|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$2,320.32
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,461.80 |
| Max. Negotiated Rate |
$2,088.29 |
| Rate for Payer: Aetna Commercial |
$1,972.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,508.21
|
| Rate for Payer: Cash Price |
$1,856.26
|
| Rate for Payer: Cofinity Advantage |
$1,624.22
|
| Rate for Payer: Cofinity Commercial |
$1,995.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,856.26
|
| Rate for Payer: Healthscope Commercial |
$2,088.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,972.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,740.24
|
| Rate for Payer: PHP Commercial |
$1,972.27
|
| Rate for Payer: Priority Health SBD |
$1,461.80
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$7,535.58
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
13691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$923.39 |
| Max. Negotiated Rate |
$6,782.02 |
| Rate for Payer: Aetna Commercial |
$6,405.24
|
| Rate for Payer: Aetna Medicare |
$1,836.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,898.13
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,206.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,206.96
|
| Rate for Payer: BCBS Complete |
$969.65
|
| Rate for Payer: BCBS MAPPO |
$1,765.57
|
| Rate for Payer: BCBS Trust/PPO |
$4,425.28
|
| Rate for Payer: BCN Commercial |
$4,425.28
|
| Rate for Payer: BCN Medicare Advantage |
$1,765.57
|
| Rate for Payer: Cash Price |
$6,028.46
|
| Rate for Payer: Cash Price |
$6,028.46
|
| Rate for Payer: Cofinity Advantage |
$5,274.91
|
| Rate for Payer: Cofinity Commercial |
$6,480.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,028.46
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,765.57
|
| Rate for Payer: Healthscope Commercial |
$6,782.02
|
| Rate for Payer: Mclaren Medicaid |
$923.39
|
| Rate for Payer: Mclaren Medicare |
$1,765.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,853.85
|
| Rate for Payer: Meridian Medicaid |
$1,853.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,030.41
|
| Rate for Payer: Molina Medicare/Medicaid |
$1,942.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,405.24
|
| Rate for Payer: Nomi Health Commercial |
$5,296.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5,651.69
|
| Rate for Payer: PACE Medicare |
$1,677.29
|
| Rate for Payer: PACE SWMI |
$1,765.57
|
| Rate for Payer: PHP Commercial |
$6,405.24
|
| Rate for Payer: PHP Medicare Advantage |
$1,765.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$923.39
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$5,457.38
|
| Rate for Payer: Priority Health Medicare |
$1,765.57
|
| Rate for Payer: Priority Health SBD |
$4,747.42
|
| Rate for Payer: Priority Health Tiered Network |
$4,365.90
|
| Rate for Payer: Railroad Medicare Medicare |
$1,765.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,910.39
|
| Rate for Payer: UHC Core |
$2,910.39
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$1,765.57
|
| Rate for Payer: UHC Exchange |
$2,910.39
|
| Rate for Payer: UHC Medicaid |
$923.39
|
| Rate for Payer: UHCCP Medicaid |
$923.39
|
| Rate for Payer: VA VA |
$1,765.57
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$7,535.58
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
13691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,747.42 |
| Max. Negotiated Rate |
$6,782.02 |
| Rate for Payer: Aetna Commercial |
$6,405.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4,898.13
|
| Rate for Payer: Cash Price |
$6,028.46
|
| Rate for Payer: Cofinity Advantage |
$5,274.91
|
| Rate for Payer: Cofinity Commercial |
$6,480.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,028.46
|
| Rate for Payer: Healthscope Commercial |
$6,782.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,405.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5,651.69
|
| Rate for Payer: PHP Commercial |
$6,405.24
|
| Rate for Payer: Priority Health SBD |
$4,747.42
|
|
|
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$643.51
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.15 |
| Max. Negotiated Rate |
$579.16 |
| Rate for Payer: Aetna Commercial |
$546.98
|
| Rate for Payer: Aetna Medicare |
$183.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$418.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.25
|
| Rate for Payer: BCBS Complete |
$96.77
|
| Rate for Payer: BCBS MAPPO |
$176.20
|
| Rate for Payer: BCBS Trust/PPO |
$444.32
|
| Rate for Payer: BCN Commercial |
$444.32
|
| Rate for Payer: BCN Medicare Advantage |
$176.20
|
| Rate for Payer: Cash Price |
$514.81
|
| Rate for Payer: Cash Price |
$514.81
|
| Rate for Payer: Cofinity Advantage |
$450.46
|
| Rate for Payer: Cofinity Commercial |
$553.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$514.81
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.20
|
| Rate for Payer: Healthscope Commercial |
$579.16
|
| Rate for Payer: Mclaren Medicaid |
$92.15
|
| Rate for Payer: Mclaren Medicare |
$176.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.01
|
| Rate for Payer: Meridian Medicaid |
$185.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.63
|
| Rate for Payer: Molina Medicare/Medicaid |
$193.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$546.98
|
| Rate for Payer: Nomi Health Commercial |
$528.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$482.63
|
| Rate for Payer: PACE Medicare |
$167.39
|
| Rate for Payer: PACE SWMI |
$176.20
|
| Rate for Payer: PHP Commercial |
$546.98
|
| Rate for Payer: PHP Medicare Advantage |
$176.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$92.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$556.52
|
| Rate for Payer: Priority Health Medicare |
$176.20
|
| Rate for Payer: Priority Health SBD |
$405.41
|
| Rate for Payer: Priority Health Tiered Network |
$445.22
|
| Rate for Payer: Railroad Medicare Medicare |
$176.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$281.79
|
| Rate for Payer: UHC Core |
$281.79
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$176.20
|
| Rate for Payer: UHC Exchange |
$281.79
|
| Rate for Payer: UHC Medicaid |
$92.15
|
| Rate for Payer: UHCCP Medicaid |
$92.15
|
| Rate for Payer: VA VA |
$176.20
|
|
|
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$643.51
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$405.41 |
| Max. Negotiated Rate |
$579.16 |
| Rate for Payer: Aetna Commercial |
$546.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$418.28
|
| Rate for Payer: Cash Price |
$514.81
|
| Rate for Payer: Cofinity Advantage |
$450.46
|
| Rate for Payer: Cofinity Commercial |
$553.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$514.81
|
| Rate for Payer: Healthscope Commercial |
$579.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$546.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$482.63
|
| Rate for Payer: PHP Commercial |
$546.98
|
| Rate for Payer: Priority Health SBD |
$405.41
|
|
|
LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$22,606.73
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,242.24 |
| Max. Negotiated Rate |
$20,346.06 |
| Rate for Payer: Aetna Commercial |
$19,215.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14,694.37
|
| Rate for Payer: Cash Price |
$18,085.38
|
| Rate for Payer: Cofinity Advantage |
$15,824.71
|
| Rate for Payer: Cofinity Commercial |
$19,441.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,085.38
|
| Rate for Payer: Healthscope Commercial |
$20,346.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19,215.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16,955.05
|
| Rate for Payer: PHP Commercial |
$19,215.72
|
| Rate for Payer: Priority Health SBD |
$14,242.24
|
|
|
LEUPROLIDE ACETATE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$22,606.73
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$923.39 |
| Max. Negotiated Rate |
$20,346.06 |
| Rate for Payer: Aetna Commercial |
$19,215.72
|
| Rate for Payer: Aetna Medicare |
$1,836.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14,694.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,206.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,206.96
|
| Rate for Payer: BCBS Complete |
$969.65
|
| Rate for Payer: BCBS MAPPO |
$1,765.57
|
| Rate for Payer: BCBS Trust/PPO |
$4,425.28
|
| Rate for Payer: BCN Commercial |
$4,425.28
|
| Rate for Payer: BCN Medicare Advantage |
$1,765.57
|
| Rate for Payer: Cash Price |
$18,085.38
|
| Rate for Payer: Cash Price |
$18,085.38
|
| Rate for Payer: Cofinity Advantage |
$15,824.71
|
| Rate for Payer: Cofinity Commercial |
$19,441.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18,085.38
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,765.57
|
| Rate for Payer: Healthscope Commercial |
$20,346.06
|
| Rate for Payer: Mclaren Medicaid |
$923.39
|
| Rate for Payer: Mclaren Medicare |
$1,765.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,853.85
|
| Rate for Payer: Meridian Medicaid |
$1,853.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,030.41
|
| Rate for Payer: Molina Medicare/Medicaid |
$1,942.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19,215.72
|
| Rate for Payer: Nomi Health Commercial |
$5,296.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16,955.05
|
| Rate for Payer: PACE Medicare |
$1,677.29
|
| Rate for Payer: PACE SWMI |
$1,765.57
|
| Rate for Payer: PHP Commercial |
$19,215.72
|
| Rate for Payer: PHP Medicare Advantage |
$1,765.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$923.39
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$5,457.38
|
| Rate for Payer: Priority Health Medicare |
$1,765.57
|
| Rate for Payer: Priority Health SBD |
$14,242.24
|
| Rate for Payer: Priority Health Tiered Network |
$4,365.90
|
| Rate for Payer: Railroad Medicare Medicare |
$1,765.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,910.39
|
| Rate for Payer: UHC Core |
$2,910.39
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$1,765.57
|
| Rate for Payer: UHC Exchange |
$2,910.39
|
| Rate for Payer: UHC Medicaid |
$923.39
|
| Rate for Payer: UHCCP Medicaid |
$923.39
|
| Rate for Payer: VA VA |
$1,765.57
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$1,740.26
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,096.36 |
| Max. Negotiated Rate |
$1,566.23 |
| Rate for Payer: Aetna Commercial |
$1,479.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,131.17
|
| Rate for Payer: Cash Price |
$1,392.21
|
| Rate for Payer: Cofinity Advantage |
$1,218.18
|
| Rate for Payer: Cofinity Commercial |
$1,496.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,392.21
|
| Rate for Payer: Healthscope Commercial |
$1,566.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,479.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,305.19
|
| Rate for Payer: PHP Commercial |
$1,479.22
|
| Rate for Payer: Priority Health SBD |
$1,096.36
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$1,740.26
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.15 |
| Max. Negotiated Rate |
$1,566.23 |
| Rate for Payer: Aetna Commercial |
$1,479.22
|
| Rate for Payer: Aetna Medicare |
$183.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,131.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.25
|
| Rate for Payer: BCBS Complete |
$96.77
|
| Rate for Payer: BCBS MAPPO |
$176.20
|
| Rate for Payer: BCBS Trust/PPO |
$444.32
|
| Rate for Payer: BCN Commercial |
$444.32
|
| Rate for Payer: BCN Medicare Advantage |
$176.20
|
| Rate for Payer: Cash Price |
$1,392.21
|
| Rate for Payer: Cash Price |
$1,392.21
|
| Rate for Payer: Cofinity Advantage |
$1,218.18
|
| Rate for Payer: Cofinity Commercial |
$1,496.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,392.21
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.20
|
| Rate for Payer: Healthscope Commercial |
$1,566.23
|
| Rate for Payer: Mclaren Medicaid |
$92.15
|
| Rate for Payer: Mclaren Medicare |
$176.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.01
|
| Rate for Payer: Meridian Medicaid |
$185.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.63
|
| Rate for Payer: Molina Medicare/Medicaid |
$193.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,479.22
|
| Rate for Payer: Nomi Health Commercial |
$528.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,305.19
|
| Rate for Payer: PACE Medicare |
$167.39
|
| Rate for Payer: PACE SWMI |
$176.20
|
| Rate for Payer: PHP Commercial |
$1,479.22
|
| Rate for Payer: PHP Medicare Advantage |
$176.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$92.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$556.52
|
| Rate for Payer: Priority Health Medicare |
$176.20
|
| Rate for Payer: Priority Health SBD |
$1,096.36
|
| Rate for Payer: Priority Health Tiered Network |
$445.22
|
| Rate for Payer: Railroad Medicare Medicare |
$176.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$281.79
|
| Rate for Payer: UHC Core |
$281.79
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$176.20
|
| Rate for Payer: UHC Exchange |
$281.79
|
| Rate for Payer: UHC Medicaid |
$92.15
|
| Rate for Payer: UHCCP Medicaid |
$92.15
|
| Rate for Payer: VA VA |
$176.20
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$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 Advantage |
$786.24
|
| Rate for Payer: Cofinity Commercial |
$965.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$898.56
|
| Rate for Payer: Healthscope Commercial |
$1,010.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$954.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$842.40
|
| Rate for Payer: PHP Commercial |
$954.72
|
| Rate for Payer: Priority Health SBD |
$707.62
|
|
|
LEUPROLIDE ACETATE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$1,123.20
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
33669
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.15 |
| Max. Negotiated Rate |
$1,010.88 |
| Rate for Payer: Aetna Commercial |
$954.72
|
| Rate for Payer: Aetna Medicare |
$183.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$730.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.25
|
| Rate for Payer: BCBS Complete |
$96.77
|
| Rate for Payer: BCBS MAPPO |
$176.20
|
| Rate for Payer: BCBS Trust/PPO |
$444.32
|
| Rate for Payer: BCN Commercial |
$444.32
|
| Rate for Payer: BCN Medicare Advantage |
$176.20
|
| Rate for Payer: Cash Price |
$898.56
|
| Rate for Payer: Cash Price |
$898.56
|
| Rate for Payer: Cofinity Advantage |
$786.24
|
| Rate for Payer: Cofinity Commercial |
$965.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$898.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.20
|
| Rate for Payer: Healthscope Commercial |
$1,010.88
|
| Rate for Payer: Mclaren Medicaid |
$92.15
|
| Rate for Payer: Mclaren Medicare |
$176.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.01
|
| Rate for Payer: Meridian Medicaid |
$185.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.63
|
| Rate for Payer: Molina Medicare/Medicaid |
$193.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$954.72
|
| Rate for Payer: Nomi Health Commercial |
$528.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$842.40
|
| Rate for Payer: PACE Medicare |
$167.39
|
| Rate for Payer: PACE SWMI |
$176.20
|
| Rate for Payer: PHP Commercial |
$954.72
|
| Rate for Payer: PHP Medicare Advantage |
$176.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$92.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$556.52
|
| Rate for Payer: Priority Health Medicare |
$176.20
|
| Rate for Payer: Priority Health SBD |
$707.62
|
| Rate for Payer: Priority Health Tiered Network |
$445.22
|
| Rate for Payer: Railroad Medicare Medicare |
$176.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$281.79
|
| Rate for Payer: UHC Core |
$281.79
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$176.20
|
| Rate for Payer: UHC Exchange |
$281.79
|
| Rate for Payer: UHC Medicaid |
$92.15
|
| Rate for Payer: UHCCP Medicaid |
$92.15
|
| Rate for Payer: VA VA |
$176.20
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$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 Advantage |
$1,532.16
|
| Rate for Payer: Cofinity Commercial |
$1,882.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,751.04
|
| Rate for Payer: Healthscope Commercial |
$1,969.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,860.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,641.60
|
| Rate for Payer: PHP Commercial |
$1,860.48
|
| Rate for Payer: Priority Health SBD |
$1,378.94
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$2,188.80
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
40801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.15 |
| Max. Negotiated Rate |
$1,969.92 |
| Rate for Payer: Aetna Commercial |
$1,860.48
|
| Rate for Payer: Aetna Medicare |
$183.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,422.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.25
|
| Rate for Payer: BCBS Complete |
$96.77
|
| Rate for Payer: BCBS MAPPO |
$176.20
|
| Rate for Payer: BCBS Trust/PPO |
$444.32
|
| Rate for Payer: BCN Commercial |
$444.32
|
| Rate for Payer: BCN Medicare Advantage |
$176.20
|
| Rate for Payer: Cash Price |
$1,751.04
|
| Rate for Payer: Cash Price |
$1,751.04
|
| Rate for Payer: Cofinity Advantage |
$1,532.16
|
| Rate for Payer: Cofinity Commercial |
$1,882.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,751.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.20
|
| Rate for Payer: Healthscope Commercial |
$1,969.92
|
| Rate for Payer: Mclaren Medicaid |
$92.15
|
| Rate for Payer: Mclaren Medicare |
$176.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.01
|
| Rate for Payer: Meridian Medicaid |
$185.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.63
|
| Rate for Payer: Molina Medicare/Medicaid |
$193.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,860.48
|
| Rate for Payer: Nomi Health Commercial |
$528.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,641.60
|
| Rate for Payer: PACE Medicare |
$167.39
|
| Rate for Payer: PACE SWMI |
$176.20
|
| Rate for Payer: PHP Commercial |
$1,860.48
|
| Rate for Payer: PHP Medicare Advantage |
$176.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$92.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$556.52
|
| Rate for Payer: Priority Health Medicare |
$176.20
|
| Rate for Payer: Priority Health SBD |
$1,378.94
|
| Rate for Payer: Priority Health Tiered Network |
$445.22
|
| Rate for Payer: Railroad Medicare Medicare |
$176.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$281.79
|
| Rate for Payer: UHC Core |
$281.79
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$176.20
|
| Rate for Payer: UHC Exchange |
$281.79
|
| Rate for Payer: UHC Medicaid |
$92.15
|
| Rate for Payer: UHCCP Medicaid |
$92.15
|
| Rate for Payer: VA VA |
$176.20
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$3,480.55
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152942
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$92.15 |
| Max. Negotiated Rate |
$3,132.49 |
| Rate for Payer: Aetna Commercial |
$2,958.47
|
| Rate for Payer: Aetna Medicare |
$183.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,262.36
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.25
|
| Rate for Payer: BCBS Complete |
$96.77
|
| Rate for Payer: BCBS MAPPO |
$176.20
|
| Rate for Payer: BCBS Trust/PPO |
$444.32
|
| Rate for Payer: BCN Commercial |
$444.32
|
| Rate for Payer: BCN Medicare Advantage |
$176.20
|
| Rate for Payer: Cash Price |
$2,784.44
|
| Rate for Payer: Cash Price |
$2,784.44
|
| Rate for Payer: Cofinity Advantage |
$2,436.39
|
| Rate for Payer: Cofinity Commercial |
$2,993.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,784.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.20
|
| Rate for Payer: Healthscope Commercial |
$3,132.49
|
| Rate for Payer: Mclaren Medicaid |
$92.15
|
| Rate for Payer: Mclaren Medicare |
$176.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.01
|
| Rate for Payer: Meridian Medicaid |
$185.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.63
|
| Rate for Payer: Molina Medicare/Medicaid |
$193.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,958.47
|
| Rate for Payer: Nomi Health Commercial |
$528.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,610.41
|
| Rate for Payer: PACE Medicare |
$167.39
|
| Rate for Payer: PACE SWMI |
$176.20
|
| Rate for Payer: PHP Commercial |
$2,958.47
|
| Rate for Payer: PHP Medicare Advantage |
$176.20
|
| Rate for Payer: Priority Health Choice Medicaid |
$92.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$556.52
|
| Rate for Payer: Priority Health Medicare |
$176.20
|
| Rate for Payer: Priority Health SBD |
$2,192.75
|
| Rate for Payer: Priority Health Tiered Network |
$445.22
|
| Rate for Payer: Railroad Medicare Medicare |
$176.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$281.79
|
| Rate for Payer: UHC Core |
$281.79
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$176.20
|
| Rate for Payer: UHC Exchange |
$281.79
|
| Rate for Payer: UHC Medicaid |
$92.15
|
| Rate for Payer: UHCCP Medicaid |
$92.15
|
| Rate for Payer: VA VA |
$176.20
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$3,480.55
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152942
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,192.75 |
| Max. Negotiated Rate |
$3,132.49 |
| Rate for Payer: Aetna Commercial |
$2,958.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,262.36
|
| Rate for Payer: Cash Price |
$2,784.44
|
| Rate for Payer: Cofinity Advantage |
$2,436.39
|
| Rate for Payer: Cofinity Commercial |
$2,993.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,784.44
|
| Rate for Payer: Healthscope Commercial |
$3,132.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,958.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,610.41
|
| Rate for Payer: PHP Commercial |
$2,958.47
|
| Rate for Payer: Priority Health SBD |
$2,192.75
|
|
|
LEVETIRACETAM 1,000 MG TABLET
|
Facility
|
OP
|
$197.40
|
|
|
Service Code
|
NDC 68180011507
|
| Hospital Charge Code |
70773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.58 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna Medicare |
$98.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: BCBS Complete |
$78.96
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Advantage |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$157.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.05
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.31
|
| Rate for Payer: UHC Core |
$102.85
|
| Rate for Payer: UHC Exchange |
$77.58
|
|
|
LEVETIRACETAM 1,000 MG TABLET
|
Facility
|
IP
|
$369.60
|
|
|
Service Code
|
NDC 60687066801
|
| Hospital Charge Code |
70773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.85 |
| Max. Negotiated Rate |
$332.64 |
| Rate for Payer: Aetna Commercial |
$314.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.24
|
| Rate for Payer: Cash Price |
$295.68
|
| Rate for Payer: Cofinity Advantage |
$258.72
|
| Rate for Payer: Cofinity Commercial |
$317.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$295.68
|
| Rate for Payer: Healthscope Commercial |
$332.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$314.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$277.20
|
| Rate for Payer: PHP Commercial |
$314.16
|
| Rate for Payer: Priority Health SBD |
$232.85
|
|
|
LEVETIRACETAM 1,000 MG TABLET
|
Facility
|
IP
|
$197.40
|
|
|
Service Code
|
NDC 68180011507
|
| Hospital Charge Code |
70773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.36 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Advantage |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.05
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health SBD |
$124.36
|
|
|
LEVETIRACETAM 1,000 MG TABLET
|
Facility
|
OP
|
$3.70
|
|
|
Service Code
|
NDC 60687066811
|
| Hospital Charge Code |
70773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: Aetna Medicare |
$1.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.40
|
| Rate for Payer: BCBS Complete |
$1.48
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cofinity Advantage |
$2.59
|
| Rate for Payer: Cofinity Commercial |
$3.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.96
|
| Rate for Payer: Healthscope Commercial |
$3.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.77
|
| Rate for Payer: PHP Commercial |
$3.15
|
| Rate for Payer: Priority Health SBD |
$2.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.40
|
| Rate for Payer: UHC Core |
$1.93
|
| Rate for Payer: UHC Exchange |
$1.45
|
|
|
LEVETIRACETAM 1,000 MG TABLET
|
Facility
|
OP
|
$369.60
|
|
|
Service Code
|
NDC 60687066801
|
| Hospital Charge Code |
70773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.25 |
| Max. Negotiated Rate |
$332.64 |
| Rate for Payer: Aetna Commercial |
$314.16
|
| Rate for Payer: Aetna Medicare |
$184.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.24
|
| Rate for Payer: BCBS Complete |
$147.84
|
| Rate for Payer: Cash Price |
$295.68
|
| Rate for Payer: Cofinity Advantage |
$258.72
|
| Rate for Payer: Cofinity Commercial |
$317.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$295.68
|
| Rate for Payer: Healthscope Commercial |
$332.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$295.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$314.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$277.20
|
| Rate for Payer: PHP Commercial |
$314.16
|
| Rate for Payer: Priority Health SBD |
$232.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$240.24
|
| Rate for Payer: UHC Core |
$192.56
|
| Rate for Payer: UHC Exchange |
$145.25
|
|
|
LEVETIRACETAM 1,000 MG TABLET
|
Facility
|
IP
|
$3.70
|
|
|
Service Code
|
NDC 60687066811
|
| Hospital Charge Code |
70773
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$3.33 |
| Rate for Payer: Aetna Commercial |
$3.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.40
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cofinity Advantage |
$2.59
|
| Rate for Payer: Cofinity Commercial |
$3.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.96
|
| Rate for Payer: Healthscope Commercial |
$3.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.77
|
| Rate for Payer: PHP Commercial |
$3.15
|
| Rate for Payer: Priority Health SBD |
$2.33
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$4,227.49
|
|
|
Service Code
|
NDC 50474000148
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,663.32 |
| Max. Negotiated Rate |
$3,804.74 |
| Rate for Payer: Aetna Commercial |
$3,593.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,747.87
|
| Rate for Payer: Cash Price |
$3,381.99
|
| Rate for Payer: Cofinity Advantage |
$2,959.24
|
| Rate for Payer: Cofinity Commercial |
$3,635.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,381.99
|
| Rate for Payer: Healthscope Commercial |
$3,804.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,593.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,170.62
|
| Rate for Payer: PHP Commercial |
$3,593.37
|
| Rate for Payer: Priority Health SBD |
$2,663.32
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$4,227.49
|
|
|
Service Code
|
NDC 50474000148
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,661.40 |
| Max. Negotiated Rate |
$3,804.74 |
| Rate for Payer: Aetna Commercial |
$3,593.37
|
| Rate for Payer: Aetna Medicare |
$2,113.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,747.87
|
| Rate for Payer: BCBS Complete |
$1,691.00
|
| Rate for Payer: Cash Price |
$3,381.99
|
| Rate for Payer: Cofinity Advantage |
$2,959.24
|
| Rate for Payer: Cofinity Commercial |
$3,635.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,381.99
|
| Rate for Payer: Healthscope Commercial |
$3,804.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,381.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,593.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,170.62
|
| Rate for Payer: PHP Commercial |
$3,593.37
|
| Rate for Payer: Priority Health SBD |
$2,663.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,747.87
|
| Rate for Payer: UHC Core |
$2,202.52
|
| Rate for Payer: UHC Exchange |
$1,661.40
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$422.39
|
|
|
Service Code
|
NDC 00121079916
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.00 |
| Max. Negotiated Rate |
$380.15 |
| Rate for Payer: Aetna Commercial |
$359.03
|
| Rate for Payer: Aetna Medicare |
$211.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.55
|
| Rate for Payer: BCBS Complete |
$168.96
|
| Rate for Payer: Cash Price |
$337.91
|
| Rate for Payer: Cofinity Advantage |
$295.67
|
| Rate for Payer: Cofinity Commercial |
$363.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.91
|
| Rate for Payer: Healthscope Commercial |
$380.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$337.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$316.79
|
| Rate for Payer: PHP Commercial |
$359.03
|
| Rate for Payer: Priority Health SBD |
$266.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$274.55
|
| Rate for Payer: UHC Core |
$220.07
|
| Rate for Payer: UHC Exchange |
$166.00
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$422.39
|
|
|
Service Code
|
NDC 00121079916
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$266.11 |
| Max. Negotiated Rate |
$380.15 |
| Rate for Payer: Aetna Commercial |
$359.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.55
|
| Rate for Payer: Cash Price |
$337.91
|
| Rate for Payer: Cofinity Advantage |
$295.67
|
| Rate for Payer: Cofinity Commercial |
$363.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.91
|
| Rate for Payer: Healthscope Commercial |
$380.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$316.79
|
| Rate for Payer: PHP Commercial |
$359.03
|
| Rate for Payer: Priority Health SBD |
$266.11
|
|
