Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION

Facility

$67.02

Service Code	HCPCS J0640
Hospital Charge Code	15426
Hospital Revenue Code	636
Min. Negotiated Rate	$42.22
Max. Negotiated Rate	$60.32
Rate for Payer: Aetna Commercial	$56.97
Rate for Payer: Aetna New Business (MI Preferred)	$43.56
Rate for Payer: Cash Price	$53.62
Rate for Payer: Cofinity Commercial	$46.91
Rate for Payer: Cofinity Commercial	$57.64
Rate for Payer: Healthscope Commercial	$60.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$56.97
Rate for Payer: PHP Commercial	$56.97
Rate for Payer: Priority Health Cigna Priority Health	$46.91
Rate for Payer: Priority Health SBD	$42.22

LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION

Facility

$67.02

Service Code	HCPCS J0640
Hospital Charge Code	15426
Hospital Revenue Code	636
Min. Negotiated Rate	$13.22
Max. Negotiated Rate	$60.32
Rate for Payer: Aetna Commercial	$56.97
Rate for Payer: Aetna New Business (MI Preferred)	$43.56
Rate for Payer: BCBS Complete	$26.81
Rate for Payer: BCBS Trust/PPO	$13.22
Rate for Payer: Cash Price	$53.62
Rate for Payer: Cash Price	$53.62
Rate for Payer: Cofinity Commercial	$46.91
Rate for Payer: Cofinity Commercial	$57.64
Rate for Payer: Healthscope Commercial	$60.32
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$56.97
Rate for Payer: PHP Commercial	$56.97
Rate for Payer: Priority Health Cigna Priority Health	$46.91
Rate for Payer: Priority Health SBD	$42.22

LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION

Facility

$52.56

Service Code	HCPCS J0640
Hospital Charge Code	4393
Hospital Revenue Code	636
Min. Negotiated Rate	$13.22
Max. Negotiated Rate	$47.30
Rate for Payer: Aetna Commercial	$44.68
Rate for Payer: Aetna Commercial	$66.65
Rate for Payer: Aetna Commercial	$91.27
Rate for Payer: Aetna New Business (MI Preferred)	$69.80
Rate for Payer: Aetna New Business (MI Preferred)	$34.16
Rate for Payer: Aetna New Business (MI Preferred)	$50.97
Rate for Payer: BCBS Complete	$42.95
Rate for Payer: BCBS Complete	$31.36
Rate for Payer: BCBS Complete	$21.02
Rate for Payer: BCBS Trust/PPO	$13.22
Rate for Payer: BCBS Trust/PPO	$13.22
Rate for Payer: BCBS Trust/PPO	$13.22
Rate for Payer: Cash Price	$42.05
Rate for Payer: Cash Price	$85.90
Rate for Payer: Cash Price	$62.73
Rate for Payer: Cash Price	$62.73
Rate for Payer: Cash Price	$85.90
Rate for Payer: Cash Price	$42.05
Rate for Payer: Cofinity Commercial	$67.43
Rate for Payer: Cofinity Commercial	$92.35
Rate for Payer: Cofinity Commercial	$75.17
Rate for Payer: Cofinity Commercial	$36.79
Rate for Payer: Cofinity Commercial	$45.20
Rate for Payer: Cofinity Commercial	$54.89
Rate for Payer: Healthscope Commercial	$47.30
Rate for Payer: Healthscope Commercial	$96.64
Rate for Payer: Healthscope Commercial	$70.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$66.65
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$91.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$44.68
Rate for Payer: PHP Commercial	$66.65
Rate for Payer: PHP Commercial	$44.68
Rate for Payer: PHP Commercial	$91.27
Rate for Payer: Priority Health Cigna Priority Health	$54.89
Rate for Payer: Priority Health Cigna Priority Health	$36.79
Rate for Payer: Priority Health Cigna Priority Health	$75.17
Rate for Payer: Priority Health SBD	$33.11
Rate for Payer: Priority Health SBD	$67.65
Rate for Payer: Priority Health SBD	$49.40

LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION

Facility

$52.56

Service Code	HCPCS J0640
Hospital Charge Code	4393
Hospital Revenue Code	636
Min. Negotiated Rate	$33.11
Max. Negotiated Rate	$47.30
Rate for Payer: Aetna Commercial	$44.68
Rate for Payer: Aetna Commercial	$66.65
Rate for Payer: Aetna Commercial	$91.27
Rate for Payer: Aetna New Business (MI Preferred)	$69.80
Rate for Payer: Aetna New Business (MI Preferred)	$50.97
Rate for Payer: Aetna New Business (MI Preferred)	$34.16
Rate for Payer: Cash Price	$42.05
Rate for Payer: Cash Price	$85.90
Rate for Payer: Cash Price	$62.73
Rate for Payer: Cofinity Commercial	$67.43
Rate for Payer: Cofinity Commercial	$92.35
Rate for Payer: Cofinity Commercial	$54.89
Rate for Payer: Cofinity Commercial	$75.17
Rate for Payer: Cofinity Commercial	$36.79
Rate for Payer: Cofinity Commercial	$45.20
Rate for Payer: Healthscope Commercial	$47.30
Rate for Payer: Healthscope Commercial	$96.64
Rate for Payer: Healthscope Commercial	$70.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$91.27
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$66.65
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$44.68
Rate for Payer: PHP Commercial	$66.65
Rate for Payer: PHP Commercial	$91.27
Rate for Payer: PHP Commercial	$44.68
Rate for Payer: Priority Health Cigna Priority Health	$36.79
Rate for Payer: Priority Health Cigna Priority Health	$75.17
Rate for Payer: Priority Health Cigna Priority Health	$54.89
Rate for Payer: Priority Health SBD	$33.11
Rate for Payer: Priority Health SBD	$67.65
Rate for Payer: Priority Health SBD	$49.40

LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION

Facility

$186.19

Service Code	HCPCS J0640
Hospital Charge Code	23617
Hospital Revenue Code	636
Min. Negotiated Rate	$13.22
Max. Negotiated Rate	$167.57
Rate for Payer: Aetna Commercial	$158.26
Rate for Payer: Aetna New Business (MI Preferred)	$121.02
Rate for Payer: BCBS Complete	$74.48
Rate for Payer: BCBS Trust/PPO	$13.22
Rate for Payer: Cash Price	$148.95
Rate for Payer: Cash Price	$148.95
Rate for Payer: Cofinity Commercial	$130.33
Rate for Payer: Cofinity Commercial	$160.12
Rate for Payer: Healthscope Commercial	$167.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$158.26
Rate for Payer: PHP Commercial	$158.26
Rate for Payer: Priority Health Cigna Priority Health	$130.33
Rate for Payer: Priority Health SBD	$117.30

LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION

Facility

$186.19

Service Code	HCPCS J0640
Hospital Charge Code	23617
Hospital Revenue Code	636
Min. Negotiated Rate	$117.30
Max. Negotiated Rate	$167.57
Rate for Payer: Aetna Commercial	$158.26
Rate for Payer: Aetna Commercial	$260.05
Rate for Payer: Aetna New Business (MI Preferred)	$121.02
Rate for Payer: Aetna New Business (MI Preferred)	$198.86
Rate for Payer: Cash Price	$148.95
Rate for Payer: Cash Price	$244.75
Rate for Payer: Cofinity Commercial	$160.12
Rate for Payer: Cofinity Commercial	$214.16
Rate for Payer: Cofinity Commercial	$263.11
Rate for Payer: Cofinity Commercial	$130.33
Rate for Payer: Healthscope Commercial	$275.35
Rate for Payer: Healthscope Commercial	$167.57
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$158.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$260.05
Rate for Payer: PHP Commercial	$260.05
Rate for Payer: PHP Commercial	$158.26
Rate for Payer: Priority Health Cigna Priority Health	$130.33
Rate for Payer: Priority Health Cigna Priority Health	$214.16
Rate for Payer: Priority Health SBD	$117.30
Rate for Payer: Priority Health SBD	$192.74

LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT

Facility

$17,707.65

Service Code	HCPCS J1950
Hospital Charge Code	21044
Hospital Revenue Code	636
Min. Negotiated Rate	$855.84
Max. Negotiated Rate	$15,936.88
Rate for Payer: Aetna Commercial	$15,051.50
Rate for Payer: Aetna Medicare	$1,627.19
Rate for Payer: Aetna New Business (MI Preferred)	$11,509.97
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,955.76
Rate for Payer: Amish Plain Church Group Commercial	$1,955.76
Rate for Payer: BCBS Complete	$898.71
Rate for Payer: BCBS MAPPO	$1,564.60
Rate for Payer: BCBS Trust/PPO	$4,632.03
Rate for Payer: BCN Medicare Advantage	$1,564.60
Rate for Payer: Cash Price	$14,166.12
Rate for Payer: Cash Price	$14,166.12
Rate for Payer: Cofinity Commercial	$15,228.58
Rate for Payer: Cofinity Commercial	$12,395.36
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,564.60
Rate for Payer: Healthscope Commercial	$15,936.88
Rate for Payer: Mclaren Medicaid	$855.84
Rate for Payer: Mclaren Medicare	$1,564.60
Rate for Payer: Meridian Medicaid	$898.71
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,642.83
Rate for Payer: MI Amish Medical Board Commercial	$1,799.29
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15,051.50
Rate for Payer: PACE Medicare	$1,486.37
Rate for Payer: PACE SWMI	$1,564.60
Rate for Payer: PHP Commercial	$15,051.50
Rate for Payer: PHP Medicare Advantage	$1,564.60
Rate for Payer: Priority Health Choice Medicaid	$855.84
Rate for Payer: Priority Health Cigna Priority Health	$12,395.36
Rate for Payer: Priority Health Medicare	$1,564.60
Rate for Payer: Priority Health SBD	$11,155.82
Rate for Payer: Railroad Medicare Medicare	$1,564.60
Rate for Payer: UHC Dual Complete DSNP	$1,564.60
Rate for Payer: UHC Medicare Advantage	$1,611.54
Rate for Payer: VA VA	$1,564.60

LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT

Facility

$17,707.65

Service Code	HCPCS J1950
Hospital Charge Code	21044
Hospital Revenue Code	636
Min. Negotiated Rate	$11,155.82
Max. Negotiated Rate	$15,936.88
Rate for Payer: Aetna Commercial	$15,051.50
Rate for Payer: Aetna New Business (MI Preferred)	$11,509.97
Rate for Payer: Cash Price	$14,166.12
Rate for Payer: Cofinity Commercial	$15,228.58
Rate for Payer: Cofinity Commercial	$12,395.36
Rate for Payer: Healthscope Commercial	$15,936.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15,051.50
Rate for Payer: PHP Commercial	$15,051.50
Rate for Payer: Priority Health Cigna Priority Health	$12,395.36
Rate for Payer: Priority Health SBD	$11,155.82

LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT

Facility

$1,505.60

Service Code	HCPCS J9217
Hospital Charge Code	21045
Hospital Revenue Code	636
Min. Negotiated Rate	$948.53
Max. Negotiated Rate	$1,355.04
Rate for Payer: Aetna Commercial	$1,279.76
Rate for Payer: Aetna New Business (MI Preferred)	$978.64
Rate for Payer: Cash Price	$1,204.48
Rate for Payer: Cofinity Commercial	$1,053.92
Rate for Payer: Cofinity Commercial	$1,294.82
Rate for Payer: Healthscope Commercial	$1,355.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,279.76
Rate for Payer: PHP Commercial	$1,279.76
Rate for Payer: Priority Health Cigna Priority Health	$1,053.92
Rate for Payer: Priority Health SBD	$948.53

LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT

Facility

$1,505.60

Service Code	HCPCS J9217
Hospital Charge Code	21045
Hospital Revenue Code	636
Min. Negotiated Rate	$99.17
Max. Negotiated Rate	$1,355.04
Rate for Payer: Aetna Commercial	$1,279.76
Rate for Payer: Aetna Medicare	$188.55
Rate for Payer: Aetna New Business (MI Preferred)	$978.64
Rate for Payer: Allen County Amish Medical Aid Commercial	$226.63
Rate for Payer: Amish Plain Church Group Commercial	$226.63
Rate for Payer: BCBS Complete	$104.14
Rate for Payer: BCBS MAPPO	$181.30
Rate for Payer: BCBS Trust/PPO	$556.62
Rate for Payer: BCN Medicare Advantage	$181.30
Rate for Payer: Cash Price	$1,204.48
Rate for Payer: Cash Price	$1,204.48
Rate for Payer: Cofinity Commercial	$1,053.92
Rate for Payer: Cofinity Commercial	$1,294.82
Rate for Payer: Health Alliance Plan Medicare Advantage	$181.30
Rate for Payer: Healthscope Commercial	$1,355.04
Rate for Payer: Mclaren Medicaid	$99.17
Rate for Payer: Mclaren Medicare	$181.30
Rate for Payer: Meridian Medicaid	$104.14
Rate for Payer: Meridian Wellcare - Medicare Advantage	$190.37
Rate for Payer: MI Amish Medical Board Commercial	$208.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,279.76
Rate for Payer: PACE Medicare	$172.24
Rate for Payer: PACE SWMI	$181.30
Rate for Payer: PHP Commercial	$1,279.76
Rate for Payer: PHP Medicare Advantage	$181.30
Rate for Payer: Priority Health Choice Medicaid	$99.17
Rate for Payer: Priority Health Cigna Priority Health	$1,053.92
Rate for Payer: Priority Health Medicare	$181.30
Rate for Payer: Priority Health SBD	$948.53
Rate for Payer: Railroad Medicare Medicare	$181.30
Rate for Payer: UHC Dual Complete DSNP	$181.30
Rate for Payer: UHC Medicare Advantage	$186.74
Rate for Payer: VA VA	$181.30

LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE

Facility

$1,123.20

Service Code	HCPCS J9217
Hospital Charge Code	33669
Hospital Revenue Code	636
Min. Negotiated Rate	$707.62
Max. Negotiated Rate	$1,010.88
Rate for Payer: Aetna Commercial	$954.72
Rate for Payer: Aetna New Business (MI Preferred)	$730.08
Rate for Payer: Cash Price	$898.56
Rate for Payer: Cofinity Commercial	$786.24
Rate for Payer: Cofinity Commercial	$965.95
Rate for Payer: Healthscope Commercial	$1,010.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$954.72
Rate for Payer: PHP Commercial	$954.72
Rate for Payer: Priority Health Cigna Priority Health	$786.24
Rate for Payer: Priority Health SBD	$707.62

LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE

Facility

$1,123.20

Service Code	HCPCS J9217
Hospital Charge Code	33669
Hospital Revenue Code	636
Min. Negotiated Rate	$99.17
Max. Negotiated Rate	$1,010.88
Rate for Payer: Aetna Commercial	$954.72
Rate for Payer: Aetna Medicare	$188.55
Rate for Payer: Aetna New Business (MI Preferred)	$730.08
Rate for Payer: Allen County Amish Medical Aid Commercial	$226.63
Rate for Payer: Amish Plain Church Group Commercial	$226.63
Rate for Payer: BCBS Complete	$104.14
Rate for Payer: BCBS MAPPO	$181.30
Rate for Payer: BCBS Trust/PPO	$556.62
Rate for Payer: BCN Medicare Advantage	$181.30
Rate for Payer: Cash Price	$898.56
Rate for Payer: Cash Price	$898.56
Rate for Payer: Cofinity Commercial	$965.95
Rate for Payer: Cofinity Commercial	$786.24
Rate for Payer: Health Alliance Plan Medicare Advantage	$181.30
Rate for Payer: Healthscope Commercial	$1,010.88
Rate for Payer: Mclaren Medicaid	$99.17
Rate for Payer: Mclaren Medicare	$181.30
Rate for Payer: Meridian Medicaid	$104.14
Rate for Payer: Meridian Wellcare - Medicare Advantage	$190.37
Rate for Payer: MI Amish Medical Board Commercial	$208.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$954.72
Rate for Payer: PACE Medicare	$172.24
Rate for Payer: PACE SWMI	$181.30
Rate for Payer: PHP Commercial	$954.72
Rate for Payer: PHP Medicare Advantage	$181.30
Rate for Payer: Priority Health Choice Medicaid	$99.17
Rate for Payer: Priority Health Cigna Priority Health	$786.24
Rate for Payer: Priority Health Medicare	$181.30
Rate for Payer: Priority Health SBD	$707.62
Rate for Payer: Railroad Medicare Medicare	$181.30
Rate for Payer: UHC Dual Complete DSNP	$181.30
Rate for Payer: UHC Medicare Advantage	$186.74
Rate for Payer: VA VA	$181.30

LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT

Facility

$2,007.46

Service Code	HCPCS J9217
Hospital Charge Code	21108
Hospital Revenue Code	636
Min. Negotiated Rate	$1,264.70
Max. Negotiated Rate	$1,806.71
Rate for Payer: Aetna Commercial	$1,706.34
Rate for Payer: Aetna New Business (MI Preferred)	$1,304.85
Rate for Payer: Cash Price	$1,605.97
Rate for Payer: Cofinity Commercial	$1,405.22
Rate for Payer: Cofinity Commercial	$1,726.42
Rate for Payer: Healthscope Commercial	$1,806.71
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,706.34
Rate for Payer: PHP Commercial	$1,706.34
Rate for Payer: Priority Health Cigna Priority Health	$1,405.22
Rate for Payer: Priority Health SBD	$1,264.70

LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT

Facility

$5,104.87

Service Code	HCPCS J1950
Hospital Charge Code	13691
Hospital Revenue Code	636
Min. Negotiated Rate	$855.84
Max. Negotiated Rate	$4,632.03
Rate for Payer: Aetna Commercial	$4,339.14
Rate for Payer: Aetna Medicare	$1,627.19
Rate for Payer: Aetna New Business (MI Preferred)	$3,318.17
Rate for Payer: Allen County Amish Medical Aid Commercial	$1,955.76
Rate for Payer: Amish Plain Church Group Commercial	$1,955.76
Rate for Payer: BCBS Complete	$898.71
Rate for Payer: BCBS MAPPO	$1,564.60
Rate for Payer: BCBS Trust/PPO	$4,632.03
Rate for Payer: BCN Medicare Advantage	$1,564.60
Rate for Payer: Cash Price	$4,083.90
Rate for Payer: Cash Price	$4,083.90
Rate for Payer: Cofinity Commercial	$4,390.19
Rate for Payer: Cofinity Commercial	$3,573.41
Rate for Payer: Health Alliance Plan Medicare Advantage	$1,564.60
Rate for Payer: Healthscope Commercial	$4,594.38
Rate for Payer: Mclaren Medicaid	$855.84
Rate for Payer: Mclaren Medicare	$1,564.60
Rate for Payer: Meridian Medicaid	$898.71
Rate for Payer: Meridian Wellcare - Medicare Advantage	$1,642.83
Rate for Payer: MI Amish Medical Board Commercial	$1,799.29
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4,339.14
Rate for Payer: PACE Medicare	$1,486.37
Rate for Payer: PACE SWMI	$1,564.60
Rate for Payer: PHP Commercial	$4,339.14
Rate for Payer: PHP Medicare Advantage	$1,564.60
Rate for Payer: Priority Health Choice Medicaid	$855.84
Rate for Payer: Priority Health Cigna Priority Health	$3,573.41
Rate for Payer: Priority Health Medicare	$1,564.60
Rate for Payer: Priority Health SBD	$3,216.07
Rate for Payer: Railroad Medicare Medicare	$1,564.60
Rate for Payer: UHC Dual Complete DSNP	$1,564.60
Rate for Payer: UHC Medicare Advantage	$1,611.54
Rate for Payer: VA VA	$1,564.60

LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT

Facility

$5,104.87

Service Code	HCPCS J1950
Hospital Charge Code	13691
Hospital Revenue Code	636
Min. Negotiated Rate	$3,216.07
Max. Negotiated Rate	$4,594.38
Rate for Payer: Aetna Commercial	$4,339.14
Rate for Payer: Aetna New Business (MI Preferred)	$3,318.17
Rate for Payer: Cash Price	$4,083.90
Rate for Payer: Cofinity Commercial	$3,573.41
Rate for Payer: Cofinity Commercial	$4,390.19
Rate for Payer: Healthscope Commercial	$4,594.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4,339.14
Rate for Payer: PHP Commercial	$4,339.14
Rate for Payer: Priority Health Cigna Priority Health	$3,573.41
Rate for Payer: Priority Health SBD	$3,216.07

LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT

Facility

$556.79

Service Code	HCPCS J9217
Hospital Charge Code	152657
Hospital Revenue Code	636
Min. Negotiated Rate	$99.17
Max. Negotiated Rate	$556.62
Rate for Payer: Aetna Commercial	$473.27
Rate for Payer: Aetna Medicare	$188.55
Rate for Payer: Aetna New Business (MI Preferred)	$361.91
Rate for Payer: Allen County Amish Medical Aid Commercial	$226.63
Rate for Payer: Amish Plain Church Group Commercial	$226.63
Rate for Payer: BCBS Complete	$104.14
Rate for Payer: BCBS MAPPO	$181.30
Rate for Payer: BCBS Trust/PPO	$556.62
Rate for Payer: BCN Medicare Advantage	$181.30
Rate for Payer: Cash Price	$445.43
Rate for Payer: Cash Price	$445.43
Rate for Payer: Cofinity Commercial	$389.75
Rate for Payer: Cofinity Commercial	$478.84
Rate for Payer: Health Alliance Plan Medicare Advantage	$181.30
Rate for Payer: Healthscope Commercial	$501.11
Rate for Payer: Mclaren Medicaid	$99.17
Rate for Payer: Mclaren Medicare	$181.30
Rate for Payer: Meridian Medicaid	$104.14
Rate for Payer: Meridian Wellcare - Medicare Advantage	$190.37
Rate for Payer: MI Amish Medical Board Commercial	$208.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$473.27
Rate for Payer: PACE Medicare	$172.24
Rate for Payer: PACE SWMI	$181.30
Rate for Payer: PHP Commercial	$473.27
Rate for Payer: PHP Medicare Advantage	$181.30
Rate for Payer: Priority Health Choice Medicaid	$99.17
Rate for Payer: Priority Health Cigna Priority Health	$389.75
Rate for Payer: Priority Health Medicare	$181.30
Rate for Payer: Priority Health SBD	$350.78
Rate for Payer: Railroad Medicare Medicare	$181.30
Rate for Payer: UHC Dual Complete DSNP	$181.30
Rate for Payer: UHC Medicare Advantage	$186.74
Rate for Payer: VA VA	$181.30

LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT

Facility

$556.79

Service Code	HCPCS J9217
Hospital Charge Code	152657
Hospital Revenue Code	636
Min. Negotiated Rate	$350.78
Max. Negotiated Rate	$501.11
Rate for Payer: Aetna Commercial	$473.27
Rate for Payer: Aetna New Business (MI Preferred)	$361.91
Rate for Payer: Cash Price	$445.43
Rate for Payer: Cofinity Commercial	$478.84
Rate for Payer: Cofinity Commercial	$389.75
Rate for Payer: Healthscope Commercial	$501.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$473.27
Rate for Payer: PHP Commercial	$473.27
Rate for Payer: Priority Health Cigna Priority Health	$389.75
Rate for Payer: Priority Health SBD	$350.78

LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE

Facility

$2,188.80

Service Code	HCPCS J9217
Hospital Charge Code	40801
Hospital Revenue Code	636
Min. Negotiated Rate	$99.17
Max. Negotiated Rate	$1,969.92
Rate for Payer: Aetna Commercial	$1,860.48
Rate for Payer: Aetna Medicare	$188.55
Rate for Payer: Aetna New Business (MI Preferred)	$1,422.72
Rate for Payer: Allen County Amish Medical Aid Commercial	$226.63
Rate for Payer: Amish Plain Church Group Commercial	$226.63
Rate for Payer: BCBS Complete	$104.14
Rate for Payer: BCBS MAPPO	$181.30
Rate for Payer: BCBS Trust/PPO	$556.62
Rate for Payer: BCN Medicare Advantage	$181.30
Rate for Payer: Cash Price	$1,751.04
Rate for Payer: Cash Price	$1,751.04
Rate for Payer: Cofinity Commercial	$1,532.16
Rate for Payer: Cofinity Commercial	$1,882.37
Rate for Payer: Health Alliance Plan Medicare Advantage	$181.30
Rate for Payer: Healthscope Commercial	$1,969.92
Rate for Payer: Mclaren Medicaid	$99.17
Rate for Payer: Mclaren Medicare	$181.30
Rate for Payer: Meridian Medicaid	$104.14
Rate for Payer: Meridian Wellcare - Medicare Advantage	$190.37
Rate for Payer: MI Amish Medical Board Commercial	$208.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,860.48
Rate for Payer: PACE Medicare	$172.24
Rate for Payer: PACE SWMI	$181.30
Rate for Payer: PHP Commercial	$1,860.48
Rate for Payer: PHP Medicare Advantage	$181.30
Rate for Payer: Priority Health Choice Medicaid	$99.17
Rate for Payer: Priority Health Cigna Priority Health	$1,532.16
Rate for Payer: Priority Health Medicare	$181.30
Rate for Payer: Priority Health SBD	$1,378.94
Rate for Payer: Railroad Medicare Medicare	$181.30
Rate for Payer: UHC Dual Complete DSNP	$181.30
Rate for Payer: UHC Medicare Advantage	$186.74
Rate for Payer: VA VA	$181.30

LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE

Facility

$2,188.80

Service Code	HCPCS J9217
Hospital Charge Code	40801
Hospital Revenue Code	636
Min. Negotiated Rate	$1,378.94
Max. Negotiated Rate	$1,969.92
Rate for Payer: Aetna Commercial	$1,860.48
Rate for Payer: Aetna New Business (MI Preferred)	$1,422.72
Rate for Payer: Cash Price	$1,751.04
Rate for Payer: Cofinity Commercial	$1,532.16
Rate for Payer: Cofinity Commercial	$1,882.37
Rate for Payer: Healthscope Commercial	$1,969.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,860.48
Rate for Payer: PHP Commercial	$1,860.48
Rate for Payer: Priority Health Cigna Priority Health	$1,532.16
Rate for Payer: Priority Health SBD	$1,378.94

LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT

Facility

$3,011.24

Service Code	HCPCS J9217
Hospital Charge Code	152942
Hospital Revenue Code	636
Min. Negotiated Rate	$99.17
Max. Negotiated Rate	$2,710.12
Rate for Payer: Aetna Commercial	$2,559.55
Rate for Payer: Aetna Medicare	$188.55
Rate for Payer: Aetna New Business (MI Preferred)	$1,957.31
Rate for Payer: Allen County Amish Medical Aid Commercial	$226.63
Rate for Payer: Amish Plain Church Group Commercial	$226.63
Rate for Payer: BCBS Complete	$104.14
Rate for Payer: BCBS MAPPO	$181.30
Rate for Payer: BCBS Trust/PPO	$556.62
Rate for Payer: BCN Medicare Advantage	$181.30
Rate for Payer: Cash Price	$2,408.99
Rate for Payer: Cash Price	$2,408.99
Rate for Payer: Cofinity Commercial	$2,589.67
Rate for Payer: Cofinity Commercial	$2,107.87
Rate for Payer: Health Alliance Plan Medicare Advantage	$181.30
Rate for Payer: Healthscope Commercial	$2,710.12
Rate for Payer: Mclaren Medicaid	$99.17
Rate for Payer: Mclaren Medicare	$181.30
Rate for Payer: Meridian Medicaid	$104.14
Rate for Payer: Meridian Wellcare - Medicare Advantage	$190.37
Rate for Payer: MI Amish Medical Board Commercial	$208.50
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2,559.55
Rate for Payer: PACE Medicare	$172.24
Rate for Payer: PACE SWMI	$181.30
Rate for Payer: PHP Commercial	$2,559.55
Rate for Payer: PHP Medicare Advantage	$181.30
Rate for Payer: Priority Health Choice Medicaid	$99.17
Rate for Payer: Priority Health Cigna Priority Health	$2,107.87
Rate for Payer: Priority Health Medicare	$181.30
Rate for Payer: Priority Health SBD	$1,897.08
Rate for Payer: Railroad Medicare Medicare	$181.30
Rate for Payer: UHC Dual Complete DSNP	$181.30
Rate for Payer: UHC Medicare Advantage	$186.74
Rate for Payer: VA VA	$181.30

LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT

Facility

$3,011.24

Service Code	HCPCS J9217
Hospital Charge Code	152942
Hospital Revenue Code	636
Min. Negotiated Rate	$1,897.08
Max. Negotiated Rate	$2,710.12
Rate for Payer: Aetna Commercial	$2,559.55
Rate for Payer: Aetna New Business (MI Preferred)	$1,957.31
Rate for Payer: Cash Price	$2,408.99
Rate for Payer: Cofinity Commercial	$2,107.87
Rate for Payer: Cofinity Commercial	$2,589.67
Rate for Payer: Healthscope Commercial	$2,710.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2,559.55
Rate for Payer: PHP Commercial	$2,559.55
Rate for Payer: Priority Health Cigna Priority Health	$2,107.87
Rate for Payer: Priority Health SBD	$1,897.08

LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION ABORTION - SPONTANEOUS/MISSED ARTERY, BIOPSY BONE MARROW, BIOPSY BONE EXOSTOSIS BRAIN/MENINGES, OTHER THAN FOR TUMOR RESECTION BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, REDUCTION MAMMOPLASTY BRONCHUS, BIOPSY CELL BLOCK, ANY SOURCE CERVIX, BIOPSY COLON, BIOPSY DUODENUM, BIOPSY ENDOCERVIX, CURETTINGS/BIOPSY ENDOMETRIUM, CURETTINGS/BIOPSY ESOPHAGUS, BIOPSY EXTREMITY, AMPUTATION, TRAUMATIC FALLOPIAN TUBE, BIOPSY FALLOPIAN TUBE, ECTOPIC PREGNANCY FEMORAL HEAD, FRACTURE FINGERS/TOES, AMPUTATION, NON-TRAUMATIC GINGIVA/ORAL MUCOSA, BIOPSY HEART VALVE JOINT, RESECTION KIDNEY, BIOPSY LARYNX, BIOPSY LEIOMYOMA(S), UTERINE MYOMECTOMY - WITHOUT UTERUS LIP, BIOPSY/WEDGE RESECTION LUNG, TRANSBRONCHIAL BIOPSY LYMPH NODE, BIOPSY MUSCLE, BIOPSY NASAL MUCOSA, BIOPSY NASOPHARYNX/OROPHARYNX, BIOPSY NERVE, BIOPSY ODONTOGENIC/DENTAL CYST OMENTUM, BIOPSY OVARY WITH OR WITHOUT TUBE, NON-NEOPLASTIC OVARY, BIOPSY/WEDGE RESECTION PARAT

Facility

$154.72

Service Code	CPT 88305
Hospital Revenue Code	360
Min. Negotiated Rate	$26.38
Max. Negotiated Rate	$154.72
Rate for Payer: Aetna Medicare	$50.15
Rate for Payer: Allen County Amish Medical Aid Commercial	$60.28
Rate for Payer: Amish Plain Church Group Commercial	$60.28
Rate for Payer: BCBS Complete	$27.70
Rate for Payer: BCBS MAPPO	$48.22
Rate for Payer: BCBS Trust/PPO	$52.24
Rate for Payer: BCCCP Commercial	$71.93
Rate for Payer: BCN Medicare Advantage	$48.22
Rate for Payer: Health Alliance Plan Medicare Advantage	$48.22
Rate for Payer: Mclaren Medicaid	$26.38
Rate for Payer: Mclaren Medicare	$48.22
Rate for Payer: Meridian Medicaid	$27.70
Rate for Payer: Meridian Wellcare - Medicare Advantage	$50.63
Rate for Payer: MI Amish Medical Board Commercial	$55.45
Rate for Payer: PACE Medicare	$45.81
Rate for Payer: PACE SWMI	$48.22
Rate for Payer: PHP Medicare Advantage	$48.22
Rate for Payer: Priority Health Choice Medicaid	$26.38
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$154.72
Rate for Payer: Priority Health Medicare	$48.22
Rate for Payer: Priority Health Narrow Network	$123.78
Rate for Payer: Railroad Medicare Medicare	$48.22
Rate for Payer: UHC All Payor (Choice/PPO)	$77.44
Rate for Payer: UHC Core	$44.17
Rate for Payer: UHC Dual Complete DSNP	$48.22
Rate for Payer: UHC Exchange	$70.40
Rate for Payer: UHC Medicare Advantage	$49.67
Rate for Payer: VA VA	$48.22

LEVETIRACETAM 1,000 MG TABLET

Facility

$312.00

Service Code	NDC 60687-668-01
Hospital Charge Code	70773
Hospital Revenue Code	637
Min. Negotiated Rate	$196.56
Max. Negotiated Rate	$280.80
Rate for Payer: Aetna Commercial	$265.20
Rate for Payer: Aetna New Business (MI Preferred)	$202.80
Rate for Payer: Cash Price	$249.60
Rate for Payer: Cofinity Commercial	$218.40
Rate for Payer: Cofinity Commercial	$268.32
Rate for Payer: Healthscope Commercial	$280.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$265.20
Rate for Payer: PHP Commercial	$265.20
Rate for Payer: Priority Health Cigna Priority Health	$218.40
Rate for Payer: Priority Health SBD	$196.56

LEVETIRACETAM 1,000 MG TABLET

Facility

$3.12

Service Code	NDC 60687-668-11
Hospital Charge Code	70773
Hospital Revenue Code	637
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.81
Rate for Payer: Aetna Commercial	$2.65
Rate for Payer: Aetna New Business (MI Preferred)	$2.03
Rate for Payer: Cash Price	$2.50
Rate for Payer: Cofinity Commercial	$2.18
Rate for Payer: Cofinity Commercial	$2.68
Rate for Payer: Healthscope Commercial	$2.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.65
Rate for Payer: PHP Commercial	$2.65
Rate for Payer: Priority Health Cigna Priority Health	$2.18
Rate for Payer: Priority Health SBD	$1.97

LEVETIRACETAM 100 MG/ML ORAL SOLUTION

Facility

$4,020.88

Service Code	NDC 50474-001-48
Hospital Charge Code	36590
Hospital Revenue Code	637
Min. Negotiated Rate	$2,533.15
Max. Negotiated Rate	$3,618.79
Rate for Payer: Aetna Commercial	$3,417.75
Rate for Payer: Aetna New Business (MI Preferred)	$2,613.57
Rate for Payer: Cash Price	$3,216.70
Rate for Payer: Cofinity Commercial	$2,814.62
Rate for Payer: Cofinity Commercial	$3,457.96
Rate for Payer: Healthscope Commercial	$3,618.79
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3,417.75
Rate for Payer: PHP Commercial	$3,417.75
Rate for Payer: Priority Health Cigna Priority Health	$2,814.62
Rate for Payer: Priority Health SBD	$2,533.15

Know your out-of-pocket cost for care.

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