|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 72205-096-92
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.12
|
|
|
Service Code
|
NDC 65862-247-08
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0904-7125-61
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR [93834]
|
Facility
|
OP
|
$10.28
|
|
|
Service Code
|
NDC 50474-598-66
|
| Hospital Charge Code |
1712575
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$7.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$6.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$6.17
|
| Rate for Payer: Cash Price |
$4.63
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$6.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.65
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.71
|
|
|
LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR [93834]
|
Facility
|
IP
|
$10.28
|
|
|
Service Code
|
NDC 50474-598-66
|
| Hospital Charge Code |
1712575
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.65 |
| Max. Negotiated Rate |
$8.22 |
| Rate for Payer: Cash Price |
$4.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$6.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.65
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$7.71
|
|
|
LEVOBUNOLOL 0.5 % EYE DROPS [10394]
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
NDC 24208-505-05
|
| Hospital Charge Code |
1740221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.22 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.58
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.22
|
|
|
LEVOBUNOLOL 0.5 % EYE DROPS [10394]
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
NDC 24208-505-05
|
| Hospital Charge Code |
1740221
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.36
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$3.22
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]
|
Facility
|
OP
|
$0.35
|
|
|
Service Code
|
NDC 70954-140-10
|
| Hospital Charge Code |
1715083
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.21
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.21
|
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]
|
Facility
|
IP
|
$0.35
|
|
|
Service Code
|
NDC 70954-140-10
|
| Hospital Charge Code |
1715083
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.28 |
| Rate for Payer: Cash Price |
$0.16
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]
|
Facility
|
IP
|
$0.49
|
|
|
Service Code
|
NDC 54482-148-01
|
| Hospital Charge Code |
1715083
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.39 |
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.39
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.37
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION [110335]
|
Facility
|
OP
|
$0.49
|
|
|
Service Code
|
NDC 54482-148-01
|
| Hospital Charge Code |
1715083
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.29
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.29
|
| Rate for Payer: Cash Price |
$0.22
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.37
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]
|
Facility
|
IP
|
$8.83
|
|
|
Service Code
|
CPT J1955
|
| Hospital Charge Code |
1764075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$7.06 |
| Rate for Payer: Cash Price |
$3.97
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.62
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION [20954]
|
Facility
|
OP
|
$8.83
|
|
|
Service Code
|
CPT J1955
|
| Hospital Charge Code |
1764075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.86 |
| Max. Negotiated Rate |
$6.62 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$5.30
|
| Rate for Payer: Aetna of CA Government/Medicare |
$5.30
|
| Rate for Payer: Cash Price |
$3.97
|
| Rate for Payer: Health Smart Auto/Commercial |
$5.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$5.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.86
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$6.62
|
|
|
LEVOCARNITINE 330 MG TABLET [20952]
|
Facility
|
OP
|
$1.05
|
|
|
Service Code
|
NDC 70954-492-10
|
| Hospital Charge Code |
1711616
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.63
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.63
|
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.79
|
|
|
LEVOCARNITINE 330 MG TABLET [20952]
|
Facility
|
IP
|
$1.42
|
|
|
Service Code
|
NDC 54482-144-07
|
| Hospital Charge Code |
1711616
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.14
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.06
|
|
|
LEVOCARNITINE 330 MG TABLET [20952]
|
Facility
|
IP
|
$1.05
|
|
|
Service Code
|
NDC 70954-492-10
|
| Hospital Charge Code |
1711616
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.58 |
| Max. Negotiated Rate |
$0.84 |
| Rate for Payer: Cash Price |
$0.47
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.84
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.79
|
|
|
LEVOCARNITINE 330 MG TABLET [20952]
|
Facility
|
OP
|
$1.42
|
|
|
Service Code
|
NDC 54482-144-07
|
| Hospital Charge Code |
1711616
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.85
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.85
|
| Rate for Payer: Cash Price |
$0.64
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.78
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.06
|
|
|
LEVOFLOXACIN 0.5 % EYE DROPS [28872]
|
Facility
|
OP
|
$27.57
|
|
|
Service Code
|
NDC 17478-106-10
|
| Hospital Charge Code |
NDG28872
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$20.68 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$16.54
|
| Rate for Payer: Aetna of CA Government/Medicare |
$16.54
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$16.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.68
|
|
|
LEVOFLOXACIN 0.5 % EYE DROPS [28872]
|
Facility
|
IP
|
$27.57
|
|
|
Service Code
|
NDC 17478-106-10
|
| Hospital Charge Code |
NDG28872
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$15.16 |
| Max. Negotiated Rate |
$22.06 |
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$16.54
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.16
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$20.68
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 50383-286-08
|
| Hospital Charge Code |
NDG39970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.00
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 50383-286-08
|
| Hospital Charge Code |
NDG39970
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.00
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
IP
|
$1.33
|
|
|
Service Code
|
NDC 50383-286-16
|
| Hospital Charge Code |
1715161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.06 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.00
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
IP
|
$1.34
|
|
|
Service Code
|
NDC 50383-286-04
|
| Hospital Charge Code |
NDG39970B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.07 |
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.00
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
OP
|
$1.34
|
|
|
Service Code
|
NDC 50383-286-04
|
| Hospital Charge Code |
NDG39970B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.74 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.80
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.00
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION [39970]
|
Facility
|
OP
|
$1.33
|
|
|
Service Code
|
NDC 50383-286-16
|
| Hospital Charge Code |
1715161
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.73 |
| Max. Negotiated Rate |
$1.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.80
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.80
|
| Rate for Payer: Cash Price |
$0.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.00
|
|
