|
HC LEVEL 6 COMPREHENSIVE
|
Facility
IP
|
$1,169.58
|
|
|
Service Code
|
CPT 88309 59
|
| Hospital Charge Code |
63002182
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$877.19 |
| Max. Negotiated Rate |
$1,087.71 |
| Rate for Payer: Aetna Commercial |
$1,010.52
|
| Rate for Payer: Cash Price |
$725.14
|
| Rate for Payer: Cigna All Commercial |
$1,009.35
|
| Rate for Payer: CORVEL All Commercial |
$1,087.71
|
| Rate for Payer: Coventry All Commercial |
$1,029.23
|
| Rate for Payer: Encore All Commercial |
$1,076.60
|
| Rate for Payer: Frontpath All Commercial |
$1,076.02
|
| Rate for Payer: Humana ChoiceCare |
$1,010.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,052.62
|
| Rate for Payer: PHCS All Commercial |
$877.19
|
| Rate for Payer: PHP All Commercial |
$887.01
|
| Rate for Payer: Sagamore Health Network All Products |
$902.92
|
| Rate for Payer: Signature Care EPO |
$970.75
|
| Rate for Payer: Signature Care PPO |
$1,029.23
|
| Rate for Payer: United Healthcare Commercial |
$921.63
|
|
|
HC LEVEL 6 COMPREHENSIVE
|
Facility
OP
|
$1,169.58
|
|
|
Service Code
|
CPT 88309 59
|
| Hospital Charge Code |
63002182
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$385.96 |
| Max. Negotiated Rate |
$1,087.71 |
| Rate for Payer: Aetna Commercial |
$987.13
|
| Rate for Payer: Aetna Medicare |
$385.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$385.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$671.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$731.11
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$443.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$424.56
|
| Rate for Payer: Cash Price |
$725.14
|
| Rate for Payer: Centivo All Commercial |
$596.49
|
| Rate for Payer: Cigna All Commercial |
$1,009.35
|
| Rate for Payer: CORVEL All Commercial |
$1,087.71
|
| Rate for Payer: Coventry All Commercial |
$1,029.23
|
| Rate for Payer: Encore All Commercial |
$1,076.60
|
| Rate for Payer: Frontpath All Commercial |
$1,076.02
|
| Rate for Payer: Humana ChoiceCare |
$1,010.17
|
| Rate for Payer: Humana Medicare |
$596.49
|
| Rate for Payer: Lucent All Commercial |
$596.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,052.62
|
| Rate for Payer: PHCS All Commercial |
$877.19
|
| Rate for Payer: PHP All Commercial |
$887.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$456.14
|
| Rate for Payer: Sagamore Health Network All Products |
$902.92
|
| Rate for Payer: Signature Care EPO |
$970.75
|
| Rate for Payer: Signature Care PPO |
$1,029.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$994.15
|
| Rate for Payer: United Healthcare Commercial |
$921.63
|
| Rate for Payer: United Healthcare Medicare |
$385.96
|
|
|
HC LEVEL 6 PATH COMP
|
Facility
OP
|
$1,169.58
|
|
|
Service Code
|
CPT 88309
|
| Hospital Charge Code |
63001260
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$385.96 |
| Max. Negotiated Rate |
$1,087.71 |
| Rate for Payer: Aetna Commercial |
$987.13
|
| Rate for Payer: Aetna Medicare |
$385.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$385.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$671.69
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$731.11
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$455.99
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$443.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$424.56
|
| Rate for Payer: Cash Price |
$725.14
|
| Rate for Payer: Cash Price |
$725.14
|
| Rate for Payer: Centivo All Commercial |
$596.49
|
| Rate for Payer: Cigna All Commercial |
$1,009.35
|
| Rate for Payer: CORVEL All Commercial |
$1,087.71
|
| Rate for Payer: Coventry All Commercial |
$1,029.23
|
| Rate for Payer: Encore All Commercial |
$1,076.60
|
| Rate for Payer: Frontpath All Commercial |
$1,076.02
|
| Rate for Payer: Humana ChoiceCare |
$1,010.17
|
| Rate for Payer: Humana Medicare |
$596.49
|
| Rate for Payer: Lucent All Commercial |
$596.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,052.62
|
| Rate for Payer: Managed Health Services Medicaid |
$455.99
|
| Rate for Payer: MDWise Medicaid |
$455.99
|
| Rate for Payer: PHCS All Commercial |
$877.19
|
| Rate for Payer: PHP All Commercial |
$887.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$456.14
|
| Rate for Payer: Sagamore Health Network All Products |
$902.92
|
| Rate for Payer: Signature Care EPO |
$970.75
|
| Rate for Payer: Signature Care PPO |
$1,029.23
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$994.15
|
| Rate for Payer: United Healthcare Commercial |
$921.63
|
| Rate for Payer: United Healthcare Medicare |
$385.96
|
|
|
HC LEVEL 6 PATH COMP
|
Facility
IP
|
$1,169.58
|
|
|
Service Code
|
CPT 88309
|
| Hospital Charge Code |
63001260
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$877.19 |
| Max. Negotiated Rate |
$1,087.71 |
| Rate for Payer: Aetna Commercial |
$1,010.52
|
| Rate for Payer: Cash Price |
$725.14
|
| Rate for Payer: Cigna All Commercial |
$1,009.35
|
| Rate for Payer: CORVEL All Commercial |
$1,087.71
|
| Rate for Payer: Coventry All Commercial |
$1,029.23
|
| Rate for Payer: Encore All Commercial |
$1,076.60
|
| Rate for Payer: Frontpath All Commercial |
$1,076.02
|
| Rate for Payer: Humana ChoiceCare |
$1,010.17
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,052.62
|
| Rate for Payer: PHCS All Commercial |
$877.19
|
| Rate for Payer: PHP All Commercial |
$887.01
|
| Rate for Payer: Sagamore Health Network All Products |
$902.92
|
| Rate for Payer: Signature Care EPO |
$970.75
|
| Rate for Payer: Signature Care PPO |
$1,029.23
|
| Rate for Payer: United Healthcare Commercial |
$921.63
|
|
|
HC LEVIN TUBE 12FR
|
Facility
IP
|
$24.85
|
|
| Hospital Charge Code |
41601445
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$18.64 |
| Max. Negotiated Rate |
$23.11 |
| Rate for Payer: Aetna Commercial |
$21.47
|
| Rate for Payer: Cash Price |
$15.41
|
| Rate for Payer: Cigna All Commercial |
$21.45
|
| Rate for Payer: CORVEL All Commercial |
$23.11
|
| Rate for Payer: Coventry All Commercial |
$21.87
|
| Rate for Payer: Encore All Commercial |
$22.87
|
| Rate for Payer: Frontpath All Commercial |
$22.86
|
| Rate for Payer: Humana ChoiceCare |
$21.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.36
|
| Rate for Payer: PHCS All Commercial |
$18.64
|
| Rate for Payer: PHP All Commercial |
$18.85
|
| Rate for Payer: Sagamore Health Network All Products |
$19.18
|
| Rate for Payer: Signature Care EPO |
$20.63
|
| Rate for Payer: Signature Care PPO |
$21.87
|
| Rate for Payer: United Healthcare Commercial |
$19.58
|
|
|
HC LEVIN TUBE 12FR
|
Facility
OP
|
$24.85
|
|
| Hospital Charge Code |
41601445
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$8.20 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$20.97
|
| Rate for Payer: Aetna Medicare |
$8.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$15.53
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.02
|
| Rate for Payer: Cash Price |
$15.41
|
| Rate for Payer: Cash Price |
$15.41
|
| Rate for Payer: Centivo All Commercial |
$12.67
|
| Rate for Payer: Cigna All Commercial |
$21.45
|
| Rate for Payer: CORVEL All Commercial |
$23.11
|
| Rate for Payer: Coventry All Commercial |
$21.87
|
| Rate for Payer: Encore All Commercial |
$22.87
|
| Rate for Payer: Frontpath All Commercial |
$22.86
|
| Rate for Payer: Humana ChoiceCare |
$21.46
|
| Rate for Payer: Humana Medicare |
$12.67
|
| Rate for Payer: Lucent All Commercial |
$12.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$22.36
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$18.64
|
| Rate for Payer: PHP All Commercial |
$18.85
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$9.69
|
| Rate for Payer: Sagamore Health Network All Products |
$19.18
|
| Rate for Payer: Signature Care EPO |
$20.63
|
| Rate for Payer: Signature Care PPO |
$21.87
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$21.12
|
| Rate for Payer: United Healthcare Commercial |
$19.58
|
| Rate for Payer: United Healthcare Medicare |
$8.20
|
|
|
HC LEVIN TUBE 14FR
|
Facility
OP
|
$4.97
|
|
| Hospital Charge Code |
41601785
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$4.19
|
| Rate for Payer: Aetna Medicare |
$1.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.85
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.11
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.89
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.80
|
| Rate for Payer: Cash Price |
$3.08
|
| Rate for Payer: Cash Price |
$3.08
|
| Rate for Payer: Centivo All Commercial |
$2.53
|
| Rate for Payer: Cigna All Commercial |
$4.29
|
| Rate for Payer: CORVEL All Commercial |
$4.62
|
| Rate for Payer: Coventry All Commercial |
$4.37
|
| Rate for Payer: Encore All Commercial |
$4.57
|
| Rate for Payer: Frontpath All Commercial |
$4.57
|
| Rate for Payer: Humana ChoiceCare |
$4.29
|
| Rate for Payer: Humana Medicare |
$2.53
|
| Rate for Payer: Lucent All Commercial |
$2.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.47
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$3.73
|
| Rate for Payer: PHP All Commercial |
$3.77
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.94
|
| Rate for Payer: Sagamore Health Network All Products |
$3.84
|
| Rate for Payer: Signature Care EPO |
$4.13
|
| Rate for Payer: Signature Care PPO |
$4.37
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4.22
|
| Rate for Payer: United Healthcare Commercial |
$3.92
|
| Rate for Payer: United Healthcare Medicare |
$1.64
|
|
|
HC LEVIN TUBE 14FR
|
Facility
IP
|
$4.97
|
|
| Hospital Charge Code |
41601785
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.73 |
| Max. Negotiated Rate |
$4.62 |
| Rate for Payer: Aetna Commercial |
$4.29
|
| Rate for Payer: Cash Price |
$3.08
|
| Rate for Payer: Cigna All Commercial |
$4.29
|
| Rate for Payer: CORVEL All Commercial |
$4.62
|
| Rate for Payer: Coventry All Commercial |
$4.37
|
| Rate for Payer: Encore All Commercial |
$4.57
|
| Rate for Payer: Frontpath All Commercial |
$4.57
|
| Rate for Payer: Humana ChoiceCare |
$4.29
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.47
|
| Rate for Payer: PHCS All Commercial |
$3.73
|
| Rate for Payer: PHP All Commercial |
$3.77
|
| Rate for Payer: Sagamore Health Network All Products |
$3.84
|
| Rate for Payer: Signature Care EPO |
$4.13
|
| Rate for Payer: Signature Care PPO |
$4.37
|
| Rate for Payer: United Healthcare Commercial |
$3.92
|
|
|
HC LEVIN TUBE 16FR
|
Facility
IP
|
$4.56
|
|
| Hospital Charge Code |
41601443
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$3.42 |
| Max. Negotiated Rate |
$4.24 |
| Rate for Payer: Aetna Commercial |
$3.94
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Cigna All Commercial |
$3.94
|
| Rate for Payer: CORVEL All Commercial |
$4.24
|
| Rate for Payer: Coventry All Commercial |
$4.01
|
| Rate for Payer: Encore All Commercial |
$4.20
|
| Rate for Payer: Frontpath All Commercial |
$4.20
|
| Rate for Payer: Humana ChoiceCare |
$3.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.10
|
| Rate for Payer: PHCS All Commercial |
$3.42
|
| Rate for Payer: PHP All Commercial |
$3.46
|
| Rate for Payer: Sagamore Health Network All Products |
$3.52
|
| Rate for Payer: Signature Care EPO |
$3.78
|
| Rate for Payer: Signature Care PPO |
$4.01
|
| Rate for Payer: United Healthcare Commercial |
$3.59
|
|
|
HC LEVIN TUBE 16FR
|
Facility
OP
|
$4.56
|
|
| Hospital Charge Code |
41601443
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$3.85
|
| Rate for Payer: Aetna Medicare |
$1.50
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.85
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.73
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.66
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Cash Price |
$2.83
|
| Rate for Payer: Centivo All Commercial |
$2.33
|
| Rate for Payer: Cigna All Commercial |
$3.94
|
| Rate for Payer: CORVEL All Commercial |
$4.24
|
| Rate for Payer: Coventry All Commercial |
$4.01
|
| Rate for Payer: Encore All Commercial |
$4.20
|
| Rate for Payer: Frontpath All Commercial |
$4.20
|
| Rate for Payer: Humana ChoiceCare |
$3.94
|
| Rate for Payer: Humana Medicare |
$2.33
|
| Rate for Payer: Lucent All Commercial |
$2.33
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4.10
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$3.42
|
| Rate for Payer: PHP All Commercial |
$3.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.78
|
| Rate for Payer: Sagamore Health Network All Products |
$3.52
|
| Rate for Payer: Signature Care EPO |
$3.78
|
| Rate for Payer: Signature Care PPO |
$4.01
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.88
|
| Rate for Payer: United Healthcare Commercial |
$3.59
|
| Rate for Payer: United Healthcare Medicare |
$1.50
|
|
|
HC LEVIN TUBE 18FR
|
Facility
OP
|
$5.95
|
|
| Hospital Charge Code |
41601444
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$5.02
|
| Rate for Payer: Aetna Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3.42
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3.72
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.26
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.16
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Centivo All Commercial |
$3.03
|
| Rate for Payer: Cigna All Commercial |
$5.13
|
| Rate for Payer: CORVEL All Commercial |
$5.53
|
| Rate for Payer: Coventry All Commercial |
$5.24
|
| Rate for Payer: Encore All Commercial |
$5.48
|
| Rate for Payer: Frontpath All Commercial |
$5.47
|
| Rate for Payer: Humana ChoiceCare |
$5.14
|
| Rate for Payer: Humana Medicare |
$3.03
|
| Rate for Payer: Lucent All Commercial |
$3.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.36
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$4.46
|
| Rate for Payer: PHP All Commercial |
$4.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.32
|
| Rate for Payer: Sagamore Health Network All Products |
$4.59
|
| Rate for Payer: Signature Care EPO |
$4.94
|
| Rate for Payer: Signature Care PPO |
$5.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5.06
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
| Rate for Payer: United Healthcare Medicare |
$1.96
|
|
|
HC LEVIN TUBE 18FR
|
Facility
IP
|
$5.95
|
|
| Hospital Charge Code |
41601444
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.46 |
| Max. Negotiated Rate |
$5.53 |
| Rate for Payer: Aetna Commercial |
$5.14
|
| Rate for Payer: Cash Price |
$3.69
|
| Rate for Payer: Cigna All Commercial |
$5.13
|
| Rate for Payer: CORVEL All Commercial |
$5.53
|
| Rate for Payer: Coventry All Commercial |
$5.24
|
| Rate for Payer: Encore All Commercial |
$5.48
|
| Rate for Payer: Frontpath All Commercial |
$5.47
|
| Rate for Payer: Humana ChoiceCare |
$5.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5.36
|
| Rate for Payer: PHCS All Commercial |
$4.46
|
| Rate for Payer: PHP All Commercial |
$4.51
|
| Rate for Payer: Sagamore Health Network All Products |
$4.59
|
| Rate for Payer: Signature Care EPO |
$4.94
|
| Rate for Payer: Signature Care PPO |
$5.24
|
| Rate for Payer: United Healthcare Commercial |
$4.69
|
|
|
HC LH
|
Facility
OP
|
$242.35
|
|
|
Service Code
|
CPT 83002
|
| Hospital Charge Code |
63001189
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.52 |
| Max. Negotiated Rate |
$225.39 |
| Rate for Payer: Aetna Commercial |
$204.55
|
| Rate for Payer: Aetna Medicare |
$79.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$79.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$111.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$111.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$18.52
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$91.97
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$87.97
|
| Rate for Payer: Cash Price |
$150.26
|
| Rate for Payer: Cash Price |
$150.26
|
| Rate for Payer: Centivo All Commercial |
$123.60
|
| Rate for Payer: Cigna All Commercial |
$209.15
|
| Rate for Payer: CORVEL All Commercial |
$225.39
|
| Rate for Payer: Coventry All Commercial |
$213.27
|
| Rate for Payer: Encore All Commercial |
$223.09
|
| Rate for Payer: Frontpath All Commercial |
$222.96
|
| Rate for Payer: Humana ChoiceCare |
$209.32
|
| Rate for Payer: Humana Medicare |
$123.60
|
| Rate for Payer: Lucent All Commercial |
$123.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$218.12
|
| Rate for Payer: Managed Health Services Medicaid |
$18.52
|
| Rate for Payer: MDWise Medicaid |
$18.52
|
| Rate for Payer: PHCS All Commercial |
$181.76
|
| Rate for Payer: PHP All Commercial |
$183.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$94.52
|
| Rate for Payer: Sagamore Health Network All Products |
$187.10
|
| Rate for Payer: Signature Care EPO |
$201.15
|
| Rate for Payer: Signature Care PPO |
$213.27
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$206.00
|
| Rate for Payer: United Healthcare Commercial |
$190.97
|
| Rate for Payer: United Healthcare Medicare |
$79.98
|
|
|
HC LH
|
Facility
IP
|
$242.35
|
|
|
Service Code
|
CPT 83002
|
| Hospital Charge Code |
63001189
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$181.76 |
| Max. Negotiated Rate |
$225.39 |
| Rate for Payer: Aetna Commercial |
$209.39
|
| Rate for Payer: Cash Price |
$150.26
|
| Rate for Payer: Cigna All Commercial |
$209.15
|
| Rate for Payer: CORVEL All Commercial |
$225.39
|
| Rate for Payer: Coventry All Commercial |
$213.27
|
| Rate for Payer: Encore All Commercial |
$223.09
|
| Rate for Payer: Frontpath All Commercial |
$222.96
|
| Rate for Payer: Humana ChoiceCare |
$209.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$218.12
|
| Rate for Payer: PHCS All Commercial |
$181.76
|
| Rate for Payer: PHP All Commercial |
$183.80
|
| Rate for Payer: Sagamore Health Network All Products |
$187.10
|
| Rate for Payer: Signature Care EPO |
$201.15
|
| Rate for Payer: Signature Care PPO |
$213.27
|
| Rate for Payer: United Healthcare Commercial |
$190.97
|
|
|
HC LIFENET FLEXIGRAFT 14X32
|
Facility
OP
|
$4,131.00
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
41607100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$3,841.83 |
| Rate for Payer: Aetna Commercial |
$3,486.56
|
| Rate for Payer: Aetna Medicare |
$1,363.23
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,363.23
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,372.43
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,582.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,567.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,499.55
|
| Rate for Payer: Cash Price |
$2,561.22
|
| Rate for Payer: Cash Price |
$2,561.22
|
| Rate for Payer: Centivo All Commercial |
$2,106.81
|
| Rate for Payer: Cigna All Commercial |
$3,565.05
|
| Rate for Payer: CORVEL All Commercial |
$3,841.83
|
| Rate for Payer: Coventry All Commercial |
$3,635.28
|
| Rate for Payer: Encore All Commercial |
$3,802.59
|
| Rate for Payer: Frontpath All Commercial |
$3,800.52
|
| Rate for Payer: Humana ChoiceCare |
$3,567.94
|
| Rate for Payer: Humana Medicare |
$2,106.81
|
| Rate for Payer: Lucent All Commercial |
$2,106.81
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,717.90
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$3,098.25
|
| Rate for Payer: PHP All Commercial |
$3,132.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,611.09
|
| Rate for Payer: Sagamore Health Network All Products |
$3,189.13
|
| Rate for Payer: Signature Care EPO |
$3,428.73
|
| Rate for Payer: Signature Care PPO |
$3,635.28
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,511.35
|
| Rate for Payer: United Healthcare Commercial |
$3,255.23
|
| Rate for Payer: United Healthcare Medicare |
$1,363.23
|
|
|
HC LIFENET FLEXIGRAFT 14X32
|
Facility
IP
|
$4,131.00
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
41607100
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,098.25 |
| Max. Negotiated Rate |
$3,841.83 |
| Rate for Payer: Aetna Commercial |
$3,569.18
|
| Rate for Payer: Cash Price |
$2,561.22
|
| Rate for Payer: Cigna All Commercial |
$3,565.05
|
| Rate for Payer: CORVEL All Commercial |
$3,841.83
|
| Rate for Payer: Coventry All Commercial |
$3,635.28
|
| Rate for Payer: Encore All Commercial |
$3,802.59
|
| Rate for Payer: Frontpath All Commercial |
$3,800.52
|
| Rate for Payer: Humana ChoiceCare |
$3,567.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,717.90
|
| Rate for Payer: PHCS All Commercial |
$3,098.25
|
| Rate for Payer: PHP All Commercial |
$3,132.95
|
| Rate for Payer: Sagamore Health Network All Products |
$3,189.13
|
| Rate for Payer: Signature Care EPO |
$3,428.73
|
| Rate for Payer: Signature Care PPO |
$3,635.28
|
| Rate for Payer: United Healthcare Commercial |
$3,255.23
|
|
|
HC LIGACLIP LARGE LT400
|
Facility
IP
|
$33.39
|
|
| Hospital Charge Code |
41601930
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$25.04 |
| Max. Negotiated Rate |
$31.05 |
| Rate for Payer: Aetna Commercial |
$28.85
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cigna All Commercial |
$28.82
|
| Rate for Payer: CORVEL All Commercial |
$31.05
|
| Rate for Payer: Coventry All Commercial |
$29.38
|
| Rate for Payer: Encore All Commercial |
$30.74
|
| Rate for Payer: Frontpath All Commercial |
$30.72
|
| Rate for Payer: Humana ChoiceCare |
$28.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.05
|
| Rate for Payer: PHCS All Commercial |
$25.04
|
| Rate for Payer: PHP All Commercial |
$25.32
|
| Rate for Payer: Sagamore Health Network All Products |
$25.78
|
| Rate for Payer: Signature Care EPO |
$27.71
|
| Rate for Payer: Signature Care PPO |
$29.38
|
| Rate for Payer: United Healthcare Commercial |
$26.31
|
|
|
HC LIGACLIP LARGE LT400
|
Facility
OP
|
$33.39
|
|
| Hospital Charge Code |
41601930
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$11.02 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$28.18
|
| Rate for Payer: Aetna Medicare |
$11.02
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.02
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19.18
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.87
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.12
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Cash Price |
$20.70
|
| Rate for Payer: Centivo All Commercial |
$17.03
|
| Rate for Payer: Cigna All Commercial |
$28.82
|
| Rate for Payer: CORVEL All Commercial |
$31.05
|
| Rate for Payer: Coventry All Commercial |
$29.38
|
| Rate for Payer: Encore All Commercial |
$30.74
|
| Rate for Payer: Frontpath All Commercial |
$30.72
|
| Rate for Payer: Humana ChoiceCare |
$28.84
|
| Rate for Payer: Humana Medicare |
$17.03
|
| Rate for Payer: Lucent All Commercial |
$17.03
|
| Rate for Payer: Lutheran Preferred All Commercial |
$30.05
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$25.04
|
| Rate for Payer: PHP All Commercial |
$25.32
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.02
|
| Rate for Payer: Sagamore Health Network All Products |
$25.78
|
| Rate for Payer: Signature Care EPO |
$27.71
|
| Rate for Payer: Signature Care PPO |
$29.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$28.38
|
| Rate for Payer: United Healthcare Commercial |
$26.31
|
| Rate for Payer: United Healthcare Medicare |
$11.02
|
|
|
HC LIGACLIP MEDIUM LT200
|
Facility
IP
|
$18.92
|
|
| Hospital Charge Code |
41601932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$14.19 |
| Max. Negotiated Rate |
$17.60 |
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: Cigna All Commercial |
$16.33
|
| Rate for Payer: CORVEL All Commercial |
$17.60
|
| Rate for Payer: Coventry All Commercial |
$16.65
|
| Rate for Payer: Encore All Commercial |
$17.42
|
| Rate for Payer: Frontpath All Commercial |
$17.41
|
| Rate for Payer: Humana ChoiceCare |
$16.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.03
|
| Rate for Payer: PHCS All Commercial |
$14.19
|
| Rate for Payer: PHP All Commercial |
$14.35
|
| Rate for Payer: Sagamore Health Network All Products |
$14.61
|
| Rate for Payer: Signature Care EPO |
$15.70
|
| Rate for Payer: Signature Care PPO |
$16.65
|
| Rate for Payer: United Healthcare Commercial |
$14.91
|
|
|
HC LIGACLIP MEDIUM LT200
|
Facility
OP
|
$18.92
|
|
| Hospital Charge Code |
41601932
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$15.97
|
| Rate for Payer: Aetna Medicare |
$6.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$6.24
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.87
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.83
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$7.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.87
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: Cash Price |
$11.73
|
| Rate for Payer: Centivo All Commercial |
$9.65
|
| Rate for Payer: Cigna All Commercial |
$16.33
|
| Rate for Payer: CORVEL All Commercial |
$17.60
|
| Rate for Payer: Coventry All Commercial |
$16.65
|
| Rate for Payer: Encore All Commercial |
$17.42
|
| Rate for Payer: Frontpath All Commercial |
$17.41
|
| Rate for Payer: Humana ChoiceCare |
$16.34
|
| Rate for Payer: Humana Medicare |
$9.65
|
| Rate for Payer: Lucent All Commercial |
$9.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$17.03
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$14.19
|
| Rate for Payer: PHP All Commercial |
$14.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.38
|
| Rate for Payer: Sagamore Health Network All Products |
$14.61
|
| Rate for Payer: Signature Care EPO |
$15.70
|
| Rate for Payer: Signature Care PPO |
$16.65
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$16.08
|
| Rate for Payer: United Healthcare Commercial |
$14.91
|
| Rate for Payer: United Healthcare Medicare |
$6.24
|
|
|
HC LIGACLIP MED/LG LT300
|
Facility
IP
|
$22.16
|
|
| Hospital Charge Code |
41601931
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$16.62 |
| Max. Negotiated Rate |
$20.61 |
| Rate for Payer: Aetna Commercial |
$19.15
|
| Rate for Payer: Cash Price |
$13.74
|
| Rate for Payer: Cigna All Commercial |
$19.12
|
| Rate for Payer: CORVEL All Commercial |
$20.61
|
| Rate for Payer: Coventry All Commercial |
$19.50
|
| Rate for Payer: Encore All Commercial |
$20.40
|
| Rate for Payer: Frontpath All Commercial |
$20.39
|
| Rate for Payer: Humana ChoiceCare |
$19.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.94
|
| Rate for Payer: PHCS All Commercial |
$16.62
|
| Rate for Payer: PHP All Commercial |
$16.81
|
| Rate for Payer: Sagamore Health Network All Products |
$17.11
|
| Rate for Payer: Signature Care EPO |
$18.39
|
| Rate for Payer: Signature Care PPO |
$19.50
|
| Rate for Payer: United Healthcare Commercial |
$17.46
|
|
|
HC LIGACLIP MED/LG LT300
|
Facility
OP
|
$22.16
|
|
| Hospital Charge Code |
41601931
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$7.31 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$18.70
|
| Rate for Payer: Aetna Medicare |
$7.31
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$7.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$12.73
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$13.85
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$8.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$8.04
|
| Rate for Payer: Cash Price |
$13.74
|
| Rate for Payer: Cash Price |
$13.74
|
| Rate for Payer: Centivo All Commercial |
$11.30
|
| Rate for Payer: Cigna All Commercial |
$19.12
|
| Rate for Payer: CORVEL All Commercial |
$20.61
|
| Rate for Payer: Coventry All Commercial |
$19.50
|
| Rate for Payer: Encore All Commercial |
$20.40
|
| Rate for Payer: Frontpath All Commercial |
$20.39
|
| Rate for Payer: Humana ChoiceCare |
$19.14
|
| Rate for Payer: Humana Medicare |
$11.30
|
| Rate for Payer: Lucent All Commercial |
$11.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$19.94
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$16.62
|
| Rate for Payer: PHP All Commercial |
$16.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.64
|
| Rate for Payer: Sagamore Health Network All Products |
$17.11
|
| Rate for Payer: Signature Care EPO |
$18.39
|
| Rate for Payer: Signature Care PPO |
$19.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$18.84
|
| Rate for Payer: United Healthcare Commercial |
$17.46
|
| Rate for Payer: United Healthcare Medicare |
$7.31
|
|
|
HC LIGACLIP SMALL LT100
|
Facility
IP
|
$14.18
|
|
| Hospital Charge Code |
41602495
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$10.64 |
| Max. Negotiated Rate |
$13.19 |
| Rate for Payer: Aetna Commercial |
$12.25
|
| Rate for Payer: Cash Price |
$8.79
|
| Rate for Payer: Cigna All Commercial |
$12.24
|
| Rate for Payer: CORVEL All Commercial |
$13.19
|
| Rate for Payer: Coventry All Commercial |
$12.48
|
| Rate for Payer: Encore All Commercial |
$13.05
|
| Rate for Payer: Frontpath All Commercial |
$13.05
|
| Rate for Payer: Humana ChoiceCare |
$12.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.76
|
| Rate for Payer: PHCS All Commercial |
$10.64
|
| Rate for Payer: PHP All Commercial |
$10.75
|
| Rate for Payer: Sagamore Health Network All Products |
$10.95
|
| Rate for Payer: Signature Care EPO |
$11.77
|
| Rate for Payer: Signature Care PPO |
$12.48
|
| Rate for Payer: United Healthcare Commercial |
$11.17
|
|
|
HC LIGACLIP SMALL LT100
|
Facility
OP
|
$14.18
|
|
| Hospital Charge Code |
41602495
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$121.68 |
| Rate for Payer: Aetna Commercial |
$11.97
|
| Rate for Payer: Aetna Medicare |
$4.68
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$4.68
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$8.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$8.86
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$121.68
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$5.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$5.15
|
| Rate for Payer: Cash Price |
$8.79
|
| Rate for Payer: Cash Price |
$8.79
|
| Rate for Payer: Centivo All Commercial |
$7.23
|
| Rate for Payer: Cigna All Commercial |
$12.24
|
| Rate for Payer: CORVEL All Commercial |
$13.19
|
| Rate for Payer: Coventry All Commercial |
$12.48
|
| Rate for Payer: Encore All Commercial |
$13.05
|
| Rate for Payer: Frontpath All Commercial |
$13.05
|
| Rate for Payer: Humana ChoiceCare |
$12.25
|
| Rate for Payer: Humana Medicare |
$7.23
|
| Rate for Payer: Lucent All Commercial |
$7.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$12.76
|
| Rate for Payer: Managed Health Services Medicaid |
$121.68
|
| Rate for Payer: MDWise Medicaid |
$121.68
|
| Rate for Payer: PHCS All Commercial |
$10.64
|
| Rate for Payer: PHP All Commercial |
$10.75
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$5.53
|
| Rate for Payer: Sagamore Health Network All Products |
$10.95
|
| Rate for Payer: Signature Care EPO |
$11.77
|
| Rate for Payer: Signature Care PPO |
$12.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$12.05
|
| Rate for Payer: United Healthcare Commercial |
$11.17
|
| Rate for Payer: United Healthcare Medicare |
$4.68
|
|
|
HC LIGASURE 5MM BLUNT
|
Facility
IP
|
$2,212.15
|
|
| Hospital Charge Code |
41603084
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,659.11 |
| Max. Negotiated Rate |
$2,057.30 |
| Rate for Payer: Aetna Commercial |
$1,911.30
|
| Rate for Payer: Cash Price |
$1,371.53
|
| Rate for Payer: Cigna All Commercial |
$1,909.09
|
| Rate for Payer: CORVEL All Commercial |
$2,057.30
|
| Rate for Payer: Coventry All Commercial |
$1,946.69
|
| Rate for Payer: Encore All Commercial |
$2,036.28
|
| Rate for Payer: Frontpath All Commercial |
$2,035.18
|
| Rate for Payer: Humana ChoiceCare |
$1,910.63
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,990.94
|
| Rate for Payer: PHCS All Commercial |
$1,659.11
|
| Rate for Payer: PHP All Commercial |
$1,677.69
|
| Rate for Payer: Sagamore Health Network All Products |
$1,707.78
|
| Rate for Payer: Signature Care EPO |
$1,836.08
|
| Rate for Payer: Signature Care PPO |
$1,946.69
|
| Rate for Payer: United Healthcare Commercial |
$1,743.17
|
|
