|
HC SPLINT; FINGER L 2 STATIC-OT
|
Facility
|
OP
|
$291.72
|
|
|
Service Code
|
CPT 29130 GO,F1
|
| Hospital Charge Code |
11738072
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$47.81 |
| Max. Negotiated Rate |
$271.30 |
| Rate for Payer: Aetna Commercial |
$246.21
|
| Rate for Payer: Aetna Medicare |
$93.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$90.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$167.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$182.35
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$107.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$102.69
|
| Rate for Payer: Cash Price |
$175.03
|
| Rate for Payer: Cash Price |
$175.03
|
| Rate for Payer: Centivo All Commercial |
$158.70
|
| Rate for Payer: Cigna All Commercial |
$251.75
|
| Rate for Payer: CORVEL All Commercial |
$271.30
|
| Rate for Payer: Coventry All Commercial |
$256.71
|
| Rate for Payer: Encore All Commercial |
$268.53
|
| Rate for Payer: Frontpath All Commercial |
$268.38
|
| Rate for Payer: Humana ChoiceCare |
$251.96
|
| Rate for Payer: Humana Medicare |
$93.35
|
| Rate for Payer: Lucent All Commercial |
$158.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$262.55
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$218.79
|
| Rate for Payer: PHP All Commercial |
$221.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$113.77
|
| Rate for Payer: Sagamore Health Network All Products |
$225.21
|
| Rate for Payer: Signature Care EPO |
$242.13
|
| Rate for Payer: Signature Care PPO |
$256.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$247.96
|
| Rate for Payer: United Healthcare Commercial |
$229.88
|
| Rate for Payer: United Healthcare Medicare |
$93.35
|
|
|
HC SPLINT; FINGER R 10 STATIC-OT
|
Facility
|
IP
|
$313.80
|
|
|
Service Code
|
CPT 29130 GO,F9
|
| Hospital Charge Code |
91738072
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$235.35 |
| Max. Negotiated Rate |
$291.83 |
| Rate for Payer: Aetna Commercial |
$271.12
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Cigna All Commercial |
$270.81
|
| Rate for Payer: CORVEL All Commercial |
$291.83
|
| Rate for Payer: Coventry All Commercial |
$276.14
|
| Rate for Payer: Encore All Commercial |
$288.85
|
| Rate for Payer: Frontpath All Commercial |
$288.70
|
| Rate for Payer: Humana ChoiceCare |
$271.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$282.42
|
| Rate for Payer: PHCS All Commercial |
$235.35
|
| Rate for Payer: PHP All Commercial |
$237.99
|
| Rate for Payer: Sagamore Health Network All Products |
$242.25
|
| Rate for Payer: Signature Care EPO |
$260.45
|
| Rate for Payer: Signature Care PPO |
$276.14
|
| Rate for Payer: United Healthcare Commercial |
$247.27
|
|
|
HC SPLINT; FINGER R 10 STATIC-OT
|
Facility
|
OP
|
$313.80
|
|
|
Service Code
|
CPT 29130 GO,F9
|
| Hospital Charge Code |
91738072
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$47.81 |
| Max. Negotiated Rate |
$291.83 |
| Rate for Payer: Aetna Commercial |
$264.85
|
| Rate for Payer: Aetna Medicare |
$100.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$180.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$196.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$115.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$110.46
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Centivo All Commercial |
$170.71
|
| Rate for Payer: Cigna All Commercial |
$270.81
|
| Rate for Payer: CORVEL All Commercial |
$291.83
|
| Rate for Payer: Coventry All Commercial |
$276.14
|
| Rate for Payer: Encore All Commercial |
$288.85
|
| Rate for Payer: Frontpath All Commercial |
$288.70
|
| Rate for Payer: Humana ChoiceCare |
$271.03
|
| Rate for Payer: Humana Medicare |
$100.42
|
| Rate for Payer: Lucent All Commercial |
$170.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$282.42
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$235.35
|
| Rate for Payer: PHP All Commercial |
$237.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$122.38
|
| Rate for Payer: Sagamore Health Network All Products |
$242.25
|
| Rate for Payer: Signature Care EPO |
$260.45
|
| Rate for Payer: Signature Care PPO |
$276.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$266.73
|
| Rate for Payer: United Healthcare Commercial |
$247.27
|
| Rate for Payer: United Healthcare Medicare |
$100.42
|
|
|
HC SPLINT; FINGER R 8 STATIC-OT
|
Facility
|
OP
|
$313.80
|
|
|
Service Code
|
CPT 29130 GO,F7
|
| Hospital Charge Code |
71738072
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$47.81 |
| Max. Negotiated Rate |
$291.83 |
| Rate for Payer: Aetna Commercial |
$264.85
|
| Rate for Payer: Aetna Medicare |
$100.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$180.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$196.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$115.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$110.46
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Centivo All Commercial |
$170.71
|
| Rate for Payer: Cigna All Commercial |
$270.81
|
| Rate for Payer: CORVEL All Commercial |
$291.83
|
| Rate for Payer: Coventry All Commercial |
$276.14
|
| Rate for Payer: Encore All Commercial |
$288.85
|
| Rate for Payer: Frontpath All Commercial |
$288.70
|
| Rate for Payer: Humana ChoiceCare |
$271.03
|
| Rate for Payer: Humana Medicare |
$100.42
|
| Rate for Payer: Lucent All Commercial |
$170.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$282.42
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$235.35
|
| Rate for Payer: PHP All Commercial |
$237.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$122.38
|
| Rate for Payer: Sagamore Health Network All Products |
$242.25
|
| Rate for Payer: Signature Care EPO |
$260.45
|
| Rate for Payer: Signature Care PPO |
$276.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$266.73
|
| Rate for Payer: United Healthcare Commercial |
$247.27
|
| Rate for Payer: United Healthcare Medicare |
$100.42
|
|
|
HC SPLINT; FINGER R 8 STATIC-OT
|
Facility
|
IP
|
$313.80
|
|
|
Service Code
|
CPT 29130 GO,F7
|
| Hospital Charge Code |
71738072
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$235.35 |
| Max. Negotiated Rate |
$291.83 |
| Rate for Payer: Aetna Commercial |
$271.12
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Cigna All Commercial |
$270.81
|
| Rate for Payer: CORVEL All Commercial |
$291.83
|
| Rate for Payer: Coventry All Commercial |
$276.14
|
| Rate for Payer: Encore All Commercial |
$288.85
|
| Rate for Payer: Frontpath All Commercial |
$288.70
|
| Rate for Payer: Humana ChoiceCare |
$271.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$282.42
|
| Rate for Payer: PHCS All Commercial |
$235.35
|
| Rate for Payer: PHP All Commercial |
$237.99
|
| Rate for Payer: Sagamore Health Network All Products |
$242.25
|
| Rate for Payer: Signature Care EPO |
$260.45
|
| Rate for Payer: Signature Care PPO |
$276.14
|
| Rate for Payer: United Healthcare Commercial |
$247.27
|
|
|
HC SPLINT FINGER STAX #4
|
Facility
|
IP
|
$9.45
|
|
| Hospital Charge Code |
41601831
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$8.79 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Cash Price |
$5.67
|
| Rate for Payer: Cigna All Commercial |
$8.16
|
| Rate for Payer: CORVEL All Commercial |
$8.79
|
| Rate for Payer: Coventry All Commercial |
$8.32
|
| Rate for Payer: Encore All Commercial |
$8.70
|
| Rate for Payer: Frontpath All Commercial |
$8.69
|
| Rate for Payer: Humana ChoiceCare |
$8.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.51
|
| Rate for Payer: PHCS All Commercial |
$7.09
|
| Rate for Payer: PHP All Commercial |
$7.17
|
| Rate for Payer: Sagamore Health Network All Products |
$7.30
|
| Rate for Payer: Signature Care EPO |
$7.84
|
| Rate for Payer: Signature Care PPO |
$8.32
|
| Rate for Payer: United Healthcare Commercial |
$7.45
|
|
|
HC SPLINT FINGER STAX #4
|
Facility
|
OP
|
$9.45
|
|
| Hospital Charge Code |
41601831
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$8.79 |
| Rate for Payer: Aetna Commercial |
$7.98
|
| Rate for Payer: Aetna Medicare |
$3.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.33
|
| Rate for Payer: Cash Price |
$5.67
|
| Rate for Payer: Centivo All Commercial |
$5.14
|
| Rate for Payer: Cigna All Commercial |
$8.16
|
| Rate for Payer: CORVEL All Commercial |
$8.79
|
| Rate for Payer: Coventry All Commercial |
$8.32
|
| Rate for Payer: Encore All Commercial |
$8.70
|
| Rate for Payer: Frontpath All Commercial |
$8.69
|
| Rate for Payer: Humana ChoiceCare |
$8.16
|
| Rate for Payer: Humana Medicare |
$3.02
|
| Rate for Payer: Lucent All Commercial |
$5.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.51
|
| Rate for Payer: PHCS All Commercial |
$7.09
|
| Rate for Payer: PHP All Commercial |
$7.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.69
|
| Rate for Payer: Sagamore Health Network All Products |
$7.30
|
| Rate for Payer: Signature Care EPO |
$7.84
|
| Rate for Payer: Signature Care PPO |
$8.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.03
|
| Rate for Payer: United Healthcare Commercial |
$7.45
|
| Rate for Payer: United Healthcare Medicare |
$3.02
|
|
|
HC SPLINT FINGER STAX #5
|
Facility
|
IP
|
$9.45
|
|
| Hospital Charge Code |
41601832
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$7.09 |
| Max. Negotiated Rate |
$8.79 |
| Rate for Payer: Aetna Commercial |
$8.16
|
| Rate for Payer: Cash Price |
$5.67
|
| Rate for Payer: Cigna All Commercial |
$8.16
|
| Rate for Payer: CORVEL All Commercial |
$8.79
|
| Rate for Payer: Coventry All Commercial |
$8.32
|
| Rate for Payer: Encore All Commercial |
$8.70
|
| Rate for Payer: Frontpath All Commercial |
$8.69
|
| Rate for Payer: Humana ChoiceCare |
$8.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.51
|
| Rate for Payer: PHCS All Commercial |
$7.09
|
| Rate for Payer: PHP All Commercial |
$7.17
|
| Rate for Payer: Sagamore Health Network All Products |
$7.30
|
| Rate for Payer: Signature Care EPO |
$7.84
|
| Rate for Payer: Signature Care PPO |
$8.32
|
| Rate for Payer: United Healthcare Commercial |
$7.45
|
|
|
HC SPLINT FINGER STAX #5
|
Facility
|
OP
|
$9.45
|
|
| Hospital Charge Code |
41601832
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$2.93 |
| Max. Negotiated Rate |
$8.79 |
| Rate for Payer: Aetna Commercial |
$7.98
|
| Rate for Payer: Aetna Medicare |
$3.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.93
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3.33
|
| Rate for Payer: Cash Price |
$5.67
|
| Rate for Payer: Centivo All Commercial |
$5.14
|
| Rate for Payer: Cigna All Commercial |
$8.16
|
| Rate for Payer: CORVEL All Commercial |
$8.79
|
| Rate for Payer: Coventry All Commercial |
$8.32
|
| Rate for Payer: Encore All Commercial |
$8.70
|
| Rate for Payer: Frontpath All Commercial |
$8.69
|
| Rate for Payer: Humana ChoiceCare |
$8.16
|
| Rate for Payer: Humana Medicare |
$3.02
|
| Rate for Payer: Lucent All Commercial |
$5.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$8.51
|
| Rate for Payer: PHCS All Commercial |
$7.09
|
| Rate for Payer: PHP All Commercial |
$7.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.69
|
| Rate for Payer: Sagamore Health Network All Products |
$7.30
|
| Rate for Payer: Signature Care EPO |
$7.84
|
| Rate for Payer: Signature Care PPO |
$8.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8.03
|
| Rate for Payer: United Healthcare Commercial |
$7.45
|
| Rate for Payer: United Healthcare Medicare |
$3.02
|
|
|
HC SPLINT FINGER STAX #6
|
Facility
|
IP
|
$16.17
|
|
| Hospital Charge Code |
41601833
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$12.13 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna Commercial |
$13.97
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Cigna All Commercial |
$13.95
|
| Rate for Payer: CORVEL All Commercial |
$15.04
|
| Rate for Payer: Coventry All Commercial |
$14.23
|
| Rate for Payer: Encore All Commercial |
$14.88
|
| Rate for Payer: Frontpath All Commercial |
$14.88
|
| Rate for Payer: Humana ChoiceCare |
$13.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.55
|
| Rate for Payer: PHCS All Commercial |
$12.13
|
| Rate for Payer: PHP All Commercial |
$12.26
|
| Rate for Payer: Sagamore Health Network All Products |
$12.48
|
| Rate for Payer: Signature Care EPO |
$13.42
|
| Rate for Payer: Signature Care PPO |
$14.23
|
| Rate for Payer: United Healthcare Commercial |
$12.74
|
|
|
HC SPLINT FINGER STAX #6
|
Facility
|
OP
|
$16.17
|
|
| Hospital Charge Code |
41601833
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$5.01 |
| Max. Negotiated Rate |
$15.04 |
| Rate for Payer: Aetna Commercial |
$13.65
|
| Rate for Payer: Aetna Medicare |
$5.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$9.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.69
|
| Rate for Payer: Cash Price |
$9.70
|
| Rate for Payer: Centivo All Commercial |
$8.80
|
| Rate for Payer: Cigna All Commercial |
$13.95
|
| Rate for Payer: CORVEL All Commercial |
$15.04
|
| Rate for Payer: Coventry All Commercial |
$14.23
|
| Rate for Payer: Encore All Commercial |
$14.88
|
| Rate for Payer: Frontpath All Commercial |
$14.88
|
| Rate for Payer: Humana ChoiceCare |
$13.97
|
| Rate for Payer: Humana Medicare |
$5.17
|
| Rate for Payer: Lucent All Commercial |
$8.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$14.55
|
| Rate for Payer: PHCS All Commercial |
$12.13
|
| Rate for Payer: PHP All Commercial |
$12.26
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.31
|
| Rate for Payer: Sagamore Health Network All Products |
$12.48
|
| Rate for Payer: Signature Care EPO |
$13.42
|
| Rate for Payer: Signature Care PPO |
$14.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13.74
|
| Rate for Payer: United Healthcare Commercial |
$12.74
|
| Rate for Payer: United Healthcare Medicare |
$5.17
|
|
|
HC SPLINT GUTTER 4 INCH
|
Facility
|
IP
|
$4.86
|
|
| Hospital Charge Code |
41601834
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$3.65 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Aetna Commercial |
$4.20
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna All Commercial |
$4.19
|
| Rate for Payer: CORVEL All Commercial |
$4.52
|
| Rate for Payer: Coventry All Commercial |
$4.28
|
| Rate for Payer: Encore All Commercial |
$4.47
|
| Rate for Payer: Frontpath All Commercial |
$4.47
|
| Rate for Payer: Humana ChoiceCare |
$4.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.37
|
| Rate for Payer: PHCS All Commercial |
$3.65
|
| Rate for Payer: PHP All Commercial |
$3.69
|
| Rate for Payer: Sagamore Health Network All Products |
$3.75
|
| Rate for Payer: Signature Care EPO |
$4.03
|
| Rate for Payer: Signature Care PPO |
$4.28
|
| Rate for Payer: United Healthcare Commercial |
$3.83
|
|
|
HC SPLINT GUTTER 4 INCH
|
Facility
|
OP
|
$4.86
|
|
| Hospital Charge Code |
41601834
|
|
Hospital Revenue Code
|
274
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$4.52 |
| Rate for Payer: Aetna Commercial |
$4.10
|
| Rate for Payer: Aetna Medicare |
$1.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.71
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Centivo All Commercial |
$2.64
|
| Rate for Payer: Cigna All Commercial |
$4.19
|
| Rate for Payer: CORVEL All Commercial |
$4.52
|
| Rate for Payer: Coventry All Commercial |
$4.28
|
| Rate for Payer: Encore All Commercial |
$4.47
|
| Rate for Payer: Frontpath All Commercial |
$4.47
|
| Rate for Payer: Humana ChoiceCare |
$4.20
|
| Rate for Payer: Humana Medicare |
$1.56
|
| Rate for Payer: Lucent All Commercial |
$2.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.37
|
| Rate for Payer: PHCS All Commercial |
$3.65
|
| Rate for Payer: PHP All Commercial |
$3.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.90
|
| Rate for Payer: Sagamore Health Network All Products |
$3.75
|
| Rate for Payer: Signature Care EPO |
$4.03
|
| Rate for Payer: Signature Care PPO |
$4.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.13
|
| Rate for Payer: United Healthcare Commercial |
$3.83
|
| Rate for Payer: United Healthcare Medicare |
$1.56
|
|
|
HC SPLINT; L THUMB STATIC-OT
|
Facility
|
OP
|
$313.80
|
|
|
Service Code
|
CPT 29130 GO,FA
|
| Hospital Charge Code |
1738072
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$47.81 |
| Max. Negotiated Rate |
$291.83 |
| Rate for Payer: Aetna Commercial |
$264.85
|
| Rate for Payer: Aetna Medicare |
$100.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$180.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$196.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$115.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$110.46
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Centivo All Commercial |
$170.71
|
| Rate for Payer: Cigna All Commercial |
$270.81
|
| Rate for Payer: CORVEL All Commercial |
$291.83
|
| Rate for Payer: Coventry All Commercial |
$276.14
|
| Rate for Payer: Encore All Commercial |
$288.85
|
| Rate for Payer: Frontpath All Commercial |
$288.70
|
| Rate for Payer: Humana ChoiceCare |
$271.03
|
| Rate for Payer: Humana Medicare |
$100.42
|
| Rate for Payer: Lucent All Commercial |
$170.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$282.42
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$235.35
|
| Rate for Payer: PHP All Commercial |
$237.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$122.38
|
| Rate for Payer: Sagamore Health Network All Products |
$242.25
|
| Rate for Payer: Signature Care EPO |
$260.45
|
| Rate for Payer: Signature Care PPO |
$276.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$266.73
|
| Rate for Payer: United Healthcare Commercial |
$247.27
|
| Rate for Payer: United Healthcare Medicare |
$100.42
|
|
|
HC SPLINT; L THUMB STATIC-OT
|
Facility
|
IP
|
$313.80
|
|
|
Service Code
|
CPT 29130 GO,FA
|
| Hospital Charge Code |
1738072
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$235.35 |
| Max. Negotiated Rate |
$291.83 |
| Rate for Payer: Aetna Commercial |
$271.12
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Cigna All Commercial |
$270.81
|
| Rate for Payer: CORVEL All Commercial |
$291.83
|
| Rate for Payer: Coventry All Commercial |
$276.14
|
| Rate for Payer: Encore All Commercial |
$288.85
|
| Rate for Payer: Frontpath All Commercial |
$288.70
|
| Rate for Payer: Humana ChoiceCare |
$271.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$282.42
|
| Rate for Payer: PHCS All Commercial |
$235.35
|
| Rate for Payer: PHP All Commercial |
$237.99
|
| Rate for Payer: Sagamore Health Network All Products |
$242.25
|
| Rate for Payer: Signature Care EPO |
$260.45
|
| Rate for Payer: Signature Care PPO |
$276.14
|
| Rate for Payer: United Healthcare Commercial |
$247.27
|
|
|
HC SPLINT; R THUMB STATIC-OT
|
Facility
|
OP
|
$313.80
|
|
|
Service Code
|
CPT 29130 GO,F5
|
| Hospital Charge Code |
51738072
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$47.81 |
| Max. Negotiated Rate |
$291.83 |
| Rate for Payer: Aetna Commercial |
$264.85
|
| Rate for Payer: Aetna Medicare |
$100.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$97.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$180.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$196.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$115.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$110.46
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Centivo All Commercial |
$170.71
|
| Rate for Payer: Cigna All Commercial |
$270.81
|
| Rate for Payer: CORVEL All Commercial |
$291.83
|
| Rate for Payer: Coventry All Commercial |
$276.14
|
| Rate for Payer: Encore All Commercial |
$288.85
|
| Rate for Payer: Frontpath All Commercial |
$288.70
|
| Rate for Payer: Humana ChoiceCare |
$271.03
|
| Rate for Payer: Humana Medicare |
$100.42
|
| Rate for Payer: Lucent All Commercial |
$170.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$282.42
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$235.35
|
| Rate for Payer: PHP All Commercial |
$237.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$122.38
|
| Rate for Payer: Sagamore Health Network All Products |
$242.25
|
| Rate for Payer: Signature Care EPO |
$260.45
|
| Rate for Payer: Signature Care PPO |
$276.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$266.73
|
| Rate for Payer: United Healthcare Commercial |
$247.27
|
| Rate for Payer: United Healthcare Medicare |
$100.42
|
|
|
HC SPLINT; R THUMB STATIC-OT
|
Facility
|
IP
|
$313.80
|
|
|
Service Code
|
CPT 29130 GO,F5
|
| Hospital Charge Code |
51738072
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$235.35 |
| Max. Negotiated Rate |
$291.83 |
| Rate for Payer: Aetna Commercial |
$271.12
|
| Rate for Payer: Cash Price |
$188.28
|
| Rate for Payer: Cigna All Commercial |
$270.81
|
| Rate for Payer: CORVEL All Commercial |
$291.83
|
| Rate for Payer: Coventry All Commercial |
$276.14
|
| Rate for Payer: Encore All Commercial |
$288.85
|
| Rate for Payer: Frontpath All Commercial |
$288.70
|
| Rate for Payer: Humana ChoiceCare |
$271.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$282.42
|
| Rate for Payer: PHCS All Commercial |
$235.35
|
| Rate for Payer: PHP All Commercial |
$237.99
|
| Rate for Payer: Sagamore Health Network All Products |
$242.25
|
| Rate for Payer: Signature Care EPO |
$260.45
|
| Rate for Payer: Signature Care PPO |
$276.14
|
| Rate for Payer: United Healthcare Commercial |
$247.27
|
|
|
HC SPLINT; SHORT ARM STATIC-OT
|
Facility
|
OP
|
$438.60
|
|
|
Service Code
|
CPT 29125 GO
|
| Hospital Charge Code |
1738076
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$47.81 |
| Max. Negotiated Rate |
$407.90 |
| Rate for Payer: Aetna Commercial |
$370.18
|
| Rate for Payer: Aetna Medicare |
$140.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$135.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$251.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$274.17
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$161.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$154.39
|
| Rate for Payer: Cash Price |
$263.16
|
| Rate for Payer: Cash Price |
$263.16
|
| Rate for Payer: Centivo All Commercial |
$238.60
|
| Rate for Payer: Cigna All Commercial |
$378.51
|
| Rate for Payer: CORVEL All Commercial |
$407.90
|
| Rate for Payer: Coventry All Commercial |
$385.97
|
| Rate for Payer: Encore All Commercial |
$403.73
|
| Rate for Payer: Frontpath All Commercial |
$403.51
|
| Rate for Payer: Humana ChoiceCare |
$378.82
|
| Rate for Payer: Humana Medicare |
$140.35
|
| Rate for Payer: Lucent All Commercial |
$238.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$394.74
|
| Rate for Payer: Managed Health Services Medicaid |
$47.81
|
| Rate for Payer: MDWise Medicaid |
$47.81
|
| Rate for Payer: PHCS All Commercial |
$328.95
|
| Rate for Payer: PHP All Commercial |
$332.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$171.05
|
| Rate for Payer: Sagamore Health Network All Products |
$338.60
|
| Rate for Payer: Signature Care EPO |
$364.04
|
| Rate for Payer: Signature Care PPO |
$385.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$372.81
|
| Rate for Payer: United Healthcare Commercial |
$345.62
|
| Rate for Payer: United Healthcare Medicare |
$140.35
|
|
|
HC SPLINT; SHORT ARM STATIC-OT
|
Facility
|
IP
|
$438.60
|
|
|
Service Code
|
CPT 29125 GO
|
| Hospital Charge Code |
1738076
|
|
Hospital Revenue Code
|
430
|
| Min. Negotiated Rate |
$328.95 |
| Max. Negotiated Rate |
$407.90 |
| Rate for Payer: Aetna Commercial |
$378.95
|
| Rate for Payer: Cash Price |
$263.16
|
| Rate for Payer: Cigna All Commercial |
$378.51
|
| Rate for Payer: CORVEL All Commercial |
$407.90
|
| Rate for Payer: Coventry All Commercial |
$385.97
|
| Rate for Payer: Encore All Commercial |
$403.73
|
| Rate for Payer: Frontpath All Commercial |
$403.51
|
| Rate for Payer: Humana ChoiceCare |
$378.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$394.74
|
| Rate for Payer: PHCS All Commercial |
$328.95
|
| Rate for Payer: PHP All Commercial |
$332.63
|
| Rate for Payer: Sagamore Health Network All Products |
$338.60
|
| Rate for Payer: Signature Care EPO |
$364.04
|
| Rate for Payer: Signature Care PPO |
$385.97
|
| Rate for Payer: United Healthcare Commercial |
$345.62
|
|
|
HC S. PNEUMONIAE AG, UR
|
Facility
|
IP
|
$66.41
|
|
|
Service Code
|
CPT 87899
|
| Hospital Charge Code |
63001357
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$49.81 |
| Max. Negotiated Rate |
$61.76 |
| Rate for Payer: Aetna Commercial |
$57.38
|
| Rate for Payer: Cash Price |
$39.85
|
| Rate for Payer: Cigna All Commercial |
$57.31
|
| Rate for Payer: CORVEL All Commercial |
$61.76
|
| Rate for Payer: Coventry All Commercial |
$58.44
|
| Rate for Payer: Encore All Commercial |
$61.13
|
| Rate for Payer: Frontpath All Commercial |
$61.10
|
| Rate for Payer: Humana ChoiceCare |
$57.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.77
|
| Rate for Payer: PHCS All Commercial |
$49.81
|
| Rate for Payer: PHP All Commercial |
$50.37
|
| Rate for Payer: Sagamore Health Network All Products |
$51.27
|
| Rate for Payer: Signature Care EPO |
$55.12
|
| Rate for Payer: Signature Care PPO |
$58.44
|
| Rate for Payer: United Healthcare Commercial |
$52.33
|
|
|
HC S. PNEUMONIAE AG, UR
|
Facility
|
OP
|
$66.41
|
|
|
Service Code
|
CPT 87899
|
| Hospital Charge Code |
63001357
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$61.76 |
| Rate for Payer: Aetna Commercial |
$56.05
|
| Rate for Payer: Aetna Medicare |
$21.25
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$16.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$30.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$30.52
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$16.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.38
|
| Rate for Payer: Cash Price |
$39.85
|
| Rate for Payer: Cash Price |
$39.85
|
| Rate for Payer: Centivo All Commercial |
$36.13
|
| Rate for Payer: Cigna All Commercial |
$57.31
|
| Rate for Payer: CORVEL All Commercial |
$61.76
|
| Rate for Payer: Coventry All Commercial |
$58.44
|
| Rate for Payer: Encore All Commercial |
$61.13
|
| Rate for Payer: Frontpath All Commercial |
$61.10
|
| Rate for Payer: Humana ChoiceCare |
$57.36
|
| Rate for Payer: Humana Medicare |
$21.25
|
| Rate for Payer: Lucent All Commercial |
$36.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.77
|
| Rate for Payer: Managed Health Services Medicaid |
$16.07
|
| Rate for Payer: MDWise Medicaid |
$16.07
|
| Rate for Payer: PHCS All Commercial |
$49.81
|
| Rate for Payer: PHP All Commercial |
$50.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.90
|
| Rate for Payer: Sagamore Health Network All Products |
$51.27
|
| Rate for Payer: Signature Care EPO |
$55.12
|
| Rate for Payer: Signature Care PPO |
$58.44
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$56.45
|
| Rate for Payer: United Healthcare Commercial |
$52.33
|
| Rate for Payer: United Healthcare Medicare |
$21.25
|
|
|
HC SPUTUM CULTURE
|
Facility
|
OP
|
$218.24
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
63001994
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.62 |
| Max. Negotiated Rate |
$202.96 |
| Rate for Payer: Aetna Commercial |
$184.19
|
| Rate for Payer: Aetna Medicare |
$69.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$8.62
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$67.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$100.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$100.30
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$8.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$80.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$76.82
|
| Rate for Payer: Cash Price |
$130.94
|
| Rate for Payer: Cash Price |
$130.94
|
| Rate for Payer: Centivo All Commercial |
$118.72
|
| Rate for Payer: Cigna All Commercial |
$188.34
|
| Rate for Payer: CORVEL All Commercial |
$202.96
|
| Rate for Payer: Coventry All Commercial |
$192.05
|
| Rate for Payer: Encore All Commercial |
$200.89
|
| Rate for Payer: Frontpath All Commercial |
$200.78
|
| Rate for Payer: Humana ChoiceCare |
$188.49
|
| Rate for Payer: Humana Medicare |
$69.84
|
| Rate for Payer: Lucent All Commercial |
$118.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$196.42
|
| Rate for Payer: Managed Health Services Medicaid |
$8.62
|
| Rate for Payer: MDWise Medicaid |
$8.62
|
| Rate for Payer: PHCS All Commercial |
$163.68
|
| Rate for Payer: PHP All Commercial |
$165.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$85.11
|
| Rate for Payer: Sagamore Health Network All Products |
$168.48
|
| Rate for Payer: Signature Care EPO |
$181.14
|
| Rate for Payer: Signature Care PPO |
$192.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$185.50
|
| Rate for Payer: United Healthcare Commercial |
$171.97
|
| Rate for Payer: United Healthcare Medicare |
$69.84
|
|
|
HC SPUTUM CULTURE
|
Facility
|
IP
|
$218.24
|
|
|
Service Code
|
CPT 87070
|
| Hospital Charge Code |
63001994
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$163.68 |
| Max. Negotiated Rate |
$202.96 |
| Rate for Payer: Aetna Commercial |
$188.56
|
| Rate for Payer: Cash Price |
$130.94
|
| Rate for Payer: Cigna All Commercial |
$188.34
|
| Rate for Payer: CORVEL All Commercial |
$202.96
|
| Rate for Payer: Coventry All Commercial |
$192.05
|
| Rate for Payer: Encore All Commercial |
$200.89
|
| Rate for Payer: Frontpath All Commercial |
$200.78
|
| Rate for Payer: Humana ChoiceCare |
$188.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$196.42
|
| Rate for Payer: PHCS All Commercial |
$163.68
|
| Rate for Payer: PHP All Commercial |
$165.51
|
| Rate for Payer: Sagamore Health Network All Products |
$168.48
|
| Rate for Payer: Signature Care EPO |
$181.14
|
| Rate for Payer: Signature Care PPO |
$192.05
|
| Rate for Payer: United Healthcare Commercial |
$171.97
|
|
|
HC SPYGLASS DIS T/A CATH
|
Facility
|
OP
|
$10,197.00
|
|
| Hospital Charge Code |
41608366
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$9,483.21 |
| Rate for Payer: Aetna Commercial |
$8,606.27
|
| Rate for Payer: Aetna Medicare |
$3,263.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,161.07
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$5,856.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,374.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,752.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,589.34
|
| Rate for Payer: Cash Price |
$6,118.20
|
| Rate for Payer: Cash Price |
$6,118.20
|
| Rate for Payer: Centivo All Commercial |
$5,547.17
|
| Rate for Payer: Cigna All Commercial |
$8,800.01
|
| Rate for Payer: CORVEL All Commercial |
$9,483.21
|
| Rate for Payer: Coventry All Commercial |
$8,973.36
|
| Rate for Payer: Encore All Commercial |
$9,386.34
|
| Rate for Payer: Frontpath All Commercial |
$9,381.24
|
| Rate for Payer: Humana ChoiceCare |
$8,807.15
|
| Rate for Payer: Humana Medicare |
$3,263.04
|
| Rate for Payer: Lucent All Commercial |
$5,547.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,177.30
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$7,647.75
|
| Rate for Payer: PHP All Commercial |
$7,733.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,976.83
|
| Rate for Payer: Sagamore Health Network All Products |
$7,872.08
|
| Rate for Payer: Signature Care EPO |
$8,463.51
|
| Rate for Payer: Signature Care PPO |
$8,973.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,667.45
|
| Rate for Payer: United Healthcare Commercial |
$8,035.24
|
| Rate for Payer: United Healthcare Medicare |
$3,263.04
|
|
|
HC SPYGLASS DIS T/A CATH
|
Facility
|
IP
|
$10,197.00
|
|
| Hospital Charge Code |
41608366
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7,647.75 |
| Max. Negotiated Rate |
$9,483.21 |
| Rate for Payer: Aetna Commercial |
$8,810.21
|
| Rate for Payer: Cash Price |
$6,118.20
|
| Rate for Payer: Cigna All Commercial |
$8,800.01
|
| Rate for Payer: CORVEL All Commercial |
$9,483.21
|
| Rate for Payer: Coventry All Commercial |
$8,973.36
|
| Rate for Payer: Encore All Commercial |
$9,386.34
|
| Rate for Payer: Frontpath All Commercial |
$9,381.24
|
| Rate for Payer: Humana ChoiceCare |
$8,807.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,177.30
|
| Rate for Payer: PHCS All Commercial |
$7,647.75
|
| Rate for Payer: PHP All Commercial |
$7,733.40
|
| Rate for Payer: Sagamore Health Network All Products |
$7,872.08
|
| Rate for Payer: Signature Care EPO |
$8,463.51
|
| Rate for Payer: Signature Care PPO |
$8,973.36
|
| Rate for Payer: United Healthcare Commercial |
$8,035.24
|
|
