|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$57.42
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.12 |
| Max. Negotiated Rate |
$51.68 |
| Rate for Payer: Aetna Commercial |
$48.81
|
| Rate for Payer: Aetna Commercial |
$73.89
|
| Rate for Payer: Aetna Medicare |
$22.60
|
| Rate for Payer: Aetna Medicare |
$14.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27.17
|
| Rate for Payer: BCBS Complete |
$10.63
|
| Rate for Payer: BCBS Complete |
$16.09
|
| Rate for Payer: BCBS MAPPO |
$14.36
|
| Rate for Payer: BCBS MAPPO |
$21.73
|
| Rate for Payer: BCBS Trust/PPO |
$47.20
|
| Rate for Payer: BCBS Trust/PPO |
$71.47
|
| Rate for Payer: BCN Commercial |
$71.47
|
| Rate for Payer: BCN Commercial |
$47.20
|
| Rate for Payer: BCN Medicare Advantage |
$21.73
|
| Rate for Payer: BCN Medicare Advantage |
$14.36
|
| Rate for Payer: Cash Price |
$45.94
|
| Rate for Payer: Cash Price |
$69.54
|
| Rate for Payer: Cofinity Commercial |
$49.38
|
| Rate for Payer: Cofinity Commercial |
$74.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.94
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$21.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14.36
|
| Rate for Payer: Healthscope Commercial |
$51.68
|
| Rate for Payer: Healthscope Commercial |
$78.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.20
|
| Rate for Payer: Mclaren Medicaid |
$15.33
|
| Rate for Payer: Mclaren Medicaid |
$10.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$22.82
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$15.07
|
| Rate for Payer: Meridian Medicaid |
$10.63
|
| Rate for Payer: Meridian Medicaid |
$16.09
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.51
|
| Rate for Payer: Molina Medicare/Medicaid |
$23.91
|
| Rate for Payer: Molina Medicare/Medicaid |
$15.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.81
|
| Rate for Payer: Nomi Health Commercial |
$71.28
|
| Rate for Payer: Nomi Health Commercial |
$47.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$65.20
|
| Rate for Payer: PACE Senior Care Partners |
$20.65
|
| Rate for Payer: PACE Senior Care Partners |
$13.64
|
| Rate for Payer: PACE SWMI |
$21.73
|
| Rate for Payer: PACE SWMI |
$14.36
|
| Rate for Payer: PHP Commercial |
$48.81
|
| Rate for Payer: PHP Commercial |
$73.89
|
| Rate for Payer: PHP Medicare Advantage |
$14.36
|
| Rate for Payer: PHP Medicare Advantage |
$21.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$15.33
|
| Rate for Payer: Priority Health Choice Medicaid |
$10.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$75.63
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$49.96
|
| Rate for Payer: Priority Health Medicare |
$21.95
|
| Rate for Payer: Priority Health Medicare |
$14.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$39.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$60.50
|
| Rate for Payer: Railroad Medicare Medicare |
$14.36
|
| Rate for Payer: Railroad Medicare Medicare |
$21.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$76.50
|
| Rate for Payer: UHC Core |
$72.59
|
| Rate for Payer: UHC Core |
$47.95
|
| Rate for Payer: UHC Exchange |
$21.73
|
| Rate for Payer: UHC Exchange |
$14.36
|
| Rate for Payer: UHC Medicaid |
$15.33
|
| Rate for Payer: UHC Medicaid |
$10.12
|
| Rate for Payer: UHC Medicare Advantage |
$14.36
|
| Rate for Payer: UHC Medicare Advantage |
$21.73
|
| Rate for Payer: UHCCP Medicaid |
$10.12
|
| Rate for Payer: UHCCP Medicaid |
$15.33
|
| Rate for Payer: VA VA |
$14.36
|
| Rate for Payer: VA VA |
$21.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.06
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$57.42
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$39.96 |
| Max. Negotiated Rate |
$51.68 |
| Rate for Payer: Aetna Commercial |
$48.81
|
| Rate for Payer: Aetna Commercial |
$73.89
|
| Rate for Payer: BCBS Trust/PPO |
$47.42
|
| Rate for Payer: BCBS Trust/PPO |
$71.80
|
| Rate for Payer: BCN Commercial |
$47.42
|
| Rate for Payer: BCN Commercial |
$71.80
|
| Rate for Payer: Cash Price |
$45.94
|
| Rate for Payer: Cash Price |
$69.54
|
| Rate for Payer: Cofinity Commercial |
$74.76
|
| Rate for Payer: Cofinity Commercial |
$49.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.94
|
| Rate for Payer: Healthscope Commercial |
$51.68
|
| Rate for Payer: Healthscope Commercial |
$78.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$43.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$65.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.89
|
| Rate for Payer: Nomi Health Commercial |
$47.08
|
| Rate for Payer: Nomi Health Commercial |
$71.28
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$65.20
|
| Rate for Payer: PHP Commercial |
$73.89
|
| Rate for Payer: PHP Commercial |
$48.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$75.63
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$49.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$39.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$60.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$76.50
|
| Rate for Payer: UHC Core |
$47.95
|
| Rate for Payer: UHC Core |
$72.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$43.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$65.20
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
OP
|
$195.70
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.50 |
| Max. Negotiated Rate |
$176.13 |
| Rate for Payer: Aetna Commercial |
$166.34
|
| Rate for Payer: Aetna Medicare |
$50.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$61.16
|
| Rate for Payer: Amish Plain Church Group Commercial |
$61.16
|
| Rate for Payer: BCBS Complete |
$36.22
|
| Rate for Payer: BCBS MAPPO |
$48.92
|
| Rate for Payer: BCBS Trust/PPO |
$160.88
|
| Rate for Payer: BCN Commercial |
$160.88
|
| Rate for Payer: BCN Medicare Advantage |
$48.92
|
| Rate for Payer: Cash Price |
$156.56
|
| Rate for Payer: Cofinity Commercial |
$168.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.92
|
| Rate for Payer: Healthscope Commercial |
$176.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.78
|
| Rate for Payer: Mclaren Medicaid |
$34.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$51.37
|
| Rate for Payer: Meridian Medicaid |
$36.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$53.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.34
|
| Rate for Payer: Nomi Health Commercial |
$160.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.78
|
| Rate for Payer: PACE Senior Care Partners |
$46.48
|
| Rate for Payer: PACE SWMI |
$48.92
|
| Rate for Payer: PHP Commercial |
$166.34
|
| Rate for Payer: PHP Medicare Advantage |
$48.92
|
| Rate for Payer: Priority Health Choice Medicaid |
$34.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$170.26
|
| Rate for Payer: Priority Health Medicare |
$49.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$136.21
|
| Rate for Payer: Railroad Medicare Medicare |
$48.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$172.22
|
| Rate for Payer: UHC Core |
$163.41
|
| Rate for Payer: UHC Exchange |
$48.92
|
| Rate for Payer: UHC Medicaid |
$34.50
|
| Rate for Payer: UHC Medicare Advantage |
$48.92
|
| Rate for Payer: UHCCP Medicaid |
$34.50
|
| Rate for Payer: VA VA |
$48.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.78
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
IP
|
$195.70
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.21 |
| Max. Negotiated Rate |
$176.13 |
| Rate for Payer: Aetna Commercial |
$166.34
|
| Rate for Payer: BCBS Trust/PPO |
$161.63
|
| Rate for Payer: BCN Commercial |
$161.63
|
| Rate for Payer: Cash Price |
$156.56
|
| Rate for Payer: Cofinity Commercial |
$168.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.56
|
| Rate for Payer: Healthscope Commercial |
$176.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.34
|
| Rate for Payer: Nomi Health Commercial |
$160.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.78
|
| Rate for Payer: PHP Commercial |
$166.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$170.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$136.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$172.22
|
| Rate for Payer: UHC Core |
$163.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.78
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$79.75
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.51 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: BCBS Trust/PPO |
$65.87
|
| Rate for Payer: BCN Commercial |
$65.87
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Healthscope Commercial |
$71.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Nomi Health Commercial |
$65.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.81
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$69.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$55.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.18
|
| Rate for Payer: UHC Core |
$66.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.81
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$79.75
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.06 |
| Max. Negotiated Rate |
$71.78 |
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: Aetna Medicare |
$20.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$24.92
|
| Rate for Payer: Amish Plain Church Group Commercial |
$24.92
|
| Rate for Payer: BCBS Complete |
$14.76
|
| Rate for Payer: BCBS MAPPO |
$19.94
|
| Rate for Payer: BCBS Trust/PPO |
$65.56
|
| Rate for Payer: BCN Commercial |
$65.56
|
| Rate for Payer: BCN Medicare Advantage |
$19.94
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$19.94
|
| Rate for Payer: Healthscope Commercial |
$71.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.81
|
| Rate for Payer: Mclaren Medicaid |
$14.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$20.93
|
| Rate for Payer: Meridian Medicaid |
$14.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.93
|
| Rate for Payer: Molina Medicare/Medicaid |
$21.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Nomi Health Commercial |
$65.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.81
|
| Rate for Payer: PACE Senior Care Partners |
$18.94
|
| Rate for Payer: PACE SWMI |
$19.94
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: PHP Medicare Advantage |
$19.94
|
| Rate for Payer: Priority Health Choice Medicaid |
$14.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$69.38
|
| Rate for Payer: Priority Health Medicare |
$20.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$55.51
|
| Rate for Payer: Railroad Medicare Medicare |
$19.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.18
|
| Rate for Payer: UHC Core |
$66.59
|
| Rate for Payer: UHC Exchange |
$19.94
|
| Rate for Payer: UHC Medicaid |
$14.06
|
| Rate for Payer: UHC Medicare Advantage |
$19.94
|
| Rate for Payer: UHCCP Medicaid |
$14.06
|
| Rate for Payer: VA VA |
$19.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.81
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
IP
|
$221.35
|
|
|
Service Code
|
NDC 00904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.06 |
| Max. Negotiated Rate |
$199.22 |
| Rate for Payer: Aetna Commercial |
$188.15
|
| Rate for Payer: BCBS Trust/PPO |
$182.81
|
| Rate for Payer: BCN Commercial |
$182.81
|
| Rate for Payer: Cash Price |
$177.08
|
| Rate for Payer: Cofinity Commercial |
$190.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.08
|
| Rate for Payer: Healthscope Commercial |
$199.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.15
|
| Rate for Payer: Nomi Health Commercial |
$181.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$166.01
|
| Rate for Payer: PHP Commercial |
$188.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$192.57
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$154.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$194.79
|
| Rate for Payer: UHC Core |
$184.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.01
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
OP
|
$221.35
|
|
|
Service Code
|
NDC 00904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.02 |
| Max. Negotiated Rate |
$199.22 |
| Rate for Payer: Aetna Commercial |
$188.15
|
| Rate for Payer: Aetna Medicare |
$57.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$69.17
|
| Rate for Payer: Amish Plain Church Group Commercial |
$69.17
|
| Rate for Payer: BCBS Complete |
$40.97
|
| Rate for Payer: BCBS MAPPO |
$55.34
|
| Rate for Payer: BCBS Trust/PPO |
$181.97
|
| Rate for Payer: BCN Commercial |
$181.97
|
| Rate for Payer: BCN Medicare Advantage |
$55.34
|
| Rate for Payer: Cash Price |
$177.08
|
| Rate for Payer: Cofinity Commercial |
$190.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$177.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$55.34
|
| Rate for Payer: Healthscope Commercial |
$199.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$166.01
|
| Rate for Payer: Mclaren Medicaid |
$39.02
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$58.10
|
| Rate for Payer: Meridian Medicaid |
$40.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.64
|
| Rate for Payer: Molina Medicare/Medicaid |
$60.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$188.15
|
| Rate for Payer: Nomi Health Commercial |
$181.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$166.01
|
| Rate for Payer: PACE Senior Care Partners |
$52.57
|
| Rate for Payer: PACE SWMI |
$55.34
|
| Rate for Payer: PHP Commercial |
$188.15
|
| Rate for Payer: PHP Medicare Advantage |
$55.34
|
| Rate for Payer: Priority Health Choice Medicaid |
$39.02
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$192.57
|
| Rate for Payer: Priority Health Medicare |
$55.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$154.06
|
| Rate for Payer: Railroad Medicare Medicare |
$55.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$194.79
|
| Rate for Payer: UHC Core |
$184.83
|
| Rate for Payer: UHC Exchange |
$55.34
|
| Rate for Payer: UHC Medicaid |
$39.02
|
| Rate for Payer: UHC Medicare Advantage |
$55.34
|
| Rate for Payer: UHCCP Medicaid |
$39.02
|
| Rate for Payer: VA VA |
$55.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$166.01
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$111.54
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.66 |
| Max. Negotiated Rate |
$100.39 |
| Rate for Payer: Aetna Commercial |
$94.81
|
| Rate for Payer: Aetna Commercial |
$77.28
|
| Rate for Payer: Aetna Commercial |
$50.85
|
| Rate for Payer: Aetna Medicare |
$23.64
|
| Rate for Payer: Aetna Medicare |
$29.00
|
| Rate for Payer: Aetna Medicare |
$15.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$28.41
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$34.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$34.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$28.41
|
| Rate for Payer: BCBS Complete |
$11.07
|
| Rate for Payer: BCBS Complete |
$20.65
|
| Rate for Payer: BCBS Complete |
$16.83
|
| Rate for Payer: BCBS MAPPO |
$22.73
|
| Rate for Payer: BCBS MAPPO |
$27.89
|
| Rate for Payer: BCBS MAPPO |
$14.96
|
| Rate for Payer: BCBS Trust/PPO |
$91.70
|
| Rate for Payer: BCBS Trust/PPO |
$49.18
|
| Rate for Payer: BCBS Trust/PPO |
$74.75
|
| Rate for Payer: BCN Commercial |
$49.18
|
| Rate for Payer: BCN Commercial |
$74.75
|
| Rate for Payer: BCN Commercial |
$91.70
|
| Rate for Payer: BCN Medicare Advantage |
$22.73
|
| Rate for Payer: BCN Medicare Advantage |
$14.96
|
| Rate for Payer: BCN Medicare Advantage |
$27.89
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cofinity Commercial |
$95.92
|
| Rate for Payer: Cofinity Commercial |
$51.45
|
| Rate for Payer: Cofinity Commercial |
$78.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.73
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27.89
|
| Rate for Payer: Healthscope Commercial |
$53.84
|
| Rate for Payer: Healthscope Commercial |
$100.39
|
| Rate for Payer: Healthscope Commercial |
$81.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.87
|
| Rate for Payer: Mclaren Medicaid |
$19.66
|
| Rate for Payer: Mclaren Medicaid |
$16.03
|
| Rate for Payer: Mclaren Medicaid |
$10.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$29.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$15.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.87
|
| Rate for Payer: Meridian Medicaid |
$16.83
|
| Rate for Payer: Meridian Medicaid |
$20.65
|
| Rate for Payer: Meridian Medicaid |
$11.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$32.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.14
|
| Rate for Payer: Molina Medicare/Medicaid |
$25.00
|
| Rate for Payer: Molina Medicare/Medicaid |
$16.45
|
| Rate for Payer: Molina Medicare/Medicaid |
$30.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.85
|
| Rate for Payer: Nomi Health Commercial |
$74.55
|
| Rate for Payer: Nomi Health Commercial |
$49.05
|
| Rate for Payer: Nomi Health Commercial |
$91.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$83.66
|
| Rate for Payer: PACE Senior Care Partners |
$14.21
|
| Rate for Payer: PACE Senior Care Partners |
$26.49
|
| Rate for Payer: PACE Senior Care Partners |
$21.59
|
| Rate for Payer: PACE SWMI |
$22.73
|
| Rate for Payer: PACE SWMI |
$14.96
|
| Rate for Payer: PACE SWMI |
$27.89
|
| Rate for Payer: PHP Commercial |
$94.81
|
| Rate for Payer: PHP Commercial |
$77.28
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: PHP Medicare Advantage |
$14.96
|
| Rate for Payer: PHP Medicare Advantage |
$27.89
|
| Rate for Payer: PHP Medicare Advantage |
$22.73
|
| Rate for Payer: Priority Health Choice Medicaid |
$19.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$10.55
|
| Rate for Payer: Priority Health Choice Medicaid |
$16.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$52.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$97.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$79.10
|
| Rate for Payer: Priority Health Medicare |
$22.96
|
| Rate for Payer: Priority Health Medicare |
$15.10
|
| Rate for Payer: Priority Health Medicare |
$28.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$41.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$63.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$77.63
|
| Rate for Payer: Railroad Medicare Medicare |
$14.96
|
| Rate for Payer: Railroad Medicare Medicare |
$22.73
|
| Rate for Payer: Railroad Medicare Medicare |
$27.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$52.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.16
|
| Rate for Payer: UHC Core |
$93.14
|
| Rate for Payer: UHC Core |
$75.92
|
| Rate for Payer: UHC Core |
$49.95
|
| Rate for Payer: UHC Exchange |
$22.73
|
| Rate for Payer: UHC Exchange |
$14.96
|
| Rate for Payer: UHC Exchange |
$27.89
|
| Rate for Payer: UHC Medicaid |
$19.66
|
| Rate for Payer: UHC Medicaid |
$16.03
|
| Rate for Payer: UHC Medicaid |
$10.55
|
| Rate for Payer: UHC Medicare Advantage |
$14.96
|
| Rate for Payer: UHC Medicare Advantage |
$27.89
|
| Rate for Payer: UHC Medicare Advantage |
$22.73
|
| Rate for Payer: UHCCP Medicaid |
$10.55
|
| Rate for Payer: UHCCP Medicaid |
$19.66
|
| Rate for Payer: UHCCP Medicaid |
$16.03
|
| Rate for Payer: VA VA |
$27.89
|
| Rate for Payer: VA VA |
$22.73
|
| Rate for Payer: VA VA |
$14.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.19
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$111.54
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$77.63 |
| Max. Negotiated Rate |
$100.39 |
| Rate for Payer: Aetna Commercial |
$94.81
|
| Rate for Payer: Aetna Commercial |
$50.85
|
| Rate for Payer: Aetna Commercial |
$77.28
|
| Rate for Payer: BCBS Trust/PPO |
$49.41
|
| Rate for Payer: BCBS Trust/PPO |
$92.12
|
| Rate for Payer: BCBS Trust/PPO |
$75.09
|
| Rate for Payer: BCN Commercial |
$49.41
|
| Rate for Payer: BCN Commercial |
$92.12
|
| Rate for Payer: BCN Commercial |
$75.09
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cofinity Commercial |
$78.19
|
| Rate for Payer: Cofinity Commercial |
$51.45
|
| Rate for Payer: Cofinity Commercial |
$95.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.74
|
| Rate for Payer: Healthscope Commercial |
$53.84
|
| Rate for Payer: Healthscope Commercial |
$100.39
|
| Rate for Payer: Healthscope Commercial |
$81.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.28
|
| Rate for Payer: Nomi Health Commercial |
$91.46
|
| Rate for Payer: Nomi Health Commercial |
$49.05
|
| Rate for Payer: Nomi Health Commercial |
$74.55
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$83.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.19
|
| Rate for Payer: PHP Commercial |
$94.81
|
| Rate for Payer: PHP Commercial |
$77.28
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$79.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$52.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$97.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$41.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$63.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$77.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$52.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.16
|
| Rate for Payer: UHC Core |
$93.14
|
| Rate for Payer: UHC Core |
$75.92
|
| Rate for Payer: UHC Core |
$49.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.87
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$385.70
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.45 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna Commercial |
$327.85
|
| Rate for Payer: BCBS Trust/PPO |
$318.55
|
| Rate for Payer: BCN Commercial |
$318.55
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.85
|
| Rate for Payer: Nomi Health Commercial |
$316.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.27
|
| Rate for Payer: PHP Commercial |
$327.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$335.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$268.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$339.42
|
| Rate for Payer: UHC Core |
$322.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.27
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
OP
|
$385.70
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.00 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna Commercial |
$327.85
|
| Rate for Payer: Aetna Medicare |
$100.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$120.53
|
| Rate for Payer: Amish Plain Church Group Commercial |
$120.53
|
| Rate for Payer: BCBS Complete |
$71.39
|
| Rate for Payer: BCBS MAPPO |
$96.42
|
| Rate for Payer: BCBS Trust/PPO |
$317.08
|
| Rate for Payer: BCN Commercial |
$317.08
|
| Rate for Payer: BCN Medicare Advantage |
$96.42
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$96.42
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.27
|
| Rate for Payer: Mclaren Medicaid |
$68.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$101.25
|
| Rate for Payer: Meridian Medicaid |
$71.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$110.89
|
| Rate for Payer: Molina Medicare/Medicaid |
$106.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.85
|
| Rate for Payer: Nomi Health Commercial |
$316.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.27
|
| Rate for Payer: PACE Senior Care Partners |
$91.60
|
| Rate for Payer: PACE SWMI |
$96.42
|
| Rate for Payer: PHP Commercial |
$327.85
|
| Rate for Payer: PHP Medicare Advantage |
$96.42
|
| Rate for Payer: Priority Health Choice Medicaid |
$68.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$335.56
|
| Rate for Payer: Priority Health Medicare |
$97.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$268.45
|
| Rate for Payer: Railroad Medicare Medicare |
$96.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$339.42
|
| Rate for Payer: UHC Core |
$322.06
|
| Rate for Payer: UHC Exchange |
$96.42
|
| Rate for Payer: UHC Medicaid |
$68.00
|
| Rate for Payer: UHC Medicare Advantage |
$96.42
|
| Rate for Payer: UHCCP Medicaid |
$68.00
|
| Rate for Payer: VA VA |
$96.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.27
|
|
|
LEVONORGESTREL 1.5 MG TABLET
|
Facility
|
OP
|
$39.63
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.99 |
| Max. Negotiated Rate |
$35.67 |
| Rate for Payer: Aetna Commercial |
$33.69
|
| Rate for Payer: Aetna Medicare |
$10.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.38
|
| Rate for Payer: BCBS Complete |
$7.34
|
| Rate for Payer: BCBS MAPPO |
$9.91
|
| Rate for Payer: BCBS Trust/PPO |
$32.58
|
| Rate for Payer: BCN Commercial |
$32.58
|
| Rate for Payer: BCN Medicare Advantage |
$9.91
|
| Rate for Payer: Cash Price |
$31.70
|
| Rate for Payer: Cofinity Commercial |
$34.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.70
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.91
|
| Rate for Payer: Healthscope Commercial |
$35.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.72
|
| Rate for Payer: Mclaren Medicaid |
$6.99
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.40
|
| Rate for Payer: Meridian Medicaid |
$7.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.39
|
| Rate for Payer: Molina Medicare/Medicaid |
$10.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.69
|
| Rate for Payer: Nomi Health Commercial |
$32.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.72
|
| Rate for Payer: PACE Senior Care Partners |
$9.41
|
| Rate for Payer: PACE SWMI |
$9.91
|
| Rate for Payer: PHP Commercial |
$33.69
|
| Rate for Payer: PHP Medicare Advantage |
$9.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$6.99
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$34.48
|
| Rate for Payer: Priority Health Medicare |
$10.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.58
|
| Rate for Payer: Railroad Medicare Medicare |
$9.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.87
|
| Rate for Payer: UHC Core |
$33.09
|
| Rate for Payer: UHC Exchange |
$9.91
|
| Rate for Payer: UHC Medicaid |
$6.99
|
| Rate for Payer: UHC Medicare Advantage |
$9.91
|
| Rate for Payer: UHCCP Medicaid |
$6.99
|
| Rate for Payer: VA VA |
$9.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.72
|
|
|
LEVONORGESTREL 1.5 MG TABLET
|
Facility
|
IP
|
$39.63
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.58 |
| Max. Negotiated Rate |
$35.67 |
| Rate for Payer: Aetna Commercial |
$33.69
|
| Rate for Payer: BCBS Trust/PPO |
$32.73
|
| Rate for Payer: BCN Commercial |
$32.73
|
| Rate for Payer: Cash Price |
$31.70
|
| Rate for Payer: Cofinity Commercial |
$34.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.70
|
| Rate for Payer: Healthscope Commercial |
$35.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.69
|
| Rate for Payer: Nomi Health Commercial |
$32.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.72
|
| Rate for Payer: PHP Commercial |
$33.69
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$34.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$27.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$34.87
|
| Rate for Payer: UHC Core |
$33.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.72
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$231.93
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$40.89 |
| Max. Negotiated Rate |
$208.74 |
| Rate for Payer: Aetna Commercial |
$197.14
|
| Rate for Payer: Aetna Medicare |
$60.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$72.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$72.48
|
| Rate for Payer: BCBS Complete |
$42.93
|
| Rate for Payer: BCBS MAPPO |
$57.98
|
| Rate for Payer: BCBS Trust/PPO |
$190.67
|
| Rate for Payer: BCN Commercial |
$190.67
|
| Rate for Payer: BCN Medicare Advantage |
$57.98
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$199.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$57.98
|
| Rate for Payer: Healthscope Commercial |
$208.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.95
|
| Rate for Payer: Mclaren Medicaid |
$40.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$60.88
|
| Rate for Payer: Meridian Medicaid |
$42.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$66.68
|
| Rate for Payer: Molina Medicare/Medicaid |
$63.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.14
|
| Rate for Payer: Nomi Health Commercial |
$190.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$173.95
|
| Rate for Payer: PACE Senior Care Partners |
$55.08
|
| Rate for Payer: PACE SWMI |
$57.98
|
| Rate for Payer: PHP Commercial |
$197.14
|
| Rate for Payer: PHP Medicare Advantage |
$57.98
|
| Rate for Payer: Priority Health Choice Medicaid |
$40.89
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$201.78
|
| Rate for Payer: Priority Health Medicare |
$58.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$161.42
|
| Rate for Payer: Railroad Medicare Medicare |
$57.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$204.10
|
| Rate for Payer: UHC Core |
$193.66
|
| Rate for Payer: UHC Exchange |
$57.98
|
| Rate for Payer: UHC Medicaid |
$40.89
|
| Rate for Payer: UHC Medicare Advantage |
$57.98
|
| Rate for Payer: UHCCP Medicaid |
$40.89
|
| Rate for Payer: VA VA |
$57.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.95
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$231.93
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$161.42 |
| Max. Negotiated Rate |
$208.74 |
| Rate for Payer: Aetna Commercial |
$197.14
|
| Rate for Payer: BCBS Trust/PPO |
$191.55
|
| Rate for Payer: BCN Commercial |
$191.55
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$199.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Healthscope Commercial |
$208.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.14
|
| Rate for Payer: Nomi Health Commercial |
$190.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$173.95
|
| Rate for Payer: PHP Commercial |
$197.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$201.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$161.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$204.10
|
| Rate for Payer: UHC Core |
$193.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.95
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$416.10
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.36 |
| Max. Negotiated Rate |
$374.49 |
| Rate for Payer: Aetna Commercial |
$353.69
|
| Rate for Payer: Aetna Medicare |
$108.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$130.03
|
| Rate for Payer: Amish Plain Church Group Commercial |
$130.03
|
| Rate for Payer: BCBS Complete |
$77.02
|
| Rate for Payer: BCBS MAPPO |
$104.03
|
| Rate for Payer: BCBS Trust/PPO |
$342.08
|
| Rate for Payer: BCN Commercial |
$342.08
|
| Rate for Payer: BCN Medicare Advantage |
$104.03
|
| Rate for Payer: Cash Price |
$332.88
|
| Rate for Payer: Cofinity Commercial |
$357.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$104.03
|
| Rate for Payer: Healthscope Commercial |
$374.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$312.07
|
| Rate for Payer: Mclaren Medicaid |
$73.36
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$109.23
|
| Rate for Payer: Meridian Medicaid |
$77.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$119.63
|
| Rate for Payer: Molina Medicare/Medicaid |
$114.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.69
|
| Rate for Payer: Nomi Health Commercial |
$341.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$312.07
|
| Rate for Payer: PACE Senior Care Partners |
$98.82
|
| Rate for Payer: PACE SWMI |
$104.03
|
| Rate for Payer: PHP Commercial |
$353.69
|
| Rate for Payer: PHP Medicare Advantage |
$104.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$73.36
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$362.01
|
| Rate for Payer: Priority Health Medicare |
$105.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$289.61
|
| Rate for Payer: Railroad Medicare Medicare |
$104.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$366.17
|
| Rate for Payer: UHC Core |
$347.44
|
| Rate for Payer: UHC Exchange |
$104.03
|
| Rate for Payer: UHC Medicaid |
$73.36
|
| Rate for Payer: UHC Medicare Advantage |
$104.03
|
| Rate for Payer: UHCCP Medicaid |
$73.36
|
| Rate for Payer: VA VA |
$104.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$312.07
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$416.10
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$289.61 |
| Max. Negotiated Rate |
$374.49 |
| Rate for Payer: Aetna Commercial |
$353.69
|
| Rate for Payer: BCBS Trust/PPO |
$343.66
|
| Rate for Payer: BCN Commercial |
$343.66
|
| Rate for Payer: Cash Price |
$332.88
|
| Rate for Payer: Cofinity Commercial |
$357.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.88
|
| Rate for Payer: Healthscope Commercial |
$374.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$312.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.69
|
| Rate for Payer: Nomi Health Commercial |
$341.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$312.07
|
| Rate for Payer: PHP Commercial |
$353.69
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$362.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$289.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$366.17
|
| Rate for Payer: UHC Core |
$347.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$312.07
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$2.64
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: Aetna Medicare |
$0.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.83
|
| Rate for Payer: BCBS Complete |
$0.49
|
| Rate for Payer: BCBS MAPPO |
$0.66
|
| Rate for Payer: BCBS Trust/PPO |
$2.17
|
| Rate for Payer: BCN Commercial |
$2.17
|
| Rate for Payer: BCN Medicare Advantage |
$0.66
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.66
|
| Rate for Payer: Healthscope Commercial |
$2.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.98
|
| Rate for Payer: Mclaren Medicaid |
$0.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.69
|
| Rate for Payer: Meridian Medicaid |
$0.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.76
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.24
|
| Rate for Payer: Nomi Health Commercial |
$2.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.98
|
| Rate for Payer: PACE Senior Care Partners |
$0.63
|
| Rate for Payer: PACE SWMI |
$0.66
|
| Rate for Payer: PHP Commercial |
$2.24
|
| Rate for Payer: PHP Medicare Advantage |
$0.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.47
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.30
|
| Rate for Payer: Priority Health Medicare |
$0.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.84
|
| Rate for Payer: Railroad Medicare Medicare |
$0.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.32
|
| Rate for Payer: UHC Core |
$2.20
|
| Rate for Payer: UHC Exchange |
$0.66
|
| Rate for Payer: UHC Medicaid |
$0.47
|
| Rate for Payer: UHC Medicare Advantage |
$0.66
|
| Rate for Payer: UHCCP Medicaid |
$0.47
|
| Rate for Payer: VA VA |
$0.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.98
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.54 |
| Max. Negotiated Rate |
$303.96 |
| Rate for Payer: Aetna Commercial |
$287.07
|
| Rate for Payer: Aetna Medicare |
$87.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$105.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$105.54
|
| Rate for Payer: BCBS Complete |
$62.51
|
| Rate for Payer: BCBS MAPPO |
$84.43
|
| Rate for Payer: BCBS Trust/PPO |
$277.65
|
| Rate for Payer: BCN Commercial |
$277.65
|
| Rate for Payer: BCN Medicare Advantage |
$84.43
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$290.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$84.43
|
| Rate for Payer: Healthscope Commercial |
$303.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$253.30
|
| Rate for Payer: Mclaren Medicaid |
$59.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$88.65
|
| Rate for Payer: Meridian Medicaid |
$62.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$97.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$92.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: Nomi Health Commercial |
$276.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$253.30
|
| Rate for Payer: PACE Senior Care Partners |
$80.21
|
| Rate for Payer: PACE SWMI |
$84.43
|
| Rate for Payer: PHP Commercial |
$287.07
|
| Rate for Payer: PHP Medicare Advantage |
$84.43
|
| Rate for Payer: Priority Health Choice Medicaid |
$59.54
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$293.83
|
| Rate for Payer: Priority Health Medicare |
$85.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$235.06
|
| Rate for Payer: Railroad Medicare Medicare |
$84.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$297.20
|
| Rate for Payer: UHC Core |
$282.00
|
| Rate for Payer: UHC Exchange |
$84.43
|
| Rate for Payer: UHC Medicaid |
$59.54
|
| Rate for Payer: UHC Medicare Advantage |
$84.43
|
| Rate for Payer: UHCCP Medicaid |
$59.54
|
| Rate for Payer: VA VA |
$84.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$253.30
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.64
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.84 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: BCBS Trust/PPO |
$2.18
|
| Rate for Payer: BCN Commercial |
$2.18
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.11
|
| Rate for Payer: Healthscope Commercial |
$2.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.24
|
| Rate for Payer: Nomi Health Commercial |
$2.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.98
|
| Rate for Payer: PHP Commercial |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.32
|
| Rate for Payer: UHC Core |
$2.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.98
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$235.06 |
| Max. Negotiated Rate |
$303.96 |
| Rate for Payer: Aetna Commercial |
$287.07
|
| Rate for Payer: BCBS Trust/PPO |
$278.93
|
| Rate for Payer: BCN Commercial |
$278.93
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$290.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$303.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$253.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: Nomi Health Commercial |
$276.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$253.30
|
| Rate for Payer: PHP Commercial |
$287.07
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$293.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$235.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$297.20
|
| Rate for Payer: UHC Core |
$282.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$253.30
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$475.00
|
|
|
Service Code
|
NDC 00904695461
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.74 |
| Max. Negotiated Rate |
$427.50 |
| Rate for Payer: Aetna Commercial |
$403.75
|
| Rate for Payer: Aetna Medicare |
$123.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$148.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$148.44
|
| Rate for Payer: BCBS Complete |
$87.92
|
| Rate for Payer: BCBS MAPPO |
$118.75
|
| Rate for Payer: BCBS Trust/PPO |
$390.50
|
| Rate for Payer: BCN Commercial |
$390.50
|
| Rate for Payer: BCN Medicare Advantage |
$118.75
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cofinity Commercial |
$408.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$118.75
|
| Rate for Payer: Healthscope Commercial |
$427.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.25
|
| Rate for Payer: Mclaren Medicaid |
$83.74
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$124.69
|
| Rate for Payer: Meridian Medicaid |
$87.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$136.56
|
| Rate for Payer: Molina Medicare/Medicaid |
$130.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.75
|
| Rate for Payer: Nomi Health Commercial |
$389.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.25
|
| Rate for Payer: PACE Senior Care Partners |
$112.81
|
| Rate for Payer: PACE SWMI |
$118.75
|
| Rate for Payer: PHP Commercial |
$403.75
|
| Rate for Payer: PHP Medicare Advantage |
$118.75
|
| Rate for Payer: Priority Health Choice Medicaid |
$83.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$413.25
|
| Rate for Payer: Priority Health Medicare |
$119.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$330.60
|
| Rate for Payer: Railroad Medicare Medicare |
$118.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$418.00
|
| Rate for Payer: UHC Core |
$396.62
|
| Rate for Payer: UHC Exchange |
$118.75
|
| Rate for Payer: UHC Medicaid |
$83.74
|
| Rate for Payer: UHC Medicare Advantage |
$118.75
|
| Rate for Payer: UHCCP Medicaid |
$83.74
|
| Rate for Payer: VA VA |
$118.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.25
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$475.00
|
|
|
Service Code
|
NDC 00904695461
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$330.60 |
| Max. Negotiated Rate |
$427.50 |
| Rate for Payer: Aetna Commercial |
$403.75
|
| Rate for Payer: BCBS Trust/PPO |
$392.30
|
| Rate for Payer: BCN Commercial |
$392.30
|
| Rate for Payer: Cash Price |
$380.00
|
| Rate for Payer: Cofinity Commercial |
$408.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$380.00
|
| Rate for Payer: Healthscope Commercial |
$427.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$356.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$403.75
|
| Rate for Payer: Nomi Health Commercial |
$389.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$356.25
|
| Rate for Payer: PHP Commercial |
$403.75
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$413.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$330.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$418.00
|
| Rate for Payer: UHC Core |
$396.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$356.25
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$389.88
|
|
|
Service Code
|
NDC 00378181177
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.36 |
| Max. Negotiated Rate |
$350.89 |
| Rate for Payer: Aetna Commercial |
$331.40
|
| Rate for Payer: BCBS Trust/PPO |
$322.00
|
| Rate for Payer: BCN Commercial |
$322.00
|
| Rate for Payer: Cash Price |
$311.90
|
| Rate for Payer: Cofinity Commercial |
$335.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.90
|
| Rate for Payer: Healthscope Commercial |
$350.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$292.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.40
|
| Rate for Payer: Nomi Health Commercial |
$319.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.41
|
| Rate for Payer: PHP Commercial |
$331.40
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$339.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$271.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$343.09
|
| Rate for Payer: UHC Core |
$325.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.41
|
|
