|
LUPRON DEPOT 11.5 MG SYRINGE
|
Facility
|
IP
|
$10,292.14
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
25003851
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,337.98 |
| Max. Negotiated Rate |
$9,880.45 |
| Rate for Payer: Aetna Commercial |
$7,924.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,027.87
|
| Rate for Payer: Cash Price |
$5,146.07
|
| Rate for Payer: Cigna Commercial |
$8,542.48
|
| Rate for Payer: First Health Commercial |
$9,777.53
|
| Rate for Payer: Humana Commercial |
$8,748.32
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,439.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,595.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,087.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,057.08
|
| Rate for Payer: Ohio Health Group HMO |
$7,719.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,058.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,337.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,190.56
|
| Rate for Payer: PHCS Commercial |
$9,880.45
|
| Rate for Payer: United Healthcare All Payer |
$9,057.08
|
|
|
LUPRON DEPOT 11.5 MG SYRINGE
|
Facility
|
OP
|
$10,292.14
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
25003851
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,337.98 |
| Max. Negotiated Rate |
$9,880.45 |
| Rate for Payer: Aetna Commercial |
$7,924.95
|
| Rate for Payer: Anthem Medicaid |
$3,539.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,564.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,027.87
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,190.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,112.22
|
| Rate for Payer: Cash Price |
$5,146.07
|
| Rate for Payer: Cash Price |
$5,146.07
|
| Rate for Payer: Cigna Commercial |
$8,542.48
|
| Rate for Payer: First Health Commercial |
$9,777.53
|
| Rate for Payer: Humana Commercial |
$8,748.32
|
| Rate for Payer: Humana KY Medicaid |
$3,539.47
|
| Rate for Payer: Humana Medicare Advantage |
$1,564.60
|
| Rate for Payer: Kentucky WC Medicaid |
$3,575.49
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$8,439.55
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,595.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,877.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,610.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,057.08
|
| Rate for Payer: Ohio Health Group HMO |
$7,719.10
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,058.43
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,337.98
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,190.56
|
| Rate for Payer: PHCS Commercial |
$9,880.45
|
| Rate for Payer: United Healthcare All Payer |
$9,057.08
|
|
|
LUPRON DEPOT 3.75MG KIT
|
Facility
|
OP
|
$3,430.68
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
25002206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$445.99 |
| Max. Negotiated Rate |
$3,293.45 |
| Rate for Payer: Aetna Commercial |
$2,641.62
|
| Rate for Payer: Anthem Medicaid |
$1,179.81
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$1,564.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,675.93
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$2,190.45
|
| Rate for Payer: CareSource Just4Me Medicare |
$2,112.22
|
| Rate for Payer: Cash Price |
$1,715.34
|
| Rate for Payer: Cash Price |
$1,715.34
|
| Rate for Payer: Cigna Commercial |
$2,847.46
|
| Rate for Payer: First Health Commercial |
$3,259.15
|
| Rate for Payer: Humana Commercial |
$2,916.08
|
| Rate for Payer: Humana KY Medicaid |
$1,179.81
|
| Rate for Payer: Humana Medicare Advantage |
$1,564.60
|
| Rate for Payer: Kentucky WC Medicaid |
$1,191.82
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,813.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,531.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,877.52
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,203.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,019.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,573.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$686.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.51
|
| Rate for Payer: PHCS Commercial |
$3,293.45
|
| Rate for Payer: United Healthcare All Payer |
$3,019.00
|
|
|
LUPRON DEPOT 3.75MG KIT
|
Facility
|
IP
|
$3,430.68
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
25002206
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$445.99 |
| Max. Negotiated Rate |
$3,293.45 |
| Rate for Payer: Aetna Commercial |
$2,641.62
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,675.93
|
| Rate for Payer: Cash Price |
$1,715.34
|
| Rate for Payer: Cigna Commercial |
$2,847.46
|
| Rate for Payer: First Health Commercial |
$3,259.15
|
| Rate for Payer: Humana Commercial |
$2,916.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$2,813.16
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,531.84
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,029.20
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,019.00
|
| Rate for Payer: Ohio Health Group HMO |
$2,573.01
|
| Rate for Payer: Ohio Health Group PPO Differential |
$686.14
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$445.99
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,063.51
|
| Rate for Payer: PHCS Commercial |
$3,293.45
|
| Rate for Payer: United Healthcare All Payer |
$3,019.00
|
|
|
LUPRON DEPOT 7.5(22.5MG DSPSYR
|
Facility
|
OP
|
$12,264.54
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$11,773.96 |
| Rate for Payer: Aetna Commercial |
$9,443.70
|
| Rate for Payer: Anthem Medicaid |
$4,217.78
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,566.34
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$6,132.27
|
| Rate for Payer: Cash Price |
$6,132.27
|
| Rate for Payer: Cigna Commercial |
$10,179.57
|
| Rate for Payer: First Health Commercial |
$11,651.31
|
| Rate for Payer: Humana Commercial |
$10,424.86
|
| Rate for Payer: Humana KY Medicaid |
$4,217.78
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$4,260.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,056.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,051.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$4,302.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,792.80
|
| Rate for Payer: Ohio Health Group HMO |
$9,198.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,452.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,594.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,802.01
|
| Rate for Payer: PHCS Commercial |
$11,773.96
|
| Rate for Payer: United Healthcare All Payer |
$10,792.80
|
|
|
LUPRON DEPOT 7.5(22.5MG DSPSYR
|
Facility
|
IP
|
$12,264.54
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002642
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,594.39 |
| Max. Negotiated Rate |
$11,773.96 |
| Rate for Payer: Aetna Commercial |
$9,443.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$9,566.34
|
| Rate for Payer: Cash Price |
$6,132.27
|
| Rate for Payer: Cigna Commercial |
$10,179.57
|
| Rate for Payer: First Health Commercial |
$11,651.31
|
| Rate for Payer: Humana Commercial |
$10,424.86
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$10,056.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$9,051.23
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,679.36
|
| Rate for Payer: Ohio Health Choice Commercial |
$10,792.80
|
| Rate for Payer: Ohio Health Group HMO |
$9,198.40
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,452.91
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,594.39
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,802.01
|
| Rate for Payer: PHCS Commercial |
$11,773.96
|
| Rate for Payer: United Healthcare All Payer |
$10,792.80
|
|
|
LUPRON DEPOT 7.5G DISP SYRIN
|
Facility
|
OP
|
$4,088.20
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$3,924.67 |
| Rate for Payer: Aetna Commercial |
$3,147.91
|
| Rate for Payer: Anthem Medicaid |
$1,405.93
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,188.80
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$2,044.10
|
| Rate for Payer: Cash Price |
$2,044.10
|
| Rate for Payer: Cigna Commercial |
$3,393.21
|
| Rate for Payer: First Health Commercial |
$3,883.79
|
| Rate for Payer: Humana Commercial |
$3,474.97
|
| Rate for Payer: Humana KY Medicaid |
$1,405.93
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1,420.24
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,352.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,017.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,434.14
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,597.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,066.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$817.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,267.34
|
| Rate for Payer: PHCS Commercial |
$3,924.67
|
| Rate for Payer: United Healthcare All Payer |
$3,597.62
|
|
|
LUPRON DEPOT 7.5G DISP SYRIN
|
Facility
|
IP
|
$4,088.20
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002637
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$531.47 |
| Max. Negotiated Rate |
$3,924.67 |
| Rate for Payer: Aetna Commercial |
$3,147.91
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,188.80
|
| Rate for Payer: Cash Price |
$2,044.10
|
| Rate for Payer: Cigna Commercial |
$3,393.21
|
| Rate for Payer: First Health Commercial |
$3,883.79
|
| Rate for Payer: Humana Commercial |
$3,474.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,352.32
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3,017.09
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,226.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,597.62
|
| Rate for Payer: Ohio Health Group HMO |
$3,066.15
|
| Rate for Payer: Ohio Health Group PPO Differential |
$817.64
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$531.47
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,267.34
|
| Rate for Payer: PHCS Commercial |
$3,924.67
|
| Rate for Payer: United Healthcare All Payer |
$3,597.62
|
|
|
LUPRON DEPOT 7.5MG (30MG KIT)
|
Facility
|
OP
|
$16,352.76
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002643
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$15,698.65 |
| Rate for Payer: Aetna Commercial |
$12,591.63
|
| Rate for Payer: Anthem Medicaid |
$5,623.71
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,755.15
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$8,176.38
|
| Rate for Payer: Cash Price |
$8,176.38
|
| Rate for Payer: Cigna Commercial |
$13,572.79
|
| Rate for Payer: First Health Commercial |
$15,535.12
|
| Rate for Payer: Humana Commercial |
$13,899.85
|
| Rate for Payer: Humana KY Medicaid |
$5,623.71
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$5,680.95
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,409.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,068.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,736.55
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,390.43
|
| Rate for Payer: Ohio Health Group HMO |
$12,264.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,270.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,125.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,069.36
|
| Rate for Payer: PHCS Commercial |
$15,698.65
|
| Rate for Payer: United Healthcare All Payer |
$14,390.43
|
|
|
LUPRON DEPOT 7.5MG (30MG KIT)
|
Facility
|
IP
|
$16,352.76
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002643
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,125.86 |
| Max. Negotiated Rate |
$15,698.65 |
| Rate for Payer: Aetna Commercial |
$12,591.63
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,755.15
|
| Rate for Payer: Cash Price |
$8,176.38
|
| Rate for Payer: Cigna Commercial |
$13,572.79
|
| Rate for Payer: First Health Commercial |
$15,535.12
|
| Rate for Payer: Humana Commercial |
$13,899.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$13,409.26
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$12,068.34
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,905.83
|
| Rate for Payer: Ohio Health Choice Commercial |
$14,390.43
|
| Rate for Payer: Ohio Health Group HMO |
$12,264.57
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,270.55
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,125.86
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$5,069.36
|
| Rate for Payer: PHCS Commercial |
$15,698.65
|
| Rate for Payer: United Healthcare All Payer |
$14,390.43
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
IP
|
$3,708.16
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636T0083
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$482.06 |
| Max. Negotiated Rate |
$3,559.83 |
| Rate for Payer: Aetna Commercial |
$2,855.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,892.36
|
| Rate for Payer: Cash Price |
$1,854.08
|
| Rate for Payer: Cigna Commercial |
$3,077.77
|
| Rate for Payer: First Health Commercial |
$3,522.75
|
| Rate for Payer: Humana Commercial |
$3,151.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,040.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,736.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,112.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,263.18
|
| Rate for Payer: Ohio Health Group HMO |
$2,781.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$741.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$482.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,149.53
|
| Rate for Payer: PHCS Commercial |
$3,559.83
|
| Rate for Payer: United Healthcare All Payer |
$3,263.18
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
IP
|
$24,529.50
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002639
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,188.84 |
| Max. Negotiated Rate |
$23,548.32 |
| Rate for Payer: Aetna Commercial |
$18,887.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,133.01
|
| Rate for Payer: Cash Price |
$12,264.75
|
| Rate for Payer: Cigna Commercial |
$20,359.48
|
| Rate for Payer: First Health Commercial |
$23,303.02
|
| Rate for Payer: Humana Commercial |
$20,850.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,114.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,102.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,358.85
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,585.96
|
| Rate for Payer: Ohio Health Group HMO |
$18,397.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,905.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,188.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,604.14
|
| Rate for Payer: PHCS Commercial |
$23,548.32
|
| Rate for Payer: United Healthcare All Payer |
$21,585.96
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
OP
|
$3,708.16
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
63600083
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$3,559.83 |
| Rate for Payer: Aetna Commercial |
$2,855.28
|
| Rate for Payer: Anthem Medicaid |
$1,275.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,892.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$1,854.08
|
| Rate for Payer: Cash Price |
$1,854.08
|
| Rate for Payer: Cigna Commercial |
$3,077.77
|
| Rate for Payer: First Health Commercial |
$3,522.75
|
| Rate for Payer: Humana Commercial |
$3,151.94
|
| Rate for Payer: Humana KY Medicaid |
$1,275.24
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1,288.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,040.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,736.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,300.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,263.18
|
| Rate for Payer: Ohio Health Group HMO |
$2,781.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$741.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$482.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,149.53
|
| Rate for Payer: PHCS Commercial |
$3,559.83
|
| Rate for Payer: United Healthcare All Payer |
$3,263.18
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
IP
|
$3,708.16
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
63600083
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$482.06 |
| Max. Negotiated Rate |
$3,559.83 |
| Rate for Payer: Aetna Commercial |
$2,855.28
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,892.36
|
| Rate for Payer: Cash Price |
$1,854.08
|
| Rate for Payer: Cigna Commercial |
$3,077.77
|
| Rate for Payer: First Health Commercial |
$3,522.75
|
| Rate for Payer: Humana Commercial |
$3,151.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,040.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,736.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1,112.45
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,263.18
|
| Rate for Payer: Ohio Health Group HMO |
$2,781.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$741.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$482.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,149.53
|
| Rate for Payer: PHCS Commercial |
$3,559.83
|
| Rate for Payer: United Healthcare All Payer |
$3,263.18
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Professional
|
Both
|
$3,708.16
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
63600083
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$190.26 |
| Max. Negotiated Rate |
$3,708.16 |
| Rate for Payer: Aetna Commercial |
$190.26
|
| Rate for Payer: Buckeye Medicare Advantage |
$3,708.16
|
| Rate for Payer: Cash Price |
$1,854.08
|
| Rate for Payer: Cash Price |
$1,854.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$289.39
|
| Rate for Payer: Multiplan PHCS |
$2,224.90
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$2,595.71
|
| Rate for Payer: UHCCP Medicaid |
$1,297.86
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
OP
|
$24,529.50
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
25002639
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$23,548.32 |
| Rate for Payer: Aetna Commercial |
$18,887.72
|
| Rate for Payer: Anthem Medicaid |
$8,435.70
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$19,133.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$12,264.75
|
| Rate for Payer: Cash Price |
$12,264.75
|
| Rate for Payer: Cigna Commercial |
$20,359.48
|
| Rate for Payer: First Health Commercial |
$23,303.02
|
| Rate for Payer: Humana Commercial |
$20,850.08
|
| Rate for Payer: Humana KY Medicaid |
$8,435.70
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$8,521.55
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$20,114.19
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$18,102.77
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,604.95
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,585.96
|
| Rate for Payer: Ohio Health Group HMO |
$18,397.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,905.90
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,188.84
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,604.14
|
| Rate for Payer: PHCS Commercial |
$23,548.32
|
| Rate for Payer: United Healthcare All Payer |
$21,585.96
|
|
|
LUPRON DEPOT 7.5 MG [45MG SYR]
|
Facility
|
OP
|
$3,708.16
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
636T0083
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$181.30 |
| Max. Negotiated Rate |
$3,559.83 |
| Rate for Payer: Aetna Commercial |
$2,855.28
|
| Rate for Payer: Anthem Medicaid |
$1,275.24
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$181.30
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,892.36
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$253.82
|
| Rate for Payer: CareSource Just4Me Medicare |
$244.76
|
| Rate for Payer: Cash Price |
$1,854.08
|
| Rate for Payer: Cash Price |
$1,854.08
|
| Rate for Payer: Cigna Commercial |
$3,077.77
|
| Rate for Payer: First Health Commercial |
$3,522.75
|
| Rate for Payer: Humana Commercial |
$3,151.94
|
| Rate for Payer: Humana KY Medicaid |
$1,275.24
|
| Rate for Payer: Humana Medicare Advantage |
$181.30
|
| Rate for Payer: Kentucky WC Medicaid |
$1,288.21
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3,040.69
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$2,736.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$217.56
|
| Rate for Payer: Molina Healthcare Medicaid |
$1,300.82
|
| Rate for Payer: Ohio Health Choice Commercial |
$3,263.18
|
| Rate for Payer: Ohio Health Group HMO |
$2,781.12
|
| Rate for Payer: Ohio Health Group PPO Differential |
$741.63
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$482.06
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,149.53
|
| Rate for Payer: PHCS Commercial |
$3,559.83
|
| Rate for Payer: United Healthcare All Payer |
$3,263.18
|
|
|
LURBINECTEDIN 0.1mg (4mg SDV)
|
Facility
|
OP
|
$43,763.50
|
|
|
Service Code
|
HCPCS J9223
|
| Hospital Charge Code |
25003944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$200.01 |
| Max. Negotiated Rate |
$42,012.96 |
| Rate for Payer: Aetna Commercial |
$33,697.90
|
| Rate for Payer: Anthem Medicaid |
$15,050.27
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$200.01
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34,135.53
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$280.01
|
| Rate for Payer: CareSource Just4Me Medicare |
$270.01
|
| Rate for Payer: Cash Price |
$21,881.75
|
| Rate for Payer: Cash Price |
$21,881.75
|
| Rate for Payer: Cigna Commercial |
$36,323.70
|
| Rate for Payer: First Health Commercial |
$41,575.32
|
| Rate for Payer: Humana Commercial |
$37,198.98
|
| Rate for Payer: Humana KY Medicaid |
$15,050.27
|
| Rate for Payer: Humana Medicare Advantage |
$200.01
|
| Rate for Payer: Kentucky WC Medicaid |
$15,203.44
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35,886.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32,297.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$240.01
|
| Rate for Payer: Molina Healthcare Medicaid |
$15,352.24
|
| Rate for Payer: Ohio Health Choice Commercial |
$38,511.88
|
| Rate for Payer: Ohio Health Group HMO |
$32,822.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,752.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,689.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,566.68
|
| Rate for Payer: PHCS Commercial |
$42,012.96
|
| Rate for Payer: United Healthcare All Payer |
$38,511.88
|
|
|
LURBINECTEDIN 0.1mg (4mg SDV)
|
Facility
|
IP
|
$43,763.50
|
|
|
Service Code
|
HCPCS J9223
|
| Hospital Charge Code |
25003944
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5,689.26 |
| Max. Negotiated Rate |
$42,012.96 |
| Rate for Payer: Aetna Commercial |
$33,697.90
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$34,135.53
|
| Rate for Payer: Cash Price |
$21,881.75
|
| Rate for Payer: Cigna Commercial |
$36,323.70
|
| Rate for Payer: First Health Commercial |
$41,575.32
|
| Rate for Payer: Humana Commercial |
$37,198.98
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$35,886.07
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$32,297.46
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$13,129.05
|
| Rate for Payer: Ohio Health Choice Commercial |
$38,511.88
|
| Rate for Payer: Ohio Health Group HMO |
$32,822.62
|
| Rate for Payer: Ohio Health Group PPO Differential |
$8,752.70
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$5,689.26
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$13,566.68
|
| Rate for Payer: PHCS Commercial |
$42,012.96
|
| Rate for Payer: United Healthcare All Payer |
$38,511.88
|
|
|
LUTEINIZING HORMONE
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
HCPCS 83002
|
| Hospital Charge Code |
30000354
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$26.00 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.60
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$60.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
LUTEINIZING HORMONE
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
HCPCS 83002
|
| Hospital Charge Code |
30000354
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$18.52 |
| Max. Negotiated Rate |
$192.00 |
| Rate for Payer: Aetna Commercial |
$154.00
|
| Rate for Payer: Anthem Medicaid |
$18.52
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$18.52
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$160.60
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$25.93
|
| Rate for Payer: CareSource Just4Me Medicare |
$18.52
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$166.00
|
| Rate for Payer: First Health Commercial |
$190.00
|
| Rate for Payer: Humana Commercial |
$170.00
|
| Rate for Payer: Humana KY Medicaid |
$18.52
|
| Rate for Payer: Humana Medicare Advantage |
$18.52
|
| Rate for Payer: Kentucky WC Medicaid |
$18.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$164.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$147.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$22.22
|
| Rate for Payer: Molina Healthcare Medicaid |
$18.89
|
| Rate for Payer: Ohio Health Choice Commercial |
$176.00
|
| Rate for Payer: Ohio Health Group HMO |
$150.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$40.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$26.00
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$62.00
|
| Rate for Payer: PHCS Commercial |
$192.00
|
| Rate for Payer: United Healthcare All Payer |
$176.00
|
|
|
LUTEINIZING HORMONE
|
Professional
|
Both
|
$200.00
|
|
|
Service Code
|
HCPCS 83002
|
| Hospital Charge Code |
30000354
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$11.11 |
| Max. Negotiated Rate |
$200.00 |
| Rate for Payer: Aetna Commercial |
$31.97
|
| Rate for Payer: Buckeye Medicare Advantage |
$200.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna Commercial |
$16.29
|
| Rate for Payer: Healthspan PPO |
$19.41
|
| Rate for Payer: Multiplan PHCS |
$120.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$140.00
|
| Rate for Payer: UHCCP Medicaid |
$70.00
|
| Rate for Payer: Wellcare CHIP/Medicaid |
$11.11
|
|
|
LUTONIX 018 DCB 4*100 4F
|
Facility
|
OP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem Medicaid |
$3,347.87
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Humana KY Medicaid |
$3,347.87
|
| Rate for Payer: Kentucky WC Medicaid |
$3,381.94
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Molina Healthcare Medicaid |
$3,415.04
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
LUTONIX 018 DCB 4*100 4F
|
Facility
|
IP
|
$9,735.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,265.55 |
| Max. Negotiated Rate |
$9,345.60 |
| Rate for Payer: Aetna Commercial |
$7,495.95
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7,593.30
|
| Rate for Payer: Cash Price |
$4,867.50
|
| Rate for Payer: Cigna Commercial |
$8,080.05
|
| Rate for Payer: First Health Commercial |
$9,248.25
|
| Rate for Payer: Humana Commercial |
$8,274.75
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7,982.70
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$7,184.43
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2,920.50
|
| Rate for Payer: Ohio Health Choice Commercial |
$8,566.80
|
| Rate for Payer: Ohio Health Group HMO |
$7,301.25
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,947.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,265.55
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,017.85
|
| Rate for Payer: PHCS Commercial |
$9,345.60
|
| Rate for Payer: United Healthcare All Payer |
$8,566.80
|
|
|
LUTONIX 018 DCB 4*150 4F
|
Facility
|
IP
|
$11,330.00
|
|
|
Service Code
|
HCPCS C2623
|
| Hospital Charge Code |
27000276
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$1,472.90 |
| Max. Negotiated Rate |
$10,876.80 |
| Rate for Payer: Aetna Commercial |
$8,724.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$8,837.40
|
| Rate for Payer: Cash Price |
$5,665.00
|
| Rate for Payer: Cigna Commercial |
$9,403.90
|
| Rate for Payer: First Health Commercial |
$10,763.50
|
| Rate for Payer: Humana Commercial |
$9,630.50
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$9,290.60
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$8,361.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$3,399.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$9,970.40
|
| Rate for Payer: Ohio Health Group HMO |
$8,497.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$2,266.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,472.90
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$3,512.30
|
| Rate for Payer: PHCS Commercial |
$10,876.80
|
| Rate for Payer: United Healthcare All Payer |
$9,970.40
|
|
