|
HC X-RAY-ORBITS 2 VIEW PRE-MRI FB
|
Facility
OP
|
$392.19
|
|
|
Service Code
|
CPT 70030
|
| Hospital Charge Code |
01610190
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$57.64 |
| Max. Negotiated Rate |
$364.74 |
| Rate for Payer: Aetna Commercial |
$331.01
|
| Rate for Payer: Aetna Medicare |
$129.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$129.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$225.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$245.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$57.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$148.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$142.36
|
| Rate for Payer: Cash Price |
$243.16
|
| Rate for Payer: Cash Price |
$243.16
|
| Rate for Payer: Centivo All Commercial |
$200.02
|
| Rate for Payer: Cigna All Commercial |
$338.46
|
| Rate for Payer: CORVEL All Commercial |
$364.74
|
| Rate for Payer: Coventry All Commercial |
$345.13
|
| Rate for Payer: Encore All Commercial |
$361.01
|
| Rate for Payer: Frontpath All Commercial |
$360.81
|
| Rate for Payer: Humana ChoiceCare |
$338.73
|
| Rate for Payer: Humana Medicare |
$200.02
|
| Rate for Payer: Lucent All Commercial |
$200.02
|
| Rate for Payer: Lutheran Preferred All Commercial |
$352.97
|
| Rate for Payer: Managed Health Services Medicaid |
$57.64
|
| Rate for Payer: MDWise Medicaid |
$57.64
|
| Rate for Payer: PHCS All Commercial |
$294.14
|
| Rate for Payer: PHP All Commercial |
$297.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$152.95
|
| Rate for Payer: Sagamore Health Network All Products |
$302.77
|
| Rate for Payer: Signature Care EPO |
$325.52
|
| Rate for Payer: Signature Care PPO |
$345.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$333.36
|
| Rate for Payer: United Healthcare Commercial |
$309.05
|
| Rate for Payer: United Healthcare Medicare |
$129.42
|
|
|
HC X-RAY-ORBITS 2 VIEW PRE-MRI FB
|
Facility
IP
|
$392.19
|
|
|
Service Code
|
CPT 70030
|
| Hospital Charge Code |
01610190
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$294.14 |
| Max. Negotiated Rate |
$364.74 |
| Rate for Payer: Aetna Commercial |
$338.85
|
| Rate for Payer: Cash Price |
$243.16
|
| Rate for Payer: Cigna All Commercial |
$338.46
|
| Rate for Payer: CORVEL All Commercial |
$364.74
|
| Rate for Payer: Coventry All Commercial |
$345.13
|
| Rate for Payer: Encore All Commercial |
$361.01
|
| Rate for Payer: Frontpath All Commercial |
$360.81
|
| Rate for Payer: Humana ChoiceCare |
$338.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$352.97
|
| Rate for Payer: PHCS All Commercial |
$294.14
|
| Rate for Payer: PHP All Commercial |
$297.44
|
| Rate for Payer: Sagamore Health Network All Products |
$302.77
|
| Rate for Payer: Signature Care EPO |
$325.52
|
| Rate for Payer: Signature Care PPO |
$345.13
|
| Rate for Payer: United Healthcare Commercial |
$309.05
|
|
|
HC X-RAY-ORBITS MIN 4 VIEWS
|
Facility
OP
|
$446.57
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
01617020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.78 |
| Max. Negotiated Rate |
$415.31 |
| Rate for Payer: Aetna Commercial |
$376.90
|
| Rate for Payer: Aetna Medicare |
$147.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$147.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$256.46
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$279.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$81.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$169.47
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$162.10
|
| Rate for Payer: Cash Price |
$276.87
|
| Rate for Payer: Cash Price |
$276.87
|
| Rate for Payer: Centivo All Commercial |
$227.75
|
| Rate for Payer: Cigna All Commercial |
$385.39
|
| Rate for Payer: CORVEL All Commercial |
$415.31
|
| Rate for Payer: Coventry All Commercial |
$392.98
|
| Rate for Payer: Encore All Commercial |
$411.06
|
| Rate for Payer: Frontpath All Commercial |
$410.84
|
| Rate for Payer: Humana ChoiceCare |
$385.70
|
| Rate for Payer: Humana Medicare |
$227.75
|
| Rate for Payer: Lucent All Commercial |
$227.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$401.91
|
| Rate for Payer: Managed Health Services Medicaid |
$81.78
|
| Rate for Payer: MDWise Medicaid |
$81.78
|
| Rate for Payer: PHCS All Commercial |
$334.92
|
| Rate for Payer: PHP All Commercial |
$338.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$174.16
|
| Rate for Payer: Sagamore Health Network All Products |
$344.75
|
| Rate for Payer: Signature Care EPO |
$370.65
|
| Rate for Payer: Signature Care PPO |
$392.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$379.58
|
| Rate for Payer: United Healthcare Commercial |
$351.89
|
| Rate for Payer: United Healthcare Medicare |
$147.37
|
|
|
HC X-RAY-ORBITS MIN 4 VIEWS
|
Facility
IP
|
$446.57
|
|
|
Service Code
|
CPT 70200
|
| Hospital Charge Code |
01617020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$334.92 |
| Max. Negotiated Rate |
$415.31 |
| Rate for Payer: Aetna Commercial |
$385.83
|
| Rate for Payer: Cash Price |
$276.87
|
| Rate for Payer: Cigna All Commercial |
$385.39
|
| Rate for Payer: CORVEL All Commercial |
$415.31
|
| Rate for Payer: Coventry All Commercial |
$392.98
|
| Rate for Payer: Encore All Commercial |
$411.06
|
| Rate for Payer: Frontpath All Commercial |
$410.84
|
| Rate for Payer: Humana ChoiceCare |
$385.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$401.91
|
| Rate for Payer: PHCS All Commercial |
$334.92
|
| Rate for Payer: PHP All Commercial |
$338.68
|
| Rate for Payer: Sagamore Health Network All Products |
$344.75
|
| Rate for Payer: Signature Care EPO |
$370.65
|
| Rate for Payer: Signature Care PPO |
$392.98
|
| Rate for Payer: United Healthcare Commercial |
$351.89
|
|
|
HC X-RAY-OSCALCIS (HEEL) 2+ VIEWS BI
|
Facility
OP
|
$462.93
|
|
|
Service Code
|
CPT 73650 50
|
| Hospital Charge Code |
21613650
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$152.77 |
| Max. Negotiated Rate |
$430.52 |
| Rate for Payer: Aetna Commercial |
$390.71
|
| Rate for Payer: Aetna Medicare |
$152.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$152.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$265.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$289.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$175.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$168.04
|
| Rate for Payer: Cash Price |
$287.02
|
| Rate for Payer: Centivo All Commercial |
$236.09
|
| Rate for Payer: Cigna All Commercial |
$399.51
|
| Rate for Payer: CORVEL All Commercial |
$430.52
|
| Rate for Payer: Coventry All Commercial |
$407.38
|
| Rate for Payer: Encore All Commercial |
$426.12
|
| Rate for Payer: Frontpath All Commercial |
$425.89
|
| Rate for Payer: Humana ChoiceCare |
$399.83
|
| Rate for Payer: Humana Medicare |
$236.09
|
| Rate for Payer: Lucent All Commercial |
$236.09
|
| Rate for Payer: Lutheran Preferred All Commercial |
$416.63
|
| Rate for Payer: PHCS All Commercial |
$347.20
|
| Rate for Payer: PHP All Commercial |
$351.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$180.54
|
| Rate for Payer: Sagamore Health Network All Products |
$357.38
|
| Rate for Payer: Signature Care EPO |
$384.23
|
| Rate for Payer: Signature Care PPO |
$407.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$393.49
|
| Rate for Payer: United Healthcare Commercial |
$364.79
|
| Rate for Payer: United Healthcare Medicare |
$152.77
|
|
|
HC X-RAY-OSCALCIS (HEEL) 2+ VIEWS BI
|
Facility
IP
|
$462.93
|
|
|
Service Code
|
CPT 73650 50
|
| Hospital Charge Code |
21613650
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$347.20 |
| Max. Negotiated Rate |
$430.52 |
| Rate for Payer: Aetna Commercial |
$399.97
|
| Rate for Payer: Cash Price |
$287.02
|
| Rate for Payer: Cigna All Commercial |
$399.51
|
| Rate for Payer: CORVEL All Commercial |
$430.52
|
| Rate for Payer: Coventry All Commercial |
$407.38
|
| Rate for Payer: Encore All Commercial |
$426.12
|
| Rate for Payer: Frontpath All Commercial |
$425.89
|
| Rate for Payer: Humana ChoiceCare |
$399.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$416.63
|
| Rate for Payer: PHCS All Commercial |
$347.20
|
| Rate for Payer: PHP All Commercial |
$351.08
|
| Rate for Payer: Sagamore Health Network All Products |
$357.38
|
| Rate for Payer: Signature Care EPO |
$384.23
|
| Rate for Payer: Signature Care PPO |
$407.38
|
| Rate for Payer: United Healthcare Commercial |
$364.79
|
|
|
HC X-RAY-OSCALCIS (HEEL) 2+ VIEWS LT
|
Facility
OP
|
$362.07
|
|
|
Service Code
|
CPT 73650 LT
|
| Hospital Charge Code |
01613650
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$119.48 |
| Max. Negotiated Rate |
$336.72 |
| Rate for Payer: Aetna Commercial |
$305.59
|
| Rate for Payer: Aetna Medicare |
$119.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$119.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$207.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$226.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$137.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$131.43
|
| Rate for Payer: Cash Price |
$224.48
|
| Rate for Payer: Centivo All Commercial |
$184.66
|
| Rate for Payer: Cigna All Commercial |
$312.47
|
| Rate for Payer: CORVEL All Commercial |
$336.72
|
| Rate for Payer: Coventry All Commercial |
$318.62
|
| Rate for Payer: Encore All Commercial |
$333.28
|
| Rate for Payer: Frontpath All Commercial |
$333.10
|
| Rate for Payer: Humana ChoiceCare |
$312.72
|
| Rate for Payer: Humana Medicare |
$184.66
|
| Rate for Payer: Lucent All Commercial |
$184.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$325.86
|
| Rate for Payer: PHCS All Commercial |
$271.55
|
| Rate for Payer: PHP All Commercial |
$274.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$141.21
|
| Rate for Payer: Sagamore Health Network All Products |
$279.52
|
| Rate for Payer: Signature Care EPO |
$300.52
|
| Rate for Payer: Signature Care PPO |
$318.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$307.76
|
| Rate for Payer: United Healthcare Commercial |
$285.31
|
| Rate for Payer: United Healthcare Medicare |
$119.48
|
|
|
HC X-RAY-OSCALCIS (HEEL) 2+ VIEWS LT
|
Facility
IP
|
$362.07
|
|
|
Service Code
|
CPT 73650 LT
|
| Hospital Charge Code |
01613650
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$271.55 |
| Max. Negotiated Rate |
$336.72 |
| Rate for Payer: Aetna Commercial |
$312.83
|
| Rate for Payer: Cash Price |
$224.48
|
| Rate for Payer: Cigna All Commercial |
$312.47
|
| Rate for Payer: CORVEL All Commercial |
$336.72
|
| Rate for Payer: Coventry All Commercial |
$318.62
|
| Rate for Payer: Encore All Commercial |
$333.28
|
| Rate for Payer: Frontpath All Commercial |
$333.10
|
| Rate for Payer: Humana ChoiceCare |
$312.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$325.86
|
| Rate for Payer: PHCS All Commercial |
$271.55
|
| Rate for Payer: PHP All Commercial |
$274.59
|
| Rate for Payer: Sagamore Health Network All Products |
$279.52
|
| Rate for Payer: Signature Care EPO |
$300.52
|
| Rate for Payer: Signature Care PPO |
$318.62
|
| Rate for Payer: United Healthcare Commercial |
$285.31
|
|
|
HC X-RAY-OSCALCIS (HEEL) 2+ VIEWS RT
|
Facility
IP
|
$362.07
|
|
|
Service Code
|
CPT 73650 RT
|
| Hospital Charge Code |
11613650
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$271.55 |
| Max. Negotiated Rate |
$336.72 |
| Rate for Payer: Aetna Commercial |
$312.83
|
| Rate for Payer: Cash Price |
$224.48
|
| Rate for Payer: Cigna All Commercial |
$312.47
|
| Rate for Payer: CORVEL All Commercial |
$336.72
|
| Rate for Payer: Coventry All Commercial |
$318.62
|
| Rate for Payer: Encore All Commercial |
$333.28
|
| Rate for Payer: Frontpath All Commercial |
$333.10
|
| Rate for Payer: Humana ChoiceCare |
$312.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$325.86
|
| Rate for Payer: PHCS All Commercial |
$271.55
|
| Rate for Payer: PHP All Commercial |
$274.59
|
| Rate for Payer: Sagamore Health Network All Products |
$279.52
|
| Rate for Payer: Signature Care EPO |
$300.52
|
| Rate for Payer: Signature Care PPO |
$318.62
|
| Rate for Payer: United Healthcare Commercial |
$285.31
|
|
|
HC X-RAY-OSCALCIS (HEEL) 2+ VIEWS RT
|
Facility
OP
|
$362.07
|
|
|
Service Code
|
CPT 73650 RT
|
| Hospital Charge Code |
11613650
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$119.48 |
| Max. Negotiated Rate |
$336.72 |
| Rate for Payer: Aetna Commercial |
$305.59
|
| Rate for Payer: Aetna Medicare |
$119.48
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$119.48
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$207.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$226.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$137.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$131.43
|
| Rate for Payer: Cash Price |
$224.48
|
| Rate for Payer: Centivo All Commercial |
$184.66
|
| Rate for Payer: Cigna All Commercial |
$312.47
|
| Rate for Payer: CORVEL All Commercial |
$336.72
|
| Rate for Payer: Coventry All Commercial |
$318.62
|
| Rate for Payer: Encore All Commercial |
$333.28
|
| Rate for Payer: Frontpath All Commercial |
$333.10
|
| Rate for Payer: Humana ChoiceCare |
$312.72
|
| Rate for Payer: Humana Medicare |
$184.66
|
| Rate for Payer: Lucent All Commercial |
$184.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$325.86
|
| Rate for Payer: PHCS All Commercial |
$271.55
|
| Rate for Payer: PHP All Commercial |
$274.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$141.21
|
| Rate for Payer: Sagamore Health Network All Products |
$279.52
|
| Rate for Payer: Signature Care EPO |
$300.52
|
| Rate for Payer: Signature Care PPO |
$318.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$307.76
|
| Rate for Payer: United Healthcare Commercial |
$285.31
|
| Rate for Payer: United Healthcare Medicare |
$119.48
|
|
|
HC X-RAY-OSSEOUS SURVEY COMPLETE
|
Facility
OP
|
$1,023.52
|
|
|
Service Code
|
CPT 77075
|
| Hospital Charge Code |
01616040
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$217.04 |
| Max. Negotiated Rate |
$951.87 |
| Rate for Payer: Aetna Commercial |
$863.85
|
| Rate for Payer: Aetna Medicare |
$337.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$337.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$587.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$639.80
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$217.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$388.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$371.54
|
| Rate for Payer: Cash Price |
$634.58
|
| Rate for Payer: Cash Price |
$634.58
|
| Rate for Payer: Centivo All Commercial |
$521.99
|
| 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 |
$521.99
|
| Rate for Payer: Lucent All Commercial |
$521.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$921.17
|
| Rate for Payer: Managed Health Services Medicaid |
$217.04
|
| Rate for Payer: MDWise Medicaid |
$217.04
|
| 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 |
$337.76
|
|
|
HC X-RAY-OSSEOUS SURVEY COMPLETE
|
Facility
IP
|
$1,023.52
|
|
|
Service Code
|
CPT 77075
|
| Hospital Charge Code |
01616040
|
|
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 |
$634.58
|
| 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
OP
|
$853.75
|
|
|
Service Code
|
CPT 77076
|
| Hospital Charge Code |
01616065
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$196.76 |
| Max. Negotiated Rate |
$793.99 |
| Rate for Payer: Aetna Commercial |
$720.57
|
| Rate for Payer: Aetna Medicare |
$281.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$281.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$490.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$533.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$196.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$324.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$309.91
|
| Rate for Payer: Cash Price |
$529.33
|
| Rate for Payer: Cash Price |
$529.33
|
| Rate for Payer: Centivo All Commercial |
$435.41
|
| 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 |
$435.41
|
| Rate for Payer: Lucent All Commercial |
$435.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$768.38
|
| Rate for Payer: Managed Health Services Medicaid |
$196.76
|
| Rate for Payer: MDWise Medicaid |
$196.76
|
| 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 |
$672.76
|
| Rate for Payer: United Healthcare Medicare |
$281.74
|
|
|
HC X-RAY-OSSEOUS SURVEY INFANT
|
Facility
IP
|
$853.75
|
|
|
Service Code
|
CPT 77076
|
| Hospital Charge Code |
01616065
|
|
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 |
$529.33
|
| 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 |
$672.76
|
|
|
HC X-RAY-OSSEOUS SURVEY LIMITED
|
Facility
OP
|
$993.88
|
|
|
Service Code
|
CPT 77074
|
| Hospital Charge Code |
01616060
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$132.02 |
| Max. Negotiated Rate |
$924.31 |
| Rate for Payer: Aetna Commercial |
$838.83
|
| Rate for Payer: Aetna Medicare |
$327.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$327.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$570.78
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$621.27
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$132.02
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$377.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$360.78
|
| Rate for Payer: Cash Price |
$616.20
|
| Rate for Payer: Cash Price |
$616.20
|
| Rate for Payer: Centivo All Commercial |
$506.88
|
| 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 |
$914.86
|
| Rate for Payer: Frontpath All Commercial |
$914.37
|
| Rate for Payer: Humana ChoiceCare |
$858.41
|
| Rate for Payer: Humana Medicare |
$506.88
|
| Rate for Payer: Lucent All Commercial |
$506.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$894.49
|
| Rate for Payer: Managed Health Services Medicaid |
$132.02
|
| Rate for Payer: MDWise Medicaid |
$132.02
|
| 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 |
$767.27
|
| 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 |
$327.98
|
|
|
HC X-RAY-OSSEOUS SURVEY LIMITED
|
Facility
IP
|
$993.88
|
|
|
Service Code
|
CPT 77074
|
| Hospital Charge Code |
01616060
|
|
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 |
$616.20
|
| 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 |
$914.86
|
| 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 |
$767.27
|
| 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 |
01610220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$72.15 |
| Max. Negotiated Rate |
$615.45 |
| Rate for Payer: Aetna Commercial |
$558.54
|
| Rate for Payer: Aetna Medicare |
$218.39
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$218.39
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$380.06
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$413.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$72.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$251.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$240.22
|
| Rate for Payer: Cash Price |
$410.30
|
| Rate for Payer: Cash Price |
$410.30
|
| Rate for Payer: Centivo All Commercial |
$337.51
|
| Rate for Payer: Cigna All Commercial |
$571.11
|
| Rate for Payer: CORVEL All Commercial |
$615.45
|
| Rate for Payer: Coventry All Commercial |
$582.36
|
| Rate for Payer: Encore All Commercial |
$609.16
|
| Rate for Payer: Frontpath All Commercial |
$608.83
|
| Rate for Payer: Humana ChoiceCare |
$571.58
|
| Rate for Payer: Humana Medicare |
$337.51
|
| Rate for Payer: Lucent All Commercial |
$337.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$595.60
|
| Rate for Payer: Managed Health Services Medicaid |
$72.15
|
| Rate for Payer: MDWise Medicaid |
$72.15
|
| 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 |
$549.27
|
| Rate for Payer: Signature Care PPO |
$582.36
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$562.51
|
| Rate for Payer: United Healthcare Commercial |
$521.48
|
| Rate for Payer: United Healthcare Medicare |
$218.39
|
|
|
HC X-RAY-PARANASAL SINUSES MIN 3 VIEWS
|
Facility
IP
|
$661.78
|
|
|
Service Code
|
CPT 70220
|
| Hospital Charge Code |
01610220
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$496.33 |
| Max. Negotiated Rate |
$615.45 |
| Rate for Payer: Aetna Commercial |
$571.77
|
| Rate for Payer: Cash Price |
$410.30
|
| Rate for Payer: Cigna All Commercial |
$571.11
|
| Rate for Payer: CORVEL All Commercial |
$615.45
|
| Rate for Payer: Coventry All Commercial |
$582.36
|
| Rate for Payer: Encore All Commercial |
$609.16
|
| Rate for Payer: Frontpath All Commercial |
$608.83
|
| 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 |
$549.27
|
| Rate for Payer: Signature Care PPO |
$582.36
|
| Rate for Payer: United Healthcare Commercial |
$521.48
|
|
|
HC X-RAY-PELVIS 1 OR 2 VIEWS
|
Facility
OP
|
$507.77
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
01612170
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$53.78 |
| Max. Negotiated Rate |
$472.22 |
| Rate for Payer: Aetna Commercial |
$428.55
|
| Rate for Payer: Aetna Medicare |
$167.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$167.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$291.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$317.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$53.78
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$192.70
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$184.32
|
| Rate for Payer: Cash Price |
$314.82
|
| Rate for Payer: Cash Price |
$314.82
|
| Rate for Payer: Centivo All Commercial |
$258.96
|
| Rate for Payer: Cigna All Commercial |
$438.20
|
| Rate for Payer: CORVEL All Commercial |
$472.22
|
| Rate for Payer: Coventry All Commercial |
$446.83
|
| Rate for Payer: Encore All Commercial |
$467.40
|
| Rate for Payer: Frontpath All Commercial |
$467.14
|
| Rate for Payer: Humana ChoiceCare |
$438.56
|
| Rate for Payer: Humana Medicare |
$258.96
|
| Rate for Payer: Lucent All Commercial |
$258.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$456.99
|
| Rate for Payer: Managed Health Services Medicaid |
$53.78
|
| Rate for Payer: MDWise Medicaid |
$53.78
|
| Rate for Payer: PHCS All Commercial |
$380.82
|
| 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 |
$446.83
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$431.60
|
| Rate for Payer: United Healthcare Commercial |
$400.12
|
| Rate for Payer: United Healthcare Medicare |
$167.56
|
|
|
HC X-RAY-PELVIS 1 OR 2 VIEWS
|
Facility
IP
|
$507.77
|
|
|
Service Code
|
CPT 72170
|
| Hospital Charge Code |
01612170
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$380.82 |
| Max. Negotiated Rate |
$472.22 |
| Rate for Payer: Aetna Commercial |
$438.71
|
| Rate for Payer: Cash Price |
$314.82
|
| Rate for Payer: Cigna All Commercial |
$438.20
|
| Rate for Payer: CORVEL All Commercial |
$472.22
|
| Rate for Payer: Coventry All Commercial |
$446.83
|
| Rate for Payer: Encore All Commercial |
$467.40
|
| Rate for Payer: Frontpath All Commercial |
$467.14
|
| Rate for Payer: Humana ChoiceCare |
$438.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$456.99
|
| Rate for Payer: PHCS All Commercial |
$380.82
|
| 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 |
$446.83
|
| Rate for Payer: United Healthcare Commercial |
$400.12
|
|
|
HC X-RAY-PELVIS MIN 3 VIEWS
|
Facility
OP
|
$607.43
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
01612190
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$86.62 |
| Max. Negotiated Rate |
$564.91 |
| Rate for Payer: Aetna Commercial |
$512.67
|
| Rate for Payer: Aetna Medicare |
$200.45
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$200.45
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$348.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$379.70
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$86.62
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$230.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$220.50
|
| Rate for Payer: Cash Price |
$376.61
|
| Rate for Payer: Cash Price |
$376.61
|
| Rate for Payer: Centivo All Commercial |
$309.79
|
| 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 |
$309.79
|
| Rate for Payer: Lucent All Commercial |
$309.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$546.69
|
| Rate for Payer: Managed Health Services Medicaid |
$86.62
|
| Rate for Payer: MDWise Medicaid |
$86.62
|
| Rate for Payer: PHCS All Commercial |
$455.57
|
| Rate for Payer: PHP All Commercial |
$460.68
|
| 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 |
$478.66
|
| Rate for Payer: United Healthcare Medicare |
$200.45
|
|
|
HC X-RAY-PELVIS MIN 3 VIEWS
|
Facility
IP
|
$607.43
|
|
|
Service Code
|
CPT 72190
|
| Hospital Charge Code |
01612190
|
|
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 |
$376.61
|
| 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 |
$460.68
|
| 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 |
$478.66
|
|
|
HC X-RAY-REHAB ESOPHOGRAM
|
Facility
OP
|
$812.55
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
01614221
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$179.36 |
| Max. Negotiated Rate |
$755.67 |
| Rate for Payer: Aetna Commercial |
$685.79
|
| Rate for Payer: Aetna Medicare |
$268.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$268.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$466.65
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$507.93
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$179.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$308.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$294.96
|
| Rate for Payer: Cash Price |
$503.78
|
| Rate for Payer: Cash Price |
$503.78
|
| Rate for Payer: Centivo All Commercial |
$414.40
|
| Rate for Payer: Cigna All Commercial |
$701.23
|
| Rate for Payer: CORVEL All Commercial |
$755.67
|
| Rate for Payer: Coventry All Commercial |
$715.05
|
| 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 |
$414.40
|
| Rate for Payer: Lucent All Commercial |
$414.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$731.30
|
| Rate for Payer: Managed Health Services Medicaid |
$179.36
|
| Rate for Payer: MDWise Medicaid |
$179.36
|
| 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 |
$316.90
|
| Rate for Payer: Sagamore Health Network All Products |
$627.29
|
| Rate for Payer: Signature Care EPO |
$674.42
|
| Rate for Payer: Signature Care PPO |
$715.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$690.67
|
| Rate for Payer: United Healthcare Commercial |
$640.29
|
| Rate for Payer: United Healthcare Medicare |
$268.14
|
|
|
HC X-RAY-REHAB ESOPHOGRAM
|
Facility
IP
|
$812.55
|
|
|
Service Code
|
CPT 74230
|
| Hospital Charge Code |
01614221
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$609.41 |
| Max. Negotiated Rate |
$755.67 |
| Rate for Payer: Aetna Commercial |
$702.05
|
| Rate for Payer: Cash Price |
$503.78
|
| Rate for Payer: Cigna All Commercial |
$701.23
|
| Rate for Payer: CORVEL All Commercial |
$755.67
|
| Rate for Payer: Coventry All Commercial |
$715.05
|
| 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 |
$731.30
|
| 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 |
$715.05
|
| 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 |
01611100
|
|
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 |
$274.30
|
| Rate for Payer: Cigna All Commercial |
$381.81
|
| Rate for Payer: CORVEL All Commercial |
$411.46
|
| Rate for Payer: Coventry All Commercial |
$389.33
|
| Rate for Payer: Encore All Commercial |
$407.25
|
| Rate for Payer: Frontpath All Commercial |
$407.03
|
| Rate for Payer: Humana ChoiceCare |
$382.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$398.18
|
| Rate for Payer: PHCS All Commercial |
$331.82
|
| Rate for Payer: PHP All Commercial |
$335.54
|
| Rate for Payer: Sagamore Health Network All Products |
$341.55
|
| Rate for Payer: Signature Care EPO |
$367.21
|
| Rate for Payer: Signature Care PPO |
$389.33
|
| Rate for Payer: United Healthcare Commercial |
$348.63
|
|
