Keystone HMO Proactive: disclosed hospital rates

iDirect answer

Based on the published hospital price files, Keystone HMO Proactive appears in disclosed negotiated rates across 4 hospitals and 220 services. This is public hospital price transparency data, not a guaranteed estimate of your bill.

Actual patient responsibility may vary based on your insurance plan, deductible, coinsurance, network status, diagnosis, setting, bundled services, clinical circumstances, and hospital billing practices.

220 prices shown.

Service	Hospital	Code	List price	Cash price	Negotiated range	Allowed (median)
ALTEPLASE (TPA) 1 MG/ML SYRINGE EVD CLEARANCE Outpatient	Penn Presbyterian Medical Center	J2997 HCPCS	$255	$255	$38.25 – $255	—
ALTEPLASE (TPA) 1 MG/ML SYRINGE EVD CLEARANCE Outpatient	Pennsylvania Hospital	J2997 HCPCS	$255	$255	$44.83 – $255	—
ALTEPLASE (TPA) 1 MG/ML SYRINGE EVD CLEARANCE Outpatient	Penn Medicine Chester County Hospital	J2997 HCPCS	$255	$255	$51.00 – $255	—
ALTEPLASE (TPA) INJECTION 1MG/ML ORD Outpatient	Penn Presbyterian Medical Center	J2997 HCPCS	$308	$308	$46.20 – $308	—
ALTEPLASE (TPA) INJECTION 1MG/ML ORD Outpatient	Pennsylvania Hospital	J2997 HCPCS	$308	$308	$54.15 – $308	—
ALTEPLASE (TPA) INJECTION 1MG/ML ORD Outpatient	Penn Medicine Chester County Hospital	J2997 HCPCS	$308	$308	$61.60 – $308	—
ALTEPLASE (TPA) INJECTION 5MG/5ML ORD Outpatient	Penn Presbyterian Medical Center	J2997 HCPCS	$1,372	$1,372	$91.48 – $1,372	—
ALTEPLASE (TPA) INJECTION 5MG/5ML ORD Outpatient	Pennsylvania Hospital	J2997 HCPCS	$1,372	$1,372	$91.48 – $1,372	—
ALTEPLASE (TPA) INJECTION 5MG/5ML ORD Outpatient	Penn Medicine Chester County Hospital	J2997 HCPCS	$1,372	$1,372	$93.83 – $1,372	—
ALTEPLASE TPA 1 MG ML SYRINGE EVD CLEARANCE Outpatient	The Hospital of the University of Pennsylvania	J2997 HCPCS	$255	$255	$44.83 – $255	—
AMINOCAPROIC ACID IVPB 10G 100ML NSS CNR Outpatient	The Hospital of the University of Pennsylvania	J0290 HCPCS	$75.00	$75.00	$0.49 – $75.00	—
AMPHOTERICIN B 100 MCG/ML NASAL IRRIGATION ORD Outpatient	Penn Presbyterian Medical Center	J0285 HCPCS	$28.00	$28.00	$3.39 – $96.37	—
AMPHOTERICIN B 100 MCG/ML NASAL IRRIGATION ORD Outpatient	Pennsylvania Hospital	J0285 HCPCS	$28.00	$28.00	$3.78 – $96.37	—
AMPHOTERICIN B 100 MCG/ML NASAL IRRIGATION ORD Outpatient	Penn Medicine Chester County Hospital	J0285 HCPCS	$28.00	$28.00	$4.56 – $47.62	—
AMPICILLIN IVPB 1G/50ML NSS (CNR) Outpatient	Penn Presbyterian Medical Center	J0290 HCPCS	$31.00	$31.00	$0.49 – $31.00	—
AMPICILLIN IVPB 1G/50ML NSS (CNR) Outpatient	Pennsylvania Hospital	J0290 HCPCS	$31.00	$31.00	$0.49 – $31.00	—
AMPICILLIN IVPB 1G/50ML NSS (CNR) Outpatient	Penn Medicine Chester County Hospital	J0290 HCPCS	$31.00	$31.00	$0.49 – $31.00	—
AMPICILLIN IVPB 2G/100ML NSS (CNR) Outpatient	Penn Presbyterian Medical Center	J0290 HCPCS	$56.00	$56.00	$0.49 – $56.00	—
AMPICILLIN IVPB 2G/100ML NSS (CNR) Outpatient	Pennsylvania Hospital	J0290 HCPCS	$56.00	$56.00	$0.49 – $56.00	—
AMPICILLIN IVPB 2G/100ML NSS (CNR) Outpatient	Penn Medicine Chester County Hospital	J0290 HCPCS	$56.00	$56.00	$0.49 – $56.00	—
ATROPINE SULFATE 0.4 MG/ML INJECTION SOLN (WRAPPER Outpatient	Penn Presbyterian Medical Center	J0461 HCPCS	$32.00	$32.00	$0.07 – $32.00	—
ATROPINE SULFATE 0.4 MG/ML INJECTION SOLN (WRAPPER Outpatient	Pennsylvania Hospital	J0461 HCPCS	$32.00	$32.00	$0.07 – $32.00	—
ATROPINE SULFATE 0.4 MG/ML INJECTION SOLN (WRAPPER Outpatient	Penn Medicine Chester County Hospital	J0461 HCPCS	$32.00	$32.00	$0.07 – $32.00	—
BETAMETHASONE SOD PHOS ACET 6 (33) MG/ML INJECTI Outpatient	Penn Presbyterian Medical Center	J0702 HCPCS	$48.00	$48.00	$5.81 – $48.00	—
BETAMETHASONE SOD PHOS ACET 6 (33) MG/ML INJECTI Outpatient	Pennsylvania Hospital	J0702 HCPCS	$48.00	$48.00	$6.48 – $48.00	—