|
HC VENOUS PH
|
Facility
|
OP
|
$122.30
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
63001547
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.00 |
| Max. Negotiated Rate |
$113.74 |
| Rate for Payer: Aetna Commercial |
$103.22
|
| Rate for Payer: Aetna Medicare |
$39.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$11.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$56.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$56.21
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$11.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$45.01
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$43.05
|
| Rate for Payer: Cash Price |
$73.38
|
| Rate for Payer: Cash Price |
$73.38
|
| Rate for Payer: Centivo All Commercial |
$66.53
|
| Rate for Payer: Cigna All Commercial |
$105.54
|
| Rate for Payer: CORVEL All Commercial |
$113.74
|
| Rate for Payer: Coventry All Commercial |
$107.62
|
| Rate for Payer: Encore All Commercial |
$112.58
|
| Rate for Payer: Frontpath All Commercial |
$112.52
|
| Rate for Payer: Humana ChoiceCare |
$105.63
|
| Rate for Payer: Humana Medicare |
$39.14
|
| Rate for Payer: Lucent All Commercial |
$66.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$110.07
|
| Rate for Payer: Managed Health Services Medicaid |
$11.00
|
| Rate for Payer: MDWise Medicaid |
$11.00
|
| Rate for Payer: PHCS All Commercial |
$91.72
|
| Rate for Payer: PHP All Commercial |
$92.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$47.70
|
| Rate for Payer: Sagamore Health Network All Products |
$94.42
|
| Rate for Payer: Signature Care EPO |
$101.51
|
| Rate for Payer: Signature Care PPO |
$107.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$103.95
|
| Rate for Payer: United Healthcare Commercial |
$96.37
|
| Rate for Payer: United Healthcare Medicare |
$39.14
|
|
|
HC VENOUS PH
|
Facility
|
IP
|
$122.30
|
|
|
Service Code
|
CPT 82800
|
| Hospital Charge Code |
63001547
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$91.72 |
| Max. Negotiated Rate |
$113.74 |
| Rate for Payer: Aetna Commercial |
$105.67
|
| Rate for Payer: Cash Price |
$73.38
|
| Rate for Payer: Cigna All Commercial |
$105.54
|
| Rate for Payer: CORVEL All Commercial |
$113.74
|
| Rate for Payer: Coventry All Commercial |
$107.62
|
| Rate for Payer: Encore All Commercial |
$112.58
|
| Rate for Payer: Frontpath All Commercial |
$112.52
|
| Rate for Payer: Humana ChoiceCare |
$105.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$110.07
|
| Rate for Payer: PHCS All Commercial |
$91.72
|
| Rate for Payer: PHP All Commercial |
$92.75
|
| Rate for Payer: Sagamore Health Network All Products |
$94.42
|
| Rate for Payer: Signature Care EPO |
$101.51
|
| Rate for Payer: Signature Care PPO |
$107.62
|
| Rate for Payer: United Healthcare Commercial |
$96.37
|
|
|
HC VENTISCAN IV
|
Facility
|
OP
|
$341.39
|
|
|
Service Code
|
NDC 99999999263
|
| Hospital Charge Code |
800705
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$317.49 |
| Rate for Payer: Aetna Commercial |
$288.13
|
| Rate for Payer: Aetna Medicare |
$109.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$105.83
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$196.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$213.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$125.63
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$120.17
|
| Rate for Payer: Cash Price |
$204.83
|
| Rate for Payer: Cash Price |
$204.83
|
| Rate for Payer: Centivo All Commercial |
$185.72
|
| Rate for Payer: Cigna All Commercial |
$294.62
|
| Rate for Payer: CORVEL All Commercial |
$317.49
|
| Rate for Payer: Coventry All Commercial |
$300.42
|
| Rate for Payer: Encore All Commercial |
$314.25
|
| Rate for Payer: Frontpath All Commercial |
$314.08
|
| Rate for Payer: Humana ChoiceCare |
$294.86
|
| Rate for Payer: Humana Medicare |
$109.24
|
| Rate for Payer: Lucent All Commercial |
$185.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.25
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$256.04
|
| Rate for Payer: PHP All Commercial |
$258.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$133.14
|
| Rate for Payer: Sagamore Health Network All Products |
$263.55
|
| Rate for Payer: Signature Care EPO |
$283.35
|
| Rate for Payer: Signature Care PPO |
$300.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$290.18
|
| Rate for Payer: United Healthcare Commercial |
$269.02
|
| Rate for Payer: United Healthcare Medicare |
$109.24
|
|
|
HC VENTISCAN IV
|
Facility
|
IP
|
$341.39
|
|
|
Service Code
|
NDC 99999999263
|
| Hospital Charge Code |
800705
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$256.04 |
| Max. Negotiated Rate |
$317.49 |
| Rate for Payer: Aetna Commercial |
$294.96
|
| Rate for Payer: Cash Price |
$204.83
|
| Rate for Payer: Cigna All Commercial |
$294.62
|
| Rate for Payer: CORVEL All Commercial |
$317.49
|
| Rate for Payer: Coventry All Commercial |
$300.42
|
| Rate for Payer: Encore All Commercial |
$314.25
|
| Rate for Payer: Frontpath All Commercial |
$314.08
|
| Rate for Payer: Humana ChoiceCare |
$294.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$307.25
|
| Rate for Payer: PHCS All Commercial |
$256.04
|
| Rate for Payer: PHP All Commercial |
$258.91
|
| Rate for Payer: Sagamore Health Network All Products |
$263.55
|
| Rate for Payer: Signature Care EPO |
$283.35
|
| Rate for Payer: Signature Care PPO |
$300.42
|
| Rate for Payer: United Healthcare Commercial |
$269.02
|
|
|
HC VERSAJET 45
|
Facility
|
IP
|
$2,700.00
|
|
| Hospital Charge Code |
41607904
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2,025.00 |
| Max. Negotiated Rate |
$2,511.00 |
| Rate for Payer: Aetna Commercial |
$2,332.80
|
| Rate for Payer: Cash Price |
$1,620.00
|
| Rate for Payer: Cigna All Commercial |
$2,330.10
|
| Rate for Payer: CORVEL All Commercial |
$2,511.00
|
| Rate for Payer: Coventry All Commercial |
$2,376.00
|
| Rate for Payer: Encore All Commercial |
$2,485.35
|
| Rate for Payer: Frontpath All Commercial |
$2,484.00
|
| Rate for Payer: Humana ChoiceCare |
$2,331.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,430.00
|
| Rate for Payer: PHCS All Commercial |
$2,025.00
|
| Rate for Payer: PHP All Commercial |
$2,047.68
|
| Rate for Payer: Sagamore Health Network All Products |
$2,084.40
|
| Rate for Payer: Signature Care EPO |
$2,241.00
|
| Rate for Payer: Signature Care PPO |
$2,376.00
|
| Rate for Payer: United Healthcare Commercial |
$2,127.60
|
|
|
HC VERSAJET 45
|
Facility
|
OP
|
$2,700.00
|
|
| Hospital Charge Code |
41607904
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$2,511.00 |
| Rate for Payer: Aetna Commercial |
$2,278.80
|
| Rate for Payer: Aetna Medicare |
$864.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$837.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,550.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,687.77
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$993.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$950.40
|
| Rate for Payer: Cash Price |
$1,620.00
|
| Rate for Payer: Cash Price |
$1,620.00
|
| Rate for Payer: Centivo All Commercial |
$1,468.80
|
| Rate for Payer: Cigna All Commercial |
$2,330.10
|
| Rate for Payer: CORVEL All Commercial |
$2,511.00
|
| Rate for Payer: Coventry All Commercial |
$2,376.00
|
| Rate for Payer: Encore All Commercial |
$2,485.35
|
| Rate for Payer: Frontpath All Commercial |
$2,484.00
|
| Rate for Payer: Humana ChoiceCare |
$2,331.99
|
| Rate for Payer: Humana Medicare |
$864.00
|
| Rate for Payer: Lucent All Commercial |
$1,468.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,430.00
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$2,025.00
|
| Rate for Payer: PHP All Commercial |
$2,047.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,053.00
|
| Rate for Payer: Sagamore Health Network All Products |
$2,084.40
|
| Rate for Payer: Signature Care EPO |
$2,241.00
|
| Rate for Payer: Signature Care PPO |
$2,376.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,295.00
|
| Rate for Payer: United Healthcare Commercial |
$2,127.60
|
| Rate for Payer: United Healthcare Medicare |
$864.00
|
|
|
HC VIRAL CULTURE NON RESPIRATORY
|
Facility
|
OP
|
$240.67
|
|
|
Service Code
|
CPT 87252
|
| Hospital Charge Code |
63002021
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.07 |
| Max. Negotiated Rate |
$223.82 |
| Rate for Payer: Aetna Commercial |
$203.13
|
| Rate for Payer: Aetna Medicare |
$77.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$26.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$74.61
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$110.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$110.61
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$26.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$88.57
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$84.72
|
| Rate for Payer: Cash Price |
$144.40
|
| Rate for Payer: Cash Price |
$144.40
|
| Rate for Payer: Centivo All Commercial |
$130.92
|
| Rate for Payer: Cigna All Commercial |
$207.70
|
| Rate for Payer: CORVEL All Commercial |
$223.82
|
| Rate for Payer: Coventry All Commercial |
$211.79
|
| Rate for Payer: Encore All Commercial |
$221.54
|
| Rate for Payer: Frontpath All Commercial |
$221.42
|
| Rate for Payer: Humana ChoiceCare |
$207.87
|
| Rate for Payer: Humana Medicare |
$77.01
|
| Rate for Payer: Lucent All Commercial |
$130.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$216.60
|
| Rate for Payer: Managed Health Services Medicaid |
$26.07
|
| Rate for Payer: MDWise Medicaid |
$26.07
|
| Rate for Payer: PHCS All Commercial |
$180.50
|
| Rate for Payer: PHP All Commercial |
$182.52
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$93.86
|
| Rate for Payer: Sagamore Health Network All Products |
$185.80
|
| Rate for Payer: Signature Care EPO |
$199.76
|
| Rate for Payer: Signature Care PPO |
$211.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$204.57
|
| Rate for Payer: United Healthcare Commercial |
$189.65
|
| Rate for Payer: United Healthcare Medicare |
$77.01
|
|
|
HC VIRAL CULTURE NON RESPIRATORY
|
Facility
|
IP
|
$240.67
|
|
|
Service Code
|
CPT 87252
|
| Hospital Charge Code |
63002021
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$180.50 |
| Max. Negotiated Rate |
$223.82 |
| Rate for Payer: Aetna Commercial |
$207.94
|
| Rate for Payer: Cash Price |
$144.40
|
| Rate for Payer: Cigna All Commercial |
$207.70
|
| Rate for Payer: CORVEL All Commercial |
$223.82
|
| Rate for Payer: Coventry All Commercial |
$211.79
|
| Rate for Payer: Encore All Commercial |
$221.54
|
| Rate for Payer: Frontpath All Commercial |
$221.42
|
| Rate for Payer: Humana ChoiceCare |
$207.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$216.60
|
| Rate for Payer: PHCS All Commercial |
$180.50
|
| Rate for Payer: PHP All Commercial |
$182.52
|
| Rate for Payer: Sagamore Health Network All Products |
$185.80
|
| Rate for Payer: Signature Care EPO |
$199.76
|
| Rate for Payer: Signature Care PPO |
$211.79
|
| Rate for Payer: United Healthcare Commercial |
$189.65
|
|
|
HC VIRAL CULTURE RESPIRATORY
|
Facility
|
OP
|
$497.68
|
|
|
Service Code
|
CPT 87252
|
| Hospital Charge Code |
63002022
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.07 |
| Max. Negotiated Rate |
$462.84 |
| Rate for Payer: Aetna Commercial |
$420.04
|
| Rate for Payer: Aetna Medicare |
$159.26
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$26.07
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$154.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$228.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$228.73
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$26.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$183.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$175.18
|
| Rate for Payer: Cash Price |
$298.61
|
| Rate for Payer: Cash Price |
$298.61
|
| Rate for Payer: Centivo All Commercial |
$270.74
|
| Rate for Payer: Cigna All Commercial |
$429.50
|
| Rate for Payer: CORVEL All Commercial |
$462.84
|
| Rate for Payer: Coventry All Commercial |
$437.96
|
| Rate for Payer: Encore All Commercial |
$458.11
|
| Rate for Payer: Frontpath All Commercial |
$457.87
|
| Rate for Payer: Humana ChoiceCare |
$429.85
|
| Rate for Payer: Humana Medicare |
$159.26
|
| Rate for Payer: Lucent All Commercial |
$270.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$447.91
|
| Rate for Payer: Managed Health Services Medicaid |
$26.07
|
| Rate for Payer: MDWise Medicaid |
$26.07
|
| Rate for Payer: PHCS All Commercial |
$373.26
|
| Rate for Payer: PHP All Commercial |
$377.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$194.10
|
| Rate for Payer: Sagamore Health Network All Products |
$384.21
|
| Rate for Payer: Signature Care EPO |
$413.07
|
| Rate for Payer: Signature Care PPO |
$437.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$423.03
|
| Rate for Payer: United Healthcare Commercial |
$392.17
|
| Rate for Payer: United Healthcare Medicare |
$159.26
|
|
|
HC VIRAL CULTURE RESPIRATORY
|
Facility
|
IP
|
$497.68
|
|
|
Service Code
|
CPT 87252
|
| Hospital Charge Code |
63002022
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$373.26 |
| Max. Negotiated Rate |
$462.84 |
| Rate for Payer: Aetna Commercial |
$430.00
|
| Rate for Payer: Cash Price |
$298.61
|
| Rate for Payer: Cigna All Commercial |
$429.50
|
| Rate for Payer: CORVEL All Commercial |
$462.84
|
| Rate for Payer: Coventry All Commercial |
$437.96
|
| Rate for Payer: Encore All Commercial |
$458.11
|
| Rate for Payer: Frontpath All Commercial |
$457.87
|
| Rate for Payer: Humana ChoiceCare |
$429.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$447.91
|
| Rate for Payer: PHCS All Commercial |
$373.26
|
| Rate for Payer: PHP All Commercial |
$377.44
|
| Rate for Payer: Sagamore Health Network All Products |
$384.21
|
| Rate for Payer: Signature Care EPO |
$413.07
|
| Rate for Payer: Signature Care PPO |
$437.96
|
| Rate for Payer: United Healthcare Commercial |
$392.17
|
|
|
HC VISTASEAL FIBRIN SEALANT 4ML
|
Facility
|
OP
|
$1,200.15
|
|
| Hospital Charge Code |
41607719
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$31.20 |
| Max. Negotiated Rate |
$1,116.14 |
| Rate for Payer: Aetna Commercial |
$1,012.93
|
| Rate for Payer: Aetna Medicare |
$384.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$31.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$372.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$689.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$750.21
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$31.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$441.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$422.45
|
| Rate for Payer: Cash Price |
$720.09
|
| Rate for Payer: Cash Price |
$720.09
|
| Rate for Payer: Centivo All Commercial |
$652.88
|
| Rate for Payer: Cigna All Commercial |
$1,035.73
|
| Rate for Payer: CORVEL All Commercial |
$1,116.14
|
| Rate for Payer: Coventry All Commercial |
$1,056.13
|
| Rate for Payer: Encore All Commercial |
$1,104.74
|
| Rate for Payer: Frontpath All Commercial |
$1,104.14
|
| Rate for Payer: Humana ChoiceCare |
$1,036.57
|
| Rate for Payer: Humana Medicare |
$384.05
|
| Rate for Payer: Lucent All Commercial |
$652.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,080.13
|
| Rate for Payer: Managed Health Services Medicaid |
$31.20
|
| Rate for Payer: MDWise Medicaid |
$31.20
|
| Rate for Payer: PHCS All Commercial |
$900.11
|
| Rate for Payer: PHP All Commercial |
$910.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$468.06
|
| Rate for Payer: Sagamore Health Network All Products |
$926.52
|
| Rate for Payer: Signature Care EPO |
$996.12
|
| Rate for Payer: Signature Care PPO |
$1,056.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,020.13
|
| Rate for Payer: United Healthcare Commercial |
$945.72
|
| Rate for Payer: United Healthcare Medicare |
$384.05
|
|
|
HC VISTASEAL FIBRIN SEALANT 4ML
|
Facility
|
IP
|
$1,200.15
|
|
| Hospital Charge Code |
41607719
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$900.11 |
| Max. Negotiated Rate |
$1,116.14 |
| Rate for Payer: Aetna Commercial |
$1,036.93
|
| Rate for Payer: Cash Price |
$720.09
|
| Rate for Payer: Cigna All Commercial |
$1,035.73
|
| Rate for Payer: CORVEL All Commercial |
$1,116.14
|
| Rate for Payer: Coventry All Commercial |
$1,056.13
|
| Rate for Payer: Encore All Commercial |
$1,104.74
|
| Rate for Payer: Frontpath All Commercial |
$1,104.14
|
| Rate for Payer: Humana ChoiceCare |
$1,036.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,080.13
|
| Rate for Payer: PHCS All Commercial |
$900.11
|
| Rate for Payer: PHP All Commercial |
$910.19
|
| Rate for Payer: Sagamore Health Network All Products |
$926.52
|
| Rate for Payer: Signature Care EPO |
$996.12
|
| Rate for Payer: Signature Care PPO |
$1,056.13
|
| Rate for Payer: United Healthcare Commercial |
$945.72
|
|
|
HC VITAMIN A
|
Facility
|
OP
|
$152.59
|
|
|
Service Code
|
CPT 84590
|
| Hospital Charge Code |
63001715
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.61 |
| Max. Negotiated Rate |
$141.91 |
| Rate for Payer: Aetna Commercial |
$128.79
|
| Rate for Payer: Aetna Medicare |
$48.83
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$11.61
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$47.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$70.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.13
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$11.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$56.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$53.71
|
| Rate for Payer: Cash Price |
$91.55
|
| Rate for Payer: Cash Price |
$91.55
|
| Rate for Payer: Centivo All Commercial |
$83.01
|
| Rate for Payer: Cigna All Commercial |
$131.69
|
| Rate for Payer: CORVEL All Commercial |
$141.91
|
| Rate for Payer: Coventry All Commercial |
$134.28
|
| Rate for Payer: Encore All Commercial |
$140.46
|
| Rate for Payer: Frontpath All Commercial |
$140.38
|
| Rate for Payer: Humana ChoiceCare |
$131.79
|
| Rate for Payer: Humana Medicare |
$48.83
|
| Rate for Payer: Lucent All Commercial |
$83.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$137.33
|
| Rate for Payer: Managed Health Services Medicaid |
$11.61
|
| Rate for Payer: MDWise Medicaid |
$11.61
|
| Rate for Payer: PHCS All Commercial |
$114.44
|
| Rate for Payer: PHP All Commercial |
$115.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$59.51
|
| Rate for Payer: Sagamore Health Network All Products |
$117.80
|
| Rate for Payer: Signature Care EPO |
$126.65
|
| Rate for Payer: Signature Care PPO |
$134.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$129.70
|
| Rate for Payer: United Healthcare Commercial |
$120.24
|
| Rate for Payer: United Healthcare Medicare |
$48.83
|
|
|
HC VITAMIN A
|
Facility
|
IP
|
$152.59
|
|
|
Service Code
|
CPT 84590
|
| Hospital Charge Code |
63001715
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$114.44 |
| Max. Negotiated Rate |
$141.91 |
| Rate for Payer: Aetna Commercial |
$131.84
|
| Rate for Payer: Cash Price |
$91.55
|
| Rate for Payer: Cigna All Commercial |
$131.69
|
| Rate for Payer: CORVEL All Commercial |
$141.91
|
| Rate for Payer: Coventry All Commercial |
$134.28
|
| Rate for Payer: Encore All Commercial |
$140.46
|
| Rate for Payer: Frontpath All Commercial |
$140.38
|
| Rate for Payer: Humana ChoiceCare |
$131.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$137.33
|
| Rate for Payer: PHCS All Commercial |
$114.44
|
| Rate for Payer: PHP All Commercial |
$115.72
|
| Rate for Payer: Sagamore Health Network All Products |
$117.80
|
| Rate for Payer: Signature Care EPO |
$126.65
|
| Rate for Payer: Signature Care PPO |
$134.28
|
| Rate for Payer: United Healthcare Commercial |
$120.24
|
|
|
HC VITAMIN B-12
|
Facility
|
IP
|
$207.57
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
63001089
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$155.68 |
| Max. Negotiated Rate |
$193.04 |
| Rate for Payer: Aetna Commercial |
$179.34
|
| Rate for Payer: Cash Price |
$124.54
|
| Rate for Payer: Cigna All Commercial |
$179.13
|
| Rate for Payer: CORVEL All Commercial |
$193.04
|
| Rate for Payer: Coventry All Commercial |
$182.66
|
| Rate for Payer: Encore All Commercial |
$191.07
|
| Rate for Payer: Frontpath All Commercial |
$190.96
|
| Rate for Payer: Humana ChoiceCare |
$179.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$186.81
|
| Rate for Payer: PHCS All Commercial |
$155.68
|
| Rate for Payer: PHP All Commercial |
$157.42
|
| Rate for Payer: Sagamore Health Network All Products |
$160.24
|
| Rate for Payer: Signature Care EPO |
$172.28
|
| Rate for Payer: Signature Care PPO |
$182.66
|
| Rate for Payer: United Healthcare Commercial |
$163.57
|
|
|
HC VITAMIN B-12
|
Facility
|
OP
|
$207.57
|
|
|
Service Code
|
CPT 82607
|
| Hospital Charge Code |
63001089
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.08 |
| Max. Negotiated Rate |
$193.04 |
| Rate for Payer: Aetna Commercial |
$175.19
|
| Rate for Payer: Aetna Medicare |
$66.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$15.08
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$64.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$95.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$95.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$15.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$76.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$73.06
|
| Rate for Payer: Cash Price |
$124.54
|
| Rate for Payer: Cash Price |
$124.54
|
| Rate for Payer: Centivo All Commercial |
$112.92
|
| Rate for Payer: Cigna All Commercial |
$179.13
|
| Rate for Payer: CORVEL All Commercial |
$193.04
|
| Rate for Payer: Coventry All Commercial |
$182.66
|
| Rate for Payer: Encore All Commercial |
$191.07
|
| Rate for Payer: Frontpath All Commercial |
$190.96
|
| Rate for Payer: Humana ChoiceCare |
$179.28
|
| Rate for Payer: Humana Medicare |
$66.42
|
| Rate for Payer: Lucent All Commercial |
$112.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$186.81
|
| Rate for Payer: Managed Health Services Medicaid |
$15.08
|
| Rate for Payer: MDWise Medicaid |
$15.08
|
| Rate for Payer: PHCS All Commercial |
$155.68
|
| Rate for Payer: PHP All Commercial |
$157.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$80.95
|
| Rate for Payer: Sagamore Health Network All Products |
$160.24
|
| Rate for Payer: Signature Care EPO |
$172.28
|
| Rate for Payer: Signature Care PPO |
$182.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$176.43
|
| Rate for Payer: United Healthcare Commercial |
$163.57
|
| Rate for Payer: United Healthcare Medicare |
$66.42
|
|
|
HC VITAMINB1 (THIAMINE)
|
Facility
|
OP
|
$185.75
|
|
|
Service Code
|
CPT 84425
|
| Hospital Charge Code |
63001685
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$21.23 |
| Max. Negotiated Rate |
$172.75 |
| Rate for Payer: Aetna Commercial |
$156.77
|
| Rate for Payer: Aetna Medicare |
$59.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$21.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$57.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$85.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$85.37
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$68.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$65.38
|
| Rate for Payer: Cash Price |
$111.45
|
| Rate for Payer: Cash Price |
$111.45
|
| Rate for Payer: Centivo All Commercial |
$101.05
|
| Rate for Payer: Cigna All Commercial |
$160.30
|
| Rate for Payer: CORVEL All Commercial |
$172.75
|
| Rate for Payer: Coventry All Commercial |
$163.46
|
| Rate for Payer: Encore All Commercial |
$170.98
|
| Rate for Payer: Frontpath All Commercial |
$170.89
|
| Rate for Payer: Humana ChoiceCare |
$160.43
|
| Rate for Payer: Humana Medicare |
$59.44
|
| Rate for Payer: Lucent All Commercial |
$101.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$167.18
|
| Rate for Payer: Managed Health Services Medicaid |
$21.23
|
| Rate for Payer: MDWise Medicaid |
$21.23
|
| Rate for Payer: PHCS All Commercial |
$139.31
|
| Rate for Payer: PHP All Commercial |
$140.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$72.44
|
| Rate for Payer: Sagamore Health Network All Products |
$143.40
|
| Rate for Payer: Signature Care EPO |
$154.17
|
| Rate for Payer: Signature Care PPO |
$163.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$157.89
|
| Rate for Payer: United Healthcare Commercial |
$146.37
|
| Rate for Payer: United Healthcare Medicare |
$59.44
|
|
|
HC VITAMINB1 (THIAMINE)
|
Facility
|
IP
|
$185.75
|
|
|
Service Code
|
CPT 84425
|
| Hospital Charge Code |
63001685
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$139.31 |
| Max. Negotiated Rate |
$172.75 |
| Rate for Payer: Aetna Commercial |
$160.49
|
| Rate for Payer: Cash Price |
$111.45
|
| Rate for Payer: Cigna All Commercial |
$160.30
|
| Rate for Payer: CORVEL All Commercial |
$172.75
|
| Rate for Payer: Coventry All Commercial |
$163.46
|
| Rate for Payer: Encore All Commercial |
$170.98
|
| Rate for Payer: Frontpath All Commercial |
$170.89
|
| Rate for Payer: Humana ChoiceCare |
$160.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$167.18
|
| Rate for Payer: PHCS All Commercial |
$139.31
|
| Rate for Payer: PHP All Commercial |
$140.87
|
| Rate for Payer: Sagamore Health Network All Products |
$143.40
|
| Rate for Payer: Signature Care EPO |
$154.17
|
| Rate for Payer: Signature Care PPO |
$163.46
|
| Rate for Payer: United Healthcare Commercial |
$146.37
|
|
|
HC VITAMIN B2, WHOLE BLOOD
|
Facility
|
IP
|
$204.33
|
|
|
Service Code
|
CPT 84252
|
| Hospital Charge Code |
63044082
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$153.25 |
| Max. Negotiated Rate |
$190.03 |
| Rate for Payer: Aetna Commercial |
$176.54
|
| Rate for Payer: Cash Price |
$122.60
|
| Rate for Payer: Cigna All Commercial |
$176.34
|
| Rate for Payer: CORVEL All Commercial |
$190.03
|
| Rate for Payer: Coventry All Commercial |
$179.81
|
| Rate for Payer: Encore All Commercial |
$188.09
|
| Rate for Payer: Frontpath All Commercial |
$187.98
|
| Rate for Payer: Humana ChoiceCare |
$176.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$183.90
|
| Rate for Payer: PHCS All Commercial |
$153.25
|
| Rate for Payer: PHP All Commercial |
$154.96
|
| Rate for Payer: Sagamore Health Network All Products |
$157.74
|
| Rate for Payer: Signature Care EPO |
$169.59
|
| Rate for Payer: Signature Care PPO |
$179.81
|
| Rate for Payer: United Healthcare Commercial |
$161.01
|
|
|
HC VITAMIN B2, WHOLE BLOOD
|
Facility
|
OP
|
$204.33
|
|
|
Service Code
|
CPT 84252
|
| Hospital Charge Code |
63044082
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.24 |
| Max. Negotiated Rate |
$190.03 |
| Rate for Payer: Aetna Commercial |
$172.45
|
| Rate for Payer: Aetna Medicare |
$65.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$20.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$63.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$93.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$93.91
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$20.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$75.19
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$71.92
|
| Rate for Payer: Cash Price |
$122.60
|
| Rate for Payer: Cash Price |
$122.60
|
| Rate for Payer: Centivo All Commercial |
$111.16
|
| Rate for Payer: Cigna All Commercial |
$176.34
|
| Rate for Payer: CORVEL All Commercial |
$190.03
|
| Rate for Payer: Coventry All Commercial |
$179.81
|
| Rate for Payer: Encore All Commercial |
$188.09
|
| Rate for Payer: Frontpath All Commercial |
$187.98
|
| Rate for Payer: Humana ChoiceCare |
$176.48
|
| Rate for Payer: Humana Medicare |
$65.39
|
| Rate for Payer: Lucent All Commercial |
$111.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$183.90
|
| Rate for Payer: Managed Health Services Medicaid |
$20.24
|
| Rate for Payer: MDWise Medicaid |
$20.24
|
| Rate for Payer: PHCS All Commercial |
$153.25
|
| Rate for Payer: PHP All Commercial |
$154.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$79.69
|
| Rate for Payer: Sagamore Health Network All Products |
$157.74
|
| Rate for Payer: Signature Care EPO |
$169.59
|
| Rate for Payer: Signature Care PPO |
$179.81
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$173.68
|
| Rate for Payer: United Healthcare Commercial |
$161.01
|
| Rate for Payer: United Healthcare Medicare |
$65.39
|
|
|
HC VITAMIN B5
|
Facility
|
IP
|
$419.79
|
|
|
Service Code
|
CPT 84591
|
| Hospital Charge Code |
63001716
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$314.84 |
| Max. Negotiated Rate |
$390.40 |
| Rate for Payer: Aetna Commercial |
$362.70
|
| Rate for Payer: Cash Price |
$251.87
|
| Rate for Payer: Cigna All Commercial |
$362.28
|
| Rate for Payer: CORVEL All Commercial |
$390.40
|
| Rate for Payer: Coventry All Commercial |
$369.42
|
| Rate for Payer: Encore All Commercial |
$386.42
|
| Rate for Payer: Frontpath All Commercial |
$386.21
|
| Rate for Payer: Humana ChoiceCare |
$362.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$377.81
|
| Rate for Payer: PHCS All Commercial |
$314.84
|
| Rate for Payer: PHP All Commercial |
$318.37
|
| Rate for Payer: Sagamore Health Network All Products |
$324.08
|
| Rate for Payer: Signature Care EPO |
$348.43
|
| Rate for Payer: Signature Care PPO |
$369.42
|
| Rate for Payer: United Healthcare Commercial |
$330.79
|
|
|
HC VITAMIN B5
|
Facility
|
OP
|
$419.79
|
|
|
Service Code
|
CPT 84591
|
| Hospital Charge Code |
63001716
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$17.06 |
| Max. Negotiated Rate |
$390.40 |
| Rate for Payer: Aetna Commercial |
$354.30
|
| Rate for Payer: Aetna Medicare |
$134.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$17.06
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$130.13
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$192.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$192.94
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$17.06
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$154.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$147.77
|
| Rate for Payer: Cash Price |
$251.87
|
| Rate for Payer: Cash Price |
$251.87
|
| Rate for Payer: Centivo All Commercial |
$228.37
|
| Rate for Payer: Cigna All Commercial |
$362.28
|
| Rate for Payer: CORVEL All Commercial |
$390.40
|
| Rate for Payer: Coventry All Commercial |
$369.42
|
| Rate for Payer: Encore All Commercial |
$386.42
|
| Rate for Payer: Frontpath All Commercial |
$386.21
|
| Rate for Payer: Humana ChoiceCare |
$362.57
|
| Rate for Payer: Humana Medicare |
$134.33
|
| Rate for Payer: Lucent All Commercial |
$228.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$377.81
|
| Rate for Payer: Managed Health Services Medicaid |
$17.06
|
| Rate for Payer: MDWise Medicaid |
$17.06
|
| Rate for Payer: PHCS All Commercial |
$314.84
|
| Rate for Payer: PHP All Commercial |
$318.37
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$163.72
|
| Rate for Payer: Sagamore Health Network All Products |
$324.08
|
| Rate for Payer: Signature Care EPO |
$348.43
|
| Rate for Payer: Signature Care PPO |
$369.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$356.82
|
| Rate for Payer: United Healthcare Commercial |
$330.79
|
| Rate for Payer: United Healthcare Medicare |
$134.33
|
|
|
HC VITAMIN B6
|
Facility
|
OP
|
$231.81
|
|
|
Service Code
|
CPT 84207
|
| Hospital Charge Code |
63001670
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$28.10 |
| Max. Negotiated Rate |
$215.58 |
| Rate for Payer: Aetna Commercial |
$195.65
|
| Rate for Payer: Aetna Medicare |
$74.18
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$28.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$71.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$106.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$106.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$28.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$85.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$81.60
|
| Rate for Payer: Cash Price |
$139.09
|
| Rate for Payer: Cash Price |
$139.09
|
| Rate for Payer: Centivo All Commercial |
$126.10
|
| Rate for Payer: Cigna All Commercial |
$200.05
|
| Rate for Payer: CORVEL All Commercial |
$215.58
|
| Rate for Payer: Coventry All Commercial |
$203.99
|
| Rate for Payer: Encore All Commercial |
$213.38
|
| Rate for Payer: Frontpath All Commercial |
$213.27
|
| Rate for Payer: Humana ChoiceCare |
$200.21
|
| Rate for Payer: Humana Medicare |
$74.18
|
| Rate for Payer: Lucent All Commercial |
$126.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$208.63
|
| Rate for Payer: Managed Health Services Medicaid |
$28.10
|
| Rate for Payer: MDWise Medicaid |
$28.10
|
| Rate for Payer: PHCS All Commercial |
$173.86
|
| Rate for Payer: PHP All Commercial |
$175.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$90.41
|
| Rate for Payer: Sagamore Health Network All Products |
$178.96
|
| Rate for Payer: Signature Care EPO |
$192.40
|
| Rate for Payer: Signature Care PPO |
$203.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$197.04
|
| Rate for Payer: United Healthcare Commercial |
$182.67
|
| Rate for Payer: United Healthcare Medicare |
$74.18
|
|
|
HC VITAMIN B6
|
Facility
|
IP
|
$231.81
|
|
|
Service Code
|
CPT 84207
|
| Hospital Charge Code |
63001670
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$173.86 |
| Max. Negotiated Rate |
$215.58 |
| Rate for Payer: Aetna Commercial |
$200.28
|
| Rate for Payer: Cash Price |
$139.09
|
| Rate for Payer: Cigna All Commercial |
$200.05
|
| Rate for Payer: CORVEL All Commercial |
$215.58
|
| Rate for Payer: Coventry All Commercial |
$203.99
|
| Rate for Payer: Encore All Commercial |
$213.38
|
| Rate for Payer: Frontpath All Commercial |
$213.27
|
| Rate for Payer: Humana ChoiceCare |
$200.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$208.63
|
| Rate for Payer: PHCS All Commercial |
$173.86
|
| Rate for Payer: PHP All Commercial |
$175.80
|
| Rate for Payer: Sagamore Health Network All Products |
$178.96
|
| Rate for Payer: Signature Care EPO |
$192.40
|
| Rate for Payer: Signature Care PPO |
$203.99
|
| Rate for Payer: United Healthcare Commercial |
$182.67
|
|
|
HC VITAMIN C
|
Facility
|
IP
|
$160.45
|
|
|
Service Code
|
CPT 82180
|
| Hospital Charge Code |
63044083
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$120.34 |
| Max. Negotiated Rate |
$149.22 |
| Rate for Payer: Aetna Commercial |
$138.63
|
| Rate for Payer: Cash Price |
$96.27
|
| Rate for Payer: Cigna All Commercial |
$138.47
|
| Rate for Payer: CORVEL All Commercial |
$149.22
|
| Rate for Payer: Coventry All Commercial |
$141.20
|
| Rate for Payer: Encore All Commercial |
$147.69
|
| Rate for Payer: Frontpath All Commercial |
$147.61
|
| Rate for Payer: Humana ChoiceCare |
$138.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$144.41
|
| Rate for Payer: PHCS All Commercial |
$120.34
|
| Rate for Payer: PHP All Commercial |
$121.69
|
| Rate for Payer: Sagamore Health Network All Products |
$123.87
|
| Rate for Payer: Signature Care EPO |
$133.17
|
| Rate for Payer: Signature Care PPO |
$141.20
|
| Rate for Payer: United Healthcare Commercial |
$126.43
|
|
