|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$3.46
|
|
|
Service Code
|
NDC 68084-859-11
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Aetna Commercial |
$3.11
|
| Rate for Payer: ASR ASR |
$3.36
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$3.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.77
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Healthscope Whirlpool |
$3.36
|
| Rate for Payer: Mclaren Commercial |
$3.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.04
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$345.45
|
|
|
Service Code
|
NDC 68084-859-01
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$241.82 |
| Max. Negotiated Rate |
$345.45 |
| Rate for Payer: Aetna Commercial |
$310.90
|
| Rate for Payer: ASR ASR |
$335.09
|
| Rate for Payer: BCBS Trust/PPO |
$267.83
|
| Rate for Payer: BCN Commercial |
$267.83
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$324.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.36
|
| Rate for Payer: Healthscope Commercial |
$345.45
|
| Rate for Payer: Healthscope Whirlpool |
$335.09
|
| Rate for Payer: Mclaren Commercial |
$310.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$304.00
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$263.20
|
|
|
Service Code
|
NDC 0904-6051-61
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.24 |
| Max. Negotiated Rate |
$263.20 |
| Rate for Payer: Aetna Commercial |
$236.88
|
| Rate for Payer: ASR ASR |
$255.30
|
| Rate for Payer: BCBS Trust/PPO |
$204.06
|
| Rate for Payer: BCN Commercial |
$204.06
|
| Rate for Payer: Cash Price |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$247.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.56
|
| Rate for Payer: Healthscope Commercial |
$263.20
|
| Rate for Payer: Healthscope Whirlpool |
$255.30
|
| Rate for Payer: Mclaren Commercial |
$236.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$223.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$231.62
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$284.35
|
|
|
Service Code
|
NDC 0904-7123-61
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.04 |
| Max. Negotiated Rate |
$284.35 |
| Rate for Payer: Aetna Commercial |
$255.92
|
| Rate for Payer: ASR ASR |
$275.82
|
| Rate for Payer: BCBS Trust/PPO |
$220.46
|
| Rate for Payer: BCN Commercial |
$220.46
|
| Rate for Payer: Cash Price |
$227.48
|
| Rate for Payer: Cofinity Commercial |
$267.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.48
|
| Rate for Payer: Healthscope Commercial |
$284.35
|
| Rate for Payer: Healthscope Whirlpool |
$275.82
|
| Rate for Payer: Mclaren Commercial |
$255.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$241.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$199.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$250.23
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$20.24
|
|
|
Service Code
|
NDC 0904-7060-41
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.17 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: BCBS Trust/PPO |
$15.69
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$13.54
|
|
|
Service Code
|
NDC 0121-4799-50
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.48 |
| Max. Negotiated Rate |
$13.54 |
| Rate for Payer: Aetna Commercial |
$12.19
|
| Rate for Payer: ASR ASR |
$13.13
|
| Rate for Payer: BCBS Trust/PPO |
$10.50
|
| Rate for Payer: BCN Commercial |
$10.50
|
| Rate for Payer: Cash Price |
$10.83
|
| Rate for Payer: Cofinity Commercial |
$12.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.83
|
| Rate for Payer: Healthscope Commercial |
$13.54
|
| Rate for Payer: Healthscope Whirlpool |
$13.13
|
| Rate for Payer: Mclaren Commercial |
$12.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.92
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$12.02
|
|
|
Service Code
|
NDC 0904-7060-93
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$12.02 |
| Rate for Payer: Aetna Commercial |
$10.82
|
| Rate for Payer: ASR ASR |
$11.66
|
| Rate for Payer: BCBS Trust/PPO |
$9.32
|
| Rate for Payer: BCN Commercial |
$9.32
|
| Rate for Payer: Cash Price |
$9.62
|
| Rate for Payer: Cofinity Commercial |
$11.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.62
|
| Rate for Payer: Healthscope Commercial |
$12.02
|
| Rate for Payer: Healthscope Whirlpool |
$11.66
|
| Rate for Payer: Mclaren Commercial |
$10.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.58
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$12.70
|
|
|
Service Code
|
NDC 0121-4799-05
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$12.70 |
| Rate for Payer: Aetna Commercial |
$11.43
|
| Rate for Payer: ASR ASR |
$12.32
|
| Rate for Payer: BCBS Trust/PPO |
$9.85
|
| Rate for Payer: BCN Commercial |
$9.85
|
| Rate for Payer: Cash Price |
$10.16
|
| Rate for Payer: Cofinity Commercial |
$11.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.16
|
| Rate for Payer: Healthscope Commercial |
$12.70
|
| Rate for Payer: Healthscope Whirlpool |
$12.32
|
| Rate for Payer: Mclaren Commercial |
$11.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.18
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$23.71
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
77195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$16.60 |
| Max. Negotiated Rate |
$23.71 |
| Rate for Payer: Aetna Commercial |
$21.34
|
| Rate for Payer: Aetna Commercial |
$13.37
|
| Rate for Payer: Aetna Commercial |
$24.27
|
| Rate for Payer: Aetna Commercial |
$24.04
|
| Rate for Payer: Aetna Commercial |
$13.75
|
| Rate for Payer: Aetna Commercial |
$18.55
|
| Rate for Payer: Aetna Commercial |
$197.78
|
| Rate for Payer: Aetna Commercial |
$14.09
|
| Rate for Payer: ASR ASR |
$26.16
|
| Rate for Payer: ASR ASR |
$25.91
|
| Rate for Payer: ASR ASR |
$15.19
|
| Rate for Payer: ASR ASR |
$14.82
|
| Rate for Payer: ASR ASR |
$23.00
|
| Rate for Payer: ASR ASR |
$14.41
|
| Rate for Payer: ASR ASR |
$213.17
|
| Rate for Payer: ASR ASR |
$19.99
|
| Rate for Payer: BCBS Trust/PPO |
$11.85
|
| Rate for Payer: BCBS Trust/PPO |
$18.38
|
| Rate for Payer: BCBS Trust/PPO |
$15.98
|
| Rate for Payer: BCBS Trust/PPO |
$170.38
|
| Rate for Payer: BCBS Trust/PPO |
$20.91
|
| Rate for Payer: BCBS Trust/PPO |
$20.71
|
| Rate for Payer: BCBS Trust/PPO |
$11.52
|
| Rate for Payer: BCBS Trust/PPO |
$12.14
|
| Rate for Payer: BCN Commercial |
$11.52
|
| Rate for Payer: BCN Commercial |
$12.14
|
| Rate for Payer: BCN Commercial |
$18.38
|
| Rate for Payer: BCN Commercial |
$20.71
|
| Rate for Payer: BCN Commercial |
$11.85
|
| Rate for Payer: BCN Commercial |
$20.91
|
| Rate for Payer: BCN Commercial |
$170.38
|
| Rate for Payer: BCN Commercial |
$15.98
|
| Rate for Payer: Cash Price |
$11.89
|
| Rate for Payer: Cash Price |
$12.22
|
| Rate for Payer: Cash Price |
$12.53
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cash Price |
$175.81
|
| Rate for Payer: Cash Price |
$18.97
|
| Rate for Payer: Cash Price |
$21.37
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cofinity Commercial |
$206.57
|
| Rate for Payer: Cofinity Commercial |
$13.97
|
| Rate for Payer: Cofinity Commercial |
$19.37
|
| Rate for Payer: Cofinity Commercial |
$14.72
|
| Rate for Payer: Cofinity Commercial |
$14.36
|
| Rate for Payer: Cofinity Commercial |
$25.35
|
| Rate for Payer: Cofinity Commercial |
$25.11
|
| Rate for Payer: Cofinity Commercial |
$22.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.49
|
| Rate for Payer: Healthscope Commercial |
$14.86
|
| Rate for Payer: Healthscope Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$26.97
|
| Rate for Payer: Healthscope Commercial |
$20.61
|
| Rate for Payer: Healthscope Commercial |
$26.71
|
| Rate for Payer: Healthscope Commercial |
$23.71
|
| Rate for Payer: Healthscope Commercial |
$219.76
|
| Rate for Payer: Healthscope Commercial |
$15.28
|
| Rate for Payer: Healthscope Whirlpool |
$26.16
|
| Rate for Payer: Healthscope Whirlpool |
$14.82
|
| Rate for Payer: Healthscope Whirlpool |
$23.00
|
| Rate for Payer: Healthscope Whirlpool |
$14.41
|
| Rate for Payer: Healthscope Whirlpool |
$25.91
|
| Rate for Payer: Healthscope Whirlpool |
$15.19
|
| Rate for Payer: Healthscope Whirlpool |
$19.99
|
| Rate for Payer: Healthscope Whirlpool |
$213.17
|
| Rate for Payer: Mclaren Commercial |
$13.37
|
| Rate for Payer: Mclaren Commercial |
$18.55
|
| Rate for Payer: Mclaren Commercial |
$24.27
|
| Rate for Payer: Mclaren Commercial |
$13.75
|
| Rate for Payer: Mclaren Commercial |
$197.78
|
| Rate for Payer: Mclaren Commercial |
$21.34
|
| Rate for Payer: Mclaren Commercial |
$24.04
|
| Rate for Payer: Mclaren Commercial |
$14.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$193.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.73
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$310.20
|
|
|
Service Code
|
NDC 0904-7124-61
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$217.14 |
| Max. Negotiated Rate |
$310.20 |
| Rate for Payer: Aetna Commercial |
$279.18
|
| Rate for Payer: ASR ASR |
$300.89
|
| Rate for Payer: BCBS Trust/PPO |
$240.50
|
| Rate for Payer: BCN Commercial |
$240.50
|
| Rate for Payer: Cash Price |
$248.16
|
| Rate for Payer: Cofinity Commercial |
$291.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.16
|
| Rate for Payer: Healthscope Commercial |
$310.20
|
| Rate for Payer: Healthscope Whirlpool |
$300.89
|
| Rate for Payer: Mclaren Commercial |
$279.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$263.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$217.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$272.98
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$2.38
|
|
|
Service Code
|
NDC 68084-870-11
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.67 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna Commercial |
$2.14
|
| Rate for Payer: ASR ASR |
$2.31
|
| Rate for Payer: BCBS Trust/PPO |
$1.85
|
| Rate for Payer: BCN Commercial |
$1.85
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.90
|
| Rate for Payer: Healthscope Commercial |
$2.38
|
| Rate for Payer: Healthscope Whirlpool |
$2.31
|
| Rate for Payer: Mclaren Commercial |
$2.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.09
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$279.65
|
|
|
Service Code
|
NDC 0904-6052-61
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.76 |
| Max. Negotiated Rate |
$279.65 |
| Rate for Payer: Aetna Commercial |
$251.68
|
| Rate for Payer: ASR ASR |
$271.26
|
| Rate for Payer: BCBS Trust/PPO |
$216.81
|
| Rate for Payer: BCN Commercial |
$216.81
|
| Rate for Payer: Cash Price |
$223.72
|
| Rate for Payer: Cofinity Commercial |
$262.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.72
|
| Rate for Payer: Healthscope Commercial |
$279.65
|
| Rate for Payer: Healthscope Whirlpool |
$271.26
|
| Rate for Payer: Mclaren Commercial |
$251.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$237.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$246.09
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 68084-870-01
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.92 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Aetna Commercial |
$214.60
|
| Rate for Payer: ASR ASR |
$231.30
|
| Rate for Payer: BCBS Trust/PPO |
$184.87
|
| Rate for Payer: BCN Commercial |
$184.87
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$224.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$238.45
|
| Rate for Payer: Healthscope Whirlpool |
$231.30
|
| Rate for Payer: Mclaren Commercial |
$214.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$209.84
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$8.40
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$8.40 |
| Rate for Payer: Aetna Commercial |
$7.56
|
| Rate for Payer: ASR ASR |
$8.15
|
| Rate for Payer: BCBS Trust/PPO |
$6.51
|
| Rate for Payer: BCN Commercial |
$6.51
|
| Rate for Payer: Cash Price |
$6.72
|
| Rate for Payer: Cofinity Commercial |
$7.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.72
|
| Rate for Payer: Healthscope Commercial |
$8.40
|
| Rate for Payer: Healthscope Whirlpool |
$8.15
|
| Rate for Payer: Mclaren Commercial |
$7.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$7.39
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
IP
|
$411.25
|
|
|
Service Code
|
NDC 0904-6351-61
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.88 |
| Max. Negotiated Rate |
$411.25 |
| Rate for Payer: Aetna Commercial |
$370.12
|
| Rate for Payer: ASR ASR |
$398.91
|
| Rate for Payer: BCBS Trust/PPO |
$318.84
|
| Rate for Payer: BCN Commercial |
$318.84
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cofinity Commercial |
$386.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$329.00
|
| Rate for Payer: Healthscope Commercial |
$411.25
|
| Rate for Payer: Healthscope Whirlpool |
$398.91
|
| Rate for Payer: Mclaren Commercial |
$370.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$349.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$361.90
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$13.20
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.24 |
| Max. Negotiated Rate |
$13.20 |
| Rate for Payer: Aetna Commercial |
$11.88
|
| Rate for Payer: Aetna Commercial |
$6.84
|
| Rate for Payer: Aetna Commercial |
$8.28
|
| Rate for Payer: ASR ASR |
$7.37
|
| Rate for Payer: ASR ASR |
$12.80
|
| Rate for Payer: ASR ASR |
$8.92
|
| Rate for Payer: BCBS Trust/PPO |
$5.89
|
| Rate for Payer: BCBS Trust/PPO |
$10.23
|
| Rate for Payer: BCBS Trust/PPO |
$7.13
|
| Rate for Payer: BCN Commercial |
$7.13
|
| Rate for Payer: BCN Commercial |
$10.23
|
| Rate for Payer: BCN Commercial |
$5.89
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cash Price |
$7.36
|
| Rate for Payer: Cash Price |
$10.56
|
| Rate for Payer: Cofinity Commercial |
$12.41
|
| Rate for Payer: Cofinity Commercial |
$7.14
|
| Rate for Payer: Cofinity Commercial |
$8.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.36
|
| Rate for Payer: Healthscope Commercial |
$13.20
|
| Rate for Payer: Healthscope Commercial |
$7.60
|
| Rate for Payer: Healthscope Commercial |
$9.20
|
| Rate for Payer: Healthscope Whirlpool |
$8.92
|
| Rate for Payer: Healthscope Whirlpool |
$7.37
|
| Rate for Payer: Healthscope Whirlpool |
$12.80
|
| Rate for Payer: Mclaren Commercial |
$11.88
|
| Rate for Payer: Mclaren Commercial |
$8.28
|
| Rate for Payer: Mclaren Commercial |
$6.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.10
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
IP
|
$213.75
|
|
|
Service Code
|
NDC 0904-6352-61
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.62 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$192.38
|
| Rate for Payer: ASR ASR |
$207.34
|
| Rate for Payer: BCBS Trust/PPO |
$165.72
|
| Rate for Payer: BCN Commercial |
$165.72
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$200.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$213.75
|
| Rate for Payer: Healthscope Whirlpool |
$207.34
|
| Rate for Payer: Mclaren Commercial |
$192.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$181.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$188.10
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
IP
|
$458.85
|
|
|
Service Code
|
NDC 68084-482-01
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$321.20 |
| Max. Negotiated Rate |
$458.85 |
| Rate for Payer: Aetna Commercial |
$412.96
|
| Rate for Payer: ASR ASR |
$445.08
|
| Rate for Payer: BCBS Trust/PPO |
$355.75
|
| Rate for Payer: BCN Commercial |
$355.75
|
| Rate for Payer: Cash Price |
$367.08
|
| Rate for Payer: Cofinity Commercial |
$431.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$367.08
|
| Rate for Payer: Healthscope Commercial |
$458.85
|
| Rate for Payer: Healthscope Whirlpool |
$445.08
|
| Rate for Payer: Mclaren Commercial |
$412.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$390.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$321.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$403.79
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
IP
|
$458.85
|
|
|
Service Code
|
NDC 68084-482-11
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$321.20 |
| Max. Negotiated Rate |
$458.85 |
| Rate for Payer: Aetna Commercial |
$412.96
|
| Rate for Payer: ASR ASR |
$445.08
|
| Rate for Payer: BCBS Trust/PPO |
$355.75
|
| Rate for Payer: BCN Commercial |
$355.75
|
| Rate for Payer: Cash Price |
$367.08
|
| Rate for Payer: Cofinity Commercial |
$431.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$367.08
|
| Rate for Payer: Healthscope Commercial |
$458.85
|
| Rate for Payer: Healthscope Whirlpool |
$445.08
|
| Rate for Payer: Mclaren Commercial |
$412.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$390.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$321.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$403.79
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$7.80
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.46 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: Aetna Commercial |
$13.50
|
| Rate for Payer: ASR ASR |
$7.57
|
| Rate for Payer: ASR ASR |
$14.55
|
| Rate for Payer: BCBS Trust/PPO |
$11.63
|
| Rate for Payer: BCBS Trust/PPO |
$6.05
|
| Rate for Payer: BCN Commercial |
$11.63
|
| Rate for Payer: BCN Commercial |
$6.05
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cofinity Commercial |
$7.33
|
| Rate for Payer: Cofinity Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.24
|
| Rate for Payer: Healthscope Commercial |
$7.80
|
| Rate for Payer: Healthscope Commercial |
$15.00
|
| Rate for Payer: Healthscope Whirlpool |
$14.55
|
| Rate for Payer: Healthscope Whirlpool |
$7.57
|
| Rate for Payer: Mclaren Commercial |
$7.02
|
| Rate for Payer: Mclaren Commercial |
$13.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.86
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$188.01
|
|
|
Service Code
|
NDC 70860-451-10
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$131.61 |
| Max. Negotiated Rate |
$188.01 |
| Rate for Payer: Aetna Commercial |
$169.21
|
| Rate for Payer: ASR ASR |
$182.37
|
| Rate for Payer: BCBS Trust/PPO |
$145.76
|
| Rate for Payer: BCN Commercial |
$145.76
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cofinity Commercial |
$176.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Healthscope Commercial |
$188.01
|
| Rate for Payer: Healthscope Whirlpool |
$182.37
|
| Rate for Payer: Mclaren Commercial |
$169.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$159.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$165.45
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$371.92
|
|
|
Service Code
|
NDC 0378-1809-77
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$260.34 |
| Max. Negotiated Rate |
$371.92 |
| Rate for Payer: Aetna Commercial |
$334.73
|
| Rate for Payer: ASR ASR |
$360.76
|
| Rate for Payer: BCBS Trust/PPO |
$288.35
|
| Rate for Payer: BCN Commercial |
$288.35
|
| Rate for Payer: Cash Price |
$297.54
|
| Rate for Payer: Cofinity Commercial |
$349.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.54
|
| Rate for Payer: Healthscope Commercial |
$371.92
|
| Rate for Payer: Healthscope Whirlpool |
$360.76
|
| Rate for Payer: Mclaren Commercial |
$334.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$316.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$327.29
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.69
|
|
|
Service Code
|
NDC 51079-442-01
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.88 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Aetna Commercial |
$2.42
|
| Rate for Payer: ASR ASR |
$2.61
|
| Rate for Payer: BCBS Trust/PPO |
$2.09
|
| Rate for Payer: BCN Commercial |
$2.09
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cofinity Commercial |
$2.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.15
|
| Rate for Payer: Healthscope Commercial |
$2.69
|
| Rate for Payer: Healthscope Whirlpool |
$2.61
|
| Rate for Payer: Mclaren Commercial |
$2.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.37
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$268.80
|
|
|
Service Code
|
NDC 51079-442-20
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.16 |
| Max. Negotiated Rate |
$268.80 |
| Rate for Payer: Aetna Commercial |
$241.92
|
| Rate for Payer: ASR ASR |
$260.74
|
| Rate for Payer: BCBS Trust/PPO |
$208.40
|
| Rate for Payer: BCN Commercial |
$208.40
|
| Rate for Payer: Cash Price |
$215.04
|
| Rate for Payer: Cofinity Commercial |
$252.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.04
|
| Rate for Payer: Healthscope Commercial |
$268.80
|
| Rate for Payer: Healthscope Whirlpool |
$260.74
|
| Rate for Payer: Mclaren Commercial |
$241.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$228.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$236.54
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$391.40
|
|
|
Service Code
|
NDC 0904-6953-61
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$273.98 |
| Max. Negotiated Rate |
$391.40 |
| Rate for Payer: Aetna Commercial |
$352.26
|
| Rate for Payer: ASR ASR |
$379.66
|
| Rate for Payer: BCBS Trust/PPO |
$303.45
|
| Rate for Payer: BCN Commercial |
$303.45
|
| Rate for Payer: Cash Price |
$313.12
|
| Rate for Payer: Cofinity Commercial |
$367.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$313.12
|
| Rate for Payer: Healthscope Commercial |
$391.40
|
| Rate for Payer: Healthscope Whirlpool |
$379.66
|
| Rate for Payer: Mclaren Commercial |
$352.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$332.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$344.43
|
|
