|
HC SED RATE MM/HR
|
Facility
|
OP
|
$146.75
|
|
|
Service Code
|
CPT 85652
|
| Hospital Charge Code |
63001243
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$2.70 |
| Max. Negotiated Rate |
$136.48 |
| Rate for Payer: Aetna Commercial |
$123.86
|
| Rate for Payer: Aetna Medicare |
$46.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$2.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$45.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$67.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$67.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$2.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$54.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$51.66
|
| Rate for Payer: Cash Price |
$88.05
|
| Rate for Payer: Cash Price |
$88.05
|
| Rate for Payer: Centivo All Commercial |
$79.83
|
| Rate for Payer: Cigna All Commercial |
$126.65
|
| Rate for Payer: CORVEL All Commercial |
$136.48
|
| Rate for Payer: Coventry All Commercial |
$129.14
|
| Rate for Payer: Encore All Commercial |
$135.08
|
| Rate for Payer: Frontpath All Commercial |
$135.01
|
| Rate for Payer: Humana ChoiceCare |
$126.75
|
| Rate for Payer: Humana Medicare |
$46.96
|
| Rate for Payer: Lucent All Commercial |
$79.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.07
|
| Rate for Payer: Managed Health Services Medicaid |
$2.70
|
| Rate for Payer: MDWise Medicaid |
$2.70
|
| Rate for Payer: PHCS All Commercial |
$110.06
|
| Rate for Payer: PHP All Commercial |
$111.30
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$57.23
|
| Rate for Payer: Sagamore Health Network All Products |
$113.29
|
| Rate for Payer: Signature Care EPO |
$121.80
|
| Rate for Payer: Signature Care PPO |
$129.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$124.74
|
| Rate for Payer: United Healthcare Commercial |
$115.64
|
| Rate for Payer: United Healthcare Medicare |
$46.96
|
|
|
HC SED RATE MM/HR
|
Facility
|
IP
|
$146.75
|
|
|
Service Code
|
CPT 85652
|
| Hospital Charge Code |
63001243
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$110.06 |
| Max. Negotiated Rate |
$136.48 |
| Rate for Payer: Aetna Commercial |
$126.79
|
| Rate for Payer: Cash Price |
$88.05
|
| Rate for Payer: Cigna All Commercial |
$126.65
|
| Rate for Payer: CORVEL All Commercial |
$136.48
|
| Rate for Payer: Coventry All Commercial |
$129.14
|
| Rate for Payer: Encore All Commercial |
$135.08
|
| Rate for Payer: Frontpath All Commercial |
$135.01
|
| Rate for Payer: Humana ChoiceCare |
$126.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.07
|
| Rate for Payer: PHCS All Commercial |
$110.06
|
| Rate for Payer: PHP All Commercial |
$111.30
|
| Rate for Payer: Sagamore Health Network All Products |
$113.29
|
| Rate for Payer: Signature Care EPO |
$121.80
|
| Rate for Payer: Signature Care PPO |
$129.14
|
| Rate for Payer: United Healthcare Commercial |
$115.64
|
|
|
HC SELENIUM
|
Facility
|
OP
|
$158.10
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
63001674
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$25.53 |
| Max. Negotiated Rate |
$147.03 |
| Rate for Payer: Aetna Commercial |
$133.44
|
| Rate for Payer: Aetna Medicare |
$50.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$25.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$49.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$72.66
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$72.66
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$25.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$58.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$55.65
|
| Rate for Payer: Cash Price |
$94.86
|
| Rate for Payer: Cash Price |
$94.86
|
| Rate for Payer: Centivo All Commercial |
$86.01
|
| Rate for Payer: Cigna All Commercial |
$136.44
|
| Rate for Payer: CORVEL All Commercial |
$147.03
|
| Rate for Payer: Coventry All Commercial |
$139.13
|
| Rate for Payer: Encore All Commercial |
$145.53
|
| Rate for Payer: Frontpath All Commercial |
$145.45
|
| Rate for Payer: Humana ChoiceCare |
$136.55
|
| Rate for Payer: Humana Medicare |
$50.59
|
| Rate for Payer: Lucent All Commercial |
$86.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$142.29
|
| Rate for Payer: Managed Health Services Medicaid |
$25.53
|
| Rate for Payer: MDWise Medicaid |
$25.53
|
| Rate for Payer: PHCS All Commercial |
$118.58
|
| Rate for Payer: PHP All Commercial |
$119.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$61.66
|
| Rate for Payer: Sagamore Health Network All Products |
$122.05
|
| Rate for Payer: Signature Care EPO |
$131.22
|
| Rate for Payer: Signature Care PPO |
$139.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$134.38
|
| Rate for Payer: United Healthcare Commercial |
$124.58
|
| Rate for Payer: United Healthcare Medicare |
$50.59
|
|
|
HC SELENIUM
|
Facility
|
IP
|
$158.10
|
|
|
Service Code
|
CPT 84255
|
| Hospital Charge Code |
63001674
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$118.58 |
| Max. Negotiated Rate |
$147.03 |
| Rate for Payer: Aetna Commercial |
$136.60
|
| Rate for Payer: Cash Price |
$94.86
|
| Rate for Payer: Cigna All Commercial |
$136.44
|
| Rate for Payer: CORVEL All Commercial |
$147.03
|
| Rate for Payer: Coventry All Commercial |
$139.13
|
| Rate for Payer: Encore All Commercial |
$145.53
|
| Rate for Payer: Frontpath All Commercial |
$145.45
|
| Rate for Payer: Humana ChoiceCare |
$136.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$142.29
|
| Rate for Payer: PHCS All Commercial |
$118.58
|
| Rate for Payer: PHP All Commercial |
$119.90
|
| Rate for Payer: Sagamore Health Network All Products |
$122.05
|
| Rate for Payer: Signature Care EPO |
$131.22
|
| Rate for Payer: Signature Care PPO |
$139.13
|
| Rate for Payer: United Healthcare Commercial |
$124.58
|
|
|
HC SENSITIVITY
|
Facility
|
OP
|
$114.92
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
63001065
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.65 |
| Max. Negotiated Rate |
$106.88 |
| Rate for Payer: Aetna Commercial |
$96.99
|
| Rate for Payer: Aetna Medicare |
$36.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$8.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$35.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$52.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$52.82
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$8.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.45
|
| Rate for Payer: Cash Price |
$68.95
|
| Rate for Payer: Cash Price |
$68.95
|
| Rate for Payer: Centivo All Commercial |
$62.52
|
| Rate for Payer: Cigna All Commercial |
$99.18
|
| Rate for Payer: CORVEL All Commercial |
$106.88
|
| Rate for Payer: Coventry All Commercial |
$101.13
|
| Rate for Payer: Encore All Commercial |
$105.78
|
| Rate for Payer: Frontpath All Commercial |
$105.73
|
| Rate for Payer: Humana ChoiceCare |
$99.26
|
| Rate for Payer: Humana Medicare |
$36.77
|
| Rate for Payer: Lucent All Commercial |
$62.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$103.43
|
| Rate for Payer: Managed Health Services Medicaid |
$8.65
|
| Rate for Payer: MDWise Medicaid |
$8.65
|
| Rate for Payer: PHCS All Commercial |
$86.19
|
| Rate for Payer: PHP All Commercial |
$87.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$44.82
|
| Rate for Payer: Sagamore Health Network All Products |
$88.72
|
| Rate for Payer: Signature Care EPO |
$95.38
|
| Rate for Payer: Signature Care PPO |
$101.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$97.68
|
| Rate for Payer: United Healthcare Commercial |
$90.56
|
| Rate for Payer: United Healthcare Medicare |
$36.77
|
|
|
HC SENSITIVITY
|
Facility
|
IP
|
$114.92
|
|
|
Service Code
|
CPT 87186
|
| Hospital Charge Code |
63001065
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$86.19 |
| Max. Negotiated Rate |
$106.88 |
| Rate for Payer: Aetna Commercial |
$99.29
|
| Rate for Payer: Cash Price |
$68.95
|
| Rate for Payer: Cigna All Commercial |
$99.18
|
| Rate for Payer: CORVEL All Commercial |
$106.88
|
| Rate for Payer: Coventry All Commercial |
$101.13
|
| Rate for Payer: Encore All Commercial |
$105.78
|
| Rate for Payer: Frontpath All Commercial |
$105.73
|
| Rate for Payer: Humana ChoiceCare |
$99.26
|
| Rate for Payer: Lutheran Preferred All Commercial |
$103.43
|
| Rate for Payer: PHCS All Commercial |
$86.19
|
| Rate for Payer: PHP All Commercial |
$87.16
|
| Rate for Payer: Sagamore Health Network All Products |
$88.72
|
| Rate for Payer: Signature Care EPO |
$95.38
|
| Rate for Payer: Signature Care PPO |
$101.13
|
| Rate for Payer: United Healthcare Commercial |
$90.56
|
|
|
HC SENSORY INTEGRATION/15 MIN-OT
|
Facility
|
IP
|
$143.02
|
|
|
Service Code
|
CPT 97533 GO
|
| Hospital Charge Code |
1738067
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$107.27 |
| Max. Negotiated Rate |
$133.01 |
| Rate for Payer: Aetna Commercial |
$123.57
|
| Rate for Payer: Cash Price |
$85.81
|
| Rate for Payer: Cigna All Commercial |
$123.43
|
| Rate for Payer: CORVEL All Commercial |
$133.01
|
| Rate for Payer: Coventry All Commercial |
$125.86
|
| Rate for Payer: Encore All Commercial |
$131.65
|
| Rate for Payer: Frontpath All Commercial |
$131.58
|
| Rate for Payer: Humana ChoiceCare |
$123.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.72
|
| Rate for Payer: PHCS All Commercial |
$107.27
|
| Rate for Payer: PHP All Commercial |
$108.47
|
| Rate for Payer: Sagamore Health Network All Products |
$110.41
|
| Rate for Payer: Signature Care EPO |
$118.71
|
| Rate for Payer: Signature Care PPO |
$125.86
|
| Rate for Payer: United Healthcare Commercial |
$112.70
|
|
|
HC SENSORY INTEGRATION/15 MIN-OT
|
Facility
|
OP
|
$143.02
|
|
|
Service Code
|
CPT 97533 GO
|
| Hospital Charge Code |
1738067
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$133.01 |
| Rate for Payer: Aetna Commercial |
$120.71
|
| Rate for Payer: Aetna Medicare |
$45.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$44.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$82.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$89.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.34
|
| Rate for Payer: Cash Price |
$85.81
|
| Rate for Payer: Cash Price |
$85.81
|
| Rate for Payer: Centivo All Commercial |
$77.80
|
| Rate for Payer: Cigna All Commercial |
$123.43
|
| Rate for Payer: CORVEL All Commercial |
$133.01
|
| Rate for Payer: Coventry All Commercial |
$125.86
|
| Rate for Payer: Encore All Commercial |
$131.65
|
| Rate for Payer: Frontpath All Commercial |
$131.58
|
| Rate for Payer: Humana ChoiceCare |
$123.53
|
| Rate for Payer: Humana Medicare |
$45.77
|
| Rate for Payer: Lucent All Commercial |
$77.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$128.72
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$107.27
|
| Rate for Payer: PHP All Commercial |
$108.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$55.78
|
| Rate for Payer: Sagamore Health Network All Products |
$110.41
|
| Rate for Payer: Signature Care EPO |
$118.71
|
| Rate for Payer: Signature Care PPO |
$125.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$121.57
|
| Rate for Payer: United Healthcare Commercial |
$112.70
|
| Rate for Payer: United Healthcare Medicare |
$45.77
|
|
|
HC SENSORY INTEGRATIVE TECH EACH 15 MINS ST
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
CPT 97533 GN
|
| Hospital Charge Code |
1747533
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$126.75 |
| Max. Negotiated Rate |
$157.17 |
| Rate for Payer: Aetna Commercial |
$146.02
|
| Rate for Payer: Cash Price |
$101.40
|
| Rate for Payer: Cigna All Commercial |
$145.85
|
| Rate for Payer: CORVEL All Commercial |
$157.17
|
| Rate for Payer: Coventry All Commercial |
$148.72
|
| Rate for Payer: Encore All Commercial |
$155.56
|
| Rate for Payer: Frontpath All Commercial |
$155.48
|
| Rate for Payer: Humana ChoiceCare |
$145.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$152.10
|
| Rate for Payer: PHCS All Commercial |
$126.75
|
| Rate for Payer: PHP All Commercial |
$128.17
|
| Rate for Payer: Sagamore Health Network All Products |
$130.47
|
| Rate for Payer: Signature Care EPO |
$140.27
|
| Rate for Payer: Signature Care PPO |
$148.72
|
| Rate for Payer: United Healthcare Commercial |
$133.17
|
|
|
HC SENSORY INTEGRATIVE TECH EACH 15 MINS ST
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
CPT 97533 GN
|
| Hospital Charge Code |
1747533
|
|
Hospital Revenue Code
|
440
|
| Min. Negotiated Rate |
$47.81 |
| Max. Negotiated Rate |
$157.17 |
| Rate for Payer: Aetna Commercial |
$142.64
|
| Rate for Payer: Aetna Medicare |
$54.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$52.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$97.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$105.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$62.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$59.49
|
| Rate for Payer: Cash Price |
$101.40
|
| Rate for Payer: Cash Price |
$101.40
|
| Rate for Payer: Centivo All Commercial |
$91.94
|
| Rate for Payer: Cigna All Commercial |
$145.85
|
| Rate for Payer: CORVEL All Commercial |
$157.17
|
| Rate for Payer: Coventry All Commercial |
$148.72
|
| Rate for Payer: Encore All Commercial |
$155.56
|
| Rate for Payer: Frontpath All Commercial |
$155.48
|
| Rate for Payer: Humana ChoiceCare |
$145.97
|
| Rate for Payer: Humana Medicare |
$54.08
|
| Rate for Payer: Lucent All Commercial |
$91.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$152.10
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$126.75
|
| Rate for Payer: PHP All Commercial |
$128.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$65.91
|
| Rate for Payer: Sagamore Health Network All Products |
$130.47
|
| Rate for Payer: Signature Care EPO |
$140.27
|
| Rate for Payer: Signature Care PPO |
$148.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$143.65
|
| Rate for Payer: United Healthcare Commercial |
$133.17
|
| Rate for Payer: United Healthcare Medicare |
$54.08
|
|
|
HC SENTINEL NODE INJECTION
|
Facility
|
IP
|
$1,088.69
|
|
| Hospital Charge Code |
1638792
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$816.52 |
| Max. Negotiated Rate |
$1,012.48 |
| Rate for Payer: Aetna Commercial |
$940.63
|
| Rate for Payer: Cash Price |
$653.21
|
| Rate for Payer: Cigna All Commercial |
$939.54
|
| Rate for Payer: CORVEL All Commercial |
$1,012.48
|
| Rate for Payer: Coventry All Commercial |
$958.05
|
| Rate for Payer: Encore All Commercial |
$1,002.14
|
| Rate for Payer: Frontpath All Commercial |
$1,001.59
|
| Rate for Payer: Humana ChoiceCare |
$940.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$979.82
|
| Rate for Payer: PHCS All Commercial |
$816.52
|
| Rate for Payer: PHP All Commercial |
$825.66
|
| Rate for Payer: Sagamore Health Network All Products |
$840.47
|
| Rate for Payer: Signature Care EPO |
$903.61
|
| Rate for Payer: Signature Care PPO |
$958.05
|
| Rate for Payer: United Healthcare Commercial |
$857.89
|
|
|
HC SENTINEL NODE INJECTION
|
Facility
|
OP
|
$1,088.69
|
|
| Hospital Charge Code |
1638792
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$337.49 |
| Max. Negotiated Rate |
$1,012.48 |
| Rate for Payer: Aetna Commercial |
$918.85
|
| Rate for Payer: Aetna Medicare |
$348.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$337.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$625.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$680.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$400.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$383.22
|
| Rate for Payer: Cash Price |
$653.21
|
| Rate for Payer: Centivo All Commercial |
$592.25
|
| Rate for Payer: Cigna All Commercial |
$939.54
|
| Rate for Payer: CORVEL All Commercial |
$1,012.48
|
| Rate for Payer: Coventry All Commercial |
$958.05
|
| Rate for Payer: Encore All Commercial |
$1,002.14
|
| Rate for Payer: Frontpath All Commercial |
$1,001.59
|
| Rate for Payer: Humana ChoiceCare |
$940.30
|
| Rate for Payer: Humana Medicare |
$348.38
|
| Rate for Payer: Lucent All Commercial |
$592.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$979.82
|
| Rate for Payer: PHCS All Commercial |
$816.52
|
| Rate for Payer: PHP All Commercial |
$825.66
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$424.59
|
| Rate for Payer: Sagamore Health Network All Products |
$840.47
|
| Rate for Payer: Signature Care EPO |
$903.61
|
| Rate for Payer: Signature Care PPO |
$958.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$925.39
|
| Rate for Payer: United Healthcare Commercial |
$857.89
|
| Rate for Payer: United Healthcare Medicare |
$348.38
|
|
|
HC SEPRAFILM
|
Facility
|
OP
|
$1,124.71
|
|
| Hospital Charge Code |
41608190
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$1,045.98 |
| Rate for Payer: Aetna Commercial |
$949.26
|
| Rate for Payer: Aetna Medicare |
$359.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$348.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$645.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$703.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$413.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$395.90
|
| Rate for Payer: Cash Price |
$674.83
|
| Rate for Payer: Cash Price |
$674.83
|
| Rate for Payer: Centivo All Commercial |
$611.84
|
| Rate for Payer: Cigna All Commercial |
$970.62
|
| Rate for Payer: CORVEL All Commercial |
$1,045.98
|
| Rate for Payer: Coventry All Commercial |
$989.74
|
| Rate for Payer: Encore All Commercial |
$1,035.30
|
| Rate for Payer: Frontpath All Commercial |
$1,034.73
|
| Rate for Payer: Humana ChoiceCare |
$971.41
|
| Rate for Payer: Humana Medicare |
$359.91
|
| Rate for Payer: Lucent All Commercial |
$611.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,012.24
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$843.53
|
| Rate for Payer: PHP All Commercial |
$852.98
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$438.64
|
| Rate for Payer: Sagamore Health Network All Products |
$868.28
|
| Rate for Payer: Signature Care EPO |
$933.51
|
| Rate for Payer: Signature Care PPO |
$989.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$956.00
|
| Rate for Payer: United Healthcare Commercial |
$886.27
|
| Rate for Payer: United Healthcare Medicare |
$359.91
|
|
|
HC SEPRAFILM
|
Facility
|
IP
|
$1,124.71
|
|
| Hospital Charge Code |
41608190
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$843.53 |
| Max. Negotiated Rate |
$1,045.98 |
| Rate for Payer: Aetna Commercial |
$971.75
|
| Rate for Payer: Cash Price |
$674.83
|
| Rate for Payer: Cigna All Commercial |
$970.62
|
| Rate for Payer: CORVEL All Commercial |
$1,045.98
|
| Rate for Payer: Coventry All Commercial |
$989.74
|
| Rate for Payer: Encore All Commercial |
$1,035.30
|
| Rate for Payer: Frontpath All Commercial |
$1,034.73
|
| Rate for Payer: Humana ChoiceCare |
$971.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,012.24
|
| Rate for Payer: PHCS All Commercial |
$843.53
|
| Rate for Payer: PHP All Commercial |
$852.98
|
| Rate for Payer: Sagamore Health Network All Products |
$868.28
|
| Rate for Payer: Signature Care EPO |
$933.51
|
| Rate for Payer: Signature Care PPO |
$989.74
|
| Rate for Payer: United Healthcare Commercial |
$886.27
|
|
|
HC SEROTONIN - WHOLE BLOOD
|
Facility
|
OP
|
$329.87
|
|
|
Service Code
|
CPT 84260
|
| Hospital Charge Code |
63001676
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$30.98 |
| Max. Negotiated Rate |
$306.78 |
| Rate for Payer: Aetna Commercial |
$278.41
|
| Rate for Payer: Aetna Medicare |
$105.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$30.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$102.26
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$151.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$151.61
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$30.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$121.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$116.11
|
| Rate for Payer: Cash Price |
$197.92
|
| Rate for Payer: Cash Price |
$197.92
|
| Rate for Payer: Centivo All Commercial |
$179.45
|
| Rate for Payer: Cigna All Commercial |
$284.68
|
| Rate for Payer: CORVEL All Commercial |
$306.78
|
| Rate for Payer: Coventry All Commercial |
$290.29
|
| Rate for Payer: Encore All Commercial |
$303.65
|
| Rate for Payer: Frontpath All Commercial |
$303.48
|
| Rate for Payer: Humana ChoiceCare |
$284.91
|
| Rate for Payer: Humana Medicare |
$105.56
|
| Rate for Payer: Lucent All Commercial |
$179.45
|
| Rate for Payer: Lutheran Preferred All Commercial |
$296.88
|
| Rate for Payer: Managed Health Services Medicaid |
$30.98
|
| Rate for Payer: MDWise Medicaid |
$30.98
|
| Rate for Payer: PHCS All Commercial |
$247.40
|
| Rate for Payer: PHP All Commercial |
$250.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$128.65
|
| Rate for Payer: Sagamore Health Network All Products |
$254.66
|
| Rate for Payer: Signature Care EPO |
$273.79
|
| Rate for Payer: Signature Care PPO |
$290.29
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$280.39
|
| Rate for Payer: United Healthcare Commercial |
$259.94
|
| Rate for Payer: United Healthcare Medicare |
$105.56
|
|
|
HC SEROTONIN - WHOLE BLOOD
|
Facility
|
IP
|
$329.87
|
|
|
Service Code
|
CPT 84260
|
| Hospital Charge Code |
63001676
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$247.40 |
| Max. Negotiated Rate |
$306.78 |
| Rate for Payer: Aetna Commercial |
$285.01
|
| Rate for Payer: Cash Price |
$197.92
|
| Rate for Payer: Cigna All Commercial |
$284.68
|
| Rate for Payer: CORVEL All Commercial |
$306.78
|
| Rate for Payer: Coventry All Commercial |
$290.29
|
| Rate for Payer: Encore All Commercial |
$303.65
|
| Rate for Payer: Frontpath All Commercial |
$303.48
|
| Rate for Payer: Humana ChoiceCare |
$284.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$296.88
|
| Rate for Payer: PHCS All Commercial |
$247.40
|
| Rate for Payer: PHP All Commercial |
$250.17
|
| Rate for Payer: Sagamore Health Network All Products |
$254.66
|
| Rate for Payer: Signature Care EPO |
$273.79
|
| Rate for Payer: Signature Care PPO |
$290.29
|
| Rate for Payer: United Healthcare Commercial |
$259.94
|
|
|
HC SET FEEDING FLUSH EPUMP KANG
|
Facility
|
OP
|
$78.54
|
|
| Hospital Charge Code |
41607867
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.35 |
| Max. Negotiated Rate |
$73.04 |
| Rate for Payer: Aetna Commercial |
$66.29
|
| Rate for Payer: Aetna Medicare |
$25.13
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$24.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$45.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.10
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$28.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$27.65
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Centivo All Commercial |
$42.73
|
| Rate for Payer: Cigna All Commercial |
$67.78
|
| Rate for Payer: CORVEL All Commercial |
$73.04
|
| Rate for Payer: Coventry All Commercial |
$69.12
|
| Rate for Payer: Encore All Commercial |
$72.30
|
| Rate for Payer: Frontpath All Commercial |
$72.26
|
| Rate for Payer: Humana ChoiceCare |
$67.83
|
| Rate for Payer: Humana Medicare |
$25.13
|
| Rate for Payer: Lucent All Commercial |
$42.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$70.69
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$58.91
|
| Rate for Payer: PHP All Commercial |
$59.56
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.63
|
| Rate for Payer: Sagamore Health Network All Products |
$60.63
|
| Rate for Payer: Signature Care EPO |
$65.19
|
| Rate for Payer: Signature Care PPO |
$69.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$66.76
|
| Rate for Payer: United Healthcare Commercial |
$61.89
|
| Rate for Payer: United Healthcare Medicare |
$25.13
|
|
|
HC SET FEEDING FLUSH EPUMP KANG
|
Facility
|
IP
|
$78.54
|
|
| Hospital Charge Code |
41607867
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$58.91 |
| Max. Negotiated Rate |
$73.04 |
| Rate for Payer: Aetna Commercial |
$67.86
|
| Rate for Payer: Cash Price |
$47.12
|
| Rate for Payer: Cigna All Commercial |
$67.78
|
| Rate for Payer: CORVEL All Commercial |
$73.04
|
| Rate for Payer: Coventry All Commercial |
$69.12
|
| Rate for Payer: Encore All Commercial |
$72.30
|
| Rate for Payer: Frontpath All Commercial |
$72.26
|
| Rate for Payer: Humana ChoiceCare |
$67.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$70.69
|
| Rate for Payer: PHCS All Commercial |
$58.91
|
| Rate for Payer: PHP All Commercial |
$59.56
|
| Rate for Payer: Sagamore Health Network All Products |
$60.63
|
| Rate for Payer: Signature Care EPO |
$65.19
|
| Rate for Payer: Signature Care PPO |
$69.12
|
| Rate for Payer: United Healthcare Commercial |
$61.89
|
|
|
HC SET RADIATION THERAPY FIELD 3D
|
Facility
|
OP
|
$7,531.68
|
|
|
Service Code
|
CPT 77295
|
| Hospital Charge Code |
1547295
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$181.00 |
| Max. Negotiated Rate |
$7,004.46 |
| Rate for Payer: Aetna Commercial |
$6,356.74
|
| Rate for Payer: Aetna Medicare |
$2,410.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$181.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,334.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4,325.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,708.05
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$181.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,771.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,651.15
|
| Rate for Payer: Cash Price |
$4,519.01
|
| Rate for Payer: Cash Price |
$4,519.01
|
| Rate for Payer: Centivo All Commercial |
$4,097.23
|
| Rate for Payer: Cigna All Commercial |
$6,499.84
|
| Rate for Payer: CORVEL All Commercial |
$7,004.46
|
| Rate for Payer: Coventry All Commercial |
$6,627.88
|
| Rate for Payer: Encore All Commercial |
$6,932.91
|
| Rate for Payer: Frontpath All Commercial |
$6,929.15
|
| Rate for Payer: Humana ChoiceCare |
$6,505.11
|
| Rate for Payer: Humana Medicare |
$2,410.14
|
| Rate for Payer: Lucent All Commercial |
$4,097.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,778.51
|
| Rate for Payer: Managed Health Services Medicaid |
$181.00
|
| Rate for Payer: MDWise Medicaid |
$181.00
|
| Rate for Payer: PHCS All Commercial |
$5,648.76
|
| Rate for Payer: PHP All Commercial |
$5,712.03
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,937.36
|
| Rate for Payer: Sagamore Health Network All Products |
$5,814.46
|
| Rate for Payer: Signature Care EPO |
$6,251.29
|
| Rate for Payer: Signature Care PPO |
$6,627.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,401.93
|
| Rate for Payer: United Healthcare Commercial |
$5,934.96
|
| Rate for Payer: United Healthcare Medicare |
$2,410.14
|
|
|
HC SET RADIATION THERAPY FIELD 3D
|
Facility
|
IP
|
$7,531.68
|
|
|
Service Code
|
CPT 77295
|
| Hospital Charge Code |
1547295
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$5,648.76 |
| Max. Negotiated Rate |
$7,004.46 |
| Rate for Payer: Aetna Commercial |
$6,507.37
|
| Rate for Payer: Cash Price |
$4,519.01
|
| Rate for Payer: Cigna All Commercial |
$6,499.84
|
| Rate for Payer: CORVEL All Commercial |
$7,004.46
|
| Rate for Payer: Coventry All Commercial |
$6,627.88
|
| Rate for Payer: Encore All Commercial |
$6,932.91
|
| Rate for Payer: Frontpath All Commercial |
$6,929.15
|
| Rate for Payer: Humana ChoiceCare |
$6,505.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,778.51
|
| Rate for Payer: PHCS All Commercial |
$5,648.76
|
| Rate for Payer: PHP All Commercial |
$5,712.03
|
| Rate for Payer: Sagamore Health Network All Products |
$5,814.46
|
| Rate for Payer: Signature Care EPO |
$6,251.29
|
| Rate for Payer: Signature Care PPO |
$6,627.88
|
| Rate for Payer: United Healthcare Commercial |
$5,934.96
|
|
|
HC SEVOFLURANE (ULTANE) LIQD CMCH
|
Facility
|
IP
|
$34.75
|
|
| Hospital Charge Code |
61301001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.06 |
| Max. Negotiated Rate |
$32.32 |
| Rate for Payer: Aetna Commercial |
$30.02
|
| Rate for Payer: Cash Price |
$20.85
|
| Rate for Payer: Cigna All Commercial |
$29.99
|
| Rate for Payer: CORVEL All Commercial |
$32.32
|
| Rate for Payer: Coventry All Commercial |
$30.58
|
| Rate for Payer: Encore All Commercial |
$31.99
|
| Rate for Payer: Frontpath All Commercial |
$31.97
|
| Rate for Payer: Humana ChoiceCare |
$30.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.27
|
| Rate for Payer: PHCS All Commercial |
$26.06
|
| Rate for Payer: PHP All Commercial |
$26.35
|
| Rate for Payer: Sagamore Health Network All Products |
$26.83
|
| Rate for Payer: Signature Care EPO |
$28.84
|
| Rate for Payer: Signature Care PPO |
$30.58
|
| Rate for Payer: United Healthcare Commercial |
$27.38
|
|
|
HC SEVOFLURANE (ULTANE) LIQD CMCH
|
Facility
|
OP
|
$34.75
|
|
| Hospital Charge Code |
61301001
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.56 |
| Max. Negotiated Rate |
$32.32 |
| Rate for Payer: Aetna Commercial |
$29.33
|
| Rate for Payer: Aetna Medicare |
$11.12
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$9.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.72
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$9.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.23
|
| Rate for Payer: Cash Price |
$20.85
|
| Rate for Payer: Cash Price |
$20.85
|
| Rate for Payer: Centivo All Commercial |
$18.90
|
| Rate for Payer: Cigna All Commercial |
$29.99
|
| Rate for Payer: CORVEL All Commercial |
$32.32
|
| Rate for Payer: Coventry All Commercial |
$30.58
|
| Rate for Payer: Encore All Commercial |
$31.99
|
| Rate for Payer: Frontpath All Commercial |
$31.97
|
| Rate for Payer: Humana ChoiceCare |
$30.01
|
| Rate for Payer: Humana Medicare |
$11.12
|
| Rate for Payer: Lucent All Commercial |
$18.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.27
|
| Rate for Payer: Managed Health Services Medicaid |
$9.56
|
| Rate for Payer: MDWise Medicaid |
$9.56
|
| Rate for Payer: PHCS All Commercial |
$26.06
|
| Rate for Payer: PHP All Commercial |
$26.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.55
|
| Rate for Payer: Sagamore Health Network All Products |
$26.83
|
| Rate for Payer: Signature Care EPO |
$28.84
|
| Rate for Payer: Signature Care PPO |
$30.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.54
|
| Rate for Payer: United Healthcare Commercial |
$27.38
|
| Rate for Payer: United Healthcare Medicare |
$11.12
|
|
|
HC SEX HORMONE BINDING GLOB
|
Facility
|
IP
|
$94.86
|
|
|
Service Code
|
CPT 84270
|
| Hospital Charge Code |
63001677
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$71.14 |
| Max. Negotiated Rate |
$88.22 |
| Rate for Payer: Aetna Commercial |
$81.96
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cigna All Commercial |
$81.86
|
| Rate for Payer: CORVEL All Commercial |
$88.22
|
| Rate for Payer: Coventry All Commercial |
$83.48
|
| Rate for Payer: Encore All Commercial |
$87.32
|
| Rate for Payer: Frontpath All Commercial |
$87.27
|
| Rate for Payer: Humana ChoiceCare |
$81.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$85.37
|
| Rate for Payer: PHCS All Commercial |
$71.14
|
| Rate for Payer: PHP All Commercial |
$71.94
|
| Rate for Payer: Sagamore Health Network All Products |
$73.23
|
| Rate for Payer: Signature Care EPO |
$78.73
|
| Rate for Payer: Signature Care PPO |
$83.48
|
| Rate for Payer: United Healthcare Commercial |
$74.75
|
|
|
HC SEX HORMONE BINDING GLOB
|
Facility
|
OP
|
$94.86
|
|
|
Service Code
|
CPT 84270
|
| Hospital Charge Code |
63001677
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.73 |
| Max. Negotiated Rate |
$88.22 |
| Rate for Payer: Aetna Commercial |
$80.06
|
| Rate for Payer: Aetna Medicare |
$30.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$21.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$29.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$43.60
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$34.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$33.39
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Centivo All Commercial |
$51.60
|
| Rate for Payer: Cigna All Commercial |
$81.86
|
| Rate for Payer: CORVEL All Commercial |
$88.22
|
| Rate for Payer: Coventry All Commercial |
$83.48
|
| Rate for Payer: Encore All Commercial |
$87.32
|
| Rate for Payer: Frontpath All Commercial |
$87.27
|
| Rate for Payer: Humana ChoiceCare |
$81.93
|
| Rate for Payer: Humana Medicare |
$30.36
|
| Rate for Payer: Lucent All Commercial |
$51.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$85.37
|
| Rate for Payer: Managed Health Services Medicaid |
$21.73
|
| Rate for Payer: MDWise Medicaid |
$21.73
|
| Rate for Payer: PHCS All Commercial |
$71.14
|
| Rate for Payer: PHP All Commercial |
$71.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$37.00
|
| Rate for Payer: Sagamore Health Network All Products |
$73.23
|
| Rate for Payer: Signature Care EPO |
$78.73
|
| Rate for Payer: Signature Care PPO |
$83.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$80.63
|
| Rate for Payer: United Healthcare Commercial |
$74.75
|
| Rate for Payer: United Healthcare Medicare |
$30.36
|
|
|
HC S FEM COMP 3 CR TRI CEM R
|
Facility
|
IP
|
$7,784.71
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41607741
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,838.53 |
| Max. Negotiated Rate |
$7,239.78 |
| Rate for Payer: Aetna Commercial |
$6,725.99
|
| Rate for Payer: Cash Price |
$4,670.83
|
| Rate for Payer: Cigna All Commercial |
$6,718.20
|
| Rate for Payer: CORVEL All Commercial |
$7,239.78
|
| Rate for Payer: Coventry All Commercial |
$6,850.54
|
| Rate for Payer: Encore All Commercial |
$7,165.83
|
| Rate for Payer: Frontpath All Commercial |
$7,161.93
|
| Rate for Payer: Humana ChoiceCare |
$6,723.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,006.24
|
| Rate for Payer: PHCS All Commercial |
$5,838.53
|
| Rate for Payer: PHP All Commercial |
$5,903.92
|
| Rate for Payer: Sagamore Health Network All Products |
$6,009.80
|
| Rate for Payer: Signature Care EPO |
$6,461.31
|
| Rate for Payer: Signature Care PPO |
$6,850.54
|
| Rate for Payer: United Healthcare Commercial |
$6,134.35
|
|
