|
HC VISCOSITY
|
Facility
|
IP
|
$69.43
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
63044081
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$52.07 |
| Max. Negotiated Rate |
$64.57 |
| Rate for Payer: Aetna Commercial |
$59.99
|
| Rate for Payer: Cash Price |
$43.05
|
| Rate for Payer: Cigna All Commercial |
$59.92
|
| Rate for Payer: CORVEL All Commercial |
$64.57
|
| Rate for Payer: Coventry All Commercial |
$61.10
|
| Rate for Payer: Encore All Commercial |
$63.91
|
| Rate for Payer: Frontpath All Commercial |
$63.88
|
| Rate for Payer: Humana ChoiceCare |
$59.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$62.49
|
| Rate for Payer: PHCS All Commercial |
$52.07
|
| Rate for Payer: PHP All Commercial |
$52.66
|
| Rate for Payer: Sagamore Health Network All Products |
$53.60
|
| Rate for Payer: Signature Care EPO |
$57.63
|
| Rate for Payer: Signature Care PPO |
$61.10
|
| Rate for Payer: United Healthcare Commercial |
$54.71
|
|
|
HC VISCOSITY
|
Facility
|
OP
|
$103.02
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
63001285
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.67 |
| Max. Negotiated Rate |
$95.81 |
| Rate for Payer: Aetna Commercial |
$86.95
|
| Rate for Payer: Aetna Medicare |
$34.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$59.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$64.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$11.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.40
|
| Rate for Payer: Cash Price |
$63.87
|
| Rate for Payer: Cash Price |
$63.87
|
| Rate for Payer: Centivo All Commercial |
$52.54
|
| Rate for Payer: Cigna All Commercial |
$88.91
|
| Rate for Payer: CORVEL All Commercial |
$95.81
|
| Rate for Payer: Coventry All Commercial |
$90.66
|
| Rate for Payer: Encore All Commercial |
$94.83
|
| Rate for Payer: Frontpath All Commercial |
$94.78
|
| Rate for Payer: Humana ChoiceCare |
$88.98
|
| Rate for Payer: Humana Medicare |
$52.54
|
| Rate for Payer: Lucent All Commercial |
$52.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$92.72
|
| Rate for Payer: Managed Health Services Medicaid |
$11.67
|
| Rate for Payer: MDWise Medicaid |
$11.67
|
| Rate for Payer: PHCS All Commercial |
$77.26
|
| Rate for Payer: PHP All Commercial |
$78.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.18
|
| Rate for Payer: Sagamore Health Network All Products |
$79.53
|
| Rate for Payer: Signature Care EPO |
$85.51
|
| Rate for Payer: Signature Care PPO |
$90.66
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$87.57
|
| Rate for Payer: United Healthcare Commercial |
$81.18
|
| Rate for Payer: United Healthcare Medicare |
$34.00
|
|
|
HC VISCOSITY
|
Facility
|
IP
|
$103.02
|
|
|
Service Code
|
CPT 85810
|
| Hospital Charge Code |
63001285
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$77.26 |
| Max. Negotiated Rate |
$95.81 |
| Rate for Payer: Aetna Commercial |
$89.01
|
| Rate for Payer: Cash Price |
$63.87
|
| Rate for Payer: Cigna All Commercial |
$88.91
|
| Rate for Payer: CORVEL All Commercial |
$95.81
|
| Rate for Payer: Coventry All Commercial |
$90.66
|
| Rate for Payer: Encore All Commercial |
$94.83
|
| Rate for Payer: Frontpath All Commercial |
$94.78
|
| Rate for Payer: Humana ChoiceCare |
$88.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$92.72
|
| Rate for Payer: PHCS All Commercial |
$77.26
|
| Rate for Payer: PHP All Commercial |
$78.13
|
| Rate for Payer: Sagamore Health Network All Products |
$79.53
|
| Rate for Payer: Signature Care EPO |
$85.51
|
| Rate for Payer: Signature Care PPO |
$90.66
|
| Rate for Payer: United Healthcare Commercial |
$81.18
|
|
|
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 |
$744.09
|
| 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 |
$1,080.14
|
| 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 VISTASEAL FIBRIN SEALANT 4ML
|
Facility
|
OP
|
$1,200.15
|
|
| Hospital Charge Code |
41607719
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$121.68 |
| Max. Negotiated Rate |
$1,116.14 |
| Rate for Payer: Aetna Commercial |
$1,012.93
|
| Rate for Payer: Aetna Medicare |
$396.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$396.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$689.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$750.21
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$455.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$435.65
|
| Rate for Payer: Cash Price |
$744.09
|
| Rate for Payer: Cash Price |
$744.09
|
| Rate for Payer: Centivo All Commercial |
$612.08
|
| 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 |
$612.08
|
| Rate for Payer: Lucent All Commercial |
$612.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,080.14
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| 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 |
$396.05
|
|
|
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 |
$50.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$50.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$87.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$95.39
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$11.61
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$57.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$55.39
|
| Rate for Payer: Cash Price |
$94.61
|
| Rate for Payer: Cash Price |
$94.61
|
| Rate for Payer: Centivo All Commercial |
$77.82
|
| 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 |
$77.82
|
| Rate for Payer: Lucent All Commercial |
$77.82
|
| 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 |
$115.73
|
| 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 |
$50.36
|
|
|
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 |
$94.61
|
| 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 |
$115.73
|
| 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 |
$128.69
|
| 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 |
$68.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$68.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$95.40
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$95.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$15.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$78.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$75.35
|
| Rate for Payer: Cash Price |
$128.69
|
| Rate for Payer: Cash Price |
$128.69
|
| Rate for Payer: Centivo All Commercial |
$105.86
|
| 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 |
$105.86
|
| Rate for Payer: Lucent All Commercial |
$105.86
|
| 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 |
$68.50
|
|
|
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 |
$115.17
|
| 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 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 |
$61.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$61.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$106.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$116.11
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$21.23
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$70.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$67.43
|
| Rate for Payer: Cash Price |
$115.17
|
| Rate for Payer: Cash Price |
$115.17
|
| Rate for Payer: Centivo All Commercial |
$94.73
|
| 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 |
$94.73
|
| Rate for Payer: Lucent All Commercial |
$94.73
|
| 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 |
$61.30
|
|
|
HC VITAMIN B2, WHOLE BLOOD
|
Facility
|
IP
|
$204.33
|
|
|
Service Code
|
CPT 84252
|
| Hospital Charge Code |
63044082
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$153.24 |
| Max. Negotiated Rate |
$190.02 |
| Rate for Payer: Aetna Commercial |
$176.54
|
| Rate for Payer: Cash Price |
$126.68
|
| Rate for Payer: Cigna All Commercial |
$176.33
|
| Rate for Payer: CORVEL All Commercial |
$190.02
|
| Rate for Payer: Coventry All Commercial |
$179.81
|
| Rate for Payer: Encore All Commercial |
$188.08
|
| Rate for Payer: Frontpath All Commercial |
$187.98
|
| Rate for Payer: Humana ChoiceCare |
$176.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$183.89
|
| Rate for Payer: PHCS All Commercial |
$153.24
|
| 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 |
$190.02 |
| Rate for Payer: Aetna Commercial |
$172.45
|
| Rate for Payer: Aetna Medicare |
$67.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$67.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$117.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$127.72
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$20.24
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$77.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$74.17
|
| Rate for Payer: Cash Price |
$126.68
|
| Rate for Payer: Cash Price |
$126.68
|
| Rate for Payer: Centivo All Commercial |
$104.21
|
| Rate for Payer: Cigna All Commercial |
$176.33
|
| Rate for Payer: CORVEL All Commercial |
$190.02
|
| Rate for Payer: Coventry All Commercial |
$179.81
|
| Rate for Payer: Encore All Commercial |
$188.08
|
| Rate for Payer: Frontpath All Commercial |
$187.98
|
| Rate for Payer: Humana ChoiceCare |
$176.48
|
| Rate for Payer: Humana Medicare |
$104.21
|
| Rate for Payer: Lucent All Commercial |
$104.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$183.89
|
| Rate for Payer: Managed Health Services Medicaid |
$20.24
|
| Rate for Payer: MDWise Medicaid |
$20.24
|
| Rate for Payer: PHCS All Commercial |
$153.24
|
| 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 |
$67.43
|
|
|
HC VITAMIN B5
|
Facility
|
OP
|
$419.79
|
|
|
Service Code
|
CPT 84591
|
| Hospital Charge Code |
63001716
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.79 |
| Max. Negotiated Rate |
$390.41 |
| Rate for Payer: Aetna Commercial |
$354.30
|
| Rate for Payer: Aetna Medicare |
$138.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$138.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$241.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$262.41
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$15.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$159.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$152.38
|
| Rate for Payer: Cash Price |
$260.27
|
| Rate for Payer: Cash Price |
$260.27
|
| Rate for Payer: Centivo All Commercial |
$214.09
|
| Rate for Payer: Cigna All Commercial |
$362.28
|
| Rate for Payer: CORVEL All Commercial |
$390.41
|
| 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 |
$214.09
|
| Rate for Payer: Lucent All Commercial |
$214.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$377.81
|
| Rate for Payer: Managed Health Services Medicaid |
$15.79
|
| Rate for Payer: MDWise Medicaid |
$15.79
|
| 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 |
$330.80
|
| Rate for Payer: United Healthcare Medicare |
$138.53
|
|
|
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 |
$390.41 |
| Rate for Payer: Aetna Commercial |
$362.70
|
| Rate for Payer: Cash Price |
$260.27
|
| Rate for Payer: Cigna All Commercial |
$362.28
|
| Rate for Payer: CORVEL All Commercial |
$390.41
|
| 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 |
$330.80
|
|
|
HC VITAMIN B6
|
Facility
|
IP
|
$231.81
|
|
|
Service Code
|
CPT 84207
|
| Hospital Charge Code |
63001670
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$173.85 |
| Max. Negotiated Rate |
$215.58 |
| Rate for Payer: Aetna Commercial |
$200.28
|
| Rate for Payer: Cash Price |
$143.72
|
| 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 |
$213.26
|
| Rate for Payer: Humana ChoiceCare |
$200.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$208.62
|
| Rate for Payer: PHCS All Commercial |
$173.85
|
| Rate for Payer: PHP All Commercial |
$175.80
|
| Rate for Payer: Sagamore Health Network All Products |
$178.95
|
| Rate for Payer: Signature Care EPO |
$192.40
|
| Rate for Payer: Signature Care PPO |
$203.99
|
| Rate for Payer: United Healthcare Commercial |
$182.66
|
|
|
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 |
$195.64
|
| Rate for Payer: Aetna Medicare |
$76.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$76.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$133.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$144.90
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$28.10
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$87.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$84.15
|
| Rate for Payer: Cash Price |
$143.72
|
| Rate for Payer: Cash Price |
$143.72
|
| Rate for Payer: Centivo All Commercial |
$118.22
|
| 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 |
$213.26
|
| Rate for Payer: Humana ChoiceCare |
$200.21
|
| Rate for Payer: Humana Medicare |
$118.22
|
| Rate for Payer: Lucent All Commercial |
$118.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$208.62
|
| Rate for Payer: Managed Health Services Medicaid |
$28.10
|
| Rate for Payer: MDWise Medicaid |
$28.10
|
| Rate for Payer: PHCS All Commercial |
$173.85
|
| Rate for Payer: PHP All Commercial |
$175.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$90.40
|
| Rate for Payer: Sagamore Health Network All Products |
$178.95
|
| Rate for Payer: Signature Care EPO |
$192.40
|
| Rate for Payer: Signature Care PPO |
$203.99
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$197.03
|
| Rate for Payer: United Healthcare Commercial |
$182.66
|
| Rate for Payer: United Healthcare Medicare |
$76.50
|
|
|
HC VITAMIN C
|
Facility
|
IP
|
$160.45
|
|
|
Service Code
|
CPT 82180
|
| Hospital Charge Code |
63044083
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$120.33 |
| Max. Negotiated Rate |
$149.21 |
| Rate for Payer: Aetna Commercial |
$138.63
|
| Rate for Payer: Cash Price |
$99.48
|
| Rate for Payer: Cigna All Commercial |
$138.46
|
| Rate for Payer: CORVEL All Commercial |
$149.21
|
| Rate for Payer: Coventry All Commercial |
$141.19
|
| 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 |
$144.40
|
| Rate for Payer: PHCS All Commercial |
$120.33
|
| Rate for Payer: PHP All Commercial |
$121.68
|
| Rate for Payer: Sagamore Health Network All Products |
$123.86
|
| Rate for Payer: Signature Care EPO |
$133.17
|
| Rate for Payer: Signature Care PPO |
$141.19
|
| Rate for Payer: United Healthcare Commercial |
$126.43
|
|
|
HC VITAMIN C
|
Facility
|
OP
|
$160.45
|
|
|
Service Code
|
CPT 82180
|
| Hospital Charge Code |
63044083
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$149.21 |
| Rate for Payer: Aetna Commercial |
$135.42
|
| Rate for Payer: Aetna Medicare |
$52.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$52.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$92.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$100.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$9.89
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$60.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$58.24
|
| Rate for Payer: Cash Price |
$99.48
|
| Rate for Payer: Cash Price |
$99.48
|
| Rate for Payer: Centivo All Commercial |
$81.83
|
| Rate for Payer: Cigna All Commercial |
$138.46
|
| Rate for Payer: CORVEL All Commercial |
$149.21
|
| Rate for Payer: Coventry All Commercial |
$141.19
|
| 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: Humana Medicare |
$81.83
|
| Rate for Payer: Lucent All Commercial |
$81.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$144.40
|
| Rate for Payer: Managed Health Services Medicaid |
$9.89
|
| Rate for Payer: MDWise Medicaid |
$9.89
|
| Rate for Payer: PHCS All Commercial |
$120.33
|
| Rate for Payer: PHP All Commercial |
$121.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$62.57
|
| Rate for Payer: Sagamore Health Network All Products |
$123.86
|
| Rate for Payer: Signature Care EPO |
$133.17
|
| Rate for Payer: Signature Care PPO |
$141.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$136.38
|
| Rate for Payer: United Healthcare Commercial |
$126.43
|
| Rate for Payer: United Healthcare Medicare |
$52.95
|
|
|
HC VITAMIN D,25-HYDROXY
|
Facility
|
IP
|
$225.59
|
|
|
Service Code
|
CPT 82306
|
| Hospital Charge Code |
63001127
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$169.20 |
| Max. Negotiated Rate |
$209.80 |
| Rate for Payer: Aetna Commercial |
$194.91
|
| Rate for Payer: Cash Price |
$139.87
|
| Rate for Payer: Cigna All Commercial |
$194.69
|
| Rate for Payer: CORVEL All Commercial |
$209.80
|
| Rate for Payer: Coventry All Commercial |
$198.52
|
| Rate for Payer: Encore All Commercial |
$207.66
|
| Rate for Payer: Frontpath All Commercial |
$207.55
|
| Rate for Payer: Humana ChoiceCare |
$194.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$203.03
|
| Rate for Payer: PHCS All Commercial |
$169.20
|
| Rate for Payer: PHP All Commercial |
$171.09
|
| Rate for Payer: Sagamore Health Network All Products |
$174.16
|
| Rate for Payer: Signature Care EPO |
$187.24
|
| Rate for Payer: Signature Care PPO |
$198.52
|
| Rate for Payer: United Healthcare Commercial |
$177.77
|
|
|
HC VITAMIN D,25-HYDROXY
|
Facility
|
OP
|
$225.59
|
|
|
Service Code
|
CPT 82306
|
| Hospital Charge Code |
63001127
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.60 |
| Max. Negotiated Rate |
$209.80 |
| Rate for Payer: Aetna Commercial |
$190.40
|
| Rate for Payer: Aetna Medicare |
$74.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$74.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$103.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$103.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$29.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$85.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$81.89
|
| Rate for Payer: Cash Price |
$139.87
|
| Rate for Payer: Cash Price |
$139.87
|
| Rate for Payer: Centivo All Commercial |
$115.05
|
| Rate for Payer: Cigna All Commercial |
$194.69
|
| Rate for Payer: CORVEL All Commercial |
$209.80
|
| Rate for Payer: Coventry All Commercial |
$198.52
|
| Rate for Payer: Encore All Commercial |
$207.66
|
| Rate for Payer: Frontpath All Commercial |
$207.55
|
| Rate for Payer: Humana ChoiceCare |
$194.85
|
| Rate for Payer: Humana Medicare |
$115.05
|
| Rate for Payer: Lucent All Commercial |
$115.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$203.03
|
| Rate for Payer: Managed Health Services Medicaid |
$29.60
|
| Rate for Payer: MDWise Medicaid |
$29.60
|
| Rate for Payer: PHCS All Commercial |
$169.20
|
| Rate for Payer: PHP All Commercial |
$171.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$87.98
|
| Rate for Payer: Sagamore Health Network All Products |
$174.16
|
| Rate for Payer: Signature Care EPO |
$187.24
|
| Rate for Payer: Signature Care PPO |
$198.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$191.75
|
| Rate for Payer: United Healthcare Commercial |
$177.77
|
| Rate for Payer: United Healthcare Medicare |
$74.45
|
|
|
HC VITAMIN D2&D3 25 HYDROXY
|
Facility
|
OP
|
$225.59
|
|
|
Service Code
|
CPT 82306
|
| Hospital Charge Code |
63001473
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$29.60 |
| Max. Negotiated Rate |
$209.80 |
| Rate for Payer: Aetna Commercial |
$190.40
|
| Rate for Payer: Aetna Medicare |
$74.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$74.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$103.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$103.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$29.60
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$85.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$81.89
|
| Rate for Payer: Cash Price |
$139.87
|
| Rate for Payer: Cash Price |
$139.87
|
| Rate for Payer: Centivo All Commercial |
$115.05
|
| Rate for Payer: Cigna All Commercial |
$194.69
|
| Rate for Payer: CORVEL All Commercial |
$209.80
|
| Rate for Payer: Coventry All Commercial |
$198.52
|
| Rate for Payer: Encore All Commercial |
$207.66
|
| Rate for Payer: Frontpath All Commercial |
$207.55
|
| Rate for Payer: Humana ChoiceCare |
$194.85
|
| Rate for Payer: Humana Medicare |
$115.05
|
| Rate for Payer: Lucent All Commercial |
$115.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$203.03
|
| Rate for Payer: Managed Health Services Medicaid |
$29.60
|
| Rate for Payer: MDWise Medicaid |
$29.60
|
| Rate for Payer: PHCS All Commercial |
$169.20
|
| Rate for Payer: PHP All Commercial |
$171.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$87.98
|
| Rate for Payer: Sagamore Health Network All Products |
$174.16
|
| Rate for Payer: Signature Care EPO |
$187.24
|
| Rate for Payer: Signature Care PPO |
$198.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$191.75
|
| Rate for Payer: United Healthcare Commercial |
$177.77
|
| Rate for Payer: United Healthcare Medicare |
$74.45
|
|
|
HC VITAMIN D2&D3 25 HYDROXY
|
Facility
|
IP
|
$225.59
|
|
|
Service Code
|
CPT 82306
|
| Hospital Charge Code |
63001473
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$169.20 |
| Max. Negotiated Rate |
$209.80 |
| Rate for Payer: Aetna Commercial |
$194.91
|
| Rate for Payer: Cash Price |
$139.87
|
| Rate for Payer: Cigna All Commercial |
$194.69
|
| Rate for Payer: CORVEL All Commercial |
$209.80
|
| Rate for Payer: Coventry All Commercial |
$198.52
|
| Rate for Payer: Encore All Commercial |
$207.66
|
| Rate for Payer: Frontpath All Commercial |
$207.55
|
| Rate for Payer: Humana ChoiceCare |
$194.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$203.03
|
| Rate for Payer: PHCS All Commercial |
$169.20
|
| Rate for Payer: PHP All Commercial |
$171.09
|
| Rate for Payer: Sagamore Health Network All Products |
$174.16
|
| Rate for Payer: Signature Care EPO |
$187.24
|
| Rate for Payer: Signature Care PPO |
$198.52
|
| Rate for Payer: United Healthcare Commercial |
$177.77
|
|
|
HC VITAMIN E
|
Facility
|
IP
|
$166.55
|
|
|
Service Code
|
CPT 84446
|
| Hospital Charge Code |
63001695
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$124.91 |
| Max. Negotiated Rate |
$154.89 |
| Rate for Payer: Aetna Commercial |
$143.90
|
| Rate for Payer: Cash Price |
$103.26
|
| Rate for Payer: Cigna All Commercial |
$143.73
|
| Rate for Payer: CORVEL All Commercial |
$154.89
|
| Rate for Payer: Coventry All Commercial |
$146.56
|
| Rate for Payer: Encore All Commercial |
$153.31
|
| Rate for Payer: Frontpath All Commercial |
$153.22
|
| Rate for Payer: Humana ChoiceCare |
$143.85
|
| Rate for Payer: Lutheran Preferred All Commercial |
$149.89
|
| Rate for Payer: PHCS All Commercial |
$124.91
|
| Rate for Payer: PHP All Commercial |
$126.31
|
| Rate for Payer: Sagamore Health Network All Products |
$128.57
|
| Rate for Payer: Signature Care EPO |
$138.23
|
| Rate for Payer: Signature Care PPO |
$146.56
|
| Rate for Payer: United Healthcare Commercial |
$131.24
|
|
|
HC VITAMIN E
|
Facility
|
OP
|
$166.55
|
|
|
Service Code
|
CPT 84446
|
| Hospital Charge Code |
63001695
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$14.18 |
| Max. Negotiated Rate |
$154.89 |
| Rate for Payer: Aetna Commercial |
$140.56
|
| Rate for Payer: Aetna Medicare |
$54.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$54.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$95.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$104.11
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$14.18
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$63.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$60.46
|
| Rate for Payer: Cash Price |
$103.26
|
| Rate for Payer: Cash Price |
$103.26
|
| Rate for Payer: Centivo All Commercial |
$84.94
|
| Rate for Payer: Cigna All Commercial |
$143.73
|
| Rate for Payer: CORVEL All Commercial |
$154.89
|
| Rate for Payer: Coventry All Commercial |
$146.56
|
| Rate for Payer: Encore All Commercial |
$153.31
|
| Rate for Payer: Frontpath All Commercial |
$153.22
|
| Rate for Payer: Humana ChoiceCare |
$143.85
|
| Rate for Payer: Humana Medicare |
$84.94
|
| Rate for Payer: Lucent All Commercial |
$84.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$149.89
|
| Rate for Payer: Managed Health Services Medicaid |
$14.18
|
| Rate for Payer: MDWise Medicaid |
$14.18
|
| Rate for Payer: PHCS All Commercial |
$124.91
|
| Rate for Payer: PHP All Commercial |
$126.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$64.95
|
| Rate for Payer: Sagamore Health Network All Products |
$128.57
|
| Rate for Payer: Signature Care EPO |
$138.23
|
| Rate for Payer: Signature Care PPO |
$146.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$141.56
|
| Rate for Payer: United Healthcare Commercial |
$131.24
|
| Rate for Payer: United Healthcare Medicare |
$54.96
|
|
