|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
OP
|
$650.90
|
|
| Hospital Charge Code |
41602382
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$121.68 |
| Max. Negotiated Rate |
$605.34 |
| Rate for Payer: Aetna Commercial |
$549.36
|
| Rate for Payer: Aetna Medicare |
$214.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$214.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$373.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$406.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$247.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$236.28
|
| Rate for Payer: Cash Price |
$403.56
|
| Rate for Payer: Cash Price |
$403.56
|
| Rate for Payer: Centivo All Commercial |
$331.96
|
| Rate for Payer: Cigna All Commercial |
$561.73
|
| Rate for Payer: CORVEL All Commercial |
$605.34
|
| Rate for Payer: Coventry All Commercial |
$572.79
|
| Rate for Payer: Encore All Commercial |
$599.15
|
| Rate for Payer: Frontpath All Commercial |
$598.83
|
| Rate for Payer: Humana ChoiceCare |
$562.18
|
| Rate for Payer: Humana Medicare |
$331.96
|
| Rate for Payer: Lucent All Commercial |
$331.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$585.81
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$488.18
|
| Rate for Payer: PHP All Commercial |
$493.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$253.85
|
| Rate for Payer: Sagamore Health Network All Products |
$502.49
|
| Rate for Payer: Signature Care EPO |
$540.25
|
| Rate for Payer: Signature Care PPO |
$572.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$553.26
|
| Rate for Payer: United Healthcare Commercial |
$512.91
|
| Rate for Payer: United Healthcare Medicare |
$214.80
|
|
|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
OP
|
$566.78
|
|
| Hospital Charge Code |
41602384
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$121.68 |
| Max. Negotiated Rate |
$527.11 |
| Rate for Payer: Aetna Commercial |
$478.36
|
| Rate for Payer: Aetna Medicare |
$187.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$187.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$325.50
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$354.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$215.09
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$205.74
|
| Rate for Payer: Cash Price |
$351.40
|
| Rate for Payer: Cash Price |
$351.40
|
| Rate for Payer: Centivo All Commercial |
$289.06
|
| Rate for Payer: Cigna All Commercial |
$489.13
|
| Rate for Payer: CORVEL All Commercial |
$527.11
|
| Rate for Payer: Coventry All Commercial |
$498.77
|
| Rate for Payer: Encore All Commercial |
$521.72
|
| Rate for Payer: Frontpath All Commercial |
$521.44
|
| Rate for Payer: Humana ChoiceCare |
$489.53
|
| Rate for Payer: Humana Medicare |
$289.06
|
| Rate for Payer: Lucent All Commercial |
$289.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$510.10
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$425.08
|
| Rate for Payer: PHP All Commercial |
$429.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$221.04
|
| Rate for Payer: Sagamore Health Network All Products |
$437.55
|
| Rate for Payer: Signature Care EPO |
$470.43
|
| Rate for Payer: Signature Care PPO |
$498.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$481.76
|
| Rate for Payer: United Healthcare Commercial |
$446.62
|
| Rate for Payer: United Healthcare Medicare |
$187.04
|
|
|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
IP
|
$566.78
|
|
| Hospital Charge Code |
41602384
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$425.08 |
| Max. Negotiated Rate |
$527.11 |
| Rate for Payer: Aetna Commercial |
$489.70
|
| Rate for Payer: Cash Price |
$351.40
|
| Rate for Payer: Cigna All Commercial |
$489.13
|
| Rate for Payer: CORVEL All Commercial |
$527.11
|
| Rate for Payer: Coventry All Commercial |
$498.77
|
| Rate for Payer: Encore All Commercial |
$521.72
|
| Rate for Payer: Frontpath All Commercial |
$521.44
|
| Rate for Payer: Humana ChoiceCare |
$489.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$510.10
|
| Rate for Payer: PHCS All Commercial |
$425.08
|
| Rate for Payer: PHP All Commercial |
$429.85
|
| Rate for Payer: Sagamore Health Network All Products |
$437.55
|
| Rate for Payer: Signature Care EPO |
$470.43
|
| Rate for Payer: Signature Care PPO |
$498.77
|
| Rate for Payer: United Healthcare Commercial |
$446.62
|
|
|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
OP
|
$661.10
|
|
| Hospital Charge Code |
41602383
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$121.68 |
| Max. Negotiated Rate |
$614.82 |
| Rate for Payer: Aetna Commercial |
$557.97
|
| Rate for Payer: Aetna Medicare |
$218.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$218.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$379.67
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$413.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$250.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$239.98
|
| Rate for Payer: Cash Price |
$409.88
|
| Rate for Payer: Cash Price |
$409.88
|
| Rate for Payer: Centivo All Commercial |
$337.16
|
| Rate for Payer: Cigna All Commercial |
$570.53
|
| Rate for Payer: CORVEL All Commercial |
$614.82
|
| Rate for Payer: Coventry All Commercial |
$581.77
|
| Rate for Payer: Encore All Commercial |
$608.54
|
| Rate for Payer: Frontpath All Commercial |
$608.21
|
| Rate for Payer: Humana ChoiceCare |
$570.99
|
| Rate for Payer: Humana Medicare |
$337.16
|
| Rate for Payer: Lucent All Commercial |
$337.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$594.99
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$495.82
|
| Rate for Payer: PHP All Commercial |
$501.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$257.83
|
| Rate for Payer: Sagamore Health Network All Products |
$510.37
|
| Rate for Payer: Signature Care EPO |
$548.71
|
| Rate for Payer: Signature Care PPO |
$581.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$561.94
|
| Rate for Payer: United Healthcare Commercial |
$520.95
|
| Rate for Payer: United Healthcare Medicare |
$218.16
|
|
|
HC RETRACTOR ELEVATOR VAG/CERV
|
Facility
IP
|
$661.10
|
|
| Hospital Charge Code |
41602383
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$495.82 |
| Max. Negotiated Rate |
$614.82 |
| Rate for Payer: Aetna Commercial |
$571.19
|
| Rate for Payer: Cash Price |
$409.88
|
| Rate for Payer: Cigna All Commercial |
$570.53
|
| Rate for Payer: CORVEL All Commercial |
$614.82
|
| Rate for Payer: Coventry All Commercial |
$581.77
|
| Rate for Payer: Encore All Commercial |
$608.54
|
| Rate for Payer: Frontpath All Commercial |
$608.21
|
| Rate for Payer: Humana ChoiceCare |
$570.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$594.99
|
| Rate for Payer: PHCS All Commercial |
$495.82
|
| Rate for Payer: PHP All Commercial |
$501.38
|
| Rate for Payer: Sagamore Health Network All Products |
$510.37
|
| Rate for Payer: Signature Care EPO |
$548.71
|
| Rate for Payer: Signature Care PPO |
$581.77
|
| Rate for Payer: United Healthcare Commercial |
$520.95
|
|
|
HC RETRACTOR ENDO FIVE FINGER 10MM
|
Facility
IP
|
$703.16
|
|
| Hospital Charge Code |
41601916
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$527.37 |
| Max. Negotiated Rate |
$653.94 |
| Rate for Payer: Aetna Commercial |
$607.53
|
| Rate for Payer: Cash Price |
$435.96
|
| Rate for Payer: Cigna All Commercial |
$606.83
|
| Rate for Payer: CORVEL All Commercial |
$653.94
|
| Rate for Payer: Coventry All Commercial |
$618.78
|
| Rate for Payer: Encore All Commercial |
$647.26
|
| Rate for Payer: Frontpath All Commercial |
$646.91
|
| Rate for Payer: Humana ChoiceCare |
$607.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$632.84
|
| Rate for Payer: PHCS All Commercial |
$527.37
|
| Rate for Payer: PHP All Commercial |
$533.28
|
| Rate for Payer: Sagamore Health Network All Products |
$542.84
|
| Rate for Payer: Signature Care EPO |
$583.62
|
| Rate for Payer: Signature Care PPO |
$618.78
|
| Rate for Payer: United Healthcare Commercial |
$554.09
|
|
|
HC RETRACTOR ENDO FIVE FINGER 10MM
|
Facility
OP
|
$703.16
|
|
| Hospital Charge Code |
41601916
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$121.68 |
| Max. Negotiated Rate |
$653.94 |
| Rate for Payer: Aetna Commercial |
$593.47
|
| Rate for Payer: Aetna Medicare |
$232.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$232.04
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$403.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$439.55
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$266.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$255.25
|
| Rate for Payer: Cash Price |
$435.96
|
| Rate for Payer: Cash Price |
$435.96
|
| Rate for Payer: Centivo All Commercial |
$358.61
|
| Rate for Payer: Cigna All Commercial |
$606.83
|
| Rate for Payer: CORVEL All Commercial |
$653.94
|
| Rate for Payer: Coventry All Commercial |
$618.78
|
| Rate for Payer: Encore All Commercial |
$647.26
|
| Rate for Payer: Frontpath All Commercial |
$646.91
|
| Rate for Payer: Humana ChoiceCare |
$607.32
|
| Rate for Payer: Humana Medicare |
$358.61
|
| Rate for Payer: Lucent All Commercial |
$358.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$632.84
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$527.37
|
| Rate for Payer: PHP All Commercial |
$533.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$274.23
|
| Rate for Payer: Sagamore Health Network All Products |
$542.84
|
| Rate for Payer: Signature Care EPO |
$583.62
|
| Rate for Payer: Signature Care PPO |
$618.78
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$597.69
|
| Rate for Payer: United Healthcare Commercial |
$554.09
|
| Rate for Payer: United Healthcare Medicare |
$232.04
|
|
|
HC RETRACTOR LONE STAR GEN
|
Facility
IP
|
$429.31
|
|
| Hospital Charge Code |
41601368
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$321.98 |
| Max. Negotiated Rate |
$399.26 |
| Rate for Payer: Aetna Commercial |
$370.92
|
| Rate for Payer: Cash Price |
$266.17
|
| Rate for Payer: Cigna All Commercial |
$370.49
|
| Rate for Payer: CORVEL All Commercial |
$399.26
|
| Rate for Payer: Coventry All Commercial |
$377.79
|
| Rate for Payer: Encore All Commercial |
$395.18
|
| Rate for Payer: Frontpath All Commercial |
$394.97
|
| Rate for Payer: Humana ChoiceCare |
$370.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$386.38
|
| Rate for Payer: PHCS All Commercial |
$321.98
|
| Rate for Payer: PHP All Commercial |
$325.59
|
| Rate for Payer: Sagamore Health Network All Products |
$331.43
|
| Rate for Payer: Signature Care EPO |
$356.33
|
| Rate for Payer: Signature Care PPO |
$377.79
|
| Rate for Payer: United Healthcare Commercial |
$338.30
|
|
|
HC RETRACTOR LONE STAR GEN
|
Facility
OP
|
$429.31
|
|
| Hospital Charge Code |
41601368
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$121.68 |
| Max. Negotiated Rate |
$399.26 |
| Rate for Payer: Aetna Commercial |
$362.34
|
| Rate for Payer: Aetna Medicare |
$141.67
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$141.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$246.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$268.36
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$162.92
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$155.84
|
| Rate for Payer: Cash Price |
$266.17
|
| Rate for Payer: Cash Price |
$266.17
|
| Rate for Payer: Centivo All Commercial |
$218.95
|
| Rate for Payer: Cigna All Commercial |
$370.49
|
| Rate for Payer: CORVEL All Commercial |
$399.26
|
| Rate for Payer: Coventry All Commercial |
$377.79
|
| Rate for Payer: Encore All Commercial |
$395.18
|
| Rate for Payer: Frontpath All Commercial |
$394.97
|
| Rate for Payer: Humana ChoiceCare |
$370.80
|
| Rate for Payer: Humana Medicare |
$218.95
|
| Rate for Payer: Lucent All Commercial |
$218.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$386.38
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$321.98
|
| Rate for Payer: PHP All Commercial |
$325.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$167.43
|
| Rate for Payer: Sagamore Health Network All Products |
$331.43
|
| Rate for Payer: Signature Care EPO |
$356.33
|
| Rate for Payer: Signature Care PPO |
$377.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$364.91
|
| Rate for Payer: United Healthcare Commercial |
$338.30
|
| Rate for Payer: United Healthcare Medicare |
$141.67
|
|
|
HC RETROBULBAR ATKINSON
|
Facility
OP
|
$34.46
|
|
| Hospital Charge Code |
41601799
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$11.37 |
| Max. Negotiated Rate |
$96.84 |
| Rate for Payer: Aetna Commercial |
$29.08
|
| Rate for Payer: Aetna Medicare |
$11.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$21.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$96.84
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.51
|
| Rate for Payer: Cash Price |
$21.37
|
| Rate for Payer: Cash Price |
$21.37
|
| Rate for Payer: Centivo All Commercial |
$17.57
|
| Rate for Payer: Cigna All Commercial |
$29.74
|
| Rate for Payer: CORVEL All Commercial |
$32.05
|
| Rate for Payer: Coventry All Commercial |
$30.32
|
| Rate for Payer: Encore All Commercial |
$31.72
|
| Rate for Payer: Frontpath All Commercial |
$31.70
|
| Rate for Payer: Humana ChoiceCare |
$29.76
|
| Rate for Payer: Humana Medicare |
$17.57
|
| Rate for Payer: Lucent All Commercial |
$17.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.01
|
| Rate for Payer: Managed Health Services Medicaid |
$96.84
|
| Rate for Payer: MDWise Medicaid |
$96.84
|
| Rate for Payer: PHCS All Commercial |
$25.84
|
| Rate for Payer: PHP All Commercial |
$26.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.44
|
| Rate for Payer: Sagamore Health Network All Products |
$26.60
|
| Rate for Payer: Signature Care EPO |
$28.60
|
| Rate for Payer: Signature Care PPO |
$30.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$29.29
|
| Rate for Payer: United Healthcare Commercial |
$27.15
|
| Rate for Payer: United Healthcare Medicare |
$11.37
|
|
|
HC RETROBULBAR ATKINSON
|
Facility
IP
|
$34.46
|
|
| Hospital Charge Code |
41601799
|
|
Hospital Revenue Code
|
270
|
| Min. Negotiated Rate |
$25.84 |
| Max. Negotiated Rate |
$32.05 |
| Rate for Payer: Aetna Commercial |
$29.77
|
| Rate for Payer: Cash Price |
$21.37
|
| Rate for Payer: Cigna All Commercial |
$29.74
|
| Rate for Payer: CORVEL All Commercial |
$32.05
|
| Rate for Payer: Coventry All Commercial |
$30.32
|
| Rate for Payer: Encore All Commercial |
$31.72
|
| Rate for Payer: Frontpath All Commercial |
$31.70
|
| Rate for Payer: Humana ChoiceCare |
$29.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$31.01
|
| Rate for Payer: PHCS All Commercial |
$25.84
|
| Rate for Payer: PHP All Commercial |
$26.13
|
| Rate for Payer: Sagamore Health Network All Products |
$26.60
|
| Rate for Payer: Signature Care EPO |
$28.60
|
| Rate for Payer: Signature Care PPO |
$30.32
|
| Rate for Payer: United Healthcare Commercial |
$27.15
|
|
|
HC RETROGRADE PYLOGRAM
|
Facility
OP
|
$948.29
|
|
|
Service Code
|
CPT 74420
|
| Hospital Charge Code |
01614431
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$255.37 |
| Max. Negotiated Rate |
$881.91 |
| Rate for Payer: Aetna Commercial |
$800.36
|
| Rate for Payer: Aetna Medicare |
$312.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$312.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$544.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$592.78
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$255.37
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$359.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$344.23
|
| Rate for Payer: Cash Price |
$587.94
|
| Rate for Payer: Cash Price |
$587.94
|
| Rate for Payer: Centivo All Commercial |
$483.63
|
| Rate for Payer: Cigna All Commercial |
$818.38
|
| Rate for Payer: CORVEL All Commercial |
$881.91
|
| Rate for Payer: Coventry All Commercial |
$834.50
|
| Rate for Payer: Encore All Commercial |
$872.90
|
| Rate for Payer: Frontpath All Commercial |
$872.43
|
| Rate for Payer: Humana ChoiceCare |
$819.04
|
| Rate for Payer: Humana Medicare |
$483.63
|
| Rate for Payer: Lucent All Commercial |
$483.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$853.46
|
| Rate for Payer: Managed Health Services Medicaid |
$255.37
|
| Rate for Payer: MDWise Medicaid |
$255.37
|
| Rate for Payer: PHCS All Commercial |
$711.22
|
| Rate for Payer: PHP All Commercial |
$719.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$369.83
|
| Rate for Payer: Sagamore Health Network All Products |
$732.08
|
| Rate for Payer: Signature Care EPO |
$787.08
|
| Rate for Payer: Signature Care PPO |
$834.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$806.05
|
| Rate for Payer: United Healthcare Commercial |
$747.26
|
| Rate for Payer: United Healthcare Medicare |
$312.94
|
|
|
HC RETROGRADE PYLOGRAM
|
Facility
IP
|
$948.29
|
|
|
Service Code
|
CPT 74420
|
| Hospital Charge Code |
01614431
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$711.22 |
| Max. Negotiated Rate |
$881.91 |
| Rate for Payer: Aetna Commercial |
$819.33
|
| Rate for Payer: Cash Price |
$587.94
|
| Rate for Payer: Cigna All Commercial |
$818.38
|
| Rate for Payer: CORVEL All Commercial |
$881.91
|
| Rate for Payer: Coventry All Commercial |
$834.50
|
| Rate for Payer: Encore All Commercial |
$872.90
|
| Rate for Payer: Frontpath All Commercial |
$872.43
|
| Rate for Payer: Humana ChoiceCare |
$819.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$853.46
|
| Rate for Payer: PHCS All Commercial |
$711.22
|
| Rate for Payer: PHP All Commercial |
$719.19
|
| Rate for Payer: Sagamore Health Network All Products |
$732.08
|
| Rate for Payer: Signature Care EPO |
$787.08
|
| Rate for Payer: Signature Care PPO |
$834.50
|
| Rate for Payer: United Healthcare Commercial |
$747.26
|
|
|
HC RETROGRADE URETHROGRAM
|
Facility
IP
|
$1,384.08
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
01614450
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,038.06 |
| Max. Negotiated Rate |
$1,287.19 |
| Rate for Payer: Aetna Commercial |
$1,195.84
|
| Rate for Payer: Cash Price |
$858.13
|
| Rate for Payer: Cigna All Commercial |
$1,194.46
|
| Rate for Payer: CORVEL All Commercial |
$1,287.19
|
| Rate for Payer: Coventry All Commercial |
$1,217.99
|
| Rate for Payer: Encore All Commercial |
$1,274.04
|
| Rate for Payer: Frontpath All Commercial |
$1,273.35
|
| Rate for Payer: Humana ChoiceCare |
$1,195.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,245.67
|
| Rate for Payer: PHCS All Commercial |
$1,038.06
|
| Rate for Payer: PHP All Commercial |
$1,049.69
|
| Rate for Payer: Sagamore Health Network All Products |
$1,068.51
|
| Rate for Payer: Signature Care EPO |
$1,148.79
|
| Rate for Payer: Signature Care PPO |
$1,217.99
|
| Rate for Payer: United Healthcare Commercial |
$1,090.65
|
|
|
HC RETROGRADE URETHROGRAM
|
Facility
OP
|
$1,384.08
|
|
|
Service Code
|
CPT 74450
|
| Hospital Charge Code |
01614450
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$142.00 |
| Max. Negotiated Rate |
$1,287.19 |
| Rate for Payer: Aetna Commercial |
$1,168.16
|
| Rate for Payer: Aetna Medicare |
$456.75
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$456.75
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$794.88
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$865.19
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$142.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$525.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$502.42
|
| Rate for Payer: Cash Price |
$858.13
|
| Rate for Payer: Cash Price |
$858.13
|
| Rate for Payer: Centivo All Commercial |
$705.88
|
| Rate for Payer: Cigna All Commercial |
$1,194.46
|
| Rate for Payer: CORVEL All Commercial |
$1,287.19
|
| Rate for Payer: Coventry All Commercial |
$1,217.99
|
| Rate for Payer: Encore All Commercial |
$1,274.04
|
| Rate for Payer: Frontpath All Commercial |
$1,273.35
|
| Rate for Payer: Humana ChoiceCare |
$1,195.43
|
| Rate for Payer: Humana Medicare |
$705.88
|
| Rate for Payer: Lucent All Commercial |
$705.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,245.67
|
| Rate for Payer: Managed Health Services Medicaid |
$142.00
|
| Rate for Payer: MDWise Medicaid |
$142.00
|
| Rate for Payer: PHCS All Commercial |
$1,038.06
|
| Rate for Payer: PHP All Commercial |
$1,049.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$539.79
|
| Rate for Payer: Sagamore Health Network All Products |
$1,068.51
|
| Rate for Payer: Signature Care EPO |
$1,148.79
|
| Rate for Payer: Signature Care PPO |
$1,217.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,176.47
|
| Rate for Payer: United Healthcare Commercial |
$1,090.65
|
| Rate for Payer: United Healthcare Medicare |
$456.75
|
|
|
HC RETRO INJ URETHRA
|
Facility
IP
|
$95.15
|
|
| Hospital Charge Code |
01611610
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$71.36 |
| Max. Negotiated Rate |
$88.49 |
| Rate for Payer: Aetna Commercial |
$82.21
|
| Rate for Payer: Cash Price |
$58.99
|
| Rate for Payer: Cigna All Commercial |
$82.11
|
| Rate for Payer: CORVEL All Commercial |
$88.49
|
| Rate for Payer: Coventry All Commercial |
$83.73
|
| Rate for Payer: Encore All Commercial |
$87.58
|
| Rate for Payer: Frontpath All Commercial |
$87.53
|
| Rate for Payer: Humana ChoiceCare |
$82.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$85.63
|
| Rate for Payer: PHCS All Commercial |
$71.36
|
| Rate for Payer: PHP All Commercial |
$72.16
|
| Rate for Payer: Sagamore Health Network All Products |
$73.45
|
| Rate for Payer: Signature Care EPO |
$78.97
|
| Rate for Payer: Signature Care PPO |
$83.73
|
| Rate for Payer: United Healthcare Commercial |
$74.97
|
|
|
HC RETRO INJ URETHRA
|
Facility
OP
|
$95.15
|
|
| Hospital Charge Code |
01611610
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$31.40 |
| Max. Negotiated Rate |
$88.49 |
| Rate for Payer: Aetna Commercial |
$80.30
|
| Rate for Payer: Aetna Medicare |
$31.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$54.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$59.48
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$34.54
|
| Rate for Payer: Cash Price |
$58.99
|
| Rate for Payer: Centivo All Commercial |
$48.52
|
| Rate for Payer: Cigna All Commercial |
$82.11
|
| Rate for Payer: CORVEL All Commercial |
$88.49
|
| Rate for Payer: Coventry All Commercial |
$83.73
|
| Rate for Payer: Encore All Commercial |
$87.58
|
| Rate for Payer: Frontpath All Commercial |
$87.53
|
| Rate for Payer: Humana ChoiceCare |
$82.18
|
| Rate for Payer: Humana Medicare |
$48.52
|
| Rate for Payer: Lucent All Commercial |
$48.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$85.63
|
| Rate for Payer: PHCS All Commercial |
$71.36
|
| Rate for Payer: PHP All Commercial |
$72.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$37.11
|
| Rate for Payer: Sagamore Health Network All Products |
$73.45
|
| Rate for Payer: Signature Care EPO |
$78.97
|
| Rate for Payer: Signature Care PPO |
$83.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$80.87
|
| Rate for Payer: United Healthcare Commercial |
$74.97
|
| Rate for Payer: United Healthcare Medicare |
$31.40
|
|
|
HC RHEUMATOID FACTOR-REF
|
Facility
IP
|
$47.28
|
|
|
Service Code
|
CPT 86431
|
| Hospital Charge Code |
63001916
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$35.46 |
| Max. Negotiated Rate |
$43.97 |
| Rate for Payer: Aetna Commercial |
$40.85
|
| Rate for Payer: Cash Price |
$29.31
|
| Rate for Payer: Cigna All Commercial |
$40.80
|
| Rate for Payer: CORVEL All Commercial |
$43.97
|
| Rate for Payer: Coventry All Commercial |
$41.60
|
| Rate for Payer: Encore All Commercial |
$43.52
|
| Rate for Payer: Frontpath All Commercial |
$43.49
|
| Rate for Payer: Humana ChoiceCare |
$40.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.55
|
| Rate for Payer: PHCS All Commercial |
$35.46
|
| Rate for Payer: PHP All Commercial |
$35.85
|
| Rate for Payer: Sagamore Health Network All Products |
$36.50
|
| Rate for Payer: Signature Care EPO |
$39.24
|
| Rate for Payer: Signature Care PPO |
$41.60
|
| Rate for Payer: United Healthcare Commercial |
$37.25
|
|
|
HC RHEUMATOID FACTOR-REF
|
Facility
OP
|
$47.28
|
|
|
Service Code
|
CPT 86431
|
| Hospital Charge Code |
63001916
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$5.67 |
| Max. Negotiated Rate |
$43.97 |
| Rate for Payer: Aetna Commercial |
$39.90
|
| Rate for Payer: Aetna Medicare |
$15.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$27.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.55
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$5.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.94
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.16
|
| Rate for Payer: Cash Price |
$29.31
|
| Rate for Payer: Cash Price |
$29.31
|
| Rate for Payer: Centivo All Commercial |
$24.11
|
| Rate for Payer: Cigna All Commercial |
$40.80
|
| Rate for Payer: CORVEL All Commercial |
$43.97
|
| Rate for Payer: Coventry All Commercial |
$41.60
|
| Rate for Payer: Encore All Commercial |
$43.52
|
| Rate for Payer: Frontpath All Commercial |
$43.49
|
| Rate for Payer: Humana ChoiceCare |
$40.83
|
| Rate for Payer: Humana Medicare |
$24.11
|
| Rate for Payer: Lucent All Commercial |
$24.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.55
|
| Rate for Payer: Managed Health Services Medicaid |
$5.67
|
| Rate for Payer: MDWise Medicaid |
$5.67
|
| Rate for Payer: PHCS All Commercial |
$35.46
|
| Rate for Payer: PHP All Commercial |
$35.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.44
|
| Rate for Payer: Sagamore Health Network All Products |
$36.50
|
| Rate for Payer: Signature Care EPO |
$39.24
|
| Rate for Payer: Signature Care PPO |
$41.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.19
|
| Rate for Payer: United Healthcare Commercial |
$37.25
|
| Rate for Payer: United Healthcare Medicare |
$15.60
|
|
|
HC RH GLOBULIN FULL DOSE
|
Facility
OP
|
$365.14
|
|
|
Service Code
|
CPT 90384
|
| Hospital Charge Code |
63002144
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$339.58 |
| Rate for Payer: Aetna Commercial |
$308.18
|
| Rate for Payer: Aetna Medicare |
$120.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$120.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$209.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$228.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$138.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$132.55
|
| Rate for Payer: Cash Price |
$226.39
|
| Rate for Payer: Cash Price |
$226.39
|
| Rate for Payer: Centivo All Commercial |
$186.22
|
| Rate for Payer: Cigna All Commercial |
$315.12
|
| Rate for Payer: CORVEL All Commercial |
$339.58
|
| Rate for Payer: Coventry All Commercial |
$321.32
|
| Rate for Payer: Encore All Commercial |
$336.11
|
| Rate for Payer: Frontpath All Commercial |
$335.93
|
| Rate for Payer: Humana ChoiceCare |
$315.37
|
| Rate for Payer: Humana Medicare |
$186.22
|
| Rate for Payer: Lucent All Commercial |
$186.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$328.63
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$273.85
|
| Rate for Payer: PHP All Commercial |
$276.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$142.40
|
| Rate for Payer: Sagamore Health Network All Products |
$281.89
|
| Rate for Payer: Signature Care EPO |
$303.07
|
| Rate for Payer: Signature Care PPO |
$321.32
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$310.37
|
| Rate for Payer: United Healthcare Commercial |
$287.73
|
| Rate for Payer: United Healthcare Medicare |
$120.50
|
|
|
HC RH GLOBULIN FULL DOSE
|
Facility
IP
|
$365.14
|
|
|
Service Code
|
CPT 90384
|
| Hospital Charge Code |
63002144
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$273.85 |
| Max. Negotiated Rate |
$339.58 |
| Rate for Payer: Aetna Commercial |
$315.48
|
| Rate for Payer: Cash Price |
$226.39
|
| Rate for Payer: Cigna All Commercial |
$315.12
|
| Rate for Payer: CORVEL All Commercial |
$339.58
|
| Rate for Payer: Coventry All Commercial |
$321.32
|
| Rate for Payer: Encore All Commercial |
$336.11
|
| Rate for Payer: Frontpath All Commercial |
$335.93
|
| Rate for Payer: Humana ChoiceCare |
$315.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$328.63
|
| Rate for Payer: PHCS All Commercial |
$273.85
|
| Rate for Payer: PHP All Commercial |
$276.92
|
| Rate for Payer: Sagamore Health Network All Products |
$281.89
|
| Rate for Payer: Signature Care EPO |
$303.07
|
| Rate for Payer: Signature Care PPO |
$321.32
|
| Rate for Payer: United Healthcare Commercial |
$287.73
|
|
|
HC RH GLOBULIN MINI DOSE
|
Facility
OP
|
$232.09
|
|
|
Service Code
|
CPT 90385
|
| Hospital Charge Code |
63001055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$76.59 |
| Max. Negotiated Rate |
$215.84 |
| Rate for Payer: Aetna Commercial |
$195.88
|
| Rate for Payer: Aetna Medicare |
$76.59
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$76.59
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$133.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$145.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$88.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$84.25
|
| Rate for Payer: Cash Price |
$143.90
|
| Rate for Payer: Centivo All Commercial |
$118.37
|
| Rate for Payer: Cigna All Commercial |
$200.29
|
| Rate for Payer: CORVEL All Commercial |
$215.84
|
| Rate for Payer: Coventry All Commercial |
$204.24
|
| Rate for Payer: Encore All Commercial |
$213.64
|
| Rate for Payer: Frontpath All Commercial |
$213.52
|
| Rate for Payer: Humana ChoiceCare |
$200.46
|
| Rate for Payer: Humana Medicare |
$118.37
|
| Rate for Payer: Lucent All Commercial |
$118.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$208.88
|
| Rate for Payer: PHCS All Commercial |
$174.07
|
| Rate for Payer: PHP All Commercial |
$176.02
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$90.52
|
| Rate for Payer: Sagamore Health Network All Products |
$179.17
|
| Rate for Payer: Signature Care EPO |
$192.64
|
| Rate for Payer: Signature Care PPO |
$204.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$197.28
|
| Rate for Payer: United Healthcare Commercial |
$182.89
|
| Rate for Payer: United Healthcare Medicare |
$76.59
|
|
|
HC RH GLOBULIN MINI DOSE
|
Facility
IP
|
$232.09
|
|
|
Service Code
|
CPT 90385
|
| Hospital Charge Code |
63001055
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$174.07 |
| Max. Negotiated Rate |
$215.84 |
| Rate for Payer: Aetna Commercial |
$200.53
|
| Rate for Payer: Cash Price |
$143.90
|
| Rate for Payer: Cigna All Commercial |
$200.29
|
| Rate for Payer: CORVEL All Commercial |
$215.84
|
| Rate for Payer: Coventry All Commercial |
$204.24
|
| Rate for Payer: Encore All Commercial |
$213.64
|
| Rate for Payer: Frontpath All Commercial |
$213.52
|
| Rate for Payer: Humana ChoiceCare |
$200.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$208.88
|
| Rate for Payer: PHCS All Commercial |
$174.07
|
| Rate for Payer: PHP All Commercial |
$176.02
|
| Rate for Payer: Sagamore Health Network All Products |
$179.17
|
| Rate for Payer: Signature Care EPO |
$192.64
|
| Rate for Payer: Signature Care PPO |
$204.24
|
| Rate for Payer: United Healthcare Commercial |
$182.89
|
|
|
HC RHOGAM INJECTION FULL DOSE
|
Facility
OP
|
$377.73
|
|
| Hospital Charge Code |
63002241
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$124.65 |
| Max. Negotiated Rate |
$351.29 |
| Rate for Payer: Aetna Commercial |
$318.80
|
| Rate for Payer: Aetna Medicare |
$124.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$124.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$216.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$236.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$143.35
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$137.11
|
| Rate for Payer: Cash Price |
$234.19
|
| Rate for Payer: Centivo All Commercial |
$192.64
|
| Rate for Payer: Cigna All Commercial |
$325.98
|
| Rate for Payer: CORVEL All Commercial |
$351.29
|
| Rate for Payer: Coventry All Commercial |
$332.40
|
| Rate for Payer: Encore All Commercial |
$347.70
|
| Rate for Payer: Frontpath All Commercial |
$347.51
|
| Rate for Payer: Humana ChoiceCare |
$326.24
|
| Rate for Payer: Humana Medicare |
$192.64
|
| Rate for Payer: Lucent All Commercial |
$192.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$339.95
|
| Rate for Payer: PHCS All Commercial |
$283.29
|
| Rate for Payer: PHP All Commercial |
$286.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$147.31
|
| Rate for Payer: Sagamore Health Network All Products |
$291.60
|
| Rate for Payer: Signature Care EPO |
$313.51
|
| Rate for Payer: Signature Care PPO |
$332.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$321.07
|
| Rate for Payer: United Healthcare Commercial |
$297.65
|
| Rate for Payer: United Healthcare Medicare |
$124.65
|
|
|
HC RHOGAM INJECTION FULL DOSE
|
Facility
IP
|
$377.73
|
|
| Hospital Charge Code |
63002241
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$283.29 |
| Max. Negotiated Rate |
$351.29 |
| Rate for Payer: Aetna Commercial |
$326.36
|
| Rate for Payer: Cash Price |
$234.19
|
| Rate for Payer: Cigna All Commercial |
$325.98
|
| Rate for Payer: CORVEL All Commercial |
$351.29
|
| Rate for Payer: Coventry All Commercial |
$332.40
|
| Rate for Payer: Encore All Commercial |
$347.70
|
| Rate for Payer: Frontpath All Commercial |
$347.51
|
| Rate for Payer: Humana ChoiceCare |
$326.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$339.95
|
| Rate for Payer: PHCS All Commercial |
$283.29
|
| Rate for Payer: PHP All Commercial |
$286.47
|
| Rate for Payer: Sagamore Health Network All Products |
$291.60
|
| Rate for Payer: Signature Care EPO |
$313.51
|
| Rate for Payer: Signature Care PPO |
$332.40
|
| Rate for Payer: United Healthcare Commercial |
$297.65
|
|
