|
LEVALBUTEROL HCL 0.63 MG/3 ML INHL NEBU
|
Facility
IP
|
$7.27
|
|
|
Service Code
|
NDC 00093414656
|
| Hospital Charge Code |
24915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.45 |
| Max. Negotiated Rate |
$6.76 |
| Rate for Payer: Aetna Commercial |
$6.28
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna All Commercial |
$6.27
|
| Rate for Payer: CORVEL All Commercial |
$6.76
|
| Rate for Payer: Coventry All Commercial |
$6.39
|
| Rate for Payer: Encore All Commercial |
$6.69
|
| Rate for Payer: Frontpath All Commercial |
$6.68
|
| Rate for Payer: Humana ChoiceCare |
$6.28
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.54
|
| Rate for Payer: PHCS All Commercial |
$5.45
|
| Rate for Payer: PHP All Commercial |
$5.51
|
| Rate for Payer: Sagamore Health Network All Products |
$5.61
|
| Rate for Payer: Signature Care EPO |
$6.03
|
| Rate for Payer: Signature Care PPO |
$6.39
|
| Rate for Payer: United Healthcare Commercial |
$5.73
|
|
|
LEVALBUTEROL HCL 0.63 MG/3 ML INHL NEBU
|
Facility
OP
|
$7.27
|
|
|
Service Code
|
NDC 00093414656
|
| Hospital Charge Code |
24915
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.40 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$6.13
|
| Rate for Payer: Aetna Medicare |
$2.40
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$2.40
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$4.17
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$4.54
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$2.76
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$2.64
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Centivo All Commercial |
$3.71
|
| Rate for Payer: Cigna All Commercial |
$6.27
|
| Rate for Payer: CORVEL All Commercial |
$6.76
|
| Rate for Payer: Coventry All Commercial |
$6.39
|
| Rate for Payer: Encore All Commercial |
$6.69
|
| Rate for Payer: Frontpath All Commercial |
$6.68
|
| Rate for Payer: Humana ChoiceCare |
$6.28
|
| Rate for Payer: Humana Medicare |
$3.71
|
| Rate for Payer: Lucent All Commercial |
$3.71
|
| Rate for Payer: Lutheran Preferred All Commercial |
$6.54
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$5.45
|
| Rate for Payer: PHP All Commercial |
$5.51
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$2.83
|
| Rate for Payer: Sagamore Health Network All Products |
$5.61
|
| Rate for Payer: Signature Care EPO |
$6.03
|
| Rate for Payer: Signature Care PPO |
$6.39
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$6.18
|
| Rate for Payer: United Healthcare Commercial |
$5.73
|
| Rate for Payer: United Healthcare Medicare |
$2.40
|
|
|
LEVALBUTEROL HCL 1.25 MG/0.5 ML INHL NEBU
|
Facility
IP
|
$32.65
|
|
|
Service Code
|
NDC 00378699393
|
| Hospital Charge Code |
39278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.49 |
| Max. Negotiated Rate |
$30.36 |
| Rate for Payer: Aetna Commercial |
$28.21
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: Cigna All Commercial |
$28.18
|
| Rate for Payer: CORVEL All Commercial |
$30.36
|
| Rate for Payer: Coventry All Commercial |
$28.73
|
| Rate for Payer: Encore All Commercial |
$30.05
|
| Rate for Payer: Frontpath All Commercial |
$30.04
|
| Rate for Payer: Humana ChoiceCare |
$28.20
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.38
|
| Rate for Payer: PHCS All Commercial |
$24.49
|
| Rate for Payer: PHP All Commercial |
$24.76
|
| Rate for Payer: Sagamore Health Network All Products |
$25.20
|
| Rate for Payer: Signature Care EPO |
$27.10
|
| Rate for Payer: Signature Care PPO |
$28.73
|
| Rate for Payer: United Healthcare Commercial |
$25.73
|
|
|
LEVALBUTEROL HCL 1.25 MG/0.5 ML INHL NEBU
|
Facility
OP
|
$32.65
|
|
|
Service Code
|
NDC 00378699393
|
| Hospital Charge Code |
39278
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$37.28 |
| Rate for Payer: Aetna Commercial |
$27.55
|
| Rate for Payer: Aetna Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$10.77
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$18.75
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$20.41
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$37.28
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$12.39
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$11.85
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: Cash Price |
$20.24
|
| Rate for Payer: Centivo All Commercial |
$16.65
|
| Rate for Payer: Cigna All Commercial |
$28.18
|
| Rate for Payer: CORVEL All Commercial |
$30.36
|
| Rate for Payer: Coventry All Commercial |
$28.73
|
| Rate for Payer: Encore All Commercial |
$30.05
|
| Rate for Payer: Frontpath All Commercial |
$30.04
|
| Rate for Payer: Humana ChoiceCare |
$28.20
|
| Rate for Payer: Humana Medicare |
$16.65
|
| Rate for Payer: Lucent All Commercial |
$16.65
|
| Rate for Payer: Lutheran Preferred All Commercial |
$29.38
|
| Rate for Payer: Managed Health Services Medicaid |
$37.28
|
| Rate for Payer: MDWise Medicaid |
$37.28
|
| Rate for Payer: PHCS All Commercial |
$24.49
|
| Rate for Payer: PHP All Commercial |
$24.76
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$12.73
|
| Rate for Payer: Sagamore Health Network All Products |
$25.20
|
| Rate for Payer: Signature Care EPO |
$27.10
|
| Rate for Payer: Signature Care PPO |
$28.73
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$27.75
|
| Rate for Payer: United Healthcare Commercial |
$25.73
|
| Rate for Payer: United Healthcare Medicare |
$10.77
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLN
|
Facility
OP
|
$82.78
|
|
|
Service Code
|
NDC 51991065116
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.32 |
| Max. Negotiated Rate |
$76.98 |
| Rate for Payer: Aetna Commercial |
$69.86
|
| Rate for Payer: Aetna Medicare |
$27.32
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$27.32
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$47.54
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$51.74
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$31.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$30.05
|
| Rate for Payer: Cash Price |
$51.32
|
| Rate for Payer: Centivo All Commercial |
$42.22
|
| Rate for Payer: Cigna All Commercial |
$71.43
|
| Rate for Payer: CORVEL All Commercial |
$76.98
|
| Rate for Payer: Coventry All Commercial |
$72.84
|
| Rate for Payer: Encore All Commercial |
$76.19
|
| Rate for Payer: Frontpath All Commercial |
$76.15
|
| Rate for Payer: Humana ChoiceCare |
$71.49
|
| Rate for Payer: Humana Medicare |
$42.22
|
| Rate for Payer: Lucent All Commercial |
$42.22
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.50
|
| Rate for Payer: PHCS All Commercial |
$62.08
|
| Rate for Payer: PHP All Commercial |
$62.78
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$32.28
|
| Rate for Payer: Sagamore Health Network All Products |
$63.90
|
| Rate for Payer: Signature Care EPO |
$68.70
|
| Rate for Payer: Signature Care PPO |
$72.84
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$70.36
|
| Rate for Payer: United Healthcare Commercial |
$65.23
|
| Rate for Payer: United Healthcare Medicare |
$27.32
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLN
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 503830241
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLN
|
Facility
IP
|
$82.78
|
|
|
Service Code
|
NDC 51991065116
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.08 |
| Max. Negotiated Rate |
$76.98 |
| Rate for Payer: Aetna Commercial |
$71.52
|
| Rate for Payer: Cash Price |
$51.32
|
| Rate for Payer: Cigna All Commercial |
$71.43
|
| Rate for Payer: CORVEL All Commercial |
$76.98
|
| Rate for Payer: Coventry All Commercial |
$72.84
|
| Rate for Payer: Encore All Commercial |
$76.19
|
| Rate for Payer: Frontpath All Commercial |
$76.15
|
| Rate for Payer: Humana ChoiceCare |
$71.49
|
| Rate for Payer: Lutheran Preferred All Commercial |
$74.50
|
| Rate for Payer: PHCS All Commercial |
$62.08
|
| Rate for Payer: PHP All Commercial |
$62.78
|
| Rate for Payer: Sagamore Health Network All Products |
$63.90
|
| Rate for Payer: Signature Care EPO |
$68.70
|
| Rate for Payer: Signature Care PPO |
$72.84
|
| Rate for Payer: United Healthcare Commercial |
$65.23
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLN
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 503830241
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| 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 |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
LEVETIRACETAM 250 MG ORAL TAB
|
Facility
IP
|
$1.07
|
|
|
Service Code
|
NDC 63739079510
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna Commercial |
$0.93
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Cigna All Commercial |
$0.92
|
| Rate for Payer: CORVEL All Commercial |
$1.00
|
| Rate for Payer: Coventry All Commercial |
$0.94
|
| Rate for Payer: Encore All Commercial |
$0.99
|
| Rate for Payer: Frontpath All Commercial |
$0.99
|
| Rate for Payer: Humana ChoiceCare |
$0.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.96
|
| Rate for Payer: PHCS All Commercial |
$0.80
|
| Rate for Payer: PHP All Commercial |
$0.81
|
| Rate for Payer: Sagamore Health Network All Products |
$0.83
|
| Rate for Payer: Signature Care EPO |
$0.89
|
| Rate for Payer: Signature Care PPO |
$0.94
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
|
|
LEVETIRACETAM 250 MG ORAL TAB
|
Facility
OP
|
$1.07
|
|
|
Service Code
|
NDC 63739079510
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.35 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna Commercial |
$0.90
|
| Rate for Payer: Aetna Medicare |
$0.35
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.35
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.62
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.67
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.41
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.39
|
| Rate for Payer: Cash Price |
$0.66
|
| Rate for Payer: Centivo All Commercial |
$0.55
|
| Rate for Payer: Cigna All Commercial |
$0.92
|
| Rate for Payer: CORVEL All Commercial |
$1.00
|
| Rate for Payer: Coventry All Commercial |
$0.94
|
| Rate for Payer: Encore All Commercial |
$0.99
|
| Rate for Payer: Frontpath All Commercial |
$0.99
|
| Rate for Payer: Humana ChoiceCare |
$0.93
|
| Rate for Payer: Humana Medicare |
$0.55
|
| Rate for Payer: Lucent All Commercial |
$0.55
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.96
|
| Rate for Payer: PHCS All Commercial |
$0.80
|
| Rate for Payer: PHP All Commercial |
$0.81
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.42
|
| Rate for Payer: Sagamore Health Network All Products |
$0.83
|
| Rate for Payer: Signature Care EPO |
$0.89
|
| Rate for Payer: Signature Care PPO |
$0.94
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.91
|
| Rate for Payer: United Healthcare Commercial |
$0.84
|
| Rate for Payer: United Healthcare Medicare |
$0.35
|
|
|
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 |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Hoosier Healthwise |
$0.03
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| 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 |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| 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 |
$5.94
|
|
|
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 |
$11.16
|
| 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 250 MG ORAL TAB
|
Facility
IP
|
$1.00
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.86
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| Rate for Payer: PHP All Commercial |
$0.76
|
| Rate for Payer: Sagamore Health Network All Products |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
|
|
LEVOFLOXACIN 250 MG ORAL TAB
|
Facility
OP
|
$1.00
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.33 |
| Max. Negotiated Rate |
$0.93 |
| Rate for Payer: Aetna Commercial |
$0.84
|
| Rate for Payer: Aetna Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.33
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.57
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$0.63
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.38
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.36
|
| Rate for Payer: Cash Price |
$0.62
|
| Rate for Payer: Centivo All Commercial |
$0.51
|
| Rate for Payer: Cigna All Commercial |
$0.86
|
| Rate for Payer: CORVEL All Commercial |
$0.93
|
| Rate for Payer: Coventry All Commercial |
$0.88
|
| Rate for Payer: Encore All Commercial |
$0.92
|
| Rate for Payer: Frontpath All Commercial |
$0.92
|
| Rate for Payer: Humana ChoiceCare |
$0.86
|
| Rate for Payer: Humana Medicare |
$0.51
|
| Rate for Payer: Lucent All Commercial |
$0.51
|
| Rate for Payer: Lutheran Preferred All Commercial |
$0.90
|
| Rate for Payer: PHCS All Commercial |
$0.75
|
| 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 |
$0.77
|
| Rate for Payer: Signature Care EPO |
$0.83
|
| Rate for Payer: Signature Care PPO |
$0.88
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$0.85
|
| Rate for Payer: United Healthcare Commercial |
$0.79
|
| Rate for Payer: United Healthcare Medicare |
$0.33
|
|
|
LEVOFLOXACIN 500 MG ORAL TAB
|
Facility
IP
|
$1.82
|
|
|
Service Code
|
NDC 00904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.57
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna All Commercial |
$1.57
|
| Rate for Payer: CORVEL All Commercial |
$1.69
|
| Rate for Payer: Coventry All Commercial |
$1.60
|
| Rate for Payer: Encore All Commercial |
$1.68
|
| Rate for Payer: Frontpath All Commercial |
$1.67
|
| Rate for Payer: Humana ChoiceCare |
$1.57
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.64
|
| Rate for Payer: PHCS All Commercial |
$1.36
|
| Rate for Payer: PHP All Commercial |
$1.38
|
| Rate for Payer: Sagamore Health Network All Products |
$1.41
|
| Rate for Payer: Signature Care EPO |
$1.51
|
| Rate for Payer: Signature Care PPO |
$1.60
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
|
|
LEVOFLOXACIN 500 MG ORAL TAB
|
Facility
OP
|
$1.82
|
|
|
Service Code
|
NDC 00904635261
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$1.69 |
| Rate for Payer: Aetna Commercial |
$1.54
|
| Rate for Payer: Aetna Medicare |
$0.60
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.60
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$1.05
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.14
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.69
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.66
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Centivo All Commercial |
$0.93
|
| Rate for Payer: Cigna All Commercial |
$1.57
|
| Rate for Payer: CORVEL All Commercial |
$1.69
|
| Rate for Payer: Coventry All Commercial |
$1.60
|
| Rate for Payer: Encore All Commercial |
$1.68
|
| Rate for Payer: Frontpath All Commercial |
$1.67
|
| Rate for Payer: Humana ChoiceCare |
$1.57
|
| Rate for Payer: Humana Medicare |
$0.93
|
| Rate for Payer: Lucent All Commercial |
$0.93
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.64
|
| Rate for Payer: PHCS All Commercial |
$1.36
|
| Rate for Payer: PHP All Commercial |
$1.38
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.71
|
| Rate for Payer: Sagamore Health Network All Products |
$1.41
|
| Rate for Payer: Signature Care EPO |
$1.51
|
| Rate for Payer: Signature Care PPO |
$1.60
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.55
|
| Rate for Payer: United Healthcare Commercial |
$1.43
|
| Rate for Payer: United Healthcare Medicare |
$0.60
|
|
|
LEVOFLOXACIN 750 MG ORAL TAB
|
Facility
IP
|
$1.62
|
|
|
Service Code
|
NDC 55111028130
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Aetna Commercial |
$1.40
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Cigna All Commercial |
$1.40
|
| Rate for Payer: CORVEL All Commercial |
$1.50
|
| Rate for Payer: Coventry All Commercial |
$1.42
|
| Rate for Payer: Encore All Commercial |
$1.49
|
| Rate for Payer: Frontpath All Commercial |
$1.49
|
| Rate for Payer: Humana ChoiceCare |
$1.40
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.46
|
| Rate for Payer: PHCS All Commercial |
$1.21
|
| Rate for Payer: PHP All Commercial |
$1.23
|
| Rate for Payer: Sagamore Health Network All Products |
$1.25
|
| Rate for Payer: Signature Care EPO |
$1.34
|
| Rate for Payer: Signature Care PPO |
$1.42
|
| Rate for Payer: United Healthcare Commercial |
$1.27
|
|
|
LEVOFLOXACIN 750 MG ORAL TAB
|
Facility
OP
|
$1.62
|
|
|
Service Code
|
NDC 55111028130
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.53 |
| Max. Negotiated Rate |
$1.50 |
| Rate for Payer: Aetna Commercial |
$1.36
|
| Rate for Payer: Aetna Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$0.53
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$0.93
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$1.01
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$0.61
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$0.59
|
| Rate for Payer: Cash Price |
$1.00
|
| Rate for Payer: Centivo All Commercial |
$0.82
|
| Rate for Payer: Cigna All Commercial |
$1.40
|
| Rate for Payer: CORVEL All Commercial |
$1.50
|
| Rate for Payer: Coventry All Commercial |
$1.42
|
| Rate for Payer: Encore All Commercial |
$1.49
|
| Rate for Payer: Frontpath All Commercial |
$1.49
|
| Rate for Payer: Humana ChoiceCare |
$1.40
|
| Rate for Payer: Humana Medicare |
$0.82
|
| Rate for Payer: Lucent All Commercial |
$0.82
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1.46
|
| Rate for Payer: PHCS All Commercial |
$1.21
|
| Rate for Payer: PHP All Commercial |
$1.23
|
| Rate for Payer: Plain Church Group Ministry All Commercial |
$0.63
|
| Rate for Payer: Sagamore Health Network All Products |
$1.25
|
| Rate for Payer: Signature Care EPO |
$1.34
|
| Rate for Payer: Signature Care PPO |
$1.42
|
| Rate for Payer: Three Rivers Preferred All Commercial |
$1.37
|
| Rate for Payer: United Healthcare Commercial |
$1.27
|
| Rate for Payer: United Healthcare Medicare |
$0.53
|
|
|
LEVOFLOXACIN IN D5W 250 MG/50 ML IV PGBK
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
108118
|
|
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 |
$11.16
|
| 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 250 MG/50 ML IV PGBK
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
108118
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| 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 |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| 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 |
$5.94
|
|
|
LEVOFLOXACIN IN D5W 500 MG/100 ML IV PGBK
|
Facility
IP
|
$18.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
108119
|
|
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 |
$11.16
|
| 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 500 MG/100 ML IV PGBK
|
Facility
OP
|
$18.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
108119
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| 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 |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| 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 |
$5.94
|
|
|
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 |
$11.16
|
| 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 |
$5.94 |
| Max. Negotiated Rate |
$16.74 |
| Rate for Payer: Aetna Commercial |
$15.19
|
| Rate for Payer: Aetna Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN Medicare |
$5.94
|
| Rate for Payer: Anthem Blue Cross of IN PPO/Exchange |
$10.34
|
| Rate for Payer: Anthem Blue Cross of IN Traditional |
$11.25
|
| Rate for Payer: CareSource Indiana of IN Just 4 Me |
$6.83
|
| Rate for Payer: CareSource Indiana of IN Medicare |
$6.53
|
| Rate for Payer: Cash Price |
$11.16
|
| Rate for Payer: Centivo All Commercial |
$9.18
|
| 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 |
$9.18
|
| Rate for Payer: Lucent All Commercial |
$9.18
|
| 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 |
$5.94
|
|
|
LEVONORGESTREL 13.5 MG IUD 14 MCG/DAY (3 YEARS)
|
Facility
IP
|
$2,119.08
|
|
|
Service Code
|
HCPCS J7301
|
| Hospital Charge Code |
162367
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1,589.31 |
| Max. Negotiated Rate |
$1,970.75 |
| Rate for Payer: Aetna Commercial |
$1,830.89
|
| Rate for Payer: Cash Price |
$1,313.83
|
| Rate for Payer: Cigna All Commercial |
$1,828.77
|
| Rate for Payer: CORVEL All Commercial |
$1,970.75
|
| Rate for Payer: Coventry All Commercial |
$1,864.79
|
| Rate for Payer: Encore All Commercial |
$1,950.62
|
| Rate for Payer: Frontpath All Commercial |
$1,949.56
|
| Rate for Payer: Humana ChoiceCare |
$1,830.25
|
| Rate for Payer: Lutheran Preferred All Commercial |
$1,907.18
|
| Rate for Payer: PHCS All Commercial |
$1,589.31
|
| Rate for Payer: PHP All Commercial |
$1,607.11
|
| Rate for Payer: Sagamore Health Network All Products |
$1,635.93
|
| Rate for Payer: Signature Care EPO |
$1,758.84
|
| Rate for Payer: Signature Care PPO |
$1,864.79
|
| Rate for Payer: United Healthcare Commercial |
$1,669.84
|
|
