|
PROCHLORPERAZINE EDISYLATE 10 MG/2 ML (5 MG/ML) INJ SOLN
|
Facility
|
IP
|
$25.94
|
|
|
Service Code
|
HCPCS J0780
|
| Hospital Charge Code |
152840
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.46 |
| Max. Negotiated Rate |
$24.13 |
| Rate for Payer: Aetna Commercial |
$22.41
|
| Rate for Payer: Cash Price |
$15.57
|
| Rate for Payer: Cigna All Commercial |
$22.39
|
| Rate for Payer: CORVEL All Commercial |
$24.13
|
| Rate for Payer: Coventry All Commercial |
$22.83
|
| Rate for Payer: Encore All Commercial |
$23.88
|
| Rate for Payer: Frontpath All Commercial |
$23.87
|
| Rate for Payer: Humana ChoiceCare |
$22.41
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.35
|
| Rate for Payer: PHCS All Commercial |
$19.46
|
| Rate for Payer: PHP All Commercial |
$19.67
|
| Rate for Payer: Sagamore Health Network All Products |
$20.03
|
| Rate for Payer: Signature Care EPO |
$21.53
|
| Rate for Payer: Signature Care PPO |
$22.83
|
| Rate for Payer: United Healthcare Commercial |
$20.44
|
|
|
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB
|
Facility
|
OP
|
$8.05
|
|
|
Service Code
|
HCPCS Q0164
|
| Hospital Charge Code |
6582
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.50 |
| Max. Negotiated Rate |
$7.49 |
| Rate for Payer: Aetna Commercial |
$6.79
|
| Rate for Payer: Aetna Medicare |
$2.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.50
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$4.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$5.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.96
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.83
|
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: Centivo All Commercial |
$4.38
|
| Rate for Payer: Cigna All Commercial |
$6.95
|
| Rate for Payer: CORVEL All Commercial |
$7.49
|
| Rate for Payer: Coventry All Commercial |
$7.08
|
| Rate for Payer: Encore All Commercial |
$7.41
|
| Rate for Payer: Frontpath All Commercial |
$7.41
|
| Rate for Payer: Humana ChoiceCare |
$6.95
|
| Rate for Payer: Humana Medicare |
$2.58
|
| Rate for Payer: Lucent All Commercial |
$4.38
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.25
|
| Rate for Payer: PHCS All Commercial |
$6.04
|
| Rate for Payer: PHP All Commercial |
$6.11
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$3.14
|
| Rate for Payer: Sagamore Health Network All Products |
$6.21
|
| Rate for Payer: Signature Care EPO |
$6.68
|
| Rate for Payer: Signature Care PPO |
$7.08
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.84
|
| Rate for Payer: United Healthcare Commercial |
$6.34
|
| Rate for Payer: United Healthcare Medicare |
$2.58
|
|
|
PROCHLORPERAZINE MALEATE 10 MG ORAL TAB
|
Facility
|
IP
|
$8.05
|
|
|
Service Code
|
HCPCS Q0164
|
| Hospital Charge Code |
6582
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.04 |
| Max. Negotiated Rate |
$7.49 |
| Rate for Payer: Aetna Commercial |
$6.96
|
| Rate for Payer: Cash Price |
$4.83
|
| Rate for Payer: Cigna All Commercial |
$6.95
|
| Rate for Payer: CORVEL All Commercial |
$7.49
|
| Rate for Payer: Coventry All Commercial |
$7.08
|
| Rate for Payer: Encore All Commercial |
$7.41
|
| Rate for Payer: Frontpath All Commercial |
$7.41
|
| Rate for Payer: Humana ChoiceCare |
$6.95
|
| Rate for Payer: Lutheran Preferred All Commercial |
$7.25
|
| Rate for Payer: PHCS All Commercial |
$6.04
|
| Rate for Payer: PHP All Commercial |
$6.11
|
| Rate for Payer: Sagamore Health Network All Products |
$6.21
|
| Rate for Payer: Signature Care EPO |
$6.68
|
| Rate for Payer: Signature Care PPO |
$7.08
|
| Rate for Payer: United Healthcare Commercial |
$6.34
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT HIGH MDM 55 MINUTES
|
Professional
|
Both
|
$393.40
|
|
|
Service Code
|
CPT 99245
|
| Hospital Charge Code |
z99245
|
| Min. Negotiated Rate |
$94.48 |
| Max. Negotiated Rate |
$17,800.00 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$201.30
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$94.48
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$94.48
|
| Rate for Payer: Cash Price |
$238.96
|
| Rate for Payer: Cash Price |
$236.04
|
| Rate for Payer: Frontpath All Commercial |
$187.56
|
| Rate for Payer: Frontpath All Commercial |
$187.56
|
| Rate for Payer: Humana ChoiceCare |
$208.58
|
| Rate for Payer: Humana ChoiceCare |
$208.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$182.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$182.00
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$94.48
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$94.48
|
| Rate for Payer: PHP All Commercial |
$174.07
|
| Rate for Payer: PHP All Commercial |
$174.07
|
| Rate for Payer: Signature Care EPO |
$232.05
|
| Rate for Payer: Signature Care EPO |
$232.05
|
| Rate for Payer: Signature Care PPO |
$232.05
|
| Rate for Payer: Signature Care PPO |
$232.05
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17,800.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17,800.00
|
| Rate for Payer: United Healthcare Commercial |
$194.47
|
| Rate for Payer: United Healthcare Commercial |
$194.47
|
| Rate for Payer: United Healthcare Medicare |
$196.70
|
| Rate for Payer: United Healthcare Medicare |
$196.70
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT LOW MDM 30 MINUTES
|
Professional
|
Both
|
$210.42
|
|
|
Service Code
|
CPT 99243
|
| Hospital Charge Code |
z99243
|
| Min. Negotiated Rate |
$47.76 |
| Max. Negotiated Rate |
$8,700.00 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$106.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$106.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$106.19
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$106.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$106.19
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$106.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$106.19
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$106.19
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$47.76
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$47.76
|
| Rate for Payer: Cash Price |
$127.80
|
| Rate for Payer: Cash Price |
$126.25
|
| Rate for Payer: Frontpath All Commercial |
$94.82
|
| Rate for Payer: Frontpath All Commercial |
$94.82
|
| Rate for Payer: Humana ChoiceCare |
$105.64
|
| Rate for Payer: Humana ChoiceCare |
$105.64
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$89.00
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$47.76
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$47.76
|
| Rate for Payer: PHP All Commercial |
$85.10
|
| Rate for Payer: PHP All Commercial |
$85.10
|
| Rate for Payer: Signature Care EPO |
$125.80
|
| Rate for Payer: Signature Care EPO |
$125.80
|
| Rate for Payer: Signature Care PPO |
$125.80
|
| Rate for Payer: Signature Care PPO |
$125.80
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,700.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,700.00
|
| Rate for Payer: United Healthcare Commercial |
$98.13
|
| Rate for Payer: United Healthcare Commercial |
$98.13
|
| Rate for Payer: United Healthcare Medicare |
$105.21
|
| Rate for Payer: United Healthcare Medicare |
$105.21
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT MOD MDM 40 MINUTES
|
Professional
|
Both
|
$301.26
|
|
|
Service Code
|
CPT 99244
|
| Hospital Charge Code |
z99244
|
| Min. Negotiated Rate |
$76.31 |
| Max. Negotiated Rate |
$13,300.00 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$162.17
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$76.31
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$76.31
|
| Rate for Payer: Cash Price |
$182.74
|
| Rate for Payer: Cash Price |
$180.76
|
| Rate for Payer: Frontpath All Commercial |
$151.41
|
| Rate for Payer: Frontpath All Commercial |
$151.41
|
| Rate for Payer: Humana ChoiceCare |
$156.76
|
| Rate for Payer: Humana ChoiceCare |
$156.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$136.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$136.00
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$76.31
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$76.31
|
| Rate for Payer: PHP All Commercial |
$129.72
|
| Rate for Payer: PHP All Commercial |
$129.72
|
| Rate for Payer: Signature Care EPO |
$179.35
|
| Rate for Payer: Signature Care EPO |
$179.35
|
| Rate for Payer: Signature Care PPO |
$179.35
|
| Rate for Payer: Signature Care PPO |
$179.35
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,300.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,300.00
|
| Rate for Payer: United Healthcare Commercial |
$155.89
|
| Rate for Payer: United Healthcare Commercial |
$155.89
|
| Rate for Payer: United Healthcare Medicare |
$150.63
|
| Rate for Payer: United Healthcare Medicare |
$150.63
|
|
|
PR OFFICE/OP CONSLTJ NEW/EST PT SF MDM 20 MINUTES
|
Professional
|
Both
|
$139.86
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
z99242
|
| Min. Negotiated Rate |
$33.92 |
| Max. Negotiated Rate |
$5,500.00 |
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$73.29
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$33.92
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$33.92
|
| Rate for Payer: Cash Price |
$85.01
|
| Rate for Payer: Cash Price |
$83.92
|
| Rate for Payer: Frontpath All Commercial |
$67.28
|
| Rate for Payer: Frontpath All Commercial |
$67.28
|
| Rate for Payer: Humana ChoiceCare |
$78.77
|
| Rate for Payer: Humana ChoiceCare |
$78.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.00
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$33.92
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$33.92
|
| Rate for Payer: PHP All Commercial |
$53.73
|
| Rate for Payer: PHP All Commercial |
$53.73
|
| Rate for Payer: Signature Care EPO |
$95.20
|
| Rate for Payer: Signature Care EPO |
$95.20
|
| Rate for Payer: Signature Care PPO |
$95.20
|
| Rate for Payer: Signature Care PPO |
$95.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,500.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$5,500.00
|
| Rate for Payer: United Healthcare Commercial |
$70.39
|
| Rate for Payer: United Healthcare Commercial |
$70.39
|
| Rate for Payer: United Healthcare Medicare |
$69.93
|
| Rate for Payer: United Healthcare Medicare |
$69.93
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40 MIN
|
Professional
|
Both
|
$340.84
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
z99215
|
| Min. Negotiated Rate |
$73.54 |
| Max. Negotiated Rate |
$14,000.00 |
| Rate for Payer: Aetna Commercial |
$138.90
|
| Rate for Payer: Aetna Commercial |
$138.90
|
| Rate for Payer: Aetna Medicare |
$138.90
|
| Rate for Payer: Aetna Medicare |
$138.90
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$141.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$141.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$141.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$141.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$141.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$141.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$141.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$141.38
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$73.54
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$73.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$167.63
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$167.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$159.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$159.74
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$152.79
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$152.79
|
| Rate for Payer: Cash Price |
$198.34
|
| Rate for Payer: Cash Price |
$204.50
|
| Rate for Payer: Centivo All Commercial |
$215.29
|
| Rate for Payer: Centivo All Commercial |
$215.29
|
| Rate for Payer: Cigna All Commercial |
$138.90
|
| Rate for Payer: Cigna All Commercial |
$138.90
|
| Rate for Payer: CORVEL All Commercial |
$138.90
|
| Rate for Payer: CORVEL All Commercial |
$138.90
|
| Rate for Payer: Coventry All Commercial |
$166.68
|
| Rate for Payer: Coventry All Commercial |
$166.68
|
| Rate for Payer: Encore All Commercial |
$138.90
|
| Rate for Payer: Encore All Commercial |
$138.90
|
| Rate for Payer: Frontpath All Commercial |
$149.79
|
| Rate for Payer: Frontpath All Commercial |
$149.79
|
| Rate for Payer: Humana ChoiceCare |
$90.72
|
| Rate for Payer: Humana ChoiceCare |
$90.72
|
| Rate for Payer: Humana Medicare |
$138.90
|
| Rate for Payer: Humana Medicare |
$138.90
|
| Rate for Payer: Lucent All Commercial |
$194.46
|
| Rate for Payer: Lucent All Commercial |
$194.46
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.00
|
| Rate for Payer: Managed Health Services Medicaid |
$167.63
|
| Rate for Payer: Managed Health Services Medicaid |
$167.63
|
| Rate for Payer: MDWise Medicaid |
$167.63
|
| Rate for Payer: MDWise Medicaid |
$167.63
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$73.54
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$73.54
|
| Rate for Payer: PHCS All Commercial |
$138.90
|
| Rate for Payer: PHCS All Commercial |
$138.90
|
| Rate for Payer: PHP All Commercial |
$136.74
|
| Rate for Payer: PHP All Commercial |
$136.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$138.90
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$138.90
|
| Rate for Payer: Sagamore Health Network All Products |
$138.90
|
| Rate for Payer: Sagamore Health Network All Products |
$138.90
|
| Rate for Payer: Signature Care EPO |
$145.60
|
| Rate for Payer: Signature Care EPO |
$145.60
|
| Rate for Payer: Signature Care PPO |
$145.60
|
| Rate for Payer: Signature Care PPO |
$145.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14,000.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$14,000.00
|
| Rate for Payer: United Healthcare Commercial |
$100.15
|
| Rate for Payer: United Healthcare Commercial |
$100.15
|
| Rate for Payer: United Healthcare Medicare |
$165.28
|
| Rate for Payer: United Healthcare Medicare |
$165.28
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN
|
Professional
|
Both
|
$171.42
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
z99213
|
| Min. Negotiated Rate |
$33.74 |
| Max. Negotiated Rate |
$6,500.00 |
| Rate for Payer: Aetna Commercial |
$63.73
|
| Rate for Payer: Aetna Commercial |
$63.73
|
| Rate for Payer: Aetna Medicare |
$63.73
|
| Rate for Payer: Aetna Medicare |
$63.73
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$74.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$74.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$74.64
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$74.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$74.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$74.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$74.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$74.64
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$33.74
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$33.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$84.31
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$84.31
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$73.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$73.29
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$70.10
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$70.10
|
| Rate for Payer: Cash Price |
$99.72
|
| Rate for Payer: Cash Price |
$102.85
|
| Rate for Payer: Centivo All Commercial |
$98.78
|
| Rate for Payer: Centivo All Commercial |
$98.78
|
| Rate for Payer: Cigna All Commercial |
$63.73
|
| Rate for Payer: Cigna All Commercial |
$63.73
|
| Rate for Payer: CORVEL All Commercial |
$63.73
|
| Rate for Payer: CORVEL All Commercial |
$63.73
|
| Rate for Payer: Coventry All Commercial |
$76.48
|
| Rate for Payer: Coventry All Commercial |
$76.48
|
| Rate for Payer: Encore All Commercial |
$63.73
|
| Rate for Payer: Encore All Commercial |
$63.73
|
| Rate for Payer: Frontpath All Commercial |
$68.80
|
| Rate for Payer: Frontpath All Commercial |
$68.80
|
| Rate for Payer: Humana ChoiceCare |
$34.13
|
| Rate for Payer: Humana ChoiceCare |
$34.13
|
| Rate for Payer: Humana Medicare |
$63.73
|
| Rate for Payer: Humana Medicare |
$63.73
|
| Rate for Payer: Lucent All Commercial |
$89.22
|
| Rate for Payer: Lucent All Commercial |
$89.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.00
|
| Rate for Payer: Managed Health Services Medicaid |
$84.31
|
| Rate for Payer: Managed Health Services Medicaid |
$84.31
|
| Rate for Payer: MDWise Medicaid |
$84.31
|
| Rate for Payer: MDWise Medicaid |
$84.31
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$33.74
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$33.74
|
| Rate for Payer: PHCS All Commercial |
$63.73
|
| Rate for Payer: PHCS All Commercial |
$63.73
|
| Rate for Payer: PHP All Commercial |
$62.95
|
| Rate for Payer: PHP All Commercial |
$62.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$63.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$63.73
|
| Rate for Payer: Sagamore Health Network All Products |
$63.73
|
| Rate for Payer: Sagamore Health Network All Products |
$63.73
|
| Rate for Payer: Signature Care EPO |
$72.96
|
| Rate for Payer: Signature Care EPO |
$72.96
|
| Rate for Payer: Signature Care PPO |
$72.96
|
| Rate for Payer: Signature Care PPO |
$72.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,500.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6,500.00
|
| Rate for Payer: United Healthcare Commercial |
$45.60
|
| Rate for Payer: United Healthcare Commercial |
$45.60
|
| Rate for Payer: United Healthcare Medicare |
$83.10
|
| Rate for Payer: United Healthcare Medicare |
$83.10
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN
|
Professional
|
Both
|
$242.22
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
z99214
|
| Min. Negotiated Rate |
$49.49 |
| Max. Negotiated Rate |
$9,500.00 |
| Rate for Payer: Aetna Commercial |
$93.91
|
| Rate for Payer: Aetna Commercial |
$93.91
|
| Rate for Payer: Aetna Medicare |
$93.91
|
| Rate for Payer: Aetna Medicare |
$93.91
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$105.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$105.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$105.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$105.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$105.54
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$105.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$105.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$105.54
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$49.49
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$49.49
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$119.13
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$119.13
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$108.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$108.00
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$103.30
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$103.30
|
| Rate for Payer: Cash Price |
$141.34
|
| Rate for Payer: Cash Price |
$145.33
|
| Rate for Payer: Centivo All Commercial |
$145.56
|
| Rate for Payer: Centivo All Commercial |
$145.56
|
| Rate for Payer: Cigna All Commercial |
$93.91
|
| Rate for Payer: Cigna All Commercial |
$93.91
|
| Rate for Payer: CORVEL All Commercial |
$93.91
|
| Rate for Payer: CORVEL All Commercial |
$93.91
|
| Rate for Payer: Coventry All Commercial |
$112.69
|
| Rate for Payer: Coventry All Commercial |
$112.69
|
| Rate for Payer: Encore All Commercial |
$93.91
|
| Rate for Payer: Encore All Commercial |
$93.91
|
| Rate for Payer: Frontpath All Commercial |
$100.78
|
| Rate for Payer: Frontpath All Commercial |
$100.78
|
| Rate for Payer: Humana ChoiceCare |
$56.59
|
| Rate for Payer: Humana ChoiceCare |
$56.59
|
| Rate for Payer: Humana Medicare |
$93.91
|
| Rate for Payer: Humana Medicare |
$93.91
|
| Rate for Payer: Lucent All Commercial |
$131.47
|
| Rate for Payer: Lucent All Commercial |
$131.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.00
|
| Rate for Payer: Managed Health Services Medicaid |
$119.13
|
| Rate for Payer: Managed Health Services Medicaid |
$119.13
|
| Rate for Payer: MDWise Medicaid |
$119.13
|
| Rate for Payer: MDWise Medicaid |
$119.13
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$49.49
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$49.49
|
| Rate for Payer: PHCS All Commercial |
$93.91
|
| Rate for Payer: PHCS All Commercial |
$93.91
|
| Rate for Payer: PHP All Commercial |
$93.08
|
| Rate for Payer: PHP All Commercial |
$93.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$93.91
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$93.91
|
| Rate for Payer: Sagamore Health Network All Products |
$93.91
|
| Rate for Payer: Sagamore Health Network All Products |
$93.91
|
| Rate for Payer: Signature Care EPO |
$103.39
|
| Rate for Payer: Signature Care EPO |
$103.39
|
| Rate for Payer: Signature Care PPO |
$103.39
|
| Rate for Payer: Signature Care PPO |
$103.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9,500.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9,500.00
|
| Rate for Payer: United Healthcare Commercial |
$70.55
|
| Rate for Payer: United Healthcare Commercial |
$70.55
|
| Rate for Payer: United Healthcare Medicare |
$117.78
|
| Rate for Payer: United Healthcare Medicare |
$117.78
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN
|
Professional
|
Both
|
$106.24
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
z99212
|
| Min. Negotiated Rate |
$18.34 |
| Max. Negotiated Rate |
$3,500.00 |
| Rate for Payer: Aetna Commercial |
$34.38
|
| Rate for Payer: Aetna Commercial |
$34.38
|
| Rate for Payer: Aetna Medicare |
$34.38
|
| Rate for Payer: Aetna Medicare |
$34.38
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$43.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$43.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$43.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$43.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$43.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$43.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.00
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$18.34
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$18.34
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$52.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$52.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$39.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.82
|
| Rate for Payer: Cash Price |
$62.15
|
| Rate for Payer: Cash Price |
$63.74
|
| Rate for Payer: Centivo All Commercial |
$53.29
|
| Rate for Payer: Centivo All Commercial |
$53.29
|
| Rate for Payer: Cigna All Commercial |
$34.38
|
| Rate for Payer: Cigna All Commercial |
$34.38
|
| Rate for Payer: CORVEL All Commercial |
$34.38
|
| Rate for Payer: CORVEL All Commercial |
$34.38
|
| Rate for Payer: Coventry All Commercial |
$41.26
|
| Rate for Payer: Coventry All Commercial |
$41.26
|
| Rate for Payer: Encore All Commercial |
$34.38
|
| Rate for Payer: Encore All Commercial |
$34.38
|
| Rate for Payer: Frontpath All Commercial |
$37.48
|
| Rate for Payer: Frontpath All Commercial |
$37.48
|
| Rate for Payer: Humana ChoiceCare |
$23.04
|
| Rate for Payer: Humana ChoiceCare |
$23.04
|
| Rate for Payer: Humana Medicare |
$34.38
|
| Rate for Payer: Humana Medicare |
$34.38
|
| Rate for Payer: Lucent All Commercial |
$48.13
|
| Rate for Payer: Lucent All Commercial |
$48.13
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.00
|
| Rate for Payer: Managed Health Services Medicaid |
$52.25
|
| Rate for Payer: Managed Health Services Medicaid |
$52.25
|
| Rate for Payer: MDWise Medicaid |
$52.25
|
| Rate for Payer: MDWise Medicaid |
$52.25
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$18.34
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$18.34
|
| Rate for Payer: PHCS All Commercial |
$34.38
|
| Rate for Payer: PHCS All Commercial |
$34.38
|
| Rate for Payer: PHP All Commercial |
$33.80
|
| Rate for Payer: PHP All Commercial |
$33.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$34.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$34.38
|
| Rate for Payer: Sagamore Health Network All Products |
$34.38
|
| Rate for Payer: Sagamore Health Network All Products |
$34.38
|
| Rate for Payer: Signature Care EPO |
$45.11
|
| Rate for Payer: Signature Care EPO |
$45.11
|
| Rate for Payer: Signature Care PPO |
$45.11
|
| Rate for Payer: Signature Care PPO |
$45.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,500.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3,500.00
|
| Rate for Payer: United Healthcare Commercial |
$23.29
|
| Rate for Payer: United Healthcare Commercial |
$23.29
|
| Rate for Payer: United Healthcare Medicare |
$51.79
|
| Rate for Payer: United Healthcare Medicare |
$51.79
|
|
|
PR OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP
|
Professional
|
Both
|
$43.62
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
z99211
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Aetna Commercial |
$8.57
|
| Rate for Payer: Aetna Commercial |
$8.57
|
| Rate for Payer: Aetna Medicare |
$8.57
|
| Rate for Payer: Aetna Medicare |
$8.57
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$19.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$19.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.98
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$19.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.98
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$5.88
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$5.88
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.45
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$21.45
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.86
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.86
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.43
|
| Rate for Payer: Cash Price |
$25.40
|
| Rate for Payer: Cash Price |
$26.17
|
| Rate for Payer: Centivo All Commercial |
$13.28
|
| Rate for Payer: Centivo All Commercial |
$13.28
|
| Rate for Payer: Cigna All Commercial |
$8.57
|
| Rate for Payer: Cigna All Commercial |
$8.57
|
| Rate for Payer: CORVEL All Commercial |
$8.57
|
| Rate for Payer: CORVEL All Commercial |
$8.57
|
| Rate for Payer: Coventry All Commercial |
$10.28
|
| Rate for Payer: Coventry All Commercial |
$10.28
|
| Rate for Payer: Encore All Commercial |
$8.57
|
| Rate for Payer: Encore All Commercial |
$8.57
|
| Rate for Payer: Frontpath All Commercial |
$9.17
|
| Rate for Payer: Frontpath All Commercial |
$9.17
|
| Rate for Payer: Humana ChoiceCare |
$8.67
|
| Rate for Payer: Humana ChoiceCare |
$8.67
|
| Rate for Payer: Humana Medicare |
$8.57
|
| Rate for Payer: Humana Medicare |
$8.57
|
| Rate for Payer: Lucent All Commercial |
$12.00
|
| Rate for Payer: Lucent All Commercial |
$12.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.00
|
| Rate for Payer: Managed Health Services Medicaid |
$21.45
|
| Rate for Payer: Managed Health Services Medicaid |
$21.45
|
| Rate for Payer: MDWise Medicaid |
$21.45
|
| Rate for Payer: MDWise Medicaid |
$21.45
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$5.88
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$5.88
|
| Rate for Payer: PHCS All Commercial |
$8.57
|
| Rate for Payer: PHCS All Commercial |
$8.57
|
| Rate for Payer: PHP All Commercial |
$8.46
|
| Rate for Payer: PHP All Commercial |
$8.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.57
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.57
|
| Rate for Payer: Sagamore Health Network All Products |
$8.57
|
| Rate for Payer: Sagamore Health Network All Products |
$8.57
|
| Rate for Payer: Signature Care EPO |
$18.40
|
| Rate for Payer: Signature Care EPO |
$18.40
|
| Rate for Payer: Signature Care PPO |
$18.40
|
| Rate for Payer: Signature Care PPO |
$18.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$900.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$900.00
|
| Rate for Payer: United Healthcare Commercial |
$8.75
|
| Rate for Payer: United Healthcare Commercial |
$8.75
|
| Rate for Payer: United Healthcare Medicare |
$21.17
|
| Rate for Payer: United Healthcare Medicare |
$21.17
|
|
|
PR OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES
|
Professional
|
Both
|
$414.92
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
z99205
|
| Min. Negotiated Rate |
$92.75 |
| Max. Negotiated Rate |
$17,600.00 |
| Rate for Payer: Aetna Commercial |
$174.24
|
| Rate for Payer: Aetna Commercial |
$174.24
|
| Rate for Payer: Aetna Medicare |
$174.24
|
| Rate for Payer: Aetna Medicare |
$174.24
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$201.30
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$92.75
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$92.75
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$204.08
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$204.08
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$200.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$200.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$191.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$191.66
|
| Rate for Payer: Cash Price |
$242.64
|
| Rate for Payer: Cash Price |
$248.95
|
| Rate for Payer: Centivo All Commercial |
$270.07
|
| Rate for Payer: Centivo All Commercial |
$270.07
|
| Rate for Payer: Cigna All Commercial |
$174.24
|
| Rate for Payer: Cigna All Commercial |
$174.24
|
| Rate for Payer: CORVEL All Commercial |
$174.24
|
| Rate for Payer: CORVEL All Commercial |
$174.24
|
| Rate for Payer: Coventry All Commercial |
$209.09
|
| Rate for Payer: Coventry All Commercial |
$209.09
|
| Rate for Payer: Encore All Commercial |
$174.24
|
| Rate for Payer: Encore All Commercial |
$174.24
|
| Rate for Payer: Frontpath All Commercial |
$189.17
|
| Rate for Payer: Frontpath All Commercial |
$189.17
|
| Rate for Payer: Humana ChoiceCare |
$136.28
|
| Rate for Payer: Humana ChoiceCare |
$136.28
|
| Rate for Payer: Humana Medicare |
$174.24
|
| Rate for Payer: Humana Medicare |
$174.24
|
| Rate for Payer: Lucent All Commercial |
$243.94
|
| Rate for Payer: Lucent All Commercial |
$243.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$180.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$180.00
|
| Rate for Payer: Managed Health Services Medicaid |
$204.08
|
| Rate for Payer: Managed Health Services Medicaid |
$204.08
|
| Rate for Payer: MDWise Medicaid |
$204.08
|
| Rate for Payer: MDWise Medicaid |
$204.08
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$92.75
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$92.75
|
| Rate for Payer: PHCS All Commercial |
$174.24
|
| Rate for Payer: PHCS All Commercial |
$174.24
|
| Rate for Payer: PHP All Commercial |
$171.97
|
| Rate for Payer: PHP All Commercial |
$171.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$174.24
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$174.24
|
| Rate for Payer: Sagamore Health Network All Products |
$174.24
|
| Rate for Payer: Sagamore Health Network All Products |
$174.24
|
| Rate for Payer: Signature Care EPO |
$177.75
|
| Rate for Payer: Signature Care EPO |
$177.75
|
| Rate for Payer: Signature Care PPO |
$177.75
|
| Rate for Payer: Signature Care PPO |
$177.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17,600.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$17,600.00
|
| Rate for Payer: United Healthcare Commercial |
$150.39
|
| Rate for Payer: United Healthcare Commercial |
$150.39
|
| Rate for Payer: United Healthcare Medicare |
$202.20
|
| Rate for Payer: United Healthcare Medicare |
$202.20
|
|
|
PR OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES
|
Professional
|
Both
|
$209.28
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
z99203
|
| Min. Negotiated Rate |
$42.22 |
| Max. Negotiated Rate |
$8,000.00 |
| Rate for Payer: Aetna Commercial |
$78.97
|
| Rate for Payer: Aetna Commercial |
$78.97
|
| Rate for Payer: Aetna Medicare |
$78.97
|
| Rate for Payer: Aetna Medicare |
$78.97
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$110.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$110.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$110.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$110.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$110.44
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$110.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$110.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$110.44
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$42.22
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$42.22
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$102.93
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$102.93
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$90.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$90.82
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$86.87
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$86.87
|
| Rate for Payer: Cash Price |
$123.06
|
| Rate for Payer: Cash Price |
$125.57
|
| Rate for Payer: Centivo All Commercial |
$122.40
|
| Rate for Payer: Centivo All Commercial |
$122.40
|
| Rate for Payer: Cigna All Commercial |
$78.97
|
| Rate for Payer: Cigna All Commercial |
$78.97
|
| Rate for Payer: CORVEL All Commercial |
$78.97
|
| Rate for Payer: CORVEL All Commercial |
$78.97
|
| Rate for Payer: Coventry All Commercial |
$94.76
|
| Rate for Payer: Coventry All Commercial |
$94.76
|
| Rate for Payer: Encore All Commercial |
$78.97
|
| Rate for Payer: Encore All Commercial |
$78.97
|
| Rate for Payer: Frontpath All Commercial |
$86.29
|
| Rate for Payer: Frontpath All Commercial |
$86.29
|
| Rate for Payer: Humana ChoiceCare |
$68.75
|
| Rate for Payer: Humana ChoiceCare |
$68.75
|
| Rate for Payer: Humana Medicare |
$78.97
|
| Rate for Payer: Humana Medicare |
$78.97
|
| Rate for Payer: Lucent All Commercial |
$110.56
|
| Rate for Payer: Lucent All Commercial |
$110.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$82.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$82.00
|
| Rate for Payer: Managed Health Services Medicaid |
$102.93
|
| Rate for Payer: Managed Health Services Medicaid |
$102.93
|
| Rate for Payer: MDWise Medicaid |
$102.93
|
| Rate for Payer: MDWise Medicaid |
$102.93
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$42.22
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$42.22
|
| Rate for Payer: PHCS All Commercial |
$78.97
|
| Rate for Payer: PHCS All Commercial |
$78.97
|
| Rate for Payer: PHP All Commercial |
$78.33
|
| Rate for Payer: PHP All Commercial |
$78.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$78.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$78.97
|
| Rate for Payer: Sagamore Health Network All Products |
$78.97
|
| Rate for Payer: Sagamore Health Network All Products |
$78.97
|
| Rate for Payer: Signature Care EPO |
$89.63
|
| Rate for Payer: Signature Care EPO |
$89.63
|
| Rate for Payer: Signature Care PPO |
$89.63
|
| Rate for Payer: Signature Care PPO |
$89.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,000.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$8,000.00
|
| Rate for Payer: United Healthcare Commercial |
$68.78
|
| Rate for Payer: United Healthcare Commercial |
$68.78
|
| Rate for Payer: United Healthcare Medicare |
$102.55
|
| Rate for Payer: United Healthcare Medicare |
$102.55
|
|
|
PR OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES
|
Professional
|
Both
|
$314.66
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
z99204
|
| Min. Negotiated Rate |
$68.35 |
| Max. Negotiated Rate |
$13,000.00 |
| Rate for Payer: Aetna Commercial |
$128.41
|
| Rate for Payer: Aetna Commercial |
$128.41
|
| Rate for Payer: Aetna Medicare |
$128.41
|
| Rate for Payer: Aetna Medicare |
$128.41
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$162.17
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$68.35
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$68.35
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$154.76
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$154.76
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$147.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$147.67
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$141.25
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$141.25
|
| Rate for Payer: Cash Price |
$183.74
|
| Rate for Payer: Cash Price |
$188.80
|
| Rate for Payer: Centivo All Commercial |
$199.04
|
| Rate for Payer: Centivo All Commercial |
$199.04
|
| Rate for Payer: Cigna All Commercial |
$128.41
|
| Rate for Payer: Cigna All Commercial |
$128.41
|
| Rate for Payer: CORVEL All Commercial |
$128.41
|
| Rate for Payer: CORVEL All Commercial |
$128.41
|
| Rate for Payer: Coventry All Commercial |
$154.09
|
| Rate for Payer: Coventry All Commercial |
$154.09
|
| Rate for Payer: Encore All Commercial |
$128.41
|
| Rate for Payer: Encore All Commercial |
$128.41
|
| Rate for Payer: Frontpath All Commercial |
$139.50
|
| Rate for Payer: Frontpath All Commercial |
$139.50
|
| Rate for Payer: Humana ChoiceCare |
$102.16
|
| Rate for Payer: Humana ChoiceCare |
$102.16
|
| Rate for Payer: Humana Medicare |
$128.41
|
| Rate for Payer: Humana Medicare |
$128.41
|
| Rate for Payer: Lucent All Commercial |
$179.77
|
| Rate for Payer: Lucent All Commercial |
$179.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.00
|
| Rate for Payer: Managed Health Services Medicaid |
$154.76
|
| Rate for Payer: Managed Health Services Medicaid |
$154.76
|
| Rate for Payer: MDWise Medicaid |
$154.76
|
| Rate for Payer: MDWise Medicaid |
$154.76
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$68.35
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$68.35
|
| Rate for Payer: PHCS All Commercial |
$128.41
|
| Rate for Payer: PHCS All Commercial |
$128.41
|
| Rate for Payer: PHP All Commercial |
$126.69
|
| Rate for Payer: PHP All Commercial |
$126.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$128.41
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$128.41
|
| Rate for Payer: Sagamore Health Network All Products |
$128.41
|
| Rate for Payer: Sagamore Health Network All Products |
$128.41
|
| Rate for Payer: Signature Care EPO |
$134.30
|
| Rate for Payer: Signature Care EPO |
$134.30
|
| Rate for Payer: Signature Care PPO |
$134.30
|
| Rate for Payer: Signature Care PPO |
$134.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,000.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$13,000.00
|
| Rate for Payer: United Healthcare Commercial |
$115.55
|
| Rate for Payer: United Healthcare Commercial |
$115.55
|
| Rate for Payer: United Healthcare Medicare |
$153.12
|
| Rate for Payer: United Healthcare Medicare |
$153.12
|
|
|
PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES
|
Professional
|
Both
|
$135.70
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
z99202
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$4,700.00 |
| Rate for Payer: Aetna Commercial |
$46.40
|
| Rate for Payer: Aetna Commercial |
$46.40
|
| Rate for Payer: Aetna Medicare |
$46.40
|
| Rate for Payer: Aetna Medicare |
$46.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$73.29
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$24.75
|
| Rate for Payer: Buckeye Health Medicaid OOS |
$24.75
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$66.74
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$66.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$53.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$53.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$51.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$51.04
|
| Rate for Payer: Cash Price |
$79.61
|
| Rate for Payer: Cash Price |
$81.42
|
| Rate for Payer: Centivo All Commercial |
$71.92
|
| Rate for Payer: Centivo All Commercial |
$71.92
|
| Rate for Payer: Cigna All Commercial |
$46.40
|
| Rate for Payer: Cigna All Commercial |
$46.40
|
| Rate for Payer: CORVEL All Commercial |
$46.40
|
| Rate for Payer: CORVEL All Commercial |
$46.40
|
| Rate for Payer: Coventry All Commercial |
$55.68
|
| Rate for Payer: Coventry All Commercial |
$55.68
|
| Rate for Payer: Encore All Commercial |
$46.40
|
| Rate for Payer: Encore All Commercial |
$46.40
|
| Rate for Payer: Frontpath All Commercial |
$50.49
|
| Rate for Payer: Frontpath All Commercial |
$50.49
|
| Rate for Payer: Humana ChoiceCare |
$44.82
|
| Rate for Payer: Humana ChoiceCare |
$44.82
|
| Rate for Payer: Humana Medicare |
$46.40
|
| Rate for Payer: Humana Medicare |
$46.40
|
| Rate for Payer: Lucent All Commercial |
$64.96
|
| Rate for Payer: Lucent All Commercial |
$64.96
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.00
|
| Rate for Payer: Managed Health Services Medicaid |
$66.74
|
| Rate for Payer: Managed Health Services Medicaid |
$66.74
|
| Rate for Payer: MDWise Medicaid |
$66.74
|
| Rate for Payer: MDWise Medicaid |
$66.74
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$24.75
|
| Rate for Payer: Molina Healthcare of OH Medicaid OOS/Medicare |
$24.75
|
| Rate for Payer: PHCS All Commercial |
$46.40
|
| Rate for Payer: PHCS All Commercial |
$46.40
|
| Rate for Payer: PHP All Commercial |
$45.68
|
| Rate for Payer: PHP All Commercial |
$45.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$46.40
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$46.40
|
| Rate for Payer: Sagamore Health Network All Products |
$46.40
|
| Rate for Payer: Sagamore Health Network All Products |
$46.40
|
| Rate for Payer: Signature Care EPO |
$58.24
|
| Rate for Payer: Signature Care EPO |
$58.24
|
| Rate for Payer: Signature Care PPO |
$58.24
|
| Rate for Payer: Signature Care PPO |
$58.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,700.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$4,700.00
|
| Rate for Payer: United Healthcare Commercial |
$45.58
|
| Rate for Payer: United Healthcare Commercial |
$45.58
|
| Rate for Payer: United Healthcare Medicare |
$66.34
|
| Rate for Payer: United Healthcare Medicare |
$66.34
|
|
|
PR OMENTAL FLAP,INTRA-ABDOMINAL
|
Professional
|
Both
|
$632.70
|
|
|
Service Code
|
CPT 49905
|
| Hospital Charge Code |
z49905
|
| Min. Negotiated Rate |
$311.19 |
| Max. Negotiated Rate |
$44,900.00 |
| Rate for Payer: Aetna Commercial |
$325.04
|
| Rate for Payer: Aetna Commercial |
$325.04
|
| Rate for Payer: Aetna Medicare |
$325.04
|
| Rate for Payer: Aetna Medicare |
$325.04
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$484.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$484.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$484.00
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$484.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$484.00
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$484.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$484.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$484.00
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$311.19
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$311.19
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$373.80
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$373.80
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$357.54
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$357.54
|
| Rate for Payer: Cash Price |
$379.62
|
| Rate for Payer: Cash Price |
$375.18
|
| Rate for Payer: Centivo All Commercial |
$503.81
|
| Rate for Payer: Centivo All Commercial |
$503.81
|
| Rate for Payer: Cigna All Commercial |
$325.04
|
| Rate for Payer: Cigna All Commercial |
$325.04
|
| Rate for Payer: CORVEL All Commercial |
$325.04
|
| Rate for Payer: CORVEL All Commercial |
$325.04
|
| Rate for Payer: Coventry All Commercial |
$390.05
|
| Rate for Payer: Coventry All Commercial |
$390.05
|
| Rate for Payer: Encore All Commercial |
$325.04
|
| Rate for Payer: Encore All Commercial |
$325.04
|
| Rate for Payer: Frontpath All Commercial |
$465.56
|
| Rate for Payer: Frontpath All Commercial |
$465.56
|
| Rate for Payer: Humana ChoiceCare |
$406.03
|
| Rate for Payer: Humana ChoiceCare |
$406.03
|
| Rate for Payer: Humana Medicare |
$325.04
|
| Rate for Payer: Humana Medicare |
$325.04
|
| Rate for Payer: Lucent All Commercial |
$455.06
|
| Rate for Payer: Lucent All Commercial |
$455.06
|
| Rate for Payer: Lutheran Preferred All Commercial |
$481.00
|
| Rate for Payer: Lutheran Preferred All Commercial |
$481.00
|
| Rate for Payer: Managed Health Services Medicaid |
$311.19
|
| Rate for Payer: Managed Health Services Medicaid |
$311.19
|
| Rate for Payer: MDWise Medicaid |
$311.19
|
| Rate for Payer: MDWise Medicaid |
$311.19
|
| Rate for Payer: PHCS All Commercial |
$325.04
|
| Rate for Payer: PHCS All Commercial |
$325.04
|
| Rate for Payer: PHP All Commercial |
$547.13
|
| Rate for Payer: PHP All Commercial |
$547.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$325.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$325.04
|
| Rate for Payer: Sagamore Health Network All Products |
$325.04
|
| Rate for Payer: Sagamore Health Network All Products |
$325.04
|
| Rate for Payer: Signature Care EPO |
$514.25
|
| Rate for Payer: Signature Care EPO |
$514.25
|
| Rate for Payer: Signature Care PPO |
$514.25
|
| Rate for Payer: Signature Care PPO |
$514.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$44,900.00
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$44,900.00
|
| Rate for Payer: United Healthcare Commercial |
$395.39
|
| Rate for Payer: United Healthcare Commercial |
$395.39
|
| Rate for Payer: United Healthcare Medicare |
$312.65
|
| Rate for Payer: United Healthcare Medicare |
$312.65
|
|
|
PROMETHAZINE 12.5 MG RECT SUPP
|
Facility
|
IP
|
$35.74
|
|
|
Service Code
|
HCPCS J8498
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.80 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$30.88
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Cigna All Commercial |
$30.84
|
| Rate for Payer: CORVEL All Commercial |
$33.23
|
| Rate for Payer: Coventry All Commercial |
$31.45
|
| Rate for Payer: Encore All Commercial |
$32.89
|
| Rate for Payer: Frontpath All Commercial |
$32.88
|
| Rate for Payer: Humana ChoiceCare |
$30.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.16
|
| Rate for Payer: PHCS All Commercial |
$26.80
|
| Rate for Payer: PHP All Commercial |
$27.10
|
| Rate for Payer: Sagamore Health Network All Products |
$27.59
|
| Rate for Payer: Signature Care EPO |
$29.66
|
| Rate for Payer: Signature Care PPO |
$31.45
|
| Rate for Payer: United Healthcare Commercial |
$28.16
|
|
|
PROMETHAZINE 12.5 MG RECT SUPP
|
Facility
|
OP
|
$35.74
|
|
|
Service Code
|
HCPCS J8498
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.08 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$30.16
|
| Rate for Payer: Aetna Medicare |
$11.44
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$20.52
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.34
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.15
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.58
|
| Rate for Payer: Cash Price |
$21.44
|
| Rate for Payer: Centivo All Commercial |
$19.44
|
| Rate for Payer: Cigna All Commercial |
$30.84
|
| Rate for Payer: CORVEL All Commercial |
$33.23
|
| Rate for Payer: Coventry All Commercial |
$31.45
|
| Rate for Payer: Encore All Commercial |
$32.89
|
| Rate for Payer: Frontpath All Commercial |
$32.88
|
| Rate for Payer: Humana ChoiceCare |
$30.86
|
| Rate for Payer: Humana Medicare |
$11.44
|
| Rate for Payer: Lucent All Commercial |
$19.44
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.16
|
| Rate for Payer: PHCS All Commercial |
$26.80
|
| Rate for Payer: PHP All Commercial |
$27.10
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.94
|
| Rate for Payer: Sagamore Health Network All Products |
$27.59
|
| Rate for Payer: Signature Care EPO |
$29.66
|
| Rate for Payer: Signature Care PPO |
$31.45
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$30.37
|
| Rate for Payer: United Healthcare Commercial |
$28.16
|
| Rate for Payer: United Healthcare Medicare |
$11.44
|
|
|
PROMETHAZINE 25 MG/ML INJ SOLN - FOR IM USE
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
800115
|
|
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
|
|
|
PROMETHAZINE 25 MG/ML INJ SOLN - FOR IM USE
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
800115
|
|
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
|
|
|
PROMETHAZINE 25 MG/ML INJ SOLN - FOR IV USE
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
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
|
|
|
PROMETHAZINE 25 MG/ML INJ SOLN - FOR IV USE
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J2550
|
| Hospital Charge Code |
6618
|
|
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
|
|
|
PROMETHAZINE 25 MG ORAL TAB
|
Facility
|
IP
|
$1.06
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna Commercial |
$0.92
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna All Commercial |
$0.92
|
| Rate for Payer: CORVEL All Commercial |
$0.99
|
| Rate for Payer: Coventry All Commercial |
$0.94
|
| Rate for Payer: Encore All Commercial |
$0.98
|
| Rate for Payer: Frontpath All Commercial |
$0.98
|
| Rate for Payer: Humana ChoiceCare |
$0.92
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.96
|
| Rate for Payer: PHCS All Commercial |
$0.80
|
| Rate for Payer: PHP All Commercial |
$0.81
|
| Rate for Payer: Sagamore Health Network All Products |
$0.82
|
| Rate for Payer: Signature Care EPO |
$0.88
|
| Rate for Payer: Signature Care PPO |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
|
|
PROMETHAZINE 25 MG ORAL TAB
|
Facility
|
OP
|
$1.06
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Medicare |
$0.34
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.61
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.37
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Centivo All Commercial |
$0.58
|
| Rate for Payer: Cigna All Commercial |
$0.92
|
| Rate for Payer: CORVEL All Commercial |
$0.99
|
| Rate for Payer: Coventry All Commercial |
$0.94
|
| Rate for Payer: Encore All Commercial |
$0.98
|
| Rate for Payer: Frontpath All Commercial |
$0.98
|
| Rate for Payer: Humana ChoiceCare |
$0.92
|
| Rate for Payer: Humana Medicare |
$0.34
|
| Rate for Payer: Lucent All Commercial |
$0.58
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.96
|
| Rate for Payer: PHCS All Commercial |
$0.80
|
| Rate for Payer: PHP All Commercial |
$0.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.41
|
| Rate for Payer: Sagamore Health Network All Products |
$0.82
|
| Rate for Payer: Signature Care EPO |
$0.88
|
| Rate for Payer: Signature Care PPO |
$0.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.90
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.34
|
|
