Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM (KEPPRA)

Facility

$110.00

Service Code	HCPCS 80299
Hospital Charge Code	38472310
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$16.50
Rate for Payer: Qualcare PPO/HMO/WC	$16.50

LEVETIRACETAM (KEPPRA)

Facility

$110.00

Service Code	HCPCS 80299
Hospital Charge Code	38472310
Hospital Revenue Code	301
Min. Negotiated Rate	$3.12
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$50.70
Rate for Payer: Aetna Medicare Advantage	$60.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$67.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$67.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$18.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$9.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$67.62
Rate for Payer: Cigna Commercial	$55.00
Rate for Payer: Cigna Medicare Advantage	$18.64
Rate for Payer: Clover Medicare Advantage	$17.71
Rate for Payer: EmblemHealth Commercial	$55.92
Rate for Payer: Humana Medicare Advantage	$19.20
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$18.64
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$28.60
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$16.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$14.91
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.64
Rate for Payer: Wellcare Medicare Advantage	$18.64
Rate for Payer: Wellpoint Medicaid Managed Care	$3.12

LEVOFLOXACIN 250 MG TAB

Facility

$191.75

Service Code	NDC 50458092010
Hospital Charge Code	60628633
Hospital Revenue Code	250
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$95.88
Rate for Payer: Aetna Commercial	$72.86
Rate for Payer: Aetna Medicare Advantage	$57.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$48.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$48.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$48.90
Rate for Payer: Cigna Commercial	$95.88
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$49.85
Rate for Payer: Oxford Commercial	$38.35
Rate for Payer: Qualcare PPO/HMO/WC	$28.76
Rate for Payer: UnitedHealthcare Commercial	$38.35
Rate for Payer: UnitedHealthcare Community & State	$6.06
Rate for Payer: Wellpoint Medicaid Managed Care	$5.45

LEVOFLOXACIN 250 MG TAB

Facility

$191.75

Service Code	NDC 50458092010
Hospital Charge Code	60628633
Hospital Revenue Code	250
Min. Negotiated Rate	$28.76
Max. Negotiated Rate	$28.76
Rate for Payer: Qualcare PPO/HMO/WC	$28.76

LEVOFLOXACIN(LEVAQUIN)250 IVPB

Facility

$154.64

Service Code	NDC 25021013281
Hospital Charge Code	60630153
Hospital Revenue Code	250
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$77.32
Rate for Payer: Aetna Commercial	$58.76
Rate for Payer: Aetna Medicare Advantage	$46.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.43
Rate for Payer: Cigna Commercial	$77.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$40.21
Rate for Payer: Oxford Commercial	$30.93
Rate for Payer: Qualcare PPO/HMO/WC	$23.20
Rate for Payer: UnitedHealthcare Commercial	$30.93
Rate for Payer: UnitedHealthcare Community & State	$4.89
Rate for Payer: Wellpoint Medicaid Managed Care	$4.39

LEVOFLOXACIN(LEVAQUIN)250 IVPB

Facility

$154.64

Service Code	NDC 25021013281
Hospital Charge Code	60630153
Hospital Revenue Code	250
Min. Negotiated Rate	$23.20
Max. Negotiated Rate	$23.20
Rate for Payer: Qualcare PPO/HMO/WC	$23.20

LEVOFLOXACIN(LEVAQUIN)500 IVPB

Facility

$154.64

Service Code	NDC 25021013282
Hospital Charge Code	60630152
Hospital Revenue Code	250
Min. Negotiated Rate	$4.39
Max. Negotiated Rate	$77.32
Rate for Payer: Aetna Commercial	$58.76
Rate for Payer: Aetna Medicare Advantage	$46.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$39.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$39.43
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$39.43
Rate for Payer: Cigna Commercial	$77.32
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$40.21
Rate for Payer: Oxford Commercial	$30.93
Rate for Payer: Qualcare PPO/HMO/WC	$23.20
Rate for Payer: UnitedHealthcare Commercial	$30.93
Rate for Payer: UnitedHealthcare Community & State	$4.89
Rate for Payer: Wellpoint Medicaid Managed Care	$4.39

LEVOFLOXACIN(LEVAQUIN)500 IVPB

Facility

$154.64

Service Code	NDC 25021013282
Hospital Charge Code	60630152
Hospital Revenue Code	250
Min. Negotiated Rate	$23.20
Max. Negotiated Rate	$23.20
Rate for Payer: Qualcare PPO/HMO/WC	$23.20

LEVOFLOXACIN(LEVAQUIN)500 TAB

Facility

$129.24

Service Code	NDC 93729253
Hospital Charge Code	60630154
Hospital Revenue Code	250
Min. Negotiated Rate	$3.67
Max. Negotiated Rate	$64.62
Rate for Payer: Aetna Commercial	$49.11
Rate for Payer: Aetna Medicare Advantage	$38.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$32.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$32.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$32.96
Rate for Payer: Cigna Commercial	$64.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$33.60
Rate for Payer: Oxford Commercial	$25.85
Rate for Payer: Qualcare PPO/HMO/WC	$19.39
Rate for Payer: UnitedHealthcare Commercial	$25.85
Rate for Payer: UnitedHealthcare Community & State	$4.08
Rate for Payer: Wellpoint Medicaid Managed Care	$3.67

LEVOFLOXACIN(LEVAQUIN)500 TAB

Facility

$129.24

Service Code	NDC 93729253
Hospital Charge Code	60630154
Hospital Revenue Code	250
Min. Negotiated Rate	$19.39
Max. Negotiated Rate	$19.39
Rate for Payer: Qualcare PPO/HMO/WC	$19.39

LEVOFLOXACIN(LEVAQUIN)750 IVPB

Facility

$37.45

Service Code	NDC 25021013283
Hospital Charge Code	60630151
Hospital Revenue Code	250
Min. Negotiated Rate	$5.62
Max. Negotiated Rate	$5.62
Rate for Payer: Qualcare PPO/HMO/WC	$5.62

LEVOFLOXACIN(LEVAQUIN)750 IVPB

Facility

$37.45

Service Code	NDC 25021013283
Hospital Charge Code	60630151
Hospital Revenue Code	250
Min. Negotiated Rate	$1.06
Max. Negotiated Rate	$18.73
Rate for Payer: Aetna Commercial	$14.23
Rate for Payer: Aetna Medicare Advantage	$11.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$9.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$9.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$9.55
Rate for Payer: Cigna Commercial	$18.73
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.74
Rate for Payer: Oxford Commercial	$7.49
Rate for Payer: Qualcare PPO/HMO/WC	$5.62
Rate for Payer: UnitedHealthcare Commercial	$7.49
Rate for Payer: UnitedHealthcare Community & State	$1.18
Rate for Payer: Wellpoint Medicaid Managed Care	$1.06

LEVOFLOXACIN(LEVAQUIN)750 TAB

Facility

$237.18

Service Code	NDC 68084048301
Hospital Charge Code	60630155
Hospital Revenue Code	250
Min. Negotiated Rate	$6.74
Max. Negotiated Rate	$118.59
Rate for Payer: Aetna Commercial	$90.13
Rate for Payer: Aetna Medicare Advantage	$71.15
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$60.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$60.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$60.48
Rate for Payer: Cigna Commercial	$118.59
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$61.67
Rate for Payer: Oxford Commercial	$47.44
Rate for Payer: Qualcare PPO/HMO/WC	$35.58
Rate for Payer: UnitedHealthcare Commercial	$47.44
Rate for Payer: UnitedHealthcare Community & State	$7.49
Rate for Payer: Wellpoint Medicaid Managed Care	$6.74

LEVOFLOXACIN(LEVAQUIN)750 TAB

Facility

$237.18

Service Code	NDC 68084048301
Hospital Charge Code	60630155
Hospital Revenue Code	250
Min. Negotiated Rate	$35.58
Max. Negotiated Rate	$35.58
Rate for Payer: Qualcare PPO/HMO/WC	$35.58

LEVONORGESTREL 1.5 MG TAB

Facility

$272.15

Service Code	NDC 51285014619
Hospital Charge Code	6063943212
Hospital Revenue Code	250
Min. Negotiated Rate	$7.73
Max. Negotiated Rate	$136.07
Rate for Payer: Aetna Commercial	$103.42
Rate for Payer: Aetna Medicare Advantage	$81.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$69.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$69.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$69.40
Rate for Payer: Cigna Commercial	$136.07
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$70.76
Rate for Payer: Oxford Commercial	$54.43
Rate for Payer: Qualcare PPO/HMO/WC	$40.82
Rate for Payer: UnitedHealthcare Commercial	$54.43
Rate for Payer: UnitedHealthcare Community & State	$8.60
Rate for Payer: Wellpoint Medicaid Managed Care	$7.73

LEVONORGESTREL 1.5 MG TAB

Facility

$272.15

Service Code	NDC 51285014619
Hospital Charge Code	6063943212
Hospital Revenue Code	250
Min. Negotiated Rate	$40.82
Max. Negotiated Rate	$40.82
Rate for Payer: Qualcare PPO/HMO/WC	$40.82

LEVONORGESTREL 52MG

Facility

$1,272.44

Service Code	HCPCS J7298
Hospital Charge Code	606494324
Hospital Revenue Code	636
Min. Negotiated Rate	$36.14
Max. Negotiated Rate	$636.22
Rate for Payer: Aetna Commercial	$483.53
Rate for Payer: Aetna Medicare Advantage	$381.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$324.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$324.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$324.47
Rate for Payer: Cigna Commercial	$636.22
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$307.93
Rate for Payer: Qualcare PPO/HMO/WC	$190.87
Rate for Payer: UnitedHealthcare Community & State	$40.21
Rate for Payer: Wellpoint Medicaid Managed Care	$36.14

LEVONORGESTREL 52MG

Facility

$1,272.44

Service Code	HCPCS J7298
Hospital Charge Code	606494324
Hospital Revenue Code	636
Min. Negotiated Rate	$190.87
Max. Negotiated Rate	$307.93
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$307.93
Rate for Payer: Qualcare PPO/HMO/WC	$190.87

LEVOTHROID TAB 137MCG

Facility

$4.00

Service Code	NDC 74372790
Hospital Charge Code	60635232
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

LEVOTHROID TAB 137MCG

Facility

$4.00

Service Code	NDC 74372790
Hospital Charge Code	60635232
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.04
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

LEVOTHYROXINE INJ 200MCG

Facility

$371.38

Service Code	NDC 63323064710
Hospital Charge Code	6003248
Hospital Revenue Code	250
Min. Negotiated Rate	$10.55
Max. Negotiated Rate	$185.69
Rate for Payer: Aetna Commercial	$141.12
Rate for Payer: Aetna Medicare Advantage	$111.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$94.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$94.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$94.70
Rate for Payer: Cigna Commercial	$185.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$96.56
Rate for Payer: Oxford Commercial	$74.28
Rate for Payer: Qualcare PPO/HMO/WC	$55.71
Rate for Payer: UnitedHealthcare Commercial	$74.28
Rate for Payer: UnitedHealthcare Community & State	$11.74
Rate for Payer: Wellpoint Medicaid Managed Care	$10.55

LEVOTHYROXINE INJ 200MCG

Facility

$371.38

Service Code	NDC 63323064710
Hospital Charge Code	6003248
Hospital Revenue Code	250
Min. Negotiated Rate	$55.71
Max. Negotiated Rate	$55.71
Rate for Payer: Qualcare PPO/HMO/WC	$55.71

LEVOTHYROXINE SODIUM 100 MCG P

Facility

$442.20

Service Code	NDC 63323064907
Hospital Charge Code	60630097
Hospital Revenue Code	250
Min. Negotiated Rate	$66.33
Max. Negotiated Rate	$66.33
Rate for Payer: Qualcare PPO/HMO/WC	$66.33

LEVOTHYROXINE SODIUM 100 MCG P

Facility

$442.20

Service Code	NDC 63323064907
Hospital Charge Code	60630097
Hospital Revenue Code	250
Min. Negotiated Rate	$12.56
Max. Negotiated Rate	$221.10
Rate for Payer: Aetna Commercial	$168.04
Rate for Payer: Aetna Medicare Advantage	$132.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$112.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$112.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$112.76
Rate for Payer: Cigna Commercial	$221.10
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$114.97
Rate for Payer: Oxford Commercial	$88.44
Rate for Payer: Qualcare PPO/HMO/WC	$66.33
Rate for Payer: UnitedHealthcare Commercial	$88.44
Rate for Payer: UnitedHealthcare Community & State	$13.97
Rate for Payer: Wellpoint Medicaid Managed Care	$12.56

LEVOTHYROXINE (SYNTHROID) 200

Facility

$5.63

Service Code	NDC 781518992
Hospital Charge Code	60630135
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$0.84
Rate for Payer: Qualcare PPO/HMO/WC	$0.84

Know your out-of-pocket cost for care.

All Charges