LEVALBUTEROL HCL 1.25MG/3ML AMIH 24X3ML
|
Facility
|
OP
|
$20.60
|
|
Service Code
|
NDC 76204090001
|
Hospital Charge Code |
4400816
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$7.00 |
Max. Negotiated Rate |
$16.58 |
Rate for Payer: Aetna of NY Commercial |
$14.42
|
Rate for Payer: Aetna of NY Medicare |
$9.48
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$15.45
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$15.45
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.62
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$10.30
|
Rate for Payer: Cash Price |
$15.45
|
Rate for Payer: CDPHP Commercial |
$16.58
|
Rate for Payer: CDPHP Medicare |
$7.62
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$16.48
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$16.48
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$16.48
|
Rate for Payer: EmblemHealth Medicaid |
$16.48
|
Rate for Payer: EmblemHealth Medicare |
$7.00
|
Rate for Payer: EmblemHealth Select Care |
$14.83
|
Rate for Payer: Fidelis Medicare |
$7.85
|
Rate for Payer: Galaxy Health Commercial |
$13.39
|
Rate for Payer: Hamaspik Choice Medicare |
$7.62
|
Rate for Payer: Humana Medicare |
$7.62
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$14.42
|
Rate for Payer: Local 1199SEIU Medicare |
$9.48
|
Rate for Payer: MVP Health Care of NY Commercial |
$15.45
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.60
|
Rate for Payer: MVP Health Care of NY Medicare |
$8.00
|
Rate for Payer: United Healthcare Medicare |
$7.62
|
Rate for Payer: WellCare Medicare |
$11.33
|
|
LEVALBUTEROL HCL 1.25MG/3ML AMIH 24X3ML
|
Facility
|
IP
|
$20.60
|
|
Service Code
|
NDC 76204090001
|
Hospital Charge Code |
4400816
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$11.33 |
Max. Negotiated Rate |
$13.39 |
Rate for Payer: Cash Price |
$15.45
|
Rate for Payer: Galaxy Health Commercial |
$13.39
|
Rate for Payer: WellCare Medicare |
$11.33
|
|
LEVETIRACETAM 100MG/ML SOLN 500 ML
|
Facility
|
IP
|
$6.18
|
|
Service Code
|
NDC 50383024105
|
Hospital Charge Code |
4400428
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$3.40 |
Max. Negotiated Rate |
$4.02 |
Rate for Payer: Cash Price |
$4.64
|
Rate for Payer: Galaxy Health Commercial |
$4.02
|
Rate for Payer: WellCare Medicare |
$3.40
|
|
LEVETIRACETAM 100MG/ML SOLN 500 ML
|
Facility
|
OP
|
$6.18
|
|
Service Code
|
NDC 50383024105
|
Hospital Charge Code |
4400428
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$2.10 |
Max. Negotiated Rate |
$4.97 |
Rate for Payer: Aetna of NY Commercial |
$4.33
|
Rate for Payer: Aetna of NY Medicare |
$2.84
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.64
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.64
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.29
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.09
|
Rate for Payer: Cash Price |
$4.64
|
Rate for Payer: CDPHP Commercial |
$4.97
|
Rate for Payer: CDPHP Medicare |
$2.29
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
Rate for Payer: EmblemHealth Medicaid |
$4.94
|
Rate for Payer: EmblemHealth Medicare |
$2.10
|
Rate for Payer: EmblemHealth Select Care |
$4.45
|
Rate for Payer: Fidelis Medicare |
$2.36
|
Rate for Payer: Galaxy Health Commercial |
$4.02
|
Rate for Payer: Hamaspik Choice Medicare |
$2.29
|
Rate for Payer: Humana Medicare |
$2.29
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
Rate for Payer: MVP Health Care of NY Commercial |
$4.64
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
Rate for Payer: MVP Health Care of NY Medicare |
$2.40
|
Rate for Payer: United Healthcare Medicare |
$2.29
|
Rate for Payer: WellCare Medicare |
$3.40
|
|
LEVETIRACETAM 250MG TABS 10X10EA
|
Facility
|
IP
|
$8.76
|
|
Service Code
|
NDC 00904605161
|
Hospital Charge Code |
4400429
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$4.82 |
Max. Negotiated Rate |
$5.69 |
Rate for Payer: Cash Price |
$6.57
|
Rate for Payer: Galaxy Health Commercial |
$5.69
|
Rate for Payer: WellCare Medicare |
$4.82
|
|
LEVETIRACETAM 250MG TABS 10X10EA
|
Facility
|
OP
|
$8.76
|
|
Service Code
|
NDC 00904605161
|
Hospital Charge Code |
4400429
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$2.98 |
Max. Negotiated Rate |
$7.05 |
Rate for Payer: Aetna of NY Commercial |
$6.13
|
Rate for Payer: Aetna of NY Medicare |
$4.03
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$6.57
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$6.57
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.24
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$4.38
|
Rate for Payer: Cash Price |
$6.57
|
Rate for Payer: CDPHP Commercial |
$7.05
|
Rate for Payer: CDPHP Medicare |
$3.24
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$7.01
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$7.01
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$7.01
|
Rate for Payer: EmblemHealth Medicaid |
$7.01
|
Rate for Payer: EmblemHealth Medicare |
$2.98
|
Rate for Payer: EmblemHealth Select Care |
$6.31
|
Rate for Payer: Fidelis Medicare |
$3.34
|
Rate for Payer: Galaxy Health Commercial |
$5.69
|
Rate for Payer: Hamaspik Choice Medicare |
$3.24
|
Rate for Payer: Humana Medicare |
$3.24
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$6.13
|
Rate for Payer: Local 1199SEIU Medicare |
$4.03
|
Rate for Payer: MVP Health Care of NY Commercial |
$6.57
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.93
|
Rate for Payer: MVP Health Care of NY Medicare |
$3.40
|
Rate for Payer: United Healthcare Medicare |
$3.24
|
Rate for Payer: WellCare Medicare |
$4.82
|
|
LEVETIRACETAM 500MG TABS 10X10EA
|
Facility
|
IP
|
$10.82
|
|
Service Code
|
NDC 00904605261
|
Hospital Charge Code |
4400430
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$5.95 |
Max. Negotiated Rate |
$7.03 |
Rate for Payer: Cash Price |
$8.12
|
Rate for Payer: Galaxy Health Commercial |
$7.03
|
Rate for Payer: WellCare Medicare |
$5.95
|
|
LEVETIRACETAM 500MG TABS 10X10EA
|
Facility
|
OP
|
$10.82
|
|
Service Code
|
NDC 00904605261
|
Hospital Charge Code |
4400430
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$3.68 |
Max. Negotiated Rate |
$8.71 |
Rate for Payer: Aetna of NY Commercial |
$7.57
|
Rate for Payer: Aetna of NY Medicare |
$4.98
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$8.12
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$8.12
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.00
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$5.41
|
Rate for Payer: Cash Price |
$8.12
|
Rate for Payer: CDPHP Commercial |
$8.71
|
Rate for Payer: CDPHP Medicare |
$4.00
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.66
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.66
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.66
|
Rate for Payer: EmblemHealth Medicaid |
$8.66
|
Rate for Payer: EmblemHealth Medicare |
$3.68
|
Rate for Payer: EmblemHealth Select Care |
$7.79
|
Rate for Payer: Fidelis Medicare |
$4.12
|
Rate for Payer: Galaxy Health Commercial |
$7.03
|
Rate for Payer: Hamaspik Choice Medicare |
$4.00
|
Rate for Payer: Humana Medicare |
$4.00
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.57
|
Rate for Payer: Local 1199SEIU Medicare |
$4.98
|
Rate for Payer: MVP Health Care of NY Commercial |
$8.12
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.09
|
Rate for Payer: MVP Health Care of NY Medicare |
$4.20
|
Rate for Payer: United Healthcare Medicare |
$4.00
|
Rate for Payer: WellCare Medicare |
$5.95
|
|
LEVETIRACETAM INJECTION 10 MG
|
Facility
|
IP
|
$0.48
|
|
Service Code
|
HCPCS J1953
|
Hospital Charge Code |
4400431
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.07 |
Max. Negotiated Rate |
$0.31 |
Rate for Payer: Aetna of NY Commercial |
$0.26
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.07
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.07
|
Rate for Payer: Cash Price |
$0.36
|
Rate for Payer: Cash Price |
$0.36
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.07
|
Rate for Payer: EmblemHealth Select Care |
$0.07
|
Rate for Payer: Galaxy Health Commercial |
$0.31
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$0.26
|
Rate for Payer: WellCare Medicare |
$0.26
|
|
LEVETIRACETAM INJECTION 10 MG
|
Facility
|
OP
|
$0.48
|
|
Service Code
|
HCPCS J1953
|
Hospital Charge Code |
4400431
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.07 |
Max. Negotiated Rate |
$0.39 |
Rate for Payer: Aetna of NY Commercial |
$0.26
|
Rate for Payer: Aetna of NY Medicare |
$0.22
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.07
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.07
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$0.18
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$0.24
|
Rate for Payer: Cash Price |
$0.36
|
Rate for Payer: Cash Price |
$0.36
|
Rate for Payer: CDPHP Commercial |
$0.39
|
Rate for Payer: CDPHP Medicare |
$0.18
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.07
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$0.38
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$0.38
|
Rate for Payer: EmblemHealth Medicaid |
$0.38
|
Rate for Payer: EmblemHealth Medicare |
$0.16
|
Rate for Payer: EmblemHealth Select Care |
$0.07
|
Rate for Payer: Fidelis Medicare |
$0.18
|
Rate for Payer: Galaxy Health Commercial |
$0.31
|
Rate for Payer: Hamaspik Choice Medicare |
$0.18
|
Rate for Payer: Humana Medicare |
$0.18
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$0.26
|
Rate for Payer: Local 1199SEIU Medicare |
$0.22
|
Rate for Payer: MVP Health Care of NY Commercial |
$0.36
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$0.27
|
Rate for Payer: MVP Health Care of NY Medicare |
$0.19
|
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.12
|
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.07
|
Rate for Payer: United Healthcare Commercial |
$0.12
|
Rate for Payer: United Healthcare Medicare |
$0.18
|
Rate for Payer: WellCare Medicare |
$0.26
|
|
levOCARNitine 1 G/10 ML SOLN 100 mg, 118 mL
|
Facility
|
IP
|
$140.00
|
|
Service Code
|
NDC 70954013910
|
Hospital Charge Code |
4401558
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$77.00 |
Max. Negotiated Rate |
$91.00 |
Rate for Payer: Cash Price |
$105.00
|
Rate for Payer: Galaxy Health Commercial |
$91.00
|
Rate for Payer: WellCare Medicare |
$77.00
|
|
levOCARNitine 1 G/10 ML SOLN 100 mg, 118 mL
|
Facility
|
OP
|
$140.00
|
|
Service Code
|
NDC 70954013910
|
Hospital Charge Code |
4401558
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$47.60 |
Max. Negotiated Rate |
$112.70 |
Rate for Payer: Aetna of NY Commercial |
$98.00
|
Rate for Payer: Aetna of NY Medicare |
$64.40
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$105.00
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$105.00
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$51.80
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$70.00
|
Rate for Payer: Cash Price |
$105.00
|
Rate for Payer: CDPHP Commercial |
$112.70
|
Rate for Payer: CDPHP Medicare |
$51.80
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$112.00
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$112.00
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$112.00
|
Rate for Payer: EmblemHealth Medicaid |
$112.00
|
Rate for Payer: EmblemHealth Medicare |
$47.60
|
Rate for Payer: EmblemHealth Select Care |
$100.80
|
Rate for Payer: Fidelis Medicare |
$53.35
|
Rate for Payer: Galaxy Health Commercial |
$91.00
|
Rate for Payer: Hamaspik Choice Medicare |
$51.80
|
Rate for Payer: Humana Medicare |
$51.80
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$98.00
|
Rate for Payer: Local 1199SEIU Medicare |
$64.40
|
Rate for Payer: MVP Health Care of NY Commercial |
$105.00
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$78.82
|
Rate for Payer: MVP Health Care of NY Medicare |
$54.39
|
Rate for Payer: United Healthcare Medicare |
$51.80
|
Rate for Payer: WellCare Medicare |
$77.00
|
|
LEVOFLOXACIN 250MG TABS 10X10EA
|
Facility
|
OP
|
$26.78
|
|
Service Code
|
NDC 00904635161
|
Hospital Charge Code |
4400424
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$9.11 |
Max. Negotiated Rate |
$21.56 |
Rate for Payer: Aetna of NY Commercial |
$18.75
|
Rate for Payer: Aetna of NY Medicare |
$12.32
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$20.08
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$20.08
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.91
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$13.39
|
Rate for Payer: Cash Price |
$20.09
|
Rate for Payer: CDPHP Commercial |
$21.56
|
Rate for Payer: CDPHP Medicare |
$9.91
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$21.42
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$21.42
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$21.42
|
Rate for Payer: EmblemHealth Medicaid |
$21.42
|
Rate for Payer: EmblemHealth Medicare |
$9.11
|
Rate for Payer: EmblemHealth Select Care |
$19.28
|
Rate for Payer: Fidelis Medicare |
$10.21
|
Rate for Payer: Galaxy Health Commercial |
$17.41
|
Rate for Payer: Hamaspik Choice Medicare |
$9.91
|
Rate for Payer: Humana Medicare |
$9.91
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$18.75
|
Rate for Payer: Local 1199SEIU Medicare |
$12.32
|
Rate for Payer: MVP Health Care of NY Commercial |
$20.08
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.08
|
Rate for Payer: MVP Health Care of NY Medicare |
$10.40
|
Rate for Payer: United Healthcare Medicare |
$9.91
|
Rate for Payer: WellCare Medicare |
$14.73
|
|
LEVOFLOXACIN 250MG TABS 10X10EA
|
Facility
|
IP
|
$26.78
|
|
Service Code
|
NDC 00904635161
|
Hospital Charge Code |
4400424
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$14.73 |
Max. Negotiated Rate |
$17.41 |
Rate for Payer: Cash Price |
$20.09
|
Rate for Payer: Galaxy Health Commercial |
$17.41
|
Rate for Payer: WellCare Medicare |
$14.73
|
|
LEVOFLOXACIN 500MG TABS 50 EA
|
Facility
|
IP
|
$58.45
|
|
Service Code
|
NDC 00904635261
|
Hospital Charge Code |
4400425
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$32.15 |
Max. Negotiated Rate |
$37.99 |
Rate for Payer: Cash Price |
$43.84
|
Rate for Payer: Galaxy Health Commercial |
$37.99
|
Rate for Payer: WellCare Medicare |
$32.15
|
|
LEVOFLOXACIN 500MG TABS 50 EA
|
Facility
|
OP
|
$58.45
|
|
Service Code
|
NDC 00904635261
|
Hospital Charge Code |
4400425
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$19.87 |
Max. Negotiated Rate |
$47.05 |
Rate for Payer: Aetna of NY Commercial |
$40.92
|
Rate for Payer: Aetna of NY Medicare |
$26.89
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$43.84
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$43.84
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$21.63
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$29.22
|
Rate for Payer: Cash Price |
$43.84
|
Rate for Payer: CDPHP Commercial |
$47.05
|
Rate for Payer: CDPHP Medicare |
$21.63
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$46.76
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$46.76
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$46.76
|
Rate for Payer: EmblemHealth Medicaid |
$46.76
|
Rate for Payer: EmblemHealth Medicare |
$19.87
|
Rate for Payer: EmblemHealth Select Care |
$42.08
|
Rate for Payer: Fidelis Medicare |
$22.28
|
Rate for Payer: Galaxy Health Commercial |
$37.99
|
Rate for Payer: Hamaspik Choice Medicare |
$21.63
|
Rate for Payer: Humana Medicare |
$21.63
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$40.92
|
Rate for Payer: Local 1199SEIU Medicare |
$26.89
|
Rate for Payer: MVP Health Care of NY Commercial |
$43.84
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$32.91
|
Rate for Payer: MVP Health Care of NY Medicare |
$22.71
|
Rate for Payer: United Healthcare Medicare |
$21.63
|
Rate for Payer: WellCare Medicare |
$32.15
|
|
LEVOFLOXACIN INJ, 250 MG
|
Facility
|
OP
|
$25.49
|
|
Service Code
|
HCPCS J1956
|
Hospital Charge Code |
4450009
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.96 |
Max. Negotiated Rate |
$20.52 |
Rate for Payer: Aetna of NY Commercial |
$14.02
|
Rate for Payer: Aetna of NY Medicare |
$11.73
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.96
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.96
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.43
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$12.74
|
Rate for Payer: Cash Price |
$19.12
|
Rate for Payer: Cash Price |
$19.12
|
Rate for Payer: CDPHP Commercial |
$20.52
|
Rate for Payer: CDPHP Medicare |
$9.43
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.96
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$20.39
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$20.39
|
Rate for Payer: EmblemHealth Medicaid |
$20.39
|
Rate for Payer: EmblemHealth Medicare |
$8.67
|
Rate for Payer: EmblemHealth Select Care |
$0.96
|
Rate for Payer: Fidelis Medicare |
$9.71
|
Rate for Payer: Galaxy Health Commercial |
$16.57
|
Rate for Payer: Hamaspik Choice Medicare |
$9.43
|
Rate for Payer: Humana Medicare |
$9.43
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$14.02
|
Rate for Payer: Local 1199SEIU Medicare |
$11.73
|
Rate for Payer: MVP Health Care of NY Commercial |
$19.12
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$14.35
|
Rate for Payer: MVP Health Care of NY Medicare |
$9.90
|
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.52
|
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.96
|
Rate for Payer: United Healthcare Commercial |
$1.52
|
Rate for Payer: United Healthcare Medicare |
$9.43
|
Rate for Payer: WellCare Medicare |
$14.02
|
|
LEVOFLOXACIN INJ, 250 MG
|
Facility
|
IP
|
$26.78
|
|
Service Code
|
HCPCS J1956
|
Hospital Charge Code |
4450008
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.96 |
Max. Negotiated Rate |
$17.41 |
Rate for Payer: Aetna of NY Commercial |
$14.73
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.96
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.96
|
Rate for Payer: Cash Price |
$20.09
|
Rate for Payer: Cash Price |
$20.09
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.96
|
Rate for Payer: EmblemHealth Select Care |
$0.96
|
Rate for Payer: Galaxy Health Commercial |
$17.41
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$14.73
|
Rate for Payer: WellCare Medicare |
$14.73
|
|
LEVOFLOXACIN INJ, 250 MG
|
Facility
|
IP
|
$25.49
|
|
Service Code
|
HCPCS J1956
|
Hospital Charge Code |
4450009
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.96 |
Max. Negotiated Rate |
$16.57 |
Rate for Payer: Aetna of NY Commercial |
$14.02
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.96
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.96
|
Rate for Payer: Cash Price |
$19.12
|
Rate for Payer: Cash Price |
$19.12
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.96
|
Rate for Payer: EmblemHealth Select Care |
$0.96
|
Rate for Payer: Galaxy Health Commercial |
$16.57
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$14.02
|
Rate for Payer: WellCare Medicare |
$14.02
|
|
LEVOFLOXACIN INJ, 250 MG
|
Facility
|
OP
|
$26.78
|
|
Service Code
|
HCPCS J1956
|
Hospital Charge Code |
4450008
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.96 |
Max. Negotiated Rate |
$21.56 |
Rate for Payer: Aetna of NY Commercial |
$14.73
|
Rate for Payer: Aetna of NY Medicare |
$12.32
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.96
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.96
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$9.91
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$13.39
|
Rate for Payer: Cash Price |
$20.09
|
Rate for Payer: Cash Price |
$20.09
|
Rate for Payer: CDPHP Commercial |
$21.56
|
Rate for Payer: CDPHP Medicare |
$9.91
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.96
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$21.42
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$21.42
|
Rate for Payer: EmblemHealth Medicaid |
$21.42
|
Rate for Payer: EmblemHealth Medicare |
$9.11
|
Rate for Payer: EmblemHealth Select Care |
$0.96
|
Rate for Payer: Fidelis Medicare |
$10.21
|
Rate for Payer: Galaxy Health Commercial |
$17.41
|
Rate for Payer: Hamaspik Choice Medicare |
$9.91
|
Rate for Payer: Humana Medicare |
$9.91
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$14.73
|
Rate for Payer: Local 1199SEIU Medicare |
$12.32
|
Rate for Payer: MVP Health Care of NY Commercial |
$20.08
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$15.08
|
Rate for Payer: MVP Health Care of NY Medicare |
$10.40
|
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.52
|
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.96
|
Rate for Payer: United Healthcare Commercial |
$1.52
|
Rate for Payer: United Healthcare Medicare |
$9.91
|
Rate for Payer: WellCare Medicare |
$14.73
|
|
LEVOFLOXACIN INJ, 750 MG
|
Facility
|
OP
|
$16.22
|
|
Service Code
|
HCPCS J1956
|
Hospital Charge Code |
4450010
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.96 |
Max. Negotiated Rate |
$13.06 |
Rate for Payer: Aetna of NY Commercial |
$8.92
|
Rate for Payer: Aetna of NY Medicare |
$7.46
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.96
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.96
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.00
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$8.11
|
Rate for Payer: Cash Price |
$12.17
|
Rate for Payer: Cash Price |
$12.17
|
Rate for Payer: CDPHP Commercial |
$13.06
|
Rate for Payer: CDPHP Medicare |
$6.00
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.96
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.98
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.98
|
Rate for Payer: EmblemHealth Medicaid |
$12.98
|
Rate for Payer: EmblemHealth Medicare |
$5.51
|
Rate for Payer: EmblemHealth Select Care |
$0.96
|
Rate for Payer: Fidelis Medicare |
$6.18
|
Rate for Payer: Galaxy Health Commercial |
$10.54
|
Rate for Payer: Hamaspik Choice Medicare |
$6.00
|
Rate for Payer: Humana Medicare |
$6.00
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.92
|
Rate for Payer: Local 1199SEIU Medicare |
$7.46
|
Rate for Payer: MVP Health Care of NY Commercial |
$12.16
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.13
|
Rate for Payer: MVP Health Care of NY Medicare |
$6.30
|
Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$1.52
|
Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.96
|
Rate for Payer: United Healthcare Commercial |
$1.52
|
Rate for Payer: United Healthcare Medicare |
$6.00
|
Rate for Payer: WellCare Medicare |
$8.92
|
|
LEVOFLOXACIN INJ, 750 MG
|
Facility
|
IP
|
$16.22
|
|
Service Code
|
HCPCS J1956
|
Hospital Charge Code |
4450010
|
Hospital Revenue Code
|
636
|
Min. Negotiated Rate |
$0.96 |
Max. Negotiated Rate |
$10.54 |
Rate for Payer: Aetna of NY Commercial |
$8.92
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$0.96
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$0.96
|
Rate for Payer: Cash Price |
$12.17
|
Rate for Payer: Cash Price |
$12.17
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$0.96
|
Rate for Payer: EmblemHealth Select Care |
$0.96
|
Rate for Payer: Galaxy Health Commercial |
$10.54
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.92
|
Rate for Payer: WellCare Medicare |
$8.92
|
|
levothyroxine 100 MCG TABLET 100 mcg, 100 eaches
|
Facility
|
OP
|
$17.00
|
|
Service Code
|
NDC 51079044201
|
Hospital Charge Code |
4400853
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$5.78 |
Max. Negotiated Rate |
$13.68 |
Rate for Payer: Aetna of NY Commercial |
$11.90
|
Rate for Payer: Aetna of NY Medicare |
$7.82
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$12.75
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$12.75
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.29
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$8.50
|
Rate for Payer: Cash Price |
$12.75
|
Rate for Payer: CDPHP Commercial |
$13.68
|
Rate for Payer: CDPHP Medicare |
$6.29
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$13.60
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$13.60
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$13.60
|
Rate for Payer: EmblemHealth Medicaid |
$13.60
|
Rate for Payer: EmblemHealth Medicare |
$5.78
|
Rate for Payer: EmblemHealth Select Care |
$12.24
|
Rate for Payer: Fidelis Medicare |
$6.48
|
Rate for Payer: Galaxy Health Commercial |
$11.05
|
Rate for Payer: Hamaspik Choice Medicare |
$6.29
|
Rate for Payer: Humana Medicare |
$6.29
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$11.90
|
Rate for Payer: Local 1199SEIU Medicare |
$7.82
|
Rate for Payer: MVP Health Care of NY Commercial |
$12.75
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$9.57
|
Rate for Payer: MVP Health Care of NY Medicare |
$6.60
|
Rate for Payer: United Healthcare Medicare |
$6.29
|
Rate for Payer: WellCare Medicare |
$9.35
|
|
levothyroxine 100 MCG TABLET 100 mcg, 100 eaches
|
Facility
|
IP
|
$17.00
|
|
Service Code
|
NDC 51079044201
|
Hospital Charge Code |
4400853
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$9.35 |
Max. Negotiated Rate |
$11.05 |
Rate for Payer: Cash Price |
$12.75
|
Rate for Payer: Galaxy Health Commercial |
$11.05
|
Rate for Payer: WellCare Medicare |
$9.35
|
|
levothyroxine 112 MCG TABLET 112 mcg, 90 eaches
|
Facility
|
OP
|
$6.00
|
|
Service Code
|
NDC 00378181177
|
Hospital Charge Code |
4401306
|
Hospital Revenue Code
|
250
|
Min. Negotiated Rate |
$2.04 |
Max. Negotiated Rate |
$4.83 |
Rate for Payer: Aetna of NY Commercial |
$4.20
|
Rate for Payer: Aetna of NY Medicare |
$2.76
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Blue Access/Small Group |
$4.50
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) EPO/HMO/Indemnity/PPO |
$4.50
|
Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.22
|
Rate for Payer: Brighton Health (Magnacare) Direct Plus/No Fault/PIP/PPO/Workers Comp |
$3.00
|
Rate for Payer: Cash Price |
$4.50
|
Rate for Payer: CDPHP Commercial |
$4.83
|
Rate for Payer: CDPHP Medicare |
$2.22
|
Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.80
|
Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.80
|
Rate for Payer: EmblemHealth Medicaid |
$4.80
|
Rate for Payer: EmblemHealth Medicare |
$2.04
|
Rate for Payer: EmblemHealth Select Care |
$4.32
|
Rate for Payer: Fidelis Medicare |
$2.29
|
Rate for Payer: Galaxy Health Commercial |
$3.90
|
Rate for Payer: Hamaspik Choice Medicare |
$2.22
|
Rate for Payer: Humana Medicare |
$2.22
|
Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
Rate for Payer: Local 1199SEIU Medicare |
$2.76
|
Rate for Payer: MVP Health Care of NY Commercial |
$4.50
|
Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.38
|
Rate for Payer: MVP Health Care of NY Medicare |
$2.33
|
Rate for Payer: United Healthcare Medicare |
$2.22
|
Rate for Payer: WellCare Medicare |
$3.30
|
|