|
FINGER LT: ROUTINE MIN 2V
|
Facility
|
OP
|
$426.00
|
|
|
Service Code
|
HCPCS 73140
|
| Hospital Charge Code |
32000089
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$408.96 |
| Rate for Payer: Aetna Commercial |
$328.02
|
| Rate for Payer: Anthem Medicaid |
$146.50
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$332.28
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$353.58
|
| Rate for Payer: First Health Commercial |
$404.70
|
| Rate for Payer: Humana Commercial |
$362.10
|
| Rate for Payer: Humana KY Medicaid |
$146.50
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$147.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$349.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$314.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$149.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.88
|
| Rate for Payer: Ohio Health Group HMO |
$319.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$370.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.94
|
| Rate for Payer: PHCS Commercial |
$408.96
|
| Rate for Payer: United Healthcare All Payer |
$374.88
|
|
|
FINGER LT: ROUTINE MIN 2V
|
Facility
|
IP
|
$426.00
|
|
|
Service Code
|
HCPCS 73140
|
| Hospital Charge Code |
32000089
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$127.80 |
| Max. Negotiated Rate |
$408.96 |
| Rate for Payer: Aetna Commercial |
$328.02
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$332.28
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$353.58
|
| Rate for Payer: First Health Commercial |
$404.70
|
| Rate for Payer: Humana Commercial |
$362.10
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$349.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$314.39
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$127.80
|
| Rate for Payer: Ohio Health Choice Commercial |
$374.88
|
| Rate for Payer: Ohio Health Group HMO |
$319.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$340.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$370.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$293.94
|
| Rate for Payer: PHCS Commercial |
$408.96
|
| Rate for Payer: United Healthcare All Payer |
$374.88
|
|
|
FINGER LT: ROUTINE MIN 2V
|
Professional
|
Both
|
$426.00
|
|
|
Service Code
|
HCPCS 73140
|
| Hospital Charge Code |
32000089
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$8.66 |
| Max. Negotiated Rate |
$255.60 |
| Rate for Payer: Aetna Commercial |
$42.82
|
| Rate for Payer: Ambetter Exchange |
$34.34
|
| Rate for Payer: Anthem Medicaid |
$17.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$34.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$34.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$41.21
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cash Price |
$213.00
|
| Rate for Payer: Cigna Commercial |
$39.27
|
| Rate for Payer: Healthspan PPO |
$40.12
|
| Rate for Payer: Humana Medicaid |
$17.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$34.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$17.46
|
| Rate for Payer: Molina Healthcare Passport |
$17.12
|
| Rate for Payer: Multiplan PHCS |
$255.60
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$44.64
|
| Rate for Payer: UHCCP Medicaid |
$149.10
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$17.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$34.34
|
|
|
FINGER LT: ROUTINE MIN 2V(P
|
Professional
|
Both
|
$35.00
|
|
|
Service Code
|
HCPCS 73140
|
| Hospital Charge Code |
320P0089
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$8.66 |
| Max. Negotiated Rate |
$44.64 |
| Rate for Payer: Aetna Commercial |
$42.82
|
| Rate for Payer: Ambetter Exchange |
$34.34
|
| Rate for Payer: Anthem Medicaid |
$17.12
|
| Rate for Payer: Buckeye Individual/Medicaid |
$34.34
|
| Rate for Payer: Buckeye Medicare Advantage |
$34.34
|
| Rate for Payer: CareSource Just4Me Medicare |
$41.21
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cash Price |
$17.50
|
| Rate for Payer: Cigna Commercial |
$39.27
|
| Rate for Payer: Healthspan PPO |
$40.12
|
| Rate for Payer: Humana Medicaid |
$17.12
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$8.66
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$34.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$34.34
|
| Rate for Payer: Molina Healthcare CHIP/Medicaid |
$17.46
|
| Rate for Payer: Molina Healthcare Passport |
$17.12
|
| Rate for Payer: Multiplan PHCS |
$21.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$44.64
|
| Rate for Payer: UHCCP Medicaid |
$12.25
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$17.29
|
| Rate for Payer: Wellcare Medicare Advantage |
$34.34
|
|
|
FINGER LT: ROUTINE MIN 2V(T
|
Facility
|
OP
|
$391.00
|
|
|
Service Code
|
HCPCS 73140
|
| Hospital Charge Code |
320T0089
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$81.36 |
| Max. Negotiated Rate |
$375.36 |
| Rate for Payer: Aetna Commercial |
$301.07
|
| Rate for Payer: Anthem Medicaid |
$134.46
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$81.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.98
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$113.90
|
| Rate for Payer: CareSource Just4Me Medicare |
$109.84
|
| Rate for Payer: Cash Price |
$195.50
|
| Rate for Payer: Cash Price |
$195.50
|
| Rate for Payer: Cigna Commercial |
$324.53
|
| Rate for Payer: First Health Commercial |
$371.45
|
| Rate for Payer: Humana Commercial |
$332.35
|
| Rate for Payer: Humana KY Medicaid |
$134.46
|
| Rate for Payer: Humana Medicare Advantage |
$81.36
|
| Rate for Payer: Kentucky WC Medicaid |
$135.83
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$320.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$288.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$97.63
|
| Rate for Payer: Molina Healthcare Medicaid |
$137.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$344.08
|
| Rate for Payer: Ohio Health Group HMO |
$293.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$340.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$269.79
|
| Rate for Payer: PHCS Commercial |
$375.36
|
| Rate for Payer: United Healthcare All Payer |
$344.08
|
|
|
FINGER LT: ROUTINE MIN 2V(T
|
Facility
|
IP
|
$391.00
|
|
|
Service Code
|
HCPCS 73140
|
| Hospital Charge Code |
320T0089
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$117.30 |
| Max. Negotiated Rate |
$375.36 |
| Rate for Payer: Aetna Commercial |
$301.07
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$304.98
|
| Rate for Payer: Cash Price |
$195.50
|
| Rate for Payer: Cigna Commercial |
$324.53
|
| Rate for Payer: First Health Commercial |
$371.45
|
| Rate for Payer: Humana Commercial |
$332.35
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$320.62
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$288.56
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$117.30
|
| Rate for Payer: Ohio Health Choice Commercial |
$344.08
|
| Rate for Payer: Ohio Health Group HMO |
$293.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$312.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$340.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$269.79
|
| Rate for Payer: PHCS Commercial |
$375.36
|
| Rate for Payer: United Healthcare All Payer |
$344.08
|
|
|
FINGER SPLINT, STATIC
|
Professional
|
Both
|
$40.00
|
|
|
Service Code
|
HCPCS Q4049
|
| Hospital Charge Code |
27000176
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Aetna Commercial |
$8.00
|
| Rate for Payer: Ambetter Exchange |
$2.63
|
| Rate for Payer: Buckeye Individual/Medicaid |
$2.63
|
| Rate for Payer: Buckeye Medicare Advantage |
$2.63
|
| Rate for Payer: CareSource Just4Me Medicare |
$3.16
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Cash Price |
$20.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$2.27
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$2.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.63
|
| Rate for Payer: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$3.42
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
| Rate for Payer: Wellcare Medicare Advantage |
$2.63
|
|
|
FIORICET #3 CAPSULE
|
Facility
|
IP
|
$61.09
|
|
|
Service Code
|
NDC 591322001
|
| Hospital Charge Code |
25000677
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.33 |
| Max. Negotiated Rate |
$58.65 |
| Rate for Payer: Aetna Commercial |
$47.04
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.65
|
| Rate for Payer: Cash Price |
$30.55
|
| Rate for Payer: Cigna Commercial |
$50.70
|
| Rate for Payer: First Health Commercial |
$58.04
|
| Rate for Payer: Humana Commercial |
$51.93
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.33
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.76
|
| Rate for Payer: Ohio Health Group HMO |
$45.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.15
|
| Rate for Payer: PHCS Commercial |
$58.65
|
| Rate for Payer: United Healthcare All Payer |
$53.76
|
|
|
FIORICET #3 CAPSULE
|
Facility
|
OP
|
$61.09
|
|
|
Service Code
|
NDC 591322001
|
| Hospital Charge Code |
25000677
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.33 |
| Max. Negotiated Rate |
$58.65 |
| Rate for Payer: Aetna Commercial |
$47.04
|
| Rate for Payer: Anthem Medicaid |
$21.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$47.65
|
| Rate for Payer: Cash Price |
$30.55
|
| Rate for Payer: Cigna Commercial |
$50.70
|
| Rate for Payer: First Health Commercial |
$58.04
|
| Rate for Payer: Humana Commercial |
$51.93
|
| Rate for Payer: Humana KY Medicaid |
$21.01
|
| Rate for Payer: Kentucky WC Medicaid |
$21.22
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$50.09
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$45.08
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$18.33
|
| Rate for Payer: Molina Healthcare Medicaid |
$21.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$53.76
|
| Rate for Payer: Ohio Health Group HMO |
$45.82
|
| Rate for Payer: Ohio Health Group PPO Differential |
$48.87
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$53.15
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$42.15
|
| Rate for Payer: PHCS Commercial |
$58.65
|
| Rate for Payer: United Healthcare All Payer |
$53.76
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
IP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
OP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem Medicaid |
$11.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Humana KY Medicaid |
$11.90
|
| Rate for Payer: Humana Medicare Advantage |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$12.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
IP
|
$4,153.39
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,246.02 |
| Max. Negotiated Rate |
$3,987.25 |
| Rate for Payer: Aetna Commercial |
$3,198.11
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,239.64
|
| Rate for Payer: Cash Price |
$2,076.70
|
| Rate for Payer: Cigna Commercial |
$3,447.31
|
| Rate for Payer: First Health Commercial |
$3,945.72
|
| Rate for Payer: Humana Commercial |
$3,530.38
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,405.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,065.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,246.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,654.98
|
| Rate for Payer: Ohio Health Group HMO |
$3,115.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,322.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,613.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,865.84
|
| Rate for Payer: PHCS Commercial |
$3,987.25
|
| Rate for Payer: United Healthcare All Payer |
$3,654.98
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
IP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
OP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem Medicaid |
$11.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Humana KY Medicaid |
$11.90
|
| Rate for Payer: Humana Medicare Advantage |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$12.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
OP
|
$4,153.39
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$3,987.25 |
| Rate for Payer: Aetna Commercial |
$3,198.11
|
| Rate for Payer: Anthem Medicaid |
$1,428.35
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,239.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$2,076.70
|
| Rate for Payer: Cash Price |
$2,076.70
|
| Rate for Payer: Cigna Commercial |
$3,447.31
|
| Rate for Payer: First Health Commercial |
$3,945.72
|
| Rate for Payer: Humana Commercial |
$3,530.38
|
| Rate for Payer: Humana KY Medicaid |
$1,428.35
|
| Rate for Payer: Humana Medicare Advantage |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$1,442.89
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,405.78
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,065.20
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,457.01
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,654.98
|
| Rate for Payer: Ohio Health Group HMO |
$3,115.04
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,322.71
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,613.45
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,865.84
|
| Rate for Payer: PHCS Commercial |
$3,987.25
|
| Rate for Payer: United Healthcare All Payer |
$3,654.98
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Professional
|
Both
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$20.77 |
| Rate for Payer: Aetna Commercial |
$5.64
|
| Rate for Payer: Ambetter Exchange |
$4.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$4.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.23
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.36
|
| Rate for Payer: Multiplan PHCS |
$20.77
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.67
|
| Rate for Payer: UHCCP Medicaid |
$12.11
|
| Rate for Payer: Wellcare Medicare Advantage |
$4.36
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
OP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem Medicaid |
$11.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Humana KY Medicaid |
$11.90
|
| Rate for Payer: Humana Medicare Advantage |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$12.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
OP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem Medicaid |
$11.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Humana KY Medicaid |
$11.90
|
| Rate for Payer: Humana Medicare Advantage |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$12.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Professional
|
Both
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$20.77 |
| Rate for Payer: Aetna Commercial |
$5.64
|
| Rate for Payer: Ambetter Exchange |
$4.36
|
| Rate for Payer: Buckeye Individual/Medicaid |
$4.36
|
| Rate for Payer: Buckeye Medicare Advantage |
$4.36
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.23
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.67
|
| Rate for Payer: Medical Mutual Of Ohio Medicare Advantage |
$4.36
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4.36
|
| Rate for Payer: Multiplan PHCS |
$20.77
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$5.67
|
| Rate for Payer: UHCCP Medicaid |
$12.11
|
| Rate for Payer: Wellcare Medicare Advantage |
$4.36
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
OP
|
$8,306.78
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002600
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$7,974.51 |
| Rate for Payer: Aetna Commercial |
$6,396.22
|
| Rate for Payer: Anthem Medicaid |
$2,856.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,479.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$4,153.39
|
| Rate for Payer: Cash Price |
$4,153.39
|
| Rate for Payer: Cigna Commercial |
$6,894.63
|
| Rate for Payer: First Health Commercial |
$7,891.44
|
| Rate for Payer: Humana Commercial |
$7,060.76
|
| Rate for Payer: Humana KY Medicaid |
$2,856.70
|
| Rate for Payer: Humana Medicare Advantage |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$2,885.78
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,811.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,130.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$2,914.02
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,309.97
|
| Rate for Payer: Ohio Health Group HMO |
$6,230.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,645.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,226.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.68
|
| Rate for Payer: PHCS Commercial |
$7,974.51
|
| Rate for Payer: United Healthcare All Payer |
$7,309.97
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
IP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
IP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.38 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.38
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
IP
|
$8,306.78
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002600
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,492.03 |
| Max. Negotiated Rate |
$7,974.51 |
| Rate for Payer: Aetna Commercial |
$6,396.22
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,479.29
|
| Rate for Payer: Cash Price |
$4,153.39
|
| Rate for Payer: Cigna Commercial |
$6,894.63
|
| Rate for Payer: First Health Commercial |
$7,891.44
|
| Rate for Payer: Humana Commercial |
$7,060.76
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$6,811.56
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6,130.40
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,492.03
|
| Rate for Payer: Ohio Health Choice Commercial |
$7,309.97
|
| Rate for Payer: Ohio Health Group HMO |
$6,230.09
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6,645.42
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7,226.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,731.68
|
| Rate for Payer: PHCS Commercial |
$7,974.51
|
| Rate for Payer: United Healthcare All Payer |
$7,309.97
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
OP
|
$34.61
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.36 |
| Max. Negotiated Rate |
$33.23 |
| Rate for Payer: Aetna Commercial |
$26.65
|
| Rate for Payer: Anthem Medicaid |
$11.90
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.36
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$27.00
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$6.10
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.89
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cash Price |
$17.30
|
| Rate for Payer: Cigna Commercial |
$28.73
|
| Rate for Payer: First Health Commercial |
$32.88
|
| Rate for Payer: Humana Commercial |
$29.42
|
| Rate for Payer: Humana KY Medicaid |
$11.90
|
| Rate for Payer: Humana Medicare Advantage |
$4.36
|
| Rate for Payer: Kentucky WC Medicaid |
$12.02
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$28.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$25.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.23
|
| Rate for Payer: Molina Healthcare Medicaid |
$12.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$30.46
|
| Rate for Payer: Ohio Health Group HMO |
$25.96
|
| Rate for Payer: Ohio Health Group PPO Differential |
$27.69
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$30.11
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$23.88
|
| Rate for Payer: PHCS Commercial |
$33.23
|
| Rate for Payer: United Healthcare All Payer |
$30.46
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
IP
|
$2,662.05
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$798.62 |
| Max. Negotiated Rate |
$2,555.57 |
| Rate for Payer: Aetna Commercial |
$2,049.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,076.40
|
| Rate for Payer: Cash Price |
$1,331.03
|
| Rate for Payer: Cigna Commercial |
$2,209.50
|
| Rate for Payer: First Health Commercial |
$2,528.95
|
| Rate for Payer: Humana Commercial |
$2,262.74
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,182.88
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$1,964.59
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$798.62
|
| Rate for Payer: Ohio Health Choice Commercial |
$2,342.60
|
| Rate for Payer: Ohio Health Group HMO |
$1,996.54
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,129.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,315.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,836.81
|
| Rate for Payer: PHCS Commercial |
$2,555.57
|
| Rate for Payer: United Healthcare All Payer |
$2,342.60
|
|
