|
LOPERAMIDE 2MG/15ML OR SUSP 120ML
|
Facility
|
OP
|
$32.00
|
|
|
Service Code
|
NDC 4.6122E+10
|
| Hospital Charge Code |
2619392
|
|
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
|
|
|
LOPERAMIDE 2MG/15ML OR SUSP 120ML
|
Facility
|
IP
|
$32.00
|
|
|
Service Code
|
NDC 4.6122E+10
|
| Hospital Charge Code |
2619392
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$28.80
|
|
|
LOPERAMIDE (IMMODIUM) 2MG/15ML OR SUSP
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
NDC 1.0939E+10
|
| Hospital Charge Code |
2697245
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.80 |
| Max. Negotiated Rate |
$21.42 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$17.76
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$21.42
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$20.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$10.80
|
|
|
LOPERAMIDE (IMMODIUM) 2MG/15ML OR SUSP
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
NDC 1.0939E+10
|
| Hospital Charge Code |
2697245
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$27.00
|
|
|
LOPERAMIDE (IMMODIUM) 2MG CAP/TAB
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 7.0677E+10
|
| Hospital Charge Code |
2655435
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$13.02
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$15.71
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.67
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.92
|
|
|
LOPERAMIDE (IMMODIUM) 2MG CAP/TAB
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 7.0677E+10
|
| Hospital Charge Code |
2655435
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$19.80
|
|
|
LOPERAMIDE (IMMODIUM AD) 1MG/5ML LIQ
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 6.8094E+10
|
| Hospital Charge Code |
2655437
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$6.43 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$5.33
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$6.43
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.00
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$3.24
|
|
|
LOPERAMIDE (IMMODIUM AD) 1MG/5ML LIQ
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 6.8094E+10
|
| Hospital Charge Code |
2655437
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$8.10
|
|
|
LOPERAMIDE (IMODIUM) 2MG TAB EMP
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 904772524
|
| Hospital Charge Code |
2623543
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$19.80
|
|
|
LOPERAMIDE (IMODIUM) 2MG TAB EMP
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
NDC 904772524
|
| Hospital Charge Code |
2623542
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$19.80
|
|
|
LOPERAMIDE (IMODIUM) 2MG TAB EMP
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 904772524
|
| Hospital Charge Code |
2623542
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$13.02
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$15.71
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.67
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.92
|
|
|
LOPERAMIDE (IMODIUM) 2MG TAB EMP
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
NDC 904772524
|
| Hospital Charge Code |
2623543
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.92 |
| Max. Negotiated Rate |
$15.71 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$13.02
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$15.71
|
| Rate for Payer: Cash Price |
$19.80
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.67
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.92
|
|
|
LORATADINE (CLARITIN) 10MG TAB
|
Facility
|
OP
|
$28.00
|
|
|
Service Code
|
NDC 5.1079E+10
|
| Hospital Charge Code |
2654604
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$19.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$16.58
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$19.99
|
| Rate for Payer: Cash Price |
$25.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$18.68
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$10.08
|
|
|
LORATADINE (CLARITIN) 10MG TAB
|
Facility
|
IP
|
$28.00
|
|
|
Service Code
|
NDC 5.1079E+10
|
| Hospital Charge Code |
2654604
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$25.20
|
|
|
LORATADINE (CLARITIN) 5MG/5ML SYR
|
Facility
|
IP
|
$16.00
|
|
|
Service Code
|
NDC 5.4838E+10
|
| Hospital Charge Code |
2626571
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$14.40
|
|
|
LORATADINE (CLARITIN) 5MG/5ML SYR
|
Facility
|
OP
|
$16.00
|
|
|
Service Code
|
NDC 5.4838E+10
|
| Hospital Charge Code |
2626571
|
|
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
|
|
|
LORAZEPAM 0.5MG TAB EMP C4
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 904600761
|
| Hospital Charge Code |
2621997
|
|
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
|
|
|
LORAZEPAM 0.5MG TAB EMP C4
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 904600761
|
| Hospital Charge Code |
2621997
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.00
|
|
|
LORAZEPAM 1MG INJ 0.5ML PFS C4
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
2626869
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$200.70
|
|
|
LORAZEPAM 1MG INJ 0.5ML PFS C4
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
2626869
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.28 |
| Max. Negotiated Rate |
$159.22 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$132.02
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$159.22
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$148.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$80.28
|
|
|
LORAZEPAM 1MG TAB EMP C4
|
Facility
|
OP
|
$21.00
|
|
|
Service Code
|
NDC 187006401
|
| Hospital Charge Code |
2697969
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.56 |
| Max. Negotiated Rate |
$14.99 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$12.43
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$14.99
|
| Rate for Payer: Cash Price |
$18.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.01
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$7.56
|
|
|
LORAZEPAM 1MG TAB EMP C4
|
Facility
|
IP
|
$21.00
|
|
|
Service Code
|
NDC 187006401
|
| Hospital Charge Code |
2697969
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$18.90
|
|
|
LORAZEPAM 2MG/ML INJ 10ML MDV C4
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
2626117
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$200.70
|
|
|
LORAZEPAM 2MG/ML INJ 10ML MDV C4
|
Facility
|
OP
|
$223.00
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
2626117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$80.28 |
| Max. Negotiated Rate |
$159.22 |
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Blue Access/Blue Preferred and Pathway/Pathway X |
$132.02
|
| Rate for Payer: Anthem Blue Cross Blue Shield Missouri Traditional |
$159.22
|
| Rate for Payer: Cash Price |
$200.70
|
| Rate for Payer: UnitedHealthcare Commercial |
$148.74
|
| Rate for Payer: UnitedHealthcare Medicare Advantage |
$80.28
|
|
|
LORAZEPAM 2MG/ML INJ PFS C4
|
Facility
|
IP
|
$223.00
|
|
|
Service Code
|
HCPCS J2060
|
| Hospital Charge Code |
2626868
|
|
Hospital Revenue Code
|
250
|
| Rate for Payer: Cash Price |
$200.70
|
|
