|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$390.10
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.76 |
| Max. Negotiated Rate |
$351.09 |
| Rate for Payer: Aetna Commercial |
$331.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.56
|
| Rate for Payer: Cash Price |
$312.08
|
| Rate for Payer: Cofinity Advantage |
$273.07
|
| Rate for Payer: Cofinity Commercial |
$335.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$312.08
|
| Rate for Payer: Healthscope Commercial |
$351.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.57
|
| Rate for Payer: PHP Commercial |
$331.58
|
| Rate for Payer: Priority Health SBD |
$245.76
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
OP
|
$261.25
|
|
|
Service Code
|
NDC 68084088201
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.67 |
| Max. Negotiated Rate |
$235.12 |
| Rate for Payer: Aetna Commercial |
$222.06
|
| Rate for Payer: Aetna Medicare |
$130.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.81
|
| Rate for Payer: BCBS Complete |
$104.50
|
| Rate for Payer: Cash Price |
$209.00
|
| Rate for Payer: Cofinity Advantage |
$182.88
|
| Rate for Payer: Cofinity Commercial |
$224.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.00
|
| Rate for Payer: Healthscope Commercial |
$235.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$209.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.94
|
| Rate for Payer: PHP Commercial |
$222.06
|
| Rate for Payer: Priority Health SBD |
$164.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$169.81
|
| Rate for Payer: UHC Core |
$136.11
|
| Rate for Payer: UHC Exchange |
$102.67
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
IP
|
$262.26
|
|
|
Service Code
|
NDC 27808026501
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.22 |
| Max. Negotiated Rate |
$236.03 |
| Rate for Payer: Aetna Commercial |
$222.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.47
|
| Rate for Payer: Cash Price |
$209.81
|
| Rate for Payer: Cofinity Advantage |
$183.58
|
| Rate for Payer: Cofinity Commercial |
$225.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.81
|
| Rate for Payer: Healthscope Commercial |
$236.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$196.69
|
| Rate for Payer: PHP Commercial |
$222.92
|
| Rate for Payer: Priority Health SBD |
$165.22
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
OP
|
$267.90
|
|
|
Service Code
|
NDC 65862024708
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.28 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna Medicare |
$133.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.13
|
| Rate for Payer: BCBS Complete |
$107.16
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Advantage |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$214.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$227.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$200.93
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health SBD |
$168.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$174.13
|
| Rate for Payer: UHC Core |
$139.58
|
| Rate for Payer: UHC Exchange |
$105.28
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
OP
|
$237.50
|
|
|
Service Code
|
NDC 00904712561
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.34 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$201.88
|
| Rate for Payer: Aetna Medicare |
$118.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.38
|
| Rate for Payer: BCBS Complete |
$95.00
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cofinity Advantage |
$166.25
|
| Rate for Payer: Cofinity Commercial |
$204.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.00
|
| Rate for Payer: Healthscope Commercial |
$213.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.12
|
| Rate for Payer: PHP Commercial |
$201.88
|
| Rate for Payer: Priority Health SBD |
$149.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.38
|
| Rate for Payer: UHC Core |
$123.74
|
| Rate for Payer: UHC Exchange |
$93.34
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
IP
|
$2.62
|
|
|
Service Code
|
NDC 68084088211
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Advantage |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.97
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health SBD |
$1.65
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
IP
|
$261.25
|
|
|
Service Code
|
NDC 68084088201
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.59 |
| Max. Negotiated Rate |
$235.12 |
| Rate for Payer: Aetna Commercial |
$222.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.81
|
| Rate for Payer: Cash Price |
$209.00
|
| Rate for Payer: Cofinity Advantage |
$182.88
|
| Rate for Payer: Cofinity Commercial |
$224.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.00
|
| Rate for Payer: Healthscope Commercial |
$235.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.94
|
| Rate for Payer: PHP Commercial |
$222.06
|
| Rate for Payer: Priority Health SBD |
$164.59
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
OP
|
$262.26
|
|
|
Service Code
|
NDC 27808026501
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.07 |
| Max. Negotiated Rate |
$236.03 |
| Rate for Payer: Aetna Commercial |
$222.92
|
| Rate for Payer: Aetna Medicare |
$131.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.47
|
| Rate for Payer: BCBS Complete |
$104.90
|
| Rate for Payer: Cash Price |
$209.81
|
| Rate for Payer: Cofinity Advantage |
$183.58
|
| Rate for Payer: Cofinity Commercial |
$225.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.81
|
| Rate for Payer: Healthscope Commercial |
$236.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$209.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$196.69
|
| Rate for Payer: PHP Commercial |
$222.92
|
| Rate for Payer: Priority Health SBD |
$165.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.47
|
| Rate for Payer: UHC Core |
$136.64
|
| Rate for Payer: UHC Exchange |
$103.07
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
IP
|
$237.50
|
|
|
Service Code
|
NDC 00904712561
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.62 |
| Max. Negotiated Rate |
$213.75 |
| Rate for Payer: Aetna Commercial |
$201.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.38
|
| Rate for Payer: Cash Price |
$190.00
|
| Rate for Payer: Cofinity Advantage |
$166.25
|
| Rate for Payer: Cofinity Commercial |
$204.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.00
|
| Rate for Payer: Healthscope Commercial |
$213.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$201.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.12
|
| Rate for Payer: PHP Commercial |
$201.88
|
| Rate for Payer: Priority Health SBD |
$149.62
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
IP
|
$267.90
|
|
|
Service Code
|
NDC 65862024708
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.78 |
| Max. Negotiated Rate |
$241.11 |
| Rate for Payer: Aetna Commercial |
$227.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.13
|
| Rate for Payer: Cash Price |
$214.32
|
| Rate for Payer: Cofinity Advantage |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.32
|
| Rate for Payer: Healthscope Commercial |
$241.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$227.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$200.93
|
| Rate for Payer: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health SBD |
$168.78
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
OP
|
$2.62
|
|
|
Service Code
|
NDC 68084088211
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.03 |
| Max. Negotiated Rate |
$2.36 |
| Rate for Payer: Aetna Commercial |
$2.23
|
| Rate for Payer: Aetna Medicare |
$1.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: BCBS Complete |
$1.05
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Advantage |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.97
|
| Rate for Payer: PHP Commercial |
$2.23
|
| Rate for Payer: Priority Health SBD |
$1.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.70
|
| Rate for Payer: UHC Core |
$1.37
|
| Rate for Payer: UHC Exchange |
$1.03
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$100.15
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
20954
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$90.14 |
| Rate for Payer: Aetna Commercial |
$85.13
|
| Rate for Payer: Aetna Medicare |
$50.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.10
|
| Rate for Payer: BCBS Complete |
$40.06
|
| Rate for Payer: BCBS Trust/PPO |
$58.36
|
| Rate for Payer: BCN Commercial |
$58.36
|
| Rate for Payer: Cash Price |
$80.12
|
| Rate for Payer: Cash Price |
$80.12
|
| Rate for Payer: Cofinity Advantage |
$70.11
|
| Rate for Payer: Cofinity Commercial |
$86.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.12
|
| Rate for Payer: Healthscope Commercial |
$90.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$80.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.11
|
| Rate for Payer: PHP Commercial |
$85.13
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$23.27
|
| Rate for Payer: Priority Health SBD |
$63.09
|
| Rate for Payer: Priority Health Tiered Network |
$18.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.40
|
| Rate for Payer: UHC Core |
$38.40
|
| Rate for Payer: UHC Exchange |
$38.40
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$100.15
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
20954
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$63.09 |
| Max. Negotiated Rate |
$90.14 |
| Rate for Payer: Aetna Commercial |
$85.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.10
|
| Rate for Payer: Cash Price |
$80.12
|
| Rate for Payer: Cofinity Advantage |
$70.11
|
| Rate for Payer: Cofinity Commercial |
$86.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.12
|
| Rate for Payer: Healthscope Commercial |
$90.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$85.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.11
|
| Rate for Payer: PHP Commercial |
$85.13
|
| Rate for Payer: Priority Health SBD |
$63.09
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
OP
|
$341.72
|
|
|
Service Code
|
NDC 70954049210
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.30 |
| Max. Negotiated Rate |
$307.55 |
| Rate for Payer: Aetna Commercial |
$290.46
|
| Rate for Payer: Aetna Medicare |
$170.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$222.12
|
| Rate for Payer: BCBS Complete |
$136.69
|
| Rate for Payer: Cash Price |
$273.38
|
| Rate for Payer: Cofinity Advantage |
$239.20
|
| Rate for Payer: Cofinity Commercial |
$293.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$273.38
|
| Rate for Payer: Healthscope Commercial |
$307.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$273.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$290.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$256.29
|
| Rate for Payer: PHP Commercial |
$290.46
|
| Rate for Payer: Priority Health SBD |
$215.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$222.12
|
| Rate for Payer: UHC Core |
$178.04
|
| Rate for Payer: UHC Exchange |
$134.30
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
OP
|
$352.52
|
|
|
Service Code
|
NDC 16571076209
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.54 |
| Max. Negotiated Rate |
$317.27 |
| Rate for Payer: Aetna Commercial |
$299.64
|
| Rate for Payer: Aetna Medicare |
$176.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.14
|
| Rate for Payer: BCBS Complete |
$141.01
|
| Rate for Payer: Cash Price |
$282.02
|
| Rate for Payer: Cofinity Advantage |
$246.76
|
| Rate for Payer: Cofinity Commercial |
$303.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.02
|
| Rate for Payer: Healthscope Commercial |
$317.27
|
| Rate for Payer: MI Amish Medical Board Commercial |
$282.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$299.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$264.39
|
| Rate for Payer: PHP Commercial |
$299.64
|
| Rate for Payer: Priority Health SBD |
$222.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$229.14
|
| Rate for Payer: UHC Core |
$183.66
|
| Rate for Payer: UHC Exchange |
$138.54
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
OP
|
$517.54
|
|
|
Service Code
|
NDC 54482014407
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.39 |
| Max. Negotiated Rate |
$465.79 |
| Rate for Payer: Aetna Commercial |
$439.91
|
| Rate for Payer: Aetna Medicare |
$258.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$336.40
|
| Rate for Payer: BCBS Complete |
$207.02
|
| Rate for Payer: Cash Price |
$414.03
|
| Rate for Payer: Cofinity Advantage |
$362.28
|
| Rate for Payer: Cofinity Commercial |
$445.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.03
|
| Rate for Payer: Healthscope Commercial |
$465.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$414.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$439.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$388.15
|
| Rate for Payer: PHP Commercial |
$439.91
|
| Rate for Payer: Priority Health SBD |
$326.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$336.40
|
| Rate for Payer: UHC Core |
$269.64
|
| Rate for Payer: UHC Exchange |
$203.39
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
OP
|
$342.58
|
|
|
Service Code
|
NDC 50383017290
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.63 |
| Max. Negotiated Rate |
$308.32 |
| Rate for Payer: Aetna Commercial |
$291.19
|
| Rate for Payer: Aetna Medicare |
$171.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$222.68
|
| Rate for Payer: BCBS Complete |
$137.03
|
| Rate for Payer: Cash Price |
$274.06
|
| Rate for Payer: Cofinity Advantage |
$239.81
|
| Rate for Payer: Cofinity Commercial |
$294.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.06
|
| Rate for Payer: Healthscope Commercial |
$308.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$274.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$256.94
|
| Rate for Payer: PHP Commercial |
$291.19
|
| Rate for Payer: Priority Health SBD |
$215.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$222.68
|
| Rate for Payer: UHC Core |
$178.48
|
| Rate for Payer: UHC Exchange |
$134.63
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$342.58
|
|
|
Service Code
|
NDC 50383017290
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$215.83 |
| Max. Negotiated Rate |
$308.32 |
| Rate for Payer: Aetna Commercial |
$291.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$222.68
|
| Rate for Payer: Cash Price |
$274.06
|
| Rate for Payer: Cofinity Advantage |
$239.81
|
| Rate for Payer: Cofinity Commercial |
$294.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.06
|
| Rate for Payer: Healthscope Commercial |
$308.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$291.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$256.94
|
| Rate for Payer: PHP Commercial |
$291.19
|
| Rate for Payer: Priority Health SBD |
$215.83
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$352.52
|
|
|
Service Code
|
NDC 16571076209
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$222.09 |
| Max. Negotiated Rate |
$317.27 |
| Rate for Payer: Aetna Commercial |
$299.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.14
|
| Rate for Payer: Cash Price |
$282.02
|
| Rate for Payer: Cofinity Advantage |
$246.76
|
| Rate for Payer: Cofinity Commercial |
$303.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.02
|
| Rate for Payer: Healthscope Commercial |
$317.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$299.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$264.39
|
| Rate for Payer: PHP Commercial |
$299.64
|
| Rate for Payer: Priority Health SBD |
$222.09
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$517.54
|
|
|
Service Code
|
NDC 54482014407
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$326.05 |
| Max. Negotiated Rate |
$465.79 |
| Rate for Payer: Aetna Commercial |
$439.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$336.40
|
| Rate for Payer: Cash Price |
$414.03
|
| Rate for Payer: Cofinity Advantage |
$362.28
|
| Rate for Payer: Cofinity Commercial |
$445.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$414.03
|
| Rate for Payer: Healthscope Commercial |
$465.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$439.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$388.15
|
| Rate for Payer: PHP Commercial |
$439.91
|
| Rate for Payer: Priority Health SBD |
$326.05
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$341.72
|
|
|
Service Code
|
NDC 70954049210
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$215.28 |
| Max. Negotiated Rate |
$307.55 |
| Rate for Payer: Aetna Commercial |
$290.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$222.12
|
| Rate for Payer: Cash Price |
$273.38
|
| Rate for Payer: Cofinity Advantage |
$239.20
|
| Rate for Payer: Cofinity Commercial |
$293.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$273.38
|
| Rate for Payer: Healthscope Commercial |
$307.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$290.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$256.29
|
| Rate for Payer: PHP Commercial |
$290.46
|
| Rate for Payer: Priority Health SBD |
$215.28
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$84.54
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$53.26 |
| Max. Negotiated Rate |
$76.09 |
| Rate for Payer: Aetna Commercial |
$71.86
|
| Rate for Payer: Aetna Commercial |
$73.89
|
| Rate for Payer: Aetna Commercial |
$48.81
|
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.32
|
| Rate for Payer: Cash Price |
$67.63
|
| Rate for Payer: Cash Price |
$69.54
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cash Price |
$45.94
|
| Rate for Payer: Cofinity Advantage |
$59.18
|
| Rate for Payer: Cofinity Advantage |
$40.19
|
| Rate for Payer: Cofinity Advantage |
$60.85
|
| Rate for Payer: Cofinity Advantage |
$51.39
|
| Rate for Payer: Cofinity Commercial |
$74.76
|
| Rate for Payer: Cofinity Commercial |
$72.70
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Cofinity Commercial |
$49.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$67.63
|
| Rate for Payer: Healthscope Commercial |
$76.09
|
| Rate for Payer: Healthscope Commercial |
$78.24
|
| Rate for Payer: Healthscope Commercial |
$51.68
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$65.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$63.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.06
|
| Rate for Payer: PHP Commercial |
$71.86
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: PHP Commercial |
$48.81
|
| Rate for Payer: PHP Commercial |
$73.89
|
| Rate for Payer: Priority Health SBD |
$46.25
|
| Rate for Payer: Priority Health SBD |
$54.77
|
| Rate for Payer: Priority Health SBD |
$53.26
|
| Rate for Payer: Priority Health SBD |
$36.17
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$73.42
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$66.08 |
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna Commercial |
$73.89
|
| Rate for Payer: Aetna Commercial |
$71.86
|
| Rate for Payer: Aetna Commercial |
$48.81
|
| Rate for Payer: Aetna Medicare |
$36.71
|
| Rate for Payer: Aetna Medicare |
$43.47
|
| Rate for Payer: Aetna Medicare |
$42.27
|
| Rate for Payer: Aetna Medicare |
$28.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$56.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: BCBS Complete |
$34.77
|
| Rate for Payer: BCBS Complete |
$29.37
|
| Rate for Payer: BCBS Complete |
$22.97
|
| Rate for Payer: BCBS Complete |
$33.82
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cash Price |
$67.63
|
| Rate for Payer: Cash Price |
$69.54
|
| Rate for Payer: Cash Price |
$67.63
|
| Rate for Payer: Cash Price |
$45.94
|
| Rate for Payer: Cash Price |
$45.94
|
| Rate for Payer: Cash Price |
$69.54
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cofinity Advantage |
$60.85
|
| Rate for Payer: Cofinity Advantage |
$40.19
|
| Rate for Payer: Cofinity Advantage |
$59.18
|
| Rate for Payer: Cofinity Advantage |
$51.39
|
| Rate for Payer: Cofinity Commercial |
$49.38
|
| Rate for Payer: Cofinity Commercial |
$74.76
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Cofinity Commercial |
$72.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$69.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$67.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Healthscope Commercial |
$76.09
|
| Rate for Payer: Healthscope Commercial |
$51.68
|
| Rate for Payer: Healthscope Commercial |
$78.24
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$58.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$67.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$69.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$63.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$43.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$65.20
|
| Rate for Payer: PHP Commercial |
$71.86
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: PHP Commercial |
$73.89
|
| Rate for Payer: PHP Commercial |
$48.81
|
| Rate for Payer: Priority Health SBD |
$36.17
|
| Rate for Payer: Priority Health SBD |
$53.26
|
| Rate for Payer: Priority Health SBD |
$54.77
|
| Rate for Payer: Priority Health SBD |
$46.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
IP
|
$195.70
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.29 |
| Max. Negotiated Rate |
$176.13 |
| Rate for Payer: Aetna Commercial |
$166.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$127.20
|
| Rate for Payer: Cash Price |
$156.56
|
| Rate for Payer: Cofinity Advantage |
$136.99
|
| Rate for Payer: Cofinity Commercial |
$168.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.56
|
| Rate for Payer: Healthscope Commercial |
$176.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.78
|
| Rate for Payer: PHP Commercial |
$166.34
|
| Rate for Payer: Priority Health SBD |
$123.29
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
IP
|
$150.40
|
|
|
Service Code
|
NDC 55111027950
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.75 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$127.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.76
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Advantage |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$129.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$135.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$112.80
|
| Rate for Payer: PHP Commercial |
$127.84
|
| Rate for Payer: Priority Health SBD |
$94.75
|
|
