|
HC Z 3.5 PLATE 5-H
|
Facility
OP
|
$1,055.45
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41606886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$348.30 |
| Max. Negotiated Rate |
$981.57 |
| Rate for Payer: Aetna Commercial |
$890.80
|
| Rate for Payer: Aetna Medicare |
$348.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$348.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$606.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$659.76
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$400.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$383.13
|
| Rate for Payer: Cash Price |
$654.38
|
| Rate for Payer: Cash Price |
$654.38
|
| Rate for Payer: Centivo All Commercial |
$538.28
|
| Rate for Payer: Cigna All Commercial |
$910.85
|
| Rate for Payer: CORVEL All Commercial |
$981.57
|
| Rate for Payer: Coventry All Commercial |
$928.80
|
| Rate for Payer: Encore All Commercial |
$971.54
|
| Rate for Payer: Frontpath All Commercial |
$971.01
|
| Rate for Payer: Humana ChoiceCare |
$911.59
|
| Rate for Payer: Humana Medicare |
$538.28
|
| Rate for Payer: Lucent All Commercial |
$538.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$949.90
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$791.59
|
| Rate for Payer: PHP All Commercial |
$800.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$411.63
|
| Rate for Payer: Sagamore Health Network All Products |
$814.81
|
| Rate for Payer: Signature Care EPO |
$876.02
|
| Rate for Payer: Signature Care PPO |
$928.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$897.13
|
| Rate for Payer: United Healthcare Commercial |
$831.69
|
| Rate for Payer: United Healthcare Medicare |
$348.30
|
|
|
HC Z 3.5 PLATE 5-H
|
Facility
IP
|
$1,055.45
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41606886
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$791.59 |
| Max. Negotiated Rate |
$981.57 |
| Rate for Payer: Aetna Commercial |
$911.91
|
| Rate for Payer: Cash Price |
$654.38
|
| Rate for Payer: Cigna All Commercial |
$910.85
|
| Rate for Payer: CORVEL All Commercial |
$981.57
|
| Rate for Payer: Coventry All Commercial |
$928.80
|
| Rate for Payer: Encore All Commercial |
$971.54
|
| Rate for Payer: Frontpath All Commercial |
$971.01
|
| Rate for Payer: Humana ChoiceCare |
$911.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$949.90
|
| Rate for Payer: PHCS All Commercial |
$791.59
|
| Rate for Payer: PHP All Commercial |
$800.45
|
| Rate for Payer: Sagamore Health Network All Products |
$814.81
|
| Rate for Payer: Signature Care EPO |
$876.02
|
| Rate for Payer: Signature Care PPO |
$928.80
|
| Rate for Payer: United Healthcare Commercial |
$831.69
|
|
|
HC Z 3.5 PLATE 6-H
|
Facility
OP
|
$1,055.45
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41606887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$348.30 |
| Max. Negotiated Rate |
$981.57 |
| Rate for Payer: Aetna Commercial |
$890.80
|
| Rate for Payer: Aetna Medicare |
$348.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$348.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$606.14
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$659.76
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$400.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$383.13
|
| Rate for Payer: Cash Price |
$654.38
|
| Rate for Payer: Cash Price |
$654.38
|
| Rate for Payer: Centivo All Commercial |
$538.28
|
| Rate for Payer: Cigna All Commercial |
$910.85
|
| Rate for Payer: CORVEL All Commercial |
$981.57
|
| Rate for Payer: Coventry All Commercial |
$928.80
|
| Rate for Payer: Encore All Commercial |
$971.54
|
| Rate for Payer: Frontpath All Commercial |
$971.01
|
| Rate for Payer: Humana ChoiceCare |
$911.59
|
| Rate for Payer: Humana Medicare |
$538.28
|
| Rate for Payer: Lucent All Commercial |
$538.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$949.90
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$791.59
|
| Rate for Payer: PHP All Commercial |
$800.45
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$411.63
|
| Rate for Payer: Sagamore Health Network All Products |
$814.81
|
| Rate for Payer: Signature Care EPO |
$876.02
|
| Rate for Payer: Signature Care PPO |
$928.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$897.13
|
| Rate for Payer: United Healthcare Commercial |
$831.69
|
| Rate for Payer: United Healthcare Medicare |
$348.30
|
|
|
HC Z 3.5 PLATE 6-H
|
Facility
IP
|
$1,055.45
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41606887
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$791.59 |
| Max. Negotiated Rate |
$981.57 |
| Rate for Payer: Aetna Commercial |
$911.91
|
| Rate for Payer: Cash Price |
$654.38
|
| Rate for Payer: Cigna All Commercial |
$910.85
|
| Rate for Payer: CORVEL All Commercial |
$981.57
|
| Rate for Payer: Coventry All Commercial |
$928.80
|
| Rate for Payer: Encore All Commercial |
$971.54
|
| Rate for Payer: Frontpath All Commercial |
$971.01
|
| Rate for Payer: Humana ChoiceCare |
$911.59
|
| Rate for Payer: Lutheran Preferred All Commercial |
$949.90
|
| Rate for Payer: PHCS All Commercial |
$791.59
|
| Rate for Payer: PHP All Commercial |
$800.45
|
| Rate for Payer: Sagamore Health Network All Products |
$814.81
|
| Rate for Payer: Signature Care EPO |
$876.02
|
| Rate for Payer: Signature Care PPO |
$928.80
|
| Rate for Payer: United Healthcare Commercial |
$831.69
|
|
|
HC Z 3.5 PLATE 7-H
|
Facility
OP
|
$1,111.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41606888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$366.63 |
| Max. Negotiated Rate |
$1,033.23 |
| Rate for Payer: Aetna Commercial |
$937.68
|
| Rate for Payer: Aetna Medicare |
$366.63
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$366.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$638.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$694.49
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$421.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$403.29
|
| Rate for Payer: Cash Price |
$688.82
|
| Rate for Payer: Cash Price |
$688.82
|
| Rate for Payer: Centivo All Commercial |
$566.61
|
| Rate for Payer: Cigna All Commercial |
$958.79
|
| Rate for Payer: CORVEL All Commercial |
$1,033.23
|
| Rate for Payer: Coventry All Commercial |
$977.68
|
| Rate for Payer: Encore All Commercial |
$1,022.68
|
| Rate for Payer: Frontpath All Commercial |
$1,022.12
|
| Rate for Payer: Humana ChoiceCare |
$959.57
|
| Rate for Payer: Humana Medicare |
$566.61
|
| Rate for Payer: Lucent All Commercial |
$566.61
|
| Rate for Payer: Lutheran Preferred All Commercial |
$999.90
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$833.25
|
| Rate for Payer: PHP All Commercial |
$842.58
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$433.29
|
| Rate for Payer: Sagamore Health Network All Products |
$857.69
|
| Rate for Payer: Signature Care EPO |
$922.13
|
| Rate for Payer: Signature Care PPO |
$977.68
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$944.35
|
| Rate for Payer: United Healthcare Commercial |
$875.47
|
| Rate for Payer: United Healthcare Medicare |
$366.63
|
|
|
HC Z 3.5 PLATE 7-H
|
Facility
IP
|
$1,111.00
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41606888
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$833.25 |
| Max. Negotiated Rate |
$1,033.23 |
| Rate for Payer: Aetna Commercial |
$959.90
|
| Rate for Payer: Cash Price |
$688.82
|
| Rate for Payer: Cigna All Commercial |
$958.79
|
| Rate for Payer: CORVEL All Commercial |
$1,033.23
|
| Rate for Payer: Coventry All Commercial |
$977.68
|
| Rate for Payer: Encore All Commercial |
$1,022.68
|
| Rate for Payer: Frontpath All Commercial |
$1,022.12
|
| Rate for Payer: Humana ChoiceCare |
$959.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$999.90
|
| Rate for Payer: PHCS All Commercial |
$833.25
|
| Rate for Payer: PHP All Commercial |
$842.58
|
| Rate for Payer: Sagamore Health Network All Products |
$857.69
|
| Rate for Payer: Signature Care EPO |
$922.13
|
| Rate for Payer: Signature Care PPO |
$977.68
|
| Rate for Payer: United Healthcare Commercial |
$875.47
|
|
|
HC Z 3.5 PLATE 8-H
|
Facility
OP
|
$1,166.55
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41606889
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$384.96 |
| Max. Negotiated Rate |
$1,084.89 |
| Rate for Payer: Aetna Commercial |
$984.57
|
| Rate for Payer: Aetna Medicare |
$384.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$384.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$669.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$729.21
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$442.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$423.46
|
| Rate for Payer: Cash Price |
$723.26
|
| Rate for Payer: Cash Price |
$723.26
|
| Rate for Payer: Centivo All Commercial |
$594.94
|
| Rate for Payer: Cigna All Commercial |
$1,006.73
|
| Rate for Payer: CORVEL All Commercial |
$1,084.89
|
| Rate for Payer: Coventry All Commercial |
$1,026.56
|
| Rate for Payer: Encore All Commercial |
$1,073.81
|
| Rate for Payer: Frontpath All Commercial |
$1,073.23
|
| Rate for Payer: Humana ChoiceCare |
$1,007.55
|
| Rate for Payer: Humana Medicare |
$594.94
|
| Rate for Payer: Lucent All Commercial |
$594.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,049.90
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$874.91
|
| Rate for Payer: PHP All Commercial |
$884.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$454.95
|
| Rate for Payer: Sagamore Health Network All Products |
$900.58
|
| Rate for Payer: Signature Care EPO |
$968.24
|
| Rate for Payer: Signature Care PPO |
$1,026.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$991.57
|
| Rate for Payer: United Healthcare Commercial |
$919.24
|
| Rate for Payer: United Healthcare Medicare |
$384.96
|
|
|
HC Z 3.5 PLATE 8-H
|
Facility
IP
|
$1,166.55
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41606889
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$874.91 |
| Max. Negotiated Rate |
$1,084.89 |
| Rate for Payer: Aetna Commercial |
$1,007.90
|
| Rate for Payer: Cash Price |
$723.26
|
| Rate for Payer: Cigna All Commercial |
$1,006.73
|
| Rate for Payer: CORVEL All Commercial |
$1,084.89
|
| Rate for Payer: Coventry All Commercial |
$1,026.56
|
| Rate for Payer: Encore All Commercial |
$1,073.81
|
| Rate for Payer: Frontpath All Commercial |
$1,073.23
|
| Rate for Payer: Humana ChoiceCare |
$1,007.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,049.90
|
| Rate for Payer: PHCS All Commercial |
$874.91
|
| Rate for Payer: PHP All Commercial |
$884.71
|
| Rate for Payer: Sagamore Health Network All Products |
$900.58
|
| Rate for Payer: Signature Care EPO |
$968.24
|
| Rate for Payer: Signature Care PPO |
$1,026.56
|
| Rate for Payer: United Healthcare Commercial |
$919.24
|
|
|
HC Z 3.5 PLATE 9-H
|
Facility
OP
|
$1,166.55
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41606890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$384.96 |
| Max. Negotiated Rate |
$1,084.89 |
| Rate for Payer: Aetna Commercial |
$984.57
|
| Rate for Payer: Aetna Medicare |
$384.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$384.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$669.95
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$729.21
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$442.71
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$423.46
|
| Rate for Payer: Cash Price |
$723.26
|
| Rate for Payer: Cash Price |
$723.26
|
| Rate for Payer: Centivo All Commercial |
$594.94
|
| Rate for Payer: Cigna All Commercial |
$1,006.73
|
| Rate for Payer: CORVEL All Commercial |
$1,084.89
|
| Rate for Payer: Coventry All Commercial |
$1,026.56
|
| Rate for Payer: Encore All Commercial |
$1,073.81
|
| Rate for Payer: Frontpath All Commercial |
$1,073.23
|
| Rate for Payer: Humana ChoiceCare |
$1,007.55
|
| Rate for Payer: Humana Medicare |
$594.94
|
| Rate for Payer: Lucent All Commercial |
$594.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,049.90
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$874.91
|
| Rate for Payer: PHP All Commercial |
$884.71
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$454.95
|
| Rate for Payer: Sagamore Health Network All Products |
$900.58
|
| Rate for Payer: Signature Care EPO |
$968.24
|
| Rate for Payer: Signature Care PPO |
$1,026.56
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$991.57
|
| Rate for Payer: United Healthcare Commercial |
$919.24
|
| Rate for Payer: United Healthcare Medicare |
$384.96
|
|
|
HC Z 3.5 PLATE 9-H
|
Facility
IP
|
$1,166.55
|
|
|
Service Code
|
CPT C1713
|
| Hospital Charge Code |
41606890
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$874.91 |
| Max. Negotiated Rate |
$1,084.89 |
| Rate for Payer: Aetna Commercial |
$1,007.90
|
| Rate for Payer: Cash Price |
$723.26
|
| Rate for Payer: Cigna All Commercial |
$1,006.73
|
| Rate for Payer: CORVEL All Commercial |
$1,084.89
|
| Rate for Payer: Coventry All Commercial |
$1,026.56
|
| Rate for Payer: Encore All Commercial |
$1,073.81
|
| Rate for Payer: Frontpath All Commercial |
$1,073.23
|
| Rate for Payer: Humana ChoiceCare |
$1,007.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,049.90
|
| Rate for Payer: PHCS All Commercial |
$874.91
|
| Rate for Payer: PHP All Commercial |
$884.71
|
| Rate for Payer: Sagamore Health Network All Products |
$900.58
|
| Rate for Payer: Signature Care EPO |
$968.24
|
| Rate for Payer: Signature Care PPO |
$1,026.56
|
| Rate for Payer: United Healthcare Commercial |
$919.24
|
|
|
HC Z 38MM SHELL OD
|
Facility
IP
|
$1,987.20
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605417
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,490.40 |
| Max. Negotiated Rate |
$1,848.10 |
| Rate for Payer: Aetna Commercial |
$1,716.94
|
| Rate for Payer: Cash Price |
$1,232.06
|
| Rate for Payer: Cigna All Commercial |
$1,714.95
|
| Rate for Payer: CORVEL All Commercial |
$1,848.10
|
| Rate for Payer: Coventry All Commercial |
$1,748.74
|
| Rate for Payer: Encore All Commercial |
$1,829.22
|
| Rate for Payer: Frontpath All Commercial |
$1,828.22
|
| Rate for Payer: Humana ChoiceCare |
$1,716.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,788.48
|
| Rate for Payer: PHCS All Commercial |
$1,490.40
|
| Rate for Payer: PHP All Commercial |
$1,507.09
|
| Rate for Payer: Sagamore Health Network All Products |
$1,534.12
|
| Rate for Payer: Signature Care EPO |
$1,649.38
|
| Rate for Payer: Signature Care PPO |
$1,748.74
|
| Rate for Payer: United Healthcare Commercial |
$1,565.91
|
|
|
HC Z 38MM SHELL OD
|
Facility
OP
|
$1,987.20
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605417
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$1,848.10 |
| Rate for Payer: Aetna Commercial |
$1,677.20
|
| Rate for Payer: Aetna Medicare |
$655.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$655.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,141.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,242.20
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$754.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$721.35
|
| Rate for Payer: Cash Price |
$1,232.06
|
| Rate for Payer: Cash Price |
$1,232.06
|
| Rate for Payer: Centivo All Commercial |
$1,013.47
|
| Rate for Payer: Cigna All Commercial |
$1,714.95
|
| Rate for Payer: CORVEL All Commercial |
$1,848.10
|
| Rate for Payer: Coventry All Commercial |
$1,748.74
|
| Rate for Payer: Encore All Commercial |
$1,829.22
|
| Rate for Payer: Frontpath All Commercial |
$1,828.22
|
| Rate for Payer: Humana ChoiceCare |
$1,716.34
|
| Rate for Payer: Humana Medicare |
$1,013.47
|
| Rate for Payer: Lucent All Commercial |
$1,013.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,788.48
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$1,490.40
|
| Rate for Payer: PHP All Commercial |
$1,507.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$775.01
|
| Rate for Payer: Sagamore Health Network All Products |
$1,534.12
|
| Rate for Payer: Signature Care EPO |
$1,649.38
|
| Rate for Payer: Signature Care PPO |
$1,748.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,689.12
|
| Rate for Payer: United Healthcare Commercial |
$1,565.91
|
| Rate for Payer: United Healthcare Medicare |
$655.78
|
|
|
HC Z 38X22 OD LINER
|
Facility
OP
|
$1,840.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605444
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$1,711.20 |
| Rate for Payer: Aetna Commercial |
$1,552.96
|
| Rate for Payer: Aetna Medicare |
$607.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$607.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,056.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,150.18
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$698.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$667.92
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Centivo All Commercial |
$938.40
|
| Rate for Payer: Cigna All Commercial |
$1,587.92
|
| Rate for Payer: CORVEL All Commercial |
$1,711.20
|
| Rate for Payer: Coventry All Commercial |
$1,619.20
|
| Rate for Payer: Encore All Commercial |
$1,693.72
|
| Rate for Payer: Frontpath All Commercial |
$1,692.80
|
| Rate for Payer: Humana ChoiceCare |
$1,589.21
|
| Rate for Payer: Humana Medicare |
$938.40
|
| Rate for Payer: Lucent All Commercial |
$938.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,656.00
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$1,380.00
|
| Rate for Payer: PHP All Commercial |
$1,395.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$717.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1,420.48
|
| Rate for Payer: Signature Care EPO |
$1,527.20
|
| Rate for Payer: Signature Care PPO |
$1,619.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,564.00
|
| Rate for Payer: United Healthcare Commercial |
$1,449.92
|
| Rate for Payer: United Healthcare Medicare |
$607.20
|
|
|
HC Z 38X22 OD LINER
|
Facility
IP
|
$1,840.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605444
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,380.00 |
| Max. Negotiated Rate |
$1,711.20 |
| Rate for Payer: Aetna Commercial |
$1,589.76
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Cigna All Commercial |
$1,587.92
|
| Rate for Payer: CORVEL All Commercial |
$1,711.20
|
| Rate for Payer: Coventry All Commercial |
$1,619.20
|
| Rate for Payer: Encore All Commercial |
$1,693.72
|
| Rate for Payer: Frontpath All Commercial |
$1,692.80
|
| Rate for Payer: Humana ChoiceCare |
$1,589.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,656.00
|
| Rate for Payer: PHCS All Commercial |
$1,380.00
|
| Rate for Payer: PHP All Commercial |
$1,395.46
|
| Rate for Payer: Sagamore Health Network All Products |
$1,420.48
|
| Rate for Payer: Signature Care EPO |
$1,527.20
|
| Rate for Payer: Signature Care PPO |
$1,619.20
|
| Rate for Payer: United Healthcare Commercial |
$1,449.92
|
|
|
HC Z 39MM SHELL OD
|
Facility
OP
|
$1,987.20
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605418
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$1,848.10 |
| Rate for Payer: Aetna Commercial |
$1,677.20
|
| Rate for Payer: Aetna Medicare |
$655.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$655.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,141.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,242.20
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$754.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$721.35
|
| Rate for Payer: Cash Price |
$1,232.06
|
| Rate for Payer: Cash Price |
$1,232.06
|
| Rate for Payer: Centivo All Commercial |
$1,013.47
|
| Rate for Payer: Cigna All Commercial |
$1,714.95
|
| Rate for Payer: CORVEL All Commercial |
$1,848.10
|
| Rate for Payer: Coventry All Commercial |
$1,748.74
|
| Rate for Payer: Encore All Commercial |
$1,829.22
|
| Rate for Payer: Frontpath All Commercial |
$1,828.22
|
| Rate for Payer: Humana ChoiceCare |
$1,716.34
|
| Rate for Payer: Humana Medicare |
$1,013.47
|
| Rate for Payer: Lucent All Commercial |
$1,013.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,788.48
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$1,490.40
|
| Rate for Payer: PHP All Commercial |
$1,507.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$775.01
|
| Rate for Payer: Sagamore Health Network All Products |
$1,534.12
|
| Rate for Payer: Signature Care EPO |
$1,649.38
|
| Rate for Payer: Signature Care PPO |
$1,748.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,689.12
|
| Rate for Payer: United Healthcare Commercial |
$1,565.91
|
| Rate for Payer: United Healthcare Medicare |
$655.78
|
|
|
HC Z 39MM SHELL OD
|
Facility
IP
|
$1,987.20
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605418
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,490.40 |
| Max. Negotiated Rate |
$1,848.10 |
| Rate for Payer: Aetna Commercial |
$1,716.94
|
| Rate for Payer: Cash Price |
$1,232.06
|
| Rate for Payer: Cigna All Commercial |
$1,714.95
|
| Rate for Payer: CORVEL All Commercial |
$1,848.10
|
| Rate for Payer: Coventry All Commercial |
$1,748.74
|
| Rate for Payer: Encore All Commercial |
$1,829.22
|
| Rate for Payer: Frontpath All Commercial |
$1,828.22
|
| Rate for Payer: Humana ChoiceCare |
$1,716.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,788.48
|
| Rate for Payer: PHCS All Commercial |
$1,490.40
|
| Rate for Payer: PHP All Commercial |
$1,507.09
|
| Rate for Payer: Sagamore Health Network All Products |
$1,534.12
|
| Rate for Payer: Signature Care EPO |
$1,649.38
|
| Rate for Payer: Signature Care PPO |
$1,748.74
|
| Rate for Payer: United Healthcare Commercial |
$1,565.91
|
|
|
HC Z 39X22 OD LINER
|
Facility
OP
|
$1,840.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$1,711.20 |
| Rate for Payer: Aetna Commercial |
$1,552.96
|
| Rate for Payer: Aetna Medicare |
$607.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$607.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,056.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,150.18
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$698.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$667.92
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Centivo All Commercial |
$938.40
|
| Rate for Payer: Cigna All Commercial |
$1,587.92
|
| Rate for Payer: CORVEL All Commercial |
$1,711.20
|
| Rate for Payer: Coventry All Commercial |
$1,619.20
|
| Rate for Payer: Encore All Commercial |
$1,693.72
|
| Rate for Payer: Frontpath All Commercial |
$1,692.80
|
| Rate for Payer: Humana ChoiceCare |
$1,589.21
|
| Rate for Payer: Humana Medicare |
$938.40
|
| Rate for Payer: Lucent All Commercial |
$938.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,656.00
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$1,380.00
|
| Rate for Payer: PHP All Commercial |
$1,395.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$717.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1,420.48
|
| Rate for Payer: Signature Care EPO |
$1,527.20
|
| Rate for Payer: Signature Care PPO |
$1,619.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,564.00
|
| Rate for Payer: United Healthcare Commercial |
$1,449.92
|
| Rate for Payer: United Healthcare Medicare |
$607.20
|
|
|
HC Z 39X22 OD LINER
|
Facility
IP
|
$1,840.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605445
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,380.00 |
| Max. Negotiated Rate |
$1,711.20 |
| Rate for Payer: Aetna Commercial |
$1,589.76
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Cigna All Commercial |
$1,587.92
|
| Rate for Payer: CORVEL All Commercial |
$1,711.20
|
| Rate for Payer: Coventry All Commercial |
$1,619.20
|
| Rate for Payer: Encore All Commercial |
$1,693.72
|
| Rate for Payer: Frontpath All Commercial |
$1,692.80
|
| Rate for Payer: Humana ChoiceCare |
$1,589.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,656.00
|
| Rate for Payer: PHCS All Commercial |
$1,380.00
|
| Rate for Payer: PHP All Commercial |
$1,395.46
|
| Rate for Payer: Sagamore Health Network All Products |
$1,420.48
|
| Rate for Payer: Signature Care EPO |
$1,527.20
|
| Rate for Payer: Signature Care PPO |
$1,619.20
|
| Rate for Payer: United Healthcare Commercial |
$1,449.92
|
|
|
HC Z 40/41X22 OD LINER
|
Facility
OP
|
$1,840.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605446
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$1,711.20 |
| Rate for Payer: Aetna Commercial |
$1,552.96
|
| Rate for Payer: Aetna Medicare |
$607.20
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$607.20
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,056.71
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,150.18
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$698.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$667.92
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Centivo All Commercial |
$938.40
|
| Rate for Payer: Cigna All Commercial |
$1,587.92
|
| Rate for Payer: CORVEL All Commercial |
$1,711.20
|
| Rate for Payer: Coventry All Commercial |
$1,619.20
|
| Rate for Payer: Encore All Commercial |
$1,693.72
|
| Rate for Payer: Frontpath All Commercial |
$1,692.80
|
| Rate for Payer: Humana ChoiceCare |
$1,589.21
|
| Rate for Payer: Humana Medicare |
$938.40
|
| Rate for Payer: Lucent All Commercial |
$938.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,656.00
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$1,380.00
|
| Rate for Payer: PHP All Commercial |
$1,395.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$717.60
|
| Rate for Payer: Sagamore Health Network All Products |
$1,420.48
|
| Rate for Payer: Signature Care EPO |
$1,527.20
|
| Rate for Payer: Signature Care PPO |
$1,619.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,564.00
|
| Rate for Payer: United Healthcare Commercial |
$1,449.92
|
| Rate for Payer: United Healthcare Medicare |
$607.20
|
|
|
HC Z 40/41X22 OD LINER
|
Facility
IP
|
$1,840.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605446
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,380.00 |
| Max. Negotiated Rate |
$1,711.20 |
| Rate for Payer: Aetna Commercial |
$1,589.76
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Cigna All Commercial |
$1,587.92
|
| Rate for Payer: CORVEL All Commercial |
$1,711.20
|
| Rate for Payer: Coventry All Commercial |
$1,619.20
|
| Rate for Payer: Encore All Commercial |
$1,693.72
|
| Rate for Payer: Frontpath All Commercial |
$1,692.80
|
| Rate for Payer: Humana ChoiceCare |
$1,589.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,656.00
|
| Rate for Payer: PHCS All Commercial |
$1,380.00
|
| Rate for Payer: PHP All Commercial |
$1,395.46
|
| Rate for Payer: Sagamore Health Network All Products |
$1,420.48
|
| Rate for Payer: Signature Care EPO |
$1,527.20
|
| Rate for Payer: Signature Care PPO |
$1,619.20
|
| Rate for Payer: United Healthcare Commercial |
$1,449.92
|
|
|
HC Z 4-0 BONE GRAFT 60 CC
|
Facility
OP
|
$5,032.80
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
41607758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$4,680.50 |
| Rate for Payer: Aetna Commercial |
$4,247.68
|
| Rate for Payer: Aetna Medicare |
$1,660.82
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,660.82
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,890.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,146.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,909.95
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,826.91
|
| Rate for Payer: Cash Price |
$3,120.34
|
| Rate for Payer: Cash Price |
$3,120.34
|
| Rate for Payer: Centivo All Commercial |
$2,566.73
|
| Rate for Payer: Cigna All Commercial |
$4,343.31
|
| Rate for Payer: CORVEL All Commercial |
$4,680.50
|
| Rate for Payer: Coventry All Commercial |
$4,428.86
|
| Rate for Payer: Encore All Commercial |
$4,632.69
|
| Rate for Payer: Frontpath All Commercial |
$4,630.18
|
| Rate for Payer: Humana ChoiceCare |
$4,346.83
|
| Rate for Payer: Humana Medicare |
$2,566.73
|
| Rate for Payer: Lucent All Commercial |
$2,566.73
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,529.52
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$3,774.60
|
| Rate for Payer: PHP All Commercial |
$3,816.88
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,962.79
|
| Rate for Payer: Sagamore Health Network All Products |
$3,885.32
|
| Rate for Payer: Signature Care EPO |
$4,177.22
|
| Rate for Payer: Signature Care PPO |
$4,428.86
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,277.88
|
| Rate for Payer: United Healthcare Commercial |
$3,965.85
|
| Rate for Payer: United Healthcare Medicare |
$1,660.82
|
|
|
HC Z 4-0 BONE GRAFT 60 CC
|
Facility
IP
|
$5,032.80
|
|
|
Service Code
|
CPT C1762
|
| Hospital Charge Code |
41607758
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,774.60 |
| Max. Negotiated Rate |
$4,680.50 |
| Rate for Payer: Aetna Commercial |
$4,348.34
|
| Rate for Payer: Cash Price |
$3,120.34
|
| Rate for Payer: Cigna All Commercial |
$4,343.31
|
| Rate for Payer: CORVEL All Commercial |
$4,680.50
|
| Rate for Payer: Coventry All Commercial |
$4,428.86
|
| Rate for Payer: Encore All Commercial |
$4,632.69
|
| Rate for Payer: Frontpath All Commercial |
$4,630.18
|
| Rate for Payer: Humana ChoiceCare |
$4,346.83
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,529.52
|
| Rate for Payer: PHCS All Commercial |
$3,774.60
|
| Rate for Payer: PHP All Commercial |
$3,816.88
|
| Rate for Payer: Sagamore Health Network All Products |
$3,885.32
|
| Rate for Payer: Signature Care EPO |
$4,177.22
|
| Rate for Payer: Signature Care PPO |
$4,428.86
|
| Rate for Payer: United Healthcare Commercial |
$3,965.85
|
|
|
HC Z 40MM SHELL OD
|
Facility
OP
|
$1,987.20
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605419
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$524.16 |
| Max. Negotiated Rate |
$1,848.10 |
| Rate for Payer: Aetna Commercial |
$1,677.20
|
| Rate for Payer: Aetna Medicare |
$655.78
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$655.78
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,141.25
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,242.20
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$524.16
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$754.14
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$721.35
|
| Rate for Payer: Cash Price |
$1,232.06
|
| Rate for Payer: Cash Price |
$1,232.06
|
| Rate for Payer: Centivo All Commercial |
$1,013.47
|
| Rate for Payer: Cigna All Commercial |
$1,714.95
|
| Rate for Payer: CORVEL All Commercial |
$1,848.10
|
| Rate for Payer: Coventry All Commercial |
$1,748.74
|
| Rate for Payer: Encore All Commercial |
$1,829.22
|
| Rate for Payer: Frontpath All Commercial |
$1,828.22
|
| Rate for Payer: Humana ChoiceCare |
$1,716.34
|
| Rate for Payer: Humana Medicare |
$1,013.47
|
| Rate for Payer: Lucent All Commercial |
$1,013.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,788.48
|
| Rate for Payer: Managed Health Services Medicaid |
$524.16
|
| Rate for Payer: MDWise Medicaid |
$524.16
|
| Rate for Payer: PHCS All Commercial |
$1,490.40
|
| Rate for Payer: PHP All Commercial |
$1,507.09
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$775.01
|
| Rate for Payer: Sagamore Health Network All Products |
$1,534.12
|
| Rate for Payer: Signature Care EPO |
$1,649.38
|
| Rate for Payer: Signature Care PPO |
$1,748.74
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,689.12
|
| Rate for Payer: United Healthcare Commercial |
$1,565.91
|
| Rate for Payer: United Healthcare Medicare |
$655.78
|
|
|
HC Z 40MM SHELL OD
|
Facility
IP
|
$1,987.20
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605419
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,490.40 |
| Max. Negotiated Rate |
$1,848.10 |
| Rate for Payer: Aetna Commercial |
$1,716.94
|
| Rate for Payer: Cash Price |
$1,232.06
|
| Rate for Payer: Cigna All Commercial |
$1,714.95
|
| Rate for Payer: CORVEL All Commercial |
$1,848.10
|
| Rate for Payer: Coventry All Commercial |
$1,748.74
|
| Rate for Payer: Encore All Commercial |
$1,829.22
|
| Rate for Payer: Frontpath All Commercial |
$1,828.22
|
| Rate for Payer: Humana ChoiceCare |
$1,716.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,788.48
|
| Rate for Payer: PHCS All Commercial |
$1,490.40
|
| Rate for Payer: PHP All Commercial |
$1,507.09
|
| Rate for Payer: Sagamore Health Network All Products |
$1,534.12
|
| Rate for Payer: Signature Care EPO |
$1,649.38
|
| Rate for Payer: Signature Care PPO |
$1,748.74
|
| Rate for Payer: United Healthcare Commercial |
$1,565.91
|
|
|
HC Z 40X26 OD LINER
|
Facility
IP
|
$1,840.00
|
|
|
Service Code
|
CPT C1776
|
| Hospital Charge Code |
41605447
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$1,380.00 |
| Max. Negotiated Rate |
$1,711.20 |
| Rate for Payer: Aetna Commercial |
$1,589.76
|
| Rate for Payer: Cash Price |
$1,140.80
|
| Rate for Payer: Cigna All Commercial |
$1,587.92
|
| Rate for Payer: CORVEL All Commercial |
$1,711.20
|
| Rate for Payer: Coventry All Commercial |
$1,619.20
|
| Rate for Payer: Encore All Commercial |
$1,693.72
|
| Rate for Payer: Frontpath All Commercial |
$1,692.80
|
| Rate for Payer: Humana ChoiceCare |
$1,589.21
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,656.00
|
| Rate for Payer: PHCS All Commercial |
$1,380.00
|
| Rate for Payer: PHP All Commercial |
$1,395.46
|
| Rate for Payer: Sagamore Health Network All Products |
$1,420.48
|
| Rate for Payer: Signature Care EPO |
$1,527.20
|
| Rate for Payer: Signature Care PPO |
$1,619.20
|
| Rate for Payer: United Healthcare Commercial |
$1,449.92
|
|
