HC AMNIOHEAL PLUS PATCH SZ 1X1
|
Facility
IP
|
$2,225.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602558
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$1,668.75 |
Max. Negotiated Rate |
$2,069.25 |
Rate for Payer: Aetna Commercial |
$1,922.40
|
Rate for Payer: Cash Price |
$1,379.50
|
Rate for Payer: Cigna All Commercial |
$1,920.18
|
Rate for Payer: CORVEL All Commercial |
$2,069.25
|
Rate for Payer: Coventry All Commercial |
$1,958.00
|
Rate for Payer: Encore All Commercial |
$2,048.11
|
Rate for Payer: Frontpath All Commercial |
$2,047.00
|
Rate for Payer: Humana ChoiceCare |
$1,921.73
|
Rate for Payer: Lutheran Preferred All Commercial |
$2,002.50
|
Rate for Payer: PHCS All Commercial |
$1,668.75
|
Rate for Payer: PHP All Commercial |
$1,687.44
|
Rate for Payer: Sagamore Health Network All Products |
$1,717.70
|
Rate for Payer: Signature Care EPO |
$1,846.75
|
Rate for Payer: Signature Care PPO |
$1,958.00
|
Rate for Payer: United Healthcare Commercial |
$1,753.30
|
|
HC AMNIOHEAL PLUS PATCH SZ 1X1
|
Facility
OP
|
$2,225.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602558
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$524.16 |
Max. Negotiated Rate |
$2,069.25 |
Rate for Payer: Aetna Commercial |
$1,877.90
|
Rate for Payer: Aetna Medicare |
$734.25
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$734.25
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,277.82
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,390.85
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$844.39
|
Rate for Payer: CareSource Indiana of IN Medicare |
$807.68
|
Rate for Payer: Cash Price |
$1,379.50
|
Rate for Payer: Cash Price |
$1,379.50
|
Rate for Payer: Centivo All Commercial |
$1,134.75
|
Rate for Payer: Cigna All Commercial |
$1,920.18
|
Rate for Payer: CORVEL All Commercial |
$2,069.25
|
Rate for Payer: Coventry All Commercial |
$1,958.00
|
Rate for Payer: Encore All Commercial |
$2,048.11
|
Rate for Payer: Frontpath All Commercial |
$2,047.00
|
Rate for Payer: Humana ChoiceCare |
$1,921.73
|
Rate for Payer: Humana Medicare |
$1,134.75
|
Rate for Payer: Lucent All Commercial |
$1,134.75
|
Rate for Payer: Lutheran Preferred All Commercial |
$2,002.50
|
Rate for Payer: Managed Health Services Medicaid |
$524.16
|
Rate for Payer: MDWise Medicaid |
$524.16
|
Rate for Payer: PHCS All Commercial |
$1,668.75
|
Rate for Payer: PHP All Commercial |
$1,687.44
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$867.75
|
Rate for Payer: Sagamore Health Network All Products |
$1,717.70
|
Rate for Payer: Signature Care EPO |
$1,846.75
|
Rate for Payer: Signature Care PPO |
$1,958.00
|
Rate for Payer: Three Rivers Preferred All Commercial |
$1,891.25
|
Rate for Payer: United Healthcare Commercial |
$1,753.30
|
Rate for Payer: United Healthcare Medicare |
$734.25
|
|
HC AMNIOHEAL PLUS PATCH SZ 2X2
|
Facility
OP
|
$3,222.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602559
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$524.16 |
Max. Negotiated Rate |
$2,996.46 |
Rate for Payer: Aetna Commercial |
$2,719.37
|
Rate for Payer: Aetna Medicare |
$1,063.26
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,063.26
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,850.39
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,014.07
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,222.75
|
Rate for Payer: CareSource Indiana of IN Medicare |
$1,169.59
|
Rate for Payer: Cash Price |
$1,997.64
|
Rate for Payer: Cash Price |
$1,997.64
|
Rate for Payer: Centivo All Commercial |
$1,643.22
|
Rate for Payer: Cigna All Commercial |
$2,780.59
|
Rate for Payer: CORVEL All Commercial |
$2,996.46
|
Rate for Payer: Coventry All Commercial |
$2,835.36
|
Rate for Payer: Encore All Commercial |
$2,965.85
|
Rate for Payer: Frontpath All Commercial |
$2,964.24
|
Rate for Payer: Humana ChoiceCare |
$2,782.84
|
Rate for Payer: Humana Medicare |
$1,643.22
|
Rate for Payer: Lucent All Commercial |
$1,643.22
|
Rate for Payer: Lutheran Preferred All Commercial |
$2,899.80
|
Rate for Payer: Managed Health Services Medicaid |
$524.16
|
Rate for Payer: MDWise Medicaid |
$524.16
|
Rate for Payer: PHCS All Commercial |
$2,416.50
|
Rate for Payer: PHP All Commercial |
$2,443.56
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$1,256.58
|
Rate for Payer: Sagamore Health Network All Products |
$2,487.38
|
Rate for Payer: Signature Care EPO |
$2,674.26
|
Rate for Payer: Signature Care PPO |
$2,835.36
|
Rate for Payer: Three Rivers Preferred All Commercial |
$2,738.70
|
Rate for Payer: United Healthcare Commercial |
$2,538.94
|
Rate for Payer: United Healthcare Medicare |
$1,063.26
|
|
HC AMNIOHEAL PLUS PATCH SZ 2X2
|
Facility
IP
|
$3,222.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602559
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$2,416.50 |
Max. Negotiated Rate |
$2,996.46 |
Rate for Payer: Aetna Commercial |
$2,783.81
|
Rate for Payer: Cash Price |
$1,997.64
|
Rate for Payer: Cigna All Commercial |
$2,780.59
|
Rate for Payer: CORVEL All Commercial |
$2,996.46
|
Rate for Payer: Coventry All Commercial |
$2,835.36
|
Rate for Payer: Encore All Commercial |
$2,965.85
|
Rate for Payer: Frontpath All Commercial |
$2,964.24
|
Rate for Payer: Humana ChoiceCare |
$2,782.84
|
Rate for Payer: Lutheran Preferred All Commercial |
$2,899.80
|
Rate for Payer: PHCS All Commercial |
$2,416.50
|
Rate for Payer: PHP All Commercial |
$2,443.56
|
Rate for Payer: Sagamore Health Network All Products |
$2,487.38
|
Rate for Payer: Signature Care EPO |
$2,674.26
|
Rate for Payer: Signature Care PPO |
$2,835.36
|
Rate for Payer: United Healthcare Commercial |
$2,538.94
|
|
HC AMNIOHEAL PLUS PATCH SZ 2X3
|
Facility
IP
|
$4,680.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602560
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$3,510.00 |
Max. Negotiated Rate |
$4,352.40 |
Rate for Payer: Aetna Commercial |
$4,043.52
|
Rate for Payer: Cash Price |
$2,901.60
|
Rate for Payer: Cigna All Commercial |
$4,038.84
|
Rate for Payer: CORVEL All Commercial |
$4,352.40
|
Rate for Payer: Coventry All Commercial |
$4,118.40
|
Rate for Payer: Encore All Commercial |
$4,307.94
|
Rate for Payer: Frontpath All Commercial |
$4,305.60
|
Rate for Payer: Humana ChoiceCare |
$4,042.12
|
Rate for Payer: Lutheran Preferred All Commercial |
$4,212.00
|
Rate for Payer: PHCS All Commercial |
$3,510.00
|
Rate for Payer: PHP All Commercial |
$3,549.31
|
Rate for Payer: Sagamore Health Network All Products |
$3,612.96
|
Rate for Payer: Signature Care EPO |
$3,884.40
|
Rate for Payer: Signature Care PPO |
$4,118.40
|
Rate for Payer: United Healthcare Commercial |
$3,687.84
|
|
HC AMNIOHEAL PLUS PATCH SZ 2X3
|
Facility
OP
|
$4,680.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602560
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$524.16 |
Max. Negotiated Rate |
$4,352.40 |
Rate for Payer: Aetna Commercial |
$3,949.92
|
Rate for Payer: Aetna Medicare |
$1,544.40
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,544.40
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,687.72
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,925.47
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,776.06
|
Rate for Payer: CareSource Indiana of IN Medicare |
$1,698.84
|
Rate for Payer: Cash Price |
$2,901.60
|
Rate for Payer: Cash Price |
$2,901.60
|
Rate for Payer: Centivo All Commercial |
$2,386.80
|
Rate for Payer: Cigna All Commercial |
$4,038.84
|
Rate for Payer: CORVEL All Commercial |
$4,352.40
|
Rate for Payer: Coventry All Commercial |
$4,118.40
|
Rate for Payer: Encore All Commercial |
$4,307.94
|
Rate for Payer: Frontpath All Commercial |
$4,305.60
|
Rate for Payer: Humana ChoiceCare |
$4,042.12
|
Rate for Payer: Humana Medicare |
$2,386.80
|
Rate for Payer: Lucent All Commercial |
$2,386.80
|
Rate for Payer: Lutheran Preferred All Commercial |
$4,212.00
|
Rate for Payer: Managed Health Services Medicaid |
$524.16
|
Rate for Payer: MDWise Medicaid |
$524.16
|
Rate for Payer: PHCS All Commercial |
$3,510.00
|
Rate for Payer: PHP All Commercial |
$3,549.31
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$1,825.20
|
Rate for Payer: Sagamore Health Network All Products |
$3,612.96
|
Rate for Payer: Signature Care EPO |
$3,884.40
|
Rate for Payer: Signature Care PPO |
$4,118.40
|
Rate for Payer: Three Rivers Preferred All Commercial |
$3,978.00
|
Rate for Payer: United Healthcare Commercial |
$3,687.84
|
Rate for Payer: United Healthcare Medicare |
$1,544.40
|
|
HC AMNIOHEAL PLUS PATCH SZ 4X4
|
Facility
OP
|
$6,472.80
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602561
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$524.16 |
Max. Negotiated Rate |
$6,019.70 |
Rate for Payer: Aetna Commercial |
$5,463.04
|
Rate for Payer: Aetna Medicare |
$2,136.02
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,136.02
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,717.33
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,046.15
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,456.43
|
Rate for Payer: CareSource Indiana of IN Medicare |
$2,349.63
|
Rate for Payer: Cash Price |
$4,013.14
|
Rate for Payer: Cash Price |
$4,013.14
|
Rate for Payer: Centivo All Commercial |
$3,301.13
|
Rate for Payer: Cigna All Commercial |
$5,586.03
|
Rate for Payer: CORVEL All Commercial |
$6,019.70
|
Rate for Payer: Coventry All Commercial |
$5,696.06
|
Rate for Payer: Encore All Commercial |
$5,958.21
|
Rate for Payer: Frontpath All Commercial |
$5,954.98
|
Rate for Payer: Humana ChoiceCare |
$5,590.56
|
Rate for Payer: Humana Medicare |
$3,301.13
|
Rate for Payer: Lucent All Commercial |
$3,301.13
|
Rate for Payer: Lutheran Preferred All Commercial |
$5,825.52
|
Rate for Payer: Managed Health Services Medicaid |
$524.16
|
Rate for Payer: MDWise Medicaid |
$524.16
|
Rate for Payer: PHCS All Commercial |
$4,854.60
|
Rate for Payer: PHP All Commercial |
$4,908.97
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$2,524.39
|
Rate for Payer: Sagamore Health Network All Products |
$4,997.00
|
Rate for Payer: Signature Care EPO |
$5,372.42
|
Rate for Payer: Signature Care PPO |
$5,696.06
|
Rate for Payer: Three Rivers Preferred All Commercial |
$5,501.88
|
Rate for Payer: United Healthcare Commercial |
$5,100.57
|
Rate for Payer: United Healthcare Medicare |
$2,136.02
|
|
HC AMNIOHEAL PLUS PATCH SZ 4X4
|
Facility
IP
|
$6,472.80
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602561
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$4,854.60 |
Max. Negotiated Rate |
$6,019.70 |
Rate for Payer: Aetna Commercial |
$5,592.50
|
Rate for Payer: Cash Price |
$4,013.14
|
Rate for Payer: Cigna All Commercial |
$5,586.03
|
Rate for Payer: CORVEL All Commercial |
$6,019.70
|
Rate for Payer: Coventry All Commercial |
$5,696.06
|
Rate for Payer: Encore All Commercial |
$5,958.21
|
Rate for Payer: Frontpath All Commercial |
$5,954.98
|
Rate for Payer: Humana ChoiceCare |
$5,590.56
|
Rate for Payer: Lutheran Preferred All Commercial |
$5,825.52
|
Rate for Payer: PHCS All Commercial |
$4,854.60
|
Rate for Payer: PHP All Commercial |
$4,908.97
|
Rate for Payer: Sagamore Health Network All Products |
$4,997.00
|
Rate for Payer: Signature Care EPO |
$5,372.42
|
Rate for Payer: Signature Care PPO |
$5,696.06
|
Rate for Payer: United Healthcare Commercial |
$5,100.57
|
|
HC AMNIOHEAL PLUS PATCH SZ 4X6
|
Facility
IP
|
$7,012.80
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602562
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$5,259.60 |
Max. Negotiated Rate |
$6,521.90 |
Rate for Payer: Aetna Commercial |
$6,059.06
|
Rate for Payer: Cash Price |
$4,347.94
|
Rate for Payer: Cigna All Commercial |
$6,052.05
|
Rate for Payer: CORVEL All Commercial |
$6,521.90
|
Rate for Payer: Coventry All Commercial |
$6,171.26
|
Rate for Payer: Encore All Commercial |
$6,455.28
|
Rate for Payer: Frontpath All Commercial |
$6,451.78
|
Rate for Payer: Humana ChoiceCare |
$6,056.96
|
Rate for Payer: Lutheran Preferred All Commercial |
$6,311.52
|
Rate for Payer: PHCS All Commercial |
$5,259.60
|
Rate for Payer: PHP All Commercial |
$5,318.51
|
Rate for Payer: Sagamore Health Network All Products |
$5,413.88
|
Rate for Payer: Signature Care EPO |
$5,820.62
|
Rate for Payer: Signature Care PPO |
$6,171.26
|
Rate for Payer: United Healthcare Commercial |
$5,526.09
|
|
HC AMNIOHEAL PLUS PATCH SZ 4X6
|
Facility
OP
|
$7,012.80
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602562
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$524.16 |
Max. Negotiated Rate |
$6,521.90 |
Rate for Payer: Aetna Commercial |
$5,918.80
|
Rate for Payer: Aetna Medicare |
$2,314.22
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,314.22
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4,027.45
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,383.70
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,661.36
|
Rate for Payer: CareSource Indiana of IN Medicare |
$2,545.65
|
Rate for Payer: Cash Price |
$4,347.94
|
Rate for Payer: Cash Price |
$4,347.94
|
Rate for Payer: Centivo All Commercial |
$3,576.53
|
Rate for Payer: Cigna All Commercial |
$6,052.05
|
Rate for Payer: CORVEL All Commercial |
$6,521.90
|
Rate for Payer: Coventry All Commercial |
$6,171.26
|
Rate for Payer: Encore All Commercial |
$6,455.28
|
Rate for Payer: Frontpath All Commercial |
$6,451.78
|
Rate for Payer: Humana ChoiceCare |
$6,056.96
|
Rate for Payer: Humana Medicare |
$3,576.53
|
Rate for Payer: Lucent All Commercial |
$3,576.53
|
Rate for Payer: Lutheran Preferred All Commercial |
$6,311.52
|
Rate for Payer: Managed Health Services Medicaid |
$524.16
|
Rate for Payer: MDWise Medicaid |
$524.16
|
Rate for Payer: PHCS All Commercial |
$5,259.60
|
Rate for Payer: PHP All Commercial |
$5,318.51
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$2,734.99
|
Rate for Payer: Sagamore Health Network All Products |
$5,413.88
|
Rate for Payer: Signature Care EPO |
$5,820.62
|
Rate for Payer: Signature Care PPO |
$6,171.26
|
Rate for Payer: Three Rivers Preferred All Commercial |
$5,960.88
|
Rate for Payer: United Healthcare Commercial |
$5,526.09
|
Rate for Payer: United Healthcare Medicare |
$2,314.22
|
|
HC AMNIOHEAL PLUS PATCH SZ 4X8
|
Facility
IP
|
$13,644.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602563
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$10,233.00 |
Max. Negotiated Rate |
$12,688.92 |
Rate for Payer: Aetna Commercial |
$11,788.42
|
Rate for Payer: Cash Price |
$8,459.28
|
Rate for Payer: Cigna All Commercial |
$11,774.77
|
Rate for Payer: CORVEL All Commercial |
$12,688.92
|
Rate for Payer: Coventry All Commercial |
$12,006.72
|
Rate for Payer: Encore All Commercial |
$12,559.30
|
Rate for Payer: Frontpath All Commercial |
$12,552.48
|
Rate for Payer: Humana ChoiceCare |
$11,784.32
|
Rate for Payer: Lutheran Preferred All Commercial |
$12,279.60
|
Rate for Payer: PHCS All Commercial |
$10,233.00
|
Rate for Payer: PHP All Commercial |
$10,347.61
|
Rate for Payer: Sagamore Health Network All Products |
$10,533.17
|
Rate for Payer: Signature Care EPO |
$11,324.52
|
Rate for Payer: Signature Care PPO |
$12,006.72
|
Rate for Payer: United Healthcare Commercial |
$10,751.47
|
|
HC AMNIOHEAL PLUS PATCH SZ 4X8
|
Facility
OP
|
$13,644.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602563
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$524.16 |
Max. Negotiated Rate |
$12,688.92 |
Rate for Payer: Aetna Commercial |
$11,515.54
|
Rate for Payer: Aetna Medicare |
$4,502.52
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$4,502.52
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$7,835.75
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$8,528.86
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5,177.90
|
Rate for Payer: CareSource Indiana of IN Medicare |
$4,952.77
|
Rate for Payer: Cash Price |
$8,459.28
|
Rate for Payer: Cash Price |
$8,459.28
|
Rate for Payer: Centivo All Commercial |
$6,958.44
|
Rate for Payer: Cigna All Commercial |
$11,774.77
|
Rate for Payer: CORVEL All Commercial |
$12,688.92
|
Rate for Payer: Coventry All Commercial |
$12,006.72
|
Rate for Payer: Encore All Commercial |
$12,559.30
|
Rate for Payer: Frontpath All Commercial |
$12,552.48
|
Rate for Payer: Humana ChoiceCare |
$11,784.32
|
Rate for Payer: Humana Medicare |
$6,958.44
|
Rate for Payer: Lucent All Commercial |
$6,958.44
|
Rate for Payer: Lutheran Preferred All Commercial |
$12,279.60
|
Rate for Payer: Managed Health Services Medicaid |
$524.16
|
Rate for Payer: MDWise Medicaid |
$524.16
|
Rate for Payer: PHCS All Commercial |
$10,233.00
|
Rate for Payer: PHP All Commercial |
$10,347.61
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$5,321.16
|
Rate for Payer: Sagamore Health Network All Products |
$10,533.17
|
Rate for Payer: Signature Care EPO |
$11,324.52
|
Rate for Payer: Signature Care PPO |
$12,006.72
|
Rate for Payer: Three Rivers Preferred All Commercial |
$11,597.40
|
Rate for Payer: United Healthcare Commercial |
$10,751.47
|
Rate for Payer: United Healthcare Medicare |
$4,502.52
|
|
HC AMNIOHEAL PLUS PWDR 125 MG
|
Facility
IP
|
$6,300.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602556
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$4,725.00 |
Max. Negotiated Rate |
$5,859.00 |
Rate for Payer: Aetna Commercial |
$5,443.20
|
Rate for Payer: Cash Price |
$3,906.00
|
Rate for Payer: Cigna All Commercial |
$5,436.90
|
Rate for Payer: CORVEL All Commercial |
$5,859.00
|
Rate for Payer: Coventry All Commercial |
$5,544.00
|
Rate for Payer: Encore All Commercial |
$5,799.15
|
Rate for Payer: Frontpath All Commercial |
$5,796.00
|
Rate for Payer: Humana ChoiceCare |
$5,441.31
|
Rate for Payer: Lutheran Preferred All Commercial |
$5,670.00
|
Rate for Payer: PHCS All Commercial |
$4,725.00
|
Rate for Payer: PHP All Commercial |
$4,777.92
|
Rate for Payer: Sagamore Health Network All Products |
$4,863.60
|
Rate for Payer: Signature Care EPO |
$5,229.00
|
Rate for Payer: Signature Care PPO |
$5,544.00
|
Rate for Payer: United Healthcare Commercial |
$4,964.40
|
|
HC AMNIOHEAL PLUS PWDR 125 MG
|
Facility
OP
|
$6,300.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602556
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$524.16 |
Max. Negotiated Rate |
$5,859.00 |
Rate for Payer: Aetna Commercial |
$5,317.20
|
Rate for Payer: Aetna Medicare |
$2,079.00
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,079.00
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,618.09
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,938.13
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,390.85
|
Rate for Payer: CareSource Indiana of IN Medicare |
$2,286.90
|
Rate for Payer: Cash Price |
$3,906.00
|
Rate for Payer: Cash Price |
$3,906.00
|
Rate for Payer: Centivo All Commercial |
$3,213.00
|
Rate for Payer: Cigna All Commercial |
$5,436.90
|
Rate for Payer: CORVEL All Commercial |
$5,859.00
|
Rate for Payer: Coventry All Commercial |
$5,544.00
|
Rate for Payer: Encore All Commercial |
$5,799.15
|
Rate for Payer: Frontpath All Commercial |
$5,796.00
|
Rate for Payer: Humana ChoiceCare |
$5,441.31
|
Rate for Payer: Humana Medicare |
$3,213.00
|
Rate for Payer: Lucent All Commercial |
$3,213.00
|
Rate for Payer: Lutheran Preferred All Commercial |
$5,670.00
|
Rate for Payer: Managed Health Services Medicaid |
$524.16
|
Rate for Payer: MDWise Medicaid |
$524.16
|
Rate for Payer: PHCS All Commercial |
$4,725.00
|
Rate for Payer: PHP All Commercial |
$4,777.92
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$2,457.00
|
Rate for Payer: Sagamore Health Network All Products |
$4,863.60
|
Rate for Payer: Signature Care EPO |
$5,229.00
|
Rate for Payer: Signature Care PPO |
$5,544.00
|
Rate for Payer: Three Rivers Preferred All Commercial |
$5,355.00
|
Rate for Payer: United Healthcare Commercial |
$4,964.40
|
Rate for Payer: United Healthcare Medicare |
$2,079.00
|
|
HC AMNIOHEAL PLUS PWDR 200 MG
|
Facility
IP
|
$8,820.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602557
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$6,615.00 |
Max. Negotiated Rate |
$8,202.60 |
Rate for Payer: Aetna Commercial |
$7,620.48
|
Rate for Payer: Cash Price |
$5,468.40
|
Rate for Payer: Cigna All Commercial |
$7,611.66
|
Rate for Payer: CORVEL All Commercial |
$8,202.60
|
Rate for Payer: Coventry All Commercial |
$7,761.60
|
Rate for Payer: Encore All Commercial |
$8,118.81
|
Rate for Payer: Frontpath All Commercial |
$8,114.40
|
Rate for Payer: Humana ChoiceCare |
$7,617.83
|
Rate for Payer: Lutheran Preferred All Commercial |
$7,938.00
|
Rate for Payer: PHCS All Commercial |
$6,615.00
|
Rate for Payer: PHP All Commercial |
$6,689.09
|
Rate for Payer: Sagamore Health Network All Products |
$6,809.04
|
Rate for Payer: Signature Care EPO |
$7,320.60
|
Rate for Payer: Signature Care PPO |
$7,761.60
|
Rate for Payer: United Healthcare Commercial |
$6,950.16
|
|
HC AMNIOHEAL PLUS PWDR 200 MG
|
Facility
OP
|
$8,820.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602557
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$524.16 |
Max. Negotiated Rate |
$8,202.60 |
Rate for Payer: Aetna Commercial |
$7,444.08
|
Rate for Payer: Aetna Medicare |
$2,910.60
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,910.60
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5,065.33
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,513.38
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,347.19
|
Rate for Payer: CareSource Indiana of IN Medicare |
$3,201.66
|
Rate for Payer: Cash Price |
$5,468.40
|
Rate for Payer: Cash Price |
$5,468.40
|
Rate for Payer: Centivo All Commercial |
$4,498.20
|
Rate for Payer: Cigna All Commercial |
$7,611.66
|
Rate for Payer: CORVEL All Commercial |
$8,202.60
|
Rate for Payer: Coventry All Commercial |
$7,761.60
|
Rate for Payer: Encore All Commercial |
$8,118.81
|
Rate for Payer: Frontpath All Commercial |
$8,114.40
|
Rate for Payer: Humana ChoiceCare |
$7,617.83
|
Rate for Payer: Humana Medicare |
$4,498.20
|
Rate for Payer: Lucent All Commercial |
$4,498.20
|
Rate for Payer: Lutheran Preferred All Commercial |
$7,938.00
|
Rate for Payer: Managed Health Services Medicaid |
$524.16
|
Rate for Payer: MDWise Medicaid |
$524.16
|
Rate for Payer: PHCS All Commercial |
$6,615.00
|
Rate for Payer: PHP All Commercial |
$6,689.09
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$3,439.80
|
Rate for Payer: Sagamore Health Network All Products |
$6,809.04
|
Rate for Payer: Signature Care EPO |
$7,320.60
|
Rate for Payer: Signature Care PPO |
$7,761.60
|
Rate for Payer: Three Rivers Preferred All Commercial |
$7,497.00
|
Rate for Payer: United Healthcare Commercial |
$6,950.16
|
Rate for Payer: United Healthcare Medicare |
$2,910.60
|
|
HC AMNIOHEAL PLUS PWDR 50 MG
|
Facility
OP
|
$4,500.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602555
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$524.16 |
Max. Negotiated Rate |
$4,185.00 |
Rate for Payer: Aetna Commercial |
$3,798.00
|
Rate for Payer: Aetna Medicare |
$1,485.00
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,485.00
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,584.35
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,812.95
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,707.75
|
Rate for Payer: CareSource Indiana of IN Medicare |
$1,633.50
|
Rate for Payer: Cash Price |
$2,790.00
|
Rate for Payer: Cash Price |
$2,790.00
|
Rate for Payer: Centivo All Commercial |
$2,295.00
|
Rate for Payer: Cigna All Commercial |
$3,883.50
|
Rate for Payer: CORVEL All Commercial |
$4,185.00
|
Rate for Payer: Coventry All Commercial |
$3,960.00
|
Rate for Payer: Encore All Commercial |
$4,142.25
|
Rate for Payer: Frontpath All Commercial |
$4,140.00
|
Rate for Payer: Humana ChoiceCare |
$3,886.65
|
Rate for Payer: Humana Medicare |
$2,295.00
|
Rate for Payer: Lucent All Commercial |
$2,295.00
|
Rate for Payer: Lutheran Preferred All Commercial |
$4,050.00
|
Rate for Payer: Managed Health Services Medicaid |
$524.16
|
Rate for Payer: MDWise Medicaid |
$524.16
|
Rate for Payer: PHCS All Commercial |
$3,375.00
|
Rate for Payer: PHP All Commercial |
$3,412.80
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$1,755.00
|
Rate for Payer: Sagamore Health Network All Products |
$3,474.00
|
Rate for Payer: Signature Care EPO |
$3,735.00
|
Rate for Payer: Signature Care PPO |
$3,960.00
|
Rate for Payer: Three Rivers Preferred All Commercial |
$3,825.00
|
Rate for Payer: United Healthcare Commercial |
$3,546.00
|
Rate for Payer: United Healthcare Medicare |
$1,485.00
|
|
HC AMNIOHEAL PLUS PWDR 50 MG
|
Facility
IP
|
$4,500.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602555
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$3,375.00 |
Max. Negotiated Rate |
$4,185.00 |
Rate for Payer: Aetna Commercial |
$3,888.00
|
Rate for Payer: Cash Price |
$2,790.00
|
Rate for Payer: Cigna All Commercial |
$3,883.50
|
Rate for Payer: CORVEL All Commercial |
$4,185.00
|
Rate for Payer: Coventry All Commercial |
$3,960.00
|
Rate for Payer: Encore All Commercial |
$4,142.25
|
Rate for Payer: Frontpath All Commercial |
$4,140.00
|
Rate for Payer: Humana ChoiceCare |
$3,886.65
|
Rate for Payer: Lutheran Preferred All Commercial |
$4,050.00
|
Rate for Payer: PHCS All Commercial |
$3,375.00
|
Rate for Payer: PHP All Commercial |
$3,412.80
|
Rate for Payer: Sagamore Health Network All Products |
$3,474.00
|
Rate for Payer: Signature Care EPO |
$3,735.00
|
Rate for Payer: Signature Care PPO |
$3,960.00
|
Rate for Payer: United Healthcare Commercial |
$3,546.00
|
|
HC AMNION THIN 4X4 CM
|
Facility
OP
|
$8,811.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602620
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$524.16 |
Max. Negotiated Rate |
$8,194.23 |
Rate for Payer: Aetna Commercial |
$7,436.48
|
Rate for Payer: Aetna Medicare |
$2,907.63
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,907.63
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5,060.16
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$5,507.76
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,343.77
|
Rate for Payer: CareSource Indiana of IN Medicare |
$3,198.39
|
Rate for Payer: Cash Price |
$5,462.82
|
Rate for Payer: Cash Price |
$5,462.82
|
Rate for Payer: Centivo All Commercial |
$4,493.61
|
Rate for Payer: Cigna All Commercial |
$7,603.89
|
Rate for Payer: CORVEL All Commercial |
$8,194.23
|
Rate for Payer: Coventry All Commercial |
$7,753.68
|
Rate for Payer: Encore All Commercial |
$8,110.53
|
Rate for Payer: Frontpath All Commercial |
$8,106.12
|
Rate for Payer: Humana ChoiceCare |
$7,610.06
|
Rate for Payer: Humana Medicare |
$4,493.61
|
Rate for Payer: Lucent All Commercial |
$4,493.61
|
Rate for Payer: Lutheran Preferred All Commercial |
$7,929.90
|
Rate for Payer: Managed Health Services Medicaid |
$524.16
|
Rate for Payer: MDWise Medicaid |
$524.16
|
Rate for Payer: PHCS All Commercial |
$6,608.25
|
Rate for Payer: PHP All Commercial |
$6,682.26
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$3,436.29
|
Rate for Payer: Sagamore Health Network All Products |
$6,802.09
|
Rate for Payer: Signature Care EPO |
$7,313.13
|
Rate for Payer: Signature Care PPO |
$7,753.68
|
Rate for Payer: Three Rivers Preferred All Commercial |
$7,489.35
|
Rate for Payer: United Healthcare Commercial |
$6,943.07
|
Rate for Payer: United Healthcare Medicare |
$2,907.63
|
|
HC AMNION THIN 4X4 CM
|
Facility
IP
|
$8,811.00
|
|
Service Code
|
CPT C9399
|
Hospital Charge Code |
41602620
|
Hospital Revenue Code
|
278
|
Min. Negotiated Rate |
$6,608.25 |
Max. Negotiated Rate |
$8,194.23 |
Rate for Payer: Aetna Commercial |
$7,612.70
|
Rate for Payer: Cash Price |
$5,462.82
|
Rate for Payer: Cigna All Commercial |
$7,603.89
|
Rate for Payer: CORVEL All Commercial |
$8,194.23
|
Rate for Payer: Coventry All Commercial |
$7,753.68
|
Rate for Payer: Encore All Commercial |
$8,110.53
|
Rate for Payer: Frontpath All Commercial |
$8,106.12
|
Rate for Payer: Humana ChoiceCare |
$7,610.06
|
Rate for Payer: Lutheran Preferred All Commercial |
$7,929.90
|
Rate for Payer: PHCS All Commercial |
$6,608.25
|
Rate for Payer: PHP All Commercial |
$6,682.26
|
Rate for Payer: Sagamore Health Network All Products |
$6,802.09
|
Rate for Payer: Signature Care EPO |
$7,313.13
|
Rate for Payer: Signature Care PPO |
$7,753.68
|
Rate for Payer: United Healthcare Commercial |
$6,943.07
|
|
HC AMPHETAMINE & METH
|
Facility
IP
|
$156.37
|
|
Service Code
|
CPT G0480
|
Hospital Charge Code |
63001405
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$117.27 |
Max. Negotiated Rate |
$145.42 |
Rate for Payer: Aetna Commercial |
$135.10
|
Rate for Payer: Cash Price |
$96.95
|
Rate for Payer: Cigna All Commercial |
$134.94
|
Rate for Payer: CORVEL All Commercial |
$145.42
|
Rate for Payer: Coventry All Commercial |
$137.60
|
Rate for Payer: Encore All Commercial |
$143.93
|
Rate for Payer: Frontpath All Commercial |
$143.86
|
Rate for Payer: Humana ChoiceCare |
$135.05
|
Rate for Payer: Lutheran Preferred All Commercial |
$140.73
|
Rate for Payer: PHCS All Commercial |
$117.27
|
Rate for Payer: PHP All Commercial |
$118.59
|
Rate for Payer: Sagamore Health Network All Products |
$120.71
|
Rate for Payer: Signature Care EPO |
$129.78
|
Rate for Payer: Signature Care PPO |
$137.60
|
Rate for Payer: United Healthcare Commercial |
$123.22
|
|
HC AMPHETAMINE & METH
|
Facility
OP
|
$156.37
|
|
Service Code
|
CPT G0480
|
Hospital Charge Code |
63001405
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$51.60 |
Max. Negotiated Rate |
$145.42 |
Rate for Payer: Aetna Commercial |
$131.97
|
Rate for Payer: Aetna Medicare |
$51.60
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$51.60
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$71.87
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$71.87
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$77.12
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$59.34
|
Rate for Payer: CareSource Indiana of IN Medicare |
$56.76
|
Rate for Payer: Cash Price |
$96.95
|
Rate for Payer: Cash Price |
$96.95
|
Rate for Payer: Centivo All Commercial |
$79.75
|
Rate for Payer: Cigna All Commercial |
$134.94
|
Rate for Payer: CORVEL All Commercial |
$145.42
|
Rate for Payer: Coventry All Commercial |
$137.60
|
Rate for Payer: Encore All Commercial |
$143.93
|
Rate for Payer: Frontpath All Commercial |
$143.86
|
Rate for Payer: Humana ChoiceCare |
$135.05
|
Rate for Payer: Humana Medicare |
$79.75
|
Rate for Payer: Lucent All Commercial |
$79.75
|
Rate for Payer: Lutheran Preferred All Commercial |
$140.73
|
Rate for Payer: Managed Health Services Medicaid |
$77.12
|
Rate for Payer: MDWise Medicaid |
$77.12
|
Rate for Payer: PHCS All Commercial |
$117.27
|
Rate for Payer: PHP All Commercial |
$118.59
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$60.98
|
Rate for Payer: Sagamore Health Network All Products |
$120.71
|
Rate for Payer: Signature Care EPO |
$129.78
|
Rate for Payer: Signature Care PPO |
$137.60
|
Rate for Payer: Three Rivers Preferred All Commercial |
$132.91
|
Rate for Payer: United Healthcare Commercial |
$123.22
|
Rate for Payer: United Healthcare Medicare |
$51.60
|
|
HC AMPHETAMINE & METHAMPHETAMINE - BLOOD
|
Facility
OP
|
$156.37
|
|
Service Code
|
CPT G0480
|
Hospital Charge Code |
63001406
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$51.60 |
Max. Negotiated Rate |
$145.42 |
Rate for Payer: Aetna Commercial |
$131.97
|
Rate for Payer: Aetna Medicare |
$51.60
|
Rate for Payer: Anthem Blue Cross of IN Medicare |
$51.60
|
Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$71.87
|
Rate for Payer: Anthem Blue Cross of IN Traditional |
$71.87
|
Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$77.12
|
Rate for Payer: CareSource Indiana of IN Just 4 Me |
$59.34
|
Rate for Payer: CareSource Indiana of IN Medicare |
$56.76
|
Rate for Payer: Cash Price |
$96.95
|
Rate for Payer: Cash Price |
$96.95
|
Rate for Payer: Centivo All Commercial |
$79.75
|
Rate for Payer: Cigna All Commercial |
$134.94
|
Rate for Payer: CORVEL All Commercial |
$145.42
|
Rate for Payer: Coventry All Commercial |
$137.60
|
Rate for Payer: Encore All Commercial |
$143.93
|
Rate for Payer: Frontpath All Commercial |
$143.86
|
Rate for Payer: Humana ChoiceCare |
$135.05
|
Rate for Payer: Humana Medicare |
$79.75
|
Rate for Payer: Lucent All Commercial |
$79.75
|
Rate for Payer: Lutheran Preferred All Commercial |
$140.73
|
Rate for Payer: Managed Health Services Medicaid |
$77.12
|
Rate for Payer: MDWise Medicaid |
$77.12
|
Rate for Payer: PHCS All Commercial |
$117.27
|
Rate for Payer: PHP All Commercial |
$118.59
|
Rate for Payer: Plain Church Group Ministry All Commercial |
$60.98
|
Rate for Payer: Sagamore Health Network All Products |
$120.71
|
Rate for Payer: Signature Care EPO |
$129.78
|
Rate for Payer: Signature Care PPO |
$137.60
|
Rate for Payer: Three Rivers Preferred All Commercial |
$132.91
|
Rate for Payer: United Healthcare Commercial |
$123.22
|
Rate for Payer: United Healthcare Medicare |
$51.60
|
|
HC AMPHETAMINE & METHAMPHETAMINE - BLOOD
|
Facility
IP
|
$156.37
|
|
Service Code
|
CPT G0480
|
Hospital Charge Code |
63001406
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$117.27 |
Max. Negotiated Rate |
$145.42 |
Rate for Payer: Aetna Commercial |
$135.10
|
Rate for Payer: Cash Price |
$96.95
|
Rate for Payer: Cigna All Commercial |
$134.94
|
Rate for Payer: CORVEL All Commercial |
$145.42
|
Rate for Payer: Coventry All Commercial |
$137.60
|
Rate for Payer: Encore All Commercial |
$143.93
|
Rate for Payer: Frontpath All Commercial |
$143.86
|
Rate for Payer: Humana ChoiceCare |
$135.05
|
Rate for Payer: Lutheran Preferred All Commercial |
$140.73
|
Rate for Payer: PHCS All Commercial |
$117.27
|
Rate for Payer: PHP All Commercial |
$118.59
|
Rate for Payer: Sagamore Health Network All Products |
$120.71
|
Rate for Payer: Signature Care EPO |
$129.78
|
Rate for Payer: Signature Care PPO |
$137.60
|
Rate for Payer: United Healthcare Commercial |
$123.22
|
|
HC AMPHETAMINE/METHAMPHETAMINE QT-URINE
|
Facility
IP
|
$156.37
|
|
Service Code
|
CPT G0480
|
Hospital Charge Code |
63001407
|
Hospital Revenue Code
|
300
|
Min. Negotiated Rate |
$117.27 |
Max. Negotiated Rate |
$145.42 |
Rate for Payer: Aetna Commercial |
$135.10
|
Rate for Payer: Cash Price |
$96.95
|
Rate for Payer: Cigna All Commercial |
$134.94
|
Rate for Payer: CORVEL All Commercial |
$145.42
|
Rate for Payer: Coventry All Commercial |
$137.60
|
Rate for Payer: Encore All Commercial |
$143.93
|
Rate for Payer: Frontpath All Commercial |
$143.86
|
Rate for Payer: Humana ChoiceCare |
$135.05
|
Rate for Payer: Lutheran Preferred All Commercial |
$140.73
|
Rate for Payer: PHCS All Commercial |
$117.27
|
Rate for Payer: PHP All Commercial |
$118.59
|
Rate for Payer: Sagamore Health Network All Products |
$120.71
|
Rate for Payer: Signature Care EPO |
$129.78
|
Rate for Payer: Signature Care PPO |
$137.60
|
Rate for Payer: United Healthcare Commercial |
$123.22
|
|