|
PHENYTOIN 125 MG/5 ML ORAL SUSP
|
Facility
IP
|
$104.52
|
|
|
Service Code
|
NDC 51672406901
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$78.39 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna Commercial |
$90.30
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Cigna All Commercial |
$90.20
|
| Rate for Payer: CORVEL All Commercial |
$97.20
|
| Rate for Payer: Coventry All Commercial |
$91.97
|
| Rate for Payer: Encore All Commercial |
$96.21
|
| Rate for Payer: Frontpath All Commercial |
$96.16
|
| Rate for Payer: Humana ChoiceCare |
$90.27
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.07
|
| Rate for Payer: PHCS All Commercial |
$78.39
|
| Rate for Payer: PHP All Commercial |
$79.27
|
| Rate for Payer: Sagamore Health Network All Products |
$80.69
|
| Rate for Payer: Signature Care EPO |
$86.75
|
| Rate for Payer: Signature Care PPO |
$91.97
|
| Rate for Payer: United Healthcare Commercial |
$82.36
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSP
|
Facility
OP
|
$2.21
|
|
|
Service Code
|
NDC 516724069
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Aetna Commercial |
$1.86
|
| Rate for Payer: Aetna Medicare |
$0.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.73
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.27
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.84
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.80
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Centivo All Commercial |
$1.12
|
| Rate for Payer: Cigna All Commercial |
$1.90
|
| Rate for Payer: CORVEL All Commercial |
$2.05
|
| Rate for Payer: Coventry All Commercial |
$1.94
|
| Rate for Payer: Encore All Commercial |
$2.03
|
| Rate for Payer: Frontpath All Commercial |
$2.03
|
| Rate for Payer: Humana ChoiceCare |
$1.90
|
| Rate for Payer: Humana Medicare |
$1.12
|
| Rate for Payer: Lucent All Commercial |
$1.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.98
|
| Rate for Payer: PHCS All Commercial |
$1.65
|
| Rate for Payer: PHP All Commercial |
$1.67
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.86
|
| Rate for Payer: Sagamore Health Network All Products |
$1.70
|
| Rate for Payer: Signature Care EPO |
$1.83
|
| Rate for Payer: Signature Care PPO |
$1.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.87
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
| Rate for Payer: United Healthcare Medicare |
$0.73
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSP
|
Facility
IP
|
$2.21
|
|
|
Service Code
|
NDC 516724069
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Aetna Commercial |
$1.91
|
| Rate for Payer: Cash Price |
$1.37
|
| Rate for Payer: Cigna All Commercial |
$1.90
|
| Rate for Payer: CORVEL All Commercial |
$2.05
|
| Rate for Payer: Coventry All Commercial |
$1.94
|
| Rate for Payer: Encore All Commercial |
$2.03
|
| Rate for Payer: Frontpath All Commercial |
$2.03
|
| Rate for Payer: Humana ChoiceCare |
$1.90
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.98
|
| Rate for Payer: PHCS All Commercial |
$1.65
|
| Rate for Payer: PHP All Commercial |
$1.67
|
| Rate for Payer: Sagamore Health Network All Products |
$1.70
|
| Rate for Payer: Signature Care EPO |
$1.83
|
| Rate for Payer: Signature Care PPO |
$1.94
|
| Rate for Payer: United Healthcare Commercial |
$1.74
|
|
|
PHENYTOIN 125 MG/5 ML ORAL SUSP
|
Facility
OP
|
$104.52
|
|
|
Service Code
|
NDC 51672406901
|
| Hospital Charge Code |
6255
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.49 |
| Max. Negotiated Rate |
$97.20 |
| Rate for Payer: Aetna Commercial |
$88.21
|
| Rate for Payer: Aetna Medicare |
$34.49
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$34.49
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$60.02
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$65.33
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.94
|
| Rate for Payer: Cash Price |
$64.80
|
| Rate for Payer: Centivo All Commercial |
$53.30
|
| Rate for Payer: Cigna All Commercial |
$90.20
|
| Rate for Payer: CORVEL All Commercial |
$97.20
|
| Rate for Payer: Coventry All Commercial |
$91.97
|
| Rate for Payer: Encore All Commercial |
$96.21
|
| Rate for Payer: Frontpath All Commercial |
$96.16
|
| Rate for Payer: Humana ChoiceCare |
$90.27
|
| Rate for Payer: Humana Medicare |
$53.30
|
| Rate for Payer: Lucent All Commercial |
$53.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$94.07
|
| Rate for Payer: PHCS All Commercial |
$78.39
|
| Rate for Payer: PHP All Commercial |
$79.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$40.76
|
| Rate for Payer: Sagamore Health Network All Products |
$80.69
|
| Rate for Payer: Signature Care EPO |
$86.75
|
| Rate for Payer: Signature Care PPO |
$91.97
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$88.84
|
| Rate for Payer: United Healthcare Commercial |
$82.36
|
| Rate for Payer: United Healthcare Medicare |
$34.49
|
|
|
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 |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| 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 |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| 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 |
$5.94
|
|
|
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 |
$11.16
|
| 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 EXTENDED 100 MG ORAL CAP
|
Facility
OP
|
$2.86
|
|
|
Service Code
|
NDC 00904618761
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.94 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna Commercial |
$2.41
|
| Rate for Payer: Aetna Medicare |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.79
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.04
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Centivo All Commercial |
$1.46
|
| Rate for Payer: Cigna All Commercial |
$2.46
|
| Rate for Payer: CORVEL All Commercial |
$2.66
|
| Rate for Payer: Coventry All Commercial |
$2.51
|
| Rate for Payer: Encore All Commercial |
$2.63
|
| Rate for Payer: Frontpath All Commercial |
$2.63
|
| Rate for Payer: Humana ChoiceCare |
$2.47
|
| Rate for Payer: Humana Medicare |
$1.46
|
| Rate for Payer: Lucent All Commercial |
$1.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.57
|
| Rate for Payer: PHCS All Commercial |
$2.14
|
| Rate for Payer: PHP All Commercial |
$2.17
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.11
|
| Rate for Payer: Sagamore Health Network All Products |
$2.20
|
| Rate for Payer: Signature Care EPO |
$2.37
|
| Rate for Payer: Signature Care PPO |
$2.51
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.43
|
| Rate for Payer: United Healthcare Commercial |
$2.25
|
| Rate for Payer: United Healthcare Medicare |
$0.94
|
|
|
PHENYTOIN SODIUM EXTENDED 100 MG ORAL CAP
|
Facility
IP
|
$2.86
|
|
|
Service Code
|
NDC 00904618761
|
| Hospital Charge Code |
6257
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$2.66 |
| Rate for Payer: Aetna Commercial |
$2.47
|
| Rate for Payer: Cash Price |
$1.77
|
| Rate for Payer: Cigna All Commercial |
$2.46
|
| Rate for Payer: CORVEL All Commercial |
$2.66
|
| Rate for Payer: Coventry All Commercial |
$2.51
|
| Rate for Payer: Encore All Commercial |
$2.63
|
| Rate for Payer: Frontpath All Commercial |
$2.63
|
| Rate for Payer: Humana ChoiceCare |
$2.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.57
|
| Rate for Payer: PHCS All Commercial |
$2.14
|
| Rate for Payer: PHP All Commercial |
$2.17
|
| Rate for Payer: Sagamore Health Network All Products |
$2.20
|
| Rate for Payer: Signature Care EPO |
$2.37
|
| Rate for Payer: Signature Care PPO |
$2.51
|
| Rate for Payer: United Healthcare Commercial |
$2.25
|
|
|
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 |
$1,116.00
|
| 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 |
$37.56 |
| Max. Negotiated Rate |
$1,674.00 |
| Rate for Payer: Aetna Commercial |
$1,519.20
|
| Rate for Payer: Aetna Medicare |
$594.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$594.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,033.74
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,125.18
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$683.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$653.40
|
| Rate for Payer: Cash Price |
$1,116.00
|
| Rate for Payer: Cash Price |
$1,116.00
|
| Rate for Payer: Centivo All Commercial |
$918.00
|
| 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: Humana Medicare |
$918.00
|
| Rate for Payer: Lucent All Commercial |
$918.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,620.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| 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 |
$594.00
|
|
|
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 |
$37.56 |
| Max. Negotiated Rate |
$2,790.00 |
| Rate for Payer: Aetna Commercial |
$2,532.00
|
| Rate for Payer: Aetna Medicare |
$990.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$990.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1,722.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,875.30
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,138.50
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,089.00
|
| Rate for Payer: Cash Price |
$1,860.00
|
| Rate for Payer: Cash Price |
$1,860.00
|
| Rate for Payer: Centivo All Commercial |
$1,530.00
|
| 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 |
$1,530.00
|
| Rate for Payer: Lucent All Commercial |
$1,530.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,700.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| 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 |
$990.00
|
|
|
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 |
$1,860.00
|
| 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 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 |
$2,232.00
|
| 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 |
$37.56 |
| Max. Negotiated Rate |
$3,348.00 |
| Rate for Payer: Aetna Commercial |
$3,038.40
|
| Rate for Payer: Aetna Medicare |
$1,188.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,188.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2,067.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2,250.36
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1,366.20
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,306.80
|
| Rate for Payer: Cash Price |
$2,232.00
|
| Rate for Payer: Cash Price |
$2,232.00
|
| Rate for Payer: Centivo All Commercial |
$1,836.00
|
| 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: Humana Medicare |
$1,836.00
|
| Rate for Payer: Lucent All Commercial |
$1,836.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3,240.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| 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 |
$1,188.00
|
|
|
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 |
$3,273.60
|
| 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 |
$37.56 |
| Max. Negotiated Rate |
$4,910.40 |
| Rate for Payer: Aetna Commercial |
$4,456.32
|
| Rate for Payer: Aetna Medicare |
$1,742.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,742.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,032.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,300.53
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,003.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,916.64
|
| Rate for Payer: Cash Price |
$3,273.60
|
| Rate for Payer: Cash Price |
$3,273.60
|
| Rate for Payer: Centivo All Commercial |
$2,692.80
|
| 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 |
$2,692.80
|
| Rate for Payer: Lucent All Commercial |
$2,692.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,752.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| 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 |
$1,742.40
|
|
|
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 |
$37.56 |
| Max. Negotiated Rate |
$4,910.40 |
| Rate for Payer: Aetna Commercial |
$4,456.32
|
| Rate for Payer: Aetna Medicare |
$1,742.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1,742.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,032.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$3,300.53
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,003.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1,916.64
|
| Rate for Payer: Cash Price |
$3,273.60
|
| Rate for Payer: Cash Price |
$3,273.60
|
| Rate for Payer: Centivo All Commercial |
$2,692.80
|
| 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 |
$2,692.80
|
| Rate for Payer: Lucent All Commercial |
$2,692.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$4,752.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| 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 |
$1,742.40
|
|
|
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 |
$3,273.60
|
| 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) 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 |
$4,285.44
|
| 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 |
$37.56 |
| Max. Negotiated Rate |
$6,428.16 |
| Rate for Payer: Frontpath All Commercial |
$6,359.04
|
| Rate for Payer: Aetna Commercial |
$5,833.73
|
| Rate for Payer: Aetna Medicare |
$2,280.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,280.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,969.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,320.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,623.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,509.06
|
| Rate for Payer: Cash Price |
$4,285.44
|
| Rate for Payer: Cash Price |
$4,285.44
|
| Rate for Payer: Centivo All Commercial |
$3,525.12
|
| 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: Humana ChoiceCare |
$5,969.89
|
| Rate for Payer: Humana Medicare |
$3,525.12
|
| Rate for Payer: Lucent All Commercial |
$3,525.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,220.80
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| 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 |
$2,280.96
|
|
|
PHMB 0.1% (PURAPLY AM) 4 X 4 WOUND MATRIX EXTRA FENESTRATED
|
Facility
IP
|
$6,912.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800595
|
|
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 |
$4,285.44
|
| 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 EXTRA FENESTRATED
|
Facility
OP
|
$6,912.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800595
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$6,428.16 |
| Rate for Payer: Aetna Commercial |
$5,833.73
|
| Rate for Payer: Aetna Medicare |
$2,280.96
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2,280.96
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$3,969.56
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4,320.69
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2,623.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2,509.06
|
| Rate for Payer: Cash Price |
$4,285.44
|
| Rate for Payer: Cash Price |
$4,285.44
|
| Rate for Payer: Centivo All Commercial |
$3,525.12
|
| 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 |
$3,525.12
|
| Rate for Payer: Lucent All Commercial |
$3,525.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6,220.80
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| 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 |
$2,280.96
|
|
|
PHMB 0.1% (PURAPLY AM) 5 X 5 WOUND MATRIX
|
Facility
IP
|
$10,400.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800578
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7,800.00 |
| Max. Negotiated Rate |
$9,672.00 |
| Rate for Payer: Aetna Commercial |
$8,985.60
|
| Rate for Payer: Cash Price |
$6,448.00
|
| Rate for Payer: Cigna All Commercial |
$8,975.20
|
| Rate for Payer: CORVEL All Commercial |
$9,672.00
|
| Rate for Payer: Coventry All Commercial |
$9,152.00
|
| Rate for Payer: Encore All Commercial |
$9,573.20
|
| Rate for Payer: Frontpath All Commercial |
$9,568.00
|
| Rate for Payer: Humana ChoiceCare |
$8,982.48
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,360.00
|
| Rate for Payer: PHCS All Commercial |
$7,800.00
|
| Rate for Payer: PHP All Commercial |
$7,887.36
|
| Rate for Payer: Sagamore Health Network All Products |
$8,028.80
|
| Rate for Payer: Signature Care EPO |
$8,632.00
|
| Rate for Payer: Signature Care PPO |
$9,152.00
|
| Rate for Payer: United Healthcare Commercial |
$8,195.20
|
|
|
PHMB 0.1% (PURAPLY AM) 5 X 5 WOUND MATRIX
|
Facility
OP
|
$10,400.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800578
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$37.56 |
| Max. Negotiated Rate |
$9,672.00 |
| Rate for Payer: Aetna Commercial |
$8,777.60
|
| Rate for Payer: Aetna Medicare |
$3,432.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$3,432.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$5,972.72
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$6,501.04
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.56
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$3,946.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$3,775.20
|
| Rate for Payer: Cash Price |
$6,448.00
|
| Rate for Payer: Cash Price |
$6,448.00
|
| Rate for Payer: Centivo All Commercial |
$5,304.00
|
| Rate for Payer: Cigna All Commercial |
$8,975.20
|
| Rate for Payer: CORVEL All Commercial |
$9,672.00
|
| Rate for Payer: Coventry All Commercial |
$9,152.00
|
| Rate for Payer: Encore All Commercial |
$9,573.20
|
| Rate for Payer: Frontpath All Commercial |
$9,568.00
|
| Rate for Payer: Humana ChoiceCare |
$8,982.48
|
| Rate for Payer: Humana Medicare |
$5,304.00
|
| Rate for Payer: Lucent All Commercial |
$5,304.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9,360.00
|
| Rate for Payer: Managed Health Services Medicaid |
$37.56
|
| Rate for Payer: MDWise Medicaid |
$37.56
|
| Rate for Payer: PHCS All Commercial |
$7,800.00
|
| Rate for Payer: PHP All Commercial |
$7,887.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$4,056.00
|
| Rate for Payer: Sagamore Health Network All Products |
$8,028.80
|
| Rate for Payer: Signature Care EPO |
$8,632.00
|
| Rate for Payer: Signature Care PPO |
$9,152.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,840.00
|
| Rate for Payer: United Healthcare Commercial |
$8,195.20
|
| Rate for Payer: United Healthcare Medicare |
$3,432.00
|
|
|
PHMB 0.1% (PURAPLY AM) 6 X 9 WOUND MATRIX
|
Facility
IP
|
$20,520.00
|
|
|
Service Code
|
HCPCS Q4196
|
| Hospital Charge Code |
800571
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15,390.00 |
| Max. Negotiated Rate |
$19,083.60 |
| Rate for Payer: Aetna Commercial |
$17,729.28
|
| Rate for Payer: Cash Price |
$12,722.40
|
| Rate for Payer: Cigna All Commercial |
$17,708.76
|
| Rate for Payer: CORVEL All Commercial |
$19,083.60
|
| Rate for Payer: Coventry All Commercial |
$18,057.60
|
| Rate for Payer: Encore All Commercial |
$18,888.66
|
| Rate for Payer: Frontpath All Commercial |
$18,878.40
|
| Rate for Payer: Humana ChoiceCare |
$17,723.12
|
| Rate for Payer: Lutheran Preferred All Commercial |
$18,468.00
|
| Rate for Payer: PHCS All Commercial |
$15,390.00
|
| Rate for Payer: PHP All Commercial |
$15,562.37
|
| Rate for Payer: Sagamore Health Network All Products |
$15,841.44
|
| Rate for Payer: Signature Care EPO |
$17,031.60
|
| Rate for Payer: Signature Care PPO |
$18,057.60
|
| Rate for Payer: United Healthcare Commercial |
$16,169.76
|
|
