|
HC X-RAY-TOE 2+ VIEWS LT
|
Facility
IP
|
$284.07
|
|
|
Service Code
|
CPT 73660 LT
|
| Hospital Charge Code |
01613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$213.05 |
| Max. Negotiated Rate |
$264.19 |
| Rate for Payer: Aetna Commercial |
$245.44
|
| Rate for Payer: Cash Price |
$176.12
|
| Rate for Payer: Cigna All Commercial |
$245.15
|
| Rate for Payer: CORVEL All Commercial |
$264.19
|
| Rate for Payer: Coventry All Commercial |
$249.98
|
| Rate for Payer: Encore All Commercial |
$261.49
|
| Rate for Payer: Frontpath All Commercial |
$261.34
|
| Rate for Payer: Humana ChoiceCare |
$245.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.66
|
| Rate for Payer: PHCS All Commercial |
$213.05
|
| Rate for Payer: PHP All Commercial |
$215.44
|
| Rate for Payer: Sagamore Health Network All Products |
$219.30
|
| Rate for Payer: Signature Care EPO |
$235.78
|
| Rate for Payer: Signature Care PPO |
$249.98
|
| Rate for Payer: United Healthcare Commercial |
$223.85
|
|
|
HC X-RAY-TOE 2+ VIEWS LT
|
Facility
OP
|
$284.07
|
|
|
Service Code
|
CPT 73660 LT
|
| Hospital Charge Code |
01613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$93.74 |
| Max. Negotiated Rate |
$264.19 |
| Rate for Payer: Aetna Commercial |
$239.76
|
| Rate for Payer: Aetna Medicare |
$93.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$93.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$163.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$177.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$107.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$103.12
|
| Rate for Payer: Cash Price |
$176.12
|
| Rate for Payer: Centivo All Commercial |
$144.88
|
| Rate for Payer: Cigna All Commercial |
$245.15
|
| Rate for Payer: CORVEL All Commercial |
$264.19
|
| Rate for Payer: Coventry All Commercial |
$249.98
|
| Rate for Payer: Encore All Commercial |
$261.49
|
| Rate for Payer: Frontpath All Commercial |
$261.34
|
| Rate for Payer: Humana ChoiceCare |
$245.35
|
| Rate for Payer: Humana Medicare |
$144.88
|
| Rate for Payer: Lucent All Commercial |
$144.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.66
|
| Rate for Payer: PHCS All Commercial |
$213.05
|
| Rate for Payer: PHP All Commercial |
$215.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$110.79
|
| Rate for Payer: Sagamore Health Network All Products |
$219.30
|
| Rate for Payer: Signature Care EPO |
$235.78
|
| Rate for Payer: Signature Care PPO |
$249.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$241.46
|
| Rate for Payer: United Healthcare Commercial |
$223.85
|
| Rate for Payer: United Healthcare Medicare |
$93.74
|
|
|
HC X-RAY-TOE 2+ VIEWS RT
|
Facility
IP
|
$284.07
|
|
|
Service Code
|
CPT 73660 RT
|
| Hospital Charge Code |
11613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$213.05 |
| Max. Negotiated Rate |
$264.19 |
| Rate for Payer: Aetna Commercial |
$245.44
|
| Rate for Payer: Cash Price |
$176.12
|
| Rate for Payer: Cigna All Commercial |
$245.15
|
| Rate for Payer: CORVEL All Commercial |
$264.19
|
| Rate for Payer: Coventry All Commercial |
$249.98
|
| Rate for Payer: Encore All Commercial |
$261.49
|
| Rate for Payer: Frontpath All Commercial |
$261.34
|
| Rate for Payer: Humana ChoiceCare |
$245.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.66
|
| Rate for Payer: PHCS All Commercial |
$213.05
|
| Rate for Payer: PHP All Commercial |
$215.44
|
| Rate for Payer: Sagamore Health Network All Products |
$219.30
|
| Rate for Payer: Signature Care EPO |
$235.78
|
| Rate for Payer: Signature Care PPO |
$249.98
|
| Rate for Payer: United Healthcare Commercial |
$223.85
|
|
|
HC X-RAY-TOE 2+ VIEWS RT
|
Facility
OP
|
$284.07
|
|
|
Service Code
|
CPT 73660 RT
|
| Hospital Charge Code |
11613660
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$93.74 |
| Max. Negotiated Rate |
$264.19 |
| Rate for Payer: Aetna Commercial |
$239.76
|
| Rate for Payer: Aetna Medicare |
$93.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$93.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$163.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$177.57
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$107.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$103.12
|
| Rate for Payer: Cash Price |
$176.12
|
| Rate for Payer: Centivo All Commercial |
$144.88
|
| Rate for Payer: Cigna All Commercial |
$245.15
|
| Rate for Payer: CORVEL All Commercial |
$264.19
|
| Rate for Payer: Coventry All Commercial |
$249.98
|
| Rate for Payer: Encore All Commercial |
$261.49
|
| Rate for Payer: Frontpath All Commercial |
$261.34
|
| Rate for Payer: Humana ChoiceCare |
$245.35
|
| Rate for Payer: Humana Medicare |
$144.88
|
| Rate for Payer: Lucent All Commercial |
$144.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$255.66
|
| Rate for Payer: PHCS All Commercial |
$213.05
|
| Rate for Payer: PHP All Commercial |
$215.44
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$110.79
|
| Rate for Payer: Sagamore Health Network All Products |
$219.30
|
| Rate for Payer: Signature Care EPO |
$235.78
|
| Rate for Payer: Signature Care PPO |
$249.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$241.46
|
| Rate for Payer: United Healthcare Commercial |
$223.85
|
| Rate for Payer: United Healthcare Medicare |
$93.74
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF BI
|
Facility
OP
|
$432.06
|
|
|
Service Code
|
CPT 73092 50
|
| Hospital Charge Code |
21613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$142.58 |
| Max. Negotiated Rate |
$401.82 |
| Rate for Payer: Aetna Commercial |
$364.66
|
| Rate for Payer: Aetna Medicare |
$142.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$142.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$248.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$270.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$163.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$156.84
|
| Rate for Payer: Cash Price |
$267.88
|
| Rate for Payer: Centivo All Commercial |
$220.35
|
| Rate for Payer: Cigna All Commercial |
$372.87
|
| Rate for Payer: CORVEL All Commercial |
$401.82
|
| Rate for Payer: Coventry All Commercial |
$380.21
|
| Rate for Payer: Encore All Commercial |
$397.71
|
| Rate for Payer: Frontpath All Commercial |
$397.50
|
| Rate for Payer: Humana ChoiceCare |
$373.17
|
| Rate for Payer: Humana Medicare |
$220.35
|
| Rate for Payer: Lucent All Commercial |
$220.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$388.86
|
| Rate for Payer: PHCS All Commercial |
$324.05
|
| Rate for Payer: PHP All Commercial |
$327.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$168.50
|
| Rate for Payer: Sagamore Health Network All Products |
$333.55
|
| Rate for Payer: Signature Care EPO |
$358.61
|
| Rate for Payer: Signature Care PPO |
$380.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$367.25
|
| Rate for Payer: United Healthcare Commercial |
$340.46
|
| Rate for Payer: United Healthcare Medicare |
$142.58
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF BI
|
Facility
IP
|
$432.06
|
|
|
Service Code
|
CPT 73092 50
|
| Hospital Charge Code |
21613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$324.05 |
| Max. Negotiated Rate |
$401.82 |
| Rate for Payer: Aetna Commercial |
$373.30
|
| Rate for Payer: Cash Price |
$267.88
|
| Rate for Payer: Cigna All Commercial |
$372.87
|
| Rate for Payer: CORVEL All Commercial |
$401.82
|
| Rate for Payer: Coventry All Commercial |
$380.21
|
| Rate for Payer: Encore All Commercial |
$397.71
|
| Rate for Payer: Frontpath All Commercial |
$397.50
|
| Rate for Payer: Humana ChoiceCare |
$373.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$388.86
|
| Rate for Payer: PHCS All Commercial |
$324.05
|
| Rate for Payer: PHP All Commercial |
$327.68
|
| Rate for Payer: Sagamore Health Network All Products |
$333.55
|
| Rate for Payer: Signature Care EPO |
$358.61
|
| Rate for Payer: Signature Care PPO |
$380.21
|
| Rate for Payer: United Healthcare Commercial |
$340.46
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF LT
|
Facility
IP
|
$288.04
|
|
|
Service Code
|
CPT 73092 LT
|
| Hospital Charge Code |
01613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$216.03 |
| Max. Negotiated Rate |
$267.88 |
| Rate for Payer: Aetna Commercial |
$248.86
|
| Rate for Payer: Cash Price |
$178.58
|
| Rate for Payer: Cigna All Commercial |
$248.58
|
| Rate for Payer: CORVEL All Commercial |
$267.88
|
| Rate for Payer: Coventry All Commercial |
$253.47
|
| Rate for Payer: Encore All Commercial |
$265.14
|
| Rate for Payer: Frontpath All Commercial |
$264.99
|
| Rate for Payer: Humana ChoiceCare |
$248.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$259.23
|
| Rate for Payer: PHCS All Commercial |
$216.03
|
| Rate for Payer: PHP All Commercial |
$218.45
|
| Rate for Payer: Sagamore Health Network All Products |
$222.37
|
| Rate for Payer: Signature Care EPO |
$239.07
|
| Rate for Payer: Signature Care PPO |
$253.47
|
| Rate for Payer: United Healthcare Commercial |
$226.97
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF LT
|
Facility
OP
|
$288.04
|
|
|
Service Code
|
CPT 73092 LT
|
| Hospital Charge Code |
01613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.05 |
| Max. Negotiated Rate |
$267.88 |
| Rate for Payer: Aetna Commercial |
$243.10
|
| Rate for Payer: Aetna Medicare |
$95.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$95.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$165.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$180.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$109.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$104.56
|
| Rate for Payer: Cash Price |
$178.58
|
| Rate for Payer: Centivo All Commercial |
$146.90
|
| Rate for Payer: Cigna All Commercial |
$248.58
|
| Rate for Payer: CORVEL All Commercial |
$267.88
|
| Rate for Payer: Coventry All Commercial |
$253.47
|
| Rate for Payer: Encore All Commercial |
$265.14
|
| Rate for Payer: Frontpath All Commercial |
$264.99
|
| Rate for Payer: Humana ChoiceCare |
$248.78
|
| Rate for Payer: Humana Medicare |
$146.90
|
| Rate for Payer: Lucent All Commercial |
$146.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$259.23
|
| Rate for Payer: PHCS All Commercial |
$216.03
|
| Rate for Payer: PHP All Commercial |
$218.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$112.33
|
| Rate for Payer: Sagamore Health Network All Products |
$222.37
|
| Rate for Payer: Signature Care EPO |
$239.07
|
| Rate for Payer: Signature Care PPO |
$253.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$244.83
|
| Rate for Payer: United Healthcare Commercial |
$226.97
|
| Rate for Payer: United Healthcare Medicare |
$95.05
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF RT
|
Facility
OP
|
$288.04
|
|
|
Service Code
|
CPT 73092 RT
|
| Hospital Charge Code |
11613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$95.05 |
| Max. Negotiated Rate |
$267.88 |
| Rate for Payer: Aetna Commercial |
$243.10
|
| Rate for Payer: Aetna Medicare |
$95.05
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$95.05
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$165.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$180.05
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$109.31
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$104.56
|
| Rate for Payer: Cash Price |
$178.58
|
| Rate for Payer: Centivo All Commercial |
$146.90
|
| Rate for Payer: Cigna All Commercial |
$248.58
|
| Rate for Payer: CORVEL All Commercial |
$267.88
|
| Rate for Payer: Coventry All Commercial |
$253.47
|
| Rate for Payer: Encore All Commercial |
$265.14
|
| Rate for Payer: Frontpath All Commercial |
$264.99
|
| Rate for Payer: Humana ChoiceCare |
$248.78
|
| Rate for Payer: Humana Medicare |
$146.90
|
| Rate for Payer: Lucent All Commercial |
$146.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$259.23
|
| Rate for Payer: PHCS All Commercial |
$216.03
|
| Rate for Payer: PHP All Commercial |
$218.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$112.33
|
| Rate for Payer: Sagamore Health Network All Products |
$222.37
|
| Rate for Payer: Signature Care EPO |
$239.07
|
| Rate for Payer: Signature Care PPO |
$253.47
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$244.83
|
| Rate for Payer: United Healthcare Commercial |
$226.97
|
| Rate for Payer: United Healthcare Medicare |
$95.05
|
|
|
HC X-RAY-UPPER EXT AP&LAT INF RT
|
Facility
IP
|
$288.04
|
|
|
Service Code
|
CPT 73092 RT
|
| Hospital Charge Code |
11613092
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$216.03 |
| Max. Negotiated Rate |
$267.88 |
| Rate for Payer: Aetna Commercial |
$248.86
|
| Rate for Payer: Cash Price |
$178.58
|
| Rate for Payer: Cigna All Commercial |
$248.58
|
| Rate for Payer: CORVEL All Commercial |
$267.88
|
| Rate for Payer: Coventry All Commercial |
$253.47
|
| Rate for Payer: Encore All Commercial |
$265.14
|
| Rate for Payer: Frontpath All Commercial |
$264.99
|
| Rate for Payer: Humana ChoiceCare |
$248.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$259.23
|
| Rate for Payer: PHCS All Commercial |
$216.03
|
| Rate for Payer: PHP All Commercial |
$218.45
|
| Rate for Payer: Sagamore Health Network All Products |
$222.37
|
| Rate for Payer: Signature Care EPO |
$239.07
|
| Rate for Payer: Signature Care PPO |
$253.47
|
| Rate for Payer: United Healthcare Commercial |
$226.97
|
|
|
HC X-RAY UPPER GI DOUBLE CONTRAST W/O KUB
|
Facility
OP
|
$1,372.01
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
01614241
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$261.50 |
| Max. Negotiated Rate |
$1,275.97 |
| Rate for Payer: Aetna Commercial |
$1,157.98
|
| Rate for Payer: Aetna Medicare |
$452.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$452.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$787.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$857.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$261.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$520.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$498.04
|
| Rate for Payer: Cash Price |
$850.65
|
| Rate for Payer: Cash Price |
$850.65
|
| Rate for Payer: Centivo All Commercial |
$699.73
|
| Rate for Payer: Cigna All Commercial |
$1,184.05
|
| Rate for Payer: CORVEL All Commercial |
$1,275.97
|
| Rate for Payer: Coventry All Commercial |
$1,207.37
|
| Rate for Payer: Encore All Commercial |
$1,262.94
|
| Rate for Payer: Frontpath All Commercial |
$1,262.25
|
| Rate for Payer: Humana ChoiceCare |
$1,185.01
|
| Rate for Payer: Humana Medicare |
$699.73
|
| Rate for Payer: Lucent All Commercial |
$699.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,234.81
|
| Rate for Payer: Managed Health Services Medicaid |
$261.50
|
| Rate for Payer: MDWise Medicaid |
$261.50
|
| Rate for Payer: PHCS All Commercial |
$1,029.01
|
| Rate for Payer: PHP All Commercial |
$1,040.53
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$535.08
|
| Rate for Payer: Sagamore Health Network All Products |
$1,059.19
|
| Rate for Payer: Signature Care EPO |
$1,138.77
|
| Rate for Payer: Signature Care PPO |
$1,207.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,166.21
|
| Rate for Payer: United Healthcare Commercial |
$1,081.15
|
| Rate for Payer: United Healthcare Medicare |
$452.76
|
|
|
HC X-RAY UPPER GI DOUBLE CONTRAST W/O KUB
|
Facility
IP
|
$1,372.01
|
|
|
Service Code
|
CPT 74246
|
| Hospital Charge Code |
01614241
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$1,029.01 |
| Max. Negotiated Rate |
$1,275.97 |
| Rate for Payer: Aetna Commercial |
$1,185.42
|
| Rate for Payer: Cash Price |
$850.65
|
| Rate for Payer: Cigna All Commercial |
$1,184.05
|
| Rate for Payer: CORVEL All Commercial |
$1,275.97
|
| Rate for Payer: Coventry All Commercial |
$1,207.37
|
| Rate for Payer: Encore All Commercial |
$1,262.94
|
| Rate for Payer: Frontpath All Commercial |
$1,262.25
|
| Rate for Payer: Humana ChoiceCare |
$1,185.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,234.81
|
| Rate for Payer: PHCS All Commercial |
$1,029.01
|
| Rate for Payer: PHP All Commercial |
$1,040.53
|
| Rate for Payer: Sagamore Health Network All Products |
$1,059.19
|
| Rate for Payer: Signature Care EPO |
$1,138.77
|
| Rate for Payer: Signature Care PPO |
$1,207.37
|
| Rate for Payer: United Healthcare Commercial |
$1,081.15
|
|
|
HC X-RAY UPPER GI SINGLE CONTRAST W/O KUB
|
Facility
OP
|
$907.97
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
01614240
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$220.90 |
| Max. Negotiated Rate |
$844.42 |
| Rate for Payer: Aetna Commercial |
$766.33
|
| Rate for Payer: Aetna Medicare |
$299.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$299.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$521.45
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$567.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$220.90
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$344.58
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$329.59
|
| Rate for Payer: Cash Price |
$562.94
|
| Rate for Payer: Cash Price |
$562.94
|
| Rate for Payer: Centivo All Commercial |
$463.07
|
| Rate for Payer: Cigna All Commercial |
$783.58
|
| Rate for Payer: CORVEL All Commercial |
$844.42
|
| Rate for Payer: Coventry All Commercial |
$799.02
|
| Rate for Payer: Encore All Commercial |
$835.79
|
| Rate for Payer: Frontpath All Commercial |
$835.34
|
| Rate for Payer: Humana ChoiceCare |
$784.22
|
| Rate for Payer: Humana Medicare |
$463.07
|
| Rate for Payer: Lucent All Commercial |
$463.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$817.18
|
| Rate for Payer: Managed Health Services Medicaid |
$220.90
|
| Rate for Payer: MDWise Medicaid |
$220.90
|
| Rate for Payer: PHCS All Commercial |
$680.98
|
| Rate for Payer: PHP All Commercial |
$688.61
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$354.11
|
| Rate for Payer: Sagamore Health Network All Products |
$700.96
|
| Rate for Payer: Signature Care EPO |
$753.62
|
| Rate for Payer: Signature Care PPO |
$799.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$771.78
|
| Rate for Payer: United Healthcare Commercial |
$715.48
|
| Rate for Payer: United Healthcare Medicare |
$299.63
|
|
|
HC X-RAY UPPER GI SINGLE CONTRAST W/O KUB
|
Facility
IP
|
$907.97
|
|
|
Service Code
|
CPT 74240
|
| Hospital Charge Code |
01614240
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$680.98 |
| Max. Negotiated Rate |
$844.42 |
| Rate for Payer: Aetna Commercial |
$784.49
|
| Rate for Payer: Cash Price |
$562.94
|
| Rate for Payer: Cigna All Commercial |
$783.58
|
| Rate for Payer: CORVEL All Commercial |
$844.42
|
| Rate for Payer: Coventry All Commercial |
$799.02
|
| Rate for Payer: Encore All Commercial |
$835.79
|
| Rate for Payer: Frontpath All Commercial |
$835.34
|
| Rate for Payer: Humana ChoiceCare |
$784.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$817.18
|
| Rate for Payer: PHCS All Commercial |
$680.98
|
| Rate for Payer: PHP All Commercial |
$688.61
|
| Rate for Payer: Sagamore Health Network All Products |
$700.96
|
| Rate for Payer: Signature Care EPO |
$753.62
|
| Rate for Payer: Signature Care PPO |
$799.02
|
| Rate for Payer: United Healthcare Commercial |
$715.48
|
|
|
HC X-RAY-VENOGRAM LT LOWER UNILAT
|
Facility
OP
|
$112.70
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
01615820
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$37.19 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$95.12
|
| Rate for Payer: Aetna Medicare |
$37.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$64.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.91
|
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Centivo All Commercial |
$57.48
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Humana Medicare |
$57.48
|
| Rate for Payer: Lucent All Commercial |
$57.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.52
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.95
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.79
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
| Rate for Payer: United Healthcare Medicare |
$37.19
|
|
|
HC X-RAY-VENOGRAM LT LOWER UNILAT
|
Facility
IP
|
$112.70
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
01615820
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$84.52 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$97.37
|
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.52
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
|
|
HC X-RAY-VENOGRAM LT UPPER UNILAT
|
Facility
OP
|
$112.70
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
01615821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$37.19 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$95.12
|
| Rate for Payer: Aetna Medicare |
$37.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$64.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.91
|
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Centivo All Commercial |
$57.48
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Humana Medicare |
$57.48
|
| Rate for Payer: Lucent All Commercial |
$57.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.52
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.95
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.79
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
| Rate for Payer: United Healthcare Medicare |
$37.19
|
|
|
HC X-RAY-VENOGRAM LT UPPER UNILAT
|
Facility
IP
|
$112.70
|
|
|
Service Code
|
CPT 75820 LT
|
| Hospital Charge Code |
01615821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$84.52 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$97.37
|
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.52
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
|
|
HC X-RAY-VENOGRAM RT LOWER UNILAT
|
Facility
OP
|
$112.70
|
|
|
Service Code
|
CPT 75820 RT
|
| Hospital Charge Code |
11615820
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$37.19 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$95.12
|
| Rate for Payer: Aetna Medicare |
$37.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$64.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.91
|
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Centivo All Commercial |
$57.48
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Humana Medicare |
$57.48
|
| Rate for Payer: Lucent All Commercial |
$57.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.52
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.95
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.79
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
| Rate for Payer: United Healthcare Medicare |
$37.19
|
|
|
HC X-RAY-VENOGRAM RT LOWER UNILAT
|
Facility
IP
|
$112.70
|
|
|
Service Code
|
CPT 75820 RT
|
| Hospital Charge Code |
11615820
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$84.52 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$97.37
|
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.52
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
|
|
HC X-RAY-VENOGRAM RT UPPER UNILAT
|
Facility
OP
|
$112.70
|
|
|
Service Code
|
CPT 75820 RT
|
| Hospital Charge Code |
11615821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$37.19 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$95.12
|
| Rate for Payer: Aetna Medicare |
$37.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$37.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$64.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$70.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$42.77
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$40.91
|
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Centivo All Commercial |
$57.48
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Humana Medicare |
$57.48
|
| Rate for Payer: Lucent All Commercial |
$57.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.52
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$43.95
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.79
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
| Rate for Payer: United Healthcare Medicare |
$37.19
|
|
|
HC X-RAY-VENOGRAM RT UPPER UNILAT
|
Facility
IP
|
$112.70
|
|
|
Service Code
|
CPT 75820 RT
|
| Hospital Charge Code |
11615821
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$84.52 |
| Max. Negotiated Rate |
$104.81 |
| Rate for Payer: Aetna Commercial |
$97.37
|
| Rate for Payer: Cash Price |
$69.87
|
| Rate for Payer: Cigna All Commercial |
$97.26
|
| Rate for Payer: CORVEL All Commercial |
$104.81
|
| Rate for Payer: Coventry All Commercial |
$99.18
|
| Rate for Payer: Encore All Commercial |
$103.74
|
| Rate for Payer: Frontpath All Commercial |
$103.68
|
| Rate for Payer: Humana ChoiceCare |
$97.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$101.43
|
| Rate for Payer: PHCS All Commercial |
$84.52
|
| Rate for Payer: PHP All Commercial |
$85.47
|
| Rate for Payer: Sagamore Health Network All Products |
$87.00
|
| Rate for Payer: Signature Care EPO |
$93.54
|
| Rate for Payer: Signature Care PPO |
$99.18
|
| Rate for Payer: United Healthcare Commercial |
$88.81
|
|
|
HC X-RAY-WRIST 1 VIEW BI
|
Facility
OP
|
$417.12
|
|
|
Service Code
|
CPT 73100 50,52
|
| Hospital Charge Code |
21615100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$137.65 |
| Max. Negotiated Rate |
$387.92 |
| Rate for Payer: Aetna Commercial |
$352.05
|
| Rate for Payer: Aetna Medicare |
$137.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$137.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$239.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$260.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$158.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$151.41
|
| Rate for Payer: Cash Price |
$258.61
|
| Rate for Payer: Centivo All Commercial |
$212.73
|
| Rate for Payer: Cigna All Commercial |
$359.97
|
| Rate for Payer: CORVEL All Commercial |
$387.92
|
| Rate for Payer: Coventry All Commercial |
$367.06
|
| Rate for Payer: Encore All Commercial |
$383.96
|
| Rate for Payer: Frontpath All Commercial |
$383.75
|
| Rate for Payer: Humana ChoiceCare |
$360.27
|
| Rate for Payer: Humana Medicare |
$212.73
|
| Rate for Payer: Lucent All Commercial |
$212.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$375.41
|
| Rate for Payer: PHCS All Commercial |
$312.84
|
| Rate for Payer: PHP All Commercial |
$316.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$162.68
|
| Rate for Payer: Sagamore Health Network All Products |
$322.02
|
| Rate for Payer: Signature Care EPO |
$346.21
|
| Rate for Payer: Signature Care PPO |
$367.06
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$354.55
|
| Rate for Payer: United Healthcare Commercial |
$328.69
|
| Rate for Payer: United Healthcare Medicare |
$137.65
|
|
|
HC X-RAY-WRIST 1 VIEW BI
|
Facility
IP
|
$417.12
|
|
|
Service Code
|
CPT 73100 50,52
|
| Hospital Charge Code |
21615100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$312.84 |
| Max. Negotiated Rate |
$387.92 |
| Rate for Payer: Aetna Commercial |
$360.39
|
| Rate for Payer: Cash Price |
$258.61
|
| Rate for Payer: Cigna All Commercial |
$359.97
|
| Rate for Payer: CORVEL All Commercial |
$387.92
|
| Rate for Payer: Coventry All Commercial |
$367.06
|
| Rate for Payer: Encore All Commercial |
$383.96
|
| Rate for Payer: Frontpath All Commercial |
$383.75
|
| Rate for Payer: Humana ChoiceCare |
$360.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$375.41
|
| Rate for Payer: PHCS All Commercial |
$312.84
|
| Rate for Payer: PHP All Commercial |
$316.34
|
| Rate for Payer: Sagamore Health Network All Products |
$322.02
|
| Rate for Payer: Signature Care EPO |
$346.21
|
| Rate for Payer: Signature Care PPO |
$367.06
|
| Rate for Payer: United Healthcare Commercial |
$328.69
|
|
|
HC X-RAY-WRIST 1 VIEW LT
|
Facility
OP
|
$278.08
|
|
|
Service Code
|
CPT 73100 LT,52
|
| Hospital Charge Code |
01615100
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$91.77 |
| Max. Negotiated Rate |
$258.62 |
| Rate for Payer: Aetna Commercial |
$234.70
|
| Rate for Payer: Aetna Medicare |
$91.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$91.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$159.70
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$173.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$105.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$100.94
|
| Rate for Payer: Cash Price |
$172.41
|
| Rate for Payer: Centivo All Commercial |
$141.82
|
| Rate for Payer: Cigna All Commercial |
$239.99
|
| Rate for Payer: CORVEL All Commercial |
$258.62
|
| Rate for Payer: Coventry All Commercial |
$244.71
|
| Rate for Payer: Encore All Commercial |
$255.98
|
| Rate for Payer: Frontpath All Commercial |
$255.84
|
| Rate for Payer: Humana ChoiceCare |
$240.18
|
| Rate for Payer: Humana Medicare |
$141.82
|
| Rate for Payer: Lucent All Commercial |
$141.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$250.27
|
| Rate for Payer: PHCS All Commercial |
$208.56
|
| Rate for Payer: PHP All Commercial |
$210.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$108.45
|
| Rate for Payer: Sagamore Health Network All Products |
$214.68
|
| Rate for Payer: Signature Care EPO |
$230.81
|
| Rate for Payer: Signature Care PPO |
$244.71
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$236.37
|
| Rate for Payer: United Healthcare Commercial |
$219.13
|
| Rate for Payer: United Healthcare Medicare |
$91.77
|
|
