|
HC DRESSING ADH ALLEVYN 5X5
|
Facility
OP
|
$30.25
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
41601038
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.98 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$25.53
|
| Rate for Payer: Aetna Medicare |
$9.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.37
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.91
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.98
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Centivo All Commercial |
$15.43
|
| Rate for Payer: Cigna All Commercial |
$26.11
|
| Rate for Payer: CORVEL All Commercial |
$28.13
|
| Rate for Payer: Coventry All Commercial |
$26.62
|
| Rate for Payer: Encore All Commercial |
$27.85
|
| Rate for Payer: Frontpath All Commercial |
$27.83
|
| Rate for Payer: Humana ChoiceCare |
$26.13
|
| Rate for Payer: Humana Medicare |
$15.43
|
| Rate for Payer: Lucent All Commercial |
$15.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.22
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$22.69
|
| Rate for Payer: PHP All Commercial |
$22.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.80
|
| Rate for Payer: Sagamore Health Network All Products |
$23.35
|
| Rate for Payer: Signature Care EPO |
$25.11
|
| Rate for Payer: Signature Care PPO |
$26.62
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.71
|
| Rate for Payer: United Healthcare Commercial |
$23.84
|
| Rate for Payer: United Healthcare Medicare |
$9.98
|
|
|
HC DRESSING ALGISITE 3/4X12 WOUND CART
|
Facility
OP
|
$32.06
|
|
| Hospital Charge Code |
41601405
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.58 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$27.06
|
| Rate for Payer: Aetna Medicare |
$10.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$18.41
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.04
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.64
|
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Centivo All Commercial |
$16.35
|
| Rate for Payer: Cigna All Commercial |
$27.67
|
| Rate for Payer: CORVEL All Commercial |
$29.82
|
| Rate for Payer: Coventry All Commercial |
$28.21
|
| Rate for Payer: Encore All Commercial |
$29.51
|
| Rate for Payer: Frontpath All Commercial |
$29.50
|
| Rate for Payer: Humana ChoiceCare |
$27.69
|
| Rate for Payer: Humana Medicare |
$16.35
|
| Rate for Payer: Lucent All Commercial |
$16.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.85
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$24.04
|
| Rate for Payer: PHP All Commercial |
$24.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.50
|
| Rate for Payer: Sagamore Health Network All Products |
$24.75
|
| Rate for Payer: Signature Care EPO |
$26.61
|
| Rate for Payer: Signature Care PPO |
$28.21
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.25
|
| Rate for Payer: United Healthcare Commercial |
$25.26
|
| Rate for Payer: United Healthcare Medicare |
$10.58
|
|
|
HC DRESSING ALGISITE 3/4X12 WOUND CART
|
Facility
IP
|
$32.06
|
|
| Hospital Charge Code |
41601405
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$24.04 |
| Max. Negotiated Rate |
$29.82 |
| Rate for Payer: Aetna Commercial |
$27.70
|
| Rate for Payer: Cash Price |
$19.88
|
| Rate for Payer: Cigna All Commercial |
$27.67
|
| Rate for Payer: CORVEL All Commercial |
$29.82
|
| Rate for Payer: Coventry All Commercial |
$28.21
|
| Rate for Payer: Encore All Commercial |
$29.51
|
| Rate for Payer: Frontpath All Commercial |
$29.50
|
| Rate for Payer: Humana ChoiceCare |
$27.69
|
| Rate for Payer: Lutheran Preferred All Commercial |
$28.85
|
| Rate for Payer: PHCS All Commercial |
$24.04
|
| Rate for Payer: PHP All Commercial |
$24.31
|
| Rate for Payer: Sagamore Health Network All Products |
$24.75
|
| Rate for Payer: Signature Care EPO |
$26.61
|
| Rate for Payer: Signature Care PPO |
$28.21
|
| Rate for Payer: United Healthcare Commercial |
$25.26
|
|
|
HC DRESSING ALGISITE 4X4 WOUND CART
|
Facility
IP
|
$27.30
|
|
| Hospital Charge Code |
41601406
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.48 |
| Max. Negotiated Rate |
$25.39 |
| Rate for Payer: Aetna Commercial |
$23.59
|
| Rate for Payer: Cash Price |
$16.93
|
| Rate for Payer: Cigna All Commercial |
$23.56
|
| Rate for Payer: CORVEL All Commercial |
$25.39
|
| Rate for Payer: Coventry All Commercial |
$24.02
|
| Rate for Payer: Encore All Commercial |
$25.13
|
| Rate for Payer: Frontpath All Commercial |
$25.12
|
| Rate for Payer: Humana ChoiceCare |
$23.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.57
|
| Rate for Payer: PHCS All Commercial |
$20.48
|
| Rate for Payer: PHP All Commercial |
$20.70
|
| Rate for Payer: Sagamore Health Network All Products |
$21.08
|
| Rate for Payer: Signature Care EPO |
$22.66
|
| Rate for Payer: Signature Care PPO |
$24.02
|
| Rate for Payer: United Healthcare Commercial |
$21.51
|
|
|
HC DRESSING ALGISITE 4X4 WOUND CART
|
Facility
OP
|
$27.30
|
|
| Hospital Charge Code |
41601406
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.01 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$23.04
|
| Rate for Payer: Aetna Medicare |
$9.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.01
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$15.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.91
|
| Rate for Payer: Cash Price |
$16.93
|
| Rate for Payer: Cash Price |
$16.93
|
| Rate for Payer: Centivo All Commercial |
$13.92
|
| Rate for Payer: Cigna All Commercial |
$23.56
|
| Rate for Payer: CORVEL All Commercial |
$25.39
|
| Rate for Payer: Coventry All Commercial |
$24.02
|
| Rate for Payer: Encore All Commercial |
$25.13
|
| Rate for Payer: Frontpath All Commercial |
$25.12
|
| Rate for Payer: Humana ChoiceCare |
$23.58
|
| Rate for Payer: Humana Medicare |
$13.92
|
| Rate for Payer: Lucent All Commercial |
$13.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$24.57
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$20.48
|
| Rate for Payer: PHP All Commercial |
$20.70
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.65
|
| Rate for Payer: Sagamore Health Network All Products |
$21.08
|
| Rate for Payer: Signature Care EPO |
$22.66
|
| Rate for Payer: Signature Care PPO |
$24.02
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$23.20
|
| Rate for Payer: United Healthcare Commercial |
$21.51
|
| Rate for Payer: United Healthcare Medicare |
$9.01
|
|
|
HC DRESSING ALLEVYN THIN 4X4
|
Facility
IP
|
$21.02
|
|
|
Service Code
|
CPT A6209
|
| Hospital Charge Code |
41601039
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.76 |
| Max. Negotiated Rate |
$19.55 |
| Rate for Payer: Aetna Commercial |
$18.16
|
| Rate for Payer: Cash Price |
$13.03
|
| Rate for Payer: Cigna All Commercial |
$18.14
|
| Rate for Payer: CORVEL All Commercial |
$19.55
|
| Rate for Payer: Coventry All Commercial |
$18.50
|
| Rate for Payer: Encore All Commercial |
$19.35
|
| Rate for Payer: Frontpath All Commercial |
$19.34
|
| Rate for Payer: Humana ChoiceCare |
$18.15
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.92
|
| Rate for Payer: PHCS All Commercial |
$15.76
|
| Rate for Payer: PHP All Commercial |
$15.94
|
| Rate for Payer: Sagamore Health Network All Products |
$16.23
|
| Rate for Payer: Signature Care EPO |
$17.45
|
| Rate for Payer: Signature Care PPO |
$18.50
|
| Rate for Payer: United Healthcare Commercial |
$16.56
|
|
|
HC DRESSING ALLEVYN THIN 4X4
|
Facility
OP
|
$21.02
|
|
|
Service Code
|
CPT A6209
|
| Hospital Charge Code |
41601039
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.94 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$17.74
|
| Rate for Payer: Aetna Medicare |
$6.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.98
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.63
|
| Rate for Payer: Cash Price |
$13.03
|
| Rate for Payer: Cash Price |
$13.03
|
| Rate for Payer: Centivo All Commercial |
$10.72
|
| Rate for Payer: Cigna All Commercial |
$18.14
|
| Rate for Payer: CORVEL All Commercial |
$19.55
|
| Rate for Payer: Coventry All Commercial |
$18.50
|
| Rate for Payer: Encore All Commercial |
$19.35
|
| Rate for Payer: Frontpath All Commercial |
$19.34
|
| Rate for Payer: Humana ChoiceCare |
$18.15
|
| Rate for Payer: Humana Medicare |
$10.72
|
| Rate for Payer: Lucent All Commercial |
$10.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18.92
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$15.76
|
| Rate for Payer: PHP All Commercial |
$15.94
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.20
|
| Rate for Payer: Sagamore Health Network All Products |
$16.23
|
| Rate for Payer: Signature Care EPO |
$17.45
|
| Rate for Payer: Signature Care PPO |
$18.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17.87
|
| Rate for Payer: United Healthcare Commercial |
$16.56
|
| Rate for Payer: United Healthcare Medicare |
$6.94
|
|
|
HC DRESSING CHANGE TRAY CENTRAL LINE/PICC
|
Facility
IP
|
$84.07
|
|
| Hospital Charge Code |
41601216
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$63.05 |
| Max. Negotiated Rate |
$78.19 |
| Rate for Payer: Aetna Commercial |
$72.64
|
| Rate for Payer: Cash Price |
$52.12
|
| Rate for Payer: Cigna All Commercial |
$72.55
|
| Rate for Payer: CORVEL All Commercial |
$78.19
|
| Rate for Payer: Coventry All Commercial |
$73.98
|
| Rate for Payer: Encore All Commercial |
$77.39
|
| Rate for Payer: Frontpath All Commercial |
$77.34
|
| Rate for Payer: Humana ChoiceCare |
$72.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.66
|
| Rate for Payer: PHCS All Commercial |
$63.05
|
| Rate for Payer: PHP All Commercial |
$63.76
|
| Rate for Payer: Sagamore Health Network All Products |
$64.90
|
| Rate for Payer: Signature Care EPO |
$69.78
|
| Rate for Payer: Signature Care PPO |
$73.98
|
| Rate for Payer: United Healthcare Commercial |
$66.25
|
|
|
HC DRESSING CHANGE TRAY CENTRAL LINE/PICC
|
Facility
OP
|
$84.07
|
|
| Hospital Charge Code |
41601216
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$27.74 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$70.96
|
| Rate for Payer: Aetna Medicare |
$27.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$48.28
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$52.55
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$31.90
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$30.52
|
| Rate for Payer: Cash Price |
$52.12
|
| Rate for Payer: Cash Price |
$52.12
|
| Rate for Payer: Centivo All Commercial |
$42.88
|
| Rate for Payer: Cigna All Commercial |
$72.55
|
| Rate for Payer: CORVEL All Commercial |
$78.19
|
| Rate for Payer: Coventry All Commercial |
$73.98
|
| Rate for Payer: Encore All Commercial |
$77.39
|
| Rate for Payer: Frontpath All Commercial |
$77.34
|
| Rate for Payer: Humana ChoiceCare |
$72.61
|
| Rate for Payer: Humana Medicare |
$42.88
|
| Rate for Payer: Lucent All Commercial |
$42.88
|
| Rate for Payer: Lutheran Preferred All Commercial |
$75.66
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$63.05
|
| Rate for Payer: PHP All Commercial |
$63.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.79
|
| Rate for Payer: Sagamore Health Network All Products |
$64.90
|
| Rate for Payer: Signature Care EPO |
$69.78
|
| Rate for Payer: Signature Care PPO |
$73.98
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$71.46
|
| Rate for Payer: United Healthcare Commercial |
$66.25
|
| Rate for Payer: United Healthcare Medicare |
$27.74
|
|
|
HC DRESSING CHANGE TRAY INFUSAPORT
|
Facility
OP
|
$43.75
|
|
| Hospital Charge Code |
41601217
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.44 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$36.92
|
| Rate for Payer: Aetna Medicare |
$14.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$14.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$25.13
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$27.35
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$16.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$15.88
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Centivo All Commercial |
$22.31
|
| Rate for Payer: Cigna All Commercial |
$37.76
|
| Rate for Payer: CORVEL All Commercial |
$40.69
|
| Rate for Payer: Coventry All Commercial |
$38.50
|
| Rate for Payer: Encore All Commercial |
$40.27
|
| Rate for Payer: Frontpath All Commercial |
$40.25
|
| Rate for Payer: Humana ChoiceCare |
$37.79
|
| Rate for Payer: Humana Medicare |
$22.31
|
| Rate for Payer: Lucent All Commercial |
$22.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$39.38
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$32.81
|
| Rate for Payer: PHP All Commercial |
$33.18
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$17.06
|
| Rate for Payer: Sagamore Health Network All Products |
$33.78
|
| Rate for Payer: Signature Care EPO |
$36.31
|
| Rate for Payer: Signature Care PPO |
$38.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$37.19
|
| Rate for Payer: United Healthcare Commercial |
$34.48
|
| Rate for Payer: United Healthcare Medicare |
$14.44
|
|
|
HC DRESSING CHANGE TRAY INFUSAPORT
|
Facility
IP
|
$43.75
|
|
| Hospital Charge Code |
41601217
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$32.81 |
| Max. Negotiated Rate |
$40.69 |
| Rate for Payer: Aetna Commercial |
$37.80
|
| Rate for Payer: Cash Price |
$27.13
|
| Rate for Payer: Cigna All Commercial |
$37.76
|
| Rate for Payer: CORVEL All Commercial |
$40.69
|
| Rate for Payer: Coventry All Commercial |
$38.50
|
| Rate for Payer: Encore All Commercial |
$40.27
|
| Rate for Payer: Frontpath All Commercial |
$40.25
|
| Rate for Payer: Humana ChoiceCare |
$37.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$39.38
|
| Rate for Payer: PHCS All Commercial |
$32.81
|
| Rate for Payer: PHP All Commercial |
$33.18
|
| Rate for Payer: Sagamore Health Network All Products |
$33.78
|
| Rate for Payer: Signature Care EPO |
$36.31
|
| Rate for Payer: Signature Care PPO |
$38.50
|
| Rate for Payer: United Healthcare Commercial |
$34.48
|
|
|
HC DRESSING CLEANSE VERAFLO V.A.C
|
Facility
IP
|
$1,236.01
|
|
| Hospital Charge Code |
41607591
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$927.01 |
| Max. Negotiated Rate |
$1,149.49 |
| Rate for Payer: Aetna Commercial |
$1,067.91
|
| Rate for Payer: Cash Price |
$766.33
|
| Rate for Payer: Cigna All Commercial |
$1,066.68
|
| Rate for Payer: CORVEL All Commercial |
$1,149.49
|
| Rate for Payer: Coventry All Commercial |
$1,087.69
|
| Rate for Payer: Encore All Commercial |
$1,137.75
|
| Rate for Payer: Frontpath All Commercial |
$1,137.13
|
| Rate for Payer: Humana ChoiceCare |
$1,067.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,112.41
|
| Rate for Payer: PHCS All Commercial |
$927.01
|
| Rate for Payer: PHP All Commercial |
$937.39
|
| Rate for Payer: Sagamore Health Network All Products |
$954.20
|
| Rate for Payer: Signature Care EPO |
$1,025.89
|
| Rate for Payer: Signature Care PPO |
$1,087.69
|
| Rate for Payer: United Healthcare Commercial |
$973.98
|
|
|
HC DRESSING CLEANSE VERAFLO V.A.C
|
Facility
OP
|
$1,236.01
|
|
| Hospital Charge Code |
41607591
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$121.68 |
| Max. Negotiated Rate |
$1,149.49 |
| Rate for Payer: Aetna Commercial |
$1,043.19
|
| Rate for Payer: Aetna Medicare |
$407.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$407.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$709.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$772.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$469.07
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$448.67
|
| Rate for Payer: Cash Price |
$766.33
|
| Rate for Payer: Cash Price |
$766.33
|
| Rate for Payer: Centivo All Commercial |
$630.37
|
| Rate for Payer: Cigna All Commercial |
$1,066.68
|
| Rate for Payer: CORVEL All Commercial |
$1,149.49
|
| Rate for Payer: Coventry All Commercial |
$1,087.69
|
| Rate for Payer: Encore All Commercial |
$1,137.75
|
| Rate for Payer: Frontpath All Commercial |
$1,137.13
|
| Rate for Payer: Humana ChoiceCare |
$1,067.54
|
| Rate for Payer: Humana Medicare |
$630.37
|
| Rate for Payer: Lucent All Commercial |
$630.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,112.41
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$927.01
|
| Rate for Payer: PHP All Commercial |
$937.39
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$482.04
|
| Rate for Payer: Sagamore Health Network All Products |
$954.20
|
| Rate for Payer: Signature Care EPO |
$1,025.89
|
| Rate for Payer: Signature Care PPO |
$1,087.69
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,050.61
|
| Rate for Payer: United Healthcare Commercial |
$973.98
|
| Rate for Payer: United Healthcare Medicare |
$407.88
|
|
|
HC DRESSING COVRSITE 4X4 WOUND CART
|
Facility
IP
|
$47.41
|
|
| Hospital Charge Code |
41601040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$35.56 |
| Max. Negotiated Rate |
$44.09 |
| Rate for Payer: Aetna Commercial |
$40.96
|
| Rate for Payer: Cash Price |
$29.39
|
| Rate for Payer: Cigna All Commercial |
$40.91
|
| Rate for Payer: CORVEL All Commercial |
$44.09
|
| Rate for Payer: Coventry All Commercial |
$41.72
|
| Rate for Payer: Encore All Commercial |
$43.64
|
| Rate for Payer: Frontpath All Commercial |
$43.62
|
| Rate for Payer: Humana ChoiceCare |
$40.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.67
|
| Rate for Payer: PHCS All Commercial |
$35.56
|
| Rate for Payer: PHP All Commercial |
$35.96
|
| Rate for Payer: Sagamore Health Network All Products |
$36.60
|
| Rate for Payer: Signature Care EPO |
$39.35
|
| Rate for Payer: Signature Care PPO |
$41.72
|
| Rate for Payer: United Healthcare Commercial |
$37.36
|
|
|
HC DRESSING COVRSITE 4X4 WOUND CART
|
Facility
OP
|
$47.41
|
|
| Hospital Charge Code |
41601040
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.65 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$40.01
|
| Rate for Payer: Aetna Medicare |
$15.65
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.65
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$27.23
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$29.64
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.21
|
| Rate for Payer: Cash Price |
$29.39
|
| Rate for Payer: Cash Price |
$29.39
|
| Rate for Payer: Centivo All Commercial |
$24.18
|
| Rate for Payer: Cigna All Commercial |
$40.91
|
| Rate for Payer: CORVEL All Commercial |
$44.09
|
| Rate for Payer: Coventry All Commercial |
$41.72
|
| Rate for Payer: Encore All Commercial |
$43.64
|
| Rate for Payer: Frontpath All Commercial |
$43.62
|
| Rate for Payer: Humana ChoiceCare |
$40.95
|
| Rate for Payer: Humana Medicare |
$24.18
|
| Rate for Payer: Lucent All Commercial |
$24.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$42.67
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$35.56
|
| Rate for Payer: PHP All Commercial |
$35.96
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.49
|
| Rate for Payer: Sagamore Health Network All Products |
$36.60
|
| Rate for Payer: Signature Care EPO |
$39.35
|
| Rate for Payer: Signature Care PPO |
$41.72
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$40.30
|
| Rate for Payer: United Healthcare Commercial |
$37.36
|
| Rate for Payer: United Healthcare Medicare |
$15.65
|
|
|
HC DRESSING COVRSITE 6X6 WOUND CART
|
Facility
OP
|
$79.36
|
|
| Hospital Charge Code |
41601442
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$26.19 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$66.98
|
| Rate for Payer: Aetna Medicare |
$26.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$26.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$45.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$49.61
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$30.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$28.81
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Centivo All Commercial |
$40.47
|
| Rate for Payer: Cigna All Commercial |
$68.49
|
| Rate for Payer: CORVEL All Commercial |
$73.80
|
| Rate for Payer: Coventry All Commercial |
$69.84
|
| Rate for Payer: Encore All Commercial |
$73.05
|
| Rate for Payer: Frontpath All Commercial |
$73.01
|
| Rate for Payer: Humana ChoiceCare |
$68.54
|
| Rate for Payer: Humana Medicare |
$40.47
|
| Rate for Payer: Lucent All Commercial |
$40.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.42
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$59.52
|
| Rate for Payer: PHP All Commercial |
$60.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$30.95
|
| Rate for Payer: Sagamore Health Network All Products |
$61.27
|
| Rate for Payer: Signature Care EPO |
$65.87
|
| Rate for Payer: Signature Care PPO |
$69.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$67.46
|
| Rate for Payer: United Healthcare Commercial |
$62.54
|
| Rate for Payer: United Healthcare Medicare |
$26.19
|
|
|
HC DRESSING COVRSITE 6X6 WOUND CART
|
Facility
IP
|
$79.36
|
|
| Hospital Charge Code |
41601442
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$59.52 |
| Max. Negotiated Rate |
$73.80 |
| Rate for Payer: Aetna Commercial |
$68.57
|
| Rate for Payer: Cash Price |
$49.20
|
| Rate for Payer: Cigna All Commercial |
$68.49
|
| Rate for Payer: CORVEL All Commercial |
$73.80
|
| Rate for Payer: Coventry All Commercial |
$69.84
|
| Rate for Payer: Encore All Commercial |
$73.05
|
| Rate for Payer: Frontpath All Commercial |
$73.01
|
| Rate for Payer: Humana ChoiceCare |
$68.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$71.42
|
| Rate for Payer: PHCS All Commercial |
$59.52
|
| Rate for Payer: PHP All Commercial |
$60.19
|
| Rate for Payer: Sagamore Health Network All Products |
$61.27
|
| Rate for Payer: Signature Care EPO |
$65.87
|
| Rate for Payer: Signature Care PPO |
$69.84
|
| Rate for Payer: United Healthcare Commercial |
$62.54
|
|
|
HC DRESSING MEPILEX 4X4
|
Facility
OP
|
$17.70
|
|
| Hospital Charge Code |
41607727
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.84 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$14.94
|
| Rate for Payer: Aetna Medicare |
$5.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.84
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.06
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.72
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.43
|
| Rate for Payer: Cash Price |
$10.97
|
| Rate for Payer: Cash Price |
$10.97
|
| Rate for Payer: Centivo All Commercial |
$9.03
|
| Rate for Payer: Cigna All Commercial |
$15.28
|
| Rate for Payer: CORVEL All Commercial |
$16.46
|
| Rate for Payer: Coventry All Commercial |
$15.58
|
| Rate for Payer: Encore All Commercial |
$16.29
|
| Rate for Payer: Frontpath All Commercial |
$16.28
|
| Rate for Payer: Humana ChoiceCare |
$15.29
|
| Rate for Payer: Humana Medicare |
$9.03
|
| Rate for Payer: Lucent All Commercial |
$9.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.93
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$13.28
|
| Rate for Payer: PHP All Commercial |
$13.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.90
|
| Rate for Payer: Sagamore Health Network All Products |
$13.66
|
| Rate for Payer: Signature Care EPO |
$14.69
|
| Rate for Payer: Signature Care PPO |
$15.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.04
|
| Rate for Payer: United Healthcare Commercial |
$13.95
|
| Rate for Payer: United Healthcare Medicare |
$5.84
|
|
|
HC DRESSING MEPILEX 4X4
|
Facility
IP
|
$17.70
|
|
| Hospital Charge Code |
41607727
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.28 |
| Max. Negotiated Rate |
$16.46 |
| Rate for Payer: Aetna Commercial |
$15.29
|
| Rate for Payer: Cash Price |
$10.97
|
| Rate for Payer: Cigna All Commercial |
$15.28
|
| Rate for Payer: CORVEL All Commercial |
$16.46
|
| Rate for Payer: Coventry All Commercial |
$15.58
|
| Rate for Payer: Encore All Commercial |
$16.29
|
| Rate for Payer: Frontpath All Commercial |
$16.28
|
| Rate for Payer: Humana ChoiceCare |
$15.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.93
|
| Rate for Payer: PHCS All Commercial |
$13.28
|
| Rate for Payer: PHP All Commercial |
$13.42
|
| Rate for Payer: Sagamore Health Network All Products |
$13.66
|
| Rate for Payer: Signature Care EPO |
$14.69
|
| Rate for Payer: Signature Care PPO |
$15.58
|
| Rate for Payer: United Healthcare Commercial |
$13.95
|
|
|
HC DRESSING MEPILEX BORDER HEEL
|
Facility
OP
|
$65.70
|
|
|
Service Code
|
CPT A6210
|
| Hospital Charge Code |
41607647
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.68 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$55.45
|
| Rate for Payer: Aetna Medicare |
$21.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$21.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$37.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$41.07
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$24.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$23.85
|
| Rate for Payer: Cash Price |
$40.73
|
| Rate for Payer: Cash Price |
$40.73
|
| Rate for Payer: Centivo All Commercial |
$33.51
|
| Rate for Payer: Cigna All Commercial |
$56.70
|
| Rate for Payer: CORVEL All Commercial |
$61.10
|
| Rate for Payer: Coventry All Commercial |
$57.82
|
| Rate for Payer: Encore All Commercial |
$60.48
|
| Rate for Payer: Frontpath All Commercial |
$60.44
|
| Rate for Payer: Humana ChoiceCare |
$56.75
|
| Rate for Payer: Humana Medicare |
$33.51
|
| Rate for Payer: Lucent All Commercial |
$33.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.13
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$49.28
|
| Rate for Payer: PHP All Commercial |
$49.83
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$25.62
|
| Rate for Payer: Sagamore Health Network All Products |
$50.72
|
| Rate for Payer: Signature Care EPO |
$54.53
|
| Rate for Payer: Signature Care PPO |
$57.82
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$55.84
|
| Rate for Payer: United Healthcare Commercial |
$51.77
|
| Rate for Payer: United Healthcare Medicare |
$21.68
|
|
|
HC DRESSING MEPILEX BORDER HEEL
|
Facility
IP
|
$65.70
|
|
|
Service Code
|
CPT A6210
|
| Hospital Charge Code |
41607647
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$49.28 |
| Max. Negotiated Rate |
$61.10 |
| Rate for Payer: Aetna Commercial |
$56.76
|
| Rate for Payer: Cash Price |
$40.73
|
| Rate for Payer: Cigna All Commercial |
$56.70
|
| Rate for Payer: CORVEL All Commercial |
$61.10
|
| Rate for Payer: Coventry All Commercial |
$57.82
|
| Rate for Payer: Encore All Commercial |
$60.48
|
| Rate for Payer: Frontpath All Commercial |
$60.44
|
| Rate for Payer: Humana ChoiceCare |
$56.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$59.13
|
| Rate for Payer: PHCS All Commercial |
$49.28
|
| Rate for Payer: PHP All Commercial |
$49.83
|
| Rate for Payer: Sagamore Health Network All Products |
$50.72
|
| Rate for Payer: Signature Care EPO |
$54.53
|
| Rate for Payer: Signature Care PPO |
$57.82
|
| Rate for Payer: United Healthcare Commercial |
$51.77
|
|
|
HC DRESSING MEPILEX OVAL 3.1X4
|
Facility
OP
|
$18.27
|
|
| Hospital Charge Code |
41607726
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.03 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$15.42
|
| Rate for Payer: Aetna Medicare |
$6.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.03
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.42
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.93
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.63
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Centivo All Commercial |
$9.32
|
| Rate for Payer: Cigna All Commercial |
$15.77
|
| Rate for Payer: CORVEL All Commercial |
$16.99
|
| Rate for Payer: Coventry All Commercial |
$16.08
|
| Rate for Payer: Encore All Commercial |
$16.82
|
| Rate for Payer: Frontpath All Commercial |
$16.81
|
| Rate for Payer: Humana ChoiceCare |
$15.78
|
| Rate for Payer: Humana Medicare |
$9.32
|
| Rate for Payer: Lucent All Commercial |
$9.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.44
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$13.70
|
| Rate for Payer: PHP All Commercial |
$13.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.13
|
| Rate for Payer: Sagamore Health Network All Products |
$14.10
|
| Rate for Payer: Signature Care EPO |
$15.16
|
| Rate for Payer: Signature Care PPO |
$16.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.53
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
| Rate for Payer: United Healthcare Medicare |
$6.03
|
|
|
HC DRESSING MEPILEX OVAL 3.1X4
|
Facility
IP
|
$18.27
|
|
| Hospital Charge Code |
41607726
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.70 |
| Max. Negotiated Rate |
$16.99 |
| Rate for Payer: Aetna Commercial |
$15.79
|
| Rate for Payer: Cash Price |
$11.33
|
| Rate for Payer: Cigna All Commercial |
$15.77
|
| Rate for Payer: CORVEL All Commercial |
$16.99
|
| Rate for Payer: Coventry All Commercial |
$16.08
|
| Rate for Payer: Encore All Commercial |
$16.82
|
| Rate for Payer: Frontpath All Commercial |
$16.81
|
| Rate for Payer: Humana ChoiceCare |
$15.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.44
|
| Rate for Payer: PHCS All Commercial |
$13.70
|
| Rate for Payer: PHP All Commercial |
$13.86
|
| Rate for Payer: Sagamore Health Network All Products |
$14.10
|
| Rate for Payer: Signature Care EPO |
$15.16
|
| Rate for Payer: Signature Care PPO |
$16.08
|
| Rate for Payer: United Healthcare Commercial |
$14.40
|
|
|
HC DRESSING MEPILEX OVAL 5.1X6.3
|
Facility
OP
|
$37.68
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
41607728
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$12.43 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$31.80
|
| Rate for Payer: Aetna Medicare |
$12.43
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.43
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$21.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$23.55
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.68
|
| Rate for Payer: Cash Price |
$23.36
|
| Rate for Payer: Cash Price |
$23.36
|
| Rate for Payer: Centivo All Commercial |
$19.22
|
| Rate for Payer: Cigna All Commercial |
$32.52
|
| Rate for Payer: CORVEL All Commercial |
$35.04
|
| Rate for Payer: Coventry All Commercial |
$33.16
|
| Rate for Payer: Encore All Commercial |
$34.68
|
| Rate for Payer: Frontpath All Commercial |
$34.67
|
| Rate for Payer: Humana ChoiceCare |
$32.54
|
| Rate for Payer: Humana Medicare |
$19.22
|
| Rate for Payer: Lucent All Commercial |
$19.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.91
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$28.26
|
| Rate for Payer: PHP All Commercial |
$28.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$14.70
|
| Rate for Payer: Sagamore Health Network All Products |
$29.09
|
| Rate for Payer: Signature Care EPO |
$31.27
|
| Rate for Payer: Signature Care PPO |
$33.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.03
|
| Rate for Payer: United Healthcare Commercial |
$29.69
|
| Rate for Payer: United Healthcare Medicare |
$12.43
|
|
|
HC DRESSING MEPILEX OVAL 5.1X6.3
|
Facility
IP
|
$37.68
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
41607728
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$28.26 |
| Max. Negotiated Rate |
$35.04 |
| Rate for Payer: Aetna Commercial |
$32.56
|
| Rate for Payer: Cash Price |
$23.36
|
| Rate for Payer: Cigna All Commercial |
$32.52
|
| Rate for Payer: CORVEL All Commercial |
$35.04
|
| Rate for Payer: Coventry All Commercial |
$33.16
|
| Rate for Payer: Encore All Commercial |
$34.68
|
| Rate for Payer: Frontpath All Commercial |
$34.67
|
| Rate for Payer: Humana ChoiceCare |
$32.54
|
| Rate for Payer: Lutheran Preferred All Commercial |
$33.91
|
| Rate for Payer: PHCS All Commercial |
$28.26
|
| Rate for Payer: PHP All Commercial |
$28.58
|
| Rate for Payer: Sagamore Health Network All Products |
$29.09
|
| Rate for Payer: Signature Care EPO |
$31.27
|
| Rate for Payer: Signature Care PPO |
$33.16
|
| Rate for Payer: United Healthcare Commercial |
$29.69
|
|
