|
HC X-RAY-SHOULDER MIN 2 VIEWS RT
|
Facility
IP
|
$519.75
|
|
|
Service Code
|
CPT 73030 RT
|
| Hospital Charge Code |
11613031
|
|
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
|
|
|
HC X-RAY-SHOULDER MIN 2 VIEWS RT
|
Facility
OP
|
$519.75
|
|
|
Service Code
|
CPT 73030 RT
|
| Hospital Charge Code |
11613031
|
|
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 SINGLE VIEW BI
|
Facility
OP
|
$516.78
|
|
|
Service Code
|
CPT 73020 50
|
| Hospital Charge Code |
21613020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$170.54 |
| Max. Negotiated Rate |
$480.61 |
| Rate for Payer: Aetna Commercial |
$436.16
|
| Rate for Payer: Aetna Medicare |
$170.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$170.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$296.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$323.04
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$196.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$187.59
|
| Rate for Payer: Cash Price |
$320.41
|
| Rate for Payer: Centivo All Commercial |
$263.56
|
| Rate for Payer: Cigna All Commercial |
$445.98
|
| Rate for Payer: CORVEL All Commercial |
$480.61
|
| Rate for Payer: Coventry All Commercial |
$454.77
|
| Rate for Payer: Encore All Commercial |
$475.70
|
| Rate for Payer: Frontpath All Commercial |
$475.44
|
| Rate for Payer: Humana ChoiceCare |
$446.35
|
| Rate for Payer: Humana Medicare |
$263.56
|
| Rate for Payer: Lucent All Commercial |
$263.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$465.10
|
| Rate for Payer: PHCS All Commercial |
$387.59
|
| Rate for Payer: PHP All Commercial |
$391.93
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$201.55
|
| Rate for Payer: Sagamore Health Network All Products |
$398.96
|
| Rate for Payer: Signature Care EPO |
$428.93
|
| Rate for Payer: Signature Care PPO |
$454.77
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$439.27
|
| Rate for Payer: United Healthcare Commercial |
$407.23
|
| Rate for Payer: United Healthcare Medicare |
$170.54
|
|
|
HC X-RAY-SHOULDER SINGLE VIEW BI
|
Facility
IP
|
$516.78
|
|
|
Service Code
|
CPT 73020 50
|
| Hospital Charge Code |
21613020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$387.59 |
| Max. Negotiated Rate |
$480.61 |
| Rate for Payer: Aetna Commercial |
$446.50
|
| Rate for Payer: Cash Price |
$320.41
|
| Rate for Payer: Cigna All Commercial |
$445.98
|
| Rate for Payer: CORVEL All Commercial |
$480.61
|
| Rate for Payer: Coventry All Commercial |
$454.77
|
| Rate for Payer: Encore All Commercial |
$475.70
|
| Rate for Payer: Frontpath All Commercial |
$475.44
|
| Rate for Payer: Humana ChoiceCare |
$446.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$465.10
|
| Rate for Payer: PHCS All Commercial |
$387.59
|
| Rate for Payer: PHP All Commercial |
$391.93
|
| Rate for Payer: Sagamore Health Network All Products |
$398.96
|
| Rate for Payer: Signature Care EPO |
$428.93
|
| Rate for Payer: Signature Care PPO |
$454.77
|
| Rate for Payer: United Healthcare Commercial |
$407.23
|
|
|
HC X-RAY-SHOULDER SINGLE VIEW LT
|
Facility
OP
|
$344.53
|
|
|
Service Code
|
CPT 73020 LT
|
| Hospital Charge Code |
01613020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$113.69 |
| Max. Negotiated Rate |
$320.41 |
| Rate for Payer: Aetna Commercial |
$290.78
|
| Rate for Payer: Aetna Medicare |
$113.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$113.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$197.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$215.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$130.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$125.06
|
| Rate for Payer: Cash Price |
$213.61
|
| Rate for Payer: Centivo All Commercial |
$175.71
|
| Rate for Payer: Cigna All Commercial |
$297.33
|
| Rate for Payer: CORVEL All Commercial |
$320.41
|
| Rate for Payer: Coventry All Commercial |
$303.18
|
| Rate for Payer: Encore All Commercial |
$317.14
|
| Rate for Payer: Frontpath All Commercial |
$316.96
|
| Rate for Payer: Humana ChoiceCare |
$297.57
|
| Rate for Payer: Humana Medicare |
$175.71
|
| Rate for Payer: Lucent All Commercial |
$175.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$310.07
|
| Rate for Payer: PHCS All Commercial |
$258.39
|
| Rate for Payer: PHP All Commercial |
$261.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$134.36
|
| Rate for Payer: Sagamore Health Network All Products |
$265.97
|
| Rate for Payer: Signature Care EPO |
$285.96
|
| Rate for Payer: Signature Care PPO |
$303.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$292.85
|
| Rate for Payer: United Healthcare Commercial |
$271.49
|
| Rate for Payer: United Healthcare Medicare |
$113.69
|
|
|
HC X-RAY-SHOULDER SINGLE VIEW LT
|
Facility
IP
|
$344.53
|
|
|
Service Code
|
CPT 73020 LT
|
| Hospital Charge Code |
01613020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$258.39 |
| Max. Negotiated Rate |
$320.41 |
| Rate for Payer: Aetna Commercial |
$297.67
|
| Rate for Payer: Cash Price |
$213.61
|
| Rate for Payer: Cigna All Commercial |
$297.33
|
| Rate for Payer: CORVEL All Commercial |
$320.41
|
| Rate for Payer: Coventry All Commercial |
$303.18
|
| Rate for Payer: Encore All Commercial |
$317.14
|
| Rate for Payer: Frontpath All Commercial |
$316.96
|
| Rate for Payer: Humana ChoiceCare |
$297.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$310.07
|
| Rate for Payer: PHCS All Commercial |
$258.39
|
| Rate for Payer: PHP All Commercial |
$261.29
|
| Rate for Payer: Sagamore Health Network All Products |
$265.97
|
| Rate for Payer: Signature Care EPO |
$285.96
|
| Rate for Payer: Signature Care PPO |
$303.18
|
| Rate for Payer: United Healthcare Commercial |
$271.49
|
|
|
HC X-RAY-SHOULDER SINGLE VIEW RT
|
Facility
OP
|
$344.53
|
|
|
Service Code
|
CPT 73020 RT
|
| Hospital Charge Code |
11613020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$113.69 |
| Max. Negotiated Rate |
$320.41 |
| Rate for Payer: Aetna Commercial |
$290.78
|
| Rate for Payer: Aetna Medicare |
$113.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$113.69
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$197.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$215.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$130.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$125.06
|
| Rate for Payer: Cash Price |
$213.61
|
| Rate for Payer: Centivo All Commercial |
$175.71
|
| Rate for Payer: Cigna All Commercial |
$297.33
|
| Rate for Payer: CORVEL All Commercial |
$320.41
|
| Rate for Payer: Coventry All Commercial |
$303.18
|
| Rate for Payer: Encore All Commercial |
$317.14
|
| Rate for Payer: Frontpath All Commercial |
$316.96
|
| Rate for Payer: Humana ChoiceCare |
$297.57
|
| Rate for Payer: Humana Medicare |
$175.71
|
| Rate for Payer: Lucent All Commercial |
$175.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$310.07
|
| Rate for Payer: PHCS All Commercial |
$258.39
|
| Rate for Payer: PHP All Commercial |
$261.29
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$134.36
|
| Rate for Payer: Sagamore Health Network All Products |
$265.97
|
| Rate for Payer: Signature Care EPO |
$285.96
|
| Rate for Payer: Signature Care PPO |
$303.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$292.85
|
| Rate for Payer: United Healthcare Commercial |
$271.49
|
| Rate for Payer: United Healthcare Medicare |
$113.69
|
|
|
HC X-RAY-SHOULDER SINGLE VIEW RT
|
Facility
IP
|
$344.53
|
|
|
Service Code
|
CPT 73020 RT
|
| Hospital Charge Code |
11613020
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$258.39 |
| Max. Negotiated Rate |
$320.41 |
| Rate for Payer: Aetna Commercial |
$297.67
|
| Rate for Payer: Cash Price |
$213.61
|
| Rate for Payer: Cigna All Commercial |
$297.33
|
| Rate for Payer: CORVEL All Commercial |
$320.41
|
| Rate for Payer: Coventry All Commercial |
$303.18
|
| Rate for Payer: Encore All Commercial |
$317.14
|
| Rate for Payer: Frontpath All Commercial |
$316.96
|
| Rate for Payer: Humana ChoiceCare |
$297.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$310.07
|
| Rate for Payer: PHCS All Commercial |
$258.39
|
| Rate for Payer: PHP All Commercial |
$261.29
|
| Rate for Payer: Sagamore Health Network All Products |
$265.97
|
| Rate for Payer: Signature Care EPO |
$285.96
|
| Rate for Payer: Signature Care PPO |
$303.18
|
| Rate for Payer: United Healthcare Commercial |
$271.49
|
|
|
HC X-RAY-SINUSES(2 VIEWS OR LESS)
|
Facility
OP
|
$586.29
|
|
|
Service Code
|
CPT 70210
|
| Hospital Charge Code |
01610210
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$60.53 |
| Max. Negotiated Rate |
$545.25 |
| Rate for Payer: Aetna Commercial |
$494.83
|
| Rate for Payer: Aetna Medicare |
$193.47
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$193.47
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$336.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$366.49
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$60.53
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$222.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$212.82
|
| Rate for Payer: Cash Price |
$363.50
|
| Rate for Payer: Cash Price |
$363.50
|
| Rate for Payer: Centivo All Commercial |
$299.01
|
| Rate for Payer: Cigna All Commercial |
$505.96
|
| Rate for Payer: CORVEL All Commercial |
$545.25
|
| Rate for Payer: Coventry All Commercial |
$515.93
|
| Rate for Payer: Encore All Commercial |
$539.68
|
| Rate for Payer: Frontpath All Commercial |
$539.38
|
| Rate for Payer: Humana ChoiceCare |
$506.38
|
| Rate for Payer: Humana Medicare |
$299.01
|
| Rate for Payer: Lucent All Commercial |
$299.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$527.66
|
| Rate for Payer: Managed Health Services Medicaid |
$60.53
|
| Rate for Payer: MDWise Medicaid |
$60.53
|
| Rate for Payer: PHCS All Commercial |
$439.71
|
| Rate for Payer: PHP All Commercial |
$444.64
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$228.65
|
| Rate for Payer: Sagamore Health Network All Products |
$452.61
|
| Rate for Payer: Signature Care EPO |
$486.62
|
| Rate for Payer: Signature Care PPO |
$515.93
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$498.34
|
| Rate for Payer: United Healthcare Commercial |
$461.99
|
| Rate for Payer: United Healthcare Medicare |
$193.47
|
|
|
HC X-RAY-SINUSES(2 VIEWS OR LESS)
|
Facility
IP
|
$586.29
|
|
|
Service Code
|
CPT 70210
|
| Hospital Charge Code |
01610210
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$439.71 |
| Max. Negotiated Rate |
$545.25 |
| Rate for Payer: Aetna Commercial |
$506.55
|
| Rate for Payer: Cash Price |
$363.50
|
| Rate for Payer: Cigna All Commercial |
$505.96
|
| Rate for Payer: CORVEL All Commercial |
$545.25
|
| Rate for Payer: Coventry All Commercial |
$515.93
|
| Rate for Payer: Encore All Commercial |
$539.68
|
| Rate for Payer: Frontpath All Commercial |
$539.38
|
| Rate for Payer: Humana ChoiceCare |
$506.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$527.66
|
| Rate for Payer: PHCS All Commercial |
$439.71
|
| Rate for Payer: PHP All Commercial |
$444.64
|
| Rate for Payer: Sagamore Health Network All Products |
$452.61
|
| Rate for Payer: Signature Care EPO |
$486.62
|
| Rate for Payer: Signature Care PPO |
$515.93
|
| Rate for Payer: United Healthcare Commercial |
$461.99
|
|
|
HC X-RAY-SINUS TRACT INJECTION
|
Facility
OP
|
$897.69
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
01611181
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$93.41 |
| Max. Negotiated Rate |
$834.85 |
| Rate for Payer: Aetna Commercial |
$757.65
|
| Rate for Payer: Aetna Medicare |
$296.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$296.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$515.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$561.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$93.41
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$340.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$325.86
|
| Rate for Payer: Cash Price |
$556.57
|
| Rate for Payer: Cash Price |
$556.57
|
| Rate for Payer: Centivo All Commercial |
$457.82
|
| Rate for Payer: Cigna All Commercial |
$774.71
|
| Rate for Payer: CORVEL All Commercial |
$834.85
|
| Rate for Payer: Coventry All Commercial |
$789.97
|
| Rate for Payer: Encore All Commercial |
$826.33
|
| Rate for Payer: Frontpath All Commercial |
$825.88
|
| Rate for Payer: Humana ChoiceCare |
$775.34
|
| Rate for Payer: Humana Medicare |
$457.82
|
| Rate for Payer: Lucent All Commercial |
$457.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$807.92
|
| Rate for Payer: Managed Health Services Medicaid |
$93.41
|
| Rate for Payer: MDWise Medicaid |
$93.41
|
| Rate for Payer: PHCS All Commercial |
$673.27
|
| Rate for Payer: PHP All Commercial |
$680.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$350.10
|
| Rate for Payer: Sagamore Health Network All Products |
$693.02
|
| Rate for Payer: Signature Care EPO |
$745.08
|
| Rate for Payer: Signature Care PPO |
$789.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$763.04
|
| Rate for Payer: United Healthcare Commercial |
$707.38
|
| Rate for Payer: United Healthcare Medicare |
$296.24
|
|
|
HC X-RAY-SINUS TRACT INJECTION
|
Facility
IP
|
$897.69
|
|
|
Service Code
|
CPT 76080
|
| Hospital Charge Code |
01611181
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$673.27 |
| Max. Negotiated Rate |
$834.85 |
| Rate for Payer: Aetna Commercial |
$775.61
|
| Rate for Payer: Cash Price |
$556.57
|
| Rate for Payer: Cigna All Commercial |
$774.71
|
| Rate for Payer: CORVEL All Commercial |
$834.85
|
| Rate for Payer: Coventry All Commercial |
$789.97
|
| Rate for Payer: Encore All Commercial |
$826.33
|
| Rate for Payer: Frontpath All Commercial |
$825.88
|
| Rate for Payer: Humana ChoiceCare |
$775.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$807.92
|
| Rate for Payer: PHCS All Commercial |
$673.27
|
| Rate for Payer: PHP All Commercial |
$680.81
|
| Rate for Payer: Sagamore Health Network All Products |
$693.02
|
| Rate for Payer: Signature Care EPO |
$745.08
|
| Rate for Payer: Signature Care PPO |
$789.97
|
| Rate for Payer: United Healthcare Commercial |
$707.38
|
|
|
HC X-RAY-SKULL 3 OR LESS VIEWS
|
Facility
OP
|
$329.04
|
|
|
Service Code
|
CPT 70250
|
| Hospital Charge Code |
01610261
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$306.01 |
| Rate for Payer: Aetna Commercial |
$277.71
|
| Rate for Payer: Aetna Medicare |
$108.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$108.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$188.97
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$205.68
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$68.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$124.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$119.44
|
| Rate for Payer: Cash Price |
$204.01
|
| Rate for Payer: Cash Price |
$204.01
|
| Rate for Payer: Centivo All Commercial |
$167.81
|
| Rate for Payer: Cigna All Commercial |
$283.96
|
| Rate for Payer: CORVEL All Commercial |
$306.01
|
| Rate for Payer: Coventry All Commercial |
$289.56
|
| Rate for Payer: Encore All Commercial |
$302.88
|
| Rate for Payer: Frontpath All Commercial |
$302.72
|
| Rate for Payer: Humana ChoiceCare |
$284.19
|
| Rate for Payer: Humana Medicare |
$167.81
|
| Rate for Payer: Lucent All Commercial |
$167.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$296.14
|
| Rate for Payer: Managed Health Services Medicaid |
$68.29
|
| Rate for Payer: MDWise Medicaid |
$68.29
|
| Rate for Payer: PHCS All Commercial |
$246.78
|
| Rate for Payer: PHP All Commercial |
$249.55
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$128.33
|
| Rate for Payer: Sagamore Health Network All Products |
$254.02
|
| Rate for Payer: Signature Care EPO |
$273.10
|
| Rate for Payer: Signature Care PPO |
$289.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$279.69
|
| Rate for Payer: United Healthcare Commercial |
$259.28
|
| Rate for Payer: United Healthcare Medicare |
$108.58
|
|
|
HC X-RAY-SKULL 3 OR LESS VIEWS
|
Facility
IP
|
$329.04
|
|
|
Service Code
|
CPT 70250
|
| Hospital Charge Code |
01610261
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$246.78 |
| Max. Negotiated Rate |
$306.01 |
| Rate for Payer: Aetna Commercial |
$284.29
|
| Rate for Payer: Cash Price |
$204.01
|
| Rate for Payer: Cigna All Commercial |
$283.96
|
| Rate for Payer: CORVEL All Commercial |
$306.01
|
| Rate for Payer: Coventry All Commercial |
$289.56
|
| Rate for Payer: Encore All Commercial |
$302.88
|
| Rate for Payer: Frontpath All Commercial |
$302.72
|
| Rate for Payer: Humana ChoiceCare |
$284.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$296.14
|
| Rate for Payer: PHCS All Commercial |
$246.78
|
| Rate for Payer: PHP All Commercial |
$249.55
|
| Rate for Payer: Sagamore Health Network All Products |
$254.02
|
| Rate for Payer: Signature Care EPO |
$273.10
|
| Rate for Payer: Signature Care PPO |
$289.56
|
| Rate for Payer: United Healthcare Commercial |
$259.28
|
|
|
HC X-RAY-SKULL 4 OR MORE VIEWS
|
Facility
OP
|
$823.84
|
|
|
Service Code
|
CPT 70260
|
| Hospital Charge Code |
01610260
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$83.73 |
| Max. Negotiated Rate |
$766.17 |
| Rate for Payer: Aetna Commercial |
$695.32
|
| Rate for Payer: Aetna Medicare |
$271.87
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$271.87
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$473.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$514.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$83.73
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$312.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$299.06
|
| Rate for Payer: Cash Price |
$510.78
|
| Rate for Payer: Cash Price |
$510.78
|
| Rate for Payer: Centivo All Commercial |
$420.16
|
| Rate for Payer: Cigna All Commercial |
$710.98
|
| Rate for Payer: CORVEL All Commercial |
$766.17
|
| Rate for Payer: Coventry All Commercial |
$724.98
|
| Rate for Payer: Encore All Commercial |
$758.35
|
| Rate for Payer: Frontpath All Commercial |
$757.94
|
| Rate for Payer: Humana ChoiceCare |
$711.55
|
| Rate for Payer: Humana Medicare |
$420.16
|
| Rate for Payer: Lucent All Commercial |
$420.16
|
| Rate for Payer: Lutheran Preferred All Commercial |
$741.46
|
| Rate for Payer: Managed Health Services Medicaid |
$83.73
|
| Rate for Payer: MDWise Medicaid |
$83.73
|
| Rate for Payer: PHCS All Commercial |
$617.88
|
| Rate for Payer: PHP All Commercial |
$624.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$321.30
|
| Rate for Payer: Sagamore Health Network All Products |
$636.01
|
| Rate for Payer: Signature Care EPO |
$683.79
|
| Rate for Payer: Signature Care PPO |
$724.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$700.27
|
| Rate for Payer: United Healthcare Commercial |
$649.19
|
| Rate for Payer: United Healthcare Medicare |
$271.87
|
|
|
HC X-RAY-SKULL 4 OR MORE VIEWS
|
Facility
IP
|
$823.84
|
|
|
Service Code
|
CPT 70260
|
| Hospital Charge Code |
01610260
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$617.88 |
| Max. Negotiated Rate |
$766.17 |
| Rate for Payer: Aetna Commercial |
$711.80
|
| Rate for Payer: Cash Price |
$510.78
|
| Rate for Payer: Cigna All Commercial |
$710.98
|
| Rate for Payer: CORVEL All Commercial |
$766.17
|
| Rate for Payer: Coventry All Commercial |
$724.98
|
| Rate for Payer: Encore All Commercial |
$758.35
|
| Rate for Payer: Frontpath All Commercial |
$757.94
|
| Rate for Payer: Humana ChoiceCare |
$711.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$741.46
|
| Rate for Payer: PHCS All Commercial |
$617.88
|
| Rate for Payer: PHP All Commercial |
$624.80
|
| Rate for Payer: Sagamore Health Network All Products |
$636.01
|
| Rate for Payer: Signature Care EPO |
$683.79
|
| Rate for Payer: Signature Care PPO |
$724.98
|
| Rate for Payer: United Healthcare Commercial |
$649.19
|
|
|
HC X-RAY-SMALL BOWEL ONLY
|
Facility
OP
|
$1,077.49
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
01614250
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$234.43 |
| Max. Negotiated Rate |
$1,002.06 |
| Rate for Payer: Aetna Commercial |
$909.40
|
| Rate for Payer: Aetna Medicare |
$355.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$355.57
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$618.80
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$673.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$234.43
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$408.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$391.13
|
| Rate for Payer: Cash Price |
$668.04
|
| Rate for Payer: Cash Price |
$668.04
|
| Rate for Payer: Centivo All Commercial |
$549.52
|
| Rate for Payer: Cigna All Commercial |
$929.87
|
| Rate for Payer: CORVEL All Commercial |
$1,002.06
|
| Rate for Payer: Coventry All Commercial |
$948.19
|
| Rate for Payer: Encore All Commercial |
$991.83
|
| Rate for Payer: Frontpath All Commercial |
$991.29
|
| Rate for Payer: Humana ChoiceCare |
$930.63
|
| Rate for Payer: Humana Medicare |
$549.52
|
| Rate for Payer: Lucent All Commercial |
$549.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$969.74
|
| Rate for Payer: Managed Health Services Medicaid |
$234.43
|
| Rate for Payer: MDWise Medicaid |
$234.43
|
| Rate for Payer: PHCS All Commercial |
$808.12
|
| Rate for Payer: PHP All Commercial |
$817.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$420.22
|
| Rate for Payer: Sagamore Health Network All Products |
$831.82
|
| Rate for Payer: Signature Care EPO |
$894.31
|
| Rate for Payer: Signature Care PPO |
$948.19
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$915.86
|
| Rate for Payer: United Healthcare Commercial |
$849.06
|
| Rate for Payer: United Healthcare Medicare |
$355.57
|
|
|
HC X-RAY-SMALL BOWEL ONLY
|
Facility
IP
|
$1,077.49
|
|
|
Service Code
|
CPT 74250
|
| Hospital Charge Code |
01614250
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$808.12 |
| Max. Negotiated Rate |
$1,002.06 |
| Rate for Payer: Aetna Commercial |
$930.95
|
| Rate for Payer: Cash Price |
$668.04
|
| Rate for Payer: Cigna All Commercial |
$929.87
|
| Rate for Payer: CORVEL All Commercial |
$1,002.06
|
| Rate for Payer: Coventry All Commercial |
$948.19
|
| Rate for Payer: Encore All Commercial |
$991.83
|
| Rate for Payer: Frontpath All Commercial |
$991.29
|
| Rate for Payer: Humana ChoiceCare |
$930.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$969.74
|
| Rate for Payer: PHCS All Commercial |
$808.12
|
| Rate for Payer: PHP All Commercial |
$817.17
|
| Rate for Payer: Sagamore Health Network All Products |
$831.82
|
| Rate for Payer: Signature Care EPO |
$894.31
|
| Rate for Payer: Signature Care PPO |
$948.19
|
| Rate for Payer: United Healthcare Commercial |
$849.06
|
|
|
HC X-RAY SM INT FOLLOW-THRU STUDY
|
Facility
IP
|
$808.12
|
|
|
Service Code
|
CPT 74248
|
| Hospital Charge Code |
01614248
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$606.09 |
| Max. Negotiated Rate |
$751.55 |
| Rate for Payer: Aetna Commercial |
$698.21
|
| Rate for Payer: Cash Price |
$501.03
|
| Rate for Payer: Cigna All Commercial |
$697.40
|
| Rate for Payer: CORVEL All Commercial |
$751.55
|
| Rate for Payer: Coventry All Commercial |
$711.14
|
| Rate for Payer: Encore All Commercial |
$743.87
|
| Rate for Payer: Frontpath All Commercial |
$743.47
|
| Rate for Payer: Humana ChoiceCare |
$697.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$727.30
|
| Rate for Payer: PHCS All Commercial |
$606.09
|
| Rate for Payer: PHP All Commercial |
$612.87
|
| Rate for Payer: Sagamore Health Network All Products |
$623.87
|
| Rate for Payer: Signature Care EPO |
$670.74
|
| Rate for Payer: Signature Care PPO |
$711.14
|
| Rate for Payer: United Healthcare Commercial |
$636.79
|
|
|
HC X-RAY SM INT FOLLOW-THRU STUDY
|
Facility
OP
|
$808.12
|
|
|
Service Code
|
CPT 74248
|
| Hospital Charge Code |
01614248
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$128.51 |
| Max. Negotiated Rate |
$751.55 |
| Rate for Payer: Aetna Commercial |
$682.05
|
| Rate for Payer: Aetna Medicare |
$266.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$266.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$464.10
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$505.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$128.51
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$306.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$293.35
|
| Rate for Payer: Cash Price |
$501.03
|
| Rate for Payer: Cash Price |
$501.03
|
| Rate for Payer: Centivo All Commercial |
$412.14
|
| Rate for Payer: Cigna All Commercial |
$697.40
|
| Rate for Payer: CORVEL All Commercial |
$751.55
|
| Rate for Payer: Coventry All Commercial |
$711.14
|
| Rate for Payer: Encore All Commercial |
$743.87
|
| Rate for Payer: Frontpath All Commercial |
$743.47
|
| Rate for Payer: Humana ChoiceCare |
$697.97
|
| Rate for Payer: Humana Medicare |
$412.14
|
| Rate for Payer: Lucent All Commercial |
$412.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$727.30
|
| Rate for Payer: Managed Health Services Medicaid |
$128.51
|
| Rate for Payer: MDWise Medicaid |
$128.51
|
| Rate for Payer: PHCS All Commercial |
$606.09
|
| Rate for Payer: PHP All Commercial |
$612.87
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$315.17
|
| Rate for Payer: Sagamore Health Network All Products |
$623.87
|
| Rate for Payer: Signature Care EPO |
$670.74
|
| Rate for Payer: Signature Care PPO |
$711.14
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$686.90
|
| Rate for Payer: United Healthcare Commercial |
$636.79
|
| Rate for Payer: United Healthcare Medicare |
$266.68
|
|
|
HC X-RAY-SPINE ENTIRE 1 VIEW
|
Facility
OP
|
$452.56
|
|
|
Service Code
|
CPT 72081
|
| Hospital Charge Code |
01612015
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$68.29 |
| Max. Negotiated Rate |
$420.88 |
| Rate for Payer: Aetna Commercial |
$381.96
|
| Rate for Payer: Aetna Medicare |
$149.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$149.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$259.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$282.90
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$68.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$171.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$164.28
|
| Rate for Payer: Cash Price |
$280.59
|
| Rate for Payer: Cash Price |
$280.59
|
| Rate for Payer: Centivo All Commercial |
$230.81
|
| Rate for Payer: Cigna All Commercial |
$390.56
|
| Rate for Payer: CORVEL All Commercial |
$420.88
|
| Rate for Payer: Coventry All Commercial |
$398.26
|
| Rate for Payer: Encore All Commercial |
$416.58
|
| Rate for Payer: Frontpath All Commercial |
$416.36
|
| Rate for Payer: Humana ChoiceCare |
$390.88
|
| Rate for Payer: Humana Medicare |
$230.81
|
| Rate for Payer: Lucent All Commercial |
$230.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$407.31
|
| Rate for Payer: Managed Health Services Medicaid |
$68.29
|
| Rate for Payer: MDWise Medicaid |
$68.29
|
| Rate for Payer: PHCS All Commercial |
$339.42
|
| Rate for Payer: PHP All Commercial |
$343.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$176.50
|
| Rate for Payer: Sagamore Health Network All Products |
$349.38
|
| Rate for Payer: Signature Care EPO |
$375.63
|
| Rate for Payer: Signature Care PPO |
$398.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$384.68
|
| Rate for Payer: United Healthcare Commercial |
$356.62
|
| Rate for Payer: United Healthcare Medicare |
$149.35
|
|
|
HC X-RAY-SPINE ENTIRE 1 VIEW
|
Facility
IP
|
$452.56
|
|
|
Service Code
|
CPT 72081
|
| Hospital Charge Code |
01612015
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$339.42 |
| Max. Negotiated Rate |
$420.88 |
| Rate for Payer: Aetna Commercial |
$391.02
|
| Rate for Payer: Cash Price |
$280.59
|
| Rate for Payer: Cigna All Commercial |
$390.56
|
| Rate for Payer: CORVEL All Commercial |
$420.88
|
| Rate for Payer: Coventry All Commercial |
$398.26
|
| Rate for Payer: Encore All Commercial |
$416.58
|
| Rate for Payer: Frontpath All Commercial |
$416.36
|
| Rate for Payer: Humana ChoiceCare |
$390.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$407.31
|
| Rate for Payer: PHCS All Commercial |
$339.42
|
| Rate for Payer: PHP All Commercial |
$343.22
|
| Rate for Payer: Sagamore Health Network All Products |
$349.38
|
| Rate for Payer: Signature Care EPO |
$375.63
|
| Rate for Payer: Signature Care PPO |
$398.26
|
| Rate for Payer: United Healthcare Commercial |
$356.62
|
|
|
HC X-RAY-SPINE ENTIRE 2-3 VIEWS
|
Facility
OP
|
$452.56
|
|
|
Service Code
|
CPT 72082
|
| Hospital Charge Code |
01612010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$124.29 |
| Max. Negotiated Rate |
$420.88 |
| Rate for Payer: Aetna Commercial |
$381.96
|
| Rate for Payer: Aetna Medicare |
$149.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$149.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$259.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$282.90
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$124.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$171.75
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$164.28
|
| Rate for Payer: Cash Price |
$280.59
|
| Rate for Payer: Cash Price |
$280.59
|
| Rate for Payer: Centivo All Commercial |
$230.81
|
| Rate for Payer: Cigna All Commercial |
$390.56
|
| Rate for Payer: CORVEL All Commercial |
$420.88
|
| Rate for Payer: Coventry All Commercial |
$398.26
|
| Rate for Payer: Encore All Commercial |
$416.58
|
| Rate for Payer: Frontpath All Commercial |
$416.36
|
| Rate for Payer: Humana ChoiceCare |
$390.88
|
| Rate for Payer: Humana Medicare |
$230.81
|
| Rate for Payer: Lucent All Commercial |
$230.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$407.31
|
| Rate for Payer: Managed Health Services Medicaid |
$124.29
|
| Rate for Payer: MDWise Medicaid |
$124.29
|
| Rate for Payer: PHCS All Commercial |
$339.42
|
| Rate for Payer: PHP All Commercial |
$343.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$176.50
|
| Rate for Payer: Sagamore Health Network All Products |
$349.38
|
| Rate for Payer: Signature Care EPO |
$375.63
|
| Rate for Payer: Signature Care PPO |
$398.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$384.68
|
| Rate for Payer: United Healthcare Commercial |
$356.62
|
| Rate for Payer: United Healthcare Medicare |
$149.35
|
|
|
HC X-RAY-SPINE ENTIRE 2-3 VIEWS
|
Facility
IP
|
$452.56
|
|
|
Service Code
|
CPT 72082
|
| Hospital Charge Code |
01612010
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$339.42 |
| Max. Negotiated Rate |
$420.88 |
| Rate for Payer: Aetna Commercial |
$391.02
|
| Rate for Payer: Cash Price |
$280.59
|
| Rate for Payer: Cigna All Commercial |
$390.56
|
| Rate for Payer: CORVEL All Commercial |
$420.88
|
| Rate for Payer: Coventry All Commercial |
$398.26
|
| Rate for Payer: Encore All Commercial |
$416.58
|
| Rate for Payer: Frontpath All Commercial |
$416.36
|
| Rate for Payer: Humana ChoiceCare |
$390.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$407.31
|
| Rate for Payer: PHCS All Commercial |
$339.42
|
| Rate for Payer: PHP All Commercial |
$343.22
|
| Rate for Payer: Sagamore Health Network All Products |
$349.38
|
| Rate for Payer: Signature Care EPO |
$375.63
|
| Rate for Payer: Signature Care PPO |
$398.26
|
| Rate for Payer: United Healthcare Commercial |
$356.62
|
|
|
HC X-RAY-SPINE SINGLE VIEW
|
Facility
IP
|
$361.68
|
|
|
Service Code
|
CPT 72020
|
| Hospital Charge Code |
01618606
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$271.26 |
| Max. Negotiated Rate |
$336.36 |
| Rate for Payer: Aetna Commercial |
$312.49
|
| Rate for Payer: Cash Price |
$224.24
|
| Rate for Payer: Cigna All Commercial |
$312.13
|
| Rate for Payer: CORVEL All Commercial |
$336.36
|
| Rate for Payer: Coventry All Commercial |
$318.28
|
| Rate for Payer: Encore All Commercial |
$332.93
|
| Rate for Payer: Frontpath All Commercial |
$332.75
|
| Rate for Payer: Humana ChoiceCare |
$312.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$325.51
|
| Rate for Payer: PHCS All Commercial |
$271.26
|
| Rate for Payer: PHP All Commercial |
$274.30
|
| Rate for Payer: Sagamore Health Network All Products |
$279.22
|
| Rate for Payer: Signature Care EPO |
$300.20
|
| Rate for Payer: Signature Care PPO |
$318.28
|
| Rate for Payer: United Healthcare Commercial |
$285.01
|
|
