|
LEUCOVORIN CALCIUM 25 MG TABLET
|
Facility
|
IP
|
$575.58
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
4397
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$253.26 |
| Max. Negotiated Rate |
$518.02 |
| Rate for Payer: Aetna American Axle |
$374.13
|
| Rate for Payer: Aetna American Axle |
$340.12
|
| Rate for Payer: Aetna American Axle |
$18.71
|
| Rate for Payer: Aetna American Axle |
$503.67
|
| Rate for Payer: Aetna Commercial |
$489.24
|
| Rate for Payer: Aetna Commercial |
$658.65
|
| Rate for Payer: Aetna Commercial |
$444.77
|
| Rate for Payer: Aetna Commercial |
$24.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$374.13
|
| Rate for Payer: Cash Price |
$418.61
|
| Rate for Payer: Cash Price |
$460.46
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Cash Price |
$619.90
|
| Rate for Payer: Cofinity Commercial |
$20.15
|
| Rate for Payer: Cofinity Commercial |
$666.40
|
| Rate for Payer: Cofinity Commercial |
$542.42
|
| Rate for Payer: Cofinity Commercial |
$402.91
|
| Rate for Payer: Cofinity Commercial |
$366.28
|
| Rate for Payer: Cofinity Commercial |
$450.00
|
| Rate for Payer: Cofinity Commercial |
$495.00
|
| Rate for Payer: Cofinity Commercial |
$24.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$402.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$460.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$418.61
|
| Rate for Payer: Healthscope Commercial |
$518.02
|
| Rate for Payer: Healthscope Commercial |
$25.90
|
| Rate for Payer: Healthscope Commercial |
$470.93
|
| Rate for Payer: Healthscope Commercial |
$697.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$542.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$402.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$431.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$581.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$444.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$489.24
|
| Rate for Payer: PHP Commercial |
$489.24
|
| Rate for Payer: PHP Commercial |
$658.65
|
| Rate for Payer: PHP Commercial |
$24.46
|
| Rate for Payer: PHP Commercial |
$444.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$374.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.71
|
| Rate for Payer: Priority Health SBD |
$488.17
|
| Rate for Payer: Priority Health SBD |
$18.13
|
| Rate for Payer: Priority Health SBD |
$329.65
|
| Rate for Payer: Priority Health SBD |
$362.62
|
| Rate for Payer: UMR Bronson Commercial |
$253.26
|
| Rate for Payer: UMR Bronson Commercial |
$340.95
|
| Rate for Payer: UMR Bronson Commercial |
$230.23
|
| Rate for Payer: UMR Bronson Commercial |
$12.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$431.68
|
|
|
LEUCOVORIN CALCIUM 25 MG TABLET
|
Facility
|
OP
|
$774.88
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
4397
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$697.39 |
| Rate for Payer: Aetna American Axle |
$503.67
|
| Rate for Payer: Aetna American Axle |
$374.13
|
| Rate for Payer: Aetna American Axle |
$18.71
|
| Rate for Payer: Aetna American Axle |
$340.12
|
| Rate for Payer: Aetna Commercial |
$658.65
|
| Rate for Payer: Aetna Commercial |
$444.77
|
| Rate for Payer: Aetna Commercial |
$24.46
|
| Rate for Payer: Aetna Commercial |
$489.24
|
| Rate for Payer: Aetna Medicare |
$287.79
|
| Rate for Payer: Aetna Medicare |
$261.63
|
| Rate for Payer: Aetna Medicare |
$14.39
|
| Rate for Payer: Aetna Medicare |
$387.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$374.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$340.12
|
| Rate for Payer: BCBS Complete |
$230.23
|
| Rate for Payer: BCBS Complete |
$11.51
|
| Rate for Payer: BCBS Complete |
$309.95
|
| Rate for Payer: BCBS Complete |
$209.30
|
| Rate for Payer: BCBS Trust/PPO |
$10.96
|
| Rate for Payer: BCBS Trust/PPO |
$10.96
|
| Rate for Payer: BCBS Trust/PPO |
$10.96
|
| Rate for Payer: BCBS Trust/PPO |
$10.96
|
| Rate for Payer: BCN Commercial |
$10.96
|
| Rate for Payer: BCN Commercial |
$10.96
|
| Rate for Payer: BCN Commercial |
$10.96
|
| Rate for Payer: BCN Commercial |
$10.96
|
| Rate for Payer: Cash Price |
$418.61
|
| Rate for Payer: Cash Price |
$619.90
|
| Rate for Payer: Cash Price |
$460.46
|
| Rate for Payer: Cash Price |
$418.61
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Cash Price |
$23.02
|
| Rate for Payer: Cash Price |
$460.46
|
| Rate for Payer: Cash Price |
$619.90
|
| Rate for Payer: Cofinity Commercial |
$666.40
|
| Rate for Payer: Cofinity Commercial |
$450.00
|
| Rate for Payer: Cofinity Commercial |
$20.15
|
| Rate for Payer: Cofinity Commercial |
$24.75
|
| Rate for Payer: Cofinity Commercial |
$366.28
|
| Rate for Payer: Cofinity Commercial |
$402.91
|
| Rate for Payer: Cofinity Commercial |
$495.00
|
| Rate for Payer: Cofinity Commercial |
$542.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$366.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$402.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$418.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$460.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.02
|
| Rate for Payer: Healthscope Commercial |
$25.90
|
| Rate for Payer: Healthscope Commercial |
$697.39
|
| Rate for Payer: Healthscope Commercial |
$518.02
|
| Rate for Payer: Healthscope Commercial |
$470.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$402.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$366.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$542.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$581.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$431.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$392.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$444.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$489.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.46
|
| Rate for Payer: PHP Commercial |
$658.65
|
| Rate for Payer: PHP Commercial |
$444.77
|
| Rate for Payer: PHP Commercial |
$24.46
|
| Rate for Payer: PHP Commercial |
$489.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$340.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$374.13
|
| Rate for Payer: Priority Health SBD |
$18.13
|
| Rate for Payer: Priority Health SBD |
$362.62
|
| Rate for Payer: Priority Health SBD |
$329.65
|
| Rate for Payer: Priority Health SBD |
$488.17
|
| Rate for Payer: UMR Bronson Commercial |
$10.65
|
| Rate for Payer: UMR Bronson Commercial |
$212.96
|
| Rate for Payer: UMR Bronson Commercial |
$286.71
|
| Rate for Payer: UMR Bronson Commercial |
$193.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$431.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$392.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.16
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION
|
Facility
|
OP
|
$257.52
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
23617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$231.77 |
| Rate for Payer: Cofinity Commercial |
$160.12
|
| Rate for Payer: Cofinity Commercial |
$123.14
|
| Rate for Payer: Cofinity Commercial |
$151.28
|
| Rate for Payer: Cofinity Commercial |
$130.33
|
| Rate for Payer: Cofinity Commercial |
$180.26
|
| Rate for Payer: Cofinity Commercial |
$221.47
|
| Rate for Payer: Cofinity Medicare Advantage |
$180.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$123.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$130.33
|
| Rate for Payer: Aetna American Axle |
$167.39
|
| Rate for Payer: Aetna American Axle |
$121.02
|
| Rate for Payer: Aetna American Axle |
$114.34
|
| Rate for Payer: Aetna Commercial |
$218.89
|
| Rate for Payer: Aetna Commercial |
$149.52
|
| Rate for Payer: Aetna Commercial |
$158.26
|
| Rate for Payer: Aetna Medicare |
$93.10
|
| Rate for Payer: Aetna Medicare |
$87.96
|
| Rate for Payer: Aetna Medicare |
$128.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.02
|
| Rate for Payer: BCBS Complete |
$74.48
|
| Rate for Payer: BCBS Complete |
$103.01
|
| Rate for Payer: BCBS Complete |
$70.36
|
| Rate for Payer: BCBS Trust/PPO |
$10.96
|
| Rate for Payer: BCBS Trust/PPO |
$10.96
|
| Rate for Payer: BCBS Trust/PPO |
$10.96
|
| Rate for Payer: BCN Commercial |
$10.96
|
| Rate for Payer: BCN Commercial |
$10.96
|
| Rate for Payer: BCN Commercial |
$10.96
|
| Rate for Payer: Cash Price |
$148.95
|
| Rate for Payer: Cash Price |
$206.02
|
| Rate for Payer: Cash Price |
$140.73
|
| Rate for Payer: Cash Price |
$148.95
|
| Rate for Payer: Cash Price |
$140.73
|
| Rate for Payer: Cash Price |
$206.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.02
|
| Rate for Payer: Healthscope Commercial |
$231.77
|
| Rate for Payer: Healthscope Commercial |
$167.57
|
| Rate for Payer: Healthscope Commercial |
$158.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$130.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$131.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$139.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$158.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$218.89
|
| Rate for Payer: PHP Commercial |
$218.89
|
| Rate for Payer: PHP Commercial |
$149.52
|
| Rate for Payer: PHP Commercial |
$158.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$167.39
|
| Rate for Payer: Priority Health SBD |
$117.30
|
| Rate for Payer: Priority Health SBD |
$162.24
|
| Rate for Payer: Priority Health SBD |
$110.82
|
| Rate for Payer: UMR Bronson Commercial |
$95.28
|
| Rate for Payer: UMR Bronson Commercial |
$65.09
|
| Rate for Payer: UMR Bronson Commercial |
$68.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$131.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$139.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.14
|
|
|
LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION
|
Facility
|
IP
|
$186.19
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
23617
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$81.92 |
| Max. Negotiated Rate |
$167.57 |
| Rate for Payer: Aetna American Axle |
$121.02
|
| Rate for Payer: Aetna Commercial |
$158.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$121.02
|
| Rate for Payer: Cash Price |
$148.95
|
| Rate for Payer: Cofinity Commercial |
$130.33
|
| Rate for Payer: Cofinity Commercial |
$160.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$130.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.95
|
| Rate for Payer: Healthscope Commercial |
$167.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$130.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$139.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$158.26
|
| Rate for Payer: PHP Commercial |
$158.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.02
|
| Rate for Payer: Priority Health SBD |
$117.30
|
| Rate for Payer: UMR Bronson Commercial |
$81.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$139.64
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET
|
Facility
|
OP
|
$5.56
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
4398
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$10.96 |
| Rate for Payer: Aetna American Axle |
$3.61
|
| Rate for Payer: Aetna American Axle |
$180.65
|
| Rate for Payer: Aetna American Axle |
$97.25
|
| Rate for Payer: Aetna Commercial |
$4.73
|
| Rate for Payer: Aetna Commercial |
$127.18
|
| Rate for Payer: Aetna Commercial |
$236.23
|
| Rate for Payer: Aetna Medicare |
$138.96
|
| Rate for Payer: Aetna Medicare |
$74.81
|
| Rate for Payer: Aetna Medicare |
$2.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.65
|
| Rate for Payer: BCBS Complete |
$111.17
|
| Rate for Payer: BCBS Complete |
$2.22
|
| Rate for Payer: BCBS Complete |
$59.85
|
| Rate for Payer: BCBS Trust/PPO |
$10.96
|
| Rate for Payer: BCBS Trust/PPO |
$10.96
|
| Rate for Payer: BCBS Trust/PPO |
$10.96
|
| Rate for Payer: BCN Commercial |
$10.96
|
| Rate for Payer: BCN Commercial |
$10.96
|
| Rate for Payer: BCN Commercial |
$10.96
|
| Rate for Payer: Cash Price |
$222.34
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cash Price |
$119.70
|
| Rate for Payer: Cash Price |
$222.34
|
| Rate for Payer: Cash Price |
$119.70
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cofinity Commercial |
$239.01
|
| Rate for Payer: Cofinity Commercial |
$104.73
|
| Rate for Payer: Cofinity Commercial |
$128.67
|
| Rate for Payer: Cofinity Commercial |
$194.54
|
| Rate for Payer: Cofinity Commercial |
$3.89
|
| Rate for Payer: Cofinity Commercial |
$4.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.89
|
| Rate for Payer: Cofinity Medicare Advantage |
$104.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.45
|
| Rate for Payer: Healthscope Commercial |
$5.00
|
| Rate for Payer: Healthscope Commercial |
$250.13
|
| Rate for Payer: Healthscope Commercial |
$134.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$236.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.73
|
| Rate for Payer: PHP Commercial |
$4.73
|
| Rate for Payer: PHP Commercial |
$127.18
|
| Rate for Payer: PHP Commercial |
$236.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.61
|
| Rate for Payer: Priority Health SBD |
$175.09
|
| Rate for Payer: Priority Health SBD |
$3.50
|
| Rate for Payer: Priority Health SBD |
$94.26
|
| Rate for Payer: UMR Bronson Commercial |
$2.06
|
| Rate for Payer: UMR Bronson Commercial |
$55.36
|
| Rate for Payer: UMR Bronson Commercial |
$102.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.17
|
|
|
LEUCOVORIN CALCIUM 5 MG TABLET
|
Facility
|
IP
|
$149.62
|
|
|
Service Code
|
HCPCS J0640
|
| Hospital Charge Code |
4398
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$65.83 |
| Max. Negotiated Rate |
$134.66 |
| Rate for Payer: Aetna American Axle |
$97.25
|
| Rate for Payer: Aetna American Axle |
$180.65
|
| Rate for Payer: Aetna American Axle |
$3.61
|
| Rate for Payer: Aetna Commercial |
$236.23
|
| Rate for Payer: Aetna Commercial |
$127.18
|
| Rate for Payer: Aetna Commercial |
$4.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.65
|
| Rate for Payer: Cash Price |
$4.45
|
| Rate for Payer: Cash Price |
$222.34
|
| Rate for Payer: Cash Price |
$119.70
|
| Rate for Payer: Cofinity Commercial |
$128.67
|
| Rate for Payer: Cofinity Commercial |
$239.01
|
| Rate for Payer: Cofinity Commercial |
$194.54
|
| Rate for Payer: Cofinity Commercial |
$4.78
|
| Rate for Payer: Cofinity Commercial |
$3.89
|
| Rate for Payer: Cofinity Commercial |
$104.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$194.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$104.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.34
|
| Rate for Payer: Healthscope Commercial |
$250.13
|
| Rate for Payer: Healthscope Commercial |
$134.66
|
| Rate for Payer: Healthscope Commercial |
$5.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$104.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$236.23
|
| Rate for Payer: PHP Commercial |
$4.73
|
| Rate for Payer: PHP Commercial |
$236.23
|
| Rate for Payer: PHP Commercial |
$127.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.25
|
| Rate for Payer: Priority Health SBD |
$3.50
|
| Rate for Payer: Priority Health SBD |
$175.09
|
| Rate for Payer: Priority Health SBD |
$94.26
|
| Rate for Payer: UMR Bronson Commercial |
$65.83
|
| Rate for Payer: UMR Bronson Commercial |
$2.45
|
| Rate for Payer: UMR Bronson Commercial |
$122.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.44
|
|
|
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 |
$893.39 |
| Max. Negotiated Rate |
$17,543.41 |
| Rate for Payer: PACE SWMI |
$1,666.78
|
| Rate for Payer: PHP Commercial |
$16,568.78
|
| Rate for Payer: PHP Medicare Advantage |
$1,666.78
|
| Rate for Payer: PACE Medicare |
$1,583.44
|
| Rate for Payer: Aetna American Axle |
$12,670.24
|
| Rate for Payer: Aetna Commercial |
$16,568.78
|
| Rate for Payer: Aetna Medicare |
$1,733.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12,670.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,083.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,083.48
|
| Rate for Payer: BCBS Complete |
$938.06
|
| Rate for Payer: BCBS MAPPO |
$1,666.78
|
| Rate for Payer: BCBS Trust/PPO |
$4,361.69
|
| Rate for Payer: BCN Commercial |
$4,361.69
|
| Rate for Payer: BCN Medicare Advantage |
$1,666.78
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cofinity Commercial |
$16,763.70
|
| Rate for Payer: Cofinity Commercial |
$13,644.88
|
| 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 |
$1,666.78
|
| Rate for Payer: Healthscope Commercial |
$17,543.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13,644.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14,619.51
|
| Rate for Payer: Mclaren Medicaid |
$893.39
|
| Rate for Payer: Mclaren Medicare |
$1,666.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,750.12
|
| Rate for Payer: Meridian Medicaid |
$938.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,916.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,568.78
|
| Rate for Payer: Nomi Health Commercial |
$5,000.34
|
| Rate for Payer: Priority Health Choice Medicaid |
$893.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,670.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,655.63
|
| Rate for Payer: Priority Health Medicare |
$1,666.78
|
| Rate for Payer: Priority Health Narrow Network |
$3,724.50
|
| Rate for Payer: Priority Health SBD |
$12,280.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1,666.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,691.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,666.78
|
| Rate for Payer: UHC Exchange |
$3,185.38
|
| Rate for Payer: UHC Medicare Advantage |
$1,666.78
|
| Rate for Payer: UHCCP Medicaid |
$893.39
|
| Rate for Payer: UMR Bronson Commercial |
$7,212.29
|
| Rate for Payer: VA VA |
$1,666.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14,619.51
|
|
|
LEUPROLIDE 11.25 MG INTRAMUSCULAR KIT
|
Facility
|
OP
|
$9,971.89
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
10390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$893.39 |
| Max. Negotiated Rate |
$8,974.70 |
| Rate for Payer: Aetna American Axle |
$6,481.73
|
| Rate for Payer: Aetna Commercial |
$8,476.11
|
| Rate for Payer: Aetna Medicare |
$1,733.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,481.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,083.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,083.48
|
| Rate for Payer: BCBS Complete |
$938.06
|
| Rate for Payer: BCBS MAPPO |
$1,666.78
|
| Rate for Payer: BCBS Trust/PPO |
$4,361.69
|
| Rate for Payer: BCN Commercial |
$4,361.69
|
| Rate for Payer: BCN Medicare Advantage |
$1,666.78
|
| Rate for Payer: Cash Price |
$7,977.51
|
| Rate for Payer: Cash Price |
$7,977.51
|
| Rate for Payer: Cofinity Commercial |
$8,575.83
|
| Rate for Payer: Cofinity Commercial |
$6,980.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,980.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,977.51
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,666.78
|
| Rate for Payer: Healthscope Commercial |
$8,974.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,980.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,478.92
|
| Rate for Payer: Mclaren Medicaid |
$893.39
|
| Rate for Payer: Mclaren Medicare |
$1,666.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,750.12
|
| Rate for Payer: Meridian Medicaid |
$938.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,916.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,476.11
|
| Rate for Payer: Nomi Health Commercial |
$5,000.34
|
| Rate for Payer: PACE Medicare |
$1,583.44
|
| Rate for Payer: PACE SWMI |
$1,666.78
|
| Rate for Payer: PHP Commercial |
$8,476.11
|
| Rate for Payer: PHP Medicare Advantage |
$1,666.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$893.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,481.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,655.63
|
| Rate for Payer: Priority Health Medicare |
$1,666.78
|
| Rate for Payer: Priority Health Narrow Network |
$3,724.50
|
| Rate for Payer: Priority Health SBD |
$6,282.29
|
| Rate for Payer: Railroad Medicare Medicare |
$1,666.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,691.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,666.78
|
| Rate for Payer: UHC Exchange |
$3,185.38
|
| Rate for Payer: UHC Medicare Advantage |
$1,666.78
|
| Rate for Payer: UHCCP Medicaid |
$893.39
|
| Rate for Payer: UMR Bronson Commercial |
$3,689.60
|
| Rate for Payer: VA VA |
$1,666.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,478.92
|
|
|
LEUPROLIDE 11.25 MG INTRAMUSCULAR KIT
|
Facility
|
IP
|
$9,971.89
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
10390
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,387.63 |
| Max. Negotiated Rate |
$8,974.70 |
| Rate for Payer: Aetna American Axle |
$6,481.73
|
| Rate for Payer: Aetna Commercial |
$8,476.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6,481.73
|
| Rate for Payer: Cash Price |
$7,977.51
|
| Rate for Payer: Cofinity Commercial |
$6,980.32
|
| Rate for Payer: Cofinity Commercial |
$8,575.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$6,980.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7,977.51
|
| Rate for Payer: Healthscope Commercial |
$8,974.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6,980.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7,478.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8,476.11
|
| Rate for Payer: PHP Commercial |
$8,476.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6,481.73
|
| Rate for Payer: Priority Health SBD |
$6,282.29
|
| Rate for Payer: UMR Bronson Commercial |
$4,387.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7,478.92
|
|
|
LEUPROLIDE 11.25 MG (PEDIATRIC 3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$29,915.73
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
153369
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$893.39 |
| Max. Negotiated Rate |
$26,924.16 |
| Rate for Payer: Aetna American Axle |
$19,445.22
|
| Rate for Payer: Aetna Commercial |
$25,428.37
|
| Rate for Payer: Aetna Medicare |
$1,733.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,445.22
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,083.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,083.48
|
| Rate for Payer: BCBS Complete |
$938.06
|
| Rate for Payer: BCBS MAPPO |
$1,666.78
|
| Rate for Payer: BCBS Trust/PPO |
$4,361.69
|
| Rate for Payer: BCN Commercial |
$4,361.69
|
| Rate for Payer: BCN Medicare Advantage |
$1,666.78
|
| Rate for Payer: Cash Price |
$23,932.58
|
| Rate for Payer: Cash Price |
$23,932.58
|
| Rate for Payer: Cofinity Commercial |
$25,727.53
|
| Rate for Payer: Cofinity Commercial |
$20,941.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,941.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,932.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,666.78
|
| Rate for Payer: Healthscope Commercial |
$26,924.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20,941.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22,436.80
|
| Rate for Payer: Mclaren Medicaid |
$893.39
|
| Rate for Payer: Mclaren Medicare |
$1,666.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,750.12
|
| Rate for Payer: Meridian Medicaid |
$938.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,916.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,428.37
|
| Rate for Payer: Nomi Health Commercial |
$5,000.34
|
| Rate for Payer: PACE Medicare |
$1,583.44
|
| Rate for Payer: PACE SWMI |
$1,666.78
|
| Rate for Payer: PHP Commercial |
$25,428.37
|
| Rate for Payer: PHP Medicare Advantage |
$1,666.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$893.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19,445.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,655.63
|
| Rate for Payer: Priority Health Medicare |
$1,666.78
|
| Rate for Payer: Priority Health Narrow Network |
$3,724.50
|
| Rate for Payer: Priority Health SBD |
$18,846.91
|
| Rate for Payer: Railroad Medicare Medicare |
$1,666.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,691.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,666.78
|
| Rate for Payer: UHC Exchange |
$3,185.38
|
| Rate for Payer: UHC Medicare Advantage |
$1,666.78
|
| Rate for Payer: UHCCP Medicaid |
$893.39
|
| Rate for Payer: UMR Bronson Commercial |
$11,068.82
|
| Rate for Payer: VA VA |
$1,666.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22,436.80
|
|
|
LEUPROLIDE 11.25 MG (PEDIATRIC 3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$29,915.73
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
153369
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13,162.92 |
| Max. Negotiated Rate |
$26,924.16 |
| Rate for Payer: Aetna American Axle |
$19,445.22
|
| Rate for Payer: Aetna Commercial |
$25,428.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19,445.22
|
| Rate for Payer: Cash Price |
$23,932.58
|
| Rate for Payer: Cofinity Commercial |
$20,941.01
|
| Rate for Payer: Cofinity Commercial |
$25,727.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$20,941.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23,932.58
|
| Rate for Payer: Healthscope Commercial |
$26,924.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20,941.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22,436.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25,428.37
|
| Rate for Payer: PHP Commercial |
$25,428.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19,445.22
|
| Rate for Payer: Priority Health SBD |
$18,846.91
|
| Rate for Payer: UMR Bronson Commercial |
$13,162.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22,436.80
|
|
|
LEUPROLIDE 15 MG INTRAMUSCULAR KIT
|
Facility
|
OP
|
$10,983.03
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
10391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$893.39 |
| Max. Negotiated Rate |
$9,884.73 |
| Rate for Payer: Aetna American Axle |
$7,138.97
|
| Rate for Payer: Aetna Commercial |
$9,335.58
|
| Rate for Payer: Aetna Medicare |
$1,733.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,138.97
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,083.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,083.48
|
| Rate for Payer: BCBS Complete |
$938.06
|
| Rate for Payer: BCBS MAPPO |
$1,666.78
|
| Rate for Payer: BCBS Trust/PPO |
$4,361.69
|
| Rate for Payer: BCN Commercial |
$4,361.69
|
| Rate for Payer: BCN Medicare Advantage |
$1,666.78
|
| Rate for Payer: Cash Price |
$8,786.42
|
| Rate for Payer: Cash Price |
$8,786.42
|
| Rate for Payer: Cofinity Commercial |
$9,445.41
|
| Rate for Payer: Cofinity Commercial |
$7,688.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$7,688.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,786.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,666.78
|
| Rate for Payer: Healthscope Commercial |
$9,884.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,688.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,237.27
|
| Rate for Payer: Mclaren Medicaid |
$893.39
|
| Rate for Payer: Mclaren Medicare |
$1,666.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,750.12
|
| Rate for Payer: Meridian Medicaid |
$938.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,916.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,335.58
|
| Rate for Payer: Nomi Health Commercial |
$5,000.34
|
| Rate for Payer: PACE Medicare |
$1,583.44
|
| Rate for Payer: PACE SWMI |
$1,666.78
|
| Rate for Payer: PHP Commercial |
$9,335.58
|
| Rate for Payer: PHP Medicare Advantage |
$1,666.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$893.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,138.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,655.63
|
| Rate for Payer: Priority Health Medicare |
$1,666.78
|
| Rate for Payer: Priority Health Narrow Network |
$3,724.50
|
| Rate for Payer: Priority Health SBD |
$6,919.31
|
| Rate for Payer: Railroad Medicare Medicare |
$1,666.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,691.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,666.78
|
| Rate for Payer: UHC Exchange |
$3,185.38
|
| Rate for Payer: UHC Medicare Advantage |
$1,666.78
|
| Rate for Payer: UHCCP Medicaid |
$893.39
|
| Rate for Payer: UMR Bronson Commercial |
$4,063.72
|
| Rate for Payer: VA VA |
$1,666.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,237.27
|
|
|
LEUPROLIDE 15 MG INTRAMUSCULAR KIT
|
Facility
|
IP
|
$10,983.03
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
10391
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4,832.53 |
| Max. Negotiated Rate |
$9,884.73 |
| Rate for Payer: Aetna American Axle |
$7,138.97
|
| Rate for Payer: Aetna Commercial |
$9,335.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7,138.97
|
| Rate for Payer: Cash Price |
$8,786.42
|
| Rate for Payer: Cofinity Commercial |
$7,688.12
|
| Rate for Payer: Cofinity Commercial |
$9,445.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$7,688.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8,786.42
|
| Rate for Payer: Healthscope Commercial |
$9,884.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7,688.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8,237.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9,335.58
|
| Rate for Payer: PHP Commercial |
$9,335.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7,138.97
|
| Rate for Payer: Priority Health SBD |
$6,919.31
|
| Rate for Payer: UMR Bronson Commercial |
$4,832.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8,237.27
|
|
|
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 |
$96.90 |
| Max. Negotiated Rate |
$1,491.64 |
| Rate for Payer: Aetna American Axle |
$1,077.30
|
| Rate for Payer: Aetna Commercial |
$1,408.77
|
| Rate for Payer: Aetna Medicare |
$188.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,077.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$225.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$225.99
|
| Rate for Payer: BCBS Complete |
$101.75
|
| Rate for Payer: BCBS MAPPO |
$180.79
|
| Rate for Payer: BCBS Trust/PPO |
$505.52
|
| Rate for Payer: BCN Commercial |
$505.52
|
| Rate for Payer: BCN Medicare Advantage |
$180.79
|
| 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 |
$180.79
|
| Rate for Payer: Healthscope Commercial |
$1,491.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,160.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,243.04
|
| Rate for Payer: Mclaren Medicaid |
$96.90
|
| Rate for Payer: Mclaren Medicare |
$180.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$189.83
|
| Rate for Payer: Meridian Medicaid |
$101.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,408.77
|
| Rate for Payer: Nomi Health Commercial |
$542.37
|
| Rate for Payer: PACE Medicare |
$171.75
|
| Rate for Payer: PACE SWMI |
$180.79
|
| Rate for Payer: PHP Commercial |
$1,408.77
|
| Rate for Payer: PHP Medicare Advantage |
$180.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,077.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$508.00
|
| Rate for Payer: Priority Health Medicare |
$180.79
|
| Rate for Payer: Priority Health Narrow Network |
$406.40
|
| Rate for Payer: Priority Health SBD |
$1,044.15
|
| Rate for Payer: Railroad Medicare Medicare |
$180.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$508.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$180.79
|
| Rate for Payer: UHC Exchange |
$345.51
|
| Rate for Payer: UHC Medicare Advantage |
$180.79
|
| Rate for Payer: UHCCP Medicaid |
$96.90
|
| Rate for Payer: UMR Bronson Commercial |
$613.23
|
| Rate for Payer: VA VA |
$180.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,243.04
|
|
|
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 |
$729.25 |
| Max. Negotiated Rate |
$1,491.64 |
| Rate for Payer: Aetna American Axle |
$1,077.30
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$1,160.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,243.04
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$729.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,243.04
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$1,094.40
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
33669
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$481.54 |
| Max. Negotiated Rate |
$984.96 |
| Rate for Payer: Aetna American Axle |
$711.36
|
| Rate for Payer: Aetna American Axle |
$730.08
|
| Rate for Payer: Aetna Commercial |
$930.24
|
| Rate for Payer: Aetna Commercial |
$954.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$711.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$730.08
|
| Rate for Payer: Cash Price |
$875.52
|
| 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 Commercial |
$766.08
|
| Rate for Payer: Cofinity Commercial |
$941.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$766.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$786.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$875.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$898.56
|
| Rate for Payer: Healthscope Commercial |
$984.96
|
| Rate for Payer: Healthscope Commercial |
$1,010.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$766.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$786.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$820.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$842.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$954.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$930.24
|
| Rate for Payer: PHP Commercial |
$954.72
|
| Rate for Payer: PHP Commercial |
$930.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$711.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$730.08
|
| Rate for Payer: Priority Health SBD |
$689.47
|
| Rate for Payer: Priority Health SBD |
$707.62
|
| Rate for Payer: UMR Bronson Commercial |
$481.54
|
| Rate for Payer: UMR Bronson Commercial |
$494.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$820.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$842.40
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$1,094.40
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
33669
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$984.96 |
| Rate for Payer: Aetna American Axle |
$711.36
|
| Rate for Payer: Aetna American Axle |
$730.08
|
| Rate for Payer: Aetna Commercial |
$954.72
|
| Rate for Payer: Aetna Commercial |
$930.24
|
| Rate for Payer: Aetna Medicare |
$188.02
|
| Rate for Payer: Aetna Medicare |
$188.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$711.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$730.08
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$225.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$225.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$225.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$225.99
|
| Rate for Payer: BCBS Complete |
$101.75
|
| Rate for Payer: BCBS Complete |
$101.75
|
| Rate for Payer: BCBS MAPPO |
$180.79
|
| Rate for Payer: BCBS MAPPO |
$180.79
|
| Rate for Payer: BCBS Trust/PPO |
$505.52
|
| Rate for Payer: BCBS Trust/PPO |
$505.52
|
| Rate for Payer: BCN Commercial |
$505.52
|
| Rate for Payer: BCN Commercial |
$505.52
|
| Rate for Payer: BCN Medicare Advantage |
$180.79
|
| Rate for Payer: BCN Medicare Advantage |
$180.79
|
| Rate for Payer: Cash Price |
$898.56
|
| Rate for Payer: Cash Price |
$875.52
|
| Rate for Payer: Cash Price |
$898.56
|
| Rate for Payer: Cash Price |
$875.52
|
| Rate for Payer: Cofinity Commercial |
$786.24
|
| Rate for Payer: Cofinity Commercial |
$766.08
|
| Rate for Payer: Cofinity Commercial |
$941.18
|
| Rate for Payer: Cofinity Commercial |
$965.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$766.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$786.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$875.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$898.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$180.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$180.79
|
| Rate for Payer: Healthscope Commercial |
$984.96
|
| Rate for Payer: Healthscope Commercial |
$1,010.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$786.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$766.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$820.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$842.40
|
| Rate for Payer: Mclaren Medicaid |
$96.90
|
| Rate for Payer: Mclaren Medicaid |
$96.90
|
| Rate for Payer: Mclaren Medicare |
$180.79
|
| Rate for Payer: Mclaren Medicare |
$180.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$189.83
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$189.83
|
| Rate for Payer: Meridian Medicaid |
$101.75
|
| Rate for Payer: Meridian Medicaid |
$101.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$207.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$930.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$954.72
|
| Rate for Payer: Nomi Health Commercial |
$542.37
|
| Rate for Payer: Nomi Health Commercial |
$542.37
|
| Rate for Payer: PACE Medicare |
$171.75
|
| Rate for Payer: PACE Medicare |
$171.75
|
| Rate for Payer: PACE SWMI |
$180.79
|
| Rate for Payer: PACE SWMI |
$180.79
|
| Rate for Payer: PHP Commercial |
$930.24
|
| Rate for Payer: PHP Commercial |
$954.72
|
| Rate for Payer: PHP Medicare Advantage |
$180.79
|
| Rate for Payer: PHP Medicare Advantage |
$180.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$711.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$730.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$508.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$508.00
|
| Rate for Payer: Priority Health Medicare |
$180.79
|
| Rate for Payer: Priority Health Medicare |
$180.79
|
| Rate for Payer: Priority Health Narrow Network |
$406.40
|
| Rate for Payer: Priority Health Narrow Network |
$406.40
|
| Rate for Payer: Priority Health SBD |
$689.47
|
| Rate for Payer: Priority Health SBD |
$707.62
|
| Rate for Payer: Railroad Medicare Medicare |
$180.79
|
| Rate for Payer: Railroad Medicare Medicare |
$180.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$508.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$508.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$180.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$180.79
|
| Rate for Payer: UHC Exchange |
$345.51
|
| Rate for Payer: UHC Exchange |
$345.51
|
| Rate for Payer: UHC Medicare Advantage |
$180.79
|
| Rate for Payer: UHC Medicare Advantage |
$180.79
|
| Rate for Payer: UHCCP Medicaid |
$96.90
|
| Rate for Payer: UHCCP Medicaid |
$96.90
|
| Rate for Payer: UMR Bronson Commercial |
$404.93
|
| Rate for Payer: UMR Bronson Commercial |
$415.58
|
| Rate for Payer: VA VA |
$180.79
|
| Rate for Payer: VA VA |
$180.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$820.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$842.40
|
|
|
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 |
$972.33 |
| Max. Negotiated Rate |
$1,988.85 |
| 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: Aetna American Axle |
$1,436.39
|
| 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: Encore Health Key Benefits Commercial |
$1,767.86
|
| Rate for Payer: Healthscope Commercial |
$1,988.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,546.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,657.37
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$972.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,657.37
|
|
|
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 |
$96.90 |
| Max. Negotiated Rate |
$1,988.85 |
| Rate for Payer: Aetna American Axle |
$1,436.39
|
| Rate for Payer: Aetna Commercial |
$1,878.36
|
| Rate for Payer: Aetna Medicare |
$188.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,436.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$225.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$225.99
|
| Rate for Payer: BCBS Complete |
$101.75
|
| Rate for Payer: BCBS MAPPO |
$180.79
|
| Rate for Payer: BCBS Trust/PPO |
$505.52
|
| Rate for Payer: BCN Commercial |
$505.52
|
| Rate for Payer: BCN Medicare Advantage |
$180.79
|
| 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 |
$180.79
|
| Rate for Payer: Healthscope Commercial |
$1,988.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,546.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,657.37
|
| Rate for Payer: Mclaren Medicaid |
$96.90
|
| Rate for Payer: Mclaren Medicare |
$180.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$189.83
|
| Rate for Payer: Meridian Medicaid |
$101.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,878.36
|
| Rate for Payer: Nomi Health Commercial |
$542.37
|
| Rate for Payer: PACE Medicare |
$171.75
|
| Rate for Payer: PACE SWMI |
$180.79
|
| Rate for Payer: PHP Commercial |
$1,878.36
|
| Rate for Payer: PHP Medicare Advantage |
$180.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,436.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$508.00
|
| Rate for Payer: Priority Health Medicare |
$180.79
|
| Rate for Payer: Priority Health Narrow Network |
$406.40
|
| Rate for Payer: Priority Health SBD |
$1,392.19
|
| Rate for Payer: Railroad Medicare Medicare |
$180.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$508.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$180.79
|
| Rate for Payer: UHC Exchange |
$345.51
|
| Rate for Payer: UHC Medicare Advantage |
$180.79
|
| Rate for Payer: UHCCP Medicaid |
$96.90
|
| Rate for Payer: UMR Bronson Commercial |
$817.64
|
| Rate for Payer: VA VA |
$180.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,657.37
|
|
|
LEUPROLIDE 30 MG (PEDIATRIC 3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$32,949.21
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
153367
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$893.39 |
| Max. Negotiated Rate |
$29,654.29 |
| Rate for Payer: Aetna American Axle |
$21,416.99
|
| Rate for Payer: Aetna Commercial |
$28,006.83
|
| Rate for Payer: Aetna Medicare |
$1,733.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21,416.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,083.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,083.48
|
| Rate for Payer: BCBS Complete |
$938.06
|
| Rate for Payer: BCBS MAPPO |
$1,666.78
|
| Rate for Payer: BCBS Trust/PPO |
$4,361.69
|
| Rate for Payer: BCN Commercial |
$4,361.69
|
| Rate for Payer: BCN Medicare Advantage |
$1,666.78
|
| Rate for Payer: Cash Price |
$26,359.37
|
| Rate for Payer: Cash Price |
$26,359.37
|
| Rate for Payer: Cofinity Commercial |
$28,336.32
|
| Rate for Payer: Cofinity Commercial |
$23,064.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$23,064.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26,359.37
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,666.78
|
| Rate for Payer: Healthscope Commercial |
$29,654.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23,064.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24,711.91
|
| Rate for Payer: Mclaren Medicaid |
$893.39
|
| Rate for Payer: Mclaren Medicare |
$1,666.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,750.12
|
| Rate for Payer: Meridian Medicaid |
$938.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,916.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28,006.83
|
| Rate for Payer: Nomi Health Commercial |
$5,000.34
|
| Rate for Payer: PACE Medicare |
$1,583.44
|
| Rate for Payer: PACE SWMI |
$1,666.78
|
| Rate for Payer: PHP Commercial |
$28,006.83
|
| Rate for Payer: PHP Medicare Advantage |
$1,666.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$893.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21,416.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,655.63
|
| Rate for Payer: Priority Health Medicare |
$1,666.78
|
| Rate for Payer: Priority Health Narrow Network |
$3,724.50
|
| Rate for Payer: Priority Health SBD |
$20,758.00
|
| Rate for Payer: Railroad Medicare Medicare |
$1,666.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,691.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,666.78
|
| Rate for Payer: UHC Exchange |
$3,185.38
|
| Rate for Payer: UHC Medicare Advantage |
$1,666.78
|
| Rate for Payer: UHCCP Medicaid |
$893.39
|
| Rate for Payer: UMR Bronson Commercial |
$12,191.21
|
| Rate for Payer: VA VA |
$1,666.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24,711.91
|
|
|
LEUPROLIDE 30 MG (PEDIATRIC 3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$32,949.21
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
153367
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14,497.65 |
| Max. Negotiated Rate |
$29,654.29 |
| Rate for Payer: Aetna American Axle |
$21,416.99
|
| Rate for Payer: Aetna Commercial |
$28,006.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21,416.99
|
| Rate for Payer: Cash Price |
$26,359.37
|
| Rate for Payer: Cofinity Commercial |
$23,064.45
|
| Rate for Payer: Cofinity Commercial |
$28,336.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$23,064.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26,359.37
|
| Rate for Payer: Healthscope Commercial |
$29,654.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23,064.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24,711.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28,006.83
|
| Rate for Payer: PHP Commercial |
$28,006.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21,416.99
|
| Rate for Payer: Priority Health SBD |
$20,758.00
|
| Rate for Payer: UMR Bronson Commercial |
$14,497.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24,711.91
|
|
|
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 |
$2,472.56 |
| Max. Negotiated Rate |
$5,057.51 |
| Rate for Payer: Aetna American Axle |
$3,652.65
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$3,933.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,214.60
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$2,472.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,214.60
|
|
|
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 |
$893.39 |
| Max. Negotiated Rate |
$5,057.51 |
| Rate for Payer: Aetna American Axle |
$3,652.65
|
| Rate for Payer: Aetna Commercial |
$4,776.54
|
| Rate for Payer: Aetna Medicare |
$1,733.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,652.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,083.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,083.48
|
| Rate for Payer: BCBS Complete |
$938.06
|
| Rate for Payer: BCBS MAPPO |
$1,666.78
|
| Rate for Payer: BCBS Trust/PPO |
$4,361.69
|
| Rate for Payer: BCN Commercial |
$4,361.69
|
| Rate for Payer: BCN Medicare Advantage |
$1,666.78
|
| Rate for Payer: Cash Price |
$4,495.57
|
| Rate for Payer: Cash Price |
$4,495.57
|
| Rate for Payer: Cofinity Commercial |
$4,832.74
|
| Rate for Payer: Cofinity Commercial |
$3,933.62
|
| 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 |
$1,666.78
|
| Rate for Payer: Healthscope Commercial |
$5,057.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,933.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4,214.60
|
| Rate for Payer: Mclaren Medicaid |
$893.39
|
| Rate for Payer: Mclaren Medicare |
$1,666.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,750.12
|
| Rate for Payer: Meridian Medicaid |
$938.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,916.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,776.54
|
| Rate for Payer: Nomi Health Commercial |
$5,000.34
|
| Rate for Payer: PACE Medicare |
$1,583.44
|
| Rate for Payer: PACE SWMI |
$1,666.78
|
| Rate for Payer: PHP Commercial |
$4,776.54
|
| Rate for Payer: PHP Medicare Advantage |
$1,666.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$893.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3,652.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,655.63
|
| Rate for Payer: Priority Health Medicare |
$1,666.78
|
| Rate for Payer: Priority Health Narrow Network |
$3,724.50
|
| Rate for Payer: Priority Health SBD |
$3,540.26
|
| Rate for Payer: Railroad Medicare Medicare |
$1,666.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,691.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,666.78
|
| Rate for Payer: UHC Exchange |
$3,185.38
|
| Rate for Payer: UHC Medicare Advantage |
$1,666.78
|
| Rate for Payer: UHCCP Medicaid |
$893.39
|
| Rate for Payer: UMR Bronson Commercial |
$2,079.20
|
| Rate for Payer: VA VA |
$1,666.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4,214.60
|
|
|
LEUPROLIDE 45 MG (PEDIATRIC 6 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$65,898.36
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
203699
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$893.39 |
| Max. Negotiated Rate |
$59,308.52 |
| Rate for Payer: BCN Medicare Advantage |
$1,666.78
|
| Rate for Payer: Cash Price |
$52,718.69
|
| Rate for Payer: Cash Price |
$52,718.69
|
| Rate for Payer: Cofinity Commercial |
$56,672.59
|
| Rate for Payer: Cofinity Commercial |
$46,128.85
|
| Rate for Payer: Aetna American Axle |
$42,833.93
|
| Rate for Payer: Aetna Commercial |
$56,013.61
|
| Rate for Payer: Aetna Medicare |
$1,733.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42,833.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,083.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,083.48
|
| Rate for Payer: BCBS Complete |
$938.06
|
| Rate for Payer: BCBS MAPPO |
$1,666.78
|
| Rate for Payer: BCBS Trust/PPO |
$4,361.69
|
| Rate for Payer: BCN Commercial |
$4,361.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$46,128.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52,718.69
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,666.78
|
| Rate for Payer: Healthscope Commercial |
$59,308.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$46,128.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49,423.77
|
| Rate for Payer: Mclaren Medicaid |
$893.39
|
| Rate for Payer: Mclaren Medicare |
$1,666.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,750.12
|
| Rate for Payer: Meridian Medicaid |
$938.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,916.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56,013.61
|
| Rate for Payer: Nomi Health Commercial |
$5,000.34
|
| Rate for Payer: PACE Medicare |
$1,583.44
|
| Rate for Payer: PACE SWMI |
$1,666.78
|
| Rate for Payer: PHP Commercial |
$56,013.61
|
| Rate for Payer: PHP Medicare Advantage |
$1,666.78
|
| Rate for Payer: Priority Health Choice Medicaid |
$893.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42,833.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4,655.63
|
| Rate for Payer: Priority Health Medicare |
$1,666.78
|
| Rate for Payer: Priority Health Narrow Network |
$3,724.50
|
| Rate for Payer: Priority Health SBD |
$41,515.97
|
| Rate for Payer: Railroad Medicare Medicare |
$1,666.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4,691.82
|
| Rate for Payer: UHC Dual Complete DSNP |
$1,666.78
|
| Rate for Payer: UHC Exchange |
$3,185.38
|
| Rate for Payer: UHC Medicare Advantage |
$1,666.78
|
| Rate for Payer: UHCCP Medicaid |
$893.39
|
| Rate for Payer: UMR Bronson Commercial |
$24,382.39
|
| Rate for Payer: VA VA |
$1,666.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49,423.77
|
|
|
LEUPROLIDE 7.5 MG (1 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$404.70
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
32893
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$542.37 |
| Rate for Payer: Aetna American Axle |
$263.06
|
| Rate for Payer: Aetna American Axle |
$269.98
|
| Rate for Payer: Aetna Commercial |
$344.00
|
| Rate for Payer: Aetna Commercial |
$353.05
|
| Rate for Payer: Aetna Medicare |
$188.02
|
| Rate for Payer: Aetna Medicare |
$188.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$263.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$269.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$225.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$225.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$225.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$225.99
|
| Rate for Payer: BCBS Complete |
$101.75
|
| Rate for Payer: BCBS Complete |
$101.75
|
| Rate for Payer: BCBS MAPPO |
$180.79
|
| Rate for Payer: BCBS MAPPO |
$180.79
|
| Rate for Payer: BCBS Trust/PPO |
$505.52
|
| Rate for Payer: BCBS Trust/PPO |
$505.52
|
| Rate for Payer: BCN Commercial |
$505.52
|
| Rate for Payer: BCN Commercial |
$505.52
|
| Rate for Payer: BCN Medicare Advantage |
$180.79
|
| Rate for Payer: BCN Medicare Advantage |
$180.79
|
| Rate for Payer: Cash Price |
$332.28
|
| Rate for Payer: Cash Price |
$323.76
|
| Rate for Payer: Cash Price |
$332.28
|
| Rate for Payer: Cash Price |
$323.76
|
| Rate for Payer: Cofinity Commercial |
$357.20
|
| Rate for Payer: Cofinity Commercial |
$290.74
|
| Rate for Payer: Cofinity Commercial |
$283.29
|
| Rate for Payer: Cofinity Commercial |
$348.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$283.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$290.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$323.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$180.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$180.79
|
| Rate for Payer: Healthscope Commercial |
$373.82
|
| Rate for Payer: Healthscope Commercial |
$364.23
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$283.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$290.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$303.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$311.51
|
| Rate for Payer: Mclaren Medicaid |
$96.90
|
| Rate for Payer: Mclaren Medicaid |
$96.90
|
| Rate for Payer: Mclaren Medicare |
$180.79
|
| Rate for Payer: Mclaren Medicare |
$180.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$189.83
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$189.83
|
| Rate for Payer: Meridian Medicaid |
$101.75
|
| Rate for Payer: Meridian Medicaid |
$101.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$207.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$344.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.05
|
| Rate for Payer: Nomi Health Commercial |
$542.37
|
| Rate for Payer: Nomi Health Commercial |
$542.37
|
| Rate for Payer: PACE Medicare |
$171.75
|
| Rate for Payer: PACE Medicare |
$171.75
|
| Rate for Payer: PACE SWMI |
$180.79
|
| Rate for Payer: PACE SWMI |
$180.79
|
| Rate for Payer: PHP Commercial |
$353.05
|
| Rate for Payer: PHP Commercial |
$344.00
|
| Rate for Payer: PHP Medicare Advantage |
$180.79
|
| Rate for Payer: PHP Medicare Advantage |
$180.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.90
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$263.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$269.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$508.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$508.00
|
| Rate for Payer: Priority Health Medicare |
$180.79
|
| Rate for Payer: Priority Health Medicare |
$180.79
|
| Rate for Payer: Priority Health Narrow Network |
$406.40
|
| Rate for Payer: Priority Health Narrow Network |
$406.40
|
| Rate for Payer: Priority Health SBD |
$254.96
|
| Rate for Payer: Priority Health SBD |
$261.67
|
| Rate for Payer: Railroad Medicare Medicare |
$180.79
|
| Rate for Payer: Railroad Medicare Medicare |
$180.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$508.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$508.91
|
| Rate for Payer: UHC Dual Complete DSNP |
$180.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$180.79
|
| Rate for Payer: UHC Exchange |
$345.51
|
| Rate for Payer: UHC Exchange |
$345.51
|
| Rate for Payer: UHC Medicare Advantage |
$180.79
|
| Rate for Payer: UHC Medicare Advantage |
$180.79
|
| Rate for Payer: UHCCP Medicaid |
$96.90
|
| Rate for Payer: UHCCP Medicaid |
$96.90
|
| Rate for Payer: UMR Bronson Commercial |
$149.74
|
| Rate for Payer: UMR Bronson Commercial |
$153.68
|
| Rate for Payer: VA VA |
$180.79
|
| Rate for Payer: VA VA |
$180.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$303.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$311.51
|
|
