|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
IP
|
$2.62
|
|
|
Service Code
|
NDC 68084088211
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.65
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
OP
|
$2.62
|
|
|
Service Code
|
NDC 68084088211
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.05 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna Medicare |
$1.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: BCBS Complete |
$1.05
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.70
|
| Rate for Payer: Priority Health SBD |
$1.65
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
IP
|
$192.85
|
|
|
Service Code
|
NDC 00904712561
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.50 |
| Max. Negotiated Rate |
$173.56 |
| Rate for Payer: Aetna Commercial |
$163.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.35
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$135.00
|
| Rate for Payer: Cofinity Commercial |
$165.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$135.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: PHP Commercial |
$163.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: Priority Health SBD |
$121.50
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
OP
|
$192.85
|
|
|
Service Code
|
NDC 00904712561
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.14 |
| Max. Negotiated Rate |
$173.56 |
| Rate for Payer: Aetna Commercial |
$163.92
|
| Rate for Payer: Aetna Medicare |
$96.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.35
|
| Rate for Payer: BCBS Complete |
$77.14
|
| Rate for Payer: Cash Price |
$154.28
|
| Rate for Payer: Cofinity Commercial |
$135.00
|
| Rate for Payer: Cofinity Commercial |
$165.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$135.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.28
|
| Rate for Payer: Healthscope Commercial |
$173.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$163.92
|
| Rate for Payer: PHP Commercial |
$163.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.35
|
| Rate for Payer: Priority Health SBD |
$121.50
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$100.15
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
20954
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.06 |
| Max. Negotiated Rate |
$90.14 |
| Rate for Payer: Aetna Commercial |
$85.13
|
| Rate for Payer: Aetna Medicare |
$50.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.10
|
| Rate for Payer: BCBS Complete |
$40.06
|
| Rate for Payer: Cash Price |
$80.12
|
| Rate for Payer: Cofinity Commercial |
$70.11
|
| Rate for Payer: Cofinity Commercial |
$86.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.12
|
| Rate for Payer: Healthscope Commercial |
$90.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.13
|
| Rate for Payer: PHP Commercial |
$85.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.10
|
| Rate for Payer: Priority Health SBD |
$63.09
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$100.15
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
20954
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.09 |
| Max. Negotiated Rate |
$90.14 |
| Rate for Payer: Aetna Commercial |
$85.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.10
|
| Rate for Payer: Cash Price |
$80.12
|
| Rate for Payer: Cofinity Commercial |
$70.11
|
| Rate for Payer: Cofinity Commercial |
$86.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$70.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.12
|
| Rate for Payer: Healthscope Commercial |
$90.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.13
|
| Rate for Payer: PHP Commercial |
$85.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.10
|
| Rate for Payer: Priority Health SBD |
$63.09
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
OP
|
$342.58
|
|
|
Service Code
|
NDC 50383017290
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.03 |
| Max. Negotiated Rate |
$308.32 |
| Rate for Payer: Aetna Commercial |
$291.19
|
| Rate for Payer: Aetna Medicare |
$171.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$222.68
|
| Rate for Payer: BCBS Complete |
$137.03
|
| Rate for Payer: Cash Price |
$274.06
|
| Rate for Payer: Cofinity Commercial |
$239.81
|
| Rate for Payer: Cofinity Commercial |
$294.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$239.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.06
|
| Rate for Payer: Healthscope Commercial |
$308.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.19
|
| Rate for Payer: PHP Commercial |
$291.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$222.68
|
| Rate for Payer: Priority Health SBD |
$215.83
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$342.58
|
|
|
Service Code
|
NDC 50383017290
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$215.83 |
| Max. Negotiated Rate |
$308.32 |
| Rate for Payer: Aetna Commercial |
$291.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$222.68
|
| Rate for Payer: Cash Price |
$274.06
|
| Rate for Payer: Cofinity Commercial |
$239.81
|
| Rate for Payer: Cofinity Commercial |
$294.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$239.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.06
|
| Rate for Payer: Healthscope Commercial |
$308.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.19
|
| Rate for Payer: PHP Commercial |
$291.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$222.68
|
| Rate for Payer: Priority Health SBD |
$215.83
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$62.71
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.08 |
| Max. Negotiated Rate |
$56.44 |
| Rate for Payer: Aetna Commercial |
$53.30
|
| Rate for Payer: Aetna Commercial |
$50.17
|
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna Commercial |
$47.55
|
| Rate for Payer: Aetna Medicare |
$36.71
|
| Rate for Payer: Aetna Medicare |
$31.36
|
| Rate for Payer: Aetna Medicare |
$29.51
|
| Rate for Payer: Aetna Medicare |
$27.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: BCBS Complete |
$22.38
|
| Rate for Payer: BCBS Complete |
$29.37
|
| Rate for Payer: BCBS Complete |
$23.61
|
| Rate for Payer: BCBS Complete |
$25.08
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cash Price |
$50.17
|
| Rate for Payer: Cash Price |
$44.75
|
| Rate for Payer: Cofinity Commercial |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Cofinity Commercial |
$43.90
|
| Rate for Payer: Cofinity Commercial |
$51.39
|
| Rate for Payer: Cofinity Commercial |
$53.93
|
| Rate for Payer: Cofinity Commercial |
$39.16
|
| Rate for Payer: Cofinity Commercial |
$48.11
|
| Rate for Payer: Cofinity Commercial |
$41.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.22
|
| Rate for Payer: Healthscope Commercial |
$50.35
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: Healthscope Commercial |
$53.12
|
| Rate for Payer: Healthscope Commercial |
$56.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.55
|
| Rate for Payer: PHP Commercial |
$50.17
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: PHP Commercial |
$53.30
|
| Rate for Payer: PHP Commercial |
$47.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.72
|
| Rate for Payer: Priority Health SBD |
$35.24
|
| Rate for Payer: Priority Health SBD |
$39.51
|
| Rate for Payer: Priority Health SBD |
$37.18
|
| Rate for Payer: Priority Health SBD |
$46.25
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$62.71
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.51 |
| Max. Negotiated Rate |
$56.44 |
| Rate for Payer: Aetna Commercial |
$53.30
|
| Rate for Payer: Aetna Commercial |
$50.17
|
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna Commercial |
$47.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: Cash Price |
$50.17
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cash Price |
$44.75
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cofinity Commercial |
$39.16
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Cofinity Commercial |
$51.39
|
| Rate for Payer: Cofinity Commercial |
$41.31
|
| Rate for Payer: Cofinity Commercial |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$53.93
|
| Rate for Payer: Cofinity Commercial |
$43.90
|
| Rate for Payer: Cofinity Commercial |
$48.11
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$43.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Healthscope Commercial |
$53.12
|
| Rate for Payer: Healthscope Commercial |
$50.35
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: Healthscope Commercial |
$56.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.55
|
| Rate for Payer: PHP Commercial |
$47.55
|
| Rate for Payer: PHP Commercial |
$53.30
|
| Rate for Payer: PHP Commercial |
$50.17
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.72
|
| Rate for Payer: Priority Health SBD |
$35.24
|
| Rate for Payer: Priority Health SBD |
$39.51
|
| Rate for Payer: Priority Health SBD |
$37.18
|
| Rate for Payer: Priority Health SBD |
$46.25
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
IP
|
$418.30
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$263.53 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.89
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$292.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.89
|
| Rate for Payer: Priority Health SBD |
$263.53
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
OP
|
$418.30
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.32 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna Medicare |
$209.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.89
|
| Rate for Payer: BCBS Complete |
$167.32
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$292.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.89
|
| Rate for Payer: Priority Health SBD |
$263.53
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
OP
|
$125.73
|
|
|
Service Code
|
NDC 55111027950
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.29 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna Commercial |
$106.87
|
| Rate for Payer: Aetna Medicare |
$62.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.72
|
| Rate for Payer: BCBS Complete |
$50.29
|
| Rate for Payer: Cash Price |
$100.58
|
| Rate for Payer: Cofinity Commercial |
$108.13
|
| Rate for Payer: Cofinity Commercial |
$88.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$88.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.58
|
| Rate for Payer: Healthscope Commercial |
$113.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$106.87
|
| Rate for Payer: PHP Commercial |
$106.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.72
|
| Rate for Payer: Priority Health SBD |
$79.21
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
IP
|
$125.73
|
|
|
Service Code
|
NDC 55111027950
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.21 |
| Max. Negotiated Rate |
$113.16 |
| Rate for Payer: Aetna Commercial |
$106.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.72
|
| Rate for Payer: Cash Price |
$100.58
|
| Rate for Payer: Cofinity Commercial |
$108.13
|
| Rate for Payer: Cofinity Commercial |
$88.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$88.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.58
|
| Rate for Payer: Healthscope Commercial |
$113.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$106.87
|
| Rate for Payer: PHP Commercial |
$106.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.72
|
| Rate for Payer: Priority Health SBD |
$79.21
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$74.97
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.23 |
| Max. Negotiated Rate |
$67.47 |
| Rate for Payer: Aetna Commercial |
$63.72
|
| Rate for Payer: Aetna Commercial |
$56.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.73
|
| Rate for Payer: Cash Price |
$53.14
|
| Rate for Payer: Cash Price |
$59.98
|
| Rate for Payer: Cofinity Commercial |
$64.47
|
| Rate for Payer: Cofinity Commercial |
$52.48
|
| Rate for Payer: Cofinity Commercial |
$46.50
|
| Rate for Payer: Cofinity Commercial |
$57.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$52.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.98
|
| Rate for Payer: Healthscope Commercial |
$67.47
|
| Rate for Payer: Healthscope Commercial |
$59.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.72
|
| Rate for Payer: PHP Commercial |
$63.72
|
| Rate for Payer: PHP Commercial |
$56.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.73
|
| Rate for Payer: Priority Health SBD |
$41.85
|
| Rate for Payer: Priority Health SBD |
$47.23
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$74.97
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.99 |
| Max. Negotiated Rate |
$67.47 |
| Rate for Payer: Aetna Commercial |
$63.72
|
| Rate for Payer: Aetna Commercial |
$56.47
|
| Rate for Payer: Aetna Medicare |
$33.22
|
| Rate for Payer: Aetna Medicare |
$37.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.18
|
| Rate for Payer: BCBS Complete |
$29.99
|
| Rate for Payer: BCBS Complete |
$26.57
|
| Rate for Payer: Cash Price |
$59.98
|
| Rate for Payer: Cash Price |
$53.14
|
| Rate for Payer: Cofinity Commercial |
$64.47
|
| Rate for Payer: Cofinity Commercial |
$46.50
|
| Rate for Payer: Cofinity Commercial |
$57.13
|
| Rate for Payer: Cofinity Commercial |
$52.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$46.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$52.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.98
|
| Rate for Payer: Healthscope Commercial |
$67.47
|
| Rate for Payer: Healthscope Commercial |
$59.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$56.47
|
| Rate for Payer: PHP Commercial |
$63.72
|
| Rate for Payer: PHP Commercial |
$56.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.73
|
| Rate for Payer: Priority Health SBD |
$41.85
|
| Rate for Payer: Priority Health SBD |
$47.23
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$68.18
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$27.27 |
| Max. Negotiated Rate |
$61.36 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Commercial |
$94.81
|
| Rate for Payer: Aetna Commercial |
$75.25
|
| Rate for Payer: Aetna Commercial |
$87.45
|
| Rate for Payer: Aetna Medicare |
$44.27
|
| Rate for Payer: Aetna Medicare |
$34.09
|
| Rate for Payer: Aetna Medicare |
$55.77
|
| Rate for Payer: Aetna Medicare |
$51.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.54
|
| Rate for Payer: BCBS Complete |
$41.15
|
| Rate for Payer: BCBS Complete |
$35.41
|
| Rate for Payer: BCBS Complete |
$44.62
|
| Rate for Payer: BCBS Complete |
$27.27
|
| Rate for Payer: Cash Price |
$70.82
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cash Price |
$82.30
|
| Rate for Payer: Cofinity Commercial |
$95.92
|
| Rate for Payer: Cofinity Commercial |
$76.14
|
| Rate for Payer: Cofinity Commercial |
$47.73
|
| Rate for Payer: Cofinity Commercial |
$61.97
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Cofinity Commercial |
$72.02
|
| Rate for Payer: Cofinity Commercial |
$88.48
|
| Rate for Payer: Cofinity Commercial |
$78.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.23
|
| Rate for Payer: Healthscope Commercial |
$92.59
|
| Rate for Payer: Healthscope Commercial |
$79.68
|
| Rate for Payer: Healthscope Commercial |
$100.39
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.45
|
| Rate for Payer: PHP Commercial |
$94.81
|
| Rate for Payer: PHP Commercial |
$75.25
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: PHP Commercial |
$87.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.54
|
| Rate for Payer: Priority Health SBD |
$64.81
|
| Rate for Payer: Priority Health SBD |
$42.95
|
| Rate for Payer: Priority Health SBD |
$70.27
|
| Rate for Payer: Priority Health SBD |
$55.77
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$68.18
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.95 |
| Max. Negotiated Rate |
$61.36 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Commercial |
$94.81
|
| Rate for Payer: Aetna Commercial |
$75.25
|
| Rate for Payer: Aetna Commercial |
$87.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.54
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$82.30
|
| Rate for Payer: Cash Price |
$70.82
|
| Rate for Payer: Cofinity Commercial |
$72.02
|
| Rate for Payer: Cofinity Commercial |
$76.14
|
| Rate for Payer: Cofinity Commercial |
$61.97
|
| Rate for Payer: Cofinity Commercial |
$78.08
|
| Rate for Payer: Cofinity Commercial |
$95.92
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Cofinity Commercial |
$47.73
|
| Rate for Payer: Cofinity Commercial |
$88.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.82
|
| Rate for Payer: Healthscope Commercial |
$100.39
|
| Rate for Payer: Healthscope Commercial |
$92.59
|
| Rate for Payer: Healthscope Commercial |
$79.68
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.45
|
| Rate for Payer: PHP Commercial |
$87.45
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: PHP Commercial |
$94.81
|
| Rate for Payer: PHP Commercial |
$75.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.54
|
| Rate for Payer: Priority Health SBD |
$64.81
|
| Rate for Payer: Priority Health SBD |
$42.95
|
| Rate for Payer: Priority Health SBD |
$70.27
|
| Rate for Payer: Priority Health SBD |
$55.77
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$135.36
|
|
|
Service Code
|
NDC 55111028130
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.28 |
| Max. Negotiated Rate |
$121.82 |
| Rate for Payer: Aetna Commercial |
$115.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.98
|
| Rate for Payer: Cash Price |
$108.29
|
| Rate for Payer: Cofinity Commercial |
$116.41
|
| Rate for Payer: Cofinity Commercial |
$94.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$94.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.29
|
| Rate for Payer: Healthscope Commercial |
$121.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.06
|
| Rate for Payer: PHP Commercial |
$115.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.98
|
| Rate for Payer: Priority Health SBD |
$85.28
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$336.30
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$211.87 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.59
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$235.41
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$235.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.59
|
| Rate for Payer: Priority Health SBD |
$211.87
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
OP
|
$135.36
|
|
|
Service Code
|
NDC 55111028130
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.14 |
| Max. Negotiated Rate |
$121.82 |
| Rate for Payer: Aetna Commercial |
$115.06
|
| Rate for Payer: Aetna Medicare |
$67.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.98
|
| Rate for Payer: BCBS Complete |
$54.14
|
| Rate for Payer: Cash Price |
$108.29
|
| Rate for Payer: Cofinity Commercial |
$116.41
|
| Rate for Payer: Cofinity Commercial |
$94.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$94.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.29
|
| Rate for Payer: Healthscope Commercial |
$121.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.06
|
| Rate for Payer: PHP Commercial |
$115.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.98
|
| Rate for Payer: Priority Health SBD |
$85.28
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
OP
|
$336.30
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.52 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna Medicare |
$168.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.59
|
| Rate for Payer: BCBS Complete |
$134.52
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$235.41
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$235.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.59
|
| Rate for Payer: Priority Health SBD |
$211.87
|
|
|
LEVOMILNACIPRAN ER 20 MG CAPSULE,24 HR,EXTENDED RELEASE
|
Facility
|
IP
|
$1,810.41
|
|
|
Service Code
|
NDC 00456222030
|
| Hospital Charge Code |
168790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,140.56 |
| Max. Negotiated Rate |
$1,629.37 |
| Rate for Payer: Aetna Commercial |
$1,538.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,176.77
|
| Rate for Payer: Cash Price |
$1,448.33
|
| Rate for Payer: Cofinity Commercial |
$1,267.29
|
| Rate for Payer: Cofinity Commercial |
$1,556.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,267.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,448.33
|
| Rate for Payer: Healthscope Commercial |
$1,629.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,538.85
|
| Rate for Payer: PHP Commercial |
$1,538.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,176.77
|
| Rate for Payer: Priority Health SBD |
$1,140.56
|
|
|
LEVOMILNACIPRAN ER 20 MG CAPSULE,24 HR,EXTENDED RELEASE
|
Facility
|
OP
|
$1,810.41
|
|
|
Service Code
|
NDC 00456222030
|
| Hospital Charge Code |
168790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$724.16 |
| Max. Negotiated Rate |
$1,629.37 |
| Rate for Payer: Aetna Commercial |
$1,538.85
|
| Rate for Payer: Aetna Medicare |
$905.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,176.77
|
| Rate for Payer: BCBS Complete |
$724.16
|
| Rate for Payer: Cash Price |
$1,448.33
|
| Rate for Payer: Cofinity Commercial |
$1,267.29
|
| Rate for Payer: Cofinity Commercial |
$1,556.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,267.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,448.33
|
| Rate for Payer: Healthscope Commercial |
$1,629.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,538.85
|
| Rate for Payer: PHP Commercial |
$1,538.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,176.77
|
| Rate for Payer: Priority Health SBD |
$1,140.56
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE
|
Facility
|
OP
|
$4,076.29
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
181058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,630.52 |
| Max. Negotiated Rate |
$3,668.66 |
| Rate for Payer: Aetna Commercial |
$3,464.85
|
| Rate for Payer: Aetna Commercial |
$3,299.86
|
| Rate for Payer: Aetna Medicare |
$1,941.10
|
| Rate for Payer: Aetna Medicare |
$2,038.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,523.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,649.59
|
| Rate for Payer: BCBS Complete |
$1,630.52
|
| Rate for Payer: BCBS Complete |
$1,552.88
|
| Rate for Payer: Cash Price |
$3,105.75
|
| Rate for Payer: Cash Price |
$3,261.03
|
| Rate for Payer: Cofinity Commercial |
$2,717.53
|
| Rate for Payer: Cofinity Commercial |
$2,853.40
|
| Rate for Payer: Cofinity Commercial |
$3,505.61
|
| Rate for Payer: Cofinity Commercial |
$3,338.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,853.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,717.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,105.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,261.03
|
| Rate for Payer: Healthscope Commercial |
$3,493.97
|
| Rate for Payer: Healthscope Commercial |
$3,668.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,299.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,464.85
|
| Rate for Payer: PHP Commercial |
$3,464.85
|
| Rate for Payer: PHP Commercial |
$3,299.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,523.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,649.59
|
| Rate for Payer: Priority Health SBD |
$2,568.06
|
| Rate for Payer: Priority Health SBD |
$2,445.78
|
|
