|
PHENYLEPHRINE HCL IN 0.9% NACL 1 MG/10 ML (100 MCG/ML) IV SYRG
|
Facility
|
OP
|
$50.54
|
|
|
Service Code
|
HCPCS J2371
|
| Hospital Charge Code |
121306
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.67 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$42.66
|
| Rate for Payer: Aetna Medicare |
$16.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$15.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$29.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$31.59
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$18.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$17.79
|
| Rate for Payer: Cash Price |
$30.32
|
| Rate for Payer: Centivo All Commercial |
$27.49
|
| Rate for Payer: Cigna All Commercial |
$43.62
|
| Rate for Payer: CORVEL All Commercial |
$47.00
|
| Rate for Payer: Coventry All Commercial |
$44.48
|
| Rate for Payer: Encore All Commercial |
$46.52
|
| Rate for Payer: Frontpath All Commercial |
$46.50
|
| Rate for Payer: Humana ChoiceCare |
$43.65
|
| Rate for Payer: Humana Medicare |
$16.17
|
| Rate for Payer: Lucent All Commercial |
$27.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$45.49
|
| Rate for Payer: PHCS All Commercial |
$37.91
|
| Rate for Payer: PHP All Commercial |
$38.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$19.71
|
| Rate for Payer: Sagamore Health Network All Products |
$39.02
|
| Rate for Payer: Signature Care EPO |
$41.95
|
| Rate for Payer: Signature Care PPO |
$44.48
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$42.96
|
| Rate for Payer: United Healthcare Commercial |
$39.83
|
| Rate for Payer: United Healthcare Medicare |
$16.17
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$102.86
|
|
|
Service Code
|
NDC 51672406901
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.89 |
| Max. Negotiated Rate |
$95.66 |
| Rate for Payer: Aetna Commercial |
$86.81
|
| Rate for Payer: Aetna Medicare |
$32.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$31.89
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$59.07
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$64.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$37.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$36.21
|
| Rate for Payer: Cash Price |
$61.71
|
| Rate for Payer: Centivo All Commercial |
$55.95
|
| Rate for Payer: Cigna All Commercial |
$88.77
|
| Rate for Payer: CORVEL All Commercial |
$95.66
|
| Rate for Payer: Coventry All Commercial |
$90.52
|
| Rate for Payer: Encore All Commercial |
$94.68
|
| Rate for Payer: Frontpath All Commercial |
$94.63
|
| Rate for Payer: Humana ChoiceCare |
$88.84
|
| Rate for Payer: Humana Medicare |
$32.91
|
| Rate for Payer: Lucent All Commercial |
$55.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$92.57
|
| Rate for Payer: PHCS All Commercial |
$77.14
|
| Rate for Payer: PHP All Commercial |
$78.01
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.11
|
| Rate for Payer: Sagamore Health Network All Products |
$79.41
|
| Rate for Payer: Signature Care EPO |
$85.37
|
| Rate for Payer: Signature Care PPO |
$90.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$87.43
|
| Rate for Payer: United Healthcare Commercial |
$81.05
|
| Rate for Payer: United Healthcare Medicare |
$32.91
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$102.86
|
|
|
Service Code
|
NDC 51672406901
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$77.14 |
| Max. Negotiated Rate |
$95.66 |
| Rate for Payer: Aetna Commercial |
$88.87
|
| Rate for Payer: Cash Price |
$61.71
|
| Rate for Payer: Cigna All Commercial |
$88.77
|
| Rate for Payer: CORVEL All Commercial |
$95.66
|
| Rate for Payer: Coventry All Commercial |
$90.52
|
| Rate for Payer: Encore All Commercial |
$94.68
|
| Rate for Payer: Frontpath All Commercial |
$94.63
|
| Rate for Payer: Humana ChoiceCare |
$88.84
|
| Rate for Payer: Lutheran Preferred All Commercial |
$92.57
|
| Rate for Payer: PHCS All Commercial |
$77.14
|
| Rate for Payer: PHP All Commercial |
$78.01
|
| Rate for Payer: Sagamore Health Network All Products |
$79.41
|
| Rate for Payer: Signature Care EPO |
$85.37
|
| Rate for Payer: Signature Care PPO |
$90.52
|
| Rate for Payer: United Healthcare Commercial |
$81.05
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSP
|
Facility
|
OP
|
$2.17
|
|
|
Service Code
|
NDC 516724069
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.83
|
| Rate for Payer: Aetna Medicare |
$0.69
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.67
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.76
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Centivo All Commercial |
$1.18
|
| Rate for Payer: Cigna All Commercial |
$1.87
|
| Rate for Payer: CORVEL All Commercial |
$2.02
|
| Rate for Payer: Coventry All Commercial |
$1.91
|
| Rate for Payer: Encore All Commercial |
$2.00
|
| Rate for Payer: Frontpath All Commercial |
$2.00
|
| Rate for Payer: Humana ChoiceCare |
$1.87
|
| Rate for Payer: Humana Medicare |
$0.69
|
| Rate for Payer: Lucent All Commercial |
$1.18
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.95
|
| Rate for Payer: PHCS All Commercial |
$1.63
|
| Rate for Payer: PHP All Commercial |
$1.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.85
|
| Rate for Payer: Sagamore Health Network All Products |
$1.68
|
| Rate for Payer: Signature Care EPO |
$1.80
|
| Rate for Payer: Signature Care PPO |
$1.91
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.84
|
| Rate for Payer: United Healthcare Commercial |
$1.71
|
| Rate for Payer: United Healthcare Medicare |
$0.69
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSP
|
Facility
|
IP
|
$2.17
|
|
|
Service Code
|
NDC 516724069
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.87
|
| Rate for Payer: Cash Price |
$1.30
|
| Rate for Payer: Cigna All Commercial |
$1.87
|
| Rate for Payer: CORVEL All Commercial |
$2.02
|
| Rate for Payer: Coventry All Commercial |
$1.91
|
| Rate for Payer: Encore All Commercial |
$2.00
|
| Rate for Payer: Frontpath All Commercial |
$2.00
|
| Rate for Payer: Humana ChoiceCare |
$1.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.95
|
| Rate for Payer: PHCS All Commercial |
$1.63
|
| Rate for Payer: PHP All Commercial |
$1.65
|
| Rate for Payer: Sagamore Health Network All Products |
$1.68
|
| Rate for Payer: Signature Care EPO |
$1.80
|
| Rate for Payer: Signature Care PPO |
$1.91
|
| Rate for Payer: United Healthcare Commercial |
$1.71
|
|
|
PHENYTOIN SODIUM 50 MG/ML IV SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
6256
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
PHENYTOIN SODIUM 50 MG/ML IV SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1165
|
| Hospital Charge Code |
6256
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP
|
Facility
|
IP
|
$1.30
|
|
|
Service Code
|
NDC 51672411101
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna Commercial |
$1.12
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.21
|
| Rate for Payer: Coventry All Commercial |
$1.15
|
| Rate for Payer: Encore All Commercial |
$1.20
|
| Rate for Payer: Frontpath All Commercial |
$1.20
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.98
|
| Rate for Payer: PHP All Commercial |
$0.99
|
| Rate for Payer: Sagamore Health Network All Products |
$1.01
|
| Rate for Payer: Signature Care EPO |
$1.08
|
| Rate for Payer: Signature Care PPO |
$1.15
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP
|
Facility
|
OP
|
$1.30
|
|
|
Service Code
|
NDC 51672411101
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.40 |
| Max. Negotiated Rate |
$1.21 |
| Rate for Payer: Aetna Commercial |
$1.10
|
| Rate for Payer: Aetna Medicare |
$0.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.81
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.46
|
| Rate for Payer: Cash Price |
$0.78
|
| Rate for Payer: Centivo All Commercial |
$0.71
|
| Rate for Payer: Cigna All Commercial |
$1.12
|
| Rate for Payer: CORVEL All Commercial |
$1.21
|
| Rate for Payer: Coventry All Commercial |
$1.15
|
| Rate for Payer: Encore All Commercial |
$1.20
|
| Rate for Payer: Frontpath All Commercial |
$1.20
|
| Rate for Payer: Humana ChoiceCare |
$1.12
|
| Rate for Payer: Humana Medicare |
$0.42
|
| Rate for Payer: Lucent All Commercial |
$0.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.17
|
| Rate for Payer: PHCS All Commercial |
$0.98
|
| Rate for Payer: PHP All Commercial |
$0.99
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.01
|
| Rate for Payer: Signature Care EPO |
$1.08
|
| Rate for Payer: Signature Care PPO |
$1.15
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.11
|
| Rate for Payer: United Healthcare Commercial |
$1.03
|
| Rate for Payer: United Healthcare Medicare |
$0.42
|
|
|
PHMB 0.1% (AFFINITY) 1.5 X 1.5 WOUND MATRIX
|
Facility
|
OP
|
$5,400.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800618
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$5,022.00 |
| Rate for Payer: Aetna Commercial |
$4,557.60
|
| Rate for Payer: Aetna Medicare |
$1,728.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,674.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,101.22
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,375.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,987.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,900.80
|
| Rate for Payer: Cash Price |
$3,240.00
|
| Rate for Payer: Cash Price |
$3,240.00
|
| Rate for Payer: Centivo All Commercial |
$2,937.60
|
| Rate for Payer: Cigna All Commercial |
$4,660.20
|
| Rate for Payer: CORVEL All Commercial |
$5,022.00
|
| Rate for Payer: Coventry All Commercial |
$4,752.00
|
| Rate for Payer: Encore All Commercial |
$4,970.70
|
| Rate for Payer: Frontpath All Commercial |
$4,968.00
|
| Rate for Payer: Humana ChoiceCare |
$4,663.98
|
| Rate for Payer: Humana Medicare |
$1,728.00
|
| Rate for Payer: Lucent All Commercial |
$2,937.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,860.00
|
| Rate for Payer: Managed Health Services Medicaid |
$47.71
|
| Rate for Payer: MDWise Medicaid |
$47.71
|
| Rate for Payer: PHCS All Commercial |
$4,050.00
|
| Rate for Payer: PHP All Commercial |
$4,095.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,106.00
|
| Rate for Payer: Sagamore Health Network All Products |
$4,168.80
|
| Rate for Payer: Signature Care EPO |
$4,482.00
|
| Rate for Payer: Signature Care PPO |
$4,752.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,590.00
|
| Rate for Payer: United Healthcare Commercial |
$4,255.20
|
| Rate for Payer: United Healthcare Medicare |
$1,728.00
|
|
|
PHMB 0.1% (AFFINITY) 1.5 X 1.5 WOUND MATRIX
|
Facility
|
IP
|
$5,400.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800618
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4,050.00 |
| Max. Negotiated Rate |
$5,022.00 |
| Rate for Payer: Aetna Commercial |
$4,665.60
|
| Rate for Payer: Cash Price |
$3,240.00
|
| Rate for Payer: Cigna All Commercial |
$4,660.20
|
| Rate for Payer: CORVEL All Commercial |
$5,022.00
|
| Rate for Payer: Coventry All Commercial |
$4,752.00
|
| Rate for Payer: Encore All Commercial |
$4,970.70
|
| Rate for Payer: Frontpath All Commercial |
$4,968.00
|
| Rate for Payer: Humana ChoiceCare |
$4,663.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,860.00
|
| Rate for Payer: PHCS All Commercial |
$4,050.00
|
| Rate for Payer: PHP All Commercial |
$4,095.36
|
| Rate for Payer: Sagamore Health Network All Products |
$4,168.80
|
| Rate for Payer: Signature Care EPO |
$4,482.00
|
| Rate for Payer: Signature Care PPO |
$4,752.00
|
| Rate for Payer: United Healthcare Commercial |
$4,255.20
|
|
|
PHMB 0.1% (AFFINITY) 2.5 X 2.5 WOUND MATRIX
|
Facility
|
OP
|
$7,200.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$6,696.00 |
| Rate for Payer: Aetna Commercial |
$6,076.80
|
| Rate for Payer: Aetna Medicare |
$2,304.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,232.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4,134.96
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,500.72
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,649.60
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,534.40
|
| Rate for Payer: Cash Price |
$4,320.00
|
| Rate for Payer: Cash Price |
$4,320.00
|
| Rate for Payer: Centivo All Commercial |
$3,916.80
|
| Rate for Payer: Cigna All Commercial |
$6,213.60
|
| Rate for Payer: CORVEL All Commercial |
$6,696.00
|
| Rate for Payer: Coventry All Commercial |
$6,336.00
|
| Rate for Payer: Encore All Commercial |
$6,627.60
|
| Rate for Payer: Frontpath All Commercial |
$6,624.00
|
| Rate for Payer: Humana ChoiceCare |
$6,218.64
|
| Rate for Payer: Humana Medicare |
$2,304.00
|
| Rate for Payer: Lucent All Commercial |
$3,916.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,480.00
|
| Rate for Payer: Managed Health Services Medicaid |
$47.71
|
| Rate for Payer: MDWise Medicaid |
$47.71
|
| Rate for Payer: PHCS All Commercial |
$5,400.00
|
| Rate for Payer: PHP All Commercial |
$5,460.48
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,808.00
|
| Rate for Payer: Sagamore Health Network All Products |
$5,558.40
|
| Rate for Payer: Signature Care EPO |
$5,976.00
|
| Rate for Payer: Signature Care PPO |
$6,336.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,120.00
|
| Rate for Payer: United Healthcare Commercial |
$5,673.60
|
| Rate for Payer: United Healthcare Medicare |
$2,304.00
|
|
|
PHMB 0.1% (AFFINITY) 2.5 X 2.5 WOUND MATRIX
|
Facility
|
IP
|
$7,200.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800617
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,400.00 |
| Max. Negotiated Rate |
$6,696.00 |
| Rate for Payer: Aetna Commercial |
$6,220.80
|
| Rate for Payer: Cash Price |
$4,320.00
|
| Rate for Payer: Cigna All Commercial |
$6,213.60
|
| Rate for Payer: CORVEL All Commercial |
$6,696.00
|
| Rate for Payer: Coventry All Commercial |
$6,336.00
|
| Rate for Payer: Encore All Commercial |
$6,627.60
|
| Rate for Payer: Frontpath All Commercial |
$6,624.00
|
| Rate for Payer: Humana ChoiceCare |
$6,218.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,480.00
|
| Rate for Payer: PHCS All Commercial |
$5,400.00
|
| Rate for Payer: PHP All Commercial |
$5,460.48
|
| Rate for Payer: Sagamore Health Network All Products |
$5,558.40
|
| Rate for Payer: Signature Care EPO |
$5,976.00
|
| Rate for Payer: Signature Care PPO |
$6,336.00
|
| Rate for Payer: United Healthcare Commercial |
$5,673.60
|
|
|
PHMB 0.1% (PURAPLY AM) 1.6 SQ CM DISC WOUND MATRIX
|
Facility
|
IP
|
$1,800.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800614
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,350.00 |
| Max. Negotiated Rate |
$1,674.00 |
| Rate for Payer: Aetna Commercial |
$1,555.20
|
| Rate for Payer: Cash Price |
$1,080.00
|
| Rate for Payer: Cigna All Commercial |
$1,553.40
|
| Rate for Payer: CORVEL All Commercial |
$1,674.00
|
| Rate for Payer: Coventry All Commercial |
$1,584.00
|
| Rate for Payer: Encore All Commercial |
$1,656.90
|
| Rate for Payer: Frontpath All Commercial |
$1,656.00
|
| Rate for Payer: Humana ChoiceCare |
$1,554.66
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,620.00
|
| Rate for Payer: PHCS All Commercial |
$1,350.00
|
| Rate for Payer: PHP All Commercial |
$1,365.12
|
| Rate for Payer: Sagamore Health Network All Products |
$1,389.60
|
| Rate for Payer: Signature Care EPO |
$1,494.00
|
| Rate for Payer: Signature Care PPO |
$1,584.00
|
| Rate for Payer: United Healthcare Commercial |
$1,418.40
|
|
|
PHMB 0.1% (PURAPLY AM) 1.6 SQ CM DISC WOUND MATRIX
|
Facility
|
OP
|
$1,800.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800614
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$1,674.00 |
| Rate for Payer: Aetna Commercial |
$1,519.20
|
| Rate for Payer: Aetna Medicare |
$576.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$558.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,033.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,125.18
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$662.40
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$633.60
|
| Rate for Payer: Cash Price |
$1,080.00
|
| Rate for Payer: Cash Price |
$1,080.00
|
| Rate for Payer: Centivo All Commercial |
$979.20
|
| Rate for Payer: Cigna All Commercial |
$1,553.40
|
| Rate for Payer: CORVEL All Commercial |
$1,674.00
|
| Rate for Payer: Coventry All Commercial |
$1,584.00
|
| Rate for Payer: Encore All Commercial |
$1,656.90
|
| Rate for Payer: Frontpath All Commercial |
$1,656.00
|
| Rate for Payer: Humana ChoiceCare |
$1,554.66
|
| Rate for Payer: Humana Medicare |
$576.00
|
| Rate for Payer: Lucent All Commercial |
$979.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,620.00
|
| Rate for Payer: Managed Health Services Medicaid |
$47.71
|
| Rate for Payer: MDWise Medicaid |
$47.71
|
| Rate for Payer: PHCS All Commercial |
$1,350.00
|
| Rate for Payer: PHP All Commercial |
$1,365.12
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$702.00
|
| Rate for Payer: Sagamore Health Network All Products |
$1,389.60
|
| Rate for Payer: Signature Care EPO |
$1,494.00
|
| Rate for Payer: Signature Care PPO |
$1,584.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,530.00
|
| Rate for Payer: United Healthcare Commercial |
$1,418.40
|
| Rate for Payer: United Healthcare Medicare |
$576.00
|
|
|
PHMB 0.1% (PURAPLY AM) 2 X 2 WOUND MATRIX
|
Facility
|
IP
|
$3,000.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800591
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,250.00 |
| Max. Negotiated Rate |
$2,790.00 |
| Rate for Payer: Aetna Commercial |
$2,592.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cigna All Commercial |
$2,589.00
|
| Rate for Payer: CORVEL All Commercial |
$2,790.00
|
| Rate for Payer: Coventry All Commercial |
$2,640.00
|
| Rate for Payer: Encore All Commercial |
$2,761.50
|
| Rate for Payer: Frontpath All Commercial |
$2,760.00
|
| Rate for Payer: Humana ChoiceCare |
$2,591.10
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,700.00
|
| Rate for Payer: PHCS All Commercial |
$2,250.00
|
| Rate for Payer: PHP All Commercial |
$2,275.20
|
| Rate for Payer: Sagamore Health Network All Products |
$2,316.00
|
| Rate for Payer: Signature Care EPO |
$2,490.00
|
| Rate for Payer: Signature Care PPO |
$2,640.00
|
| Rate for Payer: United Healthcare Commercial |
$2,364.00
|
|
|
PHMB 0.1% (PURAPLY AM) 2 X 2 WOUND MATRIX
|
Facility
|
OP
|
$3,000.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800591
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$2,790.00 |
| Rate for Payer: Aetna Commercial |
$2,532.00
|
| Rate for Payer: Aetna Medicare |
$960.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$930.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,722.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,875.30
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,104.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,056.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Cash Price |
$1,800.00
|
| Rate for Payer: Centivo All Commercial |
$1,632.00
|
| Rate for Payer: Cigna All Commercial |
$2,589.00
|
| Rate for Payer: CORVEL All Commercial |
$2,790.00
|
| Rate for Payer: Coventry All Commercial |
$2,640.00
|
| Rate for Payer: Encore All Commercial |
$2,761.50
|
| Rate for Payer: Frontpath All Commercial |
$2,760.00
|
| Rate for Payer: Humana ChoiceCare |
$2,591.10
|
| Rate for Payer: Humana Medicare |
$960.00
|
| Rate for Payer: Lucent All Commercial |
$1,632.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,700.00
|
| Rate for Payer: Managed Health Services Medicaid |
$47.71
|
| Rate for Payer: MDWise Medicaid |
$47.71
|
| Rate for Payer: PHCS All Commercial |
$2,250.00
|
| Rate for Payer: PHP All Commercial |
$2,275.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,170.00
|
| Rate for Payer: Sagamore Health Network All Products |
$2,316.00
|
| Rate for Payer: Signature Care EPO |
$2,490.00
|
| Rate for Payer: Signature Care PPO |
$2,640.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,550.00
|
| Rate for Payer: United Healthcare Commercial |
$2,364.00
|
| Rate for Payer: United Healthcare Medicare |
$960.00
|
|
|
PHMB 0.1% (PURAPLY AM) 2 X 4 WOUND MATRIX
|
Facility
|
IP
|
$3,600.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800577
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,700.00 |
| Max. Negotiated Rate |
$3,348.00 |
| Rate for Payer: Aetna Commercial |
$3,110.40
|
| Rate for Payer: Cash Price |
$2,160.00
|
| Rate for Payer: Cigna All Commercial |
$3,106.80
|
| Rate for Payer: CORVEL All Commercial |
$3,348.00
|
| Rate for Payer: Coventry All Commercial |
$3,168.00
|
| Rate for Payer: Encore All Commercial |
$3,313.80
|
| Rate for Payer: Frontpath All Commercial |
$3,312.00
|
| Rate for Payer: Humana ChoiceCare |
$3,109.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,240.00
|
| Rate for Payer: PHCS All Commercial |
$2,700.00
|
| Rate for Payer: PHP All Commercial |
$2,730.24
|
| Rate for Payer: Sagamore Health Network All Products |
$2,779.20
|
| Rate for Payer: Signature Care EPO |
$2,988.00
|
| Rate for Payer: Signature Care PPO |
$3,168.00
|
| Rate for Payer: United Healthcare Commercial |
$2,836.80
|
|
|
PHMB 0.1% (PURAPLY AM) 2 X 4 WOUND MATRIX
|
Facility
|
OP
|
$3,600.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800577
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$3,348.00 |
| Rate for Payer: Aetna Commercial |
$3,038.40
|
| Rate for Payer: Aetna Medicare |
$1,152.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,116.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$2,067.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,250.36
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,324.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,267.20
|
| Rate for Payer: Cash Price |
$2,160.00
|
| Rate for Payer: Cash Price |
$2,160.00
|
| Rate for Payer: Centivo All Commercial |
$1,958.40
|
| Rate for Payer: Cigna All Commercial |
$3,106.80
|
| Rate for Payer: CORVEL All Commercial |
$3,348.00
|
| Rate for Payer: Coventry All Commercial |
$3,168.00
|
| Rate for Payer: Encore All Commercial |
$3,313.80
|
| Rate for Payer: Frontpath All Commercial |
$3,312.00
|
| Rate for Payer: Humana ChoiceCare |
$3,109.32
|
| Rate for Payer: Humana Medicare |
$1,152.00
|
| Rate for Payer: Lucent All Commercial |
$1,958.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,240.00
|
| Rate for Payer: Managed Health Services Medicaid |
$47.71
|
| Rate for Payer: MDWise Medicaid |
$47.71
|
| Rate for Payer: PHCS All Commercial |
$2,700.00
|
| Rate for Payer: PHP All Commercial |
$2,730.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,404.00
|
| Rate for Payer: Sagamore Health Network All Products |
$2,779.20
|
| Rate for Payer: Signature Care EPO |
$2,988.00
|
| Rate for Payer: Signature Care PPO |
$3,168.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,060.00
|
| Rate for Payer: United Healthcare Commercial |
$2,836.80
|
| Rate for Payer: United Healthcare Medicare |
$1,152.00
|
|
|
PHMB 0.1% (PURAPLY AM) 3 X 4 WOUND MATRIX
|
Facility
|
IP
|
$5,280.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800592
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,960.00 |
| Max. Negotiated Rate |
$4,910.40 |
| Rate for Payer: Aetna Commercial |
$4,561.92
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Cigna All Commercial |
$4,556.64
|
| Rate for Payer: CORVEL All Commercial |
$4,910.40
|
| Rate for Payer: Coventry All Commercial |
$4,646.40
|
| Rate for Payer: Encore All Commercial |
$4,860.24
|
| Rate for Payer: Frontpath All Commercial |
$4,857.60
|
| Rate for Payer: Humana ChoiceCare |
$4,560.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,752.00
|
| Rate for Payer: PHCS All Commercial |
$3,960.00
|
| Rate for Payer: PHP All Commercial |
$4,004.35
|
| Rate for Payer: Sagamore Health Network All Products |
$4,076.16
|
| Rate for Payer: Signature Care EPO |
$4,382.40
|
| Rate for Payer: Signature Care PPO |
$4,646.40
|
| Rate for Payer: United Healthcare Commercial |
$4,160.64
|
|
|
PHMB 0.1% (PURAPLY AM) 3 X 4 WOUND MATRIX
|
Facility
|
OP
|
$5,280.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800592
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$4,910.40 |
| Rate for Payer: Aetna Commercial |
$4,456.32
|
| Rate for Payer: Aetna Medicare |
$1,689.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,636.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,032.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,300.53
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,943.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,858.56
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Centivo All Commercial |
$2,872.32
|
| Rate for Payer: Cigna All Commercial |
$4,556.64
|
| Rate for Payer: CORVEL All Commercial |
$4,910.40
|
| Rate for Payer: Coventry All Commercial |
$4,646.40
|
| Rate for Payer: Encore All Commercial |
$4,860.24
|
| Rate for Payer: Frontpath All Commercial |
$4,857.60
|
| Rate for Payer: Humana ChoiceCare |
$4,560.34
|
| Rate for Payer: Humana Medicare |
$1,689.60
|
| Rate for Payer: Lucent All Commercial |
$2,872.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,752.00
|
| Rate for Payer: Managed Health Services Medicaid |
$47.71
|
| Rate for Payer: MDWise Medicaid |
$47.71
|
| Rate for Payer: PHCS All Commercial |
$3,960.00
|
| Rate for Payer: PHP All Commercial |
$4,004.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,059.20
|
| Rate for Payer: Sagamore Health Network All Products |
$4,076.16
|
| Rate for Payer: Signature Care EPO |
$4,382.40
|
| Rate for Payer: Signature Care PPO |
$4,646.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,488.00
|
| Rate for Payer: United Healthcare Commercial |
$4,160.64
|
| Rate for Payer: United Healthcare Medicare |
$1,689.60
|
|
|
PHMB 0.1% (PURAPLY AM) 3 X 4 WOUND MATRIX EXTRA FENESTRATED
|
Facility
|
IP
|
$5,280.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800594
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3,960.00 |
| Max. Negotiated Rate |
$4,910.40 |
| Rate for Payer: Aetna Commercial |
$4,561.92
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Cigna All Commercial |
$4,556.64
|
| Rate for Payer: CORVEL All Commercial |
$4,910.40
|
| Rate for Payer: Coventry All Commercial |
$4,646.40
|
| Rate for Payer: Encore All Commercial |
$4,860.24
|
| Rate for Payer: Frontpath All Commercial |
$4,857.60
|
| Rate for Payer: Humana ChoiceCare |
$4,560.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,752.00
|
| Rate for Payer: PHCS All Commercial |
$3,960.00
|
| Rate for Payer: PHP All Commercial |
$4,004.35
|
| Rate for Payer: Sagamore Health Network All Products |
$4,076.16
|
| Rate for Payer: Signature Care EPO |
$4,382.40
|
| Rate for Payer: Signature Care PPO |
$4,646.40
|
| Rate for Payer: United Healthcare Commercial |
$4,160.64
|
|
|
PHMB 0.1% (PURAPLY AM) 3 X 4 WOUND MATRIX EXTRA FENESTRATED
|
Facility
|
OP
|
$5,280.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800594
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$4,910.40 |
| Rate for Payer: Aetna Commercial |
$4,456.32
|
| Rate for Payer: Aetna Medicare |
$1,689.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,636.80
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,032.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,300.53
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,943.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,858.56
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Cash Price |
$3,168.00
|
| Rate for Payer: Centivo All Commercial |
$2,872.32
|
| Rate for Payer: Cigna All Commercial |
$4,556.64
|
| Rate for Payer: CORVEL All Commercial |
$4,910.40
|
| Rate for Payer: Coventry All Commercial |
$4,646.40
|
| Rate for Payer: Encore All Commercial |
$4,860.24
|
| Rate for Payer: Frontpath All Commercial |
$4,857.60
|
| Rate for Payer: Humana ChoiceCare |
$4,560.34
|
| Rate for Payer: Humana Medicare |
$1,689.60
|
| Rate for Payer: Lucent All Commercial |
$2,872.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,752.00
|
| Rate for Payer: Managed Health Services Medicaid |
$47.71
|
| Rate for Payer: MDWise Medicaid |
$47.71
|
| Rate for Payer: PHCS All Commercial |
$3,960.00
|
| Rate for Payer: PHP All Commercial |
$4,004.35
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,059.20
|
| Rate for Payer: Sagamore Health Network All Products |
$4,076.16
|
| Rate for Payer: Signature Care EPO |
$4,382.40
|
| Rate for Payer: Signature Care PPO |
$4,646.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,488.00
|
| Rate for Payer: United Healthcare Commercial |
$4,160.64
|
| Rate for Payer: United Healthcare Medicare |
$1,689.60
|
|
|
PHMB 0.1% (PURAPLY AM) 4 X 4 WOUND MATRIX
|
Facility
|
IP
|
$6,912.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800593
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5,184.00 |
| Max. Negotiated Rate |
$6,428.16 |
| Rate for Payer: Aetna Commercial |
$5,971.97
|
| Rate for Payer: Cash Price |
$4,147.20
|
| Rate for Payer: Cigna All Commercial |
$5,965.06
|
| Rate for Payer: CORVEL All Commercial |
$6,428.16
|
| Rate for Payer: Coventry All Commercial |
$6,082.56
|
| Rate for Payer: Encore All Commercial |
$6,362.50
|
| Rate for Payer: Frontpath All Commercial |
$6,359.04
|
| Rate for Payer: Humana ChoiceCare |
$5,969.89
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,220.80
|
| Rate for Payer: PHCS All Commercial |
$5,184.00
|
| Rate for Payer: PHP All Commercial |
$5,242.06
|
| Rate for Payer: Sagamore Health Network All Products |
$5,336.06
|
| Rate for Payer: Signature Care EPO |
$5,736.96
|
| Rate for Payer: Signature Care PPO |
$6,082.56
|
| Rate for Payer: United Healthcare Commercial |
$5,446.66
|
|
|
PHMB 0.1% (PURAPLY AM) 4 X 4 WOUND MATRIX
|
Facility
|
OP
|
$6,912.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800593
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.71 |
| Max. Negotiated Rate |
$6,428.16 |
| Rate for Payer: Aetna Commercial |
$5,833.73
|
| Rate for Payer: Aetna Medicare |
$2,211.84
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$47.71
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,142.72
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$3,969.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,320.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$47.71
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,543.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,433.02
|
| Rate for Payer: Cash Price |
$4,147.20
|
| Rate for Payer: Cash Price |
$4,147.20
|
| Rate for Payer: Centivo All Commercial |
$3,760.13
|
| Rate for Payer: Cigna All Commercial |
$5,965.06
|
| Rate for Payer: CORVEL All Commercial |
$6,428.16
|
| Rate for Payer: Coventry All Commercial |
$6,082.56
|
| Rate for Payer: Encore All Commercial |
$6,362.50
|
| Rate for Payer: Frontpath All Commercial |
$6,359.04
|
| Rate for Payer: Humana ChoiceCare |
$5,969.89
|
| Rate for Payer: Humana Medicare |
$2,211.84
|
| Rate for Payer: Lucent All Commercial |
$3,760.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,220.80
|
| Rate for Payer: Managed Health Services Medicaid |
$47.71
|
| Rate for Payer: MDWise Medicaid |
$47.71
|
| Rate for Payer: PHCS All Commercial |
$5,184.00
|
| Rate for Payer: PHP All Commercial |
$5,242.06
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2,695.68
|
| Rate for Payer: Sagamore Health Network All Products |
$5,336.06
|
| Rate for Payer: Signature Care EPO |
$5,736.96
|
| Rate for Payer: Signature Care PPO |
$6,082.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,875.20
|
| Rate for Payer: United Healthcare Commercial |
$5,446.66
|
| Rate for Payer: United Healthcare Medicare |
$2,211.84
|
|
