Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
FOLLISTIM AQ 900 UNIT/1.08 ML SUBCUTANEOUS CARTRIDGE
Peoria, IL
See all hospitals reporting HCPCS S0128 →Price type
Proctor Community Hospital’s median price of $4.4k is 1594% above the median hospital's median price ($260), higher than 100% of the 744 hospitals reporting HCPCS S0128. The highlighted bar is where this hospital falls; shaded is the middle 50% of hospitals.
Negotiated rates from the hospital’s own file: 7 payers, 21 plan rates. A facility fee, a professional fee, a per diem and a case rate are different bills, so each is listed on its own. Open a payer to see it across hospitals.
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| # | |||||||
|---|---|---|---|---|---|---|---|
| 1 | Aetna Better Health medicare-medicaid (d-snp) fee schedule · inpatient | $215 | $215 | — | — | — | $215 – $215 |
| 2 | Aetna Better Health medicare-medicaid (d-snp) fee schedule · outpatient | $215 | $215 | — | — | — | $215 – $215 |
| 3 | UnitedHealthcare va ccn fee schedule · inpatient | $1.5k | $1.5k | — | — | — | $1.5k – $1.5k |
| 4 | UnitedHealthcare va ccn fee schedule · outpatient | $1.5k | $1.5k | — | — | — | $1.5k – $1.5k |
| 5 | Aetna Better Health managed medicaid percent of total billed charges · inpatientfrom % of charges | $2.8k | $2.8k | — | — | — | $2.8k – $2.8k |
| 6 | Aetna Better Health managed medicaid percent of total billed charges · outpatientfrom % of charges | $2.8k | $2.8k | — | — | — | $2.8k – $2.8k |
| 7 | Molina managed medicaid percent of total billed charges · inpatientfrom % of charges | $3.4k | $3.4k | — | — | — | $3.4k – $3.4k |
| 8 | Molina managed medicaid percent of total billed charges · outpatientfrom % of charges | $3.4k | $3.4k | — | — | — | $3.4k – $3.4k |
| 9 | Molina medicare-medicaid (mmai/dual) percent of total billed charges · inpatientfrom % of charges | $3.4k | $3.4k | — | — | — | $3.4k – $3.4k |
| 10 | Molina medicare-medicaid (mmai/dual) percent of total billed charges · outpatientfrom % of charges | $3.4k | $3.4k | — | — | — | $3.4k – $3.4k |
| 11 | Blue Cross Blue Shield blue choice percent of total billed charges · outpatientfrom % of charges | $4.4k | $4.4k | — | — | — | $4.4k – $4.4k |
| 12 | Blue Cross Blue Shield blue choice options percent of total billed charges · outpatientfrom % of charges | $4.4k | $4.4k | — | — | — | $4.4k – $4.4k |
| 13 | Blue Cross Blue Shield ppo percent of total billed charges · outpatientfrom % of charges | $4.5k | $4.5k | — | — | — | $4.5k – $4.5k |
| 14 | UnitedHealthcare ppo percent of total billed charges · inpatientfrom % of charges | $4.5k | $4.5k | — | — | — | $4.5k – $4.5k |
| 15 | UnitedHealthcare ppo percent of total billed charges · outpatientfrom % of charges | $4.5k | $4.5k | — | — | — | $4.5k – $4.5k |
| 16 | Blue Cross Blue Shield hmo percent of total billed charges · outpatientfrom % of charges | $5.4k | $5.4k | — | — | — | $5.4k – $5.4k |
| 17 | Aetna commercial ppo percent of total billed charges · outpatientfrom % of charges | $5.5k | $5.5k | — | — | — | $5.5k – $5.5k |
| 18 | Aetna medicare advantage percent of total billed charges · outpatientfrom % of charges | $5.6k | $5.6k | — | — | — | $5.6k – $5.6k |
| 19 | MultiPlan ppo percent of total billed charges · inpatientfrom % of charges | $5.6k | $5.6k | — | — | — | $5.6k – $5.6k |
| 20 | MultiPlan ppo percent of total billed charges · outpatientfrom % of charges | $5.6k | $5.6k | — | — | — | $5.6k – $5.6k |
| 21 | Cigna ppo percent of total billed charges · outpatientfrom % of charges | $7.6k | $7.6k | — | — | — | $7.6k – $7.6k |
Last updated: Apr 15, 2026
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