|
LETROZOLE 2.5 MG TABLET
|
Facility
|
OP
|
$3.72
|
|
|
Service Code
|
NDC 50268047611
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$3.35 |
| Rate for Payer: Aetna Commercial |
$3.16
|
| Rate for Payer: Aetna Medicare |
$1.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.42
|
| Rate for Payer: BCBS Complete |
$1.49
|
| Rate for Payer: Cash Price |
$2.98
|
| Rate for Payer: Cofinity Commercial |
$2.60
|
| Rate for Payer: Cofinity Commercial |
$3.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.98
|
| Rate for Payer: Healthscope Commercial |
$3.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.16
|
| Rate for Payer: PHP Commercial |
$3.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.42
|
| Rate for Payer: Priority Health SBD |
$2.34
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
OP
|
$185.73
|
|
|
Service Code
|
NDC 50268047615
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.29 |
| Max. Negotiated Rate |
$167.16 |
| Rate for Payer: Aetna Commercial |
$157.87
|
| Rate for Payer: Aetna Medicare |
$92.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.72
|
| Rate for Payer: BCBS Complete |
$74.29
|
| Rate for Payer: Cash Price |
$148.58
|
| Rate for Payer: Cofinity Commercial |
$130.01
|
| Rate for Payer: Cofinity Commercial |
$159.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$130.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.58
|
| Rate for Payer: Healthscope Commercial |
$167.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.87
|
| Rate for Payer: PHP Commercial |
$157.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.72
|
| Rate for Payer: Priority Health SBD |
$117.01
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
IP
|
$2,867.02
|
|
|
Service Code
|
NDC 00078024915
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,806.22 |
| Max. Negotiated Rate |
$2,580.32 |
| Rate for Payer: Aetna Commercial |
$2,436.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,863.56
|
| Rate for Payer: Cash Price |
$2,293.62
|
| Rate for Payer: Cofinity Commercial |
$2,006.91
|
| Rate for Payer: Cofinity Commercial |
$2,465.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,006.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,293.62
|
| Rate for Payer: Healthscope Commercial |
$2,580.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,436.97
|
| Rate for Payer: PHP Commercial |
$2,436.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,863.56
|
| Rate for Payer: Priority Health SBD |
$1,806.22
|
|
|
LETROZOLE 2.5 MG TABLET
|
Facility
|
OP
|
$2,867.02
|
|
|
Service Code
|
NDC 00078024915
|
| Hospital Charge Code |
21509
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,146.81 |
| Max. Negotiated Rate |
$2,580.32 |
| Rate for Payer: Aetna Commercial |
$2,436.97
|
| Rate for Payer: Aetna Medicare |
$1,433.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,863.56
|
| Rate for Payer: BCBS Complete |
$1,146.81
|
| Rate for Payer: Cash Price |
$2,293.62
|
| Rate for Payer: Cofinity Commercial |
$2,006.91
|
| Rate for Payer: Cofinity Commercial |
$2,465.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,006.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,293.62
|
| Rate for Payer: Healthscope Commercial |
$2,580.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,436.97
|
| Rate for Payer: PHP Commercial |
$2,436.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,863.56
|
| Rate for Payer: Priority Health SBD |
$1,806.22
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$49.89
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
4392
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.43 |
| Max. Negotiated Rate |
$44.90 |
| Rate for Payer: Aetna Commercial |
$42.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.43
|
| Rate for Payer: Cash Price |
$39.91
|
| Rate for Payer: Cofinity Commercial |
$34.92
|
| Rate for Payer: Cofinity Commercial |
$42.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.91
|
| Rate for Payer: Healthscope Commercial |
$44.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.41
|
| Rate for Payer: PHP Commercial |
$42.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.43
|
| Rate for Payer: Priority Health SBD |
$31.43
|
|
|
LEUCOVORIN CALCIUM 100 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$49.89
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
4392
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.96 |
| Max. Negotiated Rate |
$44.90 |
| Rate for Payer: Aetna Commercial |
$42.41
|
| Rate for Payer: Aetna Commercial |
$24.28
|
| Rate for Payer: Aetna Commercial |
$70.32
|
| Rate for Payer: Aetna Medicare |
$14.29
|
| Rate for Payer: Aetna Medicare |
$41.37
|
| Rate for Payer: Aetna Medicare |
$24.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.43
|
| Rate for Payer: BCBS Complete |
$11.43
|
| Rate for Payer: BCBS Complete |
$19.96
|
| Rate for Payer: BCBS Complete |
$33.09
|
| Rate for Payer: Cash Price |
$22.86
|
| Rate for Payer: Cash Price |
$39.91
|
| Rate for Payer: Cash Price |
$66.18
|
| Rate for Payer: Cofinity Commercial |
$57.91
|
| Rate for Payer: Cofinity Commercial |
$71.15
|
| Rate for Payer: Cofinity Commercial |
$34.92
|
| Rate for Payer: Cofinity Commercial |
$42.91
|
| Rate for Payer: Cofinity Commercial |
$24.57
|
| Rate for Payer: Cofinity Commercial |
$20.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$66.18
|
| Rate for Payer: Healthscope Commercial |
$25.71
|
| Rate for Payer: Healthscope Commercial |
$44.90
|
| Rate for Payer: Healthscope Commercial |
$74.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.41
|
| Rate for Payer: PHP Commercial |
$24.28
|
| Rate for Payer: PHP Commercial |
$42.41
|
| Rate for Payer: PHP Commercial |
$70.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.43
|
| Rate for Payer: Priority Health SBD |
$31.43
|
| Rate for Payer: Priority Health SBD |
$18.00
|
| Rate for Payer: Priority Health SBD |
$52.12
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$67.02
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
15426
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$26.81 |
| Max. Negotiated Rate |
$60.32 |
| Rate for Payer: Aetna Commercial |
$56.97
|
| Rate for Payer: Aetna Commercial |
$46.04
|
| Rate for Payer: Aetna Medicare |
$27.08
|
| Rate for Payer: Aetna Medicare |
$33.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.56
|
| Rate for Payer: BCBS Complete |
$21.66
|
| Rate for Payer: BCBS Complete |
$26.81
|
| Rate for Payer: Cash Price |
$43.33
|
| Rate for Payer: Cash Price |
$53.62
|
| Rate for Payer: Cofinity Commercial |
$46.91
|
| Rate for Payer: Cofinity Commercial |
$37.91
|
| Rate for Payer: Cofinity Commercial |
$57.64
|
| Rate for Payer: Cofinity Commercial |
$46.58
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.62
|
| Rate for Payer: Healthscope Commercial |
$48.74
|
| Rate for Payer: Healthscope Commercial |
$60.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.04
|
| Rate for Payer: PHP Commercial |
$46.04
|
| Rate for Payer: PHP Commercial |
$56.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.56
|
| Rate for Payer: Priority Health SBD |
$34.12
|
| Rate for Payer: Priority Health SBD |
$42.22
|
|
|
LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$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: Cofinity Medicare Advantage |
$46.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.62
|
| Rate for Payer: Healthscope Commercial |
$60.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.97
|
| Rate for Payer: PHP Commercial |
$56.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.56
|
| Rate for Payer: Priority Health SBD |
$42.22
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$100.35
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
4393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.22 |
| Max. Negotiated Rate |
$90.31 |
| Rate for Payer: Aetna Commercial |
$85.30
|
| Rate for Payer: Aetna Commercial |
$44.68
|
| Rate for Payer: Aetna Commercial |
$66.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.97
|
| Rate for Payer: Cash Price |
$80.28
|
| Rate for Payer: Cash Price |
$42.05
|
| Rate for Payer: Cash Price |
$62.73
|
| Rate for Payer: Cofinity Commercial |
$54.89
|
| Rate for Payer: Cofinity Commercial |
$70.25
|
| Rate for Payer: Cofinity Commercial |
$86.30
|
| Rate for Payer: Cofinity Commercial |
$67.43
|
| Rate for Payer: Cofinity Commercial |
$36.79
|
| Rate for Payer: Cofinity Commercial |
$45.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.73
|
| Rate for Payer: Healthscope Commercial |
$47.30
|
| Rate for Payer: Healthscope Commercial |
$70.57
|
| Rate for Payer: Healthscope Commercial |
$90.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.65
|
| Rate for Payer: PHP Commercial |
$66.65
|
| Rate for Payer: PHP Commercial |
$85.30
|
| Rate for Payer: PHP Commercial |
$44.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.16
|
| Rate for Payer: Priority Health SBD |
$49.40
|
| Rate for Payer: Priority Health SBD |
$63.22
|
| Rate for Payer: Priority Health SBD |
$33.11
|
|
|
LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$100.35
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
4393
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.14 |
| Max. Negotiated Rate |
$90.31 |
| Rate for Payer: Aetna Commercial |
$85.30
|
| Rate for Payer: Aetna Commercial |
$66.65
|
| Rate for Payer: Aetna Commercial |
$44.68
|
| Rate for Payer: Aetna Medicare |
$39.20
|
| Rate for Payer: Aetna Medicare |
$50.17
|
| Rate for Payer: Aetna Medicare |
$26.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$34.16
|
| Rate for Payer: BCBS Complete |
$21.02
|
| Rate for Payer: BCBS Complete |
$40.14
|
| Rate for Payer: BCBS Complete |
$31.36
|
| Rate for Payer: Cash Price |
$62.73
|
| Rate for Payer: Cash Price |
$80.28
|
| Rate for Payer: Cash Price |
$42.05
|
| Rate for Payer: Cofinity Commercial |
$67.43
|
| Rate for Payer: Cofinity Commercial |
$86.30
|
| Rate for Payer: Cofinity Commercial |
$70.25
|
| Rate for Payer: Cofinity Commercial |
$45.20
|
| Rate for Payer: Cofinity Commercial |
$36.79
|
| Rate for Payer: Cofinity Commercial |
$54.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$36.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.28
|
| Rate for Payer: Healthscope Commercial |
$47.30
|
| Rate for Payer: Healthscope Commercial |
$90.31
|
| Rate for Payer: Healthscope Commercial |
$70.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$44.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.30
|
| Rate for Payer: PHP Commercial |
$44.68
|
| Rate for Payer: PHP Commercial |
$85.30
|
| Rate for Payer: PHP Commercial |
$66.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.16
|
| Rate for Payer: Priority Health SBD |
$49.40
|
| Rate for Payer: Priority Health SBD |
$33.11
|
| Rate for Payer: Priority Health SBD |
$63.22
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$175.91
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
23617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$110.82 |
| Max. Negotiated Rate |
$158.32 |
| Rate for Payer: Aetna Commercial |
$149.52
|
| Rate for Payer: Aetna Commercial |
$158.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.02
|
| Rate for Payer: Cash Price |
$140.73
|
| Rate for Payer: Cash Price |
$148.95
|
| Rate for Payer: Cofinity Commercial |
$123.14
|
| Rate for Payer: Cofinity Commercial |
$130.33
|
| Rate for Payer: Cofinity Commercial |
$160.12
|
| Rate for Payer: Cofinity Commercial |
$151.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$130.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.95
|
| Rate for Payer: Healthscope Commercial |
$158.32
|
| Rate for Payer: Healthscope Commercial |
$167.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$158.26
|
| Rate for Payer: PHP Commercial |
$149.52
|
| Rate for Payer: PHP Commercial |
$158.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.34
|
| Rate for Payer: Priority Health SBD |
$117.30
|
| Rate for Payer: Priority Health SBD |
$110.82
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$175.91
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
23617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$70.36 |
| Max. Negotiated Rate |
$158.32 |
| Rate for Payer: Aetna Commercial |
$149.52
|
| Rate for Payer: Aetna Commercial |
$183.69
|
| Rate for Payer: Aetna Commercial |
$158.26
|
| Rate for Payer: Aetna Medicare |
$108.05
|
| Rate for Payer: Aetna Medicare |
$87.95
|
| Rate for Payer: Aetna Medicare |
$93.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$140.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.02
|
| Rate for Payer: BCBS Complete |
$74.48
|
| Rate for Payer: BCBS Complete |
$70.36
|
| Rate for Payer: BCBS Complete |
$86.44
|
| Rate for Payer: Cash Price |
$172.88
|
| Rate for Payer: Cash Price |
$140.73
|
| Rate for Payer: Cash Price |
$148.95
|
| Rate for Payer: Cofinity Commercial |
$185.85
|
| Rate for Payer: Cofinity Commercial |
$151.28
|
| Rate for Payer: Cofinity Commercial |
$123.14
|
| Rate for Payer: Cofinity Commercial |
$160.12
|
| Rate for Payer: Cofinity Commercial |
$130.33
|
| Rate for Payer: Cofinity Commercial |
$151.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$130.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$151.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$172.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.73
|
| Rate for Payer: Healthscope Commercial |
$167.57
|
| Rate for Payer: Healthscope Commercial |
$158.32
|
| Rate for Payer: Healthscope Commercial |
$194.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$158.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$183.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.52
|
| Rate for Payer: PHP Commercial |
$158.26
|
| Rate for Payer: PHP Commercial |
$149.52
|
| Rate for Payer: PHP Commercial |
$183.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.02
|
| Rate for Payer: Priority Health SBD |
$136.14
|
| Rate for Payer: Priority Health SBD |
$117.30
|
| Rate for Payer: Priority Health SBD |
$110.82
|
|
|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$19,492.68
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$927.45 |
| Max. Negotiated Rate |
$17,543.41 |
| Rate for Payer: Aetna Commercial |
$16,568.78
|
| Rate for Payer: Aetna Medicare |
$1,799.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,670.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,162.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,162.90
|
| Rate for Payer: BCBS Complete |
$973.82
|
| Rate for Payer: BCBS MAPPO |
$1,730.32
|
| Rate for Payer: BCN Medicare Advantage |
$1,730.32
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cofinity Commercial |
$13,644.88
|
| Rate for Payer: Cofinity Commercial |
$16,763.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,644.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,594.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,730.32
|
| Rate for Payer: Healthscope Commercial |
$17,543.41
|
| Rate for Payer: Mclaren Medicaid |
$927.45
|
| Rate for Payer: Mclaren Medicare |
$1,730.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,816.84
|
| Rate for Payer: Meridian Medicaid |
$973.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,989.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,568.78
|
| Rate for Payer: PACE Medicare |
$1,643.80
|
| Rate for Payer: PACE SWMI |
$1,730.32
|
| Rate for Payer: PHP Commercial |
$16,568.78
|
| Rate for Payer: PHP Medicare Advantage |
$1,730.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$927.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,670.24
|
| Rate for Payer: Priority Health Medicare |
$1,730.32
|
| Rate for Payer: Priority Health SBD |
$12,280.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1,730.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,870.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,730.32
|
| Rate for Payer: UHC Medicare Advantage |
$1,730.32
|
| Rate for Payer: UHCCP Medicaid |
$974.17
|
| Rate for Payer: VA VA |
$1,730.32
|
|
|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$19,492.68
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,280.39 |
| Max. Negotiated Rate |
$17,543.41 |
| Rate for Payer: Aetna Commercial |
$16,568.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,670.24
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cofinity Commercial |
$13,644.88
|
| Rate for Payer: Cofinity Commercial |
$16,763.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$13,644.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,594.14
|
| Rate for Payer: Healthscope Commercial |
$17,543.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,568.78
|
| Rate for Payer: PHP Commercial |
$16,568.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,670.24
|
| Rate for Payer: Priority Health SBD |
$12,280.39
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$1,657.38
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.58 |
| Max. Negotiated Rate |
$1,491.64 |
| Rate for Payer: Aetna Commercial |
$1,408.77
|
| Rate for Payer: Aetna Medicare |
$183.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.56
|
| Rate for Payer: BCBS Complete |
$99.31
|
| Rate for Payer: BCBS MAPPO |
$176.45
|
| Rate for Payer: BCN Medicare Advantage |
$176.45
|
| Rate for Payer: Cash Price |
$1,325.90
|
| Rate for Payer: Cash Price |
$1,325.90
|
| Rate for Payer: Cofinity Commercial |
$1,425.35
|
| Rate for Payer: Cofinity Commercial |
$1,160.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,160.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,325.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.45
|
| Rate for Payer: Healthscope Commercial |
$1,491.64
|
| Rate for Payer: Mclaren Medicaid |
$94.58
|
| Rate for Payer: Mclaren Medicare |
$176.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.27
|
| Rate for Payer: Meridian Medicaid |
$99.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,408.77
|
| Rate for Payer: PACE Medicare |
$167.63
|
| Rate for Payer: PACE SWMI |
$176.45
|
| Rate for Payer: PHP Commercial |
$1,408.77
|
| Rate for Payer: PHP Medicare Advantage |
$176.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$94.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,077.30
|
| Rate for Payer: Priority Health Medicare |
$176.45
|
| Rate for Payer: Priority Health SBD |
$1,044.15
|
| Rate for Payer: Railroad Medicare Medicare |
$176.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$496.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$176.45
|
| Rate for Payer: UHC Medicare Advantage |
$176.45
|
| Rate for Payer: UHCCP Medicaid |
$99.34
|
| Rate for Payer: VA VA |
$176.45
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$1,657.38
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,044.15 |
| Max. Negotiated Rate |
$1,491.64 |
| Rate for Payer: Aetna Commercial |
$1,408.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.30
|
| Rate for Payer: Cash Price |
$1,325.90
|
| Rate for Payer: Cofinity Commercial |
$1,160.17
|
| Rate for Payer: Cofinity Commercial |
$1,425.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,160.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,325.90
|
| Rate for Payer: Healthscope Commercial |
$1,491.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,408.77
|
| Rate for Payer: PHP Commercial |
$1,408.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,077.30
|
| Rate for Payer: Priority Health SBD |
$1,044.15
|
|
|
LEUPROLIDE 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 |
$94.58 |
| Max. Negotiated Rate |
$1,010.88 |
| Rate for Payer: Aetna Commercial |
$954.72
|
| Rate for Payer: Aetna Medicare |
$183.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$730.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.56
|
| Rate for Payer: BCBS Complete |
$99.31
|
| Rate for Payer: BCBS MAPPO |
$176.45
|
| Rate for Payer: BCN Medicare Advantage |
$176.45
|
| 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: Cofinity Medicare Advantage |
$786.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$898.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.45
|
| Rate for Payer: Healthscope Commercial |
$1,010.88
|
| Rate for Payer: Mclaren Medicaid |
$94.58
|
| Rate for Payer: Mclaren Medicare |
$176.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.27
|
| Rate for Payer: Meridian Medicaid |
$99.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$954.72
|
| Rate for Payer: PACE Medicare |
$167.63
|
| Rate for Payer: PACE SWMI |
$176.45
|
| Rate for Payer: PHP Commercial |
$954.72
|
| Rate for Payer: PHP Medicare Advantage |
$176.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$94.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$730.08
|
| Rate for Payer: Priority Health Medicare |
$176.45
|
| Rate for Payer: Priority Health SBD |
$707.62
|
| Rate for Payer: Railroad Medicare Medicare |
$176.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$496.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$176.45
|
| Rate for Payer: UHC Medicare Advantage |
$176.45
|
| Rate for Payer: UHCCP Medicaid |
$99.34
|
| Rate for Payer: VA VA |
$176.45
|
|
|
LEUPROLIDE 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 Commercial |
$786.24
|
| Rate for Payer: Cofinity Commercial |
$965.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$786.24
|
| 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: PHP Commercial |
$954.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$730.08
|
| Rate for Payer: Priority Health SBD |
$707.62
|
|
|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$2,209.83
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,392.19 |
| Max. Negotiated Rate |
$1,988.85 |
| Rate for Payer: Aetna Commercial |
$1,878.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,436.39
|
| Rate for Payer: Cash Price |
$1,767.86
|
| Rate for Payer: Cofinity Commercial |
$1,546.88
|
| Rate for Payer: Cofinity Commercial |
$1,900.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,546.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,767.86
|
| Rate for Payer: Healthscope Commercial |
$1,988.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,878.36
|
| Rate for Payer: PHP Commercial |
$1,878.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,436.39
|
| Rate for Payer: Priority Health SBD |
$1,392.19
|
|
|
LEUPROLIDE 30 MG (4 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$2,209.83
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21108
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.58 |
| Max. Negotiated Rate |
$1,988.85 |
| Rate for Payer: Aetna Commercial |
$1,878.36
|
| Rate for Payer: Aetna Medicare |
$183.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,436.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.56
|
| Rate for Payer: BCBS Complete |
$99.31
|
| Rate for Payer: BCBS MAPPO |
$176.45
|
| Rate for Payer: BCN Medicare Advantage |
$176.45
|
| Rate for Payer: Cash Price |
$1,767.86
|
| Rate for Payer: Cash Price |
$1,767.86
|
| Rate for Payer: Cofinity Commercial |
$1,900.45
|
| Rate for Payer: Cofinity Commercial |
$1,546.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,546.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,767.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.45
|
| Rate for Payer: Healthscope Commercial |
$1,988.85
|
| Rate for Payer: Mclaren Medicaid |
$94.58
|
| Rate for Payer: Mclaren Medicare |
$176.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.27
|
| Rate for Payer: Meridian Medicaid |
$99.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,878.36
|
| Rate for Payer: PACE Medicare |
$167.63
|
| Rate for Payer: PACE SWMI |
$176.45
|
| Rate for Payer: PHP Commercial |
$1,878.36
|
| Rate for Payer: PHP Medicare Advantage |
$176.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$94.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,436.39
|
| Rate for Payer: Priority Health Medicare |
$176.45
|
| Rate for Payer: Priority Health SBD |
$1,392.19
|
| Rate for Payer: Railroad Medicare Medicare |
$176.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$496.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$176.45
|
| Rate for Payer: UHC Medicare Advantage |
$176.45
|
| Rate for Payer: UHCCP Medicaid |
$99.34
|
| Rate for Payer: VA VA |
$176.45
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$5,619.46
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
13691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$927.45 |
| Max. Negotiated Rate |
$5,057.51 |
| Rate for Payer: Aetna Commercial |
$4,776.54
|
| Rate for Payer: Aetna Medicare |
$1,799.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,652.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,162.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,162.90
|
| Rate for Payer: BCBS Complete |
$973.82
|
| Rate for Payer: BCBS MAPPO |
$1,730.32
|
| Rate for Payer: BCN Medicare Advantage |
$1,730.32
|
| Rate for Payer: Cash Price |
$4,495.57
|
| Rate for Payer: Cash Price |
$4,495.57
|
| Rate for Payer: Cofinity Commercial |
$3,933.62
|
| Rate for Payer: Cofinity Commercial |
$4,832.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,933.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,495.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,730.32
|
| Rate for Payer: Healthscope Commercial |
$5,057.51
|
| Rate for Payer: Mclaren Medicaid |
$927.45
|
| Rate for Payer: Mclaren Medicare |
$1,730.32
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,816.84
|
| Rate for Payer: Meridian Medicaid |
$973.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,989.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,776.54
|
| Rate for Payer: PACE Medicare |
$1,643.80
|
| Rate for Payer: PACE SWMI |
$1,730.32
|
| Rate for Payer: PHP Commercial |
$4,776.54
|
| Rate for Payer: PHP Medicare Advantage |
$1,730.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$927.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,652.65
|
| Rate for Payer: Priority Health Medicare |
$1,730.32
|
| Rate for Payer: Priority Health SBD |
$3,540.26
|
| Rate for Payer: Railroad Medicare Medicare |
$1,730.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,870.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,730.32
|
| Rate for Payer: UHC Medicare Advantage |
$1,730.32
|
| Rate for Payer: UHCCP Medicaid |
$974.17
|
| Rate for Payer: VA VA |
$1,730.32
|
|
|
LEUPROLIDE 3.75 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$5,619.46
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
13691
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3,540.26 |
| Max. Negotiated Rate |
$5,057.51 |
| Rate for Payer: Aetna Commercial |
$4,776.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,652.65
|
| Rate for Payer: Cash Price |
$4,495.57
|
| Rate for Payer: Cofinity Commercial |
$3,933.62
|
| Rate for Payer: Cofinity Commercial |
$4,832.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,933.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,495.57
|
| Rate for Payer: Healthscope Commercial |
$5,057.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,776.54
|
| Rate for Payer: PHP Commercial |
$4,776.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,652.65
|
| Rate for Payer: Priority Health SBD |
$3,540.26
|
|
|
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$612.88
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$386.11 |
| Max. Negotiated Rate |
$551.59 |
| Rate for Payer: Aetna Commercial |
$520.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$398.37
|
| Rate for Payer: Cash Price |
$490.30
|
| Rate for Payer: Cofinity Commercial |
$429.02
|
| Rate for Payer: Cofinity Commercial |
$527.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$429.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$490.30
|
| Rate for Payer: Healthscope Commercial |
$551.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$520.95
|
| Rate for Payer: PHP Commercial |
$520.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$398.37
|
| Rate for Payer: Priority Health SBD |
$386.11
|
|
|
LEUPROLIDE 7.5 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$612.88
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152657
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$94.58 |
| Max. Negotiated Rate |
$551.59 |
| Rate for Payer: Aetna Commercial |
$520.95
|
| Rate for Payer: Aetna Medicare |
$183.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$398.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$220.56
|
| Rate for Payer: Amish Plain Church Group Commercial |
$220.56
|
| Rate for Payer: BCBS Complete |
$99.31
|
| Rate for Payer: BCBS MAPPO |
$176.45
|
| Rate for Payer: BCN Medicare Advantage |
$176.45
|
| Rate for Payer: Cash Price |
$490.30
|
| Rate for Payer: Cash Price |
$490.30
|
| Rate for Payer: Cofinity Commercial |
$527.08
|
| Rate for Payer: Cofinity Commercial |
$429.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$429.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$490.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$176.45
|
| Rate for Payer: Healthscope Commercial |
$551.59
|
| Rate for Payer: Mclaren Medicaid |
$94.58
|
| Rate for Payer: Mclaren Medicare |
$176.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$185.27
|
| Rate for Payer: Meridian Medicaid |
$99.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$202.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$520.95
|
| Rate for Payer: PACE Medicare |
$167.63
|
| Rate for Payer: PACE SWMI |
$176.45
|
| Rate for Payer: PHP Commercial |
$520.95
|
| Rate for Payer: PHP Medicare Advantage |
$176.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$94.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$398.37
|
| Rate for Payer: Priority Health Medicare |
$176.45
|
| Rate for Payer: Priority Health SBD |
$386.11
|
| Rate for Payer: Railroad Medicare Medicare |
$176.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$496.69
|
| Rate for Payer: UHC Dual Complete DSNP |
$176.45
|
| Rate for Payer: UHC Medicare Advantage |
$176.45
|
| Rate for Payer: UHCCP Medicaid |
$99.34
|
| Rate for Payer: VA VA |
$176.45
|
|
|
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 Commercial |
$1,532.16
|
| Rate for Payer: Cofinity Commercial |
$1,882.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,532.16
|
| 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: PHP Commercial |
$1,860.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,422.72
|
| Rate for Payer: Priority Health SBD |
$1,378.94
|
|
