| Medicine Name | HCPCS_CODE | TOT_QUANTITY | TOT_TX_AMOUNT | Charge | BCBS ALLOWED AMOUNT | HEALTHCHOICE ALLOWED AMOUNT | MEDICAID ALLOWED AMOUNT | MEDICARE ALLOWED AMOUNT | AETNA ALLOWED AMOUNT | HIGHEST ALLOWED | LOWEST ALLOWED |
|---|---|---|---|---|---|---|---|---|---|---|---|
| IOHEXOL 350 MG/ML SOLN | Q9967 | 5,400 | $21,529.80 | $3.99 | $0.00 | $0.11 | $0.11 | $1.87 | $0.11 | $1.87 | $0.00 |
| IOHEXOL 240 MG/ML SOLN | Q9966 | 3,000 | $8,971.90 | $2.99 | $0.00 | $0.39 | $0.31 | $1.41 | $0.28 | $1.41 | $0.00 |
| HEPARIN LOCK FLUSH 100 UNIT/ML SOLN | J1642 | 2,900 | $1,131.00 | $0.39 | $0.00 | $0.02 | $0.00 | $0.18 | $0.02 | $0.18 | $0.00 |
| PREDNISONE 20 MG TABS | J7512 | 2,280 | $220.40 | $0.10 | $0.00 | $0.00 | $0.01 | $0.05 | $0.01 | $0.05 | $0.00 |
| CEFTRIAXONE 1 G SOLR 1 EACH VIAL | J0696 | 1,229 | $5,440.50 | $4.43 | $0.00 | $0.72 | $0.53 | $2.08 | $0.68 | $2.08 | $0.00 |
| PIPERACILLIN - TAZOBACTAM 3.375 (3-0.375) G SOLR 1 EACH VIAL | J2543 | 893 | $17,317.90 | $19.39 | $0.00 | $1.88 | $1.68 | $9.11 | $1.79 | $9.11 | $0.00 |
| PROPOFOL 200 MG/20ML EMUL | J2704 | 756 | $945.40 | $1.25 | $0.00 | $0.13 | $0.00 | $0.59 | $0.11 | $0.59 | $0.00 |
| LEVETIRACETAM 500 MG/5ML SOLN 5 ML VIAL | J1953 | 700 | $318.60 | $0.46 | $0.00 | $0.14 | $0.14 | $0.21 | $0.11 | $0.21 | $0.00 |
| 0.9% NACL 0.9 % SOLN 100 ML FLEX CONT | J7050 | 656 | $73,472.00 | $112.00 | $0.00 | $0.72 | $0.64 | $52.64 | $0.68 | $52.64 | $0.00 |
| ONDANSETRON 2 MG/ML SOLN | J2405 | 644 | $2,905.50 | $4.51 | $0.00 | $0.10 | $0.10 | $2.12 | $0.10 | $2.12 | $0.00 |
| KETOROLAC 30 MG/ML SOLN | J1885 | 575 | $3,637.50 | $6.33 | $0.00 | $0.76 | $0.58 | $2.97 | $0.72 | $2.97 | $0.00 |
| 0.9% NACL 0.9 % SOLN | J7030 | 447 | $50,064.00 | $112.00 | $0.00 | $2.90 | $2.55 | $52.64 | $2.74 | $52.64 | $0.00 |
| FUROSEMIDE 10 MG/ML SOLN | J1940 | 430 | $9,197.30 | $21.39 | $0.00 | $0.90 | $0.60 | $10.05 | $0.85 | $10.05 | $0.00 |
| BUDESONIDE 0.5 MG/2ML SUSP | J7626 | 425 | $15,372.00 | $36.17 | $0.00 | $1.95 | $1.78 | $17.00 | $1.84 | $17.00 | $0.00 |
| INSULIN GLARGINE 100 UNIT/ML SOLN | J1815 | 415 | $2,598.40 | $6.26 | $0.00 | $0.99 | $0.83 | $2.94 | $0.67 | $2.94 | $0.00 |
| MORPHINE 4 MG/ML SOLN | J2270 | 410 | $7,995.00 | $19.50 | $0.00 | $2.13 | $3.72 | $9.17 | $2.02 | $9.17 | $0.00 |
| DEXAMETHASONE 4 MG TABS | J8540 | 400 | $98.50 | $0.25 | $0.00 | $0.00 | $0.10 | $0.12 | $0.07 | $0.12 | $0.00 |
| ALBUTEROL (2.5 MG/3ML) 0.083% NEBU | J7613 | 318 | $361.90 | $1.14 | $0.00 | $0.05 | $0.04 | $0.53 | $0.05 | $0.53 | $0.00 |
| VANCOMYCIN 1 G SOLR 1 EACH VIAL | J3370 | 301 | $3,157.10 | $10.49 | $0.00 | $3.16 | $2.77 | $4.93 | $2.99 | $4.93 | $0.00 |
| ATROPINE 0.1 MG/ML SOLN | J0461 | 300 | $60.00 | $0.20 | $0.00 | $0.10 | $0.06 | $0.09 | $0.09 | $0.10 | $0.00 |
| EPOETIN 40000 UNIT/ML SOLN | J0885 | 280 | $29,633.10 | $105.83 | $0.00 | $10.39 | $9.70 | $49.74 | $9.84 | $49.74 | $0.00 |
| HEPARIN 5000 UNIT/ML SOLN | J1644 | 270 | $1,053.00 | $3.90 | $0.00 | $0.29 | $0.25 | $1.83 | $0.31 | $1.83 | $0.00 |
| ALTEPLASE 100 MG SOLR | J2997 | 264 | $91,166.40 | $345.33 | $0.00 | $99.35 | $87.89 | $162.30 | $74.39 | $162.30 | $0.00 |
| FAMOTIDINE 10 MG/ML SOLN | J3490 | 251 | $2,457.00 | $9.79 | $0.00 | $0.00 | $0.00 | $4.60 | $0.17 | $4.60 | $0.00 |
| ENOXAPARIN 40 MG/0.4ML SOLN | J1650 | 240 | $5,501.60 | $22.92 | $0.00 | $0.78 | $0.69 | $10.77 | $0.74 | $10.77 | $0.00 |
| LACTATED RINGERS SOLN | J7120 | 221 | $14,672.00 | $66.39 | $0.00 | $2.67 | $2.34 | $31.20 | $2.53 | $31.20 | $0.00 |
| DEXAMETHASONE 4 MG/ML SOLN | J1100 | 219 | $1,053.00 | $4.81 | $0.00 | $0.16 | $0.12 | $2.26 | $0.14 | $2.26 | $0.00 |
| MEROPENEM 1 G SOLR 1 EACH VIAL | J2185 | 210 | $999.60 | $4.76 | $0.00 | $0.98 | $0.79 | $2.24 | $0.92 | $2.24 | $0.00 |
| LIDOCAINE (PF) 4 % SOLN | J2001 | 204 | $994.50 | $4.88 | $0.00 | $0.03 | $0.02 | $2.29 | $0.02 | $2.29 | $0.00 |
| LORAZEPAM 2 MG/ML SOLN | J2060 | 193 | $3,763.50 | $19.50 | $0.00 | $0.86 | $0.69 | $9.17 | $0.81 | $9.17 | $0.00 |
| EPINEPHRINE PF 1 MG/10ML | J0171 | 180 | $354.00 | $1.97 | $0.00 | $1.00 | $0.91 | $0.92 | $0.66 | $1.00 | $0.00 |
| MIDAZOLAM 1 MG/ML SOLN | J2250 | 163 | $1,257.70 | $7.72 | $0.00 | $0.15 | $0.11 | $3.63 | $0.14 | $3.63 | $0.00 |
| METHYLPREDNISOLONE SOD SUCC 40 MG SOLR | J2920 | 141 | $3,254.00 | $23.08 | $0.00 | $4.75 | $4.52 | $10.85 | $4.50 | $10.85 | $0.00 |
| MILRINONE 20-5 MG/100ML-% SOLN | J2260 | 136 | $3,808.00 | $28.00 | $0.00 | $1.72 | $1.43 | $13.16 | $1.63 | $13.16 | $0.00 |
| ARFORMOTEROL 15 MCG/2ML NEBU | J7605 | 118 | $8,151.60 | $69.08 | $0.00 | $12.73 | $11.00 | $32.47 | $12.06 | $32.47 | $0.00 |
| POTASSIUM CHLORIDE 2 MEQ/ML SOLN 20 ML VIAL | J3480 | 90 | $97.50 | $1.08 | $0.00 | $0.17 | $0.18 | $0.51 | $0.17 | $0.51 | $0.00 |
| PROMETHAZINE 25 MG/ML SOLN | J2550 | 76 | $1,482.00 | $19.50 | $0.00 | $2.63 | $2.23 | $9.17 | $2.50 | $9.17 | $0.00 |
| CIPROFLOXACIN 400 MG/200ML SOLN | J0744 | 70 | $682.50 | $9.75 | $0.00 | $1.14 | $1.13 | $4.58 | $1.08 | $4.58 | $0.00 |
| TDAP (TETANUS-DIPHTHERIA-ACELL PERTUSSIS) 5-2-15.5 LF-MCG/0.5 SUSP | 90715 | 68 | $12,318.60 | $181.16 | $0.00 | $46.28 | $33.44 | $85.14 | $37.02 | $85.14 | $0.00 |
| HYDROMORPHONE 1 MG/ML SOLN | J1170 | 66 | $1,294.20 | $19.61 | $0.00 | $2.26 | $3.11 | $9.22 | $2.13 | $9.22 | $0.00 |
| AZITHROMYCIN 500 MG SOLR 1 EACH VIAL | J0456 | 65 | $2,269.10 | $34.91 | $0.00 | $4.59 | $3.42 | $16.41 | $4.36 | $16.41 | $0.00 |
| GADOBENATE DIMEGLUMINE 529 MG/ML SOLN | A9577 | 54 | $1,213.50 | $22.47 | $0.00 | $2.06 | $0.00 | $10.56 | $1.96 | $10.56 | $0.00 |
| MAGNESIUM SULFATE 50 % SOLN 10 ML VIAL | J3475 | 52 | $253.50 | $4.88 | $0.00 | $0.48 | $0.64 | $2.29 | $0.36 | $2.29 | $0.00 |
| METHYLPREDNISOLONE ACETATE 80 MG/ML SUSP | J1040 | 51 | $3,111.40 | $61.01 | $0.00 | $12.76 | $11.70 | $28.67 | $12.09 | $28.67 | $0.00 |
| LEVALBUTEROL 1.25 MG/0.5ML NEBU | J7612 | 51 | $479.40 | $9.40 | $0.00 | $0.43 | $0.29 | $4.42 | $0.41 | $4.42 | $0.00 |
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