|
LEVETIRACETAM 250 MG ORAL TAB
|
Facility
|
IP
|
$1.15
|
|
|
Service Code
|
NDC 63739079510
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Aetna Commercial |
$0.99
|
| Rate for Payer: Cash Price |
$0.69
|
| Rate for Payer: Cigna All Commercial |
$0.99
|
| Rate for Payer: CORVEL All Commercial |
$1.07
|
| Rate for Payer: Coventry All Commercial |
$1.01
|
| Rate for Payer: Encore All Commercial |
$1.06
|
| Rate for Payer: Frontpath All Commercial |
$1.06
|
| Rate for Payer: Humana ChoiceCare |
$0.99
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.03
|
| Rate for Payer: PHCS All Commercial |
$0.86
|
| Rate for Payer: PHP All Commercial |
$0.87
|
| Rate for Payer: Sagamore Health Network All Products |
$0.89
|
| Rate for Payer: Signature Care EPO |
$0.95
|
| Rate for Payer: Signature Care PPO |
$1.01
|
| Rate for Payer: United Healthcare Commercial |
$0.90
|
|
|
LEVETIRACETAM 500 MG/5 ML IV SOLN
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
77195
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
LEVETIRACETAM 500 MG/5 ML IV SOLN
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
77195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$0.03
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$0.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: Managed Health Services Medicaid |
$0.03
|
| Rate for Payer: MDWise Medicaid |
$0.03
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
LEVOFLOXACIN 250 MG ORAL TAB
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.76 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna Commercial |
$0.87
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna All Commercial |
$0.87
|
| Rate for Payer: CORVEL All Commercial |
$0.94
|
| Rate for Payer: Coventry All Commercial |
$0.89
|
| Rate for Payer: Encore All Commercial |
$0.93
|
| Rate for Payer: Frontpath All Commercial |
$0.93
|
| Rate for Payer: Humana ChoiceCare |
$0.87
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.91
|
| Rate for Payer: PHCS All Commercial |
$0.76
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.78
|
| Rate for Payer: Signature Care EPO |
$0.84
|
| Rate for Payer: Signature Care PPO |
$0.89
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
LEVOFLOXACIN 250 MG ORAL TAB
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$0.94 |
| Rate for Payer: Aetna Commercial |
$0.85
|
| Rate for Payer: Aetna Medicare |
$0.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.31
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.37
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.35
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Centivo All Commercial |
$0.55
|
| Rate for Payer: Cigna All Commercial |
$0.87
|
| Rate for Payer: CORVEL All Commercial |
$0.94
|
| Rate for Payer: Coventry All Commercial |
$0.89
|
| Rate for Payer: Encore All Commercial |
$0.93
|
| Rate for Payer: Frontpath All Commercial |
$0.93
|
| Rate for Payer: Humana ChoiceCare |
$0.87
|
| Rate for Payer: Humana Medicare |
$0.32
|
| Rate for Payer: Lucent All Commercial |
$0.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.91
|
| Rate for Payer: PHCS All Commercial |
$0.76
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.39
|
| Rate for Payer: Sagamore Health Network All Products |
$0.78
|
| Rate for Payer: Signature Care EPO |
$0.84
|
| Rate for Payer: Signature Care PPO |
$0.89
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.86
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.32
|
|
|
LEVOFLOXACIN 500 MG ORAL TAB
|
Facility
|
IP
|
$1.80
|
|
|
Service Code
|
NDC 00904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.35 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Aetna Commercial |
$1.55
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Cigna All Commercial |
$1.55
|
| Rate for Payer: CORVEL All Commercial |
$1.67
|
| Rate for Payer: Coventry All Commercial |
$1.58
|
| Rate for Payer: Encore All Commercial |
$1.66
|
| Rate for Payer: Frontpath All Commercial |
$1.66
|
| Rate for Payer: Humana ChoiceCare |
$1.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.62
|
| Rate for Payer: PHCS All Commercial |
$1.35
|
| Rate for Payer: PHP All Commercial |
$1.36
|
| Rate for Payer: Sagamore Health Network All Products |
$1.39
|
| Rate for Payer: Signature Care EPO |
$1.49
|
| Rate for Payer: Signature Care PPO |
$1.58
|
| Rate for Payer: United Healthcare Commercial |
$1.42
|
|
|
LEVOFLOXACIN 500 MG ORAL TAB
|
Facility
|
OP
|
$1.80
|
|
|
Service Code
|
NDC 00904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.67 |
| Rate for Payer: Aetna Commercial |
$1.52
|
| Rate for Payer: Aetna Medicare |
$0.58
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.56
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.03
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.12
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.66
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$1.08
|
| Rate for Payer: Centivo All Commercial |
$0.98
|
| Rate for Payer: Cigna All Commercial |
$1.55
|
| Rate for Payer: CORVEL All Commercial |
$1.67
|
| Rate for Payer: Coventry All Commercial |
$1.58
|
| Rate for Payer: Encore All Commercial |
$1.66
|
| Rate for Payer: Frontpath All Commercial |
$1.66
|
| Rate for Payer: Humana ChoiceCare |
$1.55
|
| Rate for Payer: Humana Medicare |
$0.58
|
| Rate for Payer: Lucent All Commercial |
$0.98
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.62
|
| Rate for Payer: PHCS All Commercial |
$1.35
|
| Rate for Payer: PHP All Commercial |
$1.36
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.70
|
| Rate for Payer: Sagamore Health Network All Products |
$1.39
|
| Rate for Payer: Signature Care EPO |
$1.49
|
| Rate for Payer: Signature Care PPO |
$1.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.53
|
| Rate for Payer: United Healthcare Commercial |
$1.42
|
| Rate for Payer: United Healthcare Medicare |
$0.58
|
|
|
LEVOFLOXACIN 750 MG ORAL TAB
|
Facility
|
IP
|
$1.32
|
|
|
Service Code
|
NDC 55111028130
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna Commercial |
$1.14
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Cigna All Commercial |
$1.14
|
| Rate for Payer: CORVEL All Commercial |
$1.22
|
| Rate for Payer: Coventry All Commercial |
$1.16
|
| Rate for Payer: Encore All Commercial |
$1.21
|
| Rate for Payer: Frontpath All Commercial |
$1.21
|
| Rate for Payer: Humana ChoiceCare |
$1.14
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.18
|
| Rate for Payer: PHCS All Commercial |
$0.99
|
| Rate for Payer: PHP All Commercial |
$1.00
|
| Rate for Payer: Sagamore Health Network All Products |
$1.02
|
| Rate for Payer: Signature Care EPO |
$1.09
|
| Rate for Payer: Signature Care PPO |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
|
|
LEVOFLOXACIN 750 MG ORAL TAB
|
Facility
|
OP
|
$1.32
|
|
|
Service Code
|
NDC 55111028130
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.22 |
| Rate for Payer: Aetna Commercial |
$1.11
|
| Rate for Payer: Aetna Medicare |
$0.42
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.41
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$0.76
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.82
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.48
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.46
|
| Rate for Payer: Cash Price |
$0.79
|
| Rate for Payer: Centivo All Commercial |
$0.72
|
| Rate for Payer: Cigna All Commercial |
$1.14
|
| Rate for Payer: CORVEL All Commercial |
$1.22
|
| Rate for Payer: Coventry All Commercial |
$1.16
|
| Rate for Payer: Encore All Commercial |
$1.21
|
| Rate for Payer: Frontpath All Commercial |
$1.21
|
| Rate for Payer: Humana ChoiceCare |
$1.14
|
| Rate for Payer: Humana Medicare |
$0.42
|
| Rate for Payer: Lucent All Commercial |
$0.72
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.18
|
| Rate for Payer: PHCS All Commercial |
$0.99
|
| Rate for Payer: PHP All Commercial |
$1.00
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.51
|
| Rate for Payer: Sagamore Health Network All Products |
$1.02
|
| Rate for Payer: Signature Care EPO |
$1.09
|
| Rate for Payer: Signature Care PPO |
$1.16
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.12
|
| Rate for Payer: United Healthcare Commercial |
$1.04
|
| Rate for Payer: United Healthcare Medicare |
$0.42
|
|
|
LEVOFLOXACIN IN D5W 250 MG/50 ML IV PGBK
|
Facility
|
OP
|
$38.50
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
108118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.94 |
| Max. Negotiated Rate |
$35.80 |
| Rate for Payer: Aetna Commercial |
$32.49
|
| Rate for Payer: Aetna Medicare |
$12.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$11.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.11
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.07
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.55
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Centivo All Commercial |
$20.94
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Humana Medicare |
$12.32
|
| Rate for Payer: Lucent All Commercial |
$20.94
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.02
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Signature Care EPO |
$31.95
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$32.73
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
| Rate for Payer: United Healthcare Medicare |
$12.32
|
|
|
LEVOFLOXACIN IN D5W 250 MG/50 ML IV PGBK
|
Facility
|
IP
|
$38.50
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
108118
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.88 |
| Max. Negotiated Rate |
$35.80 |
| Rate for Payer: Aetna Commercial |
$33.26
|
| Rate for Payer: Cash Price |
$23.10
|
| Rate for Payer: Cigna All Commercial |
$33.23
|
| Rate for Payer: CORVEL All Commercial |
$35.80
|
| Rate for Payer: Coventry All Commercial |
$33.88
|
| Rate for Payer: Encore All Commercial |
$35.44
|
| Rate for Payer: Frontpath All Commercial |
$35.42
|
| Rate for Payer: Humana ChoiceCare |
$33.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$34.65
|
| Rate for Payer: PHCS All Commercial |
$28.88
|
| Rate for Payer: PHP All Commercial |
$29.20
|
| Rate for Payer: Sagamore Health Network All Products |
$29.72
|
| Rate for Payer: Signature Care EPO |
$31.95
|
| Rate for Payer: Signature Care PPO |
$33.88
|
| Rate for Payer: United Healthcare Commercial |
$30.34
|
|
|
LEVOFLOXACIN IN D5W 500 MG/100 ML IV PGBK
|
Facility
|
IP
|
$39.20
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
108119
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.40 |
| Max. Negotiated Rate |
$36.46 |
| Rate for Payer: Aetna Commercial |
$33.87
|
| Rate for Payer: Cash Price |
$23.52
|
| Rate for Payer: Cigna All Commercial |
$33.83
|
| Rate for Payer: CORVEL All Commercial |
$36.46
|
| Rate for Payer: Coventry All Commercial |
$34.50
|
| Rate for Payer: Encore All Commercial |
$36.08
|
| Rate for Payer: Frontpath All Commercial |
$36.06
|
| Rate for Payer: Humana ChoiceCare |
$33.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.28
|
| Rate for Payer: PHCS All Commercial |
$29.40
|
| Rate for Payer: PHP All Commercial |
$29.73
|
| Rate for Payer: Sagamore Health Network All Products |
$30.26
|
| Rate for Payer: Signature Care EPO |
$32.54
|
| Rate for Payer: Signature Care PPO |
$34.50
|
| Rate for Payer: United Healthcare Commercial |
$30.89
|
|
|
LEVOFLOXACIN IN D5W 500 MG/100 ML IV PGBK
|
Facility
|
OP
|
$39.20
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
108119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.15 |
| Max. Negotiated Rate |
$36.46 |
| Rate for Payer: Aetna Commercial |
$33.08
|
| Rate for Payer: Aetna Medicare |
$12.54
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$12.15
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$22.51
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$24.50
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$14.43
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$13.80
|
| Rate for Payer: Cash Price |
$23.52
|
| Rate for Payer: Centivo All Commercial |
$21.32
|
| Rate for Payer: Cigna All Commercial |
$33.83
|
| Rate for Payer: CORVEL All Commercial |
$36.46
|
| Rate for Payer: Coventry All Commercial |
$34.50
|
| Rate for Payer: Encore All Commercial |
$36.08
|
| Rate for Payer: Frontpath All Commercial |
$36.06
|
| Rate for Payer: Humana ChoiceCare |
$33.86
|
| Rate for Payer: Humana Medicare |
$12.54
|
| Rate for Payer: Lucent All Commercial |
$21.32
|
| Rate for Payer: Lutheran Preferred All Commercial |
$35.28
|
| Rate for Payer: PHCS All Commercial |
$29.40
|
| Rate for Payer: PHP All Commercial |
$29.73
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$15.29
|
| Rate for Payer: Sagamore Health Network All Products |
$30.26
|
| Rate for Payer: Signature Care EPO |
$32.54
|
| Rate for Payer: Signature Care PPO |
$34.50
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$33.32
|
| Rate for Payer: United Healthcare Commercial |
$30.89
|
| Rate for Payer: United Healthcare Medicare |
$12.54
|
|
|
LEVOFLOXACIN IN D5W 750 MG/150 ML IV PGBK
|
Facility
|
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
108120
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.50 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.55
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
|
|
LEVOFLOXACIN IN D5W 750 MG/150 ML IV PGBK
|
Facility
|
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
108120
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.58 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.76
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.58
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.62
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.34
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Centivo All Commercial |
$9.79
|
| Rate for Payer: Cigna All Commercial |
$15.53
|
| Rate for Payer: CORVEL All Commercial |
$16.74
|
| Rate for Payer: Coventry All Commercial |
$15.84
|
| Rate for Payer: Encore All Commercial |
$16.57
|
| Rate for Payer: Frontpath All Commercial |
$16.56
|
| Rate for Payer: Humana ChoiceCare |
$15.55
|
| Rate for Payer: Humana Medicare |
$5.76
|
| Rate for Payer: Lucent All Commercial |
$9.79
|
| Rate for Payer: Lutheran Preferred All Commercial |
$16.20
|
| Rate for Payer: PHCS All Commercial |
$13.50
|
| Rate for Payer: PHP All Commercial |
$13.65
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$7.02
|
| Rate for Payer: Sagamore Health Network All Products |
$13.90
|
| Rate for Payer: Signature Care EPO |
$14.94
|
| Rate for Payer: Signature Care PPO |
$15.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$15.30
|
| Rate for Payer: United Healthcare Commercial |
$14.18
|
| Rate for Payer: United Healthcare Medicare |
$5.76
|
|
|
LEVONORGESTREL 13.5 MG IUD 14 MCG/DAY (3 YEARS)
|
Facility
|
OP
|
$2,225.04
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
162367
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$689.76 |
| Max. Negotiated Rate |
$2,069.28 |
| Rate for Payer: Aetna Commercial |
$1,877.93
|
| Rate for Payer: Aetna Medicare |
$712.01
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1,061.95
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$689.76
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,277.84
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,390.87
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1,061.95
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$818.81
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$783.21
|
| Rate for Payer: Cash Price |
$1,335.02
|
| Rate for Payer: Cash Price |
$1,335.02
|
| Rate for Payer: Centivo All Commercial |
$1,210.42
|
| Rate for Payer: Cigna All Commercial |
$1,920.21
|
| Rate for Payer: CORVEL All Commercial |
$2,069.28
|
| Rate for Payer: Coventry All Commercial |
$1,958.03
|
| Rate for Payer: Encore All Commercial |
$2,048.15
|
| Rate for Payer: Frontpath All Commercial |
$2,047.03
|
| Rate for Payer: Humana ChoiceCare |
$1,921.76
|
| Rate for Payer: Humana Medicare |
$712.01
|
| Rate for Payer: Lucent All Commercial |
$1,210.42
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,002.53
|
| Rate for Payer: Managed Health Services Medicaid |
$1,061.95
|
| Rate for Payer: MDWise Medicaid |
$1,061.95
|
| Rate for Payer: PHCS All Commercial |
$1,668.78
|
| Rate for Payer: PHP All Commercial |
$1,687.47
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$867.76
|
| Rate for Payer: Sagamore Health Network All Products |
$1,717.73
|
| Rate for Payer: Signature Care EPO |
$1,846.78
|
| Rate for Payer: Signature Care PPO |
$1,958.03
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1,891.28
|
| Rate for Payer: United Healthcare Commercial |
$1,753.33
|
| Rate for Payer: United Healthcare Medicare |
$712.01
|
|
|
LEVONORGESTREL 13.5 MG IUD 14 MCG/DAY (3 YEARS)
|
Facility
|
IP
|
$2,225.04
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
162367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,668.78 |
| Max. Negotiated Rate |
$2,069.28 |
| Rate for Payer: Aetna Commercial |
$1,922.43
|
| Rate for Payer: Cash Price |
$1,335.02
|
| Rate for Payer: Cigna All Commercial |
$1,920.21
|
| Rate for Payer: CORVEL All Commercial |
$2,069.28
|
| Rate for Payer: Coventry All Commercial |
$1,958.03
|
| Rate for Payer: Encore All Commercial |
$2,048.15
|
| Rate for Payer: Frontpath All Commercial |
$2,047.03
|
| Rate for Payer: Humana ChoiceCare |
$1,921.76
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,002.53
|
| Rate for Payer: PHCS All Commercial |
$1,668.78
|
| Rate for Payer: PHP All Commercial |
$1,687.47
|
| Rate for Payer: Sagamore Health Network All Products |
$1,717.73
|
| Rate for Payer: Signature Care EPO |
$1,846.78
|
| Rate for Payer: Signature Care PPO |
$1,958.03
|
| Rate for Payer: United Healthcare Commercial |
$1,753.33
|
|
|
LEVONORGESTREL 1.5 MG ORAL TAB
|
Facility
|
OP
|
$87.43
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.10 |
| Max. Negotiated Rate |
$81.31 |
| Rate for Payer: Aetna Commercial |
$73.79
|
| Rate for Payer: Aetna Medicare |
$27.98
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.10
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$50.21
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$54.65
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$32.17
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$30.78
|
| Rate for Payer: Cash Price |
$52.46
|
| Rate for Payer: Centivo All Commercial |
$47.56
|
| Rate for Payer: Cigna All Commercial |
$75.45
|
| Rate for Payer: CORVEL All Commercial |
$81.31
|
| Rate for Payer: Coventry All Commercial |
$76.94
|
| Rate for Payer: Encore All Commercial |
$80.48
|
| Rate for Payer: Frontpath All Commercial |
$80.44
|
| Rate for Payer: Humana ChoiceCare |
$75.51
|
| Rate for Payer: Humana Medicare |
$27.98
|
| Rate for Payer: Lucent All Commercial |
$47.56
|
| Rate for Payer: Lutheran Preferred All Commercial |
$78.69
|
| Rate for Payer: PHCS All Commercial |
$65.57
|
| Rate for Payer: PHP All Commercial |
$66.31
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$34.10
|
| Rate for Payer: Sagamore Health Network All Products |
$67.50
|
| Rate for Payer: Signature Care EPO |
$72.57
|
| Rate for Payer: Signature Care PPO |
$76.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$74.32
|
| Rate for Payer: United Healthcare Commercial |
$68.89
|
| Rate for Payer: United Healthcare Medicare |
$27.98
|
|
|
LEVONORGESTREL 1.5 MG ORAL TAB
|
Facility
|
IP
|
$87.43
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$65.57 |
| Max. Negotiated Rate |
$81.31 |
| Rate for Payer: Aetna Commercial |
$75.54
|
| Rate for Payer: Cash Price |
$52.46
|
| Rate for Payer: Cigna All Commercial |
$75.45
|
| Rate for Payer: CORVEL All Commercial |
$81.31
|
| Rate for Payer: Coventry All Commercial |
$76.94
|
| Rate for Payer: Encore All Commercial |
$80.48
|
| Rate for Payer: Frontpath All Commercial |
$80.44
|
| Rate for Payer: Humana ChoiceCare |
$75.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$78.69
|
| Rate for Payer: PHCS All Commercial |
$65.57
|
| Rate for Payer: PHP All Commercial |
$66.31
|
| Rate for Payer: Sagamore Health Network All Products |
$67.50
|
| Rate for Payer: Signature Care EPO |
$72.57
|
| Rate for Payer: Signature Care PPO |
$76.94
|
| Rate for Payer: United Healthcare Commercial |
$68.89
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (5 YRS) 19.5 MG IU IUD
|
Facility
|
OP
|
$2,672.19
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
179201
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$828.38 |
| Max. Negotiated Rate |
$2,485.13 |
| Rate for Payer: Aetna Commercial |
$2,255.32
|
| Rate for Payer: Aetna Medicare |
$855.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1,275.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$828.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,534.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,670.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1,275.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$983.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$940.61
|
| Rate for Payer: Cash Price |
$1,603.31
|
| Rate for Payer: Cash Price |
$1,603.31
|
| Rate for Payer: Centivo All Commercial |
$1,453.67
|
| Rate for Payer: Cigna All Commercial |
$2,306.10
|
| Rate for Payer: CORVEL All Commercial |
$2,485.13
|
| Rate for Payer: Coventry All Commercial |
$2,351.52
|
| Rate for Payer: Encore All Commercial |
$2,459.75
|
| Rate for Payer: Frontpath All Commercial |
$2,458.41
|
| Rate for Payer: Humana ChoiceCare |
$2,307.97
|
| Rate for Payer: Humana Medicare |
$855.10
|
| Rate for Payer: Lucent All Commercial |
$1,453.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,404.97
|
| Rate for Payer: Managed Health Services Medicaid |
$1,275.36
|
| Rate for Payer: MDWise Medicaid |
$1,275.36
|
| Rate for Payer: PHCS All Commercial |
$2,004.14
|
| Rate for Payer: PHP All Commercial |
$2,026.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,042.15
|
| Rate for Payer: Sagamore Health Network All Products |
$2,062.93
|
| Rate for Payer: Signature Care EPO |
$2,217.91
|
| Rate for Payer: Signature Care PPO |
$2,351.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,271.36
|
| Rate for Payer: United Healthcare Commercial |
$2,105.68
|
| Rate for Payer: United Healthcare Medicare |
$855.10
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (5 YRS) 19.5 MG IU IUD
|
Facility
|
IP
|
$2,672.19
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
179201
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,004.14 |
| Max. Negotiated Rate |
$2,485.13 |
| Rate for Payer: Aetna Commercial |
$2,308.77
|
| Rate for Payer: Cash Price |
$1,603.31
|
| Rate for Payer: Cigna All Commercial |
$2,306.10
|
| Rate for Payer: CORVEL All Commercial |
$2,485.13
|
| Rate for Payer: Coventry All Commercial |
$2,351.52
|
| Rate for Payer: Encore All Commercial |
$2,459.75
|
| Rate for Payer: Frontpath All Commercial |
$2,458.41
|
| Rate for Payer: Humana ChoiceCare |
$2,307.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,404.97
|
| Rate for Payer: PHCS All Commercial |
$2,004.14
|
| Rate for Payer: PHP All Commercial |
$2,026.59
|
| Rate for Payer: Sagamore Health Network All Products |
$2,062.93
|
| Rate for Payer: Signature Care EPO |
$2,217.91
|
| Rate for Payer: Signature Care PPO |
$2,351.52
|
| Rate for Payer: United Healthcare Commercial |
$2,105.68
|
|
|
LEVONORGESTREL 1 EACH IU IUD
|
Facility
|
IP
|
$2,672.19
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2,004.14 |
| Max. Negotiated Rate |
$2,485.13 |
| Rate for Payer: Aetna Commercial |
$2,308.77
|
| Rate for Payer: Cash Price |
$1,603.31
|
| Rate for Payer: Cigna All Commercial |
$2,306.10
|
| Rate for Payer: CORVEL All Commercial |
$2,485.13
|
| Rate for Payer: Coventry All Commercial |
$2,351.52
|
| Rate for Payer: Encore All Commercial |
$2,459.75
|
| Rate for Payer: Frontpath All Commercial |
$2,458.41
|
| Rate for Payer: Humana ChoiceCare |
$2,307.97
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,404.97
|
| Rate for Payer: PHCS All Commercial |
$2,004.14
|
| Rate for Payer: PHP All Commercial |
$2,026.59
|
| Rate for Payer: Sagamore Health Network All Products |
$2,062.93
|
| Rate for Payer: Signature Care EPO |
$2,217.91
|
| Rate for Payer: Signature Care PPO |
$2,351.52
|
| Rate for Payer: United Healthcare Commercial |
$2,105.68
|
|
|
LEVONORGESTREL 1 EACH IU IUD
|
Facility
|
OP
|
$2,672.19
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$828.38 |
| Max. Negotiated Rate |
$2,485.13 |
| Rate for Payer: Aetna Commercial |
$2,255.32
|
| Rate for Payer: Aetna Medicare |
$855.10
|
| Rate for Payer: Anthem Blue Cross of IN Medicaid |
$1,275.36
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$828.38
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1,534.64
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1,670.38
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise/HIP |
$1,275.36
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$983.36
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$940.61
|
| Rate for Payer: Cash Price |
$1,603.31
|
| Rate for Payer: Cash Price |
$1,603.31
|
| Rate for Payer: Centivo All Commercial |
$1,453.67
|
| Rate for Payer: Cigna All Commercial |
$2,306.10
|
| Rate for Payer: CORVEL All Commercial |
$2,485.13
|
| Rate for Payer: Coventry All Commercial |
$2,351.52
|
| Rate for Payer: Encore All Commercial |
$2,459.75
|
| Rate for Payer: Frontpath All Commercial |
$2,458.41
|
| Rate for Payer: Humana ChoiceCare |
$2,307.97
|
| Rate for Payer: Humana Medicare |
$855.10
|
| Rate for Payer: Lucent All Commercial |
$1,453.67
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2,404.97
|
| Rate for Payer: Managed Health Services Medicaid |
$1,275.36
|
| Rate for Payer: MDWise Medicaid |
$1,275.36
|
| Rate for Payer: PHCS All Commercial |
$2,004.14
|
| Rate for Payer: PHP All Commercial |
$2,026.59
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1,042.15
|
| Rate for Payer: Sagamore Health Network All Products |
$2,062.93
|
| Rate for Payer: Signature Care EPO |
$2,217.91
|
| Rate for Payer: Signature Care PPO |
$2,351.52
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2,271.36
|
| Rate for Payer: United Healthcare Commercial |
$2,105.68
|
| Rate for Payer: United Healthcare Medicare |
$855.10
|
|
|
LEVOTHYROXINE 100 MCG ORAL TAB
|
Facility
|
OP
|
$2.93
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Aetna Commercial |
$2.48
|
| Rate for Payer: Aetna Medicare |
$0.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.91
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Pathway |
$1.68
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.83
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$1.08
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$1.03
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Centivo All Commercial |
$1.60
|
| Rate for Payer: Cigna All Commercial |
$2.53
|
| Rate for Payer: CORVEL All Commercial |
$2.73
|
| Rate for Payer: Coventry All Commercial |
$2.58
|
| Rate for Payer: Encore All Commercial |
$2.70
|
| Rate for Payer: Frontpath All Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$2.53
|
| Rate for Payer: Humana Medicare |
$0.94
|
| Rate for Payer: Lucent All Commercial |
$1.60
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.64
|
| Rate for Payer: PHCS All Commercial |
$2.20
|
| Rate for Payer: PHP All Commercial |
$2.22
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$1.14
|
| Rate for Payer: Sagamore Health Network All Products |
$2.26
|
| Rate for Payer: Signature Care EPO |
$2.43
|
| Rate for Payer: Signature Care PPO |
$2.58
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$2.49
|
| Rate for Payer: United Healthcare Commercial |
$2.31
|
| Rate for Payer: United Healthcare Medicare |
$0.94
|
|
|
LEVOTHYROXINE 100 MCG ORAL TAB
|
Facility
|
IP
|
$2.93
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.20 |
| Max. Negotiated Rate |
$2.73 |
| Rate for Payer: Aetna Commercial |
$2.53
|
| Rate for Payer: Cash Price |
$1.76
|
| Rate for Payer: Cigna All Commercial |
$2.53
|
| Rate for Payer: CORVEL All Commercial |
$2.73
|
| Rate for Payer: Coventry All Commercial |
$2.58
|
| Rate for Payer: Encore All Commercial |
$2.70
|
| Rate for Payer: Frontpath All Commercial |
$2.70
|
| Rate for Payer: Humana ChoiceCare |
$2.53
|
| Rate for Payer: Lutheran Preferred All Commercial |
$2.64
|
| Rate for Payer: PHCS All Commercial |
$2.20
|
| Rate for Payer: PHP All Commercial |
$2.22
|
| Rate for Payer: Sagamore Health Network All Products |
$2.26
|
| Rate for Payer: Signature Care EPO |
$2.43
|
| Rate for Payer: Signature Care PPO |
$2.58
|
| Rate for Payer: United Healthcare Commercial |
$2.31
|
|
