|
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 |
$40.00 |
| Rate for Payer: Aetna Commercial |
$8.00
|
| Rate for Payer: Buckeye Medicare Advantage |
$40.00
|
| 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: Multiplan PHCS |
$24.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$28.00
|
| Rate for Payer: UHCCP Medicaid |
$14.00
|
|
|
FIORICET #3 CAPSULE
|
Facility
|
OP
|
$61.09
|
|
|
Service Code
|
NDC 591322001
|
| Hospital Charge Code |
25000677
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.94 |
| 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 |
$12.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.94
|
| Rate for Payer: PHCS Commercial |
$58.65
|
| Rate for Payer: United Healthcare All Payer |
$53.76
|
|
|
FIORICET #3 CAPSULE
|
Facility
|
IP
|
$61.09
|
|
|
Service Code
|
NDC 591322001
|
| Hospital Charge Code |
25000677
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.94 |
| 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 |
$12.22
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$7.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$18.94
|
| Rate for Payer: PHCS Commercial |
$58.65
|
| Rate for Payer: United Healthcare All Payer |
$53.76
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
OP
|
$4,153.39
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| 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 |
$4.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3,239.64
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.65
|
| 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 |
$4.19
|
| 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 |
$5.02
|
| 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 |
$830.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$539.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.55
|
| Rate for Payer: PHCS Commercial |
$3,987.25
|
| Rate for Payer: United Healthcare All Payer |
$3,654.98
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
OP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem Medicaid |
$11.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.65
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Humana KY Medicaid |
$11.47
|
| Rate for Payer: Humana Medicare Advantage |
$4.19
|
| Rate for Payer: Kentucky WC Medicaid |
$11.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Professional
|
Both
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.64 |
| Max. Negotiated Rate |
$33.34 |
| Rate for Payer: Aetna Commercial |
$5.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$33.34
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.67
|
| Rate for Payer: Multiplan PHCS |
$20.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$23.34
|
| Rate for Payer: UHCCP Medicaid |
$11.67
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
IP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
IP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
IP
|
$4,153.39
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002601
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$539.94 |
| 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 |
$830.68
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$539.94
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1,287.55
|
| Rate for Payer: PHCS Commercial |
$3,987.25
|
| Rate for Payer: United Healthcare All Payer |
$3,654.98
|
|
|
FIRMAGON 1MG [120MG VIAL]
|
Facility
|
OP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0081
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem Medicaid |
$11.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.65
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Humana KY Medicaid |
$11.47
|
| Rate for Payer: Humana Medicare Advantage |
$4.19
|
| Rate for Payer: Kentucky WC Medicaid |
$11.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
OP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem Medicaid |
$11.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.65
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Humana KY Medicaid |
$11.47
|
| Rate for Payer: Humana Medicare Advantage |
$4.19
|
| Rate for Payer: Kentucky WC Medicaid |
$11.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
OP
|
$8,306.78
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002600
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| 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 |
$4.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$6,479.29
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.65
|
| 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 |
$4.19
|
| 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 |
$5.02
|
| 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 |
$6,230.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,661.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,079.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,575.10
|
| Rate for Payer: PHCS Commercial |
$7,974.51
|
| Rate for Payer: United Healthcare All Payer |
$7,309.97
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
IP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
IP
|
$8,306.78
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002600
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,079.88 |
| 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 |
$6,230.08
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1,661.36
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1,079.88
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2,575.10
|
| Rate for Payer: PHCS Commercial |
$7,974.51
|
| Rate for Payer: United Healthcare All Payer |
$7,309.97
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
IP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Professional
|
Both
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.64 |
| Max. Negotiated Rate |
$33.34 |
| Rate for Payer: Aetna Commercial |
$5.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$33.34
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.67
|
| Rate for Payer: Multiplan PHCS |
$20.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$23.34
|
| Rate for Payer: UHCCP Medicaid |
$11.67
|
|
|
FIRMAGON 1mg (240mg Kit)
|
Facility
|
OP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600080
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem Medicaid |
$11.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.65
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Humana KY Medicaid |
$11.47
|
| Rate for Payer: Humana Medicare Advantage |
$4.19
|
| Rate for Payer: Kentucky WC Medicaid |
$11.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
OP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem Medicaid |
$11.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.65
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Humana KY Medicaid |
$11.47
|
| Rate for Payer: Humana Medicare Advantage |
$4.19
|
| Rate for Payer: Kentucky WC Medicaid |
$11.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
IP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Professional
|
Both
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.64 |
| Max. Negotiated Rate |
$33.34 |
| Rate for Payer: Aetna Commercial |
$5.64
|
| Rate for Payer: Buckeye Medicare Advantage |
$33.34
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO/POS/PPO/Workers Compensation |
$5.67
|
| Rate for Payer: Multiplan PHCS |
$20.00
|
| Rate for Payer: Ohio Health Choice Preferred Health Choice |
$23.34
|
| Rate for Payer: UHCCP Medicaid |
$11.67
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
OP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
63600082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem Medicaid |
$11.47
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.65
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Humana KY Medicaid |
$11.47
|
| Rate for Payer: Humana Medicare Advantage |
$4.19
|
| Rate for Payer: Kentucky WC Medicaid |
$11.58
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$5.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$11.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
OP
|
$2,662.05
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.19 |
| Max. Negotiated Rate |
$2,555.57 |
| Rate for Payer: Aetna Commercial |
$2,049.78
|
| Rate for Payer: Anthem Medicaid |
$915.48
|
| Rate for Payer: Anthem Medicare Advantage/PPO |
$4.19
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$2,076.40
|
| Rate for Payer: Buckeye Individual/Medicaid/Medicare Advantage |
$5.86
|
| Rate for Payer: CareSource Just4Me Medicare |
$5.65
|
| Rate for Payer: Cash Price |
$1,331.03
|
| 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: Humana KY Medicaid |
$915.48
|
| Rate for Payer: Humana Medicare Advantage |
$4.19
|
| Rate for Payer: Kentucky WC Medicaid |
$924.80
|
| 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 |
$5.02
|
| Rate for Payer: Molina Healthcare Medicaid |
$933.85
|
| 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 |
$532.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$346.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$825.24
|
| Rate for Payer: PHCS Commercial |
$2,555.57
|
| Rate for Payer: United Healthcare All Payer |
$2,342.60
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
IP
|
$33.34
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
636T0082
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.33 |
| Max. Negotiated Rate |
$32.01 |
| Rate for Payer: Aetna Commercial |
$25.67
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$26.01
|
| Rate for Payer: Cash Price |
$16.67
|
| Rate for Payer: Cigna Commercial |
$27.67
|
| Rate for Payer: First Health Commercial |
$31.67
|
| Rate for Payer: Humana Commercial |
$28.34
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$27.34
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$24.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$10.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$29.34
|
| Rate for Payer: Ohio Health Group HMO |
$25.00
|
| Rate for Payer: Ohio Health Group PPO Differential |
$6.67
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$4.33
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$10.34
|
| Rate for Payer: PHCS Commercial |
$32.01
|
| Rate for Payer: United Healthcare All Payer |
$29.34
|
|
|
FIRMAGON 1MG [80MG VIAL]
|
Facility
|
IP
|
$2,662.05
|
|
|
Service Code
|
HCPCS J9155
|
| Hospital Charge Code |
25002602
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$346.07 |
| 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 |
$532.41
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$346.07
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$825.24
|
| Rate for Payer: PHCS Commercial |
$2,555.57
|
| Rate for Payer: United Healthcare All Payer |
$2,342.60
|
|
|
FIRVANQ 250MCG/5ML ORAL SOL
|
Facility
|
OP
|
$22.45
|
|
|
Service Code
|
NDC 65628020605
|
| Hospital Charge Code |
25003066
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$21.55 |
| Rate for Payer: Aetna Commercial |
$17.29
|
| Rate for Payer: Anthem Medicaid |
$7.72
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$17.51
|
| Rate for Payer: Cash Price |
$11.22
|
| Rate for Payer: Cigna Commercial |
$18.63
|
| Rate for Payer: First Health Commercial |
$21.33
|
| Rate for Payer: Humana Commercial |
$19.08
|
| Rate for Payer: Humana KY Medicaid |
$7.72
|
| Rate for Payer: Kentucky WC Medicaid |
$7.80
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$18.41
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$16.57
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$6.74
|
| Rate for Payer: Molina Healthcare Medicaid |
$7.88
|
| Rate for Payer: Ohio Health Choice Commercial |
$19.76
|
| Rate for Payer: Ohio Health Group HMO |
$16.84
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4.49
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2.92
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$6.96
|
| Rate for Payer: PHCS Commercial |
$21.55
|
| Rate for Payer: United Healthcare All Payer |
$19.76
|
|
