|
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
|
|
|
HC X-RAY-STERNO CLAVICULAR JOINTS 3+ VIEWS
|
Facility
OP
|
$95.15
|
|
|
Service Code
|
CPT 71130
|
| Hospital Charge Code |
01611130
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$31.40 |
| Max. Negotiated Rate |
$88.49 |
| Rate for Payer: Aetna Commercial |
$80.30
|
| Rate for Payer: Aetna Medicare |
$31.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$54.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$59.48
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$72.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$36.11
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$34.54
|
| Rate for Payer: Cash Price |
$58.99
|
| Rate for Payer: Cash Price |
$58.99
|
| Rate for Payer: Centivo All Commercial |
$48.52
|
| Rate for Payer: Cigna All Commercial |
$82.11
|
| Rate for Payer: CORVEL All Commercial |
$88.49
|
| Rate for Payer: Coventry All Commercial |
$83.73
|
| Rate for Payer: Encore All Commercial |
$87.58
|
| Rate for Payer: Frontpath All Commercial |
$87.53
|
| Rate for Payer: Humana ChoiceCare |
$82.18
|
| Rate for Payer: Humana Medicare |
$48.52
|
| Rate for Payer: Lucent All Commercial |
$48.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$85.63
|
| Rate for Payer: Managed Health Services Medicaid |
$72.15
|
| Rate for Payer: MDWise Medicaid |
$72.15
|
| Rate for Payer: PHCS All Commercial |
$71.36
|
| Rate for Payer: PHP All Commercial |
$72.16
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$37.11
|
| Rate for Payer: Sagamore Health Network All Products |
$73.45
|
| Rate for Payer: Signature Care EPO |
$78.97
|
| Rate for Payer: Signature Care PPO |
$83.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$80.87
|
| Rate for Payer: United Healthcare Commercial |
$74.97
|
| Rate for Payer: United Healthcare Medicare |
$31.40
|
|
|
HC X-RAY-STERNO CLAVICULAR JOINTS 3+ VIEWS
|
Facility
IP
|
$95.15
|
|
|
Service Code
|
CPT 71130
|
| Hospital Charge Code |
01611130
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$71.36 |
| Max. Negotiated Rate |
$88.49 |
| Rate for Payer: Aetna Commercial |
$82.21
|
| Rate for Payer: Cash Price |
$58.99
|
| Rate for Payer: Cigna All Commercial |
$82.11
|
| Rate for Payer: CORVEL All Commercial |
$88.49
|
| Rate for Payer: Coventry All Commercial |
$83.73
|
| Rate for Payer: Encore All Commercial |
$87.58
|
| Rate for Payer: Frontpath All Commercial |
$87.53
|
| Rate for Payer: Humana ChoiceCare |
$82.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$85.63
|
| Rate for Payer: PHCS All Commercial |
$71.36
|
| Rate for Payer: PHP All Commercial |
$72.16
|
| Rate for Payer: Sagamore Health Network All Products |
$73.45
|
| Rate for Payer: Signature Care EPO |
$78.97
|
| Rate for Payer: Signature Care PPO |
$83.73
|
| Rate for Payer: United Healthcare Commercial |
$74.97
|
|
|
HC X-RAY-STERNUM 2+ VIEWS
|
Facility
IP
|
$485.16
|
|
|
Service Code
|
CPT 71120
|
| Hospital Charge Code |
01611120
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$363.87 |
| Max. Negotiated Rate |
$451.20 |
| Rate for Payer: Aetna Commercial |
$419.18
|
| Rate for Payer: Cash Price |
$300.80
|
| Rate for Payer: Cigna All Commercial |
$418.70
|
| Rate for Payer: CORVEL All Commercial |
$451.20
|
| Rate for Payer: Coventry All Commercial |
$426.94
|
| Rate for Payer: Encore All Commercial |
$446.59
|
| Rate for Payer: Frontpath All Commercial |
$446.35
|
| Rate for Payer: Humana ChoiceCare |
$419.04
|
| Rate for Payer: Lutheran Preferred All Commercial |
$436.65
|
| Rate for Payer: PHCS All Commercial |
$363.87
|
| Rate for Payer: PHP All Commercial |
$367.95
|
| Rate for Payer: Sagamore Health Network All Products |
$374.55
|
| Rate for Payer: Signature Care EPO |
$402.69
|
| Rate for Payer: Signature Care PPO |
$426.94
|
| Rate for Payer: United Healthcare Commercial |
$382.31
|
|
|
HC X-RAY-STERNUM 2+ VIEWS
|
Facility
OP
|
$485.16
|
|
|
Service Code
|
CPT 71120
|
| Hospital Charge Code |
01611120
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$59.59 |
| Max. Negotiated Rate |
$451.20 |
| Rate for Payer: Aetna Commercial |
$409.48
|
| Rate for Payer: Aetna Medicare |
$160.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$160.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$278.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$303.28
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$59.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$184.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$176.11
|
| Rate for Payer: Cash Price |
$300.80
|
| Rate for Payer: Cash Price |
$300.80
|
| Rate for Payer: Centivo All Commercial |
$247.43
|
| Rate for Payer: Cigna All Commercial |
$418.70
|
| Rate for Payer: CORVEL All Commercial |
$451.20
|
| Rate for Payer: Coventry All Commercial |
$426.94
|
| Rate for Payer: Encore All Commercial |
$446.59
|
| Rate for Payer: Frontpath All Commercial |
$446.35
|
| Rate for Payer: Humana ChoiceCare |
$419.04
|
| Rate for Payer: Humana Medicare |
$247.43
|
| Rate for Payer: Lucent All Commercial |
$247.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$436.65
|
| Rate for Payer: Managed Health Services Medicaid |
$59.59
|
| Rate for Payer: MDWise Medicaid |
$59.59
|
| Rate for Payer: PHCS All Commercial |
$363.87
|
| Rate for Payer: PHP All Commercial |
$367.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$189.21
|
| Rate for Payer: Sagamore Health Network All Products |
$374.55
|
| Rate for Payer: Signature Care EPO |
$402.69
|
| Rate for Payer: Signature Care PPO |
$426.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$412.39
|
| Rate for Payer: United Healthcare Commercial |
$382.31
|
| Rate for Payer: United Healthcare Medicare |
$160.10
|
|
|
HC X-RAY-SURGICAL CHOLANGIOGRAM
|
Facility
OP
|
$1,090.32
|
|
|
Service Code
|
CPT 74300
|
| Hospital Charge Code |
01614300
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$197.22 |
| Max. Negotiated Rate |
$1,014.00 |
| Rate for Payer: Aetna Commercial |
$920.23
|
| Rate for Payer: Aetna Medicare |
$359.81
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$359.81
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$626.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$681.56
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$197.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$413.78
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$395.79
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Centivo All Commercial |
$556.06
|
| Rate for Payer: Cigna All Commercial |
$940.95
|
| Rate for Payer: CORVEL All Commercial |
$1,014.00
|
| Rate for Payer: Coventry All Commercial |
$959.48
|
| Rate for Payer: Encore All Commercial |
$1,003.64
|
| Rate for Payer: Frontpath All Commercial |
$1,003.09
|
| Rate for Payer: Humana ChoiceCare |
$941.71
|
| Rate for Payer: Humana Medicare |
$556.06
|
| Rate for Payer: Lucent All Commercial |
$556.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$981.29
|
| Rate for Payer: Managed Health Services Medicaid |
$197.22
|
| Rate for Payer: MDWise Medicaid |
$197.22
|
| Rate for Payer: PHCS All Commercial |
$817.74
|
| Rate for Payer: PHP All Commercial |
$826.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$425.22
|
| Rate for Payer: Sagamore Health Network All Products |
$841.73
|
| Rate for Payer: Signature Care EPO |
$904.96
|
| Rate for Payer: Signature Care PPO |
$959.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$926.77
|
| Rate for Payer: United Healthcare Commercial |
$859.17
|
| Rate for Payer: United Healthcare Medicare |
$359.81
|
|
|
HC X-RAY-SURGICAL CHOLANGIOGRAM
|
Facility
IP
|
$1,090.32
|
|
|
Service Code
|
CPT 74300
|
| Hospital Charge Code |
01614300
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$817.74 |
| Max. Negotiated Rate |
$1,014.00 |
| Rate for Payer: Aetna Commercial |
$942.04
|
| Rate for Payer: Cash Price |
$676.00
|
| Rate for Payer: Cigna All Commercial |
$940.95
|
| Rate for Payer: CORVEL All Commercial |
$1,014.00
|
| Rate for Payer: Coventry All Commercial |
$959.48
|
| Rate for Payer: Encore All Commercial |
$1,003.64
|
| Rate for Payer: Frontpath All Commercial |
$1,003.09
|
| Rate for Payer: Humana ChoiceCare |
$941.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$981.29
|
| Rate for Payer: PHCS All Commercial |
$817.74
|
| Rate for Payer: PHP All Commercial |
$826.90
|
| Rate for Payer: Sagamore Health Network All Products |
$841.73
|
| Rate for Payer: Signature Care EPO |
$904.96
|
| Rate for Payer: Signature Care PPO |
$959.48
|
| Rate for Payer: United Healthcare Commercial |
$859.17
|
|
|
HC X-RAY-TEMPOROMANDIBULAR JOINTS BILATERAL
|
Facility
OP
|
$693.33
|
|
|
Service Code
|
CPT 70330
|
| Hospital Charge Code |
01610330
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$100.15 |
| Max. Negotiated Rate |
$644.80 |
| Rate for Payer: Aetna Commercial |
$585.17
|
| Rate for Payer: Aetna Medicare |
$228.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$228.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$398.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$433.40
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$100.15
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$263.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$251.68
|
| Rate for Payer: Cash Price |
$429.87
|
| Rate for Payer: Cash Price |
$429.87
|
| Rate for Payer: Centivo All Commercial |
$353.60
|
| Rate for Payer: Cigna All Commercial |
$598.35
|
| Rate for Payer: CORVEL All Commercial |
$644.80
|
| Rate for Payer: Coventry All Commercial |
$610.13
|
| Rate for Payer: Encore All Commercial |
$638.21
|
| Rate for Payer: Frontpath All Commercial |
$637.87
|
| Rate for Payer: Humana ChoiceCare |
$598.83
|
| Rate for Payer: Humana Medicare |
$353.60
|
| Rate for Payer: Lucent All Commercial |
$353.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$624.00
|
| Rate for Payer: Managed Health Services Medicaid |
$100.15
|
| Rate for Payer: MDWise Medicaid |
$100.15
|
| Rate for Payer: PHCS All Commercial |
$520.00
|
| Rate for Payer: PHP All Commercial |
$525.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$270.40
|
| Rate for Payer: Sagamore Health Network All Products |
$535.25
|
| Rate for Payer: Signature Care EPO |
$575.47
|
| Rate for Payer: Signature Care PPO |
$610.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$589.33
|
| Rate for Payer: United Healthcare Commercial |
$546.35
|
| Rate for Payer: United Healthcare Medicare |
$228.80
|
|
|
HC X-RAY-TEMPOROMANDIBULAR JOINTS BILATERAL
|
Facility
IP
|
$693.33
|
|
|
Service Code
|
CPT 70330
|
| Hospital Charge Code |
01610330
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$520.00 |
| Max. Negotiated Rate |
$644.80 |
| Rate for Payer: Aetna Commercial |
$599.04
|
| Rate for Payer: Cash Price |
$429.87
|
| Rate for Payer: Cigna All Commercial |
$598.35
|
| Rate for Payer: CORVEL All Commercial |
$644.80
|
| Rate for Payer: Coventry All Commercial |
$610.13
|
| Rate for Payer: Encore All Commercial |
$638.21
|
| Rate for Payer: Frontpath All Commercial |
$637.87
|
| Rate for Payer: Humana ChoiceCare |
$598.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$624.00
|
| Rate for Payer: PHCS All Commercial |
$520.00
|
| Rate for Payer: PHP All Commercial |
$525.83
|
| Rate for Payer: Sagamore Health Network All Products |
$535.25
|
| Rate for Payer: Signature Care EPO |
$575.47
|
| Rate for Payer: Signature Care PPO |
$610.13
|
| Rate for Payer: United Healthcare Commercial |
$546.35
|
|
|
HC X-RAY-THORACIC SPINE 2 VIEWS
|
Facility
IP
|
$631.22
|
|
|
Service Code
|
CPT 72070
|
| Hospital Charge Code |
11612070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$473.41 |
| Max. Negotiated Rate |
$587.03 |
| Rate for Payer: Aetna Commercial |
$545.37
|
| Rate for Payer: Cash Price |
$391.35
|
| Rate for Payer: Cigna All Commercial |
$544.74
|
| Rate for Payer: CORVEL All Commercial |
$587.03
|
| Rate for Payer: Coventry All Commercial |
$555.47
|
| Rate for Payer: Encore All Commercial |
$581.04
|
| Rate for Payer: Frontpath All Commercial |
$580.72
|
| Rate for Payer: Humana ChoiceCare |
$545.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$568.10
|
| Rate for Payer: PHCS All Commercial |
$473.41
|
| Rate for Payer: PHP All Commercial |
$478.71
|
| Rate for Payer: Sagamore Health Network All Products |
$487.30
|
| Rate for Payer: Signature Care EPO |
$523.91
|
| Rate for Payer: Signature Care PPO |
$555.47
|
| Rate for Payer: United Healthcare Commercial |
$497.40
|
|
|
HC X-RAY-THORACIC SPINE 2 VIEWS
|
Facility
OP
|
$631.22
|
|
|
Service Code
|
CPT 72070
|
| Hospital Charge Code |
11612070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$61.50 |
| Max. Negotiated Rate |
$587.03 |
| Rate for Payer: Aetna Commercial |
$532.75
|
| Rate for Payer: Aetna Medicare |
$208.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$208.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$362.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$394.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$61.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$239.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$229.13
|
| Rate for Payer: Cash Price |
$391.35
|
| Rate for Payer: Cash Price |
$391.35
|
| Rate for Payer: Centivo All Commercial |
$321.92
|
| Rate for Payer: Cigna All Commercial |
$544.74
|
| Rate for Payer: CORVEL All Commercial |
$587.03
|
| Rate for Payer: Coventry All Commercial |
$555.47
|
| Rate for Payer: Encore All Commercial |
$581.04
|
| Rate for Payer: Frontpath All Commercial |
$580.72
|
| Rate for Payer: Humana ChoiceCare |
$545.18
|
| Rate for Payer: Humana Medicare |
$321.92
|
| Rate for Payer: Lucent All Commercial |
$321.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$568.10
|
| Rate for Payer: Managed Health Services Medicaid |
$61.50
|
| Rate for Payer: MDWise Medicaid |
$61.50
|
| Rate for Payer: PHCS All Commercial |
$473.41
|
| Rate for Payer: PHP All Commercial |
$478.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$246.17
|
| Rate for Payer: Sagamore Health Network All Products |
$487.30
|
| Rate for Payer: Signature Care EPO |
$523.91
|
| Rate for Payer: Signature Care PPO |
$555.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$536.53
|
| Rate for Payer: United Healthcare Commercial |
$497.40
|
| Rate for Payer: United Healthcare Medicare |
$208.30
|
|
|
HC X-RAY-THORACIC SPINE 3 VIEWS
|
Facility
IP
|
$550.70
|
|
|
Service Code
|
CPT 72072
|
| Hospital Charge Code |
01612070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$413.02 |
| Max. Negotiated Rate |
$512.15 |
| Rate for Payer: Aetna Commercial |
$475.80
|
| Rate for Payer: Cash Price |
$341.43
|
| Rate for Payer: Cigna All Commercial |
$475.25
|
| Rate for Payer: CORVEL All Commercial |
$512.15
|
| Rate for Payer: Coventry All Commercial |
$484.61
|
| Rate for Payer: Encore All Commercial |
$506.92
|
| Rate for Payer: Frontpath All Commercial |
$506.64
|
| Rate for Payer: Humana ChoiceCare |
$475.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$495.63
|
| Rate for Payer: PHCS All Commercial |
$413.02
|
| Rate for Payer: PHP All Commercial |
$417.65
|
| Rate for Payer: Sagamore Health Network All Products |
$425.14
|
| Rate for Payer: Signature Care EPO |
$457.08
|
| Rate for Payer: Signature Care PPO |
$484.61
|
| Rate for Payer: United Healthcare Commercial |
$433.95
|
|
|
HC X-RAY-THORACIC SPINE 3 VIEWS
|
Facility
OP
|
$550.70
|
|
|
Service Code
|
CPT 72072
|
| Hospital Charge Code |
01612070
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$73.09 |
| Max. Negotiated Rate |
$512.15 |
| Rate for Payer: Aetna Commercial |
$464.79
|
| Rate for Payer: Aetna Medicare |
$181.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$181.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$316.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$344.24
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$73.09
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$208.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$199.90
|
| Rate for Payer: Cash Price |
$341.43
|
| Rate for Payer: Cash Price |
$341.43
|
| Rate for Payer: Centivo All Commercial |
$280.86
|
| Rate for Payer: Cigna All Commercial |
$475.25
|
| Rate for Payer: CORVEL All Commercial |
$512.15
|
| Rate for Payer: Coventry All Commercial |
$484.61
|
| Rate for Payer: Encore All Commercial |
$506.92
|
| Rate for Payer: Frontpath All Commercial |
$506.64
|
| Rate for Payer: Humana ChoiceCare |
$475.64
|
| Rate for Payer: Humana Medicare |
$280.86
|
| Rate for Payer: Lucent All Commercial |
$280.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$495.63
|
| Rate for Payer: Managed Health Services Medicaid |
$73.09
|
| Rate for Payer: MDWise Medicaid |
$73.09
|
| Rate for Payer: PHCS All Commercial |
$413.02
|
| Rate for Payer: PHP All Commercial |
$417.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$214.77
|
| Rate for Payer: Sagamore Health Network All Products |
$425.14
|
| Rate for Payer: Signature Care EPO |
$457.08
|
| Rate for Payer: Signature Care PPO |
$484.61
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$468.09
|
| Rate for Payer: United Healthcare Commercial |
$433.95
|
| Rate for Payer: United Healthcare Medicare |
$181.73
|
|
|
HC X-RAY-TIBIA-FIBULA 2 VIEWS BI
|
Facility
IP
|
$623.13
|
|
|
Service Code
|
CPT 73590 50
|
| Hospital Charge Code |
21613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$467.35 |
| Max. Negotiated Rate |
$579.51 |
| Rate for Payer: Aetna Commercial |
$538.38
|
| Rate for Payer: Cash Price |
$386.34
|
| Rate for Payer: Cigna All Commercial |
$537.76
|
| Rate for Payer: CORVEL All Commercial |
$579.51
|
| Rate for Payer: Coventry All Commercial |
$548.35
|
| Rate for Payer: Encore All Commercial |
$573.59
|
| Rate for Payer: Frontpath All Commercial |
$573.28
|
| Rate for Payer: Humana ChoiceCare |
$538.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$560.82
|
| Rate for Payer: PHCS All Commercial |
$467.35
|
| Rate for Payer: PHP All Commercial |
$472.58
|
| Rate for Payer: Sagamore Health Network All Products |
$481.05
|
| Rate for Payer: Signature Care EPO |
$517.20
|
| Rate for Payer: Signature Care PPO |
$548.35
|
| Rate for Payer: United Healthcare Commercial |
$491.03
|
|
|
HC X-RAY-TIBIA-FIBULA 2 VIEWS BI
|
Facility
OP
|
$623.13
|
|
|
Service Code
|
CPT 73590 50
|
| Hospital Charge Code |
21613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$205.63 |
| Max. Negotiated Rate |
$579.51 |
| Rate for Payer: Aetna Commercial |
$525.92
|
| Rate for Payer: Aetna Medicare |
$205.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$205.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$357.86
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$389.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$236.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$226.20
|
| Rate for Payer: Cash Price |
$386.34
|
| Rate for Payer: Centivo All Commercial |
$317.80
|
| Rate for Payer: Cigna All Commercial |
$537.76
|
| Rate for Payer: CORVEL All Commercial |
$579.51
|
| Rate for Payer: Coventry All Commercial |
$548.35
|
| Rate for Payer: Encore All Commercial |
$573.59
|
| Rate for Payer: Frontpath All Commercial |
$573.28
|
| Rate for Payer: Humana ChoiceCare |
$538.20
|
| Rate for Payer: Humana Medicare |
$317.80
|
| Rate for Payer: Lucent All Commercial |
$317.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$560.82
|
| Rate for Payer: PHCS All Commercial |
$467.35
|
| Rate for Payer: PHP All Commercial |
$472.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$243.02
|
| Rate for Payer: Sagamore Health Network All Products |
$481.05
|
| Rate for Payer: Signature Care EPO |
$517.20
|
| Rate for Payer: Signature Care PPO |
$548.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$529.66
|
| Rate for Payer: United Healthcare Commercial |
$491.03
|
| Rate for Payer: United Healthcare Medicare |
$205.63
|
|
|
HC X-RAY-TIBIA-FIBULA 2 VIEWS LT
|
Facility
IP
|
$415.42
|
|
|
Service Code
|
CPT 73590 LT
|
| Hospital Charge Code |
01613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$311.56 |
| Max. Negotiated Rate |
$386.34 |
| Rate for Payer: Aetna Commercial |
$358.92
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cigna All Commercial |
$358.50
|
| Rate for Payer: CORVEL All Commercial |
$386.34
|
| Rate for Payer: Coventry All Commercial |
$365.57
|
| Rate for Payer: Encore All Commercial |
$382.39
|
| Rate for Payer: Frontpath All Commercial |
$382.18
|
| Rate for Payer: Humana ChoiceCare |
$358.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$373.87
|
| Rate for Payer: PHCS All Commercial |
$311.56
|
| Rate for Payer: PHP All Commercial |
$315.05
|
| Rate for Payer: Sagamore Health Network All Products |
$320.70
|
| Rate for Payer: Signature Care EPO |
$344.79
|
| Rate for Payer: Signature Care PPO |
$365.57
|
| Rate for Payer: United Healthcare Commercial |
$327.35
|
|
|
HC X-RAY-TIBIA-FIBULA 2 VIEWS LT
|
Facility
OP
|
$415.42
|
|
|
Service Code
|
CPT 73590 LT
|
| Hospital Charge Code |
01613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$137.09 |
| Max. Negotiated Rate |
$386.34 |
| Rate for Payer: Aetna Commercial |
$350.61
|
| Rate for Payer: Aetna Medicare |
$137.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$137.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$238.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$259.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$157.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$150.80
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Centivo All Commercial |
$211.86
|
| Rate for Payer: Cigna All Commercial |
$358.50
|
| Rate for Payer: CORVEL All Commercial |
$386.34
|
| Rate for Payer: Coventry All Commercial |
$365.57
|
| Rate for Payer: Encore All Commercial |
$382.39
|
| Rate for Payer: Frontpath All Commercial |
$382.18
|
| Rate for Payer: Humana ChoiceCare |
$358.79
|
| Rate for Payer: Humana Medicare |
$211.86
|
| Rate for Payer: Lucent All Commercial |
$211.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$373.87
|
| Rate for Payer: PHCS All Commercial |
$311.56
|
| Rate for Payer: PHP All Commercial |
$315.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$162.01
|
| Rate for Payer: Sagamore Health Network All Products |
$320.70
|
| Rate for Payer: Signature Care EPO |
$344.79
|
| Rate for Payer: Signature Care PPO |
$365.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$353.10
|
| Rate for Payer: United Healthcare Commercial |
$327.35
|
| Rate for Payer: United Healthcare Medicare |
$137.09
|
|
|
HC X-RAY-TIBIA-FIBULA 2 VIEWS RT
|
Facility
IP
|
$415.42
|
|
|
Service Code
|
CPT 73590 RT
|
| Hospital Charge Code |
11613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$311.56 |
| Max. Negotiated Rate |
$386.34 |
| Rate for Payer: Aetna Commercial |
$358.92
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Cigna All Commercial |
$358.50
|
| Rate for Payer: CORVEL All Commercial |
$386.34
|
| Rate for Payer: Coventry All Commercial |
$365.57
|
| Rate for Payer: Encore All Commercial |
$382.39
|
| Rate for Payer: Frontpath All Commercial |
$382.18
|
| Rate for Payer: Humana ChoiceCare |
$358.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$373.87
|
| Rate for Payer: PHCS All Commercial |
$311.56
|
| Rate for Payer: PHP All Commercial |
$315.05
|
| Rate for Payer: Sagamore Health Network All Products |
$320.70
|
| Rate for Payer: Signature Care EPO |
$344.79
|
| Rate for Payer: Signature Care PPO |
$365.57
|
| Rate for Payer: United Healthcare Commercial |
$327.35
|
|
|
HC X-RAY-TIBIA-FIBULA 2 VIEWS RT
|
Facility
OP
|
$415.42
|
|
|
Service Code
|
CPT 73590 RT
|
| Hospital Charge Code |
11613590
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$137.09 |
| Max. Negotiated Rate |
$386.34 |
| Rate for Payer: Aetna Commercial |
$350.61
|
| Rate for Payer: Aetna Medicare |
$137.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$137.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$238.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$259.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$157.65
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$150.80
|
| Rate for Payer: Cash Price |
$257.56
|
| Rate for Payer: Centivo All Commercial |
$211.86
|
| Rate for Payer: Cigna All Commercial |
$358.50
|
| Rate for Payer: CORVEL All Commercial |
$386.34
|
| Rate for Payer: Coventry All Commercial |
$365.57
|
| Rate for Payer: Encore All Commercial |
$382.39
|
| Rate for Payer: Frontpath All Commercial |
$382.18
|
| Rate for Payer: Humana ChoiceCare |
$358.79
|
| Rate for Payer: Humana Medicare |
$211.86
|
| Rate for Payer: Lucent All Commercial |
$211.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$373.87
|
| Rate for Payer: PHCS All Commercial |
$311.56
|
| Rate for Payer: PHP All Commercial |
$315.05
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$162.01
|
| Rate for Payer: Sagamore Health Network All Products |
$320.70
|
| Rate for Payer: Signature Care EPO |
$344.79
|
| Rate for Payer: Signature Care PPO |
$365.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$353.10
|
| Rate for Payer: United Healthcare Commercial |
$327.35
|
| Rate for Payer: United Healthcare Medicare |
$137.09
|
|
|
HC X-RAY TMJ JOINT - LT
|
Facility
IP
|
$398.74
|
|
|
Service Code
|
CPT 70328 LT
|
| Hospital Charge Code |
01611328
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$299.05 |
| Max. Negotiated Rate |
$370.83 |
| Rate for Payer: Aetna Commercial |
$344.51
|
| Rate for Payer: Cash Price |
$247.22
|
| Rate for Payer: Cigna All Commercial |
$344.11
|
| Rate for Payer: CORVEL All Commercial |
$370.83
|
| Rate for Payer: Coventry All Commercial |
$350.89
|
| Rate for Payer: Encore All Commercial |
$367.04
|
| Rate for Payer: Frontpath All Commercial |
$366.84
|
| Rate for Payer: Humana ChoiceCare |
$344.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$358.86
|
| Rate for Payer: PHCS All Commercial |
$299.05
|
| Rate for Payer: PHP All Commercial |
$302.40
|
| Rate for Payer: Sagamore Health Network All Products |
$307.83
|
| Rate for Payer: Signature Care EPO |
$330.95
|
| Rate for Payer: Signature Care PPO |
$350.89
|
| Rate for Payer: United Healthcare Commercial |
$314.21
|
|
|
HC X-RAY TMJ JOINT - LT
|
Facility
OP
|
$398.74
|
|
|
Service Code
|
CPT 70328 LT
|
| Hospital Charge Code |
01611328
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$131.58 |
| Max. Negotiated Rate |
$370.83 |
| Rate for Payer: Aetna Commercial |
$336.54
|
| Rate for Payer: Aetna Medicare |
$131.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$131.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$229.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$249.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$151.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$144.74
|
| Rate for Payer: Cash Price |
$247.22
|
| Rate for Payer: Centivo All Commercial |
$203.36
|
| Rate for Payer: Cigna All Commercial |
$344.11
|
| Rate for Payer: CORVEL All Commercial |
$370.83
|
| Rate for Payer: Coventry All Commercial |
$350.89
|
| Rate for Payer: Encore All Commercial |
$367.04
|
| Rate for Payer: Frontpath All Commercial |
$366.84
|
| Rate for Payer: Humana ChoiceCare |
$344.39
|
| Rate for Payer: Humana Medicare |
$203.36
|
| Rate for Payer: Lucent All Commercial |
$203.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$358.86
|
| Rate for Payer: PHCS All Commercial |
$299.05
|
| Rate for Payer: PHP All Commercial |
$302.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$155.51
|
| Rate for Payer: Sagamore Health Network All Products |
$307.83
|
| Rate for Payer: Signature Care EPO |
$330.95
|
| Rate for Payer: Signature Care PPO |
$350.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$338.93
|
| Rate for Payer: United Healthcare Commercial |
$314.21
|
| Rate for Payer: United Healthcare Medicare |
$131.58
|
|
|
HC X-RAY TMJ JOINT - RT
|
Facility
OP
|
$398.74
|
|
|
Service Code
|
CPT 70328 RT
|
| Hospital Charge Code |
11611328
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$131.58 |
| Max. Negotiated Rate |
$370.83 |
| Rate for Payer: Aetna Commercial |
$336.54
|
| Rate for Payer: Aetna Medicare |
$131.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$131.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$229.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$249.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$151.32
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$144.74
|
| Rate for Payer: Cash Price |
$247.22
|
| Rate for Payer: Centivo All Commercial |
$203.36
|
| Rate for Payer: Cigna All Commercial |
$344.11
|
| Rate for Payer: CORVEL All Commercial |
$370.83
|
| Rate for Payer: Coventry All Commercial |
$350.89
|
| Rate for Payer: Encore All Commercial |
$367.04
|
| Rate for Payer: Frontpath All Commercial |
$366.84
|
| Rate for Payer: Humana ChoiceCare |
$344.39
|
| Rate for Payer: Humana Medicare |
$203.36
|
| Rate for Payer: Lucent All Commercial |
$203.36
|
| Rate for Payer: Lutheran Preferred All Commercial |
$358.86
|
| Rate for Payer: PHCS All Commercial |
$299.05
|
| Rate for Payer: PHP All Commercial |
$302.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$155.51
|
| Rate for Payer: Sagamore Health Network All Products |
$307.83
|
| Rate for Payer: Signature Care EPO |
$330.95
|
| Rate for Payer: Signature Care PPO |
$350.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$338.93
|
| Rate for Payer: United Healthcare Commercial |
$314.21
|
| Rate for Payer: United Healthcare Medicare |
$131.58
|
|
|
HC X-RAY TMJ JOINT - RT
|
Facility
IP
|
$398.74
|
|
|
Service Code
|
CPT 70328 RT
|
| Hospital Charge Code |
11611328
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$299.05 |
| Max. Negotiated Rate |
$370.83 |
| Rate for Payer: Aetna Commercial |
$344.51
|
| Rate for Payer: Cash Price |
$247.22
|
| Rate for Payer: Cigna All Commercial |
$344.11
|
| Rate for Payer: CORVEL All Commercial |
$370.83
|
| Rate for Payer: Coventry All Commercial |
$350.89
|
| Rate for Payer: Encore All Commercial |
$367.04
|
| Rate for Payer: Frontpath All Commercial |
$366.84
|
| Rate for Payer: Humana ChoiceCare |
$344.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$358.86
|
| Rate for Payer: PHCS All Commercial |
$299.05
|
| Rate for Payer: PHP All Commercial |
$302.40
|
| Rate for Payer: Sagamore Health Network All Products |
$307.83
|
| Rate for Payer: Signature Care EPO |
$330.95
|
| Rate for Payer: Signature Care PPO |
$350.89
|
| Rate for Payer: United Healthcare Commercial |
$314.21
|
|
|
HC X-RAY-TOE 2+ VIEWS BI
|
Facility
IP
|
$568.14
|
|
|
Service Code
|
CPT 73660 50
|
| Hospital Charge Code |
21613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$426.10 |
| Max. Negotiated Rate |
$528.37 |
| Rate for Payer: Aetna Commercial |
$490.87
|
| Rate for Payer: Cash Price |
$352.25
|
| Rate for Payer: Cigna All Commercial |
$490.30
|
| Rate for Payer: CORVEL All Commercial |
$528.37
|
| Rate for Payer: Coventry All Commercial |
$499.96
|
| Rate for Payer: Encore All Commercial |
$522.97
|
| Rate for Payer: Frontpath All Commercial |
$522.69
|
| Rate for Payer: Humana ChoiceCare |
$490.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$511.33
|
| Rate for Payer: PHCS All Commercial |
$426.10
|
| Rate for Payer: PHP All Commercial |
$430.88
|
| Rate for Payer: Sagamore Health Network All Products |
$438.60
|
| Rate for Payer: Signature Care EPO |
$471.56
|
| Rate for Payer: Signature Care PPO |
$499.96
|
| Rate for Payer: United Healthcare Commercial |
$447.69
|
|
|
HC X-RAY-TOE 2+ VIEWS BI
|
Facility
OP
|
$568.14
|
|
|
Service Code
|
CPT 73660 50
|
| Hospital Charge Code |
21613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$187.49 |
| Max. Negotiated Rate |
$528.37 |
| Rate for Payer: Aetna Commercial |
$479.51
|
| Rate for Payer: Aetna Medicare |
$187.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$187.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$326.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$355.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$215.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$206.23
|
| Rate for Payer: Cash Price |
$352.25
|
| Rate for Payer: Centivo All Commercial |
$289.75
|
| Rate for Payer: Cigna All Commercial |
$490.30
|
| Rate for Payer: CORVEL All Commercial |
$528.37
|
| Rate for Payer: Coventry All Commercial |
$499.96
|
| Rate for Payer: Encore All Commercial |
$522.97
|
| Rate for Payer: Frontpath All Commercial |
$522.69
|
| Rate for Payer: Humana ChoiceCare |
$490.70
|
| Rate for Payer: Humana Medicare |
$289.75
|
| Rate for Payer: Lucent All Commercial |
$289.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$511.33
|
| Rate for Payer: PHCS All Commercial |
$426.10
|
| Rate for Payer: PHP All Commercial |
$430.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$221.57
|
| Rate for Payer: Sagamore Health Network All Products |
$438.60
|
| Rate for Payer: Signature Care EPO |
$471.56
|
| Rate for Payer: Signature Care PPO |
$499.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$482.92
|
| Rate for Payer: United Healthcare Commercial |
$447.69
|
| Rate for Payer: United Healthcare Medicare |
$187.49
|
|
