|
HC X-RAY-OSSEOUS SURVEY COMPLETE
|
Facility
|
OP
|
$1,023.52
|
|
|
Service Code
|
CPT 77075
|
| Hospital Charge Code |
1616040
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$55.65 |
| Max. Negotiated Rate |
$951.87 |
| Rate for Payer: Aetna Commercial |
$863.85
|
| Rate for Payer: Aetna Medicare |
$327.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$55.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$317.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$587.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$639.80
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$55.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$376.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$360.28
|
| Rate for Payer: Cash Price |
$614.11
|
| Rate for Payer: Cash Price |
$614.11
|
| Rate for Payer: Centivo All Commercial |
$556.79
|
| Rate for Payer: Cigna All Commercial |
$883.30
|
| Rate for Payer: CORVEL All Commercial |
$951.87
|
| Rate for Payer: Coventry All Commercial |
$900.70
|
| Rate for Payer: Encore All Commercial |
$942.15
|
| Rate for Payer: Frontpath All Commercial |
$941.64
|
| Rate for Payer: Humana ChoiceCare |
$884.01
|
| Rate for Payer: Humana Medicare |
$327.53
|
| Rate for Payer: Lucent All Commercial |
$556.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$921.17
|
| Rate for Payer: Managed Health Services Medicaid |
$55.65
|
| Rate for Payer: MDWise Medicaid |
$55.65
|
| Rate for Payer: PHCS All Commercial |
$767.64
|
| Rate for Payer: PHP All Commercial |
$776.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$399.17
|
| Rate for Payer: Sagamore Health Network All Products |
$790.16
|
| Rate for Payer: Signature Care EPO |
$849.52
|
| Rate for Payer: Signature Care PPO |
$900.70
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$869.99
|
| Rate for Payer: United Healthcare Commercial |
$806.53
|
| Rate for Payer: United Healthcare Medicare |
$327.53
|
|
|
HC X-RAY-OSSEOUS SURVEY COMPLETE
|
Facility
|
IP
|
$1,023.52
|
|
|
Service Code
|
CPT 77075
|
| Hospital Charge Code |
1616040
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$767.64 |
| Max. Negotiated Rate |
$951.87 |
| Rate for Payer: Aetna Commercial |
$884.32
|
| Rate for Payer: Cash Price |
$614.11
|
| Rate for Payer: Cigna All Commercial |
$883.30
|
| Rate for Payer: CORVEL All Commercial |
$951.87
|
| Rate for Payer: Coventry All Commercial |
$900.70
|
| Rate for Payer: Encore All Commercial |
$942.15
|
| Rate for Payer: Frontpath All Commercial |
$941.64
|
| Rate for Payer: Humana ChoiceCare |
$884.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$921.17
|
| Rate for Payer: PHCS All Commercial |
$767.64
|
| Rate for Payer: PHP All Commercial |
$776.24
|
| Rate for Payer: Sagamore Health Network All Products |
$790.16
|
| Rate for Payer: Signature Care EPO |
$849.52
|
| Rate for Payer: Signature Care PPO |
$900.70
|
| Rate for Payer: United Healthcare Commercial |
$806.53
|
|
|
HC X-RAY-OSSEOUS SURVEY INFANT
|
Facility
|
IP
|
$853.75
|
|
|
Service Code
|
CPT 77076
|
| Hospital Charge Code |
1616065
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$640.31 |
| Max. Negotiated Rate |
$793.99 |
| Rate for Payer: Aetna Commercial |
$737.64
|
| Rate for Payer: Cash Price |
$512.25
|
| Rate for Payer: Cigna All Commercial |
$736.79
|
| Rate for Payer: CORVEL All Commercial |
$793.99
|
| Rate for Payer: Coventry All Commercial |
$751.30
|
| Rate for Payer: Encore All Commercial |
$785.88
|
| Rate for Payer: Frontpath All Commercial |
$785.45
|
| Rate for Payer: Humana ChoiceCare |
$737.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$768.38
|
| Rate for Payer: PHCS All Commercial |
$640.31
|
| Rate for Payer: PHP All Commercial |
$647.48
|
| Rate for Payer: Sagamore Health Network All Products |
$659.10
|
| Rate for Payer: Signature Care EPO |
$708.61
|
| Rate for Payer: Signature Care PPO |
$751.30
|
| Rate for Payer: United Healthcare Commercial |
$672.75
|
|
|
HC X-RAY-OSSEOUS SURVEY INFANT
|
Facility
|
OP
|
$853.75
|
|
|
Service Code
|
CPT 77076
|
| Hospital Charge Code |
1616065
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$50.45 |
| Max. Negotiated Rate |
$793.99 |
| Rate for Payer: Aetna Commercial |
$720.57
|
| Rate for Payer: Aetna Medicare |
$273.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$50.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$264.66
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$490.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$533.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$50.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$314.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$300.52
|
| Rate for Payer: Cash Price |
$512.25
|
| Rate for Payer: Cash Price |
$512.25
|
| Rate for Payer: Centivo All Commercial |
$464.44
|
| Rate for Payer: Cigna All Commercial |
$736.79
|
| Rate for Payer: CORVEL All Commercial |
$793.99
|
| Rate for Payer: Coventry All Commercial |
$751.30
|
| Rate for Payer: Encore All Commercial |
$785.88
|
| Rate for Payer: Frontpath All Commercial |
$785.45
|
| Rate for Payer: Humana ChoiceCare |
$737.38
|
| Rate for Payer: Humana Medicare |
$273.20
|
| Rate for Payer: Lucent All Commercial |
$464.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$768.38
|
| Rate for Payer: Managed Health Services Medicaid |
$50.45
|
| Rate for Payer: MDWise Medicaid |
$50.45
|
| Rate for Payer: PHCS All Commercial |
$640.31
|
| Rate for Payer: PHP All Commercial |
$647.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$332.96
|
| Rate for Payer: Sagamore Health Network All Products |
$659.10
|
| Rate for Payer: Signature Care EPO |
$708.61
|
| Rate for Payer: Signature Care PPO |
$751.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$725.69
|
| Rate for Payer: United Healthcare Commercial |
$672.75
|
| Rate for Payer: United Healthcare Medicare |
$273.20
|
|
|
HC X-RAY-OSSEOUS SURVEY LIMITED
|
Facility
|
OP
|
$993.88
|
|
|
Service Code
|
CPT 77074
|
| Hospital Charge Code |
1616060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$33.85 |
| Max. Negotiated Rate |
$924.31 |
| Rate for Payer: Aetna Commercial |
$838.83
|
| Rate for Payer: Aetna Medicare |
$318.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$33.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$308.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$570.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$621.27
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$33.85
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$365.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$349.85
|
| Rate for Payer: Cash Price |
$596.33
|
| Rate for Payer: Cash Price |
$596.33
|
| Rate for Payer: Centivo All Commercial |
$540.67
|
| Rate for Payer: Cigna All Commercial |
$857.72
|
| Rate for Payer: CORVEL All Commercial |
$924.31
|
| Rate for Payer: Coventry All Commercial |
$874.61
|
| Rate for Payer: Encore All Commercial |
$914.87
|
| Rate for Payer: Frontpath All Commercial |
$914.37
|
| Rate for Payer: Humana ChoiceCare |
$858.41
|
| Rate for Payer: Humana Medicare |
$318.04
|
| Rate for Payer: Lucent All Commercial |
$540.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$894.49
|
| Rate for Payer: Managed Health Services Medicaid |
$33.85
|
| Rate for Payer: MDWise Medicaid |
$33.85
|
| Rate for Payer: PHCS All Commercial |
$745.41
|
| Rate for Payer: PHP All Commercial |
$753.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$387.61
|
| Rate for Payer: Sagamore Health Network All Products |
$767.28
|
| Rate for Payer: Signature Care EPO |
$824.92
|
| Rate for Payer: Signature Care PPO |
$874.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$844.80
|
| Rate for Payer: United Healthcare Commercial |
$783.18
|
| Rate for Payer: United Healthcare Medicare |
$318.04
|
|
|
HC X-RAY-OSSEOUS SURVEY LIMITED
|
Facility
|
IP
|
$993.88
|
|
|
Service Code
|
CPT 77074
|
| Hospital Charge Code |
1616060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$745.41 |
| Max. Negotiated Rate |
$924.31 |
| Rate for Payer: Aetna Commercial |
$858.71
|
| Rate for Payer: Cash Price |
$596.33
|
| Rate for Payer: Cigna All Commercial |
$857.72
|
| Rate for Payer: CORVEL All Commercial |
$924.31
|
| Rate for Payer: Coventry All Commercial |
$874.61
|
| Rate for Payer: Encore All Commercial |
$914.87
|
| Rate for Payer: Frontpath All Commercial |
$914.37
|
| Rate for Payer: Humana ChoiceCare |
$858.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$894.49
|
| Rate for Payer: PHCS All Commercial |
$745.41
|
| Rate for Payer: PHP All Commercial |
$753.76
|
| Rate for Payer: Sagamore Health Network All Products |
$767.28
|
| Rate for Payer: Signature Care EPO |
$824.92
|
| Rate for Payer: Signature Care PPO |
$874.61
|
| Rate for Payer: United Healthcare Commercial |
$783.18
|
|
|
HC X-RAY-PARANASAL SINUSES MIN 3 VIEWS
|
Facility
|
OP
|
$661.78
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
1610220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$18.50 |
| Max. Negotiated Rate |
$615.46 |
| Rate for Payer: Aetna Commercial |
$558.54
|
| Rate for Payer: Aetna Medicare |
$211.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$18.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$205.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$380.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$413.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$18.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$243.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$232.95
|
| Rate for Payer: Cash Price |
$397.07
|
| Rate for Payer: Cash Price |
$397.07
|
| Rate for Payer: Centivo All Commercial |
$360.01
|
| Rate for Payer: Cigna All Commercial |
$571.12
|
| Rate for Payer: CORVEL All Commercial |
$615.46
|
| Rate for Payer: Coventry All Commercial |
$582.37
|
| Rate for Payer: Encore All Commercial |
$609.17
|
| Rate for Payer: Frontpath All Commercial |
$608.84
|
| Rate for Payer: Humana ChoiceCare |
$571.58
|
| Rate for Payer: Humana Medicare |
$211.77
|
| Rate for Payer: Lucent All Commercial |
$360.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$595.60
|
| Rate for Payer: Managed Health Services Medicaid |
$18.50
|
| Rate for Payer: MDWise Medicaid |
$18.50
|
| Rate for Payer: PHCS All Commercial |
$496.33
|
| Rate for Payer: PHP All Commercial |
$501.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$258.09
|
| Rate for Payer: Sagamore Health Network All Products |
$510.89
|
| Rate for Payer: Signature Care EPO |
$549.28
|
| Rate for Payer: Signature Care PPO |
$582.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$562.51
|
| Rate for Payer: United Healthcare Commercial |
$521.48
|
| Rate for Payer: United Healthcare Medicare |
$211.77
|
|
|
HC X-RAY-PARANASAL SINUSES MIN 3 VIEWS
|
Facility
|
IP
|
$661.78
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
1610220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$496.33 |
| Max. Negotiated Rate |
$615.46 |
| Rate for Payer: Aetna Commercial |
$571.78
|
| Rate for Payer: Cash Price |
$397.07
|
| Rate for Payer: Cigna All Commercial |
$571.12
|
| Rate for Payer: CORVEL All Commercial |
$615.46
|
| Rate for Payer: Coventry All Commercial |
$582.37
|
| Rate for Payer: Encore All Commercial |
$609.17
|
| Rate for Payer: Frontpath All Commercial |
$608.84
|
| Rate for Payer: Humana ChoiceCare |
$571.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$595.60
|
| Rate for Payer: PHCS All Commercial |
$496.33
|
| Rate for Payer: PHP All Commercial |
$501.89
|
| Rate for Payer: Sagamore Health Network All Products |
$510.89
|
| Rate for Payer: Signature Care EPO |
$549.28
|
| Rate for Payer: Signature Care PPO |
$582.37
|
| Rate for Payer: United Healthcare Commercial |
$521.48
|
|
|
HC X-RAY-PELVIS 1 OR 2 VIEWS
|
Facility
|
IP
|
$507.77
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
1612170
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$380.83 |
| Max. Negotiated Rate |
$472.23 |
| Rate for Payer: Aetna Commercial |
$438.71
|
| Rate for Payer: Cash Price |
$304.66
|
| Rate for Payer: Cigna All Commercial |
$438.21
|
| Rate for Payer: CORVEL All Commercial |
$472.23
|
| Rate for Payer: Coventry All Commercial |
$446.84
|
| Rate for Payer: Encore All Commercial |
$467.40
|
| Rate for Payer: Frontpath All Commercial |
$467.15
|
| Rate for Payer: Humana ChoiceCare |
$438.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$456.99
|
| Rate for Payer: PHCS All Commercial |
$380.83
|
| Rate for Payer: PHP All Commercial |
$385.09
|
| Rate for Payer: Sagamore Health Network All Products |
$392.00
|
| Rate for Payer: Signature Care EPO |
$421.45
|
| Rate for Payer: Signature Care PPO |
$446.84
|
| Rate for Payer: United Healthcare Commercial |
$400.12
|
|
|
HC X-RAY-PELVIS 1 OR 2 VIEWS
|
Facility
|
OP
|
$507.77
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
1612170
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$13.79 |
| Max. Negotiated Rate |
$472.23 |
| Rate for Payer: Aetna Commercial |
$428.56
|
| Rate for Payer: Aetna Medicare |
$162.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$13.79
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$157.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$291.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$317.41
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$13.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$186.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$178.74
|
| Rate for Payer: Cash Price |
$304.66
|
| Rate for Payer: Cash Price |
$304.66
|
| Rate for Payer: Centivo All Commercial |
$276.23
|
| Rate for Payer: Cigna All Commercial |
$438.21
|
| Rate for Payer: CORVEL All Commercial |
$472.23
|
| Rate for Payer: Coventry All Commercial |
$446.84
|
| Rate for Payer: Encore All Commercial |
$467.40
|
| Rate for Payer: Frontpath All Commercial |
$467.15
|
| Rate for Payer: Humana ChoiceCare |
$438.56
|
| Rate for Payer: Humana Medicare |
$162.49
|
| Rate for Payer: Lucent All Commercial |
$276.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$456.99
|
| Rate for Payer: Managed Health Services Medicaid |
$13.79
|
| Rate for Payer: MDWise Medicaid |
$13.79
|
| Rate for Payer: PHCS All Commercial |
$380.83
|
| Rate for Payer: PHP All Commercial |
$385.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$198.03
|
| Rate for Payer: Sagamore Health Network All Products |
$392.00
|
| Rate for Payer: Signature Care EPO |
$421.45
|
| Rate for Payer: Signature Care PPO |
$446.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$431.60
|
| Rate for Payer: United Healthcare Commercial |
$400.12
|
| Rate for Payer: United Healthcare Medicare |
$162.49
|
|
|
HC X-RAY-PELVIS MIN 3 VIEWS
|
Facility
|
OP
|
$607.43
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
1612190
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$22.21 |
| Max. Negotiated Rate |
$564.91 |
| Rate for Payer: Aetna Commercial |
$512.67
|
| Rate for Payer: Aetna Medicare |
$194.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$22.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$188.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$348.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$379.70
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$22.21
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$223.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$213.82
|
| Rate for Payer: Cash Price |
$364.46
|
| Rate for Payer: Cash Price |
$364.46
|
| Rate for Payer: Centivo All Commercial |
$330.44
|
| Rate for Payer: Cigna All Commercial |
$524.21
|
| Rate for Payer: CORVEL All Commercial |
$564.91
|
| Rate for Payer: Coventry All Commercial |
$534.54
|
| Rate for Payer: Encore All Commercial |
$559.14
|
| Rate for Payer: Frontpath All Commercial |
$558.84
|
| Rate for Payer: Humana ChoiceCare |
$524.64
|
| Rate for Payer: Humana Medicare |
$194.38
|
| Rate for Payer: Lucent All Commercial |
$330.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$546.69
|
| Rate for Payer: Managed Health Services Medicaid |
$22.21
|
| Rate for Payer: MDWise Medicaid |
$22.21
|
| Rate for Payer: PHCS All Commercial |
$455.57
|
| Rate for Payer: PHP All Commercial |
$460.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$236.90
|
| Rate for Payer: Sagamore Health Network All Products |
$468.94
|
| Rate for Payer: Signature Care EPO |
$504.17
|
| Rate for Payer: Signature Care PPO |
$534.54
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$516.32
|
| Rate for Payer: United Healthcare Commercial |
$478.65
|
| Rate for Payer: United Healthcare Medicare |
$194.38
|
|
|
HC X-RAY-PELVIS MIN 3 VIEWS
|
Facility
|
IP
|
$607.43
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
1612190
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$455.57 |
| Max. Negotiated Rate |
$564.91 |
| Rate for Payer: Aetna Commercial |
$524.82
|
| Rate for Payer: Cash Price |
$364.46
|
| Rate for Payer: Cigna All Commercial |
$524.21
|
| Rate for Payer: CORVEL All Commercial |
$564.91
|
| Rate for Payer: Coventry All Commercial |
$534.54
|
| Rate for Payer: Encore All Commercial |
$559.14
|
| Rate for Payer: Frontpath All Commercial |
$558.84
|
| Rate for Payer: Humana ChoiceCare |
$524.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$546.69
|
| Rate for Payer: PHCS All Commercial |
$455.57
|
| Rate for Payer: PHP All Commercial |
$460.67
|
| Rate for Payer: Sagamore Health Network All Products |
$468.94
|
| Rate for Payer: Signature Care EPO |
$504.17
|
| Rate for Payer: Signature Care PPO |
$534.54
|
| Rate for Payer: United Healthcare Commercial |
$478.65
|
|
|
HC X-RAY-REHAB ESOPHOGRAM
|
Facility
|
OP
|
$812.55
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
1614221
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$45.99 |
| Max. Negotiated Rate |
$755.67 |
| Rate for Payer: Aetna Commercial |
$685.79
|
| Rate for Payer: Aetna Medicare |
$260.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$45.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$251.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$466.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$507.93
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$45.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$299.02
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$286.02
|
| Rate for Payer: Cash Price |
$487.53
|
| Rate for Payer: Cash Price |
$487.53
|
| Rate for Payer: Centivo All Commercial |
$442.03
|
| Rate for Payer: Cigna All Commercial |
$701.23
|
| Rate for Payer: CORVEL All Commercial |
$755.67
|
| Rate for Payer: Coventry All Commercial |
$715.04
|
| Rate for Payer: Encore All Commercial |
$747.95
|
| Rate for Payer: Frontpath All Commercial |
$747.55
|
| Rate for Payer: Humana ChoiceCare |
$701.80
|
| Rate for Payer: Humana Medicare |
$260.02
|
| Rate for Payer: Lucent All Commercial |
$442.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$731.29
|
| Rate for Payer: Managed Health Services Medicaid |
$45.99
|
| Rate for Payer: MDWise Medicaid |
$45.99
|
| Rate for Payer: PHCS All Commercial |
$609.41
|
| Rate for Payer: PHP All Commercial |
$616.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$316.89
|
| Rate for Payer: Sagamore Health Network All Products |
$627.29
|
| Rate for Payer: Signature Care EPO |
$674.42
|
| Rate for Payer: Signature Care PPO |
$715.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$690.67
|
| Rate for Payer: United Healthcare Commercial |
$640.29
|
| Rate for Payer: United Healthcare Medicare |
$260.02
|
|
|
HC X-RAY-REHAB ESOPHOGRAM
|
Facility
|
IP
|
$812.55
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
1614221
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$609.41 |
| Max. Negotiated Rate |
$755.67 |
| Rate for Payer: Aetna Commercial |
$702.04
|
| Rate for Payer: Cash Price |
$487.53
|
| Rate for Payer: Cigna All Commercial |
$701.23
|
| Rate for Payer: CORVEL All Commercial |
$755.67
|
| Rate for Payer: Coventry All Commercial |
$715.04
|
| Rate for Payer: Encore All Commercial |
$747.95
|
| Rate for Payer: Frontpath All Commercial |
$747.55
|
| Rate for Payer: Humana ChoiceCare |
$701.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$731.29
|
| Rate for Payer: PHCS All Commercial |
$609.41
|
| Rate for Payer: PHP All Commercial |
$616.24
|
| Rate for Payer: Sagamore Health Network All Products |
$627.29
|
| Rate for Payer: Signature Care EPO |
$674.42
|
| Rate for Payer: Signature Care PPO |
$715.04
|
| Rate for Payer: United Healthcare Commercial |
$640.29
|
|
|
HC X-RAY-RIBS 2 VIEWS UNILATERAL LT
|
Facility
|
IP
|
$442.43
|
|
|
Service Code
|
CPT 71100 LT
|
| Hospital Charge Code |
1611100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$331.82 |
| Max. Negotiated Rate |
$411.46 |
| Rate for Payer: Aetna Commercial |
$382.26
|
| Rate for Payer: Cash Price |
$265.46
|
| Rate for Payer: Cigna All Commercial |
$381.82
|
| Rate for Payer: CORVEL All Commercial |
$411.46
|
| Rate for Payer: Coventry All Commercial |
$389.34
|
| Rate for Payer: Encore All Commercial |
$407.26
|
| Rate for Payer: Frontpath All Commercial |
$407.04
|
| Rate for Payer: Humana ChoiceCare |
$382.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$398.19
|
| Rate for Payer: PHCS All Commercial |
$331.82
|
| Rate for Payer: PHP All Commercial |
$335.54
|
| Rate for Payer: Sagamore Health Network All Products |
$341.56
|
| Rate for Payer: Signature Care EPO |
$367.22
|
| Rate for Payer: Signature Care PPO |
$389.34
|
| Rate for Payer: United Healthcare Commercial |
$348.63
|
|
|
HC X-RAY-RIBS 2 VIEWS UNILATERAL LT
|
Facility
|
OP
|
$442.43
|
|
|
Service Code
|
CPT 71100 LT
|
| Hospital Charge Code |
1611100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.28 |
| Max. Negotiated Rate |
$411.46 |
| Rate for Payer: Aetna Commercial |
$373.41
|
| Rate for Payer: Aetna Medicare |
$141.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$15.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$137.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$254.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$276.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$15.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$162.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$155.74
|
| Rate for Payer: Cash Price |
$265.46
|
| Rate for Payer: Cash Price |
$265.46
|
| Rate for Payer: Centivo All Commercial |
$240.68
|
| Rate for Payer: Cigna All Commercial |
$381.82
|
| Rate for Payer: CORVEL All Commercial |
$411.46
|
| Rate for Payer: Coventry All Commercial |
$389.34
|
| Rate for Payer: Encore All Commercial |
$407.26
|
| Rate for Payer: Frontpath All Commercial |
$407.04
|
| Rate for Payer: Humana ChoiceCare |
$382.13
|
| Rate for Payer: Humana Medicare |
$141.58
|
| Rate for Payer: Lucent All Commercial |
$240.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$398.19
|
| Rate for Payer: Managed Health Services Medicaid |
$15.28
|
| Rate for Payer: MDWise Medicaid |
$15.28
|
| Rate for Payer: PHCS All Commercial |
$331.82
|
| Rate for Payer: PHP All Commercial |
$335.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$172.55
|
| Rate for Payer: Sagamore Health Network All Products |
$341.56
|
| Rate for Payer: Signature Care EPO |
$367.22
|
| Rate for Payer: Signature Care PPO |
$389.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$376.07
|
| Rate for Payer: United Healthcare Commercial |
$348.63
|
| Rate for Payer: United Healthcare Medicare |
$141.58
|
|
|
HC X-RAY-RIBS 2 VIEWS UNILATERAL RT
|
Facility
|
OP
|
$442.43
|
|
|
Service Code
|
CPT 71100 RT
|
| Hospital Charge Code |
11611100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$15.28 |
| Max. Negotiated Rate |
$411.46 |
| Rate for Payer: Aetna Commercial |
$373.41
|
| Rate for Payer: Aetna Medicare |
$141.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$15.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$137.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$254.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$276.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$15.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$162.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$155.74
|
| Rate for Payer: Cash Price |
$265.46
|
| Rate for Payer: Cash Price |
$265.46
|
| Rate for Payer: Centivo All Commercial |
$240.68
|
| Rate for Payer: Cigna All Commercial |
$381.82
|
| Rate for Payer: CORVEL All Commercial |
$411.46
|
| Rate for Payer: Coventry All Commercial |
$389.34
|
| Rate for Payer: Encore All Commercial |
$407.26
|
| Rate for Payer: Frontpath All Commercial |
$407.04
|
| Rate for Payer: Humana ChoiceCare |
$382.13
|
| Rate for Payer: Humana Medicare |
$141.58
|
| Rate for Payer: Lucent All Commercial |
$240.68
|
| Rate for Payer: Lutheran Preferred All Commercial |
$398.19
|
| Rate for Payer: Managed Health Services Medicaid |
$15.28
|
| Rate for Payer: MDWise Medicaid |
$15.28
|
| Rate for Payer: PHCS All Commercial |
$331.82
|
| Rate for Payer: PHP All Commercial |
$335.54
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$172.55
|
| Rate for Payer: Sagamore Health Network All Products |
$341.56
|
| Rate for Payer: Signature Care EPO |
$367.22
|
| Rate for Payer: Signature Care PPO |
$389.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$376.07
|
| Rate for Payer: United Healthcare Commercial |
$348.63
|
| Rate for Payer: United Healthcare Medicare |
$141.58
|
|
|
HC X-RAY-RIBS 2 VIEWS UNILATERAL RT
|
Facility
|
IP
|
$442.43
|
|
|
Service Code
|
CPT 71100 RT
|
| Hospital Charge Code |
11611100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$331.82 |
| Max. Negotiated Rate |
$411.46 |
| Rate for Payer: Aetna Commercial |
$382.26
|
| Rate for Payer: Cash Price |
$265.46
|
| Rate for Payer: Cigna All Commercial |
$381.82
|
| Rate for Payer: CORVEL All Commercial |
$411.46
|
| Rate for Payer: Coventry All Commercial |
$389.34
|
| Rate for Payer: Encore All Commercial |
$407.26
|
| Rate for Payer: Frontpath All Commercial |
$407.04
|
| Rate for Payer: Humana ChoiceCare |
$382.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$398.19
|
| Rate for Payer: PHCS All Commercial |
$331.82
|
| Rate for Payer: PHP All Commercial |
$335.54
|
| Rate for Payer: Sagamore Health Network All Products |
$341.56
|
| Rate for Payer: Signature Care EPO |
$367.22
|
| Rate for Payer: Signature Care PPO |
$389.34
|
| Rate for Payer: United Healthcare Commercial |
$348.63
|
|
|
HC X-RAY-RIBS 3 VIEWS BILATERAL
|
Facility
|
OP
|
$499.56
|
|
|
Service Code
|
CPT 71110
|
| Hospital Charge Code |
1611110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$19.24 |
| Max. Negotiated Rate |
$464.59 |
| Rate for Payer: Aetna Commercial |
$421.63
|
| Rate for Payer: Aetna Medicare |
$159.86
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$154.86
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$286.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$312.27
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$19.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$183.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$175.85
|
| Rate for Payer: Cash Price |
$299.74
|
| Rate for Payer: Cash Price |
$299.74
|
| Rate for Payer: Centivo All Commercial |
$271.76
|
| Rate for Payer: Cigna All Commercial |
$431.12
|
| Rate for Payer: CORVEL All Commercial |
$464.59
|
| Rate for Payer: Coventry All Commercial |
$439.61
|
| Rate for Payer: Encore All Commercial |
$459.84
|
| Rate for Payer: Frontpath All Commercial |
$459.60
|
| Rate for Payer: Humana ChoiceCare |
$431.47
|
| Rate for Payer: Humana Medicare |
$159.86
|
| Rate for Payer: Lucent All Commercial |
$271.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$449.60
|
| Rate for Payer: Managed Health Services Medicaid |
$19.24
|
| Rate for Payer: MDWise Medicaid |
$19.24
|
| Rate for Payer: PHCS All Commercial |
$374.67
|
| Rate for Payer: PHP All Commercial |
$378.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$194.83
|
| Rate for Payer: Sagamore Health Network All Products |
$385.66
|
| Rate for Payer: Signature Care EPO |
$414.63
|
| Rate for Payer: Signature Care PPO |
$439.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$424.63
|
| Rate for Payer: United Healthcare Commercial |
$393.65
|
| Rate for Payer: United Healthcare Medicare |
$159.86
|
|
|
HC X-RAY-RIBS 3 VIEWS BILATERAL
|
Facility
|
IP
|
$499.56
|
|
|
Service Code
|
CPT 71110
|
| Hospital Charge Code |
1611110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$374.67 |
| Max. Negotiated Rate |
$464.59 |
| Rate for Payer: Aetna Commercial |
$431.62
|
| Rate for Payer: Cash Price |
$299.74
|
| Rate for Payer: Cigna All Commercial |
$431.12
|
| Rate for Payer: CORVEL All Commercial |
$464.59
|
| Rate for Payer: Coventry All Commercial |
$439.61
|
| Rate for Payer: Encore All Commercial |
$459.84
|
| Rate for Payer: Frontpath All Commercial |
$459.60
|
| Rate for Payer: Humana ChoiceCare |
$431.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$449.60
|
| Rate for Payer: PHCS All Commercial |
$374.67
|
| Rate for Payer: PHP All Commercial |
$378.87
|
| Rate for Payer: Sagamore Health Network All Products |
$385.66
|
| Rate for Payer: Signature Care EPO |
$414.63
|
| Rate for Payer: Signature Care PPO |
$439.61
|
| Rate for Payer: United Healthcare Commercial |
$393.65
|
|
|
HC X-RAY-RIBS BILATERL W/PA CHEST 4+ VIEWS
|
Facility
|
OP
|
$685.28
|
|
|
Service Code
|
CPT 71111
|
| Hospital Charge Code |
1611111
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$26.42 |
| Max. Negotiated Rate |
$637.31 |
| Rate for Payer: Aetna Commercial |
$578.38
|
| Rate for Payer: Aetna Medicare |
$219.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$26.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$212.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$393.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$428.37
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$26.42
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$252.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$241.22
|
| Rate for Payer: Cash Price |
$411.17
|
| Rate for Payer: Cash Price |
$411.17
|
| Rate for Payer: Centivo All Commercial |
$372.79
|
| Rate for Payer: Cigna All Commercial |
$591.40
|
| Rate for Payer: CORVEL All Commercial |
$637.31
|
| Rate for Payer: Coventry All Commercial |
$603.05
|
| Rate for Payer: Encore All Commercial |
$630.80
|
| Rate for Payer: Frontpath All Commercial |
$630.46
|
| Rate for Payer: Humana ChoiceCare |
$591.88
|
| Rate for Payer: Humana Medicare |
$219.29
|
| Rate for Payer: Lucent All Commercial |
$372.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$616.75
|
| Rate for Payer: Managed Health Services Medicaid |
$26.42
|
| Rate for Payer: MDWise Medicaid |
$26.42
|
| Rate for Payer: PHCS All Commercial |
$513.96
|
| Rate for Payer: PHP All Commercial |
$519.72
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$267.26
|
| Rate for Payer: Sagamore Health Network All Products |
$529.04
|
| Rate for Payer: Signature Care EPO |
$568.78
|
| Rate for Payer: Signature Care PPO |
$603.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$582.49
|
| Rate for Payer: United Healthcare Commercial |
$540.00
|
| Rate for Payer: United Healthcare Medicare |
$219.29
|
|
|
HC X-RAY-RIBS BILATERL W/PA CHEST 4+ VIEWS
|
Facility
|
IP
|
$685.28
|
|
|
Service Code
|
CPT 71111
|
| Hospital Charge Code |
1611111
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$513.96 |
| Max. Negotiated Rate |
$637.31 |
| Rate for Payer: Aetna Commercial |
$592.08
|
| Rate for Payer: Cash Price |
$411.17
|
| Rate for Payer: Cigna All Commercial |
$591.40
|
| Rate for Payer: CORVEL All Commercial |
$637.31
|
| Rate for Payer: Coventry All Commercial |
$603.05
|
| Rate for Payer: Encore All Commercial |
$630.80
|
| Rate for Payer: Frontpath All Commercial |
$630.46
|
| Rate for Payer: Humana ChoiceCare |
$591.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$616.75
|
| Rate for Payer: PHCS All Commercial |
$513.96
|
| Rate for Payer: PHP All Commercial |
$519.72
|
| Rate for Payer: Sagamore Health Network All Products |
$529.04
|
| Rate for Payer: Signature Care EPO |
$568.78
|
| Rate for Payer: Signature Care PPO |
$603.05
|
| Rate for Payer: United Healthcare Commercial |
$540.00
|
|
|
HC X-RAY-RIBS UNILAT W/PA CHEST L 3+ VIEWS
|
Facility
|
IP
|
$743.03
|
|
|
Service Code
|
CPT 71101 LT
|
| Hospital Charge Code |
1611101
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$557.27 |
| Max. Negotiated Rate |
$691.02 |
| Rate for Payer: Aetna Commercial |
$641.98
|
| Rate for Payer: Cash Price |
$445.82
|
| Rate for Payer: Cigna All Commercial |
$641.23
|
| Rate for Payer: CORVEL All Commercial |
$691.02
|
| Rate for Payer: Coventry All Commercial |
$653.87
|
| Rate for Payer: Encore All Commercial |
$683.96
|
| Rate for Payer: Frontpath All Commercial |
$683.59
|
| Rate for Payer: Humana ChoiceCare |
$641.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$668.73
|
| Rate for Payer: PHCS All Commercial |
$557.27
|
| Rate for Payer: PHP All Commercial |
$563.51
|
| Rate for Payer: Sagamore Health Network All Products |
$573.62
|
| Rate for Payer: Signature Care EPO |
$616.71
|
| Rate for Payer: Signature Care PPO |
$653.87
|
| Rate for Payer: United Healthcare Commercial |
$585.51
|
|
|
HC X-RAY-RIBS UNILAT W/PA CHEST L 3+ VIEWS
|
Facility
|
OP
|
$743.03
|
|
|
Service Code
|
CPT 71101 LT
|
| Hospital Charge Code |
1611101
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$18.74 |
| Max. Negotiated Rate |
$691.02 |
| Rate for Payer: Aetna Commercial |
$627.12
|
| Rate for Payer: Aetna Medicare |
$237.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$18.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$230.34
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$426.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$464.47
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$18.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$273.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$261.55
|
| Rate for Payer: Cash Price |
$445.82
|
| Rate for Payer: Cash Price |
$445.82
|
| Rate for Payer: Centivo All Commercial |
$404.21
|
| Rate for Payer: Cigna All Commercial |
$641.23
|
| Rate for Payer: CORVEL All Commercial |
$691.02
|
| Rate for Payer: Coventry All Commercial |
$653.87
|
| Rate for Payer: Encore All Commercial |
$683.96
|
| Rate for Payer: Frontpath All Commercial |
$683.59
|
| Rate for Payer: Humana ChoiceCare |
$641.76
|
| Rate for Payer: Humana Medicare |
$237.77
|
| Rate for Payer: Lucent All Commercial |
$404.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$668.73
|
| Rate for Payer: Managed Health Services Medicaid |
$18.74
|
| Rate for Payer: MDWise Medicaid |
$18.74
|
| Rate for Payer: PHCS All Commercial |
$557.27
|
| Rate for Payer: PHP All Commercial |
$563.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$289.78
|
| Rate for Payer: Sagamore Health Network All Products |
$573.62
|
| Rate for Payer: Signature Care EPO |
$616.71
|
| Rate for Payer: Signature Care PPO |
$653.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$631.58
|
| Rate for Payer: United Healthcare Commercial |
$585.51
|
| Rate for Payer: United Healthcare Medicare |
$237.77
|
|
|
HC X-RAY-RIBS UNILAT W/PA CHEST R 3+ VIEWS
|
Facility
|
IP
|
$743.03
|
|
|
Service Code
|
CPT 71101 RT
|
| Hospital Charge Code |
11611101
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$557.27 |
| Max. Negotiated Rate |
$691.02 |
| Rate for Payer: Aetna Commercial |
$641.98
|
| Rate for Payer: Cash Price |
$445.82
|
| Rate for Payer: Cigna All Commercial |
$641.23
|
| Rate for Payer: CORVEL All Commercial |
$691.02
|
| Rate for Payer: Coventry All Commercial |
$653.87
|
| Rate for Payer: Encore All Commercial |
$683.96
|
| Rate for Payer: Frontpath All Commercial |
$683.59
|
| Rate for Payer: Humana ChoiceCare |
$641.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$668.73
|
| Rate for Payer: PHCS All Commercial |
$557.27
|
| Rate for Payer: PHP All Commercial |
$563.51
|
| Rate for Payer: Sagamore Health Network All Products |
$573.62
|
| Rate for Payer: Signature Care EPO |
$616.71
|
| Rate for Payer: Signature Care PPO |
$653.87
|
| Rate for Payer: United Healthcare Commercial |
$585.51
|
|
