|
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 |
$14.89 |
| Max. Negotiated Rate |
$56.44 |
| Rate for Payer: Aetna Commercial |
$53.30
|
| Rate for Payer: Aetna Commercial |
$50.17
|
| Rate for Payer: Aetna Medicare |
$16.30
|
| Rate for Payer: Aetna Medicare |
$15.35
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$18.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.60
|
| Rate for Payer: Amish Plain Church Group Commercial |
$18.44
|
| Rate for Payer: BCBS Complete |
$23.61
|
| Rate for Payer: BCBS Complete |
$25.08
|
| Rate for Payer: BCBS MAPPO |
$14.76
|
| Rate for Payer: BCBS MAPPO |
$15.68
|
| Rate for Payer: BCBS Trust/PPO |
$51.55
|
| Rate for Payer: BCBS Trust/PPO |
$48.52
|
| Rate for Payer: BCN Commercial |
$48.76
|
| Rate for Payer: BCN Commercial |
$45.89
|
| Rate for Payer: BCN Medicare Advantage |
$15.68
|
| Rate for Payer: BCN Medicare Advantage |
$14.76
|
| Rate for Payer: Cash Price |
$50.17
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cofinity Commercial |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$53.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.68
|
| Rate for Payer: Healthscope Commercial |
$53.12
|
| Rate for Payer: Healthscope Commercial |
$56.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.26
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$15.49
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.17
|
| Rate for Payer: Nomi Health Commercial |
$51.42
|
| Rate for Payer: Nomi Health Commercial |
$48.40
|
| Rate for Payer: PACE Senior Care Partners |
$14.89
|
| Rate for Payer: PACE Senior Care Partners |
$14.02
|
| Rate for Payer: PACE SWMI |
$15.68
|
| Rate for Payer: PACE SWMI |
$14.76
|
| Rate for Payer: PHP Commercial |
$53.30
|
| Rate for Payer: PHP Commercial |
$50.17
|
| Rate for Payer: PHP Medicare Advantage |
$14.76
|
| Rate for Payer: PHP Medicare Advantage |
$15.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.36
|
| Rate for Payer: Priority Health HMO/PPO |
$51.35
|
| Rate for Payer: Priority Health HMO/PPO |
$54.56
|
| Rate for Payer: Priority Health Medicare |
$15.83
|
| Rate for Payer: Priority Health Medicare |
$14.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$39.54
|
| Rate for Payer: Railroad Medicare Medicare |
$14.76
|
| Rate for Payer: Railroad Medicare Medicare |
$15.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.18
|
| Rate for Payer: UHC Core |
$52.36
|
| Rate for Payer: UHC Core |
$49.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$14.76
|
| Rate for Payer: UHC Exchange |
$14.76
|
| Rate for Payer: UHC Exchange |
$15.68
|
| Rate for Payer: UHC Medicare Advantage |
$14.76
|
| Rate for Payer: UHC Medicare Advantage |
$15.68
|
| Rate for Payer: VA VA |
$14.76
|
| Rate for Payer: VA VA |
$15.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.26
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
OP
|
$418.30
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.35 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna Medicare |
$108.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$130.72
|
| Rate for Payer: Amish Plain Church Group Commercial |
$130.72
|
| Rate for Payer: BCBS Complete |
$167.32
|
| Rate for Payer: BCBS MAPPO |
$104.58
|
| Rate for Payer: BCBS Trust/PPO |
$343.88
|
| Rate for Payer: BCN Commercial |
$325.23
|
| Rate for Payer: BCN Medicare Advantage |
$104.58
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$104.58
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.72
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$109.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$120.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: Nomi Health Commercial |
$343.01
|
| Rate for Payer: PACE Senior Care Partners |
$99.35
|
| Rate for Payer: PACE SWMI |
$104.58
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: PHP Medicare Advantage |
$104.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.90
|
| Rate for Payer: Priority Health HMO/PPO |
$363.92
|
| Rate for Payer: Priority Health Medicare |
$105.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$280.26
|
| Rate for Payer: Railroad Medicare Medicare |
$104.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$368.10
|
| Rate for Payer: UHC Core |
$349.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$104.58
|
| Rate for Payer: UHC Exchange |
$104.58
|
| Rate for Payer: UHC Medicare Advantage |
$104.58
|
| Rate for Payer: VA VA |
$104.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.72
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
IP
|
$418.30
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.90 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: BCBS Trust/PPO |
$341.46
|
| Rate for Payer: BCN Commercial |
$323.26
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: Nomi Health Commercial |
$343.01
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.90
|
| Rate for Payer: Priority Health HMO/PPO |
$363.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$280.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$368.10
|
| Rate for Payer: UHC Core |
$349.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.72
|
|
|
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 |
$48.73 |
| Max. Negotiated Rate |
$67.47 |
| Rate for Payer: Aetna Commercial |
$63.72
|
| Rate for Payer: BCBS Trust/PPO |
$61.20
|
| Rate for Payer: BCN Commercial |
$57.94
|
| Rate for Payer: Cash Price |
$59.98
|
| Rate for Payer: Cofinity Commercial |
$64.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.98
|
| Rate for Payer: Healthscope Commercial |
$67.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.72
|
| Rate for Payer: Nomi Health Commercial |
$61.48
|
| Rate for Payer: PHP Commercial |
$63.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.73
|
| Rate for Payer: Priority Health HMO/PPO |
$65.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$50.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.97
|
| Rate for Payer: UHC Core |
$62.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.23
|
|
|
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 |
$17.81 |
| Max. Negotiated Rate |
$67.47 |
| Rate for Payer: Aetna Commercial |
$63.72
|
| Rate for Payer: Aetna Medicare |
$19.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$23.43
|
| Rate for Payer: Amish Plain Church Group Commercial |
$23.43
|
| Rate for Payer: BCBS Complete |
$29.99
|
| Rate for Payer: BCBS MAPPO |
$18.74
|
| Rate for Payer: BCBS Trust/PPO |
$61.63
|
| Rate for Payer: BCN Commercial |
$58.29
|
| Rate for Payer: BCN Medicare Advantage |
$18.74
|
| Rate for Payer: Cash Price |
$59.98
|
| Rate for Payer: Cofinity Commercial |
$64.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$18.74
|
| Rate for Payer: Healthscope Commercial |
$67.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$19.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.72
|
| Rate for Payer: Nomi Health Commercial |
$61.48
|
| Rate for Payer: PACE Senior Care Partners |
$17.81
|
| Rate for Payer: PACE SWMI |
$18.74
|
| Rate for Payer: PHP Commercial |
$63.72
|
| Rate for Payer: PHP Medicare Advantage |
$18.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.73
|
| Rate for Payer: Priority Health HMO/PPO |
$65.22
|
| Rate for Payer: Priority Health Medicare |
$18.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$50.23
|
| Rate for Payer: Railroad Medicare Medicare |
$18.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$65.97
|
| Rate for Payer: UHC Core |
$62.60
|
| Rate for Payer: UHC Dual Complete DSNP |
$18.74
|
| Rate for Payer: UHC Exchange |
$18.74
|
| Rate for Payer: UHC Medicare Advantage |
$18.74
|
| Rate for Payer: VA VA |
$18.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.23
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
OP
|
$213.75
|
|
|
Service Code
|
NDC 00904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.77 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: Aetna Medicare |
$55.58
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$66.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$66.80
|
| Rate for Payer: BCBS Complete |
$85.50
|
| Rate for Payer: BCBS MAPPO |
$53.44
|
| Rate for Payer: BCBS Trust/PPO |
$175.72
|
| Rate for Payer: BCN Commercial |
$166.19
|
| Rate for Payer: BCN Medicare Advantage |
$53.44
|
| 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: Health Alliance Plan Medicare Advantage |
$53.44
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$56.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$61.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: Nomi Health Commercial |
$175.28
|
| Rate for Payer: PACE Senior Care Partners |
$50.77
|
| Rate for Payer: PACE SWMI |
$53.44
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: PHP Medicare Advantage |
$53.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.94
|
| Rate for Payer: Priority Health HMO/PPO |
$185.96
|
| Rate for Payer: Priority Health Medicare |
$53.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$143.21
|
| Rate for Payer: Railroad Medicare Medicare |
$53.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$188.10
|
| Rate for Payer: UHC Core |
$178.48
|
| Rate for Payer: UHC Dual Complete DSNP |
$53.44
|
| Rate for Payer: UHC Exchange |
$53.44
|
| Rate for Payer: UHC Medicare Advantage |
$53.44
|
| Rate for Payer: VA VA |
$53.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.31
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
IP
|
$213.75
|
|
|
Service Code
|
NDC 00904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.94 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: BCBS Trust/PPO |
$174.48
|
| 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 Commercial |
$181.69
|
| Rate for Payer: Nomi Health Commercial |
$175.28
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.94
|
| Rate for Payer: Priority Health HMO/PPO |
$185.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$143.21
|
| 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
|
IP
|
$458.85
|
|
|
Service Code
|
NDC 68084048211
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$298.25 |
| Max. Negotiated Rate |
$412.96 |
| Rate for Payer: Aetna Commercial |
$390.02
|
| Rate for Payer: BCBS Trust/PPO |
$374.56
|
| 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 Commercial |
$390.02
|
| Rate for Payer: Nomi Health Commercial |
$376.26
|
| Rate for Payer: PHP Commercial |
$390.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.25
|
| Rate for Payer: Priority Health HMO/PPO |
$399.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$307.43
|
| 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
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
OP
|
$458.85
|
|
|
Service Code
|
NDC 68084048211
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.98 |
| Max. Negotiated Rate |
$412.96 |
| Rate for Payer: Aetna Commercial |
$390.02
|
| Rate for Payer: Aetna Medicare |
$119.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$143.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$143.39
|
| Rate for Payer: BCBS Complete |
$183.54
|
| Rate for Payer: BCBS MAPPO |
$114.71
|
| Rate for Payer: BCBS Trust/PPO |
$377.22
|
| Rate for Payer: BCN Commercial |
$356.76
|
| Rate for Payer: BCN Medicare Advantage |
$114.71
|
| 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: Health Alliance Plan Medicare Advantage |
$114.71
|
| Rate for Payer: Healthscope Commercial |
$412.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$344.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$120.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$131.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$390.02
|
| Rate for Payer: Nomi Health Commercial |
$376.26
|
| Rate for Payer: PACE Senior Care Partners |
$108.98
|
| Rate for Payer: PACE SWMI |
$114.71
|
| Rate for Payer: PHP Commercial |
$390.02
|
| Rate for Payer: PHP Medicare Advantage |
$114.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.25
|
| Rate for Payer: Priority Health HMO/PPO |
$399.20
|
| Rate for Payer: Priority Health Medicare |
$115.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$307.43
|
| Rate for Payer: Railroad Medicare Medicare |
$114.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$403.79
|
| Rate for Payer: UHC Core |
$383.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$114.71
|
| Rate for Payer: UHC Exchange |
$114.71
|
| Rate for Payer: UHC Medicare Advantage |
$114.71
|
| Rate for Payer: VA VA |
$114.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$344.14
|
|
|
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 |
$44.32 |
| Max. Negotiated Rate |
$61.36 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Commercial |
$75.25
|
| Rate for Payer: BCBS Trust/PPO |
$55.66
|
| Rate for Payer: BCBS Trust/PPO |
$72.27
|
| Rate for Payer: BCN Commercial |
$52.69
|
| Rate for Payer: BCN Commercial |
$68.42
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cash Price |
$70.82
|
| Rate for Payer: Cofinity Commercial |
$76.14
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Healthscope Commercial |
$79.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.25
|
| Rate for Payer: Nomi Health Commercial |
$55.91
|
| Rate for Payer: Nomi Health Commercial |
$72.59
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: PHP Commercial |
$75.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.32
|
| Rate for Payer: Priority Health HMO/PPO |
$77.02
|
| Rate for Payer: Priority Health HMO/PPO |
$59.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$59.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.91
|
| Rate for Payer: UHC Core |
$56.93
|
| Rate for Payer: UHC Core |
$73.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.40
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$88.53
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.03 |
| Max. Negotiated Rate |
$79.68 |
| Rate for Payer: Aetna Commercial |
$75.25
|
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Medicare |
$23.02
|
| Rate for Payer: Aetna Medicare |
$17.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27.67
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27.67
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.31
|
| Rate for Payer: BCBS Complete |
$27.27
|
| Rate for Payer: BCBS Complete |
$35.41
|
| Rate for Payer: BCBS MAPPO |
$17.04
|
| Rate for Payer: BCBS MAPPO |
$22.13
|
| Rate for Payer: BCBS Trust/PPO |
$72.78
|
| Rate for Payer: BCBS Trust/PPO |
$56.05
|
| Rate for Payer: BCN Commercial |
$68.83
|
| Rate for Payer: BCN Commercial |
$53.01
|
| Rate for Payer: BCN Medicare Advantage |
$22.13
|
| Rate for Payer: BCN Medicare Advantage |
$17.04
|
| Rate for Payer: Cash Price |
$70.82
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Cofinity Commercial |
$76.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.13
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Healthscope Commercial |
$79.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.95
|
| Rate for Payer: Nomi Health Commercial |
$72.59
|
| Rate for Payer: Nomi Health Commercial |
$55.91
|
| Rate for Payer: PACE Senior Care Partners |
$21.03
|
| Rate for Payer: PACE Senior Care Partners |
$16.19
|
| Rate for Payer: PACE SWMI |
$22.13
|
| Rate for Payer: PACE SWMI |
$17.04
|
| Rate for Payer: PHP Commercial |
$75.25
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: PHP Medicare Advantage |
$17.04
|
| Rate for Payer: PHP Medicare Advantage |
$22.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.32
|
| Rate for Payer: Priority Health HMO/PPO |
$59.32
|
| Rate for Payer: Priority Health HMO/PPO |
$77.02
|
| Rate for Payer: Priority Health Medicare |
$22.35
|
| Rate for Payer: Priority Health Medicare |
$17.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$59.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.68
|
| Rate for Payer: Railroad Medicare Medicare |
$17.04
|
| Rate for Payer: Railroad Medicare Medicare |
$22.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.91
|
| Rate for Payer: UHC Core |
$73.92
|
| Rate for Payer: UHC Core |
$56.93
|
| Rate for Payer: UHC Dual Complete DSNP |
$22.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.04
|
| Rate for Payer: UHC Exchange |
$17.04
|
| Rate for Payer: UHC Exchange |
$22.13
|
| Rate for Payer: UHC Medicare Advantage |
$17.04
|
| Rate for Payer: UHC Medicare Advantage |
$22.13
|
| Rate for Payer: VA VA |
$17.04
|
| Rate for Payer: VA VA |
$22.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.14
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$336.30
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$218.60 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: BCBS Trust/PPO |
$274.52
|
| Rate for Payer: BCN Commercial |
$259.89
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: Nomi Health Commercial |
$275.77
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.60
|
| Rate for Payer: Priority Health HMO/PPO |
$292.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$225.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$295.94
|
| Rate for Payer: UHC Core |
$280.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
OP
|
$336.30
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.87 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna Medicare |
$87.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$105.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$105.09
|
| Rate for Payer: BCBS Complete |
$134.52
|
| Rate for Payer: BCBS MAPPO |
$84.08
|
| Rate for Payer: BCBS Trust/PPO |
$276.47
|
| Rate for Payer: BCN Commercial |
$261.47
|
| Rate for Payer: BCN Medicare Advantage |
$84.08
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$84.08
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$88.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$96.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: Nomi Health Commercial |
$275.77
|
| Rate for Payer: PACE Senior Care Partners |
$79.87
|
| Rate for Payer: PACE SWMI |
$84.08
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: PHP Medicare Advantage |
$84.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.60
|
| Rate for Payer: Priority Health HMO/PPO |
$292.58
|
| Rate for Payer: Priority Health Medicare |
$84.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$225.32
|
| Rate for Payer: Railroad Medicare Medicare |
$84.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$295.94
|
| Rate for Payer: UHC Core |
$280.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$84.08
|
| Rate for Payer: UHC Exchange |
$84.08
|
| Rate for Payer: UHC Medicare Advantage |
$84.08
|
| Rate for Payer: VA VA |
$84.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
LEVONORGESTREL 1.5 MG TABLET
|
Facility
|
IP
|
$38.52
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.04 |
| Max. Negotiated Rate |
$34.67 |
| Rate for Payer: Aetna Commercial |
$32.74
|
| Rate for Payer: BCBS Trust/PPO |
$31.44
|
| Rate for Payer: BCN Commercial |
$29.77
|
| Rate for Payer: Cash Price |
$30.82
|
| Rate for Payer: Cofinity Commercial |
$33.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.82
|
| Rate for Payer: Healthscope Commercial |
$34.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.74
|
| Rate for Payer: Nomi Health Commercial |
$31.59
|
| Rate for Payer: PHP Commercial |
$32.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.04
|
| Rate for Payer: Priority Health HMO/PPO |
$33.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.90
|
| Rate for Payer: UHC Core |
$32.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.89
|
|
|
LEVONORGESTREL 1.5 MG TABLET
|
Facility
|
OP
|
$38.52
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.15 |
| Max. Negotiated Rate |
$34.67 |
| Rate for Payer: Aetna Commercial |
$32.74
|
| Rate for Payer: Aetna Medicare |
$10.02
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.04
|
| Rate for Payer: BCBS Complete |
$15.41
|
| Rate for Payer: BCBS MAPPO |
$9.63
|
| Rate for Payer: BCBS Trust/PPO |
$31.67
|
| Rate for Payer: BCN Commercial |
$29.95
|
| Rate for Payer: BCN Medicare Advantage |
$9.63
|
| Rate for Payer: Cash Price |
$30.82
|
| Rate for Payer: Cofinity Commercial |
$33.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.63
|
| Rate for Payer: Healthscope Commercial |
$34.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.74
|
| Rate for Payer: Nomi Health Commercial |
$31.59
|
| Rate for Payer: PACE Senior Care Partners |
$9.15
|
| Rate for Payer: PACE SWMI |
$9.63
|
| Rate for Payer: PHP Commercial |
$32.74
|
| Rate for Payer: PHP Medicare Advantage |
$9.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.04
|
| Rate for Payer: Priority Health HMO/PPO |
$33.51
|
| Rate for Payer: Priority Health Medicare |
$9.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.81
|
| Rate for Payer: Railroad Medicare Medicare |
$9.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.90
|
| Rate for Payer: UHC Core |
$32.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.63
|
| Rate for Payer: UHC Exchange |
$9.63
|
| Rate for Payer: UHC Medicare Advantage |
$9.63
|
| Rate for Payer: VA VA |
$9.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.89
|
|
|
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 |
$150.75 |
| Max. Negotiated Rate |
$208.74 |
| Rate for Payer: Aetna Commercial |
$197.14
|
| Rate for Payer: BCBS Trust/PPO |
$189.32
|
| Rate for Payer: BCN Commercial |
$179.24
|
| 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: PHP Commercial |
$197.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| Rate for Payer: Priority Health HMO/PPO |
$201.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$155.39
|
| 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 INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$231.93
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.08 |
| 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 |
$92.77
|
| Rate for Payer: BCBS MAPPO |
$57.98
|
| Rate for Payer: BCBS Trust/PPO |
$190.67
|
| Rate for Payer: BCN Commercial |
$180.33
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$60.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$66.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.14
|
| Rate for Payer: Nomi Health Commercial |
$190.18
|
| 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 Cigna Priority Health |
$150.75
|
| Rate for Payer: Priority Health HMO/PPO |
$201.78
|
| Rate for Payer: Priority Health Medicare |
$58.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$155.39
|
| 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 Dual Complete DSNP |
$57.98
|
| Rate for Payer: UHC Exchange |
$57.98
|
| Rate for Payer: UHC Medicare Advantage |
$57.98
|
| Rate for Payer: VA VA |
$57.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.95
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$396.15
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.50 |
| Max. Negotiated Rate |
$356.54 |
| Rate for Payer: Aetna Commercial |
$336.73
|
| Rate for Payer: BCBS Trust/PPO |
$323.38
|
| Rate for Payer: BCN Commercial |
$306.14
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$340.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Healthscope Commercial |
$356.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: Nomi Health Commercial |
$324.84
|
| Rate for Payer: PHP Commercial |
$336.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: Priority Health HMO/PPO |
$344.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$265.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$348.61
|
| Rate for Payer: UHC Core |
$330.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$2.81
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: Aetna Medicare |
$0.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.88
|
| Rate for Payer: BCBS Complete |
$1.12
|
| Rate for Payer: BCBS MAPPO |
$0.70
|
| Rate for Payer: BCBS Trust/PPO |
$2.31
|
| Rate for Payer: BCN Commercial |
$2.18
|
| Rate for Payer: BCN Medicare Advantage |
$0.70
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.70
|
| Rate for Payer: Healthscope Commercial |
$2.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.39
|
| Rate for Payer: Nomi Health Commercial |
$2.30
|
| Rate for Payer: PACE Senior Care Partners |
$0.67
|
| Rate for Payer: PACE SWMI |
$0.70
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: PHP Medicare Advantage |
$0.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health HMO/PPO |
$2.44
|
| Rate for Payer: Priority Health Medicare |
$0.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.88
|
| Rate for Payer: Railroad Medicare Medicare |
$0.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.47
|
| Rate for Payer: UHC Core |
$2.35
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.70
|
| Rate for Payer: UHC Exchange |
$0.70
|
| Rate for Payer: UHC Medicare Advantage |
$0.70
|
| Rate for Payer: VA VA |
$0.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.21 |
| 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 |
$135.09
|
| Rate for Payer: BCBS MAPPO |
$84.43
|
| Rate for Payer: BCBS Trust/PPO |
$277.65
|
| Rate for Payer: BCN Commercial |
$262.59
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$88.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$97.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: Nomi Health Commercial |
$276.94
|
| 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 Cigna Priority Health |
$219.52
|
| Rate for Payer: Priority Health HMO/PPO |
$293.83
|
| Rate for Payer: Priority Health Medicare |
$85.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$226.28
|
| 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 Dual Complete DSNP |
$84.43
|
| Rate for Payer: UHC Exchange |
$84.43
|
| Rate for Payer: UHC Medicare Advantage |
$84.43
|
| Rate for Payer: VA VA |
$84.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$253.30
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$219.52 |
| Max. Negotiated Rate |
$303.96 |
| Rate for Payer: Aetna Commercial |
$287.07
|
| Rate for Payer: BCBS Trust/PPO |
$275.69
|
| Rate for Payer: BCN Commercial |
$261.00
|
| 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: PHP Commercial |
$287.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: Priority Health HMO/PPO |
$293.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$226.28
|
| 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 100 MCG TABLET
|
Facility
|
OP
|
$396.15
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.09 |
| Max. Negotiated Rate |
$356.54 |
| Rate for Payer: Aetna Commercial |
$336.73
|
| Rate for Payer: Aetna Medicare |
$103.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$123.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$123.80
|
| Rate for Payer: BCBS Complete |
$158.46
|
| Rate for Payer: BCBS MAPPO |
$99.04
|
| Rate for Payer: BCBS Trust/PPO |
$325.67
|
| Rate for Payer: BCN Commercial |
$308.01
|
| Rate for Payer: BCN Medicare Advantage |
$99.04
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$340.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$99.04
|
| Rate for Payer: Healthscope Commercial |
$356.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$103.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$113.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: Nomi Health Commercial |
$324.84
|
| Rate for Payer: PACE Senior Care Partners |
$94.09
|
| Rate for Payer: PACE SWMI |
$99.04
|
| Rate for Payer: PHP Commercial |
$336.73
|
| Rate for Payer: PHP Medicare Advantage |
$99.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: Priority Health HMO/PPO |
$344.65
|
| Rate for Payer: Priority Health Medicare |
$100.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$265.42
|
| Rate for Payer: Railroad Medicare Medicare |
$99.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$348.61
|
| Rate for Payer: UHC Core |
$330.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$99.04
|
| Rate for Payer: UHC Exchange |
$99.04
|
| Rate for Payer: UHC Medicare Advantage |
$99.04
|
| Rate for Payer: VA VA |
$99.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: BCBS Trust/PPO |
$2.29
|
| Rate for Payer: BCN Commercial |
$2.17
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Healthscope Commercial |
$2.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.39
|
| Rate for Payer: Nomi Health Commercial |
$2.30
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health HMO/PPO |
$2.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.47
|
| Rate for Payer: UHC Core |
$2.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.11
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$697.25
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$453.21 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: BCBS Trust/PPO |
$569.17
|
| Rate for Payer: BCN Commercial |
$538.83
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$599.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.80
|
| Rate for Payer: Healthscope Commercial |
$627.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$522.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.66
|
| Rate for Payer: Nomi Health Commercial |
$571.74
|
| Rate for Payer: PHP Commercial |
$592.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.21
|
| Rate for Payer: Priority Health HMO/PPO |
$606.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$467.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$613.58
|
| Rate for Payer: UHC Core |
$582.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$522.94
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$389.88
|
|
|
Service Code
|
NDC 00378181177
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.60 |
| Max. Negotiated Rate |
$350.89 |
| Rate for Payer: Aetna Commercial |
$331.40
|
| Rate for Payer: Aetna Medicare |
$101.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$121.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$121.84
|
| Rate for Payer: BCBS Complete |
$155.95
|
| Rate for Payer: BCBS MAPPO |
$97.47
|
| Rate for Payer: BCBS Trust/PPO |
$320.52
|
| Rate for Payer: BCN Commercial |
$303.13
|
| Rate for Payer: BCN Medicare Advantage |
$97.47
|
| 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: Health Alliance Plan Medicare Advantage |
$97.47
|
| Rate for Payer: Healthscope Commercial |
$350.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$292.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$102.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$112.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.40
|
| Rate for Payer: Nomi Health Commercial |
$319.70
|
| Rate for Payer: PACE Senior Care Partners |
$92.60
|
| Rate for Payer: PACE SWMI |
$97.47
|
| Rate for Payer: PHP Commercial |
$331.40
|
| Rate for Payer: PHP Medicare Advantage |
$97.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.42
|
| Rate for Payer: Priority Health HMO/PPO |
$339.20
|
| Rate for Payer: Priority Health Medicare |
$98.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$261.22
|
| Rate for Payer: Railroad Medicare Medicare |
$97.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$343.09
|
| Rate for Payer: UHC Core |
$325.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$97.47
|
| Rate for Payer: UHC Exchange |
$97.47
|
| Rate for Payer: UHC Medicare Advantage |
$97.47
|
| Rate for Payer: VA VA |
$97.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.41
|
|
