|
HC PORT FILMS - FIVE
|
Facility
IP
|
$1,530.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547421
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,147.50 |
| Max. Negotiated Rate |
$1,422.90 |
| Rate for Payer: Aetna Commercial |
$1,321.92
|
| Rate for Payer: Cash Price |
$948.60
|
| Rate for Payer: Cigna All Commercial |
$1,320.39
|
| Rate for Payer: CORVEL All Commercial |
$1,422.90
|
| Rate for Payer: Coventry All Commercial |
$1,346.40
|
| Rate for Payer: Encore All Commercial |
$1,408.36
|
| Rate for Payer: Frontpath All Commercial |
$1,407.60
|
| Rate for Payer: Humana ChoiceCare |
$1,321.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,377.00
|
| Rate for Payer: PHCS All Commercial |
$1,147.50
|
| Rate for Payer: PHP All Commercial |
$1,160.35
|
| Rate for Payer: Sagamore Health Network All Products |
$1,181.16
|
| Rate for Payer: Signature Care EPO |
$1,269.90
|
| Rate for Payer: Signature Care PPO |
$1,346.40
|
| Rate for Payer: United Healthcare Commercial |
$1,205.64
|
|
|
HC PORT FILMS - FOUR
|
Facility
OP
|
$1,224.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547420
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$101.60 |
| Max. Negotiated Rate |
$1,138.32 |
| Rate for Payer: Aetna Commercial |
$1,033.06
|
| Rate for Payer: Aetna Medicare |
$403.92
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$403.92
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$702.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$765.12
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$101.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$464.51
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$444.31
|
| Rate for Payer: Cash Price |
$758.88
|
| Rate for Payer: Cash Price |
$758.88
|
| Rate for Payer: Centivo All Commercial |
$624.24
|
| Rate for Payer: Cigna All Commercial |
$1,056.31
|
| Rate for Payer: CORVEL All Commercial |
$1,138.32
|
| Rate for Payer: Coventry All Commercial |
$1,077.12
|
| Rate for Payer: Encore All Commercial |
$1,126.69
|
| Rate for Payer: Frontpath All Commercial |
$1,126.08
|
| Rate for Payer: Humana ChoiceCare |
$1,057.17
|
| Rate for Payer: Humana Medicare |
$624.24
|
| Rate for Payer: Lucent All Commercial |
$624.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,101.60
|
| Rate for Payer: Managed Health Services Medicaid |
$101.60
|
| Rate for Payer: MDWise Medicaid |
$101.60
|
| Rate for Payer: PHCS All Commercial |
$918.00
|
| Rate for Payer: PHP All Commercial |
$928.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$477.36
|
| Rate for Payer: Sagamore Health Network All Products |
$944.93
|
| Rate for Payer: Signature Care EPO |
$1,015.92
|
| Rate for Payer: Signature Care PPO |
$1,077.12
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,040.40
|
| Rate for Payer: United Healthcare Commercial |
$964.51
|
| Rate for Payer: United Healthcare Medicare |
$403.92
|
|
|
HC PORT FILMS - FOUR
|
Facility
IP
|
$1,224.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547420
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$918.00 |
| Max. Negotiated Rate |
$1,138.32 |
| Rate for Payer: Aetna Commercial |
$1,057.54
|
| Rate for Payer: Cash Price |
$758.88
|
| Rate for Payer: Cigna All Commercial |
$1,056.31
|
| Rate for Payer: CORVEL All Commercial |
$1,138.32
|
| Rate for Payer: Coventry All Commercial |
$1,077.12
|
| Rate for Payer: Encore All Commercial |
$1,126.69
|
| Rate for Payer: Frontpath All Commercial |
$1,126.08
|
| Rate for Payer: Humana ChoiceCare |
$1,057.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,101.60
|
| Rate for Payer: PHCS All Commercial |
$918.00
|
| Rate for Payer: PHP All Commercial |
$928.28
|
| Rate for Payer: Sagamore Health Network All Products |
$944.93
|
| Rate for Payer: Signature Care EPO |
$1,015.92
|
| Rate for Payer: Signature Care PPO |
$1,077.12
|
| Rate for Payer: United Healthcare Commercial |
$964.51
|
|
|
HC PORT FILMS - NINE
|
Facility
OP
|
$3,111.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547425
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$101.60 |
| Max. Negotiated Rate |
$2,893.23 |
| Rate for Payer: Aetna Commercial |
$2,625.68
|
| Rate for Payer: Aetna Medicare |
$1,026.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,026.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,786.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,944.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$101.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,180.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,129.29
|
| Rate for Payer: Cash Price |
$1,928.82
|
| Rate for Payer: Cash Price |
$1,928.82
|
| Rate for Payer: Centivo All Commercial |
$1,586.61
|
| Rate for Payer: Cigna All Commercial |
$2,684.79
|
| Rate for Payer: CORVEL All Commercial |
$2,893.23
|
| Rate for Payer: Coventry All Commercial |
$2,737.68
|
| Rate for Payer: Encore All Commercial |
$2,863.68
|
| Rate for Payer: Frontpath All Commercial |
$2,862.12
|
| Rate for Payer: Humana ChoiceCare |
$2,686.97
|
| Rate for Payer: Humana Medicare |
$1,586.61
|
| Rate for Payer: Lucent All Commercial |
$1,586.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,799.90
|
| Rate for Payer: Managed Health Services Medicaid |
$101.60
|
| Rate for Payer: MDWise Medicaid |
$101.60
|
| Rate for Payer: PHCS All Commercial |
$2,333.25
|
| Rate for Payer: PHP All Commercial |
$2,359.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,213.29
|
| Rate for Payer: Sagamore Health Network All Products |
$2,401.69
|
| Rate for Payer: Signature Care EPO |
$2,582.13
|
| Rate for Payer: Signature Care PPO |
$2,737.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,644.35
|
| Rate for Payer: United Healthcare Commercial |
$2,451.47
|
| Rate for Payer: United Healthcare Medicare |
$1,026.63
|
|
|
HC PORT FILMS - NINE
|
Facility
IP
|
$3,111.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547425
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$2,333.25 |
| Max. Negotiated Rate |
$2,893.23 |
| Rate for Payer: Aetna Commercial |
$2,687.90
|
| Rate for Payer: Cash Price |
$1,928.82
|
| Rate for Payer: Cigna All Commercial |
$2,684.79
|
| Rate for Payer: CORVEL All Commercial |
$2,893.23
|
| Rate for Payer: Coventry All Commercial |
$2,737.68
|
| Rate for Payer: Encore All Commercial |
$2,863.68
|
| Rate for Payer: Frontpath All Commercial |
$2,862.12
|
| Rate for Payer: Humana ChoiceCare |
$2,686.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,799.90
|
| Rate for Payer: PHCS All Commercial |
$2,333.25
|
| Rate for Payer: PHP All Commercial |
$2,359.38
|
| Rate for Payer: Sagamore Health Network All Products |
$2,401.69
|
| Rate for Payer: Signature Care EPO |
$2,582.13
|
| Rate for Payer: Signature Care PPO |
$2,737.68
|
| Rate for Payer: United Healthcare Commercial |
$2,451.47
|
|
|
HC PORT FILMS - SEVEN
|
Facility
IP
|
$2,091.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547423
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,568.25 |
| Max. Negotiated Rate |
$1,944.63 |
| Rate for Payer: Aetna Commercial |
$1,806.62
|
| Rate for Payer: Cash Price |
$1,296.42
|
| Rate for Payer: Cigna All Commercial |
$1,804.53
|
| Rate for Payer: CORVEL All Commercial |
$1,944.63
|
| Rate for Payer: Coventry All Commercial |
$1,840.08
|
| Rate for Payer: Encore All Commercial |
$1,924.77
|
| Rate for Payer: Frontpath All Commercial |
$1,923.72
|
| Rate for Payer: Humana ChoiceCare |
$1,806.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,881.90
|
| Rate for Payer: PHCS All Commercial |
$1,568.25
|
| Rate for Payer: PHP All Commercial |
$1,585.81
|
| Rate for Payer: Sagamore Health Network All Products |
$1,614.25
|
| Rate for Payer: Signature Care EPO |
$1,735.53
|
| Rate for Payer: Signature Care PPO |
$1,840.08
|
| Rate for Payer: United Healthcare Commercial |
$1,647.71
|
|
|
HC PORT FILMS - SEVEN
|
Facility
OP
|
$2,091.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547423
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$101.60 |
| Max. Negotiated Rate |
$1,944.63 |
| Rate for Payer: Aetna Commercial |
$1,764.80
|
| Rate for Payer: Aetna Medicare |
$690.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$690.03
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,200.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,307.08
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$101.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$793.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$759.03
|
| Rate for Payer: Cash Price |
$1,296.42
|
| Rate for Payer: Cash Price |
$1,296.42
|
| Rate for Payer: Centivo All Commercial |
$1,066.41
|
| Rate for Payer: Cigna All Commercial |
$1,804.53
|
| Rate for Payer: CORVEL All Commercial |
$1,944.63
|
| Rate for Payer: Coventry All Commercial |
$1,840.08
|
| Rate for Payer: Encore All Commercial |
$1,924.77
|
| Rate for Payer: Frontpath All Commercial |
$1,923.72
|
| Rate for Payer: Humana ChoiceCare |
$1,806.00
|
| Rate for Payer: Humana Medicare |
$1,066.41
|
| Rate for Payer: Lucent All Commercial |
$1,066.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,881.90
|
| Rate for Payer: Managed Health Services Medicaid |
$101.60
|
| Rate for Payer: MDWise Medicaid |
$101.60
|
| Rate for Payer: PHCS All Commercial |
$1,568.25
|
| Rate for Payer: PHP All Commercial |
$1,585.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$815.49
|
| Rate for Payer: Sagamore Health Network All Products |
$1,614.25
|
| Rate for Payer: Signature Care EPO |
$1,735.53
|
| Rate for Payer: Signature Care PPO |
$1,840.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,777.35
|
| Rate for Payer: United Healthcare Commercial |
$1,647.71
|
| Rate for Payer: United Healthcare Medicare |
$690.03
|
|
|
HC PORT FILMS - SIX
|
Facility
IP
|
$1,734.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547422
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$1,300.50 |
| Max. Negotiated Rate |
$1,612.62 |
| Rate for Payer: Aetna Commercial |
$1,498.18
|
| Rate for Payer: Cash Price |
$1,075.08
|
| Rate for Payer: Cigna All Commercial |
$1,496.44
|
| Rate for Payer: CORVEL All Commercial |
$1,612.62
|
| Rate for Payer: Coventry All Commercial |
$1,525.92
|
| Rate for Payer: Encore All Commercial |
$1,596.15
|
| Rate for Payer: Frontpath All Commercial |
$1,595.28
|
| Rate for Payer: Humana ChoiceCare |
$1,497.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,560.60
|
| Rate for Payer: PHCS All Commercial |
$1,300.50
|
| Rate for Payer: PHP All Commercial |
$1,315.07
|
| Rate for Payer: Sagamore Health Network All Products |
$1,338.65
|
| Rate for Payer: Signature Care EPO |
$1,439.22
|
| Rate for Payer: Signature Care PPO |
$1,525.92
|
| Rate for Payer: United Healthcare Commercial |
$1,366.39
|
|
|
HC PORT FILMS - SIX
|
Facility
OP
|
$1,734.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547422
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$101.60 |
| Max. Negotiated Rate |
$1,612.62 |
| Rate for Payer: Aetna Commercial |
$1,463.50
|
| Rate for Payer: Aetna Medicare |
$572.22
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$572.22
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$995.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,083.92
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$101.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$658.05
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$629.44
|
| Rate for Payer: Cash Price |
$1,075.08
|
| Rate for Payer: Cash Price |
$1,075.08
|
| Rate for Payer: Centivo All Commercial |
$884.34
|
| Rate for Payer: Cigna All Commercial |
$1,496.44
|
| Rate for Payer: CORVEL All Commercial |
$1,612.62
|
| Rate for Payer: Coventry All Commercial |
$1,525.92
|
| Rate for Payer: Encore All Commercial |
$1,596.15
|
| Rate for Payer: Frontpath All Commercial |
$1,595.28
|
| Rate for Payer: Humana ChoiceCare |
$1,497.66
|
| Rate for Payer: Humana Medicare |
$884.34
|
| Rate for Payer: Lucent All Commercial |
$884.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,560.60
|
| Rate for Payer: Managed Health Services Medicaid |
$101.60
|
| Rate for Payer: MDWise Medicaid |
$101.60
|
| Rate for Payer: PHCS All Commercial |
$1,300.50
|
| Rate for Payer: PHP All Commercial |
$1,315.07
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$676.26
|
| Rate for Payer: Sagamore Health Network All Products |
$1,338.65
|
| Rate for Payer: Signature Care EPO |
$1,439.22
|
| Rate for Payer: Signature Care PPO |
$1,525.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,473.90
|
| Rate for Payer: United Healthcare Commercial |
$1,366.39
|
| Rate for Payer: United Healthcare Medicare |
$572.22
|
|
|
HC PORT FILMS - THREE
|
Facility
OP
|
$867.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547419
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$101.60 |
| Max. Negotiated Rate |
$806.31 |
| Rate for Payer: Aetna Commercial |
$731.75
|
| Rate for Payer: Aetna Medicare |
$286.11
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$286.11
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$497.92
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$541.96
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$101.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$329.03
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$314.72
|
| Rate for Payer: Cash Price |
$537.54
|
| Rate for Payer: Cash Price |
$537.54
|
| Rate for Payer: Centivo All Commercial |
$442.17
|
| Rate for Payer: Cigna All Commercial |
$748.22
|
| Rate for Payer: CORVEL All Commercial |
$806.31
|
| Rate for Payer: Coventry All Commercial |
$762.96
|
| Rate for Payer: Encore All Commercial |
$798.07
|
| Rate for Payer: Frontpath All Commercial |
$797.64
|
| Rate for Payer: Humana ChoiceCare |
$748.83
|
| Rate for Payer: Humana Medicare |
$442.17
|
| Rate for Payer: Lucent All Commercial |
$442.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$780.30
|
| Rate for Payer: Managed Health Services Medicaid |
$101.60
|
| Rate for Payer: MDWise Medicaid |
$101.60
|
| Rate for Payer: PHCS All Commercial |
$650.25
|
| Rate for Payer: PHP All Commercial |
$657.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$338.13
|
| Rate for Payer: Sagamore Health Network All Products |
$669.32
|
| Rate for Payer: Signature Care EPO |
$719.61
|
| Rate for Payer: Signature Care PPO |
$762.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$736.95
|
| Rate for Payer: United Healthcare Commercial |
$683.20
|
| Rate for Payer: United Healthcare Medicare |
$286.11
|
|
|
HC PORT FILMS - THREE
|
Facility
IP
|
$867.00
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547419
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$650.25 |
| Max. Negotiated Rate |
$806.31 |
| Rate for Payer: Aetna Commercial |
$749.09
|
| Rate for Payer: Cash Price |
$537.54
|
| Rate for Payer: Cigna All Commercial |
$748.22
|
| Rate for Payer: CORVEL All Commercial |
$806.31
|
| Rate for Payer: Coventry All Commercial |
$762.96
|
| Rate for Payer: Encore All Commercial |
$798.07
|
| Rate for Payer: Frontpath All Commercial |
$797.64
|
| Rate for Payer: Humana ChoiceCare |
$748.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$780.30
|
| Rate for Payer: PHCS All Commercial |
$650.25
|
| Rate for Payer: PHP All Commercial |
$657.53
|
| Rate for Payer: Sagamore Health Network All Products |
$669.32
|
| Rate for Payer: Signature Care EPO |
$719.61
|
| Rate for Payer: Signature Care PPO |
$762.96
|
| Rate for Payer: United Healthcare Commercial |
$683.20
|
|
|
HC PORT FILMS - TWO
|
Facility
OP
|
$636.48
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547418
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$101.60 |
| Max. Negotiated Rate |
$591.93 |
| Rate for Payer: Aetna Commercial |
$537.19
|
| Rate for Payer: Aetna Medicare |
$210.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$210.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$365.53
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$397.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$101.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$241.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$231.04
|
| Rate for Payer: Cash Price |
$394.62
|
| Rate for Payer: Cash Price |
$394.62
|
| Rate for Payer: Centivo All Commercial |
$324.60
|
| Rate for Payer: Cigna All Commercial |
$549.28
|
| Rate for Payer: CORVEL All Commercial |
$591.93
|
| Rate for Payer: Coventry All Commercial |
$560.10
|
| Rate for Payer: Encore All Commercial |
$585.88
|
| Rate for Payer: Frontpath All Commercial |
$585.56
|
| Rate for Payer: Humana ChoiceCare |
$549.73
|
| Rate for Payer: Humana Medicare |
$324.60
|
| Rate for Payer: Lucent All Commercial |
$324.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$572.83
|
| Rate for Payer: Managed Health Services Medicaid |
$101.60
|
| Rate for Payer: MDWise Medicaid |
$101.60
|
| Rate for Payer: PHCS All Commercial |
$477.36
|
| Rate for Payer: PHP All Commercial |
$482.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$248.23
|
| Rate for Payer: Sagamore Health Network All Products |
$491.36
|
| Rate for Payer: Signature Care EPO |
$528.28
|
| Rate for Payer: Signature Care PPO |
$560.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$541.01
|
| Rate for Payer: United Healthcare Commercial |
$501.55
|
| Rate for Payer: United Healthcare Medicare |
$210.04
|
|
|
HC PORT FILMS - TWO
|
Facility
IP
|
$636.48
|
|
|
Service Code
|
CPT 77417
|
| Hospital Charge Code |
01547418
|
|
Hospital Revenue Code
|
333
|
| Min. Negotiated Rate |
$477.36 |
| Max. Negotiated Rate |
$591.93 |
| Rate for Payer: Aetna Commercial |
$549.92
|
| Rate for Payer: Cash Price |
$394.62
|
| Rate for Payer: Cigna All Commercial |
$549.28
|
| Rate for Payer: CORVEL All Commercial |
$591.93
|
| Rate for Payer: Coventry All Commercial |
$560.10
|
| Rate for Payer: Encore All Commercial |
$585.88
|
| Rate for Payer: Frontpath All Commercial |
$585.56
|
| Rate for Payer: Humana ChoiceCare |
$549.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$572.83
|
| Rate for Payer: PHCS All Commercial |
$477.36
|
| Rate for Payer: PHP All Commercial |
$482.71
|
| Rate for Payer: Sagamore Health Network All Products |
$491.36
|
| Rate for Payer: Signature Care EPO |
$528.28
|
| Rate for Payer: Signature Care PPO |
$560.10
|
| Rate for Payer: United Healthcare Commercial |
$501.55
|
|
|
HC PORT IRRIGATION
|
Facility
IP
|
$159.12
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
01296523
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$119.34 |
| Max. Negotiated Rate |
$147.98 |
| Rate for Payer: Aetna Commercial |
$137.48
|
| Rate for Payer: Cash Price |
$98.65
|
| Rate for Payer: Cigna All Commercial |
$137.32
|
| Rate for Payer: CORVEL All Commercial |
$147.98
|
| Rate for Payer: Coventry All Commercial |
$140.03
|
| Rate for Payer: Encore All Commercial |
$146.47
|
| Rate for Payer: Frontpath All Commercial |
$146.39
|
| Rate for Payer: Humana ChoiceCare |
$137.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.21
|
| Rate for Payer: PHCS All Commercial |
$119.34
|
| Rate for Payer: PHP All Commercial |
$120.68
|
| Rate for Payer: Sagamore Health Network All Products |
$122.84
|
| Rate for Payer: Signature Care EPO |
$132.07
|
| Rate for Payer: Signature Care PPO |
$140.03
|
| Rate for Payer: United Healthcare Commercial |
$125.39
|
|
|
HC PORT IRRIGATION
|
Facility
OP
|
$159.12
|
|
|
Service Code
|
CPT 96523
|
| Hospital Charge Code |
01296523
|
|
Hospital Revenue Code
|
260
|
| Min. Negotiated Rate |
$52.51 |
| Max. Negotiated Rate |
$147.98 |
| Rate for Payer: Aetna Commercial |
$134.30
|
| Rate for Payer: Aetna Medicare |
$52.51
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$52.51
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$91.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$99.47
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$73.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$60.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$57.76
|
| Rate for Payer: Cash Price |
$98.65
|
| Rate for Payer: Cash Price |
$98.65
|
| Rate for Payer: Centivo All Commercial |
$81.15
|
| Rate for Payer: Cigna All Commercial |
$137.32
|
| Rate for Payer: CORVEL All Commercial |
$147.98
|
| Rate for Payer: Coventry All Commercial |
$140.03
|
| Rate for Payer: Encore All Commercial |
$146.47
|
| Rate for Payer: Frontpath All Commercial |
$146.39
|
| Rate for Payer: Humana ChoiceCare |
$137.43
|
| Rate for Payer: Humana Medicare |
$81.15
|
| Rate for Payer: Lucent All Commercial |
$81.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.21
|
| Rate for Payer: Managed Health Services Medicaid |
$73.71
|
| Rate for Payer: MDWise Medicaid |
$73.71
|
| Rate for Payer: PHCS All Commercial |
$119.34
|
| Rate for Payer: PHP All Commercial |
$120.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$62.06
|
| Rate for Payer: Sagamore Health Network All Products |
$122.84
|
| Rate for Payer: Signature Care EPO |
$132.07
|
| Rate for Payer: Signature Care PPO |
$140.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$135.25
|
| Rate for Payer: United Healthcare Commercial |
$125.39
|
| Rate for Payer: United Healthcare Medicare |
$52.51
|
|
|
HC POST PARTUM ROOM
|
Facility
IP
|
$1,644.24
|
|
| Hospital Charge Code |
10010026
|
|
Hospital Revenue Code
|
122
|
| Min. Negotiated Rate |
$1,233.18 |
| Max. Negotiated Rate |
$5,584.50 |
| Rate for Payer: Aetna Commercial |
$1,420.62
|
| Rate for Payer: Aetna Medicare |
$3,285.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,285.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,777.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,613.50
|
| Rate for Payer: Cash Price |
$1,019.43
|
| Rate for Payer: Cash Price |
$1,019.43
|
| Rate for Payer: Centivo All Commercial |
$3,613.50
|
| Rate for Payer: Cigna All Commercial |
$1,418.98
|
| Rate for Payer: CORVEL All Commercial |
$1,529.14
|
| Rate for Payer: Coventry All Commercial |
$1,446.93
|
| Rate for Payer: Encore All Commercial |
$1,513.52
|
| Rate for Payer: Frontpath All Commercial |
$1,512.70
|
| Rate for Payer: Humana ChoiceCare |
$1,420.13
|
| Rate for Payer: Humana Medicare |
$3,285.00
|
| Rate for Payer: Lucent All Commercial |
$5,584.50
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,479.82
|
| Rate for Payer: PHCS All Commercial |
$1,233.18
|
| Rate for Payer: PHP All Commercial |
$1,246.99
|
| Rate for Payer: Sagamore Health Network All Products |
$1,269.35
|
| Rate for Payer: Signature Care EPO |
$1,364.72
|
| Rate for Payer: Signature Care PPO |
$1,446.93
|
| Rate for Payer: United Healthcare Commercial |
$1,295.66
|
| Rate for Payer: United Healthcare Medicare |
$3,285.00
|
|
|
HC POST TIBIALIS TENDON ALLO
|
Facility
OP
|
$8,262.00
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
41603054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$7,683.66 |
| Rate for Payer: Aetna Commercial |
$6,973.13
|
| Rate for Payer: Aetna Medicare |
$2,726.46
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,726.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4,744.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,164.58
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,135.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,999.11
|
| Rate for Payer: Cash Price |
$5,122.44
|
| Rate for Payer: Cash Price |
$5,122.44
|
| Rate for Payer: Centivo All Commercial |
$4,213.62
|
| Rate for Payer: Cigna All Commercial |
$7,130.11
|
| Rate for Payer: CORVEL All Commercial |
$7,683.66
|
| Rate for Payer: Coventry All Commercial |
$7,270.56
|
| Rate for Payer: Encore All Commercial |
$7,605.17
|
| Rate for Payer: Frontpath All Commercial |
$7,601.04
|
| Rate for Payer: Humana ChoiceCare |
$7,135.89
|
| Rate for Payer: Humana Medicare |
$4,213.62
|
| Rate for Payer: Lucent All Commercial |
$4,213.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,435.80
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$6,196.50
|
| Rate for Payer: PHP All Commercial |
$6,265.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3,222.18
|
| Rate for Payer: Sagamore Health Network All Products |
$6,378.26
|
| Rate for Payer: Signature Care EPO |
$6,857.46
|
| Rate for Payer: Signature Care PPO |
$7,270.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7,022.70
|
| Rate for Payer: United Healthcare Commercial |
$6,510.46
|
| Rate for Payer: United Healthcare Medicare |
$2,726.46
|
|
|
HC POST TIBIALIS TENDON ALLO
|
Facility
IP
|
$8,262.00
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
41603054
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$6,196.50 |
| Max. Negotiated Rate |
$7,683.66 |
| Rate for Payer: Aetna Commercial |
$7,138.37
|
| Rate for Payer: Cash Price |
$5,122.44
|
| Rate for Payer: Cigna All Commercial |
$7,130.11
|
| Rate for Payer: CORVEL All Commercial |
$7,683.66
|
| Rate for Payer: Coventry All Commercial |
$7,270.56
|
| Rate for Payer: Encore All Commercial |
$7,605.17
|
| Rate for Payer: Frontpath All Commercial |
$7,601.04
|
| Rate for Payer: Humana ChoiceCare |
$7,135.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7,435.80
|
| Rate for Payer: PHCS All Commercial |
$6,196.50
|
| Rate for Payer: PHP All Commercial |
$6,265.90
|
| Rate for Payer: Sagamore Health Network All Products |
$6,378.26
|
| Rate for Payer: Signature Care EPO |
$6,857.46
|
| Rate for Payer: Signature Care PPO |
$7,270.56
|
| Rate for Payer: United Healthcare Commercial |
$6,510.46
|
|
|
HC POST TIBIALIS TENDON RTI
|
Facility
IP
|
$7,020.00
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
41603389
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$5,265.00 |
| Max. Negotiated Rate |
$6,528.60 |
| Rate for Payer: Aetna Commercial |
$6,065.28
|
| Rate for Payer: Cash Price |
$4,352.40
|
| Rate for Payer: Cigna All Commercial |
$6,058.26
|
| Rate for Payer: CORVEL All Commercial |
$6,528.60
|
| Rate for Payer: Coventry All Commercial |
$6,177.60
|
| Rate for Payer: Encore All Commercial |
$6,461.91
|
| Rate for Payer: Frontpath All Commercial |
$6,458.40
|
| Rate for Payer: Humana ChoiceCare |
$6,063.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,318.00
|
| Rate for Payer: PHCS All Commercial |
$5,265.00
|
| Rate for Payer: PHP All Commercial |
$5,323.97
|
| Rate for Payer: Sagamore Health Network All Products |
$5,419.44
|
| Rate for Payer: Signature Care EPO |
$5,826.60
|
| Rate for Payer: Signature Care PPO |
$6,177.60
|
| Rate for Payer: United Healthcare Commercial |
$5,531.76
|
|
|
HC POST TIBIALIS TENDON RTI
|
Facility
OP
|
$7,020.00
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
41603389
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$6,528.60 |
| Rate for Payer: Aetna Commercial |
$5,924.88
|
| Rate for Payer: Aetna Medicare |
$2,316.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,316.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4,031.59
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,388.20
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,664.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,548.26
|
| Rate for Payer: Cash Price |
$4,352.40
|
| Rate for Payer: Cash Price |
$4,352.40
|
| Rate for Payer: Centivo All Commercial |
$3,580.20
|
| Rate for Payer: Cigna All Commercial |
$6,058.26
|
| Rate for Payer: CORVEL All Commercial |
$6,528.60
|
| Rate for Payer: Coventry All Commercial |
$6,177.60
|
| Rate for Payer: Encore All Commercial |
$6,461.91
|
| Rate for Payer: Frontpath All Commercial |
$6,458.40
|
| Rate for Payer: Humana ChoiceCare |
$6,063.17
|
| Rate for Payer: Humana Medicare |
$3,580.20
|
| Rate for Payer: Lucent All Commercial |
$3,580.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,318.00
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$5,265.00
|
| Rate for Payer: PHP All Commercial |
$5,323.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,737.80
|
| Rate for Payer: Sagamore Health Network All Products |
$5,419.44
|
| Rate for Payer: Signature Care EPO |
$5,826.60
|
| Rate for Payer: Signature Care PPO |
$6,177.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,967.00
|
| Rate for Payer: United Healthcare Commercial |
$5,531.76
|
| Rate for Payer: United Healthcare Medicare |
$2,316.60
|
|
|
HC POTASSIUM
|
Facility
OP
|
$47.91
|
|
|
Service Code
|
CPT 84132
|
| Hospital Charge Code |
63001110
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$44.56 |
| Rate for Payer: Aetna Commercial |
$40.44
|
| Rate for Payer: Aetna Medicare |
$15.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$22.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.02
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.39
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Centivo All Commercial |
$24.43
|
| Rate for Payer: Cigna All Commercial |
$41.35
|
| Rate for Payer: CORVEL All Commercial |
$44.56
|
| Rate for Payer: Coventry All Commercial |
$42.16
|
| Rate for Payer: Encore All Commercial |
$44.10
|
| Rate for Payer: Frontpath All Commercial |
$44.08
|
| Rate for Payer: Humana ChoiceCare |
$41.38
|
| Rate for Payer: Humana Medicare |
$24.43
|
| Rate for Payer: Lucent All Commercial |
$24.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.12
|
| Rate for Payer: Managed Health Services Medicaid |
$4.76
|
| Rate for Payer: MDWise Medicaid |
$4.76
|
| Rate for Payer: PHCS All Commercial |
$35.93
|
| Rate for Payer: PHP All Commercial |
$36.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.68
|
| Rate for Payer: Sagamore Health Network All Products |
$36.99
|
| Rate for Payer: Signature Care EPO |
$39.76
|
| Rate for Payer: Signature Care PPO |
$42.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.72
|
| Rate for Payer: United Healthcare Commercial |
$37.75
|
| Rate for Payer: United Healthcare Medicare |
$15.81
|
|
|
HC POTASSIUM
|
Facility
IP
|
$47.91
|
|
|
Service Code
|
CPT 84132
|
| Hospital Charge Code |
63001110
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.93 |
| Max. Negotiated Rate |
$44.56 |
| Rate for Payer: Aetna Commercial |
$41.39
|
| Rate for Payer: Cash Price |
$29.70
|
| Rate for Payer: Cigna All Commercial |
$41.35
|
| Rate for Payer: CORVEL All Commercial |
$44.56
|
| Rate for Payer: Coventry All Commercial |
$42.16
|
| Rate for Payer: Encore All Commercial |
$44.10
|
| Rate for Payer: Frontpath All Commercial |
$44.08
|
| Rate for Payer: Humana ChoiceCare |
$41.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$43.12
|
| Rate for Payer: PHCS All Commercial |
$35.93
|
| Rate for Payer: PHP All Commercial |
$36.33
|
| Rate for Payer: Sagamore Health Network All Products |
$36.99
|
| Rate for Payer: Signature Care EPO |
$39.76
|
| Rate for Payer: Signature Care PPO |
$42.16
|
| Rate for Payer: United Healthcare Commercial |
$37.75
|
|
|
HC POTASSIUM FECES
|
Facility
OP
|
$222.23
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
63001722
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$73.34 |
| Max. Negotiated Rate |
$206.67 |
| Rate for Payer: Aetna Commercial |
$187.56
|
| Rate for Payer: Aetna Medicare |
$73.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$127.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$138.91
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$84.34
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$80.67
|
| Rate for Payer: Cash Price |
$137.78
|
| Rate for Payer: Centivo All Commercial |
$113.34
|
| Rate for Payer: Cigna All Commercial |
$191.78
|
| Rate for Payer: CORVEL All Commercial |
$206.67
|
| Rate for Payer: Coventry All Commercial |
$195.56
|
| Rate for Payer: Encore All Commercial |
$204.56
|
| Rate for Payer: Frontpath All Commercial |
$204.45
|
| Rate for Payer: Humana ChoiceCare |
$191.94
|
| Rate for Payer: Humana Medicare |
$113.34
|
| Rate for Payer: Lucent All Commercial |
$113.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$200.00
|
| Rate for Payer: PHCS All Commercial |
$166.67
|
| Rate for Payer: PHP All Commercial |
$168.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$86.67
|
| Rate for Payer: Sagamore Health Network All Products |
$171.56
|
| Rate for Payer: Signature Care EPO |
$184.45
|
| Rate for Payer: Signature Care PPO |
$195.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$188.89
|
| Rate for Payer: United Healthcare Commercial |
$175.12
|
| Rate for Payer: United Healthcare Medicare |
$73.34
|
|
|
HC POTASSIUM FECES
|
Facility
IP
|
$222.23
|
|
|
Service Code
|
CPT 84999
|
| Hospital Charge Code |
63001722
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$166.67 |
| Max. Negotiated Rate |
$206.67 |
| Rate for Payer: Aetna Commercial |
$192.00
|
| Rate for Payer: Cash Price |
$137.78
|
| Rate for Payer: Cigna All Commercial |
$191.78
|
| Rate for Payer: CORVEL All Commercial |
$206.67
|
| Rate for Payer: Coventry All Commercial |
$195.56
|
| Rate for Payer: Encore All Commercial |
$204.56
|
| Rate for Payer: Frontpath All Commercial |
$204.45
|
| Rate for Payer: Humana ChoiceCare |
$191.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$200.00
|
| Rate for Payer: PHCS All Commercial |
$166.67
|
| Rate for Payer: PHP All Commercial |
$168.54
|
| Rate for Payer: Sagamore Health Network All Products |
$171.56
|
| Rate for Payer: Signature Care EPO |
$184.45
|
| Rate for Payer: Signature Care PPO |
$195.56
|
| Rate for Payer: United Healthcare Commercial |
$175.12
|
|
|
HC POTASSIUM URINE
|
Facility
OP
|
$100.42
|
|
|
Service Code
|
CPT 84133
|
| Hospital Charge Code |
63001152
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$4.70 |
| Max. Negotiated Rate |
$93.39 |
| Rate for Payer: Aetna Commercial |
$84.75
|
| Rate for Payer: Aetna Medicare |
$33.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$33.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$57.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$62.77
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$4.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.45
|
| Rate for Payer: Cash Price |
$62.26
|
| Rate for Payer: Cash Price |
$62.26
|
| Rate for Payer: Centivo All Commercial |
$51.21
|
| Rate for Payer: Cigna All Commercial |
$86.66
|
| Rate for Payer: CORVEL All Commercial |
$93.39
|
| Rate for Payer: Coventry All Commercial |
$88.37
|
| Rate for Payer: Encore All Commercial |
$92.44
|
| Rate for Payer: Frontpath All Commercial |
$92.39
|
| Rate for Payer: Humana ChoiceCare |
$86.73
|
| Rate for Payer: Humana Medicare |
$51.21
|
| Rate for Payer: Lucent All Commercial |
$51.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$90.38
|
| Rate for Payer: Managed Health Services Medicaid |
$4.70
|
| Rate for Payer: MDWise Medicaid |
$4.70
|
| Rate for Payer: PHCS All Commercial |
$75.31
|
| Rate for Payer: PHP All Commercial |
$76.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$39.16
|
| Rate for Payer: Sagamore Health Network All Products |
$77.52
|
| Rate for Payer: Signature Care EPO |
$83.35
|
| Rate for Payer: Signature Care PPO |
$88.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$85.36
|
| Rate for Payer: United Healthcare Commercial |
$79.13
|
| Rate for Payer: United Healthcare Medicare |
$33.14
|
|
