|
LEVETIRACETAM (KEPPRA) 500MG TAB UD
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 904712461
|
| Hospital Charge Code |
2626499
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.52 |
| Max. Negotiated Rate |
$22.85 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$18.94
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$22.85
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$21.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$11.52
|
|
|
LEVETIRACETAM (KEPPRA) OR SOL 500MG 5ML
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 1.6714E+10
|
| Hospital Charge Code |
2622517
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.00
|
|
|
LEVETIRACETAM (KEPPRA) OR SOL 500MG 5ML
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 1.6714E+10
|
| Hospital Charge Code |
2622517
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.20 |
| Max. Negotiated Rate |
$14.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$11.84
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.28
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.34
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.20
|
|
|
LEVOCETIRIZINE 2.5MG/5ML ORSOL 148ML EMP
|
Facility
|
OP
|
$332.00
|
|
|
Service Code
|
NDC 4.5802E+10
|
| Hospital Charge Code |
2623265
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$119.52 |
| Max. Negotiated Rate |
$237.05 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$196.54
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$237.05
|
| Rate for Payer: Cash Price |
$298.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$221.44
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$119.52
|
|
|
LEVOCETIRIZINE 2.5MG/5ML ORSOL 148ML EMP
|
Facility
|
IP
|
$332.00
|
|
|
Service Code
|
NDC 4.5802E+10
|
| Hospital Charge Code |
2623265
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$298.80
|
|
|
LEVOCETIRIZINE 5MG TAB EMP
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 3.1722E+10
|
| Hospital Charge Code |
2619440
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$7.70
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$9.28
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.67
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$4.68
|
|
|
LEVOCETIRIZINE 5MG TAB EMP
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 3.1722E+10
|
| Hospital Charge Code |
2619440
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$11.70
|
|
|
LEVOCETIRIZINE 5MG TAB HE
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
NDC 3.1722E+10
|
| Hospital Charge Code |
2626116
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$11.70
|
|
|
LEVOCETIRIZINE 5MG TAB HE
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
NDC 3.1722E+10
|
| Hospital Charge Code |
2626116
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.68 |
| Max. Negotiated Rate |
$9.28 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$7.70
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$9.28
|
| Rate for Payer: Cash Price |
$11.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$8.67
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$4.68
|
|
|
LEVOFLOXACIN 500MG/20ML VIAL
|
Facility
|
OP
|
$276.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
2626307
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$99.36 |
| Max. Negotiated Rate |
$197.06 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$163.39
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$197.06
|
| Rate for Payer: Cash Price |
$248.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$184.09
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$99.36
|
|
|
LEVOFLOXACIN 500MG/20ML VIAL
|
Facility
|
IP
|
$276.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
2626307
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$248.40
|
|
|
LEVOFLOXACIN 750MG (DIABETIC) VIAL 30ML
|
Facility
|
OP
|
$325.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
2697052
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$117.00 |
| Max. Negotiated Rate |
$232.05 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$192.40
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$232.05
|
| Rate for Payer: Cash Price |
$292.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$216.78
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$117.00
|
|
|
LEVOFLOXACIN 750MG (DIABETIC) VIAL 30ML
|
Facility
|
IP
|
$325.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
2697052
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$292.50
|
|
|
LEVOFLOXACIN (LEVAQUIN) 250MG TAB
|
Facility
|
OP
|
$67.00
|
|
|
Service Code
|
NDC 904635161
|
| Hospital Charge Code |
2655379
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.12 |
| Max. Negotiated Rate |
$47.84 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$39.66
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$47.84
|
| Rate for Payer: Cash Price |
$60.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$44.69
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$24.12
|
|
|
LEVOFLOXACIN (LEVAQUIN) 250MG TAB
|
Facility
|
IP
|
$67.00
|
|
|
Service Code
|
NDC 904635161
|
| Hospital Charge Code |
2655379
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$60.30
|
|
|
LEVOFLOXACIN (LEVAQUIN) 500MG/100ML PREM
|
Facility
|
IP
|
$308.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
2655375
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$277.20
|
|
|
LEVOFLOXACIN (LEVAQUIN) 500MG/100ML PREM
|
Facility
|
OP
|
$308.00
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
2655375
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$110.88 |
| Max. Negotiated Rate |
$219.91 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$182.34
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$219.91
|
| Rate for Payer: Cash Price |
$277.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$205.44
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$110.88
|
|
|
LEVOFLOXACIN (LEVAQUIN) 500MG TAB
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
NDC 6.5862E+10
|
| Hospital Charge Code |
2655377
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$53.55 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$44.40
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$53.55
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$50.02
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$27.00
|
|
|
LEVOFLOXACIN (LEVAQUIN) 500MG TAB
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
NDC 6.5862E+10
|
| Hospital Charge Code |
2655377
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$67.50
|
|
|
LEVOFLOXACIN (LEVAQUIN) 500MG TAB EMP
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
NDC 6.5862E+10
|
| Hospital Charge Code |
2623573
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$67.50
|
|
|
LEVOFLOXACIN (LEVAQUIN) 500MG TAB EMP
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
NDC 6.5862E+10
|
| Hospital Charge Code |
2623573
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$53.55 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$44.40
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$53.55
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$50.02
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$27.00
|
|
|
LEVOFLOXACIN (LEVAQUIN) 750MG TAB
|
Facility
|
IP
|
$62.00
|
|
|
Service Code
|
NDC 5.9762E+10
|
| Hospital Charge Code |
2626384
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$55.80
|
|
|
LEVOFLOXACIN (LEVAQUIN) 750MG TAB
|
Facility
|
OP
|
$62.00
|
|
|
Service Code
|
NDC 5.9762E+10
|
| Hospital Charge Code |
2626384
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$22.32 |
| Max. Negotiated Rate |
$44.27 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$36.70
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$44.27
|
| Rate for Payer: Cash Price |
$55.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.35
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$22.32
|
|
|
LEVOFLOXACIN (LEVAQUIN) 750MG TAB EMP
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
NDC 6.5862E+10
|
| Hospital Charge Code |
2623024
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.00 |
| Max. Negotiated Rate |
$53.55 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$44.40
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$53.55
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$50.02
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$27.00
|
|
|
LEVOFLOXACIN (LEVAQUIN) 750MG TAB EMP
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
NDC 6.5862E+10
|
| Hospital Charge Code |
2623024
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$67.50
|
|
