|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$317.25
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.21 |
| Max. Negotiated Rate |
$317.25 |
| Rate for Payer: Aetna Commercial |
$285.52
|
| Rate for Payer: ASR ASR |
$307.73
|
| Rate for Payer: ASR Commercial |
$307.73
|
| Rate for Payer: BCBS Trust/PPO |
$258.53
|
| Rate for Payer: BCN Commercial |
$245.96
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cofinity Commercial |
$298.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.80
|
| Rate for Payer: Healthscope Commercial |
$317.25
|
| Rate for Payer: Healthscope Whirlpool |
$307.73
|
| Rate for Payer: Mclaren Commercial |
$285.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.66
|
| Rate for Payer: Nomi Health Commercial |
$260.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$279.18
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$14.80
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.92 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: Aetna Medicare |
$7.40
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Complete |
$5.92
|
| Rate for Payer: BCBS Trust/PPO |
$12.12
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$12.97
|
| Rate for Payer: Priority Health Narrow Network |
$10.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$14.80
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$14.80 |
| Rate for Payer: Aetna Commercial |
$13.32
|
| Rate for Payer: ASR ASR |
$14.36
|
| Rate for Payer: ASR Commercial |
$14.36
|
| Rate for Payer: BCBS Trust/PPO |
$12.06
|
| Rate for Payer: BCN Commercial |
$11.47
|
| Rate for Payer: Cash Price |
$11.84
|
| Rate for Payer: Cofinity Commercial |
$13.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.84
|
| Rate for Payer: Healthscope Commercial |
$14.80
|
| Rate for Payer: Healthscope Whirlpool |
$14.36
|
| Rate for Payer: Mclaren Commercial |
$13.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.58
|
| Rate for Payer: Nomi Health Commercial |
$12.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.02
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
IP
|
$418.30
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.89 |
| Max. Negotiated Rate |
$418.30 |
| Rate for Payer: Aetna Commercial |
$376.47
|
| Rate for Payer: ASR ASR |
$405.75
|
| Rate for Payer: ASR Commercial |
$405.75
|
| Rate for Payer: BCBS Trust/PPO |
$340.87
|
| Rate for Payer: BCN Commercial |
$324.31
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$393.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$418.30
|
| Rate for Payer: Healthscope Whirlpool |
$405.75
|
| Rate for Payer: Mclaren Commercial |
$376.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: Nomi Health Commercial |
$343.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$368.10
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
OP
|
$418.30
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.32 |
| Max. Negotiated Rate |
$418.30 |
| Rate for Payer: Aetna Commercial |
$376.47
|
| Rate for Payer: Aetna Medicare |
$209.15
|
| Rate for Payer: ASR ASR |
$405.75
|
| Rate for Payer: ASR Commercial |
$405.75
|
| Rate for Payer: BCBS Complete |
$167.32
|
| Rate for Payer: BCBS Trust/PPO |
$342.55
|
| Rate for Payer: BCN Commercial |
$324.31
|
| Rate for Payer: Cash Price |
$334.64
|
| Rate for Payer: Cofinity Commercial |
$393.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.64
|
| Rate for Payer: Healthscope Commercial |
$418.30
|
| Rate for Payer: Healthscope Whirlpool |
$405.75
|
| Rate for Payer: Mclaren Commercial |
$376.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.56
|
| Rate for Payer: Nomi Health Commercial |
$343.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.89
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$366.51
|
| Rate for Payer: Priority Health Narrow Network |
$293.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$368.10
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$46.80
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.42 |
| Max. Negotiated Rate |
$46.80 |
| Rate for Payer: Aetna Commercial |
$42.12
|
| Rate for Payer: Aetna Commercial |
$16.92
|
| Rate for Payer: Aetna Commercial |
$6.84
|
| Rate for Payer: ASR ASR |
$18.24
|
| Rate for Payer: ASR ASR |
$45.40
|
| Rate for Payer: ASR ASR |
$7.37
|
| Rate for Payer: ASR Commercial |
$45.40
|
| Rate for Payer: ASR Commercial |
$18.24
|
| Rate for Payer: ASR Commercial |
$7.37
|
| Rate for Payer: BCBS Trust/PPO |
$6.19
|
| Rate for Payer: BCBS Trust/PPO |
$15.32
|
| Rate for Payer: BCBS Trust/PPO |
$38.14
|
| Rate for Payer: BCN Commercial |
$14.58
|
| Rate for Payer: BCN Commercial |
$5.89
|
| Rate for Payer: BCN Commercial |
$36.28
|
| Rate for Payer: Cash Price |
$37.44
|
| Rate for Payer: Cash Price |
$15.04
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cofinity Commercial |
$7.14
|
| Rate for Payer: Cofinity Commercial |
$17.67
|
| Rate for Payer: Cofinity Commercial |
$43.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.08
|
| Rate for Payer: Healthscope Commercial |
$18.80
|
| Rate for Payer: Healthscope Commercial |
$46.80
|
| Rate for Payer: Healthscope Commercial |
$7.60
|
| Rate for Payer: Healthscope Whirlpool |
$45.40
|
| Rate for Payer: Healthscope Whirlpool |
$18.24
|
| Rate for Payer: Healthscope Whirlpool |
$7.37
|
| Rate for Payer: Mclaren Commercial |
$42.12
|
| Rate for Payer: Mclaren Commercial |
$16.92
|
| Rate for Payer: Mclaren Commercial |
$6.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.98
|
| Rate for Payer: Nomi Health Commercial |
$38.38
|
| Rate for Payer: Nomi Health Commercial |
$15.42
|
| Rate for Payer: Nomi Health Commercial |
$6.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.54
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$18.80
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$18.80 |
| Rate for Payer: Aetna Commercial |
$16.92
|
| Rate for Payer: Aetna Commercial |
$42.12
|
| Rate for Payer: Aetna Commercial |
$6.84
|
| Rate for Payer: Aetna Medicare |
$23.40
|
| Rate for Payer: Aetna Medicare |
$3.80
|
| Rate for Payer: Aetna Medicare |
$9.40
|
| Rate for Payer: ASR ASR |
$45.40
|
| Rate for Payer: ASR ASR |
$18.24
|
| Rate for Payer: ASR ASR |
$7.37
|
| Rate for Payer: ASR Commercial |
$7.37
|
| Rate for Payer: ASR Commercial |
$45.40
|
| Rate for Payer: ASR Commercial |
$18.24
|
| Rate for Payer: BCBS Complete |
$7.52
|
| Rate for Payer: BCBS Complete |
$18.72
|
| Rate for Payer: BCBS Complete |
$3.04
|
| Rate for Payer: BCBS Trust/PPO |
$15.40
|
| Rate for Payer: BCBS Trust/PPO |
$38.32
|
| Rate for Payer: BCBS Trust/PPO |
$6.22
|
| Rate for Payer: BCN Commercial |
$5.89
|
| Rate for Payer: BCN Commercial |
$14.58
|
| Rate for Payer: BCN Commercial |
$36.28
|
| Rate for Payer: Cash Price |
$37.44
|
| Rate for Payer: Cash Price |
$15.04
|
| Rate for Payer: Cash Price |
$6.08
|
| Rate for Payer: Cofinity Commercial |
$7.14
|
| Rate for Payer: Cofinity Commercial |
$17.67
|
| Rate for Payer: Cofinity Commercial |
$43.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.08
|
| Rate for Payer: Healthscope Commercial |
$18.80
|
| Rate for Payer: Healthscope Commercial |
$46.80
|
| Rate for Payer: Healthscope Commercial |
$7.60
|
| Rate for Payer: Healthscope Whirlpool |
$45.40
|
| Rate for Payer: Healthscope Whirlpool |
$18.24
|
| Rate for Payer: Healthscope Whirlpool |
$7.37
|
| Rate for Payer: Mclaren Commercial |
$16.92
|
| Rate for Payer: Mclaren Commercial |
$42.12
|
| Rate for Payer: Mclaren Commercial |
$6.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.46
|
| Rate for Payer: Nomi Health Commercial |
$15.42
|
| Rate for Payer: Nomi Health Commercial |
$38.38
|
| Rate for Payer: Nomi Health Commercial |
$6.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$41.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.47
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.66
|
| Rate for Payer: Priority Health Narrow Network |
$5.33
|
| Rate for Payer: Priority Health Narrow Network |
$13.18
|
| Rate for Payer: Priority Health Narrow Network |
$32.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.69
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
OP
|
$458.85
|
|
|
Service Code
|
NDC 68084048201
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.54 |
| Max. Negotiated Rate |
$458.85 |
| Rate for Payer: Aetna Commercial |
$412.96
|
| Rate for Payer: Aetna Medicare |
$229.43
|
| Rate for Payer: ASR ASR |
$445.08
|
| Rate for Payer: ASR Commercial |
$445.08
|
| Rate for Payer: BCBS Complete |
$183.54
|
| Rate for Payer: BCBS Trust/PPO |
$375.75
|
| 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 Commercial |
$390.02
|
| Rate for Payer: Nomi Health Commercial |
$376.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$402.04
|
| Rate for Payer: Priority Health Narrow Network |
$321.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$403.79
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
OP
|
$458.85
|
|
|
Service Code
|
NDC 68084048211
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.54 |
| Max. Negotiated Rate |
$458.85 |
| Rate for Payer: Aetna Commercial |
$412.96
|
| Rate for Payer: Aetna Medicare |
$229.43
|
| Rate for Payer: ASR ASR |
$445.08
|
| Rate for Payer: ASR Commercial |
$445.08
|
| Rate for Payer: BCBS Complete |
$183.54
|
| Rate for Payer: BCBS Trust/PPO |
$375.75
|
| 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 Commercial |
$390.02
|
| Rate for Payer: Nomi Health Commercial |
$376.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$402.04
|
| Rate for Payer: Priority Health Narrow Network |
$321.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$403.79
|
|
|
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 |
$458.85 |
| Rate for Payer: Aetna Commercial |
$412.96
|
| Rate for Payer: ASR ASR |
$445.08
|
| Rate for Payer: ASR Commercial |
$445.08
|
| Rate for Payer: BCBS Trust/PPO |
$373.92
|
| 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 Commercial |
$390.02
|
| Rate for Payer: Nomi Health Commercial |
$376.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$403.79
|
|
|
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 |
$213.75 |
| Rate for Payer: Aetna Commercial |
$192.38
|
| Rate for Payer: ASR ASR |
$207.34
|
| Rate for Payer: ASR Commercial |
$207.34
|
| Rate for Payer: BCBS Trust/PPO |
$174.18
|
| Rate for Payer: BCN Commercial |
$165.72
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$200.93
|
| 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 Commercial |
$181.69
|
| Rate for Payer: Nomi Health Commercial |
$175.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$188.10
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
IP
|
$458.85
|
|
|
Service Code
|
NDC 68084048201
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$298.25 |
| Max. Negotiated Rate |
$458.85 |
| Rate for Payer: Aetna Commercial |
$412.96
|
| Rate for Payer: ASR ASR |
$445.08
|
| Rate for Payer: ASR Commercial |
$445.08
|
| Rate for Payer: BCBS Trust/PPO |
$373.92
|
| 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 Commercial |
$390.02
|
| Rate for Payer: Nomi Health Commercial |
$376.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$403.79
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
OP
|
$213.75
|
|
|
Service Code
|
NDC 00904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.50 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$192.38
|
| Rate for Payer: Aetna Medicare |
$106.88
|
| Rate for Payer: ASR ASR |
$207.34
|
| Rate for Payer: ASR Commercial |
$207.34
|
| Rate for Payer: BCBS Complete |
$85.50
|
| Rate for Payer: BCBS Trust/PPO |
$175.04
|
| Rate for Payer: BCN Commercial |
$165.72
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$200.93
|
| 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 Commercial |
$181.69
|
| Rate for Payer: Nomi Health Commercial |
$175.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$138.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$187.29
|
| Rate for Payer: Priority Health Narrow Network |
$149.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$188.10
|
|
|
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 |
$5.07 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: Aetna Commercial |
$19.98
|
| Rate for Payer: ASR ASR |
$21.53
|
| Rate for Payer: ASR ASR |
$7.57
|
| Rate for Payer: ASR Commercial |
$21.53
|
| Rate for Payer: ASR Commercial |
$7.57
|
| Rate for Payer: BCBS Trust/PPO |
$18.09
|
| Rate for Payer: BCBS Trust/PPO |
$6.36
|
| Rate for Payer: BCN Commercial |
$6.05
|
| Rate for Payer: BCN Commercial |
$17.21
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$20.87
|
| Rate for Payer: Cofinity Commercial |
$7.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.24
|
| Rate for Payer: Healthscope Commercial |
$22.20
|
| Rate for Payer: Healthscope Commercial |
$7.80
|
| Rate for Payer: Healthscope Whirlpool |
$7.57
|
| Rate for Payer: Healthscope Whirlpool |
$21.53
|
| Rate for Payer: Mclaren Commercial |
$19.98
|
| Rate for Payer: Mclaren Commercial |
$7.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.87
|
| Rate for Payer: Nomi Health Commercial |
$6.40
|
| Rate for Payer: Nomi Health Commercial |
$18.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.86
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$22.20
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.88 |
| Max. Negotiated Rate |
$22.20 |
| Rate for Payer: Aetna Commercial |
$19.98
|
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: Aetna Medicare |
$11.10
|
| Rate for Payer: Aetna Medicare |
$3.90
|
| Rate for Payer: ASR ASR |
$21.53
|
| Rate for Payer: ASR ASR |
$7.57
|
| Rate for Payer: ASR Commercial |
$7.57
|
| Rate for Payer: ASR Commercial |
$21.53
|
| Rate for Payer: BCBS Complete |
$8.88
|
| Rate for Payer: BCBS Complete |
$3.12
|
| Rate for Payer: BCBS Trust/PPO |
$18.18
|
| Rate for Payer: BCBS Trust/PPO |
$6.39
|
| Rate for Payer: BCN Commercial |
$6.05
|
| Rate for Payer: BCN Commercial |
$17.21
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cofinity Commercial |
$20.87
|
| Rate for Payer: Cofinity Commercial |
$7.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.24
|
| Rate for Payer: Healthscope Commercial |
$22.20
|
| Rate for Payer: Healthscope Commercial |
$7.80
|
| Rate for Payer: Healthscope Whirlpool |
$21.53
|
| Rate for Payer: Healthscope Whirlpool |
$7.57
|
| Rate for Payer: Mclaren Commercial |
$19.98
|
| Rate for Payer: Mclaren Commercial |
$7.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.87
|
| Rate for Payer: Nomi Health Commercial |
$18.20
|
| Rate for Payer: Nomi Health Commercial |
$6.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.83
|
| Rate for Payer: Priority Health Narrow Network |
$5.47
|
| Rate for Payer: Priority Health Narrow Network |
$15.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.54
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$188.01
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$75.20 |
| Max. Negotiated Rate |
$188.01 |
| Rate for Payer: Aetna Commercial |
$169.21
|
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Medicare |
$94.00
|
| Rate for Payer: Aetna Medicare |
$115.96
|
| Rate for Payer: ASR ASR |
$182.37
|
| Rate for Payer: ASR ASR |
$224.96
|
| Rate for Payer: ASR Commercial |
$224.96
|
| Rate for Payer: ASR Commercial |
$182.37
|
| Rate for Payer: BCBS Complete |
$75.20
|
| Rate for Payer: BCBS Complete |
$92.77
|
| Rate for Payer: BCBS Trust/PPO |
$153.96
|
| Rate for Payer: BCBS Trust/PPO |
$189.92
|
| Rate for Payer: BCN Commercial |
$179.81
|
| Rate for Payer: BCN Commercial |
$145.76
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$176.73
|
| Rate for Payer: Cofinity Commercial |
$218.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Healthscope Commercial |
$188.01
|
| Rate for Payer: Healthscope Commercial |
$231.92
|
| Rate for Payer: Healthscope Whirlpool |
$182.37
|
| Rate for Payer: Healthscope Whirlpool |
$224.96
|
| Rate for Payer: Mclaren Commercial |
$169.21
|
| Rate for Payer: Mclaren Commercial |
$208.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: Nomi Health Commercial |
$154.17
|
| Rate for Payer: Nomi Health Commercial |
$190.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$164.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$203.21
|
| Rate for Payer: Priority Health Narrow Network |
$162.58
|
| Rate for Payer: Priority Health Narrow Network |
$131.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$204.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$165.45
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$231.92
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.75 |
| Max. Negotiated Rate |
$231.92 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Commercial |
$169.21
|
| Rate for Payer: ASR ASR |
$182.37
|
| Rate for Payer: ASR ASR |
$224.96
|
| Rate for Payer: ASR Commercial |
$182.37
|
| Rate for Payer: ASR Commercial |
$224.96
|
| Rate for Payer: BCBS Trust/PPO |
$153.21
|
| Rate for Payer: BCBS Trust/PPO |
$188.99
|
| Rate for Payer: BCN Commercial |
$179.81
|
| Rate for Payer: BCN Commercial |
$145.76
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cofinity Commercial |
$176.73
|
| Rate for Payer: Cofinity Commercial |
$218.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Healthscope Commercial |
$188.01
|
| Rate for Payer: Healthscope Commercial |
$231.92
|
| Rate for Payer: Healthscope Whirlpool |
$224.96
|
| Rate for Payer: Healthscope Whirlpool |
$182.37
|
| Rate for Payer: Mclaren Commercial |
$169.21
|
| Rate for Payer: Mclaren Commercial |
$208.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: Nomi Health Commercial |
$190.17
|
| Rate for Payer: Nomi Health Commercial |
$154.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$165.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$204.09
|
|
|
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 |
$396.15 |
| Rate for Payer: Aetna Commercial |
$356.54
|
| Rate for Payer: ASR ASR |
$384.27
|
| Rate for Payer: ASR Commercial |
$384.27
|
| Rate for Payer: BCBS Trust/PPO |
$322.82
|
| Rate for Payer: BCN Commercial |
$307.14
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$372.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Healthscope Commercial |
$396.15
|
| Rate for Payer: Healthscope Whirlpool |
$384.27
|
| Rate for Payer: Mclaren Commercial |
$356.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: Nomi Health Commercial |
$324.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$348.61
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$337.72
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.09 |
| Max. Negotiated Rate |
$337.72 |
| Rate for Payer: Aetna Commercial |
$303.95
|
| Rate for Payer: Aetna Medicare |
$168.86
|
| Rate for Payer: ASR ASR |
$327.59
|
| Rate for Payer: ASR Commercial |
$327.59
|
| Rate for Payer: BCBS Complete |
$135.09
|
| Rate for Payer: BCBS Trust/PPO |
$276.56
|
| Rate for Payer: BCN Commercial |
$261.83
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$317.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$337.72
|
| Rate for Payer: Healthscope Whirlpool |
$327.59
|
| Rate for Payer: Mclaren Commercial |
$303.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.06
|
| Rate for Payer: Nomi Health Commercial |
$276.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$295.91
|
| Rate for Payer: Priority Health Narrow Network |
$236.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$297.19
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$280.32
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.13 |
| Max. Negotiated Rate |
$280.32 |
| Rate for Payer: Aetna Commercial |
$252.29
|
| Rate for Payer: Aetna Medicare |
$140.16
|
| Rate for Payer: ASR ASR |
$271.91
|
| Rate for Payer: ASR Commercial |
$271.91
|
| Rate for Payer: BCBS Complete |
$112.13
|
| Rate for Payer: BCBS Trust/PPO |
$229.55
|
| Rate for Payer: BCN Commercial |
$217.33
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$263.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.26
|
| Rate for Payer: Healthscope Commercial |
$280.32
|
| Rate for Payer: Healthscope Whirlpool |
$271.91
|
| Rate for Payer: Mclaren Commercial |
$252.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.27
|
| Rate for Payer: Nomi Health Commercial |
$229.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$245.62
|
| Rate for Payer: Priority Health Narrow Network |
$196.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$246.68
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$396.15
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.46 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Aetna Commercial |
$356.54
|
| Rate for Payer: Aetna Medicare |
$198.07
|
| Rate for Payer: ASR ASR |
$384.27
|
| Rate for Payer: ASR Commercial |
$384.27
|
| Rate for Payer: BCBS Complete |
$158.46
|
| Rate for Payer: BCBS Trust/PPO |
$324.41
|
| Rate for Payer: BCN Commercial |
$307.14
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$372.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Healthscope Commercial |
$396.15
|
| Rate for Payer: Healthscope Whirlpool |
$384.27
|
| Rate for Payer: Mclaren Commercial |
$356.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: Nomi Health Commercial |
$324.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$347.11
|
| Rate for Payer: Priority Health Narrow Network |
$277.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$348.61
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$337.72
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$219.52 |
| Max. Negotiated Rate |
$337.72 |
| Rate for Payer: Aetna Commercial |
$303.95
|
| Rate for Payer: ASR ASR |
$327.59
|
| Rate for Payer: ASR Commercial |
$327.59
|
| Rate for Payer: BCBS Trust/PPO |
$275.21
|
| Rate for Payer: BCN Commercial |
$261.83
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$317.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$337.72
|
| Rate for Payer: Healthscope Whirlpool |
$327.59
|
| Rate for Payer: Mclaren Commercial |
$303.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.06
|
| Rate for Payer: Nomi Health Commercial |
$276.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$297.19
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074662411
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$503.57 |
| Max. Negotiated Rate |
$774.72 |
| Rate for Payer: Aetna Commercial |
$697.25
|
| Rate for Payer: ASR ASR |
$751.48
|
| Rate for Payer: ASR Commercial |
$751.48
|
| Rate for Payer: BCBS Trust/PPO |
$631.32
|
| Rate for Payer: BCN Commercial |
$600.64
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$728.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$774.72
|
| Rate for Payer: Healthscope Whirlpool |
$751.48
|
| Rate for Payer: Mclaren Commercial |
$697.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: Nomi Health Commercial |
$635.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$681.75
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: ASR ASR |
$2.72
|
| Rate for Payer: ASR Commercial |
$2.72
|
| Rate for Payer: BCBS Trust/PPO |
$2.28
|
| Rate for Payer: BCN Commercial |
$2.17
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cofinity Commercial |
$2.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.24
|
| Rate for Payer: Healthscope Commercial |
$2.80
|
| Rate for Payer: Healthscope Whirlpool |
$2.72
|
| Rate for Payer: Mclaren Commercial |
$2.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.38
|
| Rate for Payer: Nomi Health Commercial |
$2.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.46
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$280.32
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.21 |
| Max. Negotiated Rate |
$280.32 |
| Rate for Payer: Aetna Commercial |
$252.29
|
| Rate for Payer: ASR ASR |
$271.91
|
| Rate for Payer: ASR Commercial |
$271.91
|
| Rate for Payer: BCBS Trust/PPO |
$228.43
|
| Rate for Payer: BCN Commercial |
$217.33
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$263.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.26
|
| Rate for Payer: Healthscope Commercial |
$280.32
|
| Rate for Payer: Healthscope Whirlpool |
$271.91
|
| Rate for Payer: Mclaren Commercial |
$252.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.27
|
| Rate for Payer: Nomi Health Commercial |
$229.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$246.68
|
|
