|
HC DRESSING MEPILEX SACRAL BORDER
|
Facility
IP
|
$62.41
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
41607646
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$46.81 |
| Max. Negotiated Rate |
$58.04 |
| Rate for Payer: Aetna Commercial |
$53.92
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Cigna All Commercial |
$53.86
|
| Rate for Payer: CORVEL All Commercial |
$58.04
|
| Rate for Payer: Coventry All Commercial |
$54.92
|
| Rate for Payer: Encore All Commercial |
$57.45
|
| Rate for Payer: Frontpath All Commercial |
$57.42
|
| Rate for Payer: Humana ChoiceCare |
$53.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.17
|
| Rate for Payer: PHCS All Commercial |
$46.81
|
| Rate for Payer: PHP All Commercial |
$47.33
|
| Rate for Payer: Sagamore Health Network All Products |
$48.18
|
| Rate for Payer: Signature Care EPO |
$51.80
|
| Rate for Payer: Signature Care PPO |
$54.92
|
| Rate for Payer: United Healthcare Commercial |
$49.18
|
|
|
HC DRESSING MEPILEX SACRAL BORDER
|
Facility
OP
|
$62.41
|
|
|
Service Code
|
CPT A6213
|
| Hospital Charge Code |
41607646
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$20.60 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$52.67
|
| Rate for Payer: Aetna Medicare |
$20.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$20.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$35.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$39.01
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$23.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$22.65
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Cash Price |
$38.69
|
| Rate for Payer: Centivo All Commercial |
$31.83
|
| Rate for Payer: Cigna All Commercial |
$53.86
|
| Rate for Payer: CORVEL All Commercial |
$58.04
|
| Rate for Payer: Coventry All Commercial |
$54.92
|
| Rate for Payer: Encore All Commercial |
$57.45
|
| Rate for Payer: Frontpath All Commercial |
$57.42
|
| Rate for Payer: Humana ChoiceCare |
$53.90
|
| Rate for Payer: Humana Medicare |
$31.83
|
| Rate for Payer: Lucent All Commercial |
$31.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.17
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$46.81
|
| Rate for Payer: PHP All Commercial |
$47.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$24.34
|
| Rate for Payer: Sagamore Health Network All Products |
$48.18
|
| Rate for Payer: Signature Care EPO |
$51.80
|
| Rate for Payer: Signature Care PPO |
$54.92
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$53.05
|
| Rate for Payer: United Healthcare Commercial |
$49.18
|
| Rate for Payer: United Healthcare Medicare |
$20.60
|
|
|
HC DRESSING POLYMEM 2X3 #3
|
Facility
IP
|
$8.23
|
|
| Hospital Charge Code |
41601883
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.17 |
| Max. Negotiated Rate |
$7.65 |
| Rate for Payer: Aetna Commercial |
$7.11
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cigna All Commercial |
$7.10
|
| Rate for Payer: CORVEL All Commercial |
$7.65
|
| Rate for Payer: Coventry All Commercial |
$7.24
|
| Rate for Payer: Encore All Commercial |
$7.58
|
| Rate for Payer: Frontpath All Commercial |
$7.57
|
| Rate for Payer: Humana ChoiceCare |
$7.11
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.41
|
| Rate for Payer: PHCS All Commercial |
$6.17
|
| Rate for Payer: PHP All Commercial |
$6.24
|
| Rate for Payer: Sagamore Health Network All Products |
$6.35
|
| Rate for Payer: Signature Care EPO |
$6.83
|
| Rate for Payer: Signature Care PPO |
$7.24
|
| Rate for Payer: United Healthcare Commercial |
$6.49
|
|
|
HC DRESSING POLYMEM 2X3 #3
|
Facility
OP
|
$8.23
|
|
| Hospital Charge Code |
41601883
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$6.95
|
| Rate for Payer: Aetna Medicare |
$2.72
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.14
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3.12
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.99
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Centivo All Commercial |
$4.20
|
| Rate for Payer: Cigna All Commercial |
$7.10
|
| Rate for Payer: CORVEL All Commercial |
$7.65
|
| Rate for Payer: Coventry All Commercial |
$7.24
|
| Rate for Payer: Encore All Commercial |
$7.58
|
| Rate for Payer: Frontpath All Commercial |
$7.57
|
| Rate for Payer: Humana ChoiceCare |
$7.11
|
| Rate for Payer: Humana Medicare |
$4.20
|
| Rate for Payer: Lucent All Commercial |
$4.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.41
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$6.17
|
| Rate for Payer: PHP All Commercial |
$6.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.21
|
| Rate for Payer: Sagamore Health Network All Products |
$6.35
|
| Rate for Payer: Signature Care EPO |
$6.83
|
| Rate for Payer: Signature Care PPO |
$7.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$7.00
|
| Rate for Payer: United Healthcare Commercial |
$6.49
|
| Rate for Payer: United Healthcare Medicare |
$2.72
|
|
|
HC DRESSING POLYMEM #3 SILVER OVAL
|
Facility
OP
|
$17.57
|
|
| Hospital Charge Code |
41601885
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$14.83
|
| Rate for Payer: Aetna Medicare |
$5.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.09
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$10.98
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.38
|
| Rate for Payer: Cash Price |
$10.89
|
| Rate for Payer: Cash Price |
$10.89
|
| Rate for Payer: Centivo All Commercial |
$8.96
|
| Rate for Payer: Cigna All Commercial |
$15.16
|
| Rate for Payer: CORVEL All Commercial |
$16.34
|
| Rate for Payer: Coventry All Commercial |
$15.46
|
| Rate for Payer: Encore All Commercial |
$16.17
|
| Rate for Payer: Frontpath All Commercial |
$16.16
|
| Rate for Payer: Humana ChoiceCare |
$15.18
|
| Rate for Payer: Humana Medicare |
$8.96
|
| Rate for Payer: Lucent All Commercial |
$8.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.81
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$13.18
|
| Rate for Payer: PHP All Commercial |
$13.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$6.85
|
| Rate for Payer: Sagamore Health Network All Products |
$13.56
|
| Rate for Payer: Signature Care EPO |
$14.58
|
| Rate for Payer: Signature Care PPO |
$15.46
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14.93
|
| Rate for Payer: United Healthcare Commercial |
$13.85
|
| Rate for Payer: United Healthcare Medicare |
$5.80
|
|
|
HC DRESSING POLYMEM #3 SILVER OVAL
|
Facility
IP
|
$17.57
|
|
| Hospital Charge Code |
41601885
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$13.18 |
| Max. Negotiated Rate |
$16.34 |
| Rate for Payer: Aetna Commercial |
$15.18
|
| Rate for Payer: Cash Price |
$10.89
|
| Rate for Payer: Cigna All Commercial |
$15.16
|
| Rate for Payer: CORVEL All Commercial |
$16.34
|
| Rate for Payer: Coventry All Commercial |
$15.46
|
| Rate for Payer: Encore All Commercial |
$16.17
|
| Rate for Payer: Frontpath All Commercial |
$16.16
|
| Rate for Payer: Humana ChoiceCare |
$15.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$15.81
|
| Rate for Payer: PHCS All Commercial |
$13.18
|
| Rate for Payer: PHP All Commercial |
$13.33
|
| Rate for Payer: Sagamore Health Network All Products |
$13.56
|
| Rate for Payer: Signature Care EPO |
$14.58
|
| Rate for Payer: Signature Care PPO |
$15.46
|
| Rate for Payer: United Healthcare Commercial |
$13.85
|
|
|
HC DRESSING POLYMEM 4X4 NON-ADHESIVE
|
Facility
IP
|
$21.71
|
|
| Hospital Charge Code |
41601886
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.28 |
| Max. Negotiated Rate |
$20.19 |
| Rate for Payer: Aetna Commercial |
$18.76
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cigna All Commercial |
$18.74
|
| Rate for Payer: CORVEL All Commercial |
$20.19
|
| Rate for Payer: Coventry All Commercial |
$19.10
|
| Rate for Payer: Encore All Commercial |
$19.98
|
| Rate for Payer: Frontpath All Commercial |
$19.97
|
| Rate for Payer: Humana ChoiceCare |
$18.75
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.54
|
| Rate for Payer: PHCS All Commercial |
$16.28
|
| Rate for Payer: PHP All Commercial |
$16.46
|
| Rate for Payer: Sagamore Health Network All Products |
$16.76
|
| Rate for Payer: Signature Care EPO |
$18.02
|
| Rate for Payer: Signature Care PPO |
$19.10
|
| Rate for Payer: United Healthcare Commercial |
$17.11
|
|
|
HC DRESSING POLYMEM 4X4 NON-ADHESIVE
|
Facility
OP
|
$21.71
|
|
| Hospital Charge Code |
41601886
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$18.32
|
| Rate for Payer: Aetna Medicare |
$7.16
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.16
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12.47
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.57
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.24
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.88
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Centivo All Commercial |
$11.07
|
| Rate for Payer: Cigna All Commercial |
$18.74
|
| Rate for Payer: CORVEL All Commercial |
$20.19
|
| Rate for Payer: Coventry All Commercial |
$19.10
|
| Rate for Payer: Encore All Commercial |
$19.98
|
| Rate for Payer: Frontpath All Commercial |
$19.97
|
| Rate for Payer: Humana ChoiceCare |
$18.75
|
| Rate for Payer: Humana Medicare |
$11.07
|
| Rate for Payer: Lucent All Commercial |
$11.07
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.54
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$16.28
|
| Rate for Payer: PHP All Commercial |
$16.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.47
|
| Rate for Payer: Sagamore Health Network All Products |
$16.76
|
| Rate for Payer: Signature Care EPO |
$18.02
|
| Rate for Payer: Signature Care PPO |
$19.10
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.45
|
| Rate for Payer: United Healthcare Commercial |
$17.11
|
| Rate for Payer: United Healthcare Medicare |
$7.16
|
|
|
HC DRESSING POLYMEM 4X4 SILVER
|
Facility
IP
|
$28.60
|
|
|
Service Code
|
CPT A6209
|
| Hospital Charge Code |
41601882
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$21.45 |
| Max. Negotiated Rate |
$26.60 |
| Rate for Payer: Aetna Commercial |
$24.71
|
| Rate for Payer: Cash Price |
$17.73
|
| Rate for Payer: Cigna All Commercial |
$24.68
|
| Rate for Payer: CORVEL All Commercial |
$26.60
|
| Rate for Payer: Coventry All Commercial |
$25.17
|
| Rate for Payer: Encore All Commercial |
$26.33
|
| Rate for Payer: Frontpath All Commercial |
$26.31
|
| Rate for Payer: Humana ChoiceCare |
$24.70
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.74
|
| Rate for Payer: PHCS All Commercial |
$21.45
|
| Rate for Payer: PHP All Commercial |
$21.69
|
| Rate for Payer: Sagamore Health Network All Products |
$22.08
|
| Rate for Payer: Signature Care EPO |
$23.74
|
| Rate for Payer: Signature Care PPO |
$25.17
|
| Rate for Payer: United Healthcare Commercial |
$22.54
|
|
|
HC DRESSING POLYMEM 4X4 SILVER
|
Facility
OP
|
$28.60
|
|
|
Service Code
|
CPT A6209
|
| Hospital Charge Code |
41601882
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$24.14
|
| Rate for Payer: Aetna Medicare |
$9.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$16.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$17.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$10.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.38
|
| Rate for Payer: Cash Price |
$17.73
|
| Rate for Payer: Cash Price |
$17.73
|
| Rate for Payer: Centivo All Commercial |
$14.59
|
| Rate for Payer: Cigna All Commercial |
$24.68
|
| Rate for Payer: CORVEL All Commercial |
$26.60
|
| Rate for Payer: Coventry All Commercial |
$25.17
|
| Rate for Payer: Encore All Commercial |
$26.33
|
| Rate for Payer: Frontpath All Commercial |
$26.31
|
| Rate for Payer: Humana ChoiceCare |
$24.70
|
| Rate for Payer: Humana Medicare |
$14.59
|
| Rate for Payer: Lucent All Commercial |
$14.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$25.74
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$21.45
|
| Rate for Payer: PHP All Commercial |
$21.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.15
|
| Rate for Payer: Sagamore Health Network All Products |
$22.08
|
| Rate for Payer: Signature Care EPO |
$23.74
|
| Rate for Payer: Signature Care PPO |
$25.17
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$24.31
|
| Rate for Payer: United Healthcare Commercial |
$22.54
|
| Rate for Payer: United Healthcare Medicare |
$9.44
|
|
|
HC DRESSING POLYMEM 5X3 1/2 #5
|
Facility
IP
|
$19.67
|
|
| Hospital Charge Code |
41601884
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.75 |
| Max. Negotiated Rate |
$18.29 |
| Rate for Payer: Aetna Commercial |
$16.99
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Cigna All Commercial |
$16.98
|
| Rate for Payer: CORVEL All Commercial |
$18.29
|
| Rate for Payer: Coventry All Commercial |
$17.31
|
| Rate for Payer: Encore All Commercial |
$18.11
|
| Rate for Payer: Frontpath All Commercial |
$18.10
|
| Rate for Payer: Humana ChoiceCare |
$16.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.70
|
| Rate for Payer: PHCS All Commercial |
$14.75
|
| Rate for Payer: PHP All Commercial |
$14.92
|
| Rate for Payer: Sagamore Health Network All Products |
$15.19
|
| Rate for Payer: Signature Care EPO |
$16.33
|
| Rate for Payer: Signature Care PPO |
$17.31
|
| Rate for Payer: United Healthcare Commercial |
$15.50
|
|
|
HC DRESSING POLYMEM 5X3 1/2 #5
|
Facility
OP
|
$19.67
|
|
| Hospital Charge Code |
41601884
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.49 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$16.60
|
| Rate for Payer: Aetna Medicare |
$6.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$11.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$12.30
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.46
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$7.14
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Cash Price |
$12.20
|
| Rate for Payer: Centivo All Commercial |
$10.03
|
| Rate for Payer: Cigna All Commercial |
$16.98
|
| Rate for Payer: CORVEL All Commercial |
$18.29
|
| Rate for Payer: Coventry All Commercial |
$17.31
|
| Rate for Payer: Encore All Commercial |
$18.11
|
| Rate for Payer: Frontpath All Commercial |
$18.10
|
| Rate for Payer: Humana ChoiceCare |
$16.99
|
| Rate for Payer: Humana Medicare |
$10.03
|
| Rate for Payer: Lucent All Commercial |
$10.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.70
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$14.75
|
| Rate for Payer: PHP All Commercial |
$14.92
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.67
|
| Rate for Payer: Sagamore Health Network All Products |
$15.19
|
| Rate for Payer: Signature Care EPO |
$16.33
|
| Rate for Payer: Signature Care PPO |
$17.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.72
|
| Rate for Payer: United Healthcare Commercial |
$15.50
|
| Rate for Payer: United Healthcare Medicare |
$6.49
|
|
|
HC DRESSING POLYMEM ISL 4X5
|
Facility
IP
|
$26.01
|
|
|
Service Code
|
CPT A6212
|
| Hospital Charge Code |
41601041
|
|
Hospital Revenue Code
|
623
|
| Min. Negotiated Rate |
$19.51 |
| Max. Negotiated Rate |
$24.19 |
| Rate for Payer: Aetna Commercial |
$22.47
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Cigna All Commercial |
$22.45
|
| Rate for Payer: CORVEL All Commercial |
$24.19
|
| Rate for Payer: Coventry All Commercial |
$22.89
|
| Rate for Payer: Encore All Commercial |
$23.94
|
| Rate for Payer: Frontpath All Commercial |
$23.93
|
| Rate for Payer: Humana ChoiceCare |
$22.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.41
|
| Rate for Payer: PHCS All Commercial |
$19.51
|
| Rate for Payer: PHP All Commercial |
$19.73
|
| Rate for Payer: Sagamore Health Network All Products |
$20.08
|
| Rate for Payer: Signature Care EPO |
$21.59
|
| Rate for Payer: Signature Care PPO |
$22.89
|
| Rate for Payer: United Healthcare Commercial |
$20.50
|
|
|
HC DRESSING POLYMEM ISL 4X5
|
Facility
OP
|
$26.01
|
|
|
Service Code
|
CPT A6212
|
| Hospital Charge Code |
41601041
|
|
Hospital Revenue Code
|
623
|
| Min. Negotiated Rate |
$8.58 |
| Max. Negotiated Rate |
$24.19 |
| Rate for Payer: Aetna Commercial |
$21.95
|
| Rate for Payer: Aetna Medicare |
$8.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.94
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.26
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.44
|
| Rate for Payer: Cash Price |
$16.13
|
| Rate for Payer: Centivo All Commercial |
$13.27
|
| Rate for Payer: Cigna All Commercial |
$22.45
|
| Rate for Payer: CORVEL All Commercial |
$24.19
|
| Rate for Payer: Coventry All Commercial |
$22.89
|
| Rate for Payer: Encore All Commercial |
$23.94
|
| Rate for Payer: Frontpath All Commercial |
$23.93
|
| Rate for Payer: Humana ChoiceCare |
$22.46
|
| Rate for Payer: Humana Medicare |
$13.27
|
| Rate for Payer: Lucent All Commercial |
$13.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.41
|
| Rate for Payer: PHCS All Commercial |
$19.51
|
| Rate for Payer: PHP All Commercial |
$19.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.14
|
| Rate for Payer: Sagamore Health Network All Products |
$20.08
|
| Rate for Payer: Signature Care EPO |
$21.59
|
| Rate for Payer: Signature Care PPO |
$22.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.11
|
| Rate for Payer: United Healthcare Commercial |
$20.50
|
| Rate for Payer: United Healthcare Medicare |
$8.58
|
|
|
HC DRESSING POLYMEM SACRAL
|
Facility
IP
|
$46.37
|
|
| Hospital Charge Code |
41601042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$34.78 |
| Max. Negotiated Rate |
$43.12 |
| Rate for Payer: Aetna Commercial |
$40.06
|
| Rate for Payer: Cash Price |
$28.75
|
| Rate for Payer: Cigna All Commercial |
$40.02
|
| Rate for Payer: CORVEL All Commercial |
$43.12
|
| Rate for Payer: Coventry All Commercial |
$40.81
|
| Rate for Payer: Encore All Commercial |
$42.68
|
| Rate for Payer: Frontpath All Commercial |
$42.66
|
| Rate for Payer: Humana ChoiceCare |
$40.05
|
| Rate for Payer: Lutheran Preferred All Commercial |
$41.73
|
| Rate for Payer: PHCS All Commercial |
$34.78
|
| Rate for Payer: PHP All Commercial |
$35.17
|
| Rate for Payer: Sagamore Health Network All Products |
$35.80
|
| Rate for Payer: Signature Care EPO |
$38.49
|
| Rate for Payer: Signature Care PPO |
$40.81
|
| Rate for Payer: United Healthcare Commercial |
$36.54
|
|
|
HC DRESSING POLYMEM SACRAL
|
Facility
OP
|
$46.37
|
|
| Hospital Charge Code |
41601042
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$15.30 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$39.14
|
| Rate for Payer: Aetna Medicare |
$15.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$26.63
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$28.99
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$17.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$16.83
|
| Rate for Payer: Cash Price |
$28.75
|
| Rate for Payer: Cash Price |
$28.75
|
| Rate for Payer: Centivo All Commercial |
$23.65
|
| Rate for Payer: Cigna All Commercial |
$40.02
|
| Rate for Payer: CORVEL All Commercial |
$43.12
|
| Rate for Payer: Coventry All Commercial |
$40.81
|
| Rate for Payer: Encore All Commercial |
$42.68
|
| Rate for Payer: Frontpath All Commercial |
$42.66
|
| Rate for Payer: Humana ChoiceCare |
$40.05
|
| Rate for Payer: Humana Medicare |
$23.65
|
| Rate for Payer: Lucent All Commercial |
$23.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$41.73
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$34.78
|
| Rate for Payer: PHP All Commercial |
$35.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$18.08
|
| Rate for Payer: Sagamore Health Network All Products |
$35.80
|
| Rate for Payer: Signature Care EPO |
$38.49
|
| Rate for Payer: Signature Care PPO |
$40.81
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$39.41
|
| Rate for Payer: United Healthcare Commercial |
$36.54
|
| Rate for Payer: United Healthcare Medicare |
$15.30
|
|
|
HC DRESSING POLYWIC 3X3 SILVER
|
Facility
OP
|
$51.43
|
|
|
Service Code
|
CPT A6215
|
| Hospital Charge Code |
41601881
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.97 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$43.41
|
| Rate for Payer: Aetna Medicare |
$16.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$16.97
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$29.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$32.15
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$19.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$18.67
|
| Rate for Payer: Cash Price |
$31.89
|
| Rate for Payer: Cash Price |
$31.89
|
| Rate for Payer: Centivo All Commercial |
$26.23
|
| Rate for Payer: Cigna All Commercial |
$44.38
|
| Rate for Payer: CORVEL All Commercial |
$47.83
|
| Rate for Payer: Coventry All Commercial |
$45.26
|
| Rate for Payer: Encore All Commercial |
$47.34
|
| Rate for Payer: Frontpath All Commercial |
$47.32
|
| Rate for Payer: Humana ChoiceCare |
$44.42
|
| Rate for Payer: Humana Medicare |
$26.23
|
| Rate for Payer: Lucent All Commercial |
$26.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.29
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$38.57
|
| Rate for Payer: PHP All Commercial |
$39.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$20.06
|
| Rate for Payer: Sagamore Health Network All Products |
$39.70
|
| Rate for Payer: Signature Care EPO |
$42.69
|
| Rate for Payer: Signature Care PPO |
$45.26
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$43.72
|
| Rate for Payer: United Healthcare Commercial |
$40.53
|
| Rate for Payer: United Healthcare Medicare |
$16.97
|
|
|
HC DRESSING POLYWIC 3X3 SILVER
|
Facility
IP
|
$51.43
|
|
|
Service Code
|
CPT A6215
|
| Hospital Charge Code |
41601881
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$38.57 |
| Max. Negotiated Rate |
$47.83 |
| Rate for Payer: Aetna Commercial |
$44.44
|
| Rate for Payer: Cash Price |
$31.89
|
| Rate for Payer: Cigna All Commercial |
$44.38
|
| Rate for Payer: CORVEL All Commercial |
$47.83
|
| Rate for Payer: Coventry All Commercial |
$45.26
|
| Rate for Payer: Encore All Commercial |
$47.34
|
| Rate for Payer: Frontpath All Commercial |
$47.32
|
| Rate for Payer: Humana ChoiceCare |
$44.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$46.29
|
| Rate for Payer: PHCS All Commercial |
$38.57
|
| Rate for Payer: PHP All Commercial |
$39.00
|
| Rate for Payer: Sagamore Health Network All Products |
$39.70
|
| Rate for Payer: Signature Care EPO |
$42.69
|
| Rate for Payer: Signature Care PPO |
$45.26
|
| Rate for Payer: United Healthcare Commercial |
$40.53
|
|
|
HC DRESSING POLYWIC FILLER 3X3
|
Facility
IP
|
$30.14
|
|
| Hospital Charge Code |
41601887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$22.60 |
| Max. Negotiated Rate |
$28.03 |
| Rate for Payer: Aetna Commercial |
$26.04
|
| Rate for Payer: Cash Price |
$18.69
|
| Rate for Payer: Cigna All Commercial |
$26.01
|
| Rate for Payer: CORVEL All Commercial |
$28.03
|
| Rate for Payer: Coventry All Commercial |
$26.52
|
| Rate for Payer: Encore All Commercial |
$27.74
|
| Rate for Payer: Frontpath All Commercial |
$27.73
|
| Rate for Payer: Humana ChoiceCare |
$26.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.13
|
| Rate for Payer: PHCS All Commercial |
$22.60
|
| Rate for Payer: PHP All Commercial |
$22.86
|
| Rate for Payer: Sagamore Health Network All Products |
$23.27
|
| Rate for Payer: Signature Care EPO |
$25.02
|
| Rate for Payer: Signature Care PPO |
$26.52
|
| Rate for Payer: United Healthcare Commercial |
$23.75
|
|
|
HC DRESSING POLYWIC FILLER 3X3
|
Facility
OP
|
$30.14
|
|
| Hospital Charge Code |
41601887
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna Medicare |
$9.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$9.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$17.31
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$18.84
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$11.44
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$10.94
|
| Rate for Payer: Cash Price |
$18.69
|
| Rate for Payer: Cash Price |
$18.69
|
| Rate for Payer: Centivo All Commercial |
$15.37
|
| Rate for Payer: Cigna All Commercial |
$26.01
|
| Rate for Payer: CORVEL All Commercial |
$28.03
|
| Rate for Payer: Coventry All Commercial |
$26.52
|
| Rate for Payer: Encore All Commercial |
$27.74
|
| Rate for Payer: Frontpath All Commercial |
$27.73
|
| Rate for Payer: Humana ChoiceCare |
$26.03
|
| Rate for Payer: Humana Medicare |
$15.37
|
| Rate for Payer: Lucent All Commercial |
$15.37
|
| Rate for Payer: Lutheran Preferred All Commercial |
$27.13
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$22.60
|
| Rate for Payer: PHP All Commercial |
$22.86
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$11.75
|
| Rate for Payer: Sagamore Health Network All Products |
$23.27
|
| Rate for Payer: Signature Care EPO |
$25.02
|
| Rate for Payer: Signature Care PPO |
$26.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$25.62
|
| Rate for Payer: United Healthcare Commercial |
$23.75
|
| Rate for Payer: United Healthcare Medicare |
$9.95
|
|
|
HC DRESSING XEROFORM 1X8
|
Facility
IP
|
$3.75
|
|
| Hospital Charge Code |
41603449
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.81 |
| Max. Negotiated Rate |
$3.49 |
| Rate for Payer: Aetna Commercial |
$3.24
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna All Commercial |
$3.24
|
| Rate for Payer: CORVEL All Commercial |
$3.49
|
| Rate for Payer: Coventry All Commercial |
$3.30
|
| Rate for Payer: Encore All Commercial |
$3.45
|
| Rate for Payer: Frontpath All Commercial |
$3.45
|
| Rate for Payer: Humana ChoiceCare |
$3.24
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.38
|
| Rate for Payer: PHCS All Commercial |
$2.81
|
| Rate for Payer: PHP All Commercial |
$2.84
|
| Rate for Payer: Sagamore Health Network All Products |
$2.90
|
| Rate for Payer: Signature Care EPO |
$3.11
|
| Rate for Payer: Signature Care PPO |
$3.30
|
| Rate for Payer: United Healthcare Commercial |
$2.96
|
|
|
HC DRESSING XEROFORM 1X8
|
Facility
OP
|
$3.75
|
|
| Hospital Charge Code |
41603449
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$3.16
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.15
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.34
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.42
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.36
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Centivo All Commercial |
$1.91
|
| Rate for Payer: Cigna All Commercial |
$3.24
|
| Rate for Payer: CORVEL All Commercial |
$3.49
|
| Rate for Payer: Coventry All Commercial |
$3.30
|
| Rate for Payer: Encore All Commercial |
$3.45
|
| Rate for Payer: Frontpath All Commercial |
$3.45
|
| Rate for Payer: Humana ChoiceCare |
$3.24
|
| Rate for Payer: Humana Medicare |
$1.91
|
| Rate for Payer: Lucent All Commercial |
$1.91
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.38
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$2.81
|
| Rate for Payer: PHP All Commercial |
$2.84
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.46
|
| Rate for Payer: Sagamore Health Network All Products |
$2.90
|
| Rate for Payer: Signature Care EPO |
$3.11
|
| Rate for Payer: Signature Care PPO |
$3.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.19
|
| Rate for Payer: United Healthcare Commercial |
$2.96
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
|
|
HC DRESSING XEROFORM 2X2
|
Facility
IP
|
$3.76
|
|
| Hospital Charge Code |
41601043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.82 |
| Max. Negotiated Rate |
$3.50 |
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cigna All Commercial |
$3.24
|
| Rate for Payer: CORVEL All Commercial |
$3.50
|
| Rate for Payer: Coventry All Commercial |
$3.31
|
| Rate for Payer: Encore All Commercial |
$3.46
|
| Rate for Payer: Frontpath All Commercial |
$3.46
|
| Rate for Payer: Humana ChoiceCare |
$3.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.38
|
| Rate for Payer: PHCS All Commercial |
$2.82
|
| Rate for Payer: PHP All Commercial |
$2.85
|
| Rate for Payer: Sagamore Health Network All Products |
$2.90
|
| Rate for Payer: Signature Care EPO |
$3.12
|
| Rate for Payer: Signature Care PPO |
$3.31
|
| Rate for Payer: United Healthcare Commercial |
$2.96
|
|
|
HC DRESSING XEROFORM 2X2
|
Facility
OP
|
$3.76
|
|
| Hospital Charge Code |
41601043
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$3.17
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.16
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.35
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.36
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Cash Price |
$2.33
|
| Rate for Payer: Centivo All Commercial |
$1.92
|
| Rate for Payer: Cigna All Commercial |
$3.24
|
| Rate for Payer: CORVEL All Commercial |
$3.50
|
| Rate for Payer: Coventry All Commercial |
$3.31
|
| Rate for Payer: Encore All Commercial |
$3.46
|
| Rate for Payer: Frontpath All Commercial |
$3.46
|
| Rate for Payer: Humana ChoiceCare |
$3.25
|
| Rate for Payer: Humana Medicare |
$1.92
|
| Rate for Payer: Lucent All Commercial |
$1.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.38
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$2.82
|
| Rate for Payer: PHP All Commercial |
$2.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.47
|
| Rate for Payer: Sagamore Health Network All Products |
$2.90
|
| Rate for Payer: Signature Care EPO |
$3.12
|
| Rate for Payer: Signature Care PPO |
$3.31
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.20
|
| Rate for Payer: United Healthcare Commercial |
$2.96
|
| Rate for Payer: United Healthcare Medicare |
$1.24
|
|
|
HC DRESSING XEROFORM 5X9
|
Facility
OP
|
$6.65
|
|
| Hospital Charge Code |
41603450
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$5.61
|
| Rate for Payer: Aetna Medicare |
$2.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.82
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.16
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.41
|
| Rate for Payer: Cash Price |
$4.12
|
| Rate for Payer: Cash Price |
$4.12
|
| Rate for Payer: Centivo All Commercial |
$3.39
|
| Rate for Payer: Cigna All Commercial |
$5.74
|
| Rate for Payer: CORVEL All Commercial |
$6.18
|
| Rate for Payer: Coventry All Commercial |
$5.85
|
| Rate for Payer: Encore All Commercial |
$6.12
|
| Rate for Payer: Frontpath All Commercial |
$6.12
|
| Rate for Payer: Humana ChoiceCare |
$5.74
|
| Rate for Payer: Humana Medicare |
$3.39
|
| Rate for Payer: Lucent All Commercial |
$3.39
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.98
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$4.99
|
| Rate for Payer: PHP All Commercial |
$5.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.59
|
| Rate for Payer: Sagamore Health Network All Products |
$5.13
|
| Rate for Payer: Signature Care EPO |
$5.52
|
| Rate for Payer: Signature Care PPO |
$5.85
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.65
|
| Rate for Payer: United Healthcare Commercial |
$5.24
|
| Rate for Payer: United Healthcare Medicare |
$2.19
|
|
