
$80.31
|
| Rate for Payer: Aetna Medicare |
$30.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$29.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$54.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$59.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$35.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$33.49
|
| Rate for Payer: Cash Price |
$57.09
|
| Rate for Payer: Centivo All Commercial |
$51.76
|
| Rate for Payer: Cigna All Commercial |
$82.11
|
| Rate for Payer: CORVEL All Commercial |
$88.49
|
| Rate for Payer: Coventry All Commercial |
$83.73
|
| Rate for Payer: Encore All Commercial |
$87.59
|
| Rate for Payer: Frontpath All Commercial |
$87.54
|
| Rate for Payer: Humana ChoiceCare |
$82.18
|
| Rate for Payer: Humana Medicare |
$30.45
|
| Rate for Payer: Lucent All Commercial |
$51.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$85.64
|
| Rate for Payer: PHCS All Commercial |
$71.36
|
| Rate for Payer: PHP All Commercial |
$72.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$37.11
|
| Rate for Payer: Sagamore Health Network All Products |
$73.46
|
| Rate for Payer: Signature Care EPO |
$78.97
|
| Rate for Payer: Signature Care PPO |
$83.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$80.88
|
| Rate for Payer: United Healthcare Commercial |
$74.98
|
| Rate for Payer: United Healthcare Medicare |
$30.45
|
|
|
HC RHEUMATOID FACTOR-REF
|
Facility
|
IP
|
$47.28
|
|
|
Service Code
|
CPT 86431
|
| Hospital Charge Code |
63001916
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.46 |
| Max. Negotiated Rate |
$43.97 |
| Rate for Payer: Aetna Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$28.37
|
| Rate for Payer: Cigna All Commercial |
$40.80
|
| Rate for Payer: CORVEL All Commercial |
$43.97
|
| Rate for Payer: Coventry All Commercial |
$41.61
|
| Rate for Payer: Encore All Commercial |
$43.52
|
| Rate for Payer: Frontpath All Commercial |
$43.50
|
| Rate for Payer: Humana ChoiceCare |
$40.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.55
|
| Rate for Payer: PHCS All Commercial |
$35.46
|
| Rate for Payer: PHP All Commercial |
$35.86
|
| Rate for Payer: Sagamore Health Network All Products |
$36.50
|
| Rate for Payer: Signature Care EPO |
$39.24
|
| Rate for Payer: Signature Care PPO |
$41.61
|
| Rate for Payer: United Healthcare Commercial |
$37.26
|
|
|
HC RHEUMATOID FACTOR-REF
|
Facility
|
OP
|
$47.28
|
|
|
Service Code
|
CPT 86431
|
| Hospital Charge Code |
63001916
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.67 |
| Max. Negotiated Rate |
$43.97 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Medicare |
$15.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$5.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$21.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.73
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$5.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.64
|
| Rate for Payer: Cash Price |
$28.37
|
| Rate for Payer: Cash Price |
$28.37
|
| Rate for Payer: Centivo All Commercial |
$25.72
|
| Rate for Payer: Cigna All Commercial |
$40.80
|
| Rate for Payer: CORVEL All Commercial |
$43.97
|
| Rate for Payer: Coventry All Commercial |
$41.61
|
| Rate for Payer: Encore All Commercial |
$43.52
|
| Rate for Payer: Frontpath All Commercial |
$43.50
|
| Rate for Payer: Humana ChoiceCare |
$40.84
|
| Rate for Payer: Humana Medicare |
$15.13
|
| Rate for Payer: Lucent All Commercial |
$25.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.55
|
| Rate for Payer: Managed Health Services Medicaid |
$5.67
|
| Rate for Payer: MDWise Medicaid |
$5.67
|
| Rate for Payer: PHCS All Commercial |
$35.46
|
| Rate for Payer: PHP All Commercial |
$35.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.44
|
| Rate for Payer: Sagamore Health Network All Products |
$36.50
|
| Rate for Payer: Signature Care EPO |
$39.24
|
| Rate for Payer: Signature Care PPO |
$41.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.19
|
| Rate for Payer: United Healthcare Commercial |
$37.26
|
| Rate for Payer: United Healthcare Medicare |
$15.13
|
|
|
HC RHOGAM WORKUP
|
Facility
|
IP
|
$191.45
|
|
| Hospital Charge Code |
63002243
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$143.59 |
| Max. Negotiated Rate |
$178.05 |
| Rate for Payer: Aetna Commercial |
$165.41
|
| Rate for Payer: Cash Price |
$114.87
|
| Rate for Payer: Cigna All Commercial |
$165.22
|
| Rate for Payer: CORVEL All Commercial |
$178.05
|
| Rate for Payer: Coventry All Commercial |
$168.48
|
| Rate for Payer: Encore All Commercial |
$176.23
|
| Rate for Payer: Frontpath All Commercial |
$176.13
|
| Rate for Payer: Humana ChoiceCare |
$165.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$172.31
|
| Rate for Payer: PHCS All Commercial |
$143.59
|
| Rate for Payer: PHP All Commercial |
$145.20
|
| Rate for Payer: Sagamore Health Network All Products |
$147.80
|
| Rate for Payer: Signature Care EPO |
$158.90
|
| Rate for Payer: Signature Care PPO |
$168.48
|
| Rate for Payer: United Healthcare Commercial |
$150.86
|
|
|
HC RHOGAM WORKUP
|
Facility
|
OP
|
$191.45
|
|
| Hospital Charge Code |
63002243
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$59.35 |
| Max. Negotiated Rate |
$178.05 |
| Rate for Payer: Aetna Commercial |
$161.58
|
| Rate for Payer: Aetna Medicare |
$61.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$59.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$87.99
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$87.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$70.45
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$67.39
|
| Rate for Payer: Cash Price |
$114.87
|
| Rate for Payer: Centivo All Commercial |
$104.15
|
| Rate for Payer: Cigna All Commercial |
$165.22
|
| Rate for Payer: CORVEL All Commercial |
$178.05
|
| Rate for Payer: Coventry All Commercial |
$168.48
|
| Rate for Payer: Encore All Commercial |
$176.23
|
| Rate for Payer: Frontpath All Commercial |
$176.13
|
| Rate for Payer: Humana ChoiceCare |
$165.36
|
| Rate for Payer: Humana Medicare |
$61.26
|
| Rate for Payer: Lucent All Commercial |
$104.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$172.31
|
| Rate for Payer: PHCS All Commercial |
$143.59
|
| Rate for Payer: PHP All Commercial |
$145.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$74.67
|
| Rate for Payer: Sagamore Health Network All Products |
$147.80
|
| Rate for Payer: Signature Care EPO |
$158.90
|
| Rate for Payer: Signature Care PPO |
$168.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$162.73
|
| Rate for Payer: United Healthcare Commercial |
$150.86
|
| Rate for Payer: United Healthcare Medicare |
$61.26
|
|
|
HC RH TYPE
|
Facility
|
OP
|
$69.56
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
63001355
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.99 |
| Max. Negotiated Rate |
$64.69 |
| Rate for Payer: Aetna Commercial |
$58.71
|
| Rate for Payer: Aetna Medicare |
$22.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$2.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$31.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.97
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$2.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$25.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$24.49
|
| Rate for Payer: Cash Price |
$41.74
|
| Rate for Payer: Cash Price |
$41.74
|
| Rate for Payer: Centivo All Commercial |
$37.84
|
| Rate for Payer: Cigna All Commercial |
$60.03
|
| Rate for Payer: CORVEL All Commercial |
$64.69
|
| Rate for Payer: Coventry All Commercial |
$61.21
|
| Rate for Payer: Encore All Commercial |
$64.03
|
| Rate for Payer: Frontpath All Commercial |
$64.00
|
| Rate for Payer: Humana ChoiceCare |
$60.08
|
| Rate for Payer: Humana Medicare |
$22.26
|
| Rate for Payer: Lucent All Commercial |
$37.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.60
|
| Rate for Payer: Managed Health Services Medicaid |
$2.99
|
| Rate for Payer: MDWise Medicaid |
$2.99
|
| Rate for Payer: PHCS All Commercial |
$52.17
|
| Rate for Payer: PHP All Commercial |
$52.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$27.13
|
| Rate for Payer: Sagamore Health Network All Products |
$53.70
|
| Rate for Payer: Signature Care EPO |
$57.73
|
| Rate for Payer: Signature Care PPO |
$61.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$59.13
|
| Rate for Payer: United Healthcare Commercial |
$54.81
|
| Rate for Payer: United Healthcare Medicare |
$22.26
|
|
|
HC RH TYPE
|
Facility
|
IP
|
$69.56
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
63001355
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.17 |
| Max. Negotiated Rate |
$64.69 |
| Rate for Payer: Aetna Commercial |
$60.10
|
| Rate for Payer: Cash Price |
$41.74
|
| Rate for Payer: Cigna All Commercial |
$60.03
|
| Rate for Payer: CORVEL All Commercial |
$64.69
|
| Rate for Payer: Coventry All Commercial |
$61.21
|
| Rate for Payer: Encore All Commercial |
$64.03
|
| Rate for Payer: Frontpath All Commercial |
$64.00
|
| Rate for Payer: Humana ChoiceCare |
$60.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.60
|
| Rate for Payer: PHCS All Commercial |
$52.17
|
| Rate for Payer: PHP All Commercial |
$52.75
|
| Rate for Payer: Sagamore Health Network All Products |
$53.70
|
| Rate for Payer: Signature Care EPO |
$57.73
|
| Rate for Payer: Signature Care PPO |
$61.21
|
| Rate for Payer: United Healthcare Commercial |
$54.81
|
|
