St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LEVOFLOXACIN 750 MG PO TABS [28964]

Facility

$24.61

Service Code	NDC 00904635361
Hospital Charge Code	00904635361
Hospital Revenue Code	250
Min. Negotiated Rate	$8.61
Max. Negotiated Rate	$19.69
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13.54
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.31
Rate for Payer: Aetna Government	$12.31
Rate for Payer: Brighton Health Commercial	$18.46
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$19.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$16.74
Rate for Payer: Group Health Inc Commercial	$12.31
Rate for Payer: Group Health Inc Medicare	$8.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.31
Rate for Payer: Hamaspik Choice Inc Medicare	$12.31
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.00

LEVOFLOXACIN 750 MG PO TABS [28964]

Facility

$36.08

Service Code	NDC 65862053820
Hospital Charge Code	65862053820
Hospital Revenue Code	250
Min. Negotiated Rate	$12.63
Max. Negotiated Rate	$28.86
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$19.84
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.04
Rate for Payer: Aetna Government	$18.04
Rate for Payer: Brighton Health Commercial	$27.06
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$28.86
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.53
Rate for Payer: Group Health Inc Commercial	$18.04
Rate for Payer: Group Health Inc Medicare	$12.63
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.04
Rate for Payer: Hamaspik Choice Inc Medicare	$18.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$23.45

LEVOFLOXACIN 750 MG TAB

Facility

$1.00

Hospital Charge Code	41643325
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

LEVOFLOXACIN 750 MG TAB

Facility

$1.00

Hospital Charge Code	41653325
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN [108118]

Facility

$0.14

Service Code	HCPCS J1956
Hospital Charge Code	00143972201
Hospital Revenue Code	278
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07

LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN [108118]

Facility

$0.14

Service Code	HCPCS J1956
Hospital Charge Code	00143972224
Hospital Revenue Code	278
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: EmblemHealth Commercial	$0.07
Rate for Payer: Fidelis Medicare Advantage	$0.15
Rate for Payer: Group Health Inc Commercial	$0.07
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.09

LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN [108118]

Facility

$0.14

Service Code	HCPCS J1956
Hospital Charge Code	00143972201
Hospital Revenue Code	278
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.07
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.08
Rate for Payer: EmblemHealth Commercial	$0.07
Rate for Payer: Fidelis Medicare Advantage	$0.15
Rate for Payer: Group Health Inc Commercial	$0.07
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.09

LEVOFLOXACIN IN D5W 250 MG/50ML IV SOLN [108118]

Facility

$0.14

Service Code	HCPCS J1956
Hospital Charge Code	00143972224
Hospital Revenue Code	278
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.07
Rate for Payer: Hamaspik Choice Inc Medicare	$0.07

LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN [108119]

Facility

$0.15

Service Code	HCPCS J1956
Hospital Charge Code	44567043624
Hospital Revenue Code	278
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08

LEVOFLOXACIN IN D5W 500 MG/100ML IV SOLN [108119]

Facility

$0.15

Service Code	HCPCS J1956
Hospital Charge Code	44567043624
Hospital Revenue Code	278
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$0.09
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.08
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.09
Rate for Payer: EmblemHealth Commercial	$0.08
Rate for Payer: Fidelis Medicare Advantage	$0.16
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.10

LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN [108120]

Facility

$0.09

Service Code	HCPCS J1956
Hospital Charge Code	25021013283
Hospital Revenue Code	278
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.05
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$0.05
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.04
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.05
Rate for Payer: EmblemHealth Commercial	$0.04
Rate for Payer: Fidelis Medicare Advantage	$0.09
Rate for Payer: Group Health Inc Commercial	$0.04
Rate for Payer: Group Health Inc Medicare	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.06

LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN [108120]

Facility

$0.05

Service Code	HCPCS J1956
Hospital Charge Code	36000004824
Hospital Revenue Code	278
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.03
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: EmblemHealth Commercial	$0.03
Rate for Payer: Fidelis Medicare Advantage	$0.05
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN [108120]

Facility

$0.05

Service Code	HCPCS J1956
Hospital Charge Code	00143972024
Hospital Revenue Code	278
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.91
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.03
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.91
Rate for Payer: Aetna Government	$0.91
Rate for Payer: Brighton Health Commercial	$0.03
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.03
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.03
Rate for Payer: EmblemHealth Commercial	$0.03
Rate for Payer: Fidelis Medicare Advantage	$0.05
Rate for Payer: Group Health Inc Commercial	$0.03
Rate for Payer: Group Health Inc Medicare	$0.02
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.03

LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN [108120]

Facility

$0.09

Service Code	HCPCS J1956
Hospital Charge Code	25021013283
Hospital Revenue Code	278
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.04
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.04
Rate for Payer: Hamaspik Choice Inc Medicare	$0.04

LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN [108120]

Facility

$0.05

Service Code	HCPCS J1956
Hospital Charge Code	36000004824
Hospital Revenue Code	278
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03

LEVOFLOXACIN IN D5W 750 MG/150ML IV SOLN [108120]

Facility

$0.05

Service Code	HCPCS J1956
Hospital Charge Code	00143972024
Hospital Revenue Code	278
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.03
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.03
Rate for Payer: Hamaspik Choice Inc Medicare	$0.03

LEVOLEUCOVORIN 50MG INJ

Facility

$5.70

Service Code	HCPCS J0641
Hospital Charge Code	41656652
Hospital Revenue Code	636
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$2.85
Rate for Payer: Cash Price	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.85
Rate for Payer: Hamaspik Choice Inc Medicare	$2.85

LEVOLEUCOVORIN 50MG INJ

Facility

$5.70

Service Code	HCPCS J0641
Hospital Charge Code	41646652
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$3.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Affinity Essential Plan 1&2	$0.06
Rate for Payer: Affinity Essential Plan 3&4	$0.06
Rate for Payer: Affinity Medicaid/CHP/HARP	$0.06
Rate for Payer: Brighton Health Commercial	$3.42
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$0.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.85
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.28
Rate for Payer: Elderplan Medicare Advantage	$0.08
Rate for Payer: EmblemHealth Commercial	$0.08
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.08
Rate for Payer: Fidelis Essential Plan Aliesa	$0.08
Rate for Payer: Fidelis Essential Plan QHP	$0.08
Rate for Payer: Fidelis Medicare Advantage	$0.08
Rate for Payer: Fidelis Qualified Health Plan	$0.08
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.85
Rate for Payer: Hamaspik Choice Inc Medicare	$2.85
Rate for Payer: Healthfirst Medicare Advantage	$0.07
Rate for Payer: Healthfirst QHP	$0.08
Rate for Payer: Humana Medicare	$0.08
Rate for Payer: Senior Whole Health Medicare Advantage	$0.08
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.06
Rate for Payer: SOMOS Essential	$0.06
Rate for Payer: United Healthcare Commercial	$0.27
Rate for Payer: United Healthcare Medicare Advantage	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.70
Rate for Payer: Wellcare CHP/FHP/Medicaid	$0.06
Rate for Payer: Wellcare Medicare	$0.08

LEVOLEUCOVORIN 50MG INJ

Facility

$5.70

Service Code	HCPCS J0641
Hospital Charge Code	41656652
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$3.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$3.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Affinity Essential Plan 1&2	$0.06
Rate for Payer: Affinity Essential Plan 3&4	$0.06
Rate for Payer: Affinity Medicaid/CHP/HARP	$0.06
Rate for Payer: Brighton Health Commercial	$3.42
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cash Price	$0.08
Rate for Payer: Centers Plan For Healthy Living Dual Advantage/Medicare Advantage/Medicare Advantage Plus	$0.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.85
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.28
Rate for Payer: Elderplan Medicare Advantage	$0.08
Rate for Payer: EmblemHealth Commercial	$0.08
Rate for Payer: Fidelis CHP/HARP/Medicaid	$0.08
Rate for Payer: Fidelis Essential Plan Aliesa	$0.08
Rate for Payer: Fidelis Essential Plan QHP	$0.08
Rate for Payer: Fidelis Medicare Advantage	$0.08
Rate for Payer: Fidelis Qualified Health Plan	$0.08
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.85
Rate for Payer: Hamaspik Choice Inc Medicare	$2.85
Rate for Payer: Healthfirst Medicare Advantage	$0.07
Rate for Payer: Healthfirst QHP	$0.08
Rate for Payer: Humana Medicare	$0.08
Rate for Payer: Senior Whole Health Medicare Advantage	$0.08
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.06
Rate for Payer: SOMOS Essential	$0.06
Rate for Payer: United Healthcare Commercial	$0.27
Rate for Payer: United Healthcare Medicare Advantage	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.70
Rate for Payer: Wellcare CHP/FHP/Medicaid	$0.06
Rate for Payer: Wellcare Medicare	$0.08

LEVOLEUCOVORIN 50MG INJ

Facility

$5.70

Service Code	HCPCS J0641
Hospital Charge Code	41646652
Hospital Revenue Code	636
Min. Negotiated Rate	$2.85
Max. Negotiated Rate	$2.85
Rate for Payer: Cash Price	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.85
Rate for Payer: Hamaspik Choice Inc Medicare	$2.85

LEVONORGESTREL 1.5 MG PO TABS [99445]

Facility

$36.56

Service Code	NDC 68180085211
Hospital Charge Code	68180085211
Hospital Revenue Code	250
Min. Negotiated Rate	$12.80
Max. Negotiated Rate	$29.25
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.28
Rate for Payer: Aetna Government	$18.28
Rate for Payer: Brighton Health Commercial	$27.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$29.25
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.86
Rate for Payer: Group Health Inc Commercial	$18.28
Rate for Payer: Group Health Inc Medicare	$12.80
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.28
Rate for Payer: Hamaspik Choice Inc Medicare	$18.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$23.76

LEVONORGESTREL 1.5 MG PO TABS [99445]

Facility

$36.55

Service Code	NDC 70700016406
Hospital Charge Code	70700016406
Hospital Revenue Code	250
Min. Negotiated Rate	$12.79
Max. Negotiated Rate	$29.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$20.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$18.28
Rate for Payer: Aetna Government	$18.28
Rate for Payer: Brighton Health Commercial	$27.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$29.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$24.85
Rate for Payer: Group Health Inc Commercial	$18.28
Rate for Payer: Group Health Inc Medicare	$12.79
Rate for Payer: Hamaspik Choice Inc Medicaid	$18.28
Rate for Payer: Hamaspik Choice Inc Medicare	$18.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$23.76

LEVONORGESTREL 1.5 MG PO TABS [99445]

Facility

$9.05

Service Code	NDC 00536114263
Hospital Charge Code	00536114263
Hospital Revenue Code	250
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$7.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.98
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.52
Rate for Payer: Aetna Government	$4.52
Rate for Payer: Brighton Health Commercial	$6.79
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.15
Rate for Payer: Group Health Inc Commercial	$4.52
Rate for Payer: Group Health Inc Medicare	$3.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.52
Rate for Payer: Hamaspik Choice Inc Medicare	$4.52
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.88

LEVONORGESTREL 1.5 MG PO TABS [99445]

Facility

$25.00

Service Code	NDC 62756072060
Hospital Charge Code	62756072060
Hospital Revenue Code	250
Min. Negotiated Rate	$8.75
Max. Negotiated Rate	$20.00
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$13.75
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$12.50
Rate for Payer: Aetna Government	$12.50
Rate for Payer: Brighton Health Commercial	$18.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$20.00
Rate for Payer: Cigna LocalPlus Benefit Plan	$17.00
Rate for Payer: Group Health Inc Commercial	$12.50
Rate for Payer: Group Health Inc Medicare	$8.75
Rate for Payer: Hamaspik Choice Inc Medicaid	$12.50
Rate for Payer: Hamaspik Choice Inc Medicare	$12.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$16.25

LEVONORGESTREL 1.5 MG PO TABS [99445]

Facility

$39.00

Service Code	NDC 69536016288
Hospital Charge Code	69536016288
Hospital Revenue Code	250
Min. Negotiated Rate	$13.65
Max. Negotiated Rate	$31.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$21.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$19.50
Rate for Payer: Aetna Government	$19.50
Rate for Payer: Brighton Health Commercial	$29.25
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$31.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$26.52
Rate for Payer: Group Health Inc Commercial	$19.50
Rate for Payer: Group Health Inc Medicare	$13.65
Rate for Payer: Hamaspik Choice Inc Medicaid	$19.50
Rate for Payer: Hamaspik Choice Inc Medicare	$19.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$25.35

Know your out-of-pocket cost for care.

All Charges