|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
OP
|
$3.50
|
|
|
Service Code
|
NDC 09900000879
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Aetna American Axle |
$2.28
|
| Rate for Payer: Aetna Commercial |
$2.98
|
| Rate for Payer: Aetna Medicare |
$1.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.28
|
| Rate for Payer: BCBS Complete |
$1.40
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$2.45
|
| Rate for Payer: Cofinity Commercial |
$3.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: PHP Commercial |
$2.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.28
|
| Rate for Payer: Priority Health SBD |
$2.20
|
| Rate for Payer: UMR Bronson Commercial |
$1.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.62
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
OP
|
$503.72
|
|
|
Service Code
|
NDC 54482014407
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.38 |
| Max. Negotiated Rate |
$453.35 |
| Rate for Payer: Aetna American Axle |
$327.42
|
| Rate for Payer: Aetna Commercial |
$428.16
|
| Rate for Payer: Aetna Medicare |
$251.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$327.42
|
| Rate for Payer: BCBS Complete |
$201.49
|
| Rate for Payer: Cash Price |
$402.98
|
| Rate for Payer: Cofinity Commercial |
$352.60
|
| Rate for Payer: Cofinity Commercial |
$433.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$352.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$402.98
|
| Rate for Payer: Healthscope Commercial |
$453.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$352.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$377.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$428.16
|
| Rate for Payer: PHP Commercial |
$428.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$327.42
|
| Rate for Payer: Priority Health SBD |
$317.34
|
| Rate for Payer: UMR Bronson Commercial |
$186.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$377.79
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
OP
|
$342.58
|
|
|
Service Code
|
NDC 50383017290
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.75 |
| Max. Negotiated Rate |
$308.32 |
| Rate for Payer: Aetna American Axle |
$222.68
|
| Rate for Payer: Aetna Commercial |
$291.19
|
| Rate for Payer: Aetna Medicare |
$171.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$222.68
|
| Rate for Payer: BCBS Complete |
$137.03
|
| Rate for Payer: Cash Price |
$274.06
|
| Rate for Payer: Cofinity Commercial |
$239.81
|
| Rate for Payer: Cofinity Commercial |
$294.62
|
| Rate for Payer: Cofinity Medicare Advantage |
$239.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.06
|
| Rate for Payer: Healthscope Commercial |
$308.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$239.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$256.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.19
|
| Rate for Payer: PHP Commercial |
$291.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$222.68
|
| Rate for Payer: Priority Health SBD |
$215.83
|
| Rate for Payer: UMR Bronson Commercial |
$126.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$256.94
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$332.64
|
|
|
Service Code
|
NDC 70954049210
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.36 |
| Max. Negotiated Rate |
$299.38 |
| Rate for Payer: Aetna American Axle |
$216.22
|
| Rate for Payer: Aetna Commercial |
$282.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$216.22
|
| Rate for Payer: Cash Price |
$266.11
|
| Rate for Payer: Cofinity Commercial |
$232.85
|
| Rate for Payer: Cofinity Commercial |
$286.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$232.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$266.11
|
| Rate for Payer: Healthscope Commercial |
$299.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$249.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$282.74
|
| Rate for Payer: PHP Commercial |
$282.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.22
|
| Rate for Payer: Priority Health SBD |
$209.56
|
| Rate for Payer: UMR Bronson Commercial |
$146.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$249.48
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$503.72
|
|
|
Service Code
|
NDC 54482014407
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$221.64 |
| Max. Negotiated Rate |
$453.35 |
| Rate for Payer: Aetna American Axle |
$327.42
|
| Rate for Payer: Aetna Commercial |
$428.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$327.42
|
| Rate for Payer: Cash Price |
$402.98
|
| Rate for Payer: Cofinity Commercial |
$352.60
|
| Rate for Payer: Cofinity Commercial |
$433.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$352.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$402.98
|
| Rate for Payer: Healthscope Commercial |
$453.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$352.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$377.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$428.16
|
| Rate for Payer: PHP Commercial |
$428.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$327.42
|
| Rate for Payer: Priority Health SBD |
$317.34
|
| Rate for Payer: UMR Bronson Commercial |
$221.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$377.79
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
OP
|
$332.64
|
|
|
Service Code
|
NDC 70954049210
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.08 |
| Max. Negotiated Rate |
$299.38 |
| Rate for Payer: Aetna American Axle |
$216.22
|
| Rate for Payer: Aetna Commercial |
$282.74
|
| Rate for Payer: Aetna Medicare |
$166.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$216.22
|
| Rate for Payer: BCBS Complete |
$133.06
|
| Rate for Payer: Cash Price |
$266.11
|
| Rate for Payer: Cofinity Commercial |
$232.85
|
| Rate for Payer: Cofinity Commercial |
$286.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$232.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$266.11
|
| Rate for Payer: Healthscope Commercial |
$299.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$249.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$282.74
|
| Rate for Payer: PHP Commercial |
$282.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$216.22
|
| Rate for Payer: Priority Health SBD |
$209.56
|
| Rate for Payer: UMR Bronson Commercial |
$123.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$249.48
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$3.50
|
|
|
Service Code
|
NDC 09900000879
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Aetna American Axle |
$2.28
|
| Rate for Payer: Aetna Commercial |
$2.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.28
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$2.45
|
| Rate for Payer: Cofinity Commercial |
$3.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: PHP Commercial |
$2.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.28
|
| Rate for Payer: Priority Health SBD |
$2.20
|
| Rate for Payer: UMR Bronson Commercial |
$1.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.62
|
|
|
LEVOCARNITINE SD 20 MG/ML IV
|
Facility
|
OP
|
$65.00
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
157117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.45 |
| Max. Negotiated Rate |
$74.73 |
| Rate for Payer: Aetna American Axle |
$42.25
|
| Rate for Payer: Aetna Commercial |
$55.25
|
| Rate for Payer: Aetna Medicare |
$32.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.25
|
| Rate for Payer: BCBS Complete |
$26.00
|
| Rate for Payer: BCBS Trust/PPO |
$74.73
|
| Rate for Payer: BCN Commercial |
$74.73
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cofinity Commercial |
$45.50
|
| Rate for Payer: Cofinity Commercial |
$55.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$45.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.00
|
| Rate for Payer: Healthscope Commercial |
$58.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.25
|
| Rate for Payer: PHP Commercial |
$55.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25.56
|
| Rate for Payer: Priority Health Narrow Network |
$20.45
|
| Rate for Payer: Priority Health SBD |
$40.95
|
| Rate for Payer: UMR Bronson Commercial |
$24.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.75
|
|
|
LEVOCARNITINE SD 20 MG/ML IV
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
157117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.60 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna American Axle |
$42.25
|
| Rate for Payer: Aetna Commercial |
$55.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.25
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cofinity Commercial |
$45.50
|
| Rate for Payer: Cofinity Commercial |
$55.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$45.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.00
|
| Rate for Payer: Healthscope Commercial |
$58.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.25
|
| Rate for Payer: PHP Commercial |
$55.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.25
|
| Rate for Payer: Priority Health SBD |
$40.95
|
| Rate for Payer: UMR Bronson Commercial |
$28.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.75
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
IP
|
$996.48
|
|
|
Service Code
|
NDC 50383028608
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$438.45 |
| Max. Negotiated Rate |
$896.83 |
| Rate for Payer: Aetna American Axle |
$647.71
|
| Rate for Payer: Aetna Commercial |
$847.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$647.71
|
| Rate for Payer: Cash Price |
$797.18
|
| Rate for Payer: Cofinity Commercial |
$697.54
|
| Rate for Payer: Cofinity Commercial |
$856.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$697.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$797.18
|
| Rate for Payer: Healthscope Commercial |
$896.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$697.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$747.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$847.01
|
| Rate for Payer: PHP Commercial |
$847.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$647.71
|
| Rate for Payer: Priority Health SBD |
$627.78
|
| Rate for Payer: UMR Bronson Commercial |
$438.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$747.36
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
IP
|
$2,154.24
|
|
|
Service Code
|
NDC 50383028616
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$947.87 |
| Max. Negotiated Rate |
$1,938.82 |
| Rate for Payer: Aetna American Axle |
$1,400.26
|
| Rate for Payer: Aetna Commercial |
$1,831.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,400.26
|
| Rate for Payer: Cash Price |
$1,723.39
|
| Rate for Payer: Cofinity Commercial |
$1,507.97
|
| Rate for Payer: Cofinity Commercial |
$1,852.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,507.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,723.39
|
| Rate for Payer: Healthscope Commercial |
$1,938.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,507.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,615.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,831.10
|
| Rate for Payer: PHP Commercial |
$1,831.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,400.26
|
| Rate for Payer: Priority Health SBD |
$1,357.17
|
| Rate for Payer: UMR Bronson Commercial |
$947.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,615.68
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
OP
|
$760.72
|
|
|
Service Code
|
NDC 00527194866
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.47 |
| Max. Negotiated Rate |
$684.65 |
| Rate for Payer: Aetna American Axle |
$494.47
|
| Rate for Payer: Aetna Commercial |
$646.61
|
| Rate for Payer: Aetna Medicare |
$380.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$494.47
|
| Rate for Payer: BCBS Complete |
$304.29
|
| Rate for Payer: Cash Price |
$608.58
|
| Rate for Payer: Cofinity Commercial |
$532.50
|
| Rate for Payer: Cofinity Commercial |
$654.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$532.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$608.58
|
| Rate for Payer: Healthscope Commercial |
$684.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$532.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$570.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$646.61
|
| Rate for Payer: PHP Commercial |
$646.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$494.47
|
| Rate for Payer: Priority Health SBD |
$479.25
|
| Rate for Payer: UMR Bronson Commercial |
$281.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$570.54
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,639.68
|
|
|
Service Code
|
NDC 00527194868
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$721.46 |
| Max. Negotiated Rate |
$1,475.71 |
| Rate for Payer: Aetna American Axle |
$1,065.79
|
| Rate for Payer: Aetna Commercial |
$1,393.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,065.79
|
| Rate for Payer: Cash Price |
$1,311.74
|
| Rate for Payer: Cofinity Commercial |
$1,147.78
|
| Rate for Payer: Cofinity Commercial |
$1,410.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,147.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,311.74
|
| Rate for Payer: Healthscope Commercial |
$1,475.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,147.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,229.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,393.73
|
| Rate for Payer: PHP Commercial |
$1,393.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,065.79
|
| Rate for Payer: Priority Health SBD |
$1,033.00
|
| Rate for Payer: UMR Bronson Commercial |
$721.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,229.76
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
OP
|
$996.48
|
|
|
Service Code
|
NDC 50383028608
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$368.70 |
| Max. Negotiated Rate |
$896.83 |
| Rate for Payer: Aetna American Axle |
$647.71
|
| Rate for Payer: Aetna Commercial |
$847.01
|
| Rate for Payer: Aetna Medicare |
$498.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$647.71
|
| Rate for Payer: BCBS Complete |
$398.59
|
| Rate for Payer: Cash Price |
$797.18
|
| Rate for Payer: Cofinity Commercial |
$697.54
|
| Rate for Payer: Cofinity Commercial |
$856.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$697.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$797.18
|
| Rate for Payer: Healthscope Commercial |
$896.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$697.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$747.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$847.01
|
| Rate for Payer: PHP Commercial |
$847.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$647.71
|
| Rate for Payer: Priority Health SBD |
$627.78
|
| Rate for Payer: UMR Bronson Commercial |
$368.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$747.36
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
OP
|
$1,639.68
|
|
|
Service Code
|
NDC 00527194868
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$606.68 |
| Max. Negotiated Rate |
$1,475.71 |
| Rate for Payer: Aetna American Axle |
$1,065.79
|
| Rate for Payer: Aetna Commercial |
$1,393.73
|
| Rate for Payer: Aetna Medicare |
$819.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,065.79
|
| Rate for Payer: BCBS Complete |
$655.87
|
| Rate for Payer: Cash Price |
$1,311.74
|
| Rate for Payer: Cofinity Commercial |
$1,147.78
|
| Rate for Payer: Cofinity Commercial |
$1,410.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,147.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,311.74
|
| Rate for Payer: Healthscope Commercial |
$1,475.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,147.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,229.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,393.73
|
| Rate for Payer: PHP Commercial |
$1,393.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,065.79
|
| Rate for Payer: Priority Health SBD |
$1,033.00
|
| Rate for Payer: UMR Bronson Commercial |
$606.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,229.76
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
OP
|
$2,154.24
|
|
|
Service Code
|
NDC 50383028616
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$797.07 |
| Max. Negotiated Rate |
$1,938.82 |
| Rate for Payer: Aetna American Axle |
$1,400.26
|
| Rate for Payer: Aetna Commercial |
$1,831.10
|
| Rate for Payer: Aetna Medicare |
$1,077.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,400.26
|
| Rate for Payer: BCBS Complete |
$861.70
|
| Rate for Payer: Cash Price |
$1,723.39
|
| Rate for Payer: Cofinity Commercial |
$1,507.97
|
| Rate for Payer: Cofinity Commercial |
$1,852.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,507.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,723.39
|
| Rate for Payer: Healthscope Commercial |
$1,938.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,507.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,615.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,831.10
|
| Rate for Payer: PHP Commercial |
$1,831.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,400.26
|
| Rate for Payer: Priority Health SBD |
$1,357.17
|
| Rate for Payer: UMR Bronson Commercial |
$797.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,615.68
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
IP
|
$760.72
|
|
|
Service Code
|
NDC 00527194866
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$334.72 |
| Max. Negotiated Rate |
$684.65 |
| Rate for Payer: Aetna American Axle |
$494.47
|
| Rate for Payer: Aetna Commercial |
$646.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$494.47
|
| Rate for Payer: Cash Price |
$608.58
|
| Rate for Payer: Cofinity Commercial |
$532.50
|
| Rate for Payer: Cofinity Commercial |
$654.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$532.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$608.58
|
| Rate for Payer: Healthscope Commercial |
$684.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$532.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$570.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$646.61
|
| Rate for Payer: PHP Commercial |
$646.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$494.47
|
| Rate for Payer: Priority Health SBD |
$479.25
|
| Rate for Payer: UMR Bronson Commercial |
$334.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$570.54
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$59.02
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$53.12 |
| Rate for Payer: Aetna American Axle |
$38.36
|
| Rate for Payer: Aetna Commercial |
$50.17
|
| Rate for Payer: Aetna Medicare |
$29.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.36
|
| Rate for Payer: BCBS Complete |
$23.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.10
|
| Rate for Payer: BCN Commercial |
$3.10
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cofinity Commercial |
$41.31
|
| Rate for Payer: Cofinity Commercial |
$50.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.22
|
| Rate for Payer: Healthscope Commercial |
$53.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.17
|
| Rate for Payer: PHP Commercial |
$50.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.36
|
| Rate for Payer: Priority Health SBD |
$37.18
|
| Rate for Payer: UMR Bronson Commercial |
$21.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.26
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$59.02
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.97 |
| Max. Negotiated Rate |
$53.12 |
| Rate for Payer: Aetna American Axle |
$38.36
|
| Rate for Payer: Aetna Commercial |
$50.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.36
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cofinity Commercial |
$41.31
|
| Rate for Payer: Cofinity Commercial |
$50.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$41.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.22
|
| Rate for Payer: Healthscope Commercial |
$53.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.17
|
| Rate for Payer: PHP Commercial |
$50.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.36
|
| Rate for Payer: Priority Health SBD |
$37.18
|
| Rate for Payer: UMR Bronson Commercial |
$25.97
|
| 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 |
$154.77 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna American Axle |
$271.90
|
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna Medicare |
$209.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.90
|
| Rate for Payer: BCBS Complete |
$167.32
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$292.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.90
|
| Rate for Payer: Priority Health SBD |
$263.53
|
| Rate for Payer: UMR Bronson Commercial |
$154.77
|
| 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 |
$184.05 |
| Max. Negotiated Rate |
$376.47 |
| Rate for Payer: Aetna American Axle |
$271.90
|
| Rate for Payer: Aetna Commercial |
$355.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.90
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$292.81
|
| Rate for Payer: Cofinity Commercial |
$359.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$292.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$376.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$292.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: PHP Commercial |
$355.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.90
|
| Rate for Payer: Priority Health SBD |
$263.53
|
| Rate for Payer: UMR Bronson Commercial |
$184.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.72
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$107.41
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$47.26 |
| Max. Negotiated Rate |
$96.67 |
| Rate for Payer: Aetna American Axle |
$69.82
|
| Rate for Payer: Aetna American Axle |
$48.73
|
| Rate for Payer: Aetna Commercial |
$91.30
|
| Rate for Payer: Aetna Commercial |
$63.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.73
|
| Rate for Payer: Cash Price |
$85.93
|
| Rate for Payer: Cash Price |
$59.98
|
| Rate for Payer: Cofinity Commercial |
$64.47
|
| Rate for Payer: Cofinity Commercial |
$52.48
|
| Rate for Payer: Cofinity Commercial |
$75.19
|
| Rate for Payer: Cofinity Commercial |
$92.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$52.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.98
|
| Rate for Payer: Healthscope Commercial |
$96.67
|
| Rate for Payer: Healthscope Commercial |
$67.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.30
|
| Rate for Payer: PHP Commercial |
$63.72
|
| Rate for Payer: PHP Commercial |
$91.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.73
|
| Rate for Payer: Priority Health SBD |
$67.67
|
| Rate for Payer: Priority Health SBD |
$47.23
|
| Rate for Payer: UMR Bronson Commercial |
$47.26
|
| Rate for Payer: UMR Bronson Commercial |
$32.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.23
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$107.41
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$96.67 |
| Rate for Payer: Aetna American Axle |
$69.82
|
| Rate for Payer: Aetna American Axle |
$48.73
|
| Rate for Payer: Aetna Commercial |
$63.72
|
| Rate for Payer: Aetna Commercial |
$91.30
|
| Rate for Payer: Aetna Medicare |
$53.70
|
| Rate for Payer: Aetna Medicare |
$37.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.73
|
| Rate for Payer: BCBS Complete |
$29.99
|
| Rate for Payer: BCBS Complete |
$42.96
|
| Rate for Payer: BCBS Trust/PPO |
$3.10
|
| Rate for Payer: BCBS Trust/PPO |
$3.10
|
| Rate for Payer: BCN Commercial |
$3.10
|
| Rate for Payer: BCN Commercial |
$3.10
|
| Rate for Payer: Cash Price |
$59.98
|
| Rate for Payer: Cash Price |
$59.98
|
| Rate for Payer: Cash Price |
$85.93
|
| Rate for Payer: Cash Price |
$85.93
|
| Rate for Payer: Cofinity Commercial |
$64.47
|
| Rate for Payer: Cofinity Commercial |
$75.19
|
| Rate for Payer: Cofinity Commercial |
$52.48
|
| Rate for Payer: Cofinity Commercial |
$92.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.19
|
| Rate for Payer: Cofinity Medicare Advantage |
$52.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.93
|
| Rate for Payer: Healthscope Commercial |
$67.47
|
| Rate for Payer: Healthscope Commercial |
$96.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.72
|
| Rate for Payer: PHP Commercial |
$91.30
|
| Rate for Payer: PHP Commercial |
$63.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.73
|
| Rate for Payer: Priority Health SBD |
$47.23
|
| Rate for Payer: Priority Health SBD |
$67.67
|
| Rate for Payer: UMR Bronson Commercial |
$39.74
|
| Rate for Payer: UMR Bronson Commercial |
$27.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.56
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
OP
|
$213.75
|
|
|
Service Code
|
NDC 00904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.09 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna American Axle |
$138.94
|
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: Aetna Medicare |
$106.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.94
|
| Rate for Payer: BCBS Complete |
$85.50
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$149.62
|
| Rate for Payer: Cofinity Commercial |
$183.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$149.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$149.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.94
|
| Rate for Payer: Priority Health SBD |
$134.66
|
| Rate for Payer: UMR Bronson Commercial |
$79.09
|
| 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 |
$94.05 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna American Axle |
$138.94
|
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.94
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$149.62
|
| Rate for Payer: Cofinity Commercial |
$183.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$149.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$149.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.69
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.94
|
| Rate for Payer: Priority Health SBD |
$134.66
|
| Rate for Payer: UMR Bronson Commercial |
$94.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.31
|
|
