Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE

Facility

$2,188.80

Service Code	HCPCS J9217
Hospital Charge Code	40801
Hospital Revenue Code	636
Min. Negotiated Rate	$94.58
Max. Negotiated Rate	$1,969.92
Rate for Payer: Aetna Commercial	$1,860.48
Rate for Payer: Aetna Medicare	$183.51
Rate for Payer: Aetna New Business (MI Preferred)	$1,422.72
Rate for Payer: Allen County Amish Medical Aid Commercial	$220.56
Rate for Payer: Amish Plain Church Group Commercial	$220.56
Rate for Payer: BCBS Complete	$99.31
Rate for Payer: BCBS MAPPO	$176.45
Rate for Payer: BCN Medicare Advantage	$176.45
Rate for Payer: Cash Price	$1,751.04
Rate for Payer: Cash Price	$1,751.04
Rate for Payer: Cofinity Commercial	$1,882.37
Rate for Payer: Cofinity Commercial	$1,532.16
Rate for Payer: Cofinity Medicare Advantage	$1,532.16
Rate for Payer: Encore Health Key Benefits Commercial	$1,751.04
Rate for Payer: Health Alliance Plan Medicare Advantage	$176.45
Rate for Payer: Healthscope Commercial	$1,969.92
Rate for Payer: Mclaren Medicaid	$94.58
Rate for Payer: Mclaren Medicare	$176.45
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$185.27
Rate for Payer: Meridian Medicaid	$99.31
Rate for Payer: MI Amish Medical Board Commercial	$202.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1,860.48
Rate for Payer: PACE Medicare	$167.63
Rate for Payer: PACE SWMI	$176.45
Rate for Payer: PHP Commercial	$1,860.48
Rate for Payer: PHP Medicare Advantage	$176.45
Rate for Payer: Priority Health Choice Medicaid	$94.58
Rate for Payer: Priority Health Cigna Priority Health	$1,422.72
Rate for Payer: Priority Health Medicare	$176.45
Rate for Payer: Priority Health SBD	$1,378.94
Rate for Payer: Railroad Medicare Medicare	$176.45
Rate for Payer: UHC All Payor (Choice/PPO)	$496.69
Rate for Payer: UHC Dual Complete DSNP	$176.45
Rate for Payer: UHC Medicare Advantage	$176.45
Rate for Payer: UHCCP Medicaid	$99.34
Rate for Payer: VA VA	$176.45

LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT

Facility

$3,314.79

Service Code	HCPCS J9217
Hospital Charge Code	152942
Hospital Revenue Code	636
Min. Negotiated Rate	$94.58
Max. Negotiated Rate	$2,983.31
Rate for Payer: Aetna Commercial	$2,817.57
Rate for Payer: Aetna Medicare	$183.51
Rate for Payer: Aetna New Business (MI Preferred)	$2,154.61
Rate for Payer: Allen County Amish Medical Aid Commercial	$220.56
Rate for Payer: Amish Plain Church Group Commercial	$220.56
Rate for Payer: BCBS Complete	$99.31
Rate for Payer: BCBS MAPPO	$176.45
Rate for Payer: BCN Medicare Advantage	$176.45
Rate for Payer: Cash Price	$2,651.83
Rate for Payer: Cash Price	$2,651.83
Rate for Payer: Cofinity Commercial	$2,320.35
Rate for Payer: Cofinity Commercial	$2,850.72
Rate for Payer: Cofinity Medicare Advantage	$2,320.35
Rate for Payer: Encore Health Key Benefits Commercial	$2,651.83
Rate for Payer: Health Alliance Plan Medicare Advantage	$176.45
Rate for Payer: Healthscope Commercial	$2,983.31
Rate for Payer: Mclaren Medicaid	$94.58
Rate for Payer: Mclaren Medicare	$176.45
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$185.27
Rate for Payer: Meridian Medicaid	$99.31
Rate for Payer: MI Amish Medical Board Commercial	$202.92
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,817.57
Rate for Payer: PACE Medicare	$167.63
Rate for Payer: PACE SWMI	$176.45
Rate for Payer: PHP Commercial	$2,817.57
Rate for Payer: PHP Medicare Advantage	$176.45
Rate for Payer: Priority Health Choice Medicaid	$94.58
Rate for Payer: Priority Health Cigna Priority Health	$2,154.61
Rate for Payer: Priority Health Medicare	$176.45
Rate for Payer: Priority Health SBD	$2,088.32
Rate for Payer: Railroad Medicare Medicare	$176.45
Rate for Payer: UHC All Payor (Choice/PPO)	$496.69
Rate for Payer: UHC Dual Complete DSNP	$176.45
Rate for Payer: UHC Medicare Advantage	$176.45
Rate for Payer: UHCCP Medicaid	$99.34
Rate for Payer: VA VA	$176.45

LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT

Facility

$3,314.79

Service Code	HCPCS J9217
Hospital Charge Code	152942
Hospital Revenue Code	636
Min. Negotiated Rate	$2,088.32
Max. Negotiated Rate	$2,983.31
Rate for Payer: Aetna Commercial	$2,817.57
Rate for Payer: Aetna New Business (MI Preferred)	$2,154.61
Rate for Payer: Cash Price	$2,651.83
Rate for Payer: Cofinity Commercial	$2,320.35
Rate for Payer: Cofinity Commercial	$2,850.72
Rate for Payer: Cofinity Medicare Advantage	$2,320.35
Rate for Payer: Encore Health Key Benefits Commercial	$2,651.83
Rate for Payer: Healthscope Commercial	$2,983.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2,817.57
Rate for Payer: PHP Commercial	$2,817.57
Rate for Payer: Priority Health Cigna Priority Health	$2,154.61
Rate for Payer: Priority Health SBD	$2,088.32

LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION ABORTION - SPONTANEOUS/MISSED ARTERY, BIOPSY BONE MARROW, BIOPSY BONE EXOSTOSIS BRAIN/MENINGES, OTHER THAN FOR TUMOR RESECTION BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, REDUCTION MAMMOPLASTY BRONCHUS, BIOPSY CELL BLOCK, ANY SOURCE CERVIX, BIOPSY COLON, BIOPSY DUODENUM, BIOPSY ENDOCERVIX, CURETTINGS/BIOPSY ENDOMETRIUM, CURETTINGS/BIOPSY ESOPHAGUS, BIOPSY EXTREMITY, AMPUTATION, TRAUMATIC FALLOPIAN TUBE, BIOPSY FALLOPIAN TUBE, ECTOPIC PREGNANCY FEMORAL HEAD, FRACTURE FINGERS/TOES, AMPUTATION, NON-TRAUMATIC GINGIVA/ORAL MUCOSA, BIOPSY HEART VALVE JOINT, RESECTION KIDNEY, BIOPSY LARYNX, BIOPSY LEIOMYOMA(S), UTERINE MYOMECTOMY - WITHOUT UTERUS LIP, BIOPSY/WEDGE RESECTION LUNG, TRANSBRONCHIAL BIOPSY LYMPH NODE, BIOPSY MUSCLE, BIOPSY NASAL MUCOSA, BIOPSY NASOPHARYNX/OROPHARYNX, BIOPSY NERVE, BIOPSY ODONTOGENIC/DENTAL CYST OMENTUM, BIOPSY OVARY WITH OR WITHOUT TUBE, NON-NEOPLASTIC OVARY, BIOPSY/WEDGE RESECTION PARAT

Facility

$146.68

Service Code	CPT 88305
Hospital Revenue Code	360
Min. Negotiated Rate	$27.93
Max. Negotiated Rate	$146.68
Rate for Payer: Aetna Medicare	$54.19
Rate for Payer: Allen County Amish Medical Aid Commercial	$65.14
Rate for Payer: Amish Plain Church Group Commercial	$65.14
Rate for Payer: BCBS Complete	$29.33
Rate for Payer: BCBS MAPPO	$52.11
Rate for Payer: BCN Medicare Advantage	$52.11
Rate for Payer: Health Alliance Plan Medicare Advantage	$52.11
Rate for Payer: Mclaren Medicaid	$27.93
Rate for Payer: Mclaren Medicare	$52.11
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$54.72
Rate for Payer: Meridian Medicaid	$29.33
Rate for Payer: MI Amish Medical Board Commercial	$59.93
Rate for Payer: PACE Medicare	$49.50
Rate for Payer: PACE SWMI	$52.11
Rate for Payer: PHP Medicare Advantage	$52.11
Rate for Payer: Priority Health Choice Medicaid	$27.93
Rate for Payer: Priority Health Medicare	$52.11
Rate for Payer: Railroad Medicare Medicare	$52.11
Rate for Payer: UHC All Payor (Choice/PPO)	$146.68
Rate for Payer: UHC Dual Complete DSNP	$52.11
Rate for Payer: UHC Medicare Advantage	$52.11
Rate for Payer: UHCCP Medicaid	$29.34
Rate for Payer: VA VA	$52.11

LEVETIRACETAM 1,000 MG TABLET

Facility

$316.32

Service Code	NDC 60687066801
Hospital Charge Code	70773
Hospital Revenue Code	637
Min. Negotiated Rate	$199.28
Max. Negotiated Rate	$284.69
Rate for Payer: Aetna Commercial	$268.87
Rate for Payer: Aetna New Business (MI Preferred)	$205.61
Rate for Payer: Cash Price	$253.06
Rate for Payer: Cofinity Commercial	$221.42
Rate for Payer: Cofinity Commercial	$272.04
Rate for Payer: Cofinity Medicare Advantage	$221.42
Rate for Payer: Encore Health Key Benefits Commercial	$253.06
Rate for Payer: Healthscope Commercial	$284.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$268.87
Rate for Payer: PHP Commercial	$268.87
Rate for Payer: Priority Health Cigna Priority Health	$205.61
Rate for Payer: Priority Health SBD	$199.28

LEVETIRACETAM 1,000 MG TABLET

Facility

$197.40

Service Code	NDC 68180011507
Hospital Charge Code	70773
Hospital Revenue Code	637
Min. Negotiated Rate	$78.96
Max. Negotiated Rate	$177.66
Rate for Payer: Aetna Commercial	$167.79
Rate for Payer: Aetna Medicare	$98.70
Rate for Payer: Aetna New Business (MI Preferred)	$128.31
Rate for Payer: BCBS Complete	$78.96
Rate for Payer: Cash Price	$157.92
Rate for Payer: Cofinity Commercial	$138.18
Rate for Payer: Cofinity Commercial	$169.76
Rate for Payer: Cofinity Medicare Advantage	$138.18
Rate for Payer: Encore Health Key Benefits Commercial	$157.92
Rate for Payer: Healthscope Commercial	$177.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$167.79
Rate for Payer: PHP Commercial	$167.79
Rate for Payer: Priority Health Cigna Priority Health	$128.31
Rate for Payer: Priority Health SBD	$124.36

LEVETIRACETAM 1,000 MG TABLET

Facility

$197.40

Service Code	NDC 68180011507
Hospital Charge Code	70773
Hospital Revenue Code	637
Min. Negotiated Rate	$124.36
Max. Negotiated Rate	$177.66
Rate for Payer: Aetna Commercial	$167.79
Rate for Payer: Aetna New Business (MI Preferred)	$128.31
Rate for Payer: Cash Price	$157.92
Rate for Payer: Cofinity Commercial	$138.18
Rate for Payer: Cofinity Commercial	$169.76
Rate for Payer: Cofinity Medicare Advantage	$138.18
Rate for Payer: Encore Health Key Benefits Commercial	$157.92
Rate for Payer: Healthscope Commercial	$177.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$167.79
Rate for Payer: PHP Commercial	$167.79
Rate for Payer: Priority Health Cigna Priority Health	$128.31
Rate for Payer: Priority Health SBD	$124.36

LEVETIRACETAM 1,000 MG TABLET

Facility

$316.32

Service Code	NDC 60687066801
Hospital Charge Code	70773
Hospital Revenue Code	637
Min. Negotiated Rate	$126.53
Max. Negotiated Rate	$284.69
Rate for Payer: Aetna Commercial	$268.87
Rate for Payer: Aetna Medicare	$158.16
Rate for Payer: Aetna New Business (MI Preferred)	$205.61
Rate for Payer: BCBS Complete	$126.53
Rate for Payer: Cash Price	$253.06
Rate for Payer: Cofinity Commercial	$221.42
Rate for Payer: Cofinity Commercial	$272.04
Rate for Payer: Cofinity Medicare Advantage	$221.42
Rate for Payer: Encore Health Key Benefits Commercial	$253.06
Rate for Payer: Healthscope Commercial	$284.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$268.87
Rate for Payer: PHP Commercial	$268.87
Rate for Payer: Priority Health Cigna Priority Health	$205.61
Rate for Payer: Priority Health SBD	$199.28

LEVETIRACETAM 1,000 MG TABLET

Facility

$3.17

Service Code	NDC 60687066811
Hospital Charge Code	70773
Hospital Revenue Code	637
Min. Negotiated Rate	$2.00
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.69
Rate for Payer: Aetna New Business (MI Preferred)	$2.06
Rate for Payer: Cash Price	$2.54
Rate for Payer: Cofinity Commercial	$2.22
Rate for Payer: Cofinity Commercial	$2.73
Rate for Payer: Cofinity Medicare Advantage	$2.22
Rate for Payer: Encore Health Key Benefits Commercial	$2.54
Rate for Payer: Healthscope Commercial	$2.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.69
Rate for Payer: PHP Commercial	$2.69
Rate for Payer: Priority Health Cigna Priority Health	$2.06
Rate for Payer: Priority Health SBD	$2.00

LEVETIRACETAM 1,000 MG TABLET

Facility

$3.17

Service Code	NDC 60687066811
Hospital Charge Code	70773
Hospital Revenue Code	637
Min. Negotiated Rate	$1.27
Max. Negotiated Rate	$2.85
Rate for Payer: Aetna Commercial	$2.69
Rate for Payer: Aetna Medicare	$1.58
Rate for Payer: Aetna New Business (MI Preferred)	$2.06
Rate for Payer: BCBS Complete	$1.27
Rate for Payer: Cash Price	$2.54
Rate for Payer: Cofinity Commercial	$2.22
Rate for Payer: Cofinity Commercial	$2.73
Rate for Payer: Cofinity Medicare Advantage	$2.22
Rate for Payer: Encore Health Key Benefits Commercial	$2.54
Rate for Payer: Healthscope Commercial	$2.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.69
Rate for Payer: PHP Commercial	$2.69
Rate for Payer: Priority Health Cigna Priority Health	$2.06
Rate for Payer: Priority Health SBD	$2.00

LEVETIRACETAM 100 MG/ML ORAL SOLUTION

Facility

$266.78

Service Code	NDC 51991065116
Hospital Charge Code	36590
Hospital Revenue Code	637
Min. Negotiated Rate	$106.71
Max. Negotiated Rate	$240.10
Rate for Payer: Aetna Commercial	$226.76
Rate for Payer: Aetna Medicare	$133.39
Rate for Payer: Aetna New Business (MI Preferred)	$173.41
Rate for Payer: BCBS Complete	$106.71
Rate for Payer: Cash Price	$213.42
Rate for Payer: Cofinity Commercial	$186.75
Rate for Payer: Cofinity Commercial	$229.43
Rate for Payer: Cofinity Medicare Advantage	$186.75
Rate for Payer: Encore Health Key Benefits Commercial	$213.42
Rate for Payer: Healthscope Commercial	$240.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$226.76
Rate for Payer: PHP Commercial	$226.76
Rate for Payer: Priority Health Cigna Priority Health	$173.41
Rate for Payer: Priority Health SBD	$168.07

LEVETIRACETAM 100 MG/ML ORAL SOLUTION

Facility

$422.39

Service Code	NDC 00121079916
Hospital Charge Code	36590
Hospital Revenue Code	637
Min. Negotiated Rate	$168.96
Max. Negotiated Rate	$380.15
Rate for Payer: Aetna Commercial	$359.03
Rate for Payer: Aetna Medicare	$211.19
Rate for Payer: Aetna New Business (MI Preferred)	$274.55
Rate for Payer: BCBS Complete	$168.96
Rate for Payer: Cash Price	$337.91
Rate for Payer: Cofinity Commercial	$295.67
Rate for Payer: Cofinity Commercial	$363.26
Rate for Payer: Cofinity Medicare Advantage	$295.67
Rate for Payer: Encore Health Key Benefits Commercial	$337.91
Rate for Payer: Healthscope Commercial	$380.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$359.03
Rate for Payer: PHP Commercial	$359.03
Rate for Payer: Priority Health Cigna Priority Health	$274.55
Rate for Payer: Priority Health SBD	$266.11

LEVETIRACETAM 100 MG/ML ORAL SOLUTION

Facility

$4,120.78

Service Code	NDC 50474000148
Hospital Charge Code	36590
Hospital Revenue Code	637
Min. Negotiated Rate	$2,596.09
Max. Negotiated Rate	$3,708.70
Rate for Payer: Aetna Commercial	$3,502.66
Rate for Payer: Aetna New Business (MI Preferred)	$2,678.51
Rate for Payer: Cash Price	$3,296.62
Rate for Payer: Cofinity Commercial	$2,884.55
Rate for Payer: Cofinity Commercial	$3,543.87
Rate for Payer: Cofinity Medicare Advantage	$2,884.55
Rate for Payer: Encore Health Key Benefits Commercial	$3,296.62
Rate for Payer: Healthscope Commercial	$3,708.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,502.66
Rate for Payer: PHP Commercial	$3,502.66
Rate for Payer: Priority Health Cigna Priority Health	$2,678.51
Rate for Payer: Priority Health SBD	$2,596.09

LEVETIRACETAM 100 MG/ML ORAL SOLUTION

Facility

$4,120.78

Service Code	NDC 50474000148
Hospital Charge Code	36590
Hospital Revenue Code	637
Min. Negotiated Rate	$1,648.31
Max. Negotiated Rate	$3,708.70
Rate for Payer: Aetna Commercial	$3,502.66
Rate for Payer: Aetna Medicare	$2,060.39
Rate for Payer: Aetna New Business (MI Preferred)	$2,678.51
Rate for Payer: BCBS Complete	$1,648.31
Rate for Payer: Cash Price	$3,296.62
Rate for Payer: Cofinity Commercial	$2,884.55
Rate for Payer: Cofinity Commercial	$3,543.87
Rate for Payer: Cofinity Medicare Advantage	$2,884.55
Rate for Payer: Encore Health Key Benefits Commercial	$3,296.62
Rate for Payer: Healthscope Commercial	$3,708.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,502.66
Rate for Payer: PHP Commercial	$3,502.66
Rate for Payer: Priority Health Cigna Priority Health	$2,678.51
Rate for Payer: Priority Health SBD	$2,596.09

LEVETIRACETAM 100 MG/ML ORAL SOLUTION

Facility

$422.39

Service Code	NDC 00121079916
Hospital Charge Code	36590
Hospital Revenue Code	637
Min. Negotiated Rate	$266.11
Max. Negotiated Rate	$380.15
Rate for Payer: Aetna Commercial	$359.03
Rate for Payer: Aetna New Business (MI Preferred)	$274.55
Rate for Payer: Cash Price	$337.91
Rate for Payer: Cofinity Commercial	$295.67
Rate for Payer: Cofinity Commercial	$363.26
Rate for Payer: Cofinity Medicare Advantage	$295.67
Rate for Payer: Encore Health Key Benefits Commercial	$337.91
Rate for Payer: Healthscope Commercial	$380.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$359.03
Rate for Payer: PHP Commercial	$359.03
Rate for Payer: Priority Health Cigna Priority Health	$274.55
Rate for Payer: Priority Health SBD	$266.11

LEVETIRACETAM 100 MG/ML ORAL SOLUTION

Facility

$266.78

Service Code	NDC 51991065116
Hospital Charge Code	36590
Hospital Revenue Code	637
Min. Negotiated Rate	$168.07
Max. Negotiated Rate	$240.10
Rate for Payer: Aetna Commercial	$226.76
Rate for Payer: Aetna New Business (MI Preferred)	$173.41
Rate for Payer: Cash Price	$213.42
Rate for Payer: Cofinity Commercial	$186.75
Rate for Payer: Cofinity Commercial	$229.43
Rate for Payer: Cofinity Medicare Advantage	$186.75
Rate for Payer: Encore Health Key Benefits Commercial	$213.42
Rate for Payer: Healthscope Commercial	$240.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$226.76
Rate for Payer: PHP Commercial	$226.76
Rate for Payer: Priority Health Cigna Priority Health	$173.41
Rate for Payer: Priority Health SBD	$168.07

LEVETIRACETAM 250 MG TABLET

Facility

$3.46

Service Code	NDC 68084085911
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$2.18
Max. Negotiated Rate	$3.11
Rate for Payer: Aetna Commercial	$2.94
Rate for Payer: Aetna New Business (MI Preferred)	$2.25
Rate for Payer: Cash Price	$2.77
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Cofinity Commercial	$2.98
Rate for Payer: Cofinity Medicare Advantage	$2.42
Rate for Payer: Encore Health Key Benefits Commercial	$2.77
Rate for Payer: Healthscope Commercial	$3.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.94
Rate for Payer: PHP Commercial	$2.94
Rate for Payer: Priority Health Cigna Priority Health	$2.25
Rate for Payer: Priority Health SBD	$2.18

LEVETIRACETAM 250 MG TABLET

Facility

$345.45

Service Code	NDC 68084085901
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$217.63
Max. Negotiated Rate	$310.90
Rate for Payer: Aetna Commercial	$293.63
Rate for Payer: Aetna New Business (MI Preferred)	$224.54
Rate for Payer: Cash Price	$276.36
Rate for Payer: Cofinity Commercial	$241.81
Rate for Payer: Cofinity Commercial	$297.09
Rate for Payer: Cofinity Medicare Advantage	$241.81
Rate for Payer: Encore Health Key Benefits Commercial	$276.36
Rate for Payer: Healthscope Commercial	$310.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$293.63
Rate for Payer: PHP Commercial	$293.63
Rate for Payer: Priority Health Cigna Priority Health	$224.54
Rate for Payer: Priority Health SBD	$217.63

LEVETIRACETAM 250 MG TABLET

Facility

$345.45

Service Code	NDC 68084085901
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$138.18
Max. Negotiated Rate	$310.90
Rate for Payer: Aetna Commercial	$293.63
Rate for Payer: Aetna Medicare	$172.72
Rate for Payer: Aetna New Business (MI Preferred)	$224.54
Rate for Payer: BCBS Complete	$138.18
Rate for Payer: Cash Price	$276.36
Rate for Payer: Cofinity Commercial	$241.81
Rate for Payer: Cofinity Commercial	$297.09
Rate for Payer: Cofinity Medicare Advantage	$241.81
Rate for Payer: Encore Health Key Benefits Commercial	$276.36
Rate for Payer: Healthscope Commercial	$310.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$293.63
Rate for Payer: PHP Commercial	$293.63
Rate for Payer: Priority Health Cigna Priority Health	$224.54
Rate for Payer: Priority Health SBD	$217.63

LEVETIRACETAM 250 MG TABLET

Facility

$3.46

Service Code	NDC 68084085911
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$3.11
Rate for Payer: Aetna Commercial	$2.94
Rate for Payer: Aetna Medicare	$1.73
Rate for Payer: Aetna New Business (MI Preferred)	$2.25
Rate for Payer: BCBS Complete	$1.38
Rate for Payer: Cash Price	$2.77
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Cofinity Commercial	$2.98
Rate for Payer: Cofinity Medicare Advantage	$2.42
Rate for Payer: Encore Health Key Benefits Commercial	$2.77
Rate for Payer: Healthscope Commercial	$3.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.94
Rate for Payer: PHP Commercial	$2.94
Rate for Payer: Priority Health Cigna Priority Health	$2.25
Rate for Payer: Priority Health SBD	$2.18

LEVETIRACETAM 250 MG TABLET

Facility

$2.25

Service Code	NDC 51079082001
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$1.42
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna Commercial	$1.91
Rate for Payer: Aetna New Business (MI Preferred)	$1.46
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cofinity Commercial	$1.57
Rate for Payer: Cofinity Commercial	$1.94
Rate for Payer: Cofinity Medicare Advantage	$1.57
Rate for Payer: Encore Health Key Benefits Commercial	$1.80
Rate for Payer: Healthscope Commercial	$2.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.91
Rate for Payer: PHP Commercial	$1.91
Rate for Payer: Priority Health Cigna Priority Health	$1.46
Rate for Payer: Priority Health SBD	$1.42

LEVETIRACETAM 250 MG TABLET

Facility

$291.40

Service Code	NDC 00904712361
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$116.56
Max. Negotiated Rate	$262.26
Rate for Payer: Aetna Commercial	$247.69
Rate for Payer: Aetna Medicare	$145.70
Rate for Payer: Aetna New Business (MI Preferred)	$189.41
Rate for Payer: BCBS Complete	$116.56
Rate for Payer: Cash Price	$233.12
Rate for Payer: Cofinity Commercial	$203.98
Rate for Payer: Cofinity Commercial	$250.60
Rate for Payer: Cofinity Medicare Advantage	$203.98
Rate for Payer: Encore Health Key Benefits Commercial	$233.12
Rate for Payer: Healthscope Commercial	$262.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$247.69
Rate for Payer: PHP Commercial	$247.69
Rate for Payer: Priority Health Cigna Priority Health	$189.41
Rate for Payer: Priority Health SBD	$183.58

LEVETIRACETAM 250 MG TABLET

Facility

$224.20

Service Code	NDC 51079082020
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$89.68
Max. Negotiated Rate	$201.78
Rate for Payer: Aetna Commercial	$190.57
Rate for Payer: Aetna Medicare	$112.10
Rate for Payer: Aetna New Business (MI Preferred)	$145.73
Rate for Payer: BCBS Complete	$89.68
Rate for Payer: Cash Price	$179.36
Rate for Payer: Cofinity Commercial	$156.94
Rate for Payer: Cofinity Commercial	$192.81
Rate for Payer: Cofinity Medicare Advantage	$156.94
Rate for Payer: Encore Health Key Benefits Commercial	$179.36
Rate for Payer: Healthscope Commercial	$201.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$190.57
Rate for Payer: PHP Commercial	$190.57
Rate for Payer: Priority Health Cigna Priority Health	$145.73
Rate for Payer: Priority Health SBD	$141.25

LEVETIRACETAM 250 MG TABLET

Facility

$224.20

Service Code	NDC 51079082020
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$141.25
Max. Negotiated Rate	$201.78
Rate for Payer: Aetna Commercial	$190.57
Rate for Payer: Aetna New Business (MI Preferred)	$145.73
Rate for Payer: Cash Price	$179.36
Rate for Payer: Cofinity Commercial	$156.94
Rate for Payer: Cofinity Commercial	$192.81
Rate for Payer: Cofinity Medicare Advantage	$156.94
Rate for Payer: Encore Health Key Benefits Commercial	$179.36
Rate for Payer: Healthscope Commercial	$201.78
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$190.57
Rate for Payer: PHP Commercial	$190.57
Rate for Payer: Priority Health Cigna Priority Health	$145.73
Rate for Payer: Priority Health SBD	$141.25

LEVETIRACETAM 250 MG TABLET

Facility

$2.25

Service Code	NDC 51079082001
Hospital Charge Code	26816
Hospital Revenue Code	637
Min. Negotiated Rate	$0.90
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna Commercial	$1.91
Rate for Payer: Aetna Medicare	$1.12
Rate for Payer: Aetna New Business (MI Preferred)	$1.46
Rate for Payer: BCBS Complete	$0.90
Rate for Payer: Cash Price	$1.80
Rate for Payer: Cofinity Commercial	$1.57
Rate for Payer: Cofinity Commercial	$1.94
Rate for Payer: Cofinity Medicare Advantage	$1.57
Rate for Payer: Encore Health Key Benefits Commercial	$1.80
Rate for Payer: Healthscope Commercial	$2.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.91
Rate for Payer: PHP Commercial	$1.91
Rate for Payer: Priority Health Cigna Priority Health	$1.46
Rate for Payer: Priority Health SBD	$1.42

Know your out-of-pocket cost for care.

All Charges