|
HC X-RAY-RIBS 2 VIEWS UNILATERAL LT
|
Facility
OP
|
$442.43
|
|
|
Service Code
|
CPT 71100 LT
|
| Hospital Charge Code |
01611100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$146.00 |
| Max. Negotiated Rate |
$411.46 |
| Rate for Payer: Aetna Commercial |
$373.41
|
| Rate for Payer: Aetna Medicare |
$146.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$146.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$254.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$276.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$167.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$160.60
|
| Rate for Payer: Cash Price |
$274.30
|
| Rate for Payer: Centivo All Commercial |
$225.64
|
| 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: Humana Medicare |
$225.64
|
| Rate for Payer: Lucent All Commercial |
$225.64
|
| 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: Plain Church Group Ministry All Commercial |
$172.55
|
| 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: Three Rivers Preferred All Commercial |
$376.06
|
| Rate for Payer: United Healthcare Commercial |
$348.63
|
| Rate for Payer: United Healthcare Medicare |
$146.00
|
|
|
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 |
$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
|
|
|
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 |
$146.00 |
| Max. Negotiated Rate |
$411.46 |
| Rate for Payer: Aetna Commercial |
$373.41
|
| Rate for Payer: Aetna Medicare |
$146.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$146.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$254.08
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$276.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$167.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$160.60
|
| Rate for Payer: Cash Price |
$274.30
|
| Rate for Payer: Centivo All Commercial |
$225.64
|
| 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: Humana Medicare |
$225.64
|
| Rate for Payer: Lucent All Commercial |
$225.64
|
| 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: Plain Church Group Ministry All Commercial |
$172.55
|
| 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: Three Rivers Preferred All Commercial |
$376.06
|
| Rate for Payer: United Healthcare Commercial |
$348.63
|
| Rate for Payer: United Healthcare Medicare |
$146.00
|
|
|
HC X-RAY-RIBS 3 VIEWS BILATERAL
|
Facility
IP
|
$499.56
|
|
|
Service Code
|
CPT 71110
|
| Hospital Charge Code |
01611110
|
|
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 |
$309.72
|
| 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 |
$459.59
|
| 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 |
$378.86
|
| 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 3 VIEWS BILATERAL
|
Facility
OP
|
$499.56
|
|
|
Service Code
|
CPT 71110
|
| Hospital Charge Code |
01611110
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$75.04 |
| Max. Negotiated Rate |
$464.59 |
| Rate for Payer: Aetna Commercial |
$421.62
|
| Rate for Payer: Aetna Medicare |
$164.85
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$164.85
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$286.89
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$312.27
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$75.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$189.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$181.34
|
| Rate for Payer: Cash Price |
$309.72
|
| Rate for Payer: Cash Price |
$309.72
|
| Rate for Payer: Centivo All Commercial |
$254.77
|
| 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 |
$459.59
|
| Rate for Payer: Humana ChoiceCare |
$431.47
|
| Rate for Payer: Humana Medicare |
$254.77
|
| Rate for Payer: Lucent All Commercial |
$254.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$449.60
|
| Rate for Payer: Managed Health Services Medicaid |
$75.04
|
| Rate for Payer: MDWise Medicaid |
$75.04
|
| Rate for Payer: PHCS All Commercial |
$374.67
|
| Rate for Payer: PHP All Commercial |
$378.86
|
| 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 |
$424.62
|
| Rate for Payer: United Healthcare Commercial |
$393.65
|
| Rate for Payer: United Healthcare Medicare |
$164.85
|
|
|
HC X-RAY-RIBS BILATERL W/PA CHEST 4+ VIEWS
|
Facility
OP
|
$685.28
|
|
|
Service Code
|
CPT 71111
|
| Hospital Charge Code |
01611111
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$103.04 |
| Max. Negotiated Rate |
$637.31 |
| Rate for Payer: Aetna Commercial |
$578.37
|
| Rate for Payer: Aetna Medicare |
$226.14
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$226.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$393.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$428.37
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$103.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$260.06
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$248.76
|
| Rate for Payer: Cash Price |
$424.87
|
| Rate for Payer: Cash Price |
$424.87
|
| Rate for Payer: Centivo All Commercial |
$349.49
|
| Rate for Payer: Cigna All Commercial |
$591.39
|
| Rate for Payer: CORVEL All Commercial |
$637.31
|
| Rate for Payer: Coventry All Commercial |
$603.04
|
| Rate for Payer: Encore All Commercial |
$630.80
|
| Rate for Payer: Frontpath All Commercial |
$630.45
|
| Rate for Payer: Humana ChoiceCare |
$591.87
|
| Rate for Payer: Humana Medicare |
$349.49
|
| Rate for Payer: Lucent All Commercial |
$349.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$616.75
|
| Rate for Payer: Managed Health Services Medicaid |
$103.04
|
| Rate for Payer: MDWise Medicaid |
$103.04
|
| Rate for Payer: PHCS All Commercial |
$513.96
|
| Rate for Payer: PHP All Commercial |
$519.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$267.26
|
| Rate for Payer: Sagamore Health Network All Products |
$529.03
|
| Rate for Payer: Signature Care EPO |
$568.78
|
| Rate for Payer: Signature Care PPO |
$603.04
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$582.49
|
| Rate for Payer: United Healthcare Commercial |
$540.00
|
| Rate for Payer: United Healthcare Medicare |
$226.14
|
|
|
HC X-RAY-RIBS BILATERL W/PA CHEST 4+ VIEWS
|
Facility
IP
|
$685.28
|
|
|
Service Code
|
CPT 71111
|
| Hospital Charge Code |
01611111
|
|
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 |
$424.87
|
| Rate for Payer: Cigna All Commercial |
$591.39
|
| Rate for Payer: CORVEL All Commercial |
$637.31
|
| Rate for Payer: Coventry All Commercial |
$603.04
|
| Rate for Payer: Encore All Commercial |
$630.80
|
| Rate for Payer: Frontpath All Commercial |
$630.45
|
| Rate for Payer: Humana ChoiceCare |
$591.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$616.75
|
| Rate for Payer: PHCS All Commercial |
$513.96
|
| Rate for Payer: PHP All Commercial |
$519.71
|
| Rate for Payer: Sagamore Health Network All Products |
$529.03
|
| Rate for Payer: Signature Care EPO |
$568.78
|
| Rate for Payer: Signature Care PPO |
$603.04
|
| Rate for Payer: United Healthcare Commercial |
$540.00
|
|
|
HC X-RAY-RIBS UNILAT W/PA CHEST L 3+ VIEWS
|
Facility
OP
|
$743.03
|
|
|
Service Code
|
CPT 71101 LT
|
| Hospital Charge Code |
01611101
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$245.20 |
| Max. Negotiated Rate |
$691.02 |
| Rate for Payer: Aetna Commercial |
$627.12
|
| Rate for Payer: Aetna Medicare |
$245.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$245.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$426.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$464.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$281.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$269.72
|
| Rate for Payer: Cash Price |
$460.68
|
| Rate for Payer: Centivo All Commercial |
$378.94
|
| 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 |
$641.75
|
| Rate for Payer: Humana Medicare |
$378.94
|
| Rate for Payer: Lucent All Commercial |
$378.94
|
| 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: 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 |
$631.57
|
| Rate for Payer: United Healthcare Commercial |
$585.51
|
| Rate for Payer: United Healthcare Medicare |
$245.20
|
|
|
HC X-RAY-RIBS UNILAT W/PA CHEST L 3+ VIEWS
|
Facility
IP
|
$743.03
|
|
|
Service Code
|
CPT 71101 LT
|
| Hospital Charge Code |
01611101
|
|
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 |
$460.68
|
| 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 |
$641.75
|
| 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 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 |
$460.68
|
| 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 |
$641.75
|
| 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 R 3+ VIEWS
|
Facility
OP
|
$743.03
|
|
|
Service Code
|
CPT 71101 RT
|
| Hospital Charge Code |
11611101
|
|
Hospital Revenue Code
|
324
|
| Min. Negotiated Rate |
$245.20 |
| Max. Negotiated Rate |
$691.02 |
| Rate for Payer: Aetna Commercial |
$627.12
|
| Rate for Payer: Aetna Medicare |
$245.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$245.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$426.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$464.47
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$281.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$269.72
|
| Rate for Payer: Cash Price |
$460.68
|
| Rate for Payer: Centivo All Commercial |
$378.94
|
| 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 |
$641.75
|
| Rate for Payer: Humana Medicare |
$378.94
|
| Rate for Payer: Lucent All Commercial |
$378.94
|
| 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: 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 |
$631.57
|
| Rate for Payer: United Healthcare Commercial |
$585.51
|
| Rate for Payer: United Healthcare Medicare |
$245.20
|
|
|
HC X-RAY-SACROILIAC JOINTS 3+ VIEWS
|
Facility
OP
|
$421.47
|
|
|
Service Code
|
CPT 72202
|
| Hospital Charge Code |
01612202
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$70.20 |
| Max. Negotiated Rate |
$391.97 |
| Rate for Payer: Aetna Commercial |
$355.72
|
| Rate for Payer: Aetna Medicare |
$139.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$139.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$242.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$263.46
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$70.20
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$159.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$153.00
|
| Rate for Payer: Cash Price |
$261.31
|
| Rate for Payer: Cash Price |
$261.31
|
| Rate for Payer: Centivo All Commercial |
$214.95
|
| Rate for Payer: Cigna All Commercial |
$363.73
|
| Rate for Payer: CORVEL All Commercial |
$391.97
|
| Rate for Payer: Coventry All Commercial |
$370.90
|
| Rate for Payer: Encore All Commercial |
$387.97
|
| Rate for Payer: Frontpath All Commercial |
$387.76
|
| Rate for Payer: Humana ChoiceCare |
$364.03
|
| Rate for Payer: Humana Medicare |
$214.95
|
| Rate for Payer: Lucent All Commercial |
$214.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$379.33
|
| Rate for Payer: Managed Health Services Medicaid |
$70.20
|
| Rate for Payer: MDWise Medicaid |
$70.20
|
| Rate for Payer: PHCS All Commercial |
$316.11
|
| Rate for Payer: PHP All Commercial |
$319.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$164.37
|
| Rate for Payer: Sagamore Health Network All Products |
$325.38
|
| Rate for Payer: Signature Care EPO |
$349.82
|
| Rate for Payer: Signature Care PPO |
$370.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$358.25
|
| Rate for Payer: United Healthcare Commercial |
$332.12
|
| Rate for Payer: United Healthcare Medicare |
$139.09
|
|
|
HC X-RAY-SACROILIAC JOINTS 3+ VIEWS
|
Facility
IP
|
$421.47
|
|
|
Service Code
|
CPT 72202
|
| Hospital Charge Code |
01612202
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$316.11 |
| Max. Negotiated Rate |
$391.97 |
| Rate for Payer: Aetna Commercial |
$364.15
|
| Rate for Payer: Cash Price |
$261.31
|
| Rate for Payer: Cigna All Commercial |
$363.73
|
| Rate for Payer: CORVEL All Commercial |
$391.97
|
| Rate for Payer: Coventry All Commercial |
$370.90
|
| Rate for Payer: Encore All Commercial |
$387.97
|
| Rate for Payer: Frontpath All Commercial |
$387.76
|
| Rate for Payer: Humana ChoiceCare |
$364.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$379.33
|
| Rate for Payer: PHCS All Commercial |
$316.11
|
| Rate for Payer: PHP All Commercial |
$319.65
|
| Rate for Payer: Sagamore Health Network All Products |
$325.38
|
| Rate for Payer: Signature Care EPO |
$349.82
|
| Rate for Payer: Signature Care PPO |
$370.90
|
| Rate for Payer: United Healthcare Commercial |
$332.12
|
|
|
HC X-RAY-SACRUM / COCCYX 2+ VIEWS
|
Facility
IP
|
$507.77
|
|
|
Service Code
|
CPT 72220
|
| Hospital Charge Code |
01612221
|
|
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-SACRUM / COCCYX 2+ VIEWS
|
Facility
OP
|
$507.77
|
|
|
Service Code
|
CPT 72220
|
| Hospital Charge Code |
01612221
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$55.69 |
| 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 |
$55.69
|
| 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 |
$55.69
|
| Rate for Payer: MDWise Medicaid |
$55.69
|
| 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-SCAPULA BI
|
Facility
IP
|
$719.85
|
|
|
Service Code
|
CPT 73010 50
|
| Hospital Charge Code |
21613010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$539.89 |
| Max. Negotiated Rate |
$669.46 |
| Rate for Payer: Aetna Commercial |
$621.95
|
| Rate for Payer: Cash Price |
$446.31
|
| Rate for Payer: Cigna All Commercial |
$621.23
|
| Rate for Payer: CORVEL All Commercial |
$669.46
|
| Rate for Payer: Coventry All Commercial |
$633.47
|
| Rate for Payer: Encore All Commercial |
$662.63
|
| Rate for Payer: Frontpath All Commercial |
$662.27
|
| Rate for Payer: Humana ChoiceCare |
$621.74
|
| Rate for Payer: Lutheran Preferred All Commercial |
$647.87
|
| Rate for Payer: PHCS All Commercial |
$539.89
|
| Rate for Payer: PHP All Commercial |
$545.94
|
| Rate for Payer: Sagamore Health Network All Products |
$555.73
|
| Rate for Payer: Signature Care EPO |
$597.48
|
| Rate for Payer: Signature Care PPO |
$633.47
|
| Rate for Payer: United Healthcare Commercial |
$567.25
|
|
|
HC X-RAY-SCAPULA BI
|
Facility
OP
|
$719.85
|
|
|
Service Code
|
CPT 73010 50
|
| Hospital Charge Code |
21613010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$237.55 |
| Max. Negotiated Rate |
$669.46 |
| Rate for Payer: Aetna Commercial |
$607.56
|
| Rate for Payer: Aetna Medicare |
$237.55
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$237.55
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$413.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$449.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$273.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$261.31
|
| Rate for Payer: Cash Price |
$446.31
|
| Rate for Payer: Centivo All Commercial |
$367.13
|
| Rate for Payer: Cigna All Commercial |
$621.23
|
| Rate for Payer: CORVEL All Commercial |
$669.46
|
| Rate for Payer: Coventry All Commercial |
$633.47
|
| Rate for Payer: Encore All Commercial |
$662.63
|
| Rate for Payer: Frontpath All Commercial |
$662.27
|
| Rate for Payer: Humana ChoiceCare |
$621.74
|
| Rate for Payer: Humana Medicare |
$367.13
|
| Rate for Payer: Lucent All Commercial |
$367.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$647.87
|
| Rate for Payer: PHCS All Commercial |
$539.89
|
| Rate for Payer: PHP All Commercial |
$545.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$280.74
|
| Rate for Payer: Sagamore Health Network All Products |
$555.73
|
| Rate for Payer: Signature Care EPO |
$597.48
|
| Rate for Payer: Signature Care PPO |
$633.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$611.88
|
| Rate for Payer: United Healthcare Commercial |
$567.25
|
| Rate for Payer: United Healthcare Medicare |
$237.55
|
|
|
HC X-RAY-SCAPULA LT
|
Facility
OP
|
$479.90
|
|
|
Service Code
|
CPT 73010 LT
|
| Hospital Charge Code |
01613010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$158.37 |
| Max. Negotiated Rate |
$446.31 |
| Rate for Payer: Aetna Commercial |
$405.04
|
| Rate for Payer: Aetna Medicare |
$158.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$158.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$275.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$299.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$182.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$174.20
|
| Rate for Payer: Cash Price |
$297.54
|
| Rate for Payer: Centivo All Commercial |
$244.75
|
| Rate for Payer: Cigna All Commercial |
$414.15
|
| Rate for Payer: CORVEL All Commercial |
$446.31
|
| Rate for Payer: Coventry All Commercial |
$422.31
|
| Rate for Payer: Encore All Commercial |
$441.75
|
| Rate for Payer: Frontpath All Commercial |
$441.51
|
| Rate for Payer: Humana ChoiceCare |
$414.49
|
| Rate for Payer: Humana Medicare |
$244.75
|
| Rate for Payer: Lucent All Commercial |
$244.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$431.91
|
| Rate for Payer: PHCS All Commercial |
$359.92
|
| Rate for Payer: PHP All Commercial |
$363.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$187.16
|
| Rate for Payer: Sagamore Health Network All Products |
$370.48
|
| Rate for Payer: Signature Care EPO |
$398.32
|
| Rate for Payer: Signature Care PPO |
$422.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$407.91
|
| Rate for Payer: United Healthcare Commercial |
$378.16
|
| Rate for Payer: United Healthcare Medicare |
$158.37
|
|
|
HC X-RAY-SCAPULA LT
|
Facility
IP
|
$479.90
|
|
|
Service Code
|
CPT 73010 LT
|
| Hospital Charge Code |
01613010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$359.92 |
| Max. Negotiated Rate |
$446.31 |
| Rate for Payer: Aetna Commercial |
$414.63
|
| Rate for Payer: Cash Price |
$297.54
|
| Rate for Payer: Cigna All Commercial |
$414.15
|
| Rate for Payer: CORVEL All Commercial |
$446.31
|
| Rate for Payer: Coventry All Commercial |
$422.31
|
| Rate for Payer: Encore All Commercial |
$441.75
|
| Rate for Payer: Frontpath All Commercial |
$441.51
|
| Rate for Payer: Humana ChoiceCare |
$414.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$431.91
|
| Rate for Payer: PHCS All Commercial |
$359.92
|
| Rate for Payer: PHP All Commercial |
$363.96
|
| Rate for Payer: Sagamore Health Network All Products |
$370.48
|
| Rate for Payer: Signature Care EPO |
$398.32
|
| Rate for Payer: Signature Care PPO |
$422.31
|
| Rate for Payer: United Healthcare Commercial |
$378.16
|
|
|
HC X-RAY-SCAPULA RT
|
Facility
OP
|
$479.90
|
|
|
Service Code
|
CPT 73010 RT
|
| Hospital Charge Code |
11613010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$158.37 |
| Max. Negotiated Rate |
$446.31 |
| Rate for Payer: Aetna Commercial |
$405.04
|
| Rate for Payer: Aetna Medicare |
$158.37
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$158.37
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$275.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$299.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$182.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$174.20
|
| Rate for Payer: Cash Price |
$297.54
|
| Rate for Payer: Centivo All Commercial |
$244.75
|
| Rate for Payer: Cigna All Commercial |
$414.15
|
| Rate for Payer: CORVEL All Commercial |
$446.31
|
| Rate for Payer: Coventry All Commercial |
$422.31
|
| Rate for Payer: Encore All Commercial |
$441.75
|
| Rate for Payer: Frontpath All Commercial |
$441.51
|
| Rate for Payer: Humana ChoiceCare |
$414.49
|
| Rate for Payer: Humana Medicare |
$244.75
|
| Rate for Payer: Lucent All Commercial |
$244.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$431.91
|
| Rate for Payer: PHCS All Commercial |
$359.92
|
| Rate for Payer: PHP All Commercial |
$363.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$187.16
|
| Rate for Payer: Sagamore Health Network All Products |
$370.48
|
| Rate for Payer: Signature Care EPO |
$398.32
|
| Rate for Payer: Signature Care PPO |
$422.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$407.91
|
| Rate for Payer: United Healthcare Commercial |
$378.16
|
| Rate for Payer: United Healthcare Medicare |
$158.37
|
|
|
HC X-RAY-SCAPULA RT
|
Facility
IP
|
$479.90
|
|
|
Service Code
|
CPT 73010 RT
|
| Hospital Charge Code |
11613010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$359.92 |
| Max. Negotiated Rate |
$446.31 |
| Rate for Payer: Aetna Commercial |
$414.63
|
| Rate for Payer: Cash Price |
$297.54
|
| Rate for Payer: Cigna All Commercial |
$414.15
|
| Rate for Payer: CORVEL All Commercial |
$446.31
|
| Rate for Payer: Coventry All Commercial |
$422.31
|
| Rate for Payer: Encore All Commercial |
$441.75
|
| Rate for Payer: Frontpath All Commercial |
$441.51
|
| Rate for Payer: Humana ChoiceCare |
$414.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$431.91
|
| Rate for Payer: PHCS All Commercial |
$359.92
|
| Rate for Payer: PHP All Commercial |
$363.96
|
| Rate for Payer: Sagamore Health Network All Products |
$370.48
|
| Rate for Payer: Signature Care EPO |
$398.32
|
| Rate for Payer: Signature Care PPO |
$422.31
|
| Rate for Payer: United Healthcare Commercial |
$378.16
|
|
|
HC X-RAY-SHOULDER MIN 2 VIEWS BI
|
Facility
IP
|
$779.65
|
|
|
Service Code
|
CPT 73030 50
|
| Hospital Charge Code |
21613031
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$584.74 |
| Max. Negotiated Rate |
$725.07 |
| Rate for Payer: Aetna Commercial |
$673.62
|
| Rate for Payer: Cash Price |
$483.38
|
| Rate for Payer: Cigna All Commercial |
$672.84
|
| Rate for Payer: CORVEL All Commercial |
$725.07
|
| Rate for Payer: Coventry All Commercial |
$686.09
|
| Rate for Payer: Encore All Commercial |
$717.67
|
| Rate for Payer: Frontpath All Commercial |
$717.28
|
| Rate for Payer: Humana ChoiceCare |
$673.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$701.68
|
| Rate for Payer: PHCS All Commercial |
$584.74
|
| Rate for Payer: PHP All Commercial |
$591.28
|
| Rate for Payer: Sagamore Health Network All Products |
$601.89
|
| Rate for Payer: Signature Care EPO |
$647.11
|
| Rate for Payer: Signature Care PPO |
$686.09
|
| Rate for Payer: United Healthcare Commercial |
$614.36
|
|
|
HC X-RAY-SHOULDER MIN 2 VIEWS BI
|
Facility
OP
|
$779.65
|
|
|
Service Code
|
CPT 73030 50
|
| Hospital Charge Code |
21613031
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$257.28 |
| Max. Negotiated Rate |
$725.07 |
| Rate for Payer: Aetna Commercial |
$658.02
|
| Rate for Payer: Aetna Medicare |
$257.28
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$257.28
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$447.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$487.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$295.88
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$283.01
|
| Rate for Payer: Cash Price |
$483.38
|
| Rate for Payer: Centivo All Commercial |
$397.62
|
| Rate for Payer: Cigna All Commercial |
$672.84
|
| Rate for Payer: CORVEL All Commercial |
$725.07
|
| Rate for Payer: Coventry All Commercial |
$686.09
|
| Rate for Payer: Encore All Commercial |
$717.67
|
| Rate for Payer: Frontpath All Commercial |
$717.28
|
| Rate for Payer: Humana ChoiceCare |
$673.38
|
| Rate for Payer: Humana Medicare |
$397.62
|
| Rate for Payer: Lucent All Commercial |
$397.62
|
| Rate for Payer: Lutheran Preferred All Commercial |
$701.68
|
| Rate for Payer: PHCS All Commercial |
$584.74
|
| Rate for Payer: PHP All Commercial |
$591.28
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$304.06
|
| Rate for Payer: Sagamore Health Network All Products |
$601.89
|
| Rate for Payer: Signature Care EPO |
$647.11
|
| Rate for Payer: Signature Care PPO |
$686.09
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$662.70
|
| Rate for Payer: United Healthcare Commercial |
$614.36
|
| Rate for Payer: United Healthcare Medicare |
$257.28
|
|
|
HC X-RAY-SHOULDER MIN 2 VIEWS LT
|
Facility
OP
|
$519.75
|
|
|
Service Code
|
CPT 73030 LT
|
| Hospital Charge Code |
01613031
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$171.52 |
| Max. Negotiated Rate |
$483.37 |
| Rate for Payer: Aetna Commercial |
$438.67
|
| Rate for Payer: Aetna Medicare |
$171.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$171.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$298.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$324.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$197.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$188.67
|
| Rate for Payer: Cash Price |
$322.25
|
| Rate for Payer: Centivo All Commercial |
$265.07
|
| Rate for Payer: Cigna All Commercial |
$448.55
|
| Rate for Payer: CORVEL All Commercial |
$483.37
|
| Rate for Payer: Coventry All Commercial |
$457.38
|
| Rate for Payer: Encore All Commercial |
$478.43
|
| Rate for Payer: Frontpath All Commercial |
$478.17
|
| Rate for Payer: Humana ChoiceCare |
$448.91
|
| Rate for Payer: Humana Medicare |
$265.07
|
| Rate for Payer: Lucent All Commercial |
$265.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$467.78
|
| Rate for Payer: PHCS All Commercial |
$389.81
|
| Rate for Payer: PHP All Commercial |
$394.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$202.70
|
| Rate for Payer: Sagamore Health Network All Products |
$401.25
|
| Rate for Payer: Signature Care EPO |
$431.39
|
| Rate for Payer: Signature Care PPO |
$457.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$441.79
|
| Rate for Payer: United Healthcare Commercial |
$409.56
|
| Rate for Payer: United Healthcare Medicare |
$171.52
|
|
|
HC X-RAY-SHOULDER MIN 2 VIEWS LT
|
Facility
IP
|
$519.75
|
|
|
Service Code
|
CPT 73030 LT
|
| Hospital Charge Code |
01613031
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$389.81 |
| Max. Negotiated Rate |
$483.37 |
| Rate for Payer: Aetna Commercial |
$449.07
|
| Rate for Payer: Cash Price |
$322.25
|
| Rate for Payer: Cigna All Commercial |
$448.55
|
| Rate for Payer: CORVEL All Commercial |
$483.37
|
| Rate for Payer: Coventry All Commercial |
$457.38
|
| Rate for Payer: Encore All Commercial |
$478.43
|
| Rate for Payer: Frontpath All Commercial |
$478.17
|
| Rate for Payer: Humana ChoiceCare |
$448.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$467.78
|
| Rate for Payer: PHCS All Commercial |
$389.81
|
| Rate for Payer: PHP All Commercial |
$394.18
|
| Rate for Payer: Sagamore Health Network All Products |
$401.25
|
| Rate for Payer: Signature Care EPO |
$431.39
|
| Rate for Payer: Signature Care PPO |
$457.38
|
| Rate for Payer: United Healthcare Commercial |
$409.56
|
|
