|
HC MESH BARD SOFT 12X12
|
Facility
IP
|
$917.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601809
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$687.75 |
| Max. Negotiated Rate |
$852.81 |
| Rate for Payer: Aetna Commercial |
$792.29
|
| Rate for Payer: Cash Price |
$568.54
|
| Rate for Payer: Cigna All Commercial |
$791.37
|
| Rate for Payer: CORVEL All Commercial |
$852.81
|
| Rate for Payer: Coventry All Commercial |
$806.96
|
| Rate for Payer: Encore All Commercial |
$844.10
|
| Rate for Payer: Frontpath All Commercial |
$843.64
|
| Rate for Payer: Humana ChoiceCare |
$792.01
|
| Rate for Payer: Lutheran Preferred All Commercial |
$825.30
|
| Rate for Payer: PHCS All Commercial |
$687.75
|
| Rate for Payer: PHP All Commercial |
$695.45
|
| Rate for Payer: Sagamore Health Network All Products |
$707.92
|
| Rate for Payer: Signature Care EPO |
$761.11
|
| Rate for Payer: Signature Care PPO |
$806.96
|
| Rate for Payer: United Healthcare Commercial |
$722.60
|
|
|
HC MESH BARD SOFT 3X6
|
Facility
OP
|
$320.60
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41602110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$105.80 |
| Max. Negotiated Rate |
$524.16 |
| Rate for Payer: Aetna Commercial |
$270.59
|
| Rate for Payer: Aetna Medicare |
$105.80
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$105.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$184.12
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$200.41
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$121.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$116.38
|
| Rate for Payer: Cash Price |
$198.77
|
| Rate for Payer: Cash Price |
$198.77
|
| Rate for Payer: Centivo All Commercial |
$163.51
|
| Rate for Payer: Cigna All Commercial |
$276.68
|
| Rate for Payer: CORVEL All Commercial |
$298.16
|
| Rate for Payer: Coventry All Commercial |
$282.13
|
| Rate for Payer: Encore All Commercial |
$295.11
|
| Rate for Payer: Frontpath All Commercial |
$294.95
|
| Rate for Payer: Humana ChoiceCare |
$276.90
|
| Rate for Payer: Humana Medicare |
$163.51
|
| Rate for Payer: Lucent All Commercial |
$163.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$288.54
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$240.45
|
| Rate for Payer: PHP All Commercial |
$243.14
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$125.03
|
| Rate for Payer: Sagamore Health Network All Products |
$247.50
|
| Rate for Payer: Signature Care EPO |
$266.10
|
| Rate for Payer: Signature Care PPO |
$282.13
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$272.51
|
| Rate for Payer: United Healthcare Commercial |
$252.63
|
| Rate for Payer: United Healthcare Medicare |
$105.80
|
|
|
HC MESH BARD SOFT 3X6
|
Facility
IP
|
$320.60
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41602110
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$240.45 |
| Max. Negotiated Rate |
$298.16 |
| Rate for Payer: Aetna Commercial |
$277.00
|
| Rate for Payer: Cash Price |
$198.77
|
| Rate for Payer: Cigna All Commercial |
$276.68
|
| Rate for Payer: CORVEL All Commercial |
$298.16
|
| Rate for Payer: Coventry All Commercial |
$282.13
|
| Rate for Payer: Encore All Commercial |
$295.11
|
| Rate for Payer: Frontpath All Commercial |
$294.95
|
| Rate for Payer: Humana ChoiceCare |
$276.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$288.54
|
| Rate for Payer: PHCS All Commercial |
$240.45
|
| Rate for Payer: PHP All Commercial |
$243.14
|
| Rate for Payer: Sagamore Health Network All Products |
$247.50
|
| Rate for Payer: Signature Care EPO |
$266.10
|
| Rate for Payer: Signature Care PPO |
$282.13
|
| Rate for Payer: United Healthcare Commercial |
$252.63
|
|
|
HC MESH BARD SOFT 6X6
|
Facility
OP
|
$980.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41602109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$323.40 |
| Max. Negotiated Rate |
$911.40 |
| Rate for Payer: Aetna Commercial |
$827.12
|
| Rate for Payer: Aetna Medicare |
$323.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$323.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$562.81
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$612.60
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$371.91
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$355.74
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Centivo All Commercial |
$499.80
|
| Rate for Payer: Cigna All Commercial |
$845.74
|
| Rate for Payer: CORVEL All Commercial |
$911.40
|
| Rate for Payer: Coventry All Commercial |
$862.40
|
| Rate for Payer: Encore All Commercial |
$902.09
|
| Rate for Payer: Frontpath All Commercial |
$901.60
|
| Rate for Payer: Humana ChoiceCare |
$846.43
|
| Rate for Payer: Humana Medicare |
$499.80
|
| Rate for Payer: Lucent All Commercial |
$499.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$882.00
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$735.00
|
| Rate for Payer: PHP All Commercial |
$743.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$382.20
|
| Rate for Payer: Sagamore Health Network All Products |
$756.56
|
| Rate for Payer: Signature Care EPO |
$813.40
|
| Rate for Payer: Signature Care PPO |
$862.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$833.00
|
| Rate for Payer: United Healthcare Commercial |
$772.24
|
| Rate for Payer: United Healthcare Medicare |
$323.40
|
|
|
HC MESH BARD SOFT 6X6
|
Facility
IP
|
$980.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41602109
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$735.00 |
| Max. Negotiated Rate |
$911.40 |
| Rate for Payer: Aetna Commercial |
$846.72
|
| Rate for Payer: Cash Price |
$607.60
|
| Rate for Payer: Cigna All Commercial |
$845.74
|
| Rate for Payer: CORVEL All Commercial |
$911.40
|
| Rate for Payer: Coventry All Commercial |
$862.40
|
| Rate for Payer: Encore All Commercial |
$902.09
|
| Rate for Payer: Frontpath All Commercial |
$901.60
|
| Rate for Payer: Humana ChoiceCare |
$846.43
|
| Rate for Payer: Lutheran Preferred All Commercial |
$882.00
|
| Rate for Payer: PHCS All Commercial |
$735.00
|
| Rate for Payer: PHP All Commercial |
$743.23
|
| Rate for Payer: Sagamore Health Network All Products |
$756.56
|
| Rate for Payer: Signature Care EPO |
$813.40
|
| Rate for Payer: Signature Care PPO |
$862.40
|
| Rate for Payer: United Healthcare Commercial |
$772.24
|
|
|
HC MESH BARD W KEYHOLE 13.7X5.9
|
Facility
OP
|
$415.80
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41607953
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$137.21 |
| Max. Negotiated Rate |
$524.16 |
| Rate for Payer: Aetna Commercial |
$350.94
|
| Rate for Payer: Aetna Medicare |
$137.21
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$137.21
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$238.79
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$259.92
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$157.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$150.94
|
| Rate for Payer: Cash Price |
$257.80
|
| Rate for Payer: Cash Price |
$257.80
|
| Rate for Payer: Centivo All Commercial |
$212.06
|
| Rate for Payer: Cigna All Commercial |
$358.84
|
| Rate for Payer: CORVEL All Commercial |
$386.69
|
| Rate for Payer: Coventry All Commercial |
$365.90
|
| Rate for Payer: Encore All Commercial |
$382.74
|
| Rate for Payer: Frontpath All Commercial |
$382.54
|
| Rate for Payer: Humana ChoiceCare |
$359.13
|
| Rate for Payer: Humana Medicare |
$212.06
|
| Rate for Payer: Lucent All Commercial |
$212.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$374.22
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$311.85
|
| Rate for Payer: PHP All Commercial |
$315.34
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$162.16
|
| Rate for Payer: Sagamore Health Network All Products |
$321.00
|
| Rate for Payer: Signature Care EPO |
$345.11
|
| Rate for Payer: Signature Care PPO |
$365.90
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$353.43
|
| Rate for Payer: United Healthcare Commercial |
$327.65
|
| Rate for Payer: United Healthcare Medicare |
$137.21
|
|
|
HC MESH BARD W KEYHOLE 13.7X5.9
|
Facility
IP
|
$415.80
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41607953
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$311.85 |
| Max. Negotiated Rate |
$386.69 |
| Rate for Payer: Aetna Commercial |
$359.25
|
| Rate for Payer: Cash Price |
$257.80
|
| Rate for Payer: Cigna All Commercial |
$358.84
|
| Rate for Payer: CORVEL All Commercial |
$386.69
|
| Rate for Payer: Coventry All Commercial |
$365.90
|
| Rate for Payer: Encore All Commercial |
$382.74
|
| Rate for Payer: Frontpath All Commercial |
$382.54
|
| Rate for Payer: Humana ChoiceCare |
$359.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$374.22
|
| Rate for Payer: PHCS All Commercial |
$311.85
|
| Rate for Payer: PHP All Commercial |
$315.34
|
| Rate for Payer: Sagamore Health Network All Products |
$321.00
|
| Rate for Payer: Signature Care EPO |
$345.11
|
| Rate for Payer: Signature Care PPO |
$365.90
|
| Rate for Payer: United Healthcare Commercial |
$327.65
|
|
|
HC MESH COMPOSIX KUGEL LG CIRCLE
|
Facility
IP
|
$2,178.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601937
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,633.50 |
| Max. Negotiated Rate |
$2,025.54 |
| Rate for Payer: Aetna Commercial |
$1,881.79
|
| Rate for Payer: Cash Price |
$1,350.36
|
| Rate for Payer: Cigna All Commercial |
$1,879.61
|
| Rate for Payer: CORVEL All Commercial |
$2,025.54
|
| Rate for Payer: Coventry All Commercial |
$1,916.64
|
| Rate for Payer: Encore All Commercial |
$2,004.85
|
| Rate for Payer: Frontpath All Commercial |
$2,003.76
|
| Rate for Payer: Humana ChoiceCare |
$1,881.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,960.20
|
| Rate for Payer: PHCS All Commercial |
$1,633.50
|
| Rate for Payer: PHP All Commercial |
$1,651.80
|
| Rate for Payer: Sagamore Health Network All Products |
$1,681.42
|
| Rate for Payer: Signature Care EPO |
$1,807.74
|
| Rate for Payer: Signature Care PPO |
$1,916.64
|
| Rate for Payer: United Healthcare Commercial |
$1,716.26
|
|
|
HC MESH COMPOSIX KUGEL LG CIRCLE
|
Facility
OP
|
$2,178.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601937
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$2,025.54 |
| Rate for Payer: Aetna Commercial |
$1,838.23
|
| Rate for Payer: Aetna Medicare |
$718.74
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$718.74
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,250.83
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,361.47
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$826.55
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$790.61
|
| Rate for Payer: Cash Price |
$1,350.36
|
| Rate for Payer: Cash Price |
$1,350.36
|
| Rate for Payer: Centivo All Commercial |
$1,110.78
|
| Rate for Payer: Cigna All Commercial |
$1,879.61
|
| Rate for Payer: CORVEL All Commercial |
$2,025.54
|
| Rate for Payer: Coventry All Commercial |
$1,916.64
|
| Rate for Payer: Encore All Commercial |
$2,004.85
|
| Rate for Payer: Frontpath All Commercial |
$2,003.76
|
| Rate for Payer: Humana ChoiceCare |
$1,881.14
|
| Rate for Payer: Humana Medicare |
$1,110.78
|
| Rate for Payer: Lucent All Commercial |
$1,110.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,960.20
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$1,633.50
|
| Rate for Payer: PHP All Commercial |
$1,651.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$849.42
|
| Rate for Payer: Sagamore Health Network All Products |
$1,681.42
|
| Rate for Payer: Signature Care EPO |
$1,807.74
|
| Rate for Payer: Signature Care PPO |
$1,916.64
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,851.30
|
| Rate for Payer: United Healthcare Commercial |
$1,716.26
|
| Rate for Payer: United Healthcare Medicare |
$718.74
|
|
|
HC MESH COMPOSIX KUGEL SM CIRCLE
|
Facility
OP
|
$2,430.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601940
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$2,259.90 |
| Rate for Payer: Aetna Commercial |
$2,050.92
|
| Rate for Payer: Aetna Medicare |
$801.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$801.90
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,395.55
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,518.99
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$922.18
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$882.09
|
| Rate for Payer: Cash Price |
$1,506.60
|
| Rate for Payer: Cash Price |
$1,506.60
|
| Rate for Payer: Centivo All Commercial |
$1,239.30
|
| Rate for Payer: Cigna All Commercial |
$2,097.09
|
| Rate for Payer: CORVEL All Commercial |
$2,259.90
|
| Rate for Payer: Coventry All Commercial |
$2,138.40
|
| Rate for Payer: Encore All Commercial |
$2,236.82
|
| Rate for Payer: Frontpath All Commercial |
$2,235.60
|
| Rate for Payer: Humana ChoiceCare |
$2,098.79
|
| Rate for Payer: Humana Medicare |
$1,239.30
|
| Rate for Payer: Lucent All Commercial |
$1,239.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,187.00
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$1,822.50
|
| Rate for Payer: PHP All Commercial |
$1,842.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$947.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1,875.96
|
| Rate for Payer: Signature Care EPO |
$2,016.90
|
| Rate for Payer: Signature Care PPO |
$2,138.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,065.50
|
| Rate for Payer: United Healthcare Commercial |
$1,914.84
|
| Rate for Payer: United Healthcare Medicare |
$801.90
|
|
|
HC MESH COMPOSIX KUGEL SM CIRCLE
|
Facility
IP
|
$2,430.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601940
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,822.50 |
| Max. Negotiated Rate |
$2,259.90 |
| Rate for Payer: Aetna Commercial |
$2,099.52
|
| Rate for Payer: Cash Price |
$1,506.60
|
| Rate for Payer: Cigna All Commercial |
$2,097.09
|
| Rate for Payer: CORVEL All Commercial |
$2,259.90
|
| Rate for Payer: Coventry All Commercial |
$2,138.40
|
| Rate for Payer: Encore All Commercial |
$2,236.82
|
| Rate for Payer: Frontpath All Commercial |
$2,235.60
|
| Rate for Payer: Humana ChoiceCare |
$2,098.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,187.00
|
| Rate for Payer: PHCS All Commercial |
$1,822.50
|
| Rate for Payer: PHP All Commercial |
$1,842.91
|
| Rate for Payer: Sagamore Health Network All Products |
$1,875.96
|
| Rate for Payer: Signature Care EPO |
$2,016.90
|
| Rate for Payer: Signature Care PPO |
$2,138.40
|
| Rate for Payer: United Healthcare Commercial |
$1,914.84
|
|
|
HC MESH COMPSIX KUGEL LG OVAL
|
Facility
OP
|
$5,784.48
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601938
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$5,379.57 |
| Rate for Payer: Aetna Commercial |
$4,882.10
|
| Rate for Payer: Aetna Medicare |
$1,908.88
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,908.88
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,322.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,615.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,195.21
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,099.77
|
| Rate for Payer: Cash Price |
$3,586.38
|
| Rate for Payer: Cash Price |
$3,586.38
|
| Rate for Payer: Centivo All Commercial |
$2,950.08
|
| Rate for Payer: Cigna All Commercial |
$4,992.01
|
| Rate for Payer: CORVEL All Commercial |
$5,379.57
|
| Rate for Payer: Coventry All Commercial |
$5,090.34
|
| Rate for Payer: Encore All Commercial |
$5,324.61
|
| Rate for Payer: Frontpath All Commercial |
$5,321.72
|
| Rate for Payer: Humana ChoiceCare |
$4,996.06
|
| Rate for Payer: Humana Medicare |
$2,950.08
|
| Rate for Payer: Lucent All Commercial |
$2,950.08
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,206.03
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$4,338.36
|
| Rate for Payer: PHP All Commercial |
$4,386.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,255.95
|
| Rate for Payer: Sagamore Health Network All Products |
$4,465.62
|
| Rate for Payer: Signature Care EPO |
$4,801.12
|
| Rate for Payer: Signature Care PPO |
$5,090.34
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,916.81
|
| Rate for Payer: United Healthcare Commercial |
$4,558.17
|
| Rate for Payer: United Healthcare Medicare |
$1,908.88
|
|
|
HC MESH COMPSIX KUGEL LG OVAL
|
Facility
IP
|
$5,784.48
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601938
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,338.36 |
| Max. Negotiated Rate |
$5,379.57 |
| Rate for Payer: Aetna Commercial |
$4,997.79
|
| Rate for Payer: Cash Price |
$3,586.38
|
| Rate for Payer: Cigna All Commercial |
$4,992.01
|
| Rate for Payer: CORVEL All Commercial |
$5,379.57
|
| Rate for Payer: Coventry All Commercial |
$5,090.34
|
| Rate for Payer: Encore All Commercial |
$5,324.61
|
| Rate for Payer: Frontpath All Commercial |
$5,321.72
|
| Rate for Payer: Humana ChoiceCare |
$4,996.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,206.03
|
| Rate for Payer: PHCS All Commercial |
$4,338.36
|
| Rate for Payer: PHP All Commercial |
$4,386.95
|
| Rate for Payer: Sagamore Health Network All Products |
$4,465.62
|
| Rate for Payer: Signature Care EPO |
$4,801.12
|
| Rate for Payer: Signature Care PPO |
$5,090.34
|
| Rate for Payer: United Healthcare Commercial |
$4,558.17
|
|
|
HC MESH COMPSIX KUGEL MED OVAL
|
Facility
IP
|
$2,880.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601939
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,160.00 |
| Max. Negotiated Rate |
$2,678.40 |
| Rate for Payer: Aetna Commercial |
$2,488.32
|
| Rate for Payer: Cash Price |
$1,785.60
|
| Rate for Payer: Cigna All Commercial |
$2,485.44
|
| Rate for Payer: CORVEL All Commercial |
$2,678.40
|
| Rate for Payer: Coventry All Commercial |
$2,534.40
|
| Rate for Payer: Encore All Commercial |
$2,651.04
|
| Rate for Payer: Frontpath All Commercial |
$2,649.60
|
| Rate for Payer: Humana ChoiceCare |
$2,487.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,592.00
|
| Rate for Payer: PHCS All Commercial |
$2,160.00
|
| Rate for Payer: PHP All Commercial |
$2,184.19
|
| Rate for Payer: Sagamore Health Network All Products |
$2,223.36
|
| Rate for Payer: Signature Care EPO |
$2,390.40
|
| Rate for Payer: Signature Care PPO |
$2,534.40
|
| Rate for Payer: United Healthcare Commercial |
$2,269.44
|
|
|
HC MESH COMPSIX KUGEL MED OVAL
|
Facility
OP
|
$2,880.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601939
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$2,678.40 |
| Rate for Payer: Aetna Commercial |
$2,430.72
|
| Rate for Payer: Aetna Medicare |
$950.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$950.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,653.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,800.29
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,092.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,045.44
|
| Rate for Payer: Cash Price |
$1,785.60
|
| Rate for Payer: Cash Price |
$1,785.60
|
| Rate for Payer: Centivo All Commercial |
$1,468.80
|
| Rate for Payer: Cigna All Commercial |
$2,485.44
|
| Rate for Payer: CORVEL All Commercial |
$2,678.40
|
| Rate for Payer: Coventry All Commercial |
$2,534.40
|
| Rate for Payer: Encore All Commercial |
$2,651.04
|
| Rate for Payer: Frontpath All Commercial |
$2,649.60
|
| Rate for Payer: Humana ChoiceCare |
$2,487.46
|
| Rate for Payer: Humana Medicare |
$1,468.80
|
| Rate for Payer: Lucent All Commercial |
$1,468.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,592.00
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$2,160.00
|
| Rate for Payer: PHP All Commercial |
$2,184.19
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,123.20
|
| Rate for Payer: Sagamore Health Network All Products |
$2,223.36
|
| Rate for Payer: Signature Care EPO |
$2,390.40
|
| Rate for Payer: Signature Care PPO |
$2,534.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,448.00
|
| Rate for Payer: United Healthcare Commercial |
$2,269.44
|
| Rate for Payer: United Healthcare Medicare |
$950.40
|
|
|
HC MESH COMPSIX KUGEL SM OVAL
|
Facility
IP
|
$1,980.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,485.00 |
| Max. Negotiated Rate |
$1,841.40 |
| Rate for Payer: Aetna Commercial |
$1,710.72
|
| Rate for Payer: Cash Price |
$1,227.60
|
| Rate for Payer: Cigna All Commercial |
$1,708.74
|
| Rate for Payer: CORVEL All Commercial |
$1,841.40
|
| Rate for Payer: Coventry All Commercial |
$1,742.40
|
| Rate for Payer: Encore All Commercial |
$1,822.59
|
| Rate for Payer: Frontpath All Commercial |
$1,821.60
|
| Rate for Payer: Humana ChoiceCare |
$1,710.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,782.00
|
| Rate for Payer: PHCS All Commercial |
$1,485.00
|
| Rate for Payer: PHP All Commercial |
$1,501.63
|
| Rate for Payer: Sagamore Health Network All Products |
$1,528.56
|
| Rate for Payer: Signature Care EPO |
$1,643.40
|
| Rate for Payer: Signature Care PPO |
$1,742.40
|
| Rate for Payer: United Healthcare Commercial |
$1,560.24
|
|
|
HC MESH COMPSIX KUGEL SM OVAL
|
Facility
OP
|
$1,980.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601941
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$1,841.40 |
| Rate for Payer: Aetna Commercial |
$1,671.12
|
| Rate for Payer: Aetna Medicare |
$653.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$653.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,137.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,237.70
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$751.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$718.74
|
| Rate for Payer: Cash Price |
$1,227.60
|
| Rate for Payer: Cash Price |
$1,227.60
|
| Rate for Payer: Centivo All Commercial |
$1,009.80
|
| Rate for Payer: Cigna All Commercial |
$1,708.74
|
| Rate for Payer: CORVEL All Commercial |
$1,841.40
|
| Rate for Payer: Coventry All Commercial |
$1,742.40
|
| Rate for Payer: Encore All Commercial |
$1,822.59
|
| Rate for Payer: Frontpath All Commercial |
$1,821.60
|
| Rate for Payer: Humana ChoiceCare |
$1,710.13
|
| Rate for Payer: Humana Medicare |
$1,009.80
|
| Rate for Payer: Lucent All Commercial |
$1,009.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,782.00
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$1,485.00
|
| Rate for Payer: PHP All Commercial |
$1,501.63
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$772.20
|
| Rate for Payer: Sagamore Health Network All Products |
$1,528.56
|
| Rate for Payer: Signature Care EPO |
$1,643.40
|
| Rate for Payer: Signature Care PPO |
$1,742.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,683.00
|
| Rate for Payer: United Healthcare Commercial |
$1,560.24
|
| Rate for Payer: United Healthcare Medicare |
$653.40
|
|
|
HC MESH DUAL PLUS 10X15
|
Facility
IP
|
$2,490.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601942
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,867.50 |
| Max. Negotiated Rate |
$2,315.70 |
| Rate for Payer: Aetna Commercial |
$2,151.36
|
| Rate for Payer: Cash Price |
$1,543.80
|
| Rate for Payer: Cigna All Commercial |
$2,148.87
|
| Rate for Payer: CORVEL All Commercial |
$2,315.70
|
| Rate for Payer: Coventry All Commercial |
$2,191.20
|
| Rate for Payer: Encore All Commercial |
$2,292.04
|
| Rate for Payer: Frontpath All Commercial |
$2,290.80
|
| Rate for Payer: Humana ChoiceCare |
$2,150.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,241.00
|
| Rate for Payer: PHCS All Commercial |
$1,867.50
|
| Rate for Payer: PHP All Commercial |
$1,888.42
|
| Rate for Payer: Sagamore Health Network All Products |
$1,922.28
|
| Rate for Payer: Signature Care EPO |
$2,066.70
|
| Rate for Payer: Signature Care PPO |
$2,191.20
|
| Rate for Payer: United Healthcare Commercial |
$1,962.12
|
|
|
HC MESH DUAL PLUS 10X15
|
Facility
OP
|
$2,490.00
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601942
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$2,315.70 |
| Rate for Payer: Aetna Commercial |
$2,101.56
|
| Rate for Payer: Aetna Medicare |
$821.70
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$821.70
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,430.01
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,556.50
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$944.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$903.87
|
| Rate for Payer: Cash Price |
$1,543.80
|
| Rate for Payer: Cash Price |
$1,543.80
|
| Rate for Payer: Centivo All Commercial |
$1,269.90
|
| Rate for Payer: Cigna All Commercial |
$2,148.87
|
| Rate for Payer: CORVEL All Commercial |
$2,315.70
|
| Rate for Payer: Coventry All Commercial |
$2,191.20
|
| Rate for Payer: Encore All Commercial |
$2,292.04
|
| Rate for Payer: Frontpath All Commercial |
$2,290.80
|
| Rate for Payer: Humana ChoiceCare |
$2,150.61
|
| Rate for Payer: Humana Medicare |
$1,269.90
|
| Rate for Payer: Lucent All Commercial |
$1,269.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,241.00
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$1,867.50
|
| Rate for Payer: PHP All Commercial |
$1,888.42
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$971.10
|
| Rate for Payer: Sagamore Health Network All Products |
$1,922.28
|
| Rate for Payer: Signature Care EPO |
$2,066.70
|
| Rate for Payer: Signature Care PPO |
$2,191.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,116.50
|
| Rate for Payer: United Healthcare Commercial |
$1,962.12
|
| Rate for Payer: United Healthcare Medicare |
$821.70
|
|
|
HC MESH DUAL PLUS 15X19
|
Facility
OP
|
$3,333.60
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601943
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$3,100.25 |
| Rate for Payer: Aetna Commercial |
$2,813.56
|
| Rate for Payer: Aetna Medicare |
$1,100.09
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,100.09
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,914.49
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,083.83
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,265.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,210.10
|
| Rate for Payer: Cash Price |
$2,066.83
|
| Rate for Payer: Cash Price |
$2,066.83
|
| Rate for Payer: Centivo All Commercial |
$1,700.14
|
| Rate for Payer: Cigna All Commercial |
$2,876.90
|
| Rate for Payer: CORVEL All Commercial |
$3,100.25
|
| Rate for Payer: Coventry All Commercial |
$2,933.57
|
| Rate for Payer: Encore All Commercial |
$3,068.58
|
| Rate for Payer: Frontpath All Commercial |
$3,066.91
|
| Rate for Payer: Humana ChoiceCare |
$2,879.23
|
| Rate for Payer: Humana Medicare |
$1,700.14
|
| Rate for Payer: Lucent All Commercial |
$1,700.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,000.24
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$2,500.20
|
| Rate for Payer: PHP All Commercial |
$2,528.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,300.10
|
| Rate for Payer: Sagamore Health Network All Products |
$2,573.54
|
| Rate for Payer: Signature Care EPO |
$2,766.89
|
| Rate for Payer: Signature Care PPO |
$2,933.57
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,833.56
|
| Rate for Payer: United Healthcare Commercial |
$2,626.88
|
| Rate for Payer: United Healthcare Medicare |
$1,100.09
|
|
|
HC MESH DUAL PLUS 15X19
|
Facility
IP
|
$3,333.60
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601943
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,500.20 |
| Max. Negotiated Rate |
$3,100.25 |
| Rate for Payer: Aetna Commercial |
$2,880.23
|
| Rate for Payer: Cash Price |
$2,066.83
|
| Rate for Payer: Cigna All Commercial |
$2,876.90
|
| Rate for Payer: CORVEL All Commercial |
$3,100.25
|
| Rate for Payer: Coventry All Commercial |
$2,933.57
|
| Rate for Payer: Encore All Commercial |
$3,068.58
|
| Rate for Payer: Frontpath All Commercial |
$3,066.91
|
| Rate for Payer: Humana ChoiceCare |
$2,879.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,000.24
|
| Rate for Payer: PHCS All Commercial |
$2,500.20
|
| Rate for Payer: PHP All Commercial |
$2,528.20
|
| Rate for Payer: Sagamore Health Network All Products |
$2,573.54
|
| Rate for Payer: Signature Care EPO |
$2,766.89
|
| Rate for Payer: Signature Care PPO |
$2,933.57
|
| Rate for Payer: United Healthcare Commercial |
$2,626.88
|
|
|
HC MESH DUAL PLUS 18X24
|
Facility
IP
|
$4,165.20
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601944
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,123.90 |
| Max. Negotiated Rate |
$3,873.64 |
| Rate for Payer: Aetna Commercial |
$3,598.73
|
| Rate for Payer: Cash Price |
$2,582.42
|
| Rate for Payer: Cigna All Commercial |
$3,594.57
|
| Rate for Payer: CORVEL All Commercial |
$3,873.64
|
| Rate for Payer: Coventry All Commercial |
$3,665.38
|
| Rate for Payer: Encore All Commercial |
$3,834.07
|
| Rate for Payer: Frontpath All Commercial |
$3,831.98
|
| Rate for Payer: Humana ChoiceCare |
$3,597.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,748.68
|
| Rate for Payer: PHCS All Commercial |
$3,123.90
|
| Rate for Payer: PHP All Commercial |
$3,158.89
|
| Rate for Payer: Sagamore Health Network All Products |
$3,215.53
|
| Rate for Payer: Signature Care EPO |
$3,457.12
|
| Rate for Payer: Signature Care PPO |
$3,665.38
|
| Rate for Payer: United Healthcare Commercial |
$3,282.18
|
|
|
HC MESH DUAL PLUS 18X24
|
Facility
OP
|
$4,165.20
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601944
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$3,873.64 |
| Rate for Payer: Aetna Commercial |
$3,515.43
|
| Rate for Payer: Aetna Medicare |
$1,374.52
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,374.52
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,392.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,603.67
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,580.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,511.97
|
| Rate for Payer: Cash Price |
$2,582.42
|
| Rate for Payer: Cash Price |
$2,582.42
|
| Rate for Payer: Centivo All Commercial |
$2,124.25
|
| Rate for Payer: Cigna All Commercial |
$3,594.57
|
| Rate for Payer: CORVEL All Commercial |
$3,873.64
|
| Rate for Payer: Coventry All Commercial |
$3,665.38
|
| Rate for Payer: Encore All Commercial |
$3,834.07
|
| Rate for Payer: Frontpath All Commercial |
$3,831.98
|
| Rate for Payer: Humana ChoiceCare |
$3,597.48
|
| Rate for Payer: Humana Medicare |
$2,124.25
|
| Rate for Payer: Lucent All Commercial |
$2,124.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,748.68
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$3,123.90
|
| Rate for Payer: PHP All Commercial |
$3,158.89
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,624.43
|
| Rate for Payer: Sagamore Health Network All Products |
$3,215.53
|
| Rate for Payer: Signature Care EPO |
$3,457.12
|
| Rate for Payer: Signature Care PPO |
$3,665.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,540.42
|
| Rate for Payer: United Healthcare Commercial |
$3,282.18
|
| Rate for Payer: United Healthcare Medicare |
$1,374.52
|
|
|
HC MESH DUAL PLUS 20X30
|
Facility
IP
|
$6,663.60
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601945
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$4,997.70 |
| Max. Negotiated Rate |
$6,197.15 |
| Rate for Payer: Aetna Commercial |
$5,757.35
|
| Rate for Payer: Cash Price |
$4,131.43
|
| Rate for Payer: Cigna All Commercial |
$5,750.69
|
| Rate for Payer: CORVEL All Commercial |
$6,197.15
|
| Rate for Payer: Coventry All Commercial |
$5,863.97
|
| Rate for Payer: Encore All Commercial |
$6,133.84
|
| Rate for Payer: Frontpath All Commercial |
$6,130.51
|
| Rate for Payer: Humana ChoiceCare |
$5,755.35
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,997.24
|
| Rate for Payer: PHCS All Commercial |
$4,997.70
|
| Rate for Payer: PHP All Commercial |
$5,053.67
|
| Rate for Payer: Sagamore Health Network All Products |
$5,144.30
|
| Rate for Payer: Signature Care EPO |
$5,530.79
|
| Rate for Payer: Signature Care PPO |
$5,863.97
|
| Rate for Payer: United Healthcare Commercial |
$5,250.92
|
|
|
HC MESH DUAL PLUS 20X30
|
Facility
OP
|
$6,663.60
|
|
|
Service Code
|
CPT C1781
|
| Hospital Charge Code |
41601945
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$6,197.15 |
| Rate for Payer: Aetna Commercial |
$5,624.08
|
| Rate for Payer: Aetna Medicare |
$2,198.99
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,198.99
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,826.91
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,165.42
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,528.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,418.89
|
| Rate for Payer: Cash Price |
$4,131.43
|
| Rate for Payer: Cash Price |
$4,131.43
|
| Rate for Payer: Centivo All Commercial |
$3,398.44
|
| Rate for Payer: Cigna All Commercial |
$5,750.69
|
| Rate for Payer: CORVEL All Commercial |
$6,197.15
|
| Rate for Payer: Coventry All Commercial |
$5,863.97
|
| Rate for Payer: Encore All Commercial |
$6,133.84
|
| Rate for Payer: Frontpath All Commercial |
$6,130.51
|
| Rate for Payer: Humana ChoiceCare |
$5,755.35
|
| Rate for Payer: Humana Medicare |
$3,398.44
|
| Rate for Payer: Lucent All Commercial |
$3,398.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$5,997.24
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$4,997.70
|
| Rate for Payer: PHP All Commercial |
$5,053.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,598.80
|
| Rate for Payer: Sagamore Health Network All Products |
$5,144.30
|
| Rate for Payer: Signature Care EPO |
$5,530.79
|
| Rate for Payer: Signature Care PPO |
$5,863.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,664.06
|
| Rate for Payer: United Healthcare Commercial |
$5,250.92
|
| Rate for Payer: United Healthcare Medicare |
$2,198.99
|
|
