|
PR OFFICE/OP CONSLTJ NEW/EST PT SF MDM 20 MINUTES
|
Professional
|
$139.86
|
|
|
Service Code
|
CPT 99242
|
| Hospital Charge Code |
z99242
|
| Min. Negotiated Rate |
$53.73 |
| Max. Negotiated Rate |
$104.90 |
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$73.29
|
| Rate for Payer: Cash Price |
$86.71
|
| Rate for Payer: Cash Price |
$86.71
|
| Rate for Payer: Frontpath All Commercial |
$67.28
|
| Rate for Payer: Humana ChoiceCare |
$78.77
|
| Rate for Payer: Lutheran Preferred All Commercial |
$56.00
|
| Rate for Payer: PHCS All Commercial |
$104.90
|
| Rate for Payer: PHP All Commercial |
$53.73
|
| Rate for Payer: Signature Care EPO |
$95.20
|
| Rate for Payer: Signature Care PPO |
$95.20
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$55.00
|
| Rate for Payer: United Healthcare Commercial |
$70.39
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED HIGH MDM 40 MIN
|
Professional
|
$330.56
|
|
|
Service Code
|
CPT 99215
|
| Hospital Charge Code |
z99215
|
| Min. Negotiated Rate |
$90.72 |
| Max. Negotiated Rate |
$247.92 |
| Rate for Payer: Aetna Medicare |
$136.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$141.38
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$141.38
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$156.49
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$149.69
|
| Rate for Payer: Cash Price |
$204.95
|
| Rate for Payer: Cash Price |
$204.95
|
| Rate for Payer: Coventry All Commercial |
$163.30
|
| Rate for Payer: Frontpath All Commercial |
$149.79
|
| Rate for Payer: Humana ChoiceCare |
$90.72
|
| Rate for Payer: Humana Medicare |
$136.08
|
| Rate for Payer: Lucent All Commercial |
$231.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$143.00
|
| Rate for Payer: PHCS All Commercial |
$247.92
|
| Rate for Payer: PHP All Commercial |
$136.74
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$136.08
|
| Rate for Payer: Signature Care EPO |
$145.60
|
| Rate for Payer: Signature Care PPO |
$145.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$140.00
|
| Rate for Payer: United Healthcare Commercial |
$100.15
|
| Rate for Payer: United Healthcare Medicare |
$136.08
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED LOW MDM 20 MIN
|
Professional
|
$166.20
|
|
|
Service Code
|
CPT 99213
|
| Hospital Charge Code |
z99213
|
| Min. Negotiated Rate |
$34.13 |
| Max. Negotiated Rate |
$124.65 |
| Rate for Payer: Aetna Medicare |
$62.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$74.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$74.64
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$72.04
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$68.90
|
| Rate for Payer: Cash Price |
$103.04
|
| Rate for Payer: Cash Price |
$103.04
|
| Rate for Payer: Coventry All Commercial |
$75.17
|
| Rate for Payer: Frontpath All Commercial |
$68.80
|
| Rate for Payer: Humana ChoiceCare |
$34.13
|
| Rate for Payer: Humana Medicare |
$62.64
|
| Rate for Payer: Lucent All Commercial |
$106.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$66.00
|
| Rate for Payer: PHCS All Commercial |
$124.65
|
| Rate for Payer: PHP All Commercial |
$62.95
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$62.64
|
| Rate for Payer: Signature Care EPO |
$72.96
|
| Rate for Payer: Signature Care PPO |
$72.96
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$65.00
|
| Rate for Payer: United Healthcare Commercial |
$45.60
|
| Rate for Payer: United Healthcare Medicare |
$62.64
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED MOD MDM 30 MIN
|
Professional
|
$235.56
|
|
|
Service Code
|
CPT 99214
|
| Hospital Charge Code |
z99214
|
| Min. Negotiated Rate |
$56.59 |
| Max. Negotiated Rate |
$176.67 |
| Rate for Payer: Aetna Medicare |
$92.63
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$105.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$105.54
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$106.52
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$101.89
|
| Rate for Payer: Cash Price |
$146.05
|
| Rate for Payer: Cash Price |
$146.05
|
| Rate for Payer: Coventry All Commercial |
$111.16
|
| Rate for Payer: Frontpath All Commercial |
$100.78
|
| Rate for Payer: Humana ChoiceCare |
$56.59
|
| Rate for Payer: Humana Medicare |
$92.63
|
| Rate for Payer: Lucent All Commercial |
$157.47
|
| Rate for Payer: Lutheran Preferred All Commercial |
$97.00
|
| Rate for Payer: PHCS All Commercial |
$176.67
|
| Rate for Payer: PHP All Commercial |
$93.08
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$92.63
|
| Rate for Payer: Signature Care EPO |
$103.39
|
| Rate for Payer: Signature Care PPO |
$103.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$95.00
|
| Rate for Payer: United Healthcare Commercial |
$70.55
|
| Rate for Payer: United Healthcare Medicare |
$92.63
|
|
|
PR OFFICE/OUTPATIENT ESTABLISHED SF MDM 10 MIN
|
Professional
|
$103.58
|
|
|
Service Code
|
CPT 99212
|
| Hospital Charge Code |
z99212
|
| Min. Negotiated Rate |
$23.04 |
| Max. Negotiated Rate |
$77.68 |
| Rate for Payer: Aetna Medicare |
$33.64
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$43.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$43.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$38.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$37.00
|
| Rate for Payer: Cash Price |
$64.22
|
| Rate for Payer: Cash Price |
$64.22
|
| Rate for Payer: Coventry All Commercial |
$40.37
|
| Rate for Payer: Frontpath All Commercial |
$37.48
|
| Rate for Payer: Humana ChoiceCare |
$23.04
|
| Rate for Payer: Humana Medicare |
$33.64
|
| Rate for Payer: Lucent All Commercial |
$57.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.00
|
| Rate for Payer: PHCS All Commercial |
$77.68
|
| Rate for Payer: PHP All Commercial |
$33.80
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$33.64
|
| Rate for Payer: Signature Care EPO |
$45.11
|
| Rate for Payer: Signature Care PPO |
$45.11
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$35.00
|
| Rate for Payer: United Healthcare Commercial |
$23.29
|
| Rate for Payer: United Healthcare Medicare |
$33.64
|
|
|
PR OFFICE/OUTPATIENT EST PT MAY NOT REQ PHYS/QHP
|
Professional
|
$42.34
|
|
|
Service Code
|
CPT 99211
|
| Hospital Charge Code |
z99211
|
| Min. Negotiated Rate |
$8.42 |
| Max. Negotiated Rate |
$31.76 |
| Rate for Payer: Aetna Medicare |
$8.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$19.98
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$19.98
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.68
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.26
|
| Rate for Payer: Cash Price |
$26.25
|
| Rate for Payer: Cash Price |
$26.25
|
| Rate for Payer: Coventry All Commercial |
$10.10
|
| Rate for Payer: Frontpath All Commercial |
$9.17
|
| Rate for Payer: Humana ChoiceCare |
$8.67
|
| Rate for Payer: Humana Medicare |
$8.42
|
| Rate for Payer: Lucent All Commercial |
$14.31
|
| Rate for Payer: Lutheran Preferred All Commercial |
$9.00
|
| Rate for Payer: PHCS All Commercial |
$31.76
|
| Rate for Payer: PHP All Commercial |
$8.46
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$8.42
|
| Rate for Payer: Signature Care EPO |
$18.40
|
| Rate for Payer: Signature Care PPO |
$18.40
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$9.00
|
| Rate for Payer: United Healthcare Commercial |
$8.75
|
| Rate for Payer: United Healthcare Medicare |
$8.42
|
|
|
PR OFFICE/OUTPATIENT NEW HIGH MDM 60 MINUTES
|
Professional
|
$404.40
|
|
|
Service Code
|
CPT 99205
|
| Hospital Charge Code |
z99205
|
| Min. Negotiated Rate |
$136.28 |
| Max. Negotiated Rate |
$303.30 |
| Rate for Payer: Aetna Medicare |
$171.14
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$201.30
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$201.30
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$196.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$188.25
|
| Rate for Payer: Cash Price |
$250.73
|
| Rate for Payer: Cash Price |
$250.73
|
| Rate for Payer: Coventry All Commercial |
$205.37
|
| Rate for Payer: Frontpath All Commercial |
$189.17
|
| Rate for Payer: Humana ChoiceCare |
$136.28
|
| Rate for Payer: Humana Medicare |
$171.14
|
| Rate for Payer: Lucent All Commercial |
$290.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$180.00
|
| Rate for Payer: PHCS All Commercial |
$303.30
|
| Rate for Payer: PHP All Commercial |
$171.97
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$171.14
|
| Rate for Payer: Signature Care EPO |
$177.75
|
| Rate for Payer: Signature Care PPO |
$177.75
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$176.00
|
| Rate for Payer: United Healthcare Commercial |
$150.39
|
| Rate for Payer: United Healthcare Medicare |
$171.14
|
|
|
PR OFFICE/OUTPATIENT NEW LOW MDM 30 MINUTES
|
Professional
|
$205.10
|
|
|
Service Code
|
CPT 99203
|
| Hospital Charge Code |
z99203
|
| Min. Negotiated Rate |
$68.75 |
| Max. Negotiated Rate |
$153.82 |
| Rate for Payer: Aetna Medicare |
$77.95
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$110.44
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$110.44
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$89.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$85.74
|
| Rate for Payer: Cash Price |
$127.16
|
| Rate for Payer: Cash Price |
$127.16
|
| Rate for Payer: Coventry All Commercial |
$93.54
|
| Rate for Payer: Frontpath All Commercial |
$86.29
|
| Rate for Payer: Humana ChoiceCare |
$68.75
|
| Rate for Payer: Humana Medicare |
$77.95
|
| Rate for Payer: Lucent All Commercial |
$132.52
|
| Rate for Payer: Lutheran Preferred All Commercial |
$82.00
|
| Rate for Payer: PHCS All Commercial |
$153.82
|
| Rate for Payer: PHP All Commercial |
$78.33
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$77.95
|
| Rate for Payer: Signature Care EPO |
$89.63
|
| Rate for Payer: Signature Care PPO |
$89.63
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$80.00
|
| Rate for Payer: United Healthcare Commercial |
$68.78
|
| Rate for Payer: United Healthcare Medicare |
$77.95
|
|
|
PR OFFICE/OUTPATIENT NEW MODERATE MDM 45 MINUTES
|
Professional
|
$306.24
|
|
|
Service Code
|
CPT 99204
|
| Hospital Charge Code |
z99204
|
| Min. Negotiated Rate |
$102.16 |
| Max. Negotiated Rate |
$229.68 |
| Rate for Payer: Aetna Medicare |
$126.08
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$162.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$162.17
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$144.99
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$138.69
|
| Rate for Payer: Cash Price |
$189.87
|
| Rate for Payer: Cash Price |
$189.87
|
| Rate for Payer: Coventry All Commercial |
$151.30
|
| Rate for Payer: Frontpath All Commercial |
$139.50
|
| Rate for Payer: Humana ChoiceCare |
$102.16
|
| Rate for Payer: Humana Medicare |
$126.08
|
| Rate for Payer: Lucent All Commercial |
$214.34
|
| Rate for Payer: Lutheran Preferred All Commercial |
$132.00
|
| Rate for Payer: PHCS All Commercial |
$229.68
|
| Rate for Payer: PHP All Commercial |
$126.69
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$126.08
|
| Rate for Payer: Signature Care EPO |
$134.30
|
| Rate for Payer: Signature Care PPO |
$134.30
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$130.00
|
| Rate for Payer: United Healthcare Commercial |
$115.55
|
| Rate for Payer: United Healthcare Medicare |
$126.08
|
|
|
PR OFFICE/OUTPATIENT NEW SF MDM 15 MINUTES
|
Professional
|
$132.68
|
|
|
Service Code
|
CPT 99202
|
| Hospital Charge Code |
z99202
|
| Min. Negotiated Rate |
$44.82 |
| Max. Negotiated Rate |
$99.51 |
| Rate for Payer: Aetna Medicare |
$45.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$73.29
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$73.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$52.28
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$50.01
|
| Rate for Payer: Cash Price |
$82.26
|
| Rate for Payer: Cash Price |
$82.26
|
| Rate for Payer: Coventry All Commercial |
$54.55
|
| Rate for Payer: Frontpath All Commercial |
$50.49
|
| Rate for Payer: Humana ChoiceCare |
$44.82
|
| Rate for Payer: Humana Medicare |
$45.46
|
| Rate for Payer: Lucent All Commercial |
$77.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$48.00
|
| Rate for Payer: PHCS All Commercial |
$99.51
|
| Rate for Payer: PHP All Commercial |
$45.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$45.46
|
| Rate for Payer: Signature Care EPO |
$58.24
|
| Rate for Payer: Signature Care PPO |
$58.24
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$47.00
|
| Rate for Payer: United Healthcare Commercial |
$45.58
|
| Rate for Payer: United Healthcare Medicare |
$45.46
|
|
|
PR OMENTAL FLAP,INTRA-ABDOMINAL
|
Professional
|
$625.30
|
|
|
Service Code
|
CPT 49905
|
| Hospital Charge Code |
z49905
|
| Min. Negotiated Rate |
$320.46 |
| Max. Negotiated Rate |
$547.13 |
| Rate for Payer: Aetna Medicare |
$320.46
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$484.00
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$484.00
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$368.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$352.51
|
| Rate for Payer: Cash Price |
$387.69
|
| Rate for Payer: Cash Price |
$387.69
|
| Rate for Payer: Coventry All Commercial |
$384.55
|
| Rate for Payer: Frontpath All Commercial |
$465.56
|
| Rate for Payer: Humana ChoiceCare |
$406.03
|
| Rate for Payer: Humana Medicare |
$320.46
|
| Rate for Payer: Lucent All Commercial |
$544.78
|
| Rate for Payer: Lutheran Preferred All Commercial |
$481.00
|
| Rate for Payer: PHCS All Commercial |
$468.98
|
| Rate for Payer: PHP All Commercial |
$547.13
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$320.46
|
| Rate for Payer: Signature Care EPO |
$514.25
|
| Rate for Payer: Signature Care PPO |
$514.25
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$449.00
|
| Rate for Payer: United Healthcare Commercial |
$395.39
|
| Rate for Payer: United Healthcare Medicare |
$320.46
|
|
|
PROMETHAZINE 12.5 MG RECT SUPP
|
Facility
OP
|
$35.66
|
|
|
Service Code
|
HCPCS J8498
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.77 |
| Max. Negotiated Rate |
$33.16 |
| Rate for Payer: Aetna Commercial |
$30.10
|
| Rate for Payer: Aetna Medicare |
$11.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$20.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$22.29
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$13.53
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$12.94
|
| Rate for Payer: Cash Price |
$22.11
|
| Rate for Payer: Centivo All Commercial |
$18.19
|
| Rate for Payer: Cigna All Commercial |
$30.77
|
| Rate for Payer: CORVEL All Commercial |
$33.16
|
| Rate for Payer: Coventry All Commercial |
$31.38
|
| Rate for Payer: Encore All Commercial |
$32.82
|
| Rate for Payer: Frontpath All Commercial |
$32.81
|
| Rate for Payer: Humana ChoiceCare |
$30.80
|
| Rate for Payer: Humana Medicare |
$18.19
|
| Rate for Payer: Lucent All Commercial |
$18.19
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.09
|
| Rate for Payer: PHCS All Commercial |
$26.74
|
| Rate for Payer: PHP All Commercial |
$27.04
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$13.91
|
| Rate for Payer: Sagamore Health Network All Products |
$27.53
|
| Rate for Payer: Signature Care EPO |
$29.60
|
| Rate for Payer: Signature Care PPO |
$31.38
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$30.31
|
| Rate for Payer: United Healthcare Commercial |
$28.10
|
| Rate for Payer: United Healthcare Medicare |
$11.77
|
|
|
PROMETHAZINE 12.5 MG RECT SUPP
|
Facility
IP
|
$35.66
|
|
|
Service Code
|
HCPCS J8498
|
| Hospital Charge Code |
11143
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$26.74 |
| Max. Negotiated Rate |
$33.16 |
| Rate for Payer: Aetna Commercial |
$30.81
|
| Rate for Payer: Cash Price |
$22.11
|
| Rate for Payer: Cigna All Commercial |
$30.77
|
| Rate for Payer: CORVEL All Commercial |
$33.16
|
| Rate for Payer: Coventry All Commercial |
$31.38
|
| Rate for Payer: Encore All Commercial |
$32.82
|
| Rate for Payer: Frontpath All Commercial |
$32.81
|
| Rate for Payer: Humana ChoiceCare |
$30.80
|
| Rate for Payer: Lutheran Preferred All Commercial |
$32.09
|
| Rate for Payer: PHCS All Commercial |
$26.74
|
| Rate for Payer: PHP All Commercial |
$27.04
|
| Rate for Payer: Sagamore Health Network All Products |
$27.53
|
| Rate for Payer: Signature Care EPO |
$29.60
|
| Rate for Payer: Signature Care PPO |
$31.38
|
| Rate for Payer: United Healthcare Commercial |
$28.10
|
|
|
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 |
$5.94 |
| 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
|
|
|
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 |
$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
|
|
|
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 |
$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
|
|
|
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 |
$5.94 |
| 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
|
|
|
PROMETHAZINE 25 MG ORAL TAB
|
Facility
OP
|
$1.08
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna Commercial |
$0.91
|
| Rate for Payer: Aetna Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.36
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Centivo All Commercial |
$0.55
|
| Rate for Payer: Cigna All Commercial |
$0.93
|
| Rate for Payer: CORVEL All Commercial |
$1.00
|
| Rate for Payer: Coventry All Commercial |
$0.95
|
| Rate for Payer: Encore All Commercial |
$0.99
|
| Rate for Payer: Frontpath All Commercial |
$0.99
|
| Rate for Payer: Humana ChoiceCare |
$0.93
|
| Rate for Payer: Humana Medicare |
$0.55
|
| Rate for Payer: Lucent All Commercial |
$0.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.97
|
| Rate for Payer: PHCS All Commercial |
$0.81
|
| Rate for Payer: PHP All Commercial |
$0.82
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.42
|
| Rate for Payer: Sagamore Health Network All Products |
$0.83
|
| Rate for Payer: Signature Care EPO |
$0.89
|
| Rate for Payer: Signature Care PPO |
$0.95
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.92
|
| Rate for Payer: United Healthcare Commercial |
$0.85
|
| Rate for Payer: United Healthcare Medicare |
$0.36
|
|
|
PROMETHAZINE 25 MG ORAL TAB
|
Facility
IP
|
$1.08
|
|
|
Service Code
|
HCPCS Q0169
|
| Hospital Charge Code |
6622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna Commercial |
$0.93
|
| Rate for Payer: Cash Price |
$0.67
|
| Rate for Payer: Cigna All Commercial |
$0.93
|
| Rate for Payer: CORVEL All Commercial |
$1.00
|
| Rate for Payer: Coventry All Commercial |
$0.95
|
| Rate for Payer: Encore All Commercial |
$0.99
|
| Rate for Payer: Frontpath All Commercial |
$0.99
|
| Rate for Payer: Humana ChoiceCare |
$0.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.97
|
| Rate for Payer: PHCS All Commercial |
$0.81
|
| Rate for Payer: PHP All Commercial |
$0.82
|
| Rate for Payer: Sagamore Health Network All Products |
$0.83
|
| Rate for Payer: Signature Care EPO |
$0.89
|
| Rate for Payer: Signature Care PPO |
$0.95
|
| Rate for Payer: United Healthcare Commercial |
$0.85
|
|
|
PROMETHAZINE 25 MG RECT SUPP
|
Facility
OP
|
$25.95
|
|
|
Service Code
|
HCPCS J8498
|
| Hospital Charge Code |
11144
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.56 |
| Max. Negotiated Rate |
$24.13 |
| Rate for Payer: Aetna Commercial |
$21.90
|
| Rate for Payer: Aetna Medicare |
$8.56
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$8.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$14.90
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$16.22
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$9.85
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$9.42
|
| Rate for Payer: Cash Price |
$16.09
|
| Rate for Payer: Centivo All Commercial |
$13.23
|
| Rate for Payer: Cigna All Commercial |
$22.39
|
| Rate for Payer: CORVEL All Commercial |
$24.13
|
| Rate for Payer: Coventry All Commercial |
$22.84
|
| Rate for Payer: Encore All Commercial |
$23.89
|
| Rate for Payer: Frontpath All Commercial |
$23.87
|
| Rate for Payer: Humana ChoiceCare |
$22.41
|
| Rate for Payer: Humana Medicare |
$13.23
|
| Rate for Payer: Lucent All Commercial |
$13.23
|
| Rate for Payer: Lutheran Preferred All Commercial |
$23.35
|
| Rate for Payer: PHCS All Commercial |
$19.46
|
| Rate for Payer: PHP All Commercial |
$19.68
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$10.12
|
| Rate for Payer: Sagamore Health Network All Products |
$20.03
|
| Rate for Payer: Signature Care EPO |
$21.54
|
| Rate for Payer: Signature Care PPO |
$22.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$22.06
|
| Rate for Payer: United Healthcare Commercial |
$20.45
|
| Rate for Payer: United Healthcare Medicare |
$8.56
|
|
|
PROMETHAZINE 25 MG RECT SUPP
|
Facility
IP
|
$25.95
|
|
|
Service Code
|
HCPCS J8498
|
| Hospital Charge Code |
11144
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.46 |
| Max. Negotiated Rate |
$24.13 |
| Rate for Payer: Aetna Commercial |
$22.42
|
| Rate for Payer: Cash Price |
$16.09
|
| Rate for Payer: Cigna All Commercial |
$22.39
|
| Rate for Payer: CORVEL All Commercial |
$24.13
|
| Rate for Payer: Coventry All Commercial |
$22.84
|
| Rate for Payer: Encore All Commercial |
$23.89
|
| 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 |
$19.68
|
| Rate for Payer: Sagamore Health Network All Products |
$20.03
|
| Rate for Payer: Signature Care EPO |
$21.54
|
| Rate for Payer: Signature Care PPO |
$22.84
|
| Rate for Payer: United Healthcare Commercial |
$20.45
|
|
|
PROMETHAZINE 25 MG TABLET #4 ED PACK (CAMERON)
|
Facility
IP
|
$4.31
|
|
|
Service Code
|
NDC 009047304
|
| Hospital Charge Code |
1401000800203
|
|
Hospital Revenue Code
|
253
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$4.01 |
| Rate for Payer: Aetna Commercial |
$3.73
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Cigna All Commercial |
$3.72
|
| Rate for Payer: CORVEL All Commercial |
$4.01
|
| Rate for Payer: Coventry All Commercial |
$3.79
|
| Rate for Payer: Encore All Commercial |
$3.97
|
| Rate for Payer: Frontpath All Commercial |
$3.97
|
| Rate for Payer: Humana ChoiceCare |
$3.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.88
|
| Rate for Payer: PHCS All Commercial |
$3.23
|
| Rate for Payer: PHP All Commercial |
$3.27
|
| Rate for Payer: Sagamore Health Network All Products |
$3.33
|
| Rate for Payer: Signature Care EPO |
$3.58
|
| Rate for Payer: Signature Care PPO |
$3.79
|
| Rate for Payer: United Healthcare Commercial |
$3.40
|
|
|
PROMETHAZINE 25 MG TABLET #4 ED PACK (CAMERON)
|
Facility
OP
|
$4.31
|
|
|
Service Code
|
NDC 009047304
|
| Hospital Charge Code |
1401000800203
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.42 |
| Max. Negotiated Rate |
$4.01 |
| Rate for Payer: Aetna Commercial |
$3.64
|
| Rate for Payer: Aetna Medicare |
$1.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$1.42
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$2.48
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$2.70
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.64
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.57
|
| Rate for Payer: Cash Price |
$2.67
|
| Rate for Payer: Centivo All Commercial |
$2.20
|
| Rate for Payer: Cigna All Commercial |
$3.72
|
| Rate for Payer: CORVEL All Commercial |
$4.01
|
| Rate for Payer: Coventry All Commercial |
$3.79
|
| Rate for Payer: Encore All Commercial |
$3.97
|
| Rate for Payer: Frontpath All Commercial |
$3.97
|
| Rate for Payer: Humana ChoiceCare |
$3.72
|
| Rate for Payer: Humana Medicare |
$2.20
|
| Rate for Payer: Lucent All Commercial |
$2.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$3.88
|
| Rate for Payer: PHCS All Commercial |
$3.23
|
| Rate for Payer: PHP All Commercial |
$3.27
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.68
|
| Rate for Payer: Sagamore Health Network All Products |
$3.33
|
| Rate for Payer: Signature Care EPO |
$3.58
|
| Rate for Payer: Signature Care PPO |
$3.79
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$3.67
|
| Rate for Payer: United Healthcare Commercial |
$3.40
|
| Rate for Payer: United Healthcare Medicare |
$1.42
|
|
|
PR ONDANSETRON ORAL
|
Professional
|
$0.01
|
|
|
Service Code
|
CPT Q0162
|
| Hospital Charge Code |
zQ0162
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Humana ChoiceCare |
$0.01
|
| Rate for Payer: United Healthcare Commercial |
$0.01
|
|
|
PROPARACAINE 0.5 % OPHT DROP
|
Facility
IP
|
$205.28
|
|
|
Service Code
|
NDC 61314001601
|
| Hospital Charge Code |
6644
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$153.96 |
| Max. Negotiated Rate |
$190.91 |
| Rate for Payer: Aetna Commercial |
$177.36
|
| Rate for Payer: Cash Price |
$127.27
|
| Rate for Payer: Cigna All Commercial |
$177.15
|
| Rate for Payer: CORVEL All Commercial |
$190.91
|
| Rate for Payer: Coventry All Commercial |
$180.64
|
| Rate for Payer: Encore All Commercial |
$188.96
|
| Rate for Payer: Frontpath All Commercial |
$188.85
|
| Rate for Payer: Humana ChoiceCare |
$177.30
|
| Rate for Payer: Lutheran Preferred All Commercial |
$184.75
|
| Rate for Payer: PHCS All Commercial |
$153.96
|
| Rate for Payer: PHP All Commercial |
$155.68
|
| Rate for Payer: Sagamore Health Network All Products |
$158.47
|
| Rate for Payer: Signature Care EPO |
$170.38
|
| Rate for Payer: Signature Care PPO |
$180.64
|
| Rate for Payer: United Healthcare Commercial |
$161.76
|
|
