Bronson Lakeview Hospital

All Charges

Charge

Type

Setting

Price

LANSOPRAZOLE (FIRST LANSOPRAZOLE) 3 MG/ML ORAL SUSPENSION

Facility

$781.20

Service Code	NDC 65628-080-05
Hospital Charge Code	158811
Hospital Revenue Code	637
Min. Negotiated Rate	$476.45
Max. Negotiated Rate	$703.08
Rate for Payer: Aetna Commercial	$664.02
Rate for Payer: BCBS Trust/PPO	$603.71
Rate for Payer: BCN Commercial	$603.71
Rate for Payer: Cash Price	$624.96
Rate for Payer: Cofinity Commercial	$671.83
Rate for Payer: Encore Health Key Benefits Commercial	$624.96
Rate for Payer: Healthscope Commercial	$703.08
Rate for Payer: Lakeland Regional Health Systems Commercial	$585.90
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$664.02
Rate for Payer: PHP Commercial	$664.02
Rate for Payer: Priority Health Cigna Priority Health	$546.84
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$679.64
Rate for Payer: Priority Health Narrow/Tiered Network	$476.45
Rate for Payer: UHC All Payor (Choice/PPO)	$687.46
Rate for Payer: UHC Core	$652.30
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$585.90

LANSOPRAZOLE (FIRST LANSOPRAZOLE) 3 MG/ML ORAL SUSPENSION

Facility

$25.75

Service Code	NDC 9900-0009-34
Hospital Charge Code	158811
Hospital Revenue Code	637
Min. Negotiated Rate	$15.70
Max. Negotiated Rate	$23.18
Rate for Payer: Aetna Commercial	$21.89
Rate for Payer: BCBS Trust/PPO	$19.90
Rate for Payer: BCN Commercial	$19.90
Rate for Payer: Cash Price	$20.60
Rate for Payer: Cofinity Commercial	$22.14
Rate for Payer: Encore Health Key Benefits Commercial	$20.60
Rate for Payer: Healthscope Commercial	$23.18
Rate for Payer: Lakeland Regional Health Systems Commercial	$19.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.89
Rate for Payer: PHP Commercial	$21.89
Rate for Payer: Priority Health Cigna Priority Health	$18.02
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.40
Rate for Payer: Priority Health Narrow/Tiered Network	$15.70
Rate for Payer: UHC All Payor (Choice/PPO)	$22.66
Rate for Payer: UHC Core	$21.50
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$19.31

LAPAROSCOPY, ABDOMEN, PERITONEUM, AND OMENTUM, DIAGNOSTIC, WITH OR WITHOUT COLLECTION OF SPECIMEN(S) BY BRUSHING OR WASHING (SEPARATE PROCEDURE)

Facility

$3,974.31

Service Code	CPT 49320
Hospital Revenue Code	360
Min. Negotiated Rate	$3,785.06
Max. Negotiated Rate	$3,974.31
Rate for Payer: BCBS Complete	$3,974.31
Rate for Payer: Mclaren Medicaid	$3,785.06
Rate for Payer: Meridian Medicaid	$3,974.31
Rate for Payer: Priority Health Choice Medicaid	$3,785.06

LAPAROSCOPY, SURGICAL, APPENDECTOMY

Facility

$3,974.31

Service Code	CPT 44970
Hospital Revenue Code	360
Min. Negotiated Rate	$3,785.06
Max. Negotiated Rate	$3,974.31
Rate for Payer: BCBS Complete	$3,974.31
Rate for Payer: Mclaren Medicaid	$3,785.06
Rate for Payer: Meridian Medicaid	$3,974.31
Rate for Payer: Priority Health Choice Medicaid	$3,785.06

LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY

Facility

$3,974.31

Service Code	CPT 47562
Hospital Revenue Code	360
Min. Negotiated Rate	$3,785.06
Max. Negotiated Rate	$3,974.31
Rate for Payer: BCBS Complete	$3,974.31
Rate for Payer: Mclaren Medicaid	$3,785.06
Rate for Payer: Meridian Medicaid	$3,974.31
Rate for Payer: Priority Health Choice Medicaid	$3,785.06

LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY

Facility

$3,974.31

Service Code	CPT 47563
Hospital Revenue Code	360
Min. Negotiated Rate	$3,785.06
Max. Negotiated Rate	$3,974.31
Rate for Payer: BCBS Complete	$3,974.31
Rate for Payer: Mclaren Medicaid	$3,785.06
Rate for Payer: Meridian Medicaid	$3,974.31
Rate for Payer: Priority Health Choice Medicaid	$3,785.06

LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA

Facility

$3,974.31

Service Code	CPT 49650
Hospital Revenue Code	360
Min. Negotiated Rate	$3,785.06
Max. Negotiated Rate	$3,974.31
Rate for Payer: BCBS Complete	$3,974.31
Rate for Payer: Mclaren Medicaid	$3,785.06
Rate for Payer: Meridian Medicaid	$3,974.31
Rate for Payer: Priority Health Choice Medicaid	$3,785.06

LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA

Facility

$3,974.31

Service Code	CPT 49651
Hospital Revenue Code	360
Min. Negotiated Rate	$3,785.06
Max. Negotiated Rate	$3,974.31
Rate for Payer: BCBS Complete	$3,974.31
Rate for Payer: Mclaren Medicaid	$3,785.06
Rate for Payer: Meridian Medicaid	$3,974.31
Rate for Payer: Priority Health Choice Medicaid	$3,785.06

LAPAROSCOPY, SURGICAL; WITH FULGURATION OR EXCISION OF LESIONS OF THE OVARY, PELVIC VISCERA, OR PERITONEAL SURFACE BY ANY METHOD

Facility

$3,974.31

Service Code	CPT 58662
Hospital Revenue Code	360
Min. Negotiated Rate	$3,785.06
Max. Negotiated Rate	$3,974.31
Rate for Payer: BCBS Complete	$3,974.31
Rate for Payer: Mclaren Medicaid	$3,785.06
Rate for Payer: Meridian Medicaid	$3,974.31
Rate for Payer: Priority Health Choice Medicaid	$3,785.06

LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)

Facility

$3,974.31

Service Code	CPT 58661
Hospital Revenue Code	360
Min. Negotiated Rate	$3,785.06
Max. Negotiated Rate	$3,974.31
Rate for Payer: BCBS Complete	$3,974.31
Rate for Payer: Mclaren Medicaid	$3,785.06
Rate for Payer: Meridian Medicaid	$3,974.31
Rate for Payer: Priority Health Choice Medicaid	$3,785.06

LATANOPROST 0.005 % EYE DROPS

Facility

$25.92

Service Code	NDC 61314-547-01
Hospital Charge Code	18621
Hospital Revenue Code	637
Min. Negotiated Rate	$15.81
Max. Negotiated Rate	$23.33
Rate for Payer: Aetna Commercial	$22.03
Rate for Payer: BCBS Trust/PPO	$20.03
Rate for Payer: BCN Commercial	$20.03
Rate for Payer: Cash Price	$20.74
Rate for Payer: Cofinity Commercial	$22.29
Rate for Payer: Encore Health Key Benefits Commercial	$20.74
Rate for Payer: Healthscope Commercial	$23.33
Rate for Payer: Lakeland Regional Health Systems Commercial	$19.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.03
Rate for Payer: PHP Commercial	$22.03
Rate for Payer: Priority Health Cigna Priority Health	$18.14
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$22.55
Rate for Payer: Priority Health Narrow/Tiered Network	$15.81
Rate for Payer: UHC All Payor (Choice/PPO)	$22.81
Rate for Payer: UHC Core	$21.64
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$19.44

LATANOPROST 0.005 % EYE DROPS

Facility

$18.63

Service Code	NDC 70069-421-01
Hospital Charge Code	18621
Hospital Revenue Code	637
Min. Negotiated Rate	$11.36
Max. Negotiated Rate	$16.77
Rate for Payer: Aetna Commercial	$15.84
Rate for Payer: BCBS Trust/PPO	$14.40
Rate for Payer: BCN Commercial	$14.40
Rate for Payer: Cash Price	$14.90
Rate for Payer: Cofinity Commercial	$16.02
Rate for Payer: Encore Health Key Benefits Commercial	$14.90
Rate for Payer: Healthscope Commercial	$16.77
Rate for Payer: Lakeland Regional Health Systems Commercial	$13.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15.84
Rate for Payer: PHP Commercial	$15.84
Rate for Payer: Priority Health Cigna Priority Health	$13.04
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$16.21
Rate for Payer: Priority Health Narrow/Tiered Network	$11.36
Rate for Payer: UHC All Payor (Choice/PPO)	$16.39
Rate for Payer: UHC Core	$15.56
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$13.97

LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER

Facility

$155.35

Service Code	NDC 63402-510-01
Hospital Charge Code	43472
Hospital Revenue Code	250
Min. Negotiated Rate	$94.75
Max. Negotiated Rate	$139.82
Rate for Payer: Aetna Commercial	$132.05
Rate for Payer: BCBS Trust/PPO	$120.05
Rate for Payer: BCN Commercial	$120.05
Rate for Payer: Cash Price	$124.28
Rate for Payer: Cofinity Commercial	$133.60
Rate for Payer: Encore Health Key Benefits Commercial	$124.28
Rate for Payer: Healthscope Commercial	$139.82
Rate for Payer: Lakeland Regional Health Systems Commercial	$116.51
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$132.05
Rate for Payer: PHP Commercial	$132.05
Rate for Payer: Priority Health Cigna Priority Health	$108.74
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$135.15
Rate for Payer: Priority Health Narrow/Tiered Network	$94.75
Rate for Payer: UHC All Payor (Choice/PPO)	$136.71
Rate for Payer: UHC Core	$129.72
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$116.51

LEVETIRACETAM 250 MG TABLET

Facility

$263.20

Service Code	NDC 0904-6051-61
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$160.53
Max. Negotiated Rate	$236.88
Rate for Payer: Aetna Commercial	$223.72
Rate for Payer: BCBS Trust/PPO	$203.40
Rate for Payer: BCN Commercial	$203.40
Rate for Payer: Cash Price	$210.56
Rate for Payer: Cofinity Commercial	$226.35
Rate for Payer: Encore Health Key Benefits Commercial	$210.56
Rate for Payer: Healthscope Commercial	$236.88
Rate for Payer: Lakeland Regional Health Systems Commercial	$197.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$223.72
Rate for Payer: PHP Commercial	$223.72
Rate for Payer: Priority Health Cigna Priority Health	$184.24
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$228.98
Rate for Payer: Priority Health Narrow/Tiered Network	$160.53
Rate for Payer: UHC All Payor (Choice/PPO)	$231.62
Rate for Payer: UHC Core	$219.77
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$197.40

LEVETIRACETAM 250 MG TABLET

Facility

$284.35

Service Code	NDC 0904-7123-61
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$173.43
Max. Negotiated Rate	$255.92
Rate for Payer: Aetna Commercial	$241.70
Rate for Payer: BCBS Trust/PPO	$219.75
Rate for Payer: BCN Commercial	$219.75
Rate for Payer: Cash Price	$227.48
Rate for Payer: Cofinity Commercial	$244.54
Rate for Payer: Encore Health Key Benefits Commercial	$227.48
Rate for Payer: Healthscope Commercial	$255.92
Rate for Payer: Lakeland Regional Health Systems Commercial	$213.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$241.70
Rate for Payer: PHP Commercial	$241.70
Rate for Payer: Priority Health Cigna Priority Health	$199.04
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$247.38
Rate for Payer: Priority Health Narrow/Tiered Network	$173.43
Rate for Payer: UHC All Payor (Choice/PPO)	$250.23
Rate for Payer: UHC Core	$237.43
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$213.26

LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION

Facility

$14.36

Service Code	HCPCS J1953
Hospital Charge Code	77195
Hospital Revenue Code	636
Min. Negotiated Rate	$8.76
Max. Negotiated Rate	$12.92
Rate for Payer: Aetna Commercial	$12.21
Rate for Payer: Aetna Commercial	$22.92
Rate for Payer: Aetna Commercial	$13.06
Rate for Payer: Aetna Commercial	$17.52
Rate for Payer: Aetna Commercial	$14.98
Rate for Payer: BCBS Trust/PPO	$15.93
Rate for Payer: BCBS Trust/PPO	$11.88
Rate for Payer: BCBS Trust/PPO	$11.10
Rate for Payer: BCBS Trust/PPO	$20.84
Rate for Payer: BCBS Trust/PPO	$13.62
Rate for Payer: BCN Commercial	$15.93
Rate for Payer: BCN Commercial	$13.62
Rate for Payer: BCN Commercial	$11.10
Rate for Payer: BCN Commercial	$11.88
Rate for Payer: BCN Commercial	$20.84
Rate for Payer: Cash Price	$12.30
Rate for Payer: Cash Price	$16.49
Rate for Payer: Cash Price	$11.49
Rate for Payer: Cash Price	$21.58
Rate for Payer: Cash Price	$14.10
Rate for Payer: Cofinity Commercial	$12.35
Rate for Payer: Cofinity Commercial	$23.19
Rate for Payer: Cofinity Commercial	$13.22
Rate for Payer: Cofinity Commercial	$17.72
Rate for Payer: Cofinity Commercial	$15.15
Rate for Payer: Encore Health Key Benefits Commercial	$16.49
Rate for Payer: Encore Health Key Benefits Commercial	$12.30
Rate for Payer: Encore Health Key Benefits Commercial	$11.49
Rate for Payer: Encore Health Key Benefits Commercial	$21.58
Rate for Payer: Encore Health Key Benefits Commercial	$14.10
Rate for Payer: Healthscope Commercial	$24.27
Rate for Payer: Healthscope Commercial	$13.83
Rate for Payer: Healthscope Commercial	$12.92
Rate for Payer: Healthscope Commercial	$18.55
Rate for Payer: Healthscope Commercial	$15.86
Rate for Payer: Lakeland Regional Health Systems Commercial	$13.22
Rate for Payer: Lakeland Regional Health Systems Commercial	$10.77
Rate for Payer: Lakeland Regional Health Systems Commercial	$11.53
Rate for Payer: Lakeland Regional Health Systems Commercial	$15.46
Rate for Payer: Lakeland Regional Health Systems Commercial	$20.23
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.52
Rate for Payer: PHP Commercial	$22.92
Rate for Payer: PHP Commercial	$17.52
Rate for Payer: PHP Commercial	$14.98
Rate for Payer: PHP Commercial	$12.21
Rate for Payer: PHP Commercial	$13.06
Rate for Payer: Priority Health Cigna Priority Health	$18.88
Rate for Payer: Priority Health Cigna Priority Health	$10.76
Rate for Payer: Priority Health Cigna Priority Health	$14.43
Rate for Payer: Priority Health Cigna Priority Health	$10.05
Rate for Payer: Priority Health Cigna Priority Health	$12.33
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$17.93
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$12.49
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$23.46
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$13.37
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$15.33
Rate for Payer: Priority Health Narrow/Tiered Network	$8.76
Rate for Payer: Priority Health Narrow/Tiered Network	$10.75
Rate for Payer: Priority Health Narrow/Tiered Network	$9.37
Rate for Payer: Priority Health Narrow/Tiered Network	$12.57
Rate for Payer: Priority Health Narrow/Tiered Network	$16.45
Rate for Payer: UHC All Payor (Choice/PPO)	$23.73
Rate for Payer: UHC All Payor (Choice/PPO)	$15.51
Rate for Payer: UHC All Payor (Choice/PPO)	$13.53
Rate for Payer: UHC All Payor (Choice/PPO)	$18.14
Rate for Payer: UHC All Payor (Choice/PPO)	$12.64
Rate for Payer: UHC Core	$11.99
Rate for Payer: UHC Core	$17.21
Rate for Payer: UHC Core	$12.83
Rate for Payer: UHC Core	$14.71
Rate for Payer: UHC Core	$22.52
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$11.53
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$15.46
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$20.23
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$13.22
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$10.77

LEVETIRACETAM 500 MG TABLET

Facility

$310.20

Service Code	NDC 0904-7124-61
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$189.19
Max. Negotiated Rate	$279.18
Rate for Payer: Aetna Commercial	$263.67
Rate for Payer: BCBS Trust/PPO	$239.72
Rate for Payer: BCN Commercial	$239.72
Rate for Payer: Cash Price	$248.16
Rate for Payer: Cofinity Commercial	$266.77
Rate for Payer: Encore Health Key Benefits Commercial	$248.16
Rate for Payer: Healthscope Commercial	$279.18
Rate for Payer: Lakeland Regional Health Systems Commercial	$232.65
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$263.67
Rate for Payer: PHP Commercial	$263.67
Rate for Payer: Priority Health Cigna Priority Health	$217.14
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$269.87
Rate for Payer: Priority Health Narrow/Tiered Network	$189.19
Rate for Payer: UHC All Payor (Choice/PPO)	$272.98
Rate for Payer: UHC Core	$259.02
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$232.65

LEVETIRACETAM 500 MG TABLET

Facility

$279.65

Service Code	NDC 0904-6052-61
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$170.56
Max. Negotiated Rate	$251.68
Rate for Payer: Aetna Commercial	$237.70
Rate for Payer: BCBS Trust/PPO	$216.11
Rate for Payer: BCN Commercial	$216.11
Rate for Payer: Cash Price	$223.72
Rate for Payer: Cofinity Commercial	$240.50
Rate for Payer: Encore Health Key Benefits Commercial	$223.72
Rate for Payer: Healthscope Commercial	$251.68
Rate for Payer: Lakeland Regional Health Systems Commercial	$209.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$237.70
Rate for Payer: PHP Commercial	$237.70
Rate for Payer: Priority Health Cigna Priority Health	$195.76
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$243.30
Rate for Payer: Priority Health Narrow/Tiered Network	$170.56
Rate for Payer: UHC All Payor (Choice/PPO)	$246.09
Rate for Payer: UHC Core	$233.51
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$209.74

LEVETIRACETAM 500 MG TABLET

Facility

$257.45

Service Code	NDC 51079-821-20
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$157.02
Max. Negotiated Rate	$231.70
Rate for Payer: Aetna Commercial	$218.83
Rate for Payer: BCBS Trust/PPO	$198.96
Rate for Payer: BCN Commercial	$198.96
Rate for Payer: Cash Price	$205.96
Rate for Payer: Cofinity Commercial	$221.41
Rate for Payer: Encore Health Key Benefits Commercial	$205.96
Rate for Payer: Healthscope Commercial	$231.70
Rate for Payer: Lakeland Regional Health Systems Commercial	$193.09
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$218.83
Rate for Payer: PHP Commercial	$218.83
Rate for Payer: Priority Health Cigna Priority Health	$180.22
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$223.98
Rate for Payer: Priority Health Narrow/Tiered Network	$157.02
Rate for Payer: UHC All Payor (Choice/PPO)	$226.56
Rate for Payer: UHC Core	$214.97
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$193.09

LEVETIRACETAM 500 MG TABLET

Facility

$2.58

Service Code	NDC 51079-821-01
Hospital Charge Code	26817
Hospital Revenue Code	637
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.32
Rate for Payer: Aetna Commercial	$2.19
Rate for Payer: BCBS Trust/PPO	$1.99
Rate for Payer: BCN Commercial	$1.99
Rate for Payer: Cash Price	$2.06
Rate for Payer: Cofinity Commercial	$2.22
Rate for Payer: Encore Health Key Benefits Commercial	$2.06
Rate for Payer: Healthscope Commercial	$2.32
Rate for Payer: Lakeland Regional Health Systems Commercial	$1.94
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.19
Rate for Payer: PHP Commercial	$2.19
Rate for Payer: Priority Health Cigna Priority Health	$1.81
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2.24
Rate for Payer: Priority Health Narrow/Tiered Network	$1.57
Rate for Payer: UHC All Payor (Choice/PPO)	$2.27
Rate for Payer: UHC Core	$2.15
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$1.94

LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK

Facility

$73.42

Service Code	HCPCS J1956
Hospital Charge Code	112929
Hospital Revenue Code	636
Min. Negotiated Rate	$44.78
Max. Negotiated Rate	$66.08
Rate for Payer: Aetna Commercial	$62.41
Rate for Payer: Aetna Commercial	$53.30
Rate for Payer: BCBS Trust/PPO	$56.74
Rate for Payer: BCBS Trust/PPO	$48.46
Rate for Payer: BCN Commercial	$56.74
Rate for Payer: BCN Commercial	$48.46
Rate for Payer: Cash Price	$58.74
Rate for Payer: Cash Price	$50.17
Rate for Payer: Cofinity Commercial	$53.93
Rate for Payer: Cofinity Commercial	$63.14
Rate for Payer: Encore Health Key Benefits Commercial	$58.74
Rate for Payer: Encore Health Key Benefits Commercial	$50.17
Rate for Payer: Healthscope Commercial	$56.44
Rate for Payer: Healthscope Commercial	$66.08
Rate for Payer: Lakeland Regional Health Systems Commercial	$55.06
Rate for Payer: Lakeland Regional Health Systems Commercial	$47.03
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$62.41
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$53.30
Rate for Payer: PHP Commercial	$62.41
Rate for Payer: PHP Commercial	$53.30
Rate for Payer: Priority Health Cigna Priority Health	$43.90
Rate for Payer: Priority Health Cigna Priority Health	$51.39
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$54.56
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$63.88
Rate for Payer: Priority Health Narrow/Tiered Network	$38.25
Rate for Payer: Priority Health Narrow/Tiered Network	$44.78
Rate for Payer: UHC All Payor (Choice/PPO)	$55.18
Rate for Payer: UHC All Payor (Choice/PPO)	$64.61
Rate for Payer: UHC Core	$52.36
Rate for Payer: UHC Core	$61.31
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$47.03
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$55.06

LEVOFLOXACIN 250 MG TABLET

Facility

$411.25

Service Code	NDC 0904-6351-61
Hospital Charge Code	18918
Hospital Revenue Code	637
Min. Negotiated Rate	$250.82
Max. Negotiated Rate	$370.12
Rate for Payer: Aetna Commercial	$349.56
Rate for Payer: BCBS Trust/PPO	$317.81
Rate for Payer: BCN Commercial	$317.81
Rate for Payer: Cash Price	$329.00
Rate for Payer: Cofinity Commercial	$353.68
Rate for Payer: Encore Health Key Benefits Commercial	$329.00
Rate for Payer: Healthscope Commercial	$370.12
Rate for Payer: Lakeland Regional Health Systems Commercial	$308.44
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$349.56
Rate for Payer: PHP Commercial	$349.56
Rate for Payer: Priority Health Cigna Priority Health	$287.88
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$357.79
Rate for Payer: Priority Health Narrow/Tiered Network	$250.82
Rate for Payer: UHC All Payor (Choice/PPO)	$361.90
Rate for Payer: UHC Core	$343.39
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$308.44

LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK

Facility

$73.42

Service Code	HCPCS J1956
Hospital Charge Code	18924
Hospital Revenue Code	636
Min. Negotiated Rate	$44.78
Max. Negotiated Rate	$66.08
Rate for Payer: Aetna Commercial	$62.41
Rate for Payer: BCBS Trust/PPO	$56.74
Rate for Payer: BCN Commercial	$56.74
Rate for Payer: Cash Price	$58.74
Rate for Payer: Cofinity Commercial	$63.14
Rate for Payer: Encore Health Key Benefits Commercial	$58.74
Rate for Payer: Healthscope Commercial	$66.08
Rate for Payer: Lakeland Regional Health Systems Commercial	$55.06
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$62.41
Rate for Payer: PHP Commercial	$62.41
Rate for Payer: Priority Health Cigna Priority Health	$51.39
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$63.88
Rate for Payer: Priority Health Narrow/Tiered Network	$44.78
Rate for Payer: UHC All Payor (Choice/PPO)	$64.61
Rate for Payer: UHC Core	$61.31
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$55.06

LEVOFLOXACIN 500 MG TABLET

Facility

$213.75

Service Code	NDC 0904-6352-61
Hospital Charge Code	18919
Hospital Revenue Code	637
Min. Negotiated Rate	$130.37
Max. Negotiated Rate	$192.38
Rate for Payer: Aetna Commercial	$181.69
Rate for Payer: BCBS Trust/PPO	$165.19
Rate for Payer: BCN Commercial	$165.19
Rate for Payer: Cash Price	$171.00
Rate for Payer: Cofinity Commercial	$183.82
Rate for Payer: Encore Health Key Benefits Commercial	$171.00
Rate for Payer: Healthscope Commercial	$192.38
Rate for Payer: Lakeland Regional Health Systems Commercial	$160.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$181.69
Rate for Payer: PHP Commercial	$181.69
Rate for Payer: Priority Health Cigna Priority Health	$149.62
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$185.96
Rate for Payer: Priority Health Narrow/Tiered Network	$130.37
Rate for Payer: UHC All Payor (Choice/PPO)	$188.10
Rate for Payer: UHC Core	$178.48
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$160.31

LEVOFLOXACIN 500 MG TABLET

Facility

$458.85

Service Code	NDC 68084-482-11
Hospital Charge Code	18919
Hospital Revenue Code	637
Min. Negotiated Rate	$279.85
Max. Negotiated Rate	$412.96
Rate for Payer: Aetna Commercial	$390.02
Rate for Payer: BCBS Trust/PPO	$354.60
Rate for Payer: BCN Commercial	$354.60
Rate for Payer: Cash Price	$367.08
Rate for Payer: Cofinity Commercial	$394.61
Rate for Payer: Encore Health Key Benefits Commercial	$367.08
Rate for Payer: Healthscope Commercial	$412.96
Rate for Payer: Lakeland Regional Health Systems Commercial	$344.14
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$390.02
Rate for Payer: PHP Commercial	$390.02
Rate for Payer: Priority Health Cigna Priority Health	$321.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$399.20
Rate for Payer: Priority Health Narrow/Tiered Network	$279.85
Rate for Payer: UHC All Payor (Choice/PPO)	$403.79
Rate for Payer: UHC Core	$383.14
Rate for Payer: Van Buren County Sheriff Dept. Commercial	$344.14

Know your out-of-pocket cost for care.

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