Madison Medical Center

All Charges

Charge

Type

Setting

Price

LEVOFLOX (LEVAQUIN) 250MG/50ML PREMIX

Facility

$274.00

Service Code	HCPCS J1956
Hospital Charge Code	2626380
Hospital Revenue Code	250
Rate for Payer: Cash Price	$246.60

LEVOFLOX (LEVAQUIN) 250MG/50ML PREMIX

Facility

$274.00

Service Code	HCPCS J1956
Hospital Charge Code	2626380
Hospital Revenue Code	250
Min. Negotiated Rate	$98.64
Max. Negotiated Rate	$195.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$162.21
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$195.64
Rate for Payer: Cash Price	$246.60
Rate for Payer: UnitedHealthcare Commercial	$182.76
Rate for Payer: UnitedHealthcare Medicare Advantage	$98.64

LEVOFLOX (LEVAQUIN) 750MG PREMIX 150ML

Facility

$325.00

Service Code	HCPCS J1956
Hospital Charge Code	2626376
Hospital Revenue Code	250
Rate for Payer: Cash Price	$292.50

LEVOFLOX (LEVAQUIN) 750MG PREMIX 150ML

Facility

$325.00

Service Code	HCPCS J1956
Hospital Charge Code	2626376
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

LEVONOR/ETH 0.1/0.02MG TAB 3X28 PAK EMP

Facility

$18.00

Service Code	NDC 555904558
Hospital Charge Code	2622872
Hospital Revenue Code	250
Min. Negotiated Rate	$6.48
Max. Negotiated Rate	$12.85
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$10.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$12.85
Rate for Payer: Cash Price	$16.20
Rate for Payer: UnitedHealthcare Commercial	$12.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$6.48

LEVONOR/ETH 0.1/0.02MG TAB 3X28 PAK EMP

Facility

$18.00

Service Code	NDC 555904558
Hospital Charge Code	2622872
Hospital Revenue Code	250
Rate for Payer: Cash Price	$16.20

LEVONORGES (PLAN-B ONE STEP) 1.5MG TAB

Facility

$192.00

Service Code	NDC 536114263
Hospital Charge Code	2697137
Hospital Revenue Code	250
Rate for Payer: Cash Price	$172.80

LEVONORGES (PLAN-B ONE STEP) 1.5MG TAB

Facility

$192.00

Service Code	NDC 536114263
Hospital Charge Code	2697137
Hospital Revenue Code	250
Min. Negotiated Rate	$69.12
Max. Negotiated Rate	$137.09
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$113.66
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$137.09
Rate for Payer: Cash Price	$172.80
Rate for Payer: UnitedHealthcare Commercial	$128.06
Rate for Payer: UnitedHealthcare Medicare Advantage	$69.12

LEVOTHYROXINE 100MCG INJ

Facility

$534.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2620864
Hospital Revenue Code	250
Rate for Payer: Cash Price	$480.60

LEVOTHYROXINE 100MCG INJ

Facility

$534.00

Service Code	NDC 6.3323E+10
Hospital Charge Code	2620864
Hospital Revenue Code	250
Min. Negotiated Rate	$192.24
Max. Negotiated Rate	$381.28
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$316.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$381.28
Rate for Payer: Cash Price	$480.60
Rate for Payer: UnitedHealthcare Commercial	$356.18
Rate for Payer: UnitedHealthcare Medicare Advantage	$192.24

LEVOTHYROXINE 100MCG TAB EMP

Facility

$20.00

Service Code	NDC 74662490
Hospital Charge Code	2619352
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LEVOTHYROXINE 100MCG TAB EMP

Facility

$20.00

Service Code	NDC 74662490
Hospital Charge Code	2619352
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

LEVOTHYROXINE 125MCG TAB EMP

Facility

$45.00

Service Code	NDC 781518692
Hospital Charge Code	2622803
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

LEVOTHYROXINE 125MCG TAB EMP

Facility

$45.00

Service Code	NDC 781518692
Hospital Charge Code	2622803
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.13
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

LEVOTHYROXINE 150MCG TAB EMP

Facility

$45.00

Service Code	NDC 74706990
Hospital Charge Code	2620030
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.13
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

LEVOTHYROXINE 150MCG TAB EMP

Facility

$45.00

Service Code	NDC 74706990
Hospital Charge Code	2620030
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

LEVOTHYROXINE 175MCG TAB EMP

Facility

$45.00

Service Code	NDC 378181777
Hospital Charge Code	2697579
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.13
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

LEVOTHYROXINE 175MCG TAB EMP

Facility

$45.00

Service Code	NDC 378181777
Hospital Charge Code	2697579
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

LEVOTHYROXINE 200MCG TAB EMP

Facility

$45.00

Service Code	NDC 378181777
Hospital Charge Code	2624289
Hospital Revenue Code	250
Min. Negotiated Rate	$16.20
Max. Negotiated Rate	$32.13
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$26.64
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$32.13
Rate for Payer: Cash Price	$40.50
Rate for Payer: UnitedHealthcare Commercial	$30.02
Rate for Payer: UnitedHealthcare Medicare Advantage	$16.20

LEVOTHYROXINE 200MCG TAB EMP

Facility

$45.00

Service Code	NDC 378181777
Hospital Charge Code	2624289
Hospital Revenue Code	250
Rate for Payer: Cash Price	$40.50

LEVOTHYROXINE 25MCG TAB EMP

Facility

$20.00

Service Code	NDC 781518092
Hospital Charge Code	2622107
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

LEVOTHYROXINE 25MCG TAB EMP

Facility

$20.00

Service Code	NDC 781518092
Hospital Charge Code	2622107
Hospital Revenue Code	250
Rate for Payer: Cash Price	$18.00

LEVOTHYROXINE 50MCG TAB EMP

Facility

$16.00

Service Code	NDC 6.0846E+10
Hospital Charge Code	2697303
Hospital Revenue Code	250
Rate for Payer: Cash Price	$14.40

LEVOTHYROXINE 50MCG TAB EMP

Facility

$16.00

Service Code	NDC 6.0846E+10
Hospital Charge Code	2697303
Hospital Revenue Code	250
Min. Negotiated Rate	$5.76
Max. Negotiated Rate	$11.42
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X	$9.47
Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional	$11.42
Rate for Payer: Cash Price	$14.40
Rate for Payer: UnitedHealthcare Commercial	$10.67
Rate for Payer: UnitedHealthcare Medicare Advantage	$5.76

LEVOTHYROXINE 75MCG TAB EMP

Facility

$20.00

Service Code	NDC 74518290
Hospital Charge Code	2618988
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

Know your out-of-pocket cost for care.

All Charges