|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 00904712361
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.58 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| 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 500 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$24.79
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
77195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Aetna Commercial |
$21.07
|
| Rate for Payer: Aetna Commercial |
$24.28
|
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Aetna Commercial |
$15.28
|
| Rate for Payer: Aetna Commercial |
$12.21
|
| Rate for Payer: Aetna Commercial |
$13.56
|
| Rate for Payer: Aetna Commercial |
$18.73
|
| Rate for Payer: Aetna Commercial |
$14.98
|
| Rate for Payer: Aetna Medicare |
$8.81
|
| Rate for Payer: Aetna Medicare |
$12.39
|
| Rate for Payer: Aetna Medicare |
$8.99
|
| Rate for Payer: Aetna Medicare |
$14.29
|
| Rate for Payer: Aetna Medicare |
$7.97
|
| Rate for Payer: Aetna Medicare |
$7.18
|
| Rate for Payer: Aetna Medicare |
$10.30
|
| Rate for Payer: Aetna Medicare |
$11.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.40
|
| Rate for Payer: BCBS Complete |
$7.19
|
| Rate for Payer: BCBS Complete |
$6.38
|
| Rate for Payer: BCBS Complete |
$11.43
|
| Rate for Payer: BCBS Complete |
$7.05
|
| Rate for Payer: BCBS Complete |
$5.74
|
| Rate for Payer: BCBS Complete |
$8.24
|
| Rate for Payer: BCBS Complete |
$8.82
|
| Rate for Payer: BCBS Complete |
$9.92
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cash Price |
$12.76
|
| Rate for Payer: Cash Price |
$17.63
|
| Rate for Payer: Cash Price |
$22.86
|
| Rate for Payer: Cash Price |
$19.83
|
| Rate for Payer: Cofinity Commercial |
$15.43
|
| Rate for Payer: Cofinity Commercial |
$11.16
|
| Rate for Payer: Cofinity Commercial |
$12.35
|
| Rate for Payer: Cofinity Commercial |
$10.05
|
| Rate for Payer: Cofinity Commercial |
$15.46
|
| Rate for Payer: Cofinity Commercial |
$17.72
|
| Rate for Payer: Cofinity Commercial |
$24.57
|
| Rate for Payer: Cofinity Commercial |
$20.00
|
| Rate for Payer: Cofinity Commercial |
$18.95
|
| Rate for Payer: Cofinity Commercial |
$12.59
|
| Rate for Payer: Cofinity Commercial |
$15.15
|
| Rate for Payer: Cofinity Commercial |
$12.33
|
| Rate for Payer: Cofinity Commercial |
$13.72
|
| Rate for Payer: Cofinity Commercial |
$14.43
|
| Rate for Payer: Cofinity Commercial |
$21.32
|
| Rate for Payer: Cofinity Commercial |
$17.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.86
|
| Rate for Payer: Healthscope Commercial |
$18.55
|
| Rate for Payer: Healthscope Commercial |
$25.71
|
| Rate for Payer: Healthscope Commercial |
$16.18
|
| Rate for Payer: Healthscope Commercial |
$14.36
|
| Rate for Payer: Healthscope Commercial |
$12.92
|
| Rate for Payer: Healthscope Commercial |
$22.31
|
| Rate for Payer: Healthscope Commercial |
$15.86
|
| Rate for Payer: Healthscope Commercial |
$19.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.28
|
| Rate for Payer: PHP Commercial |
$17.52
|
| Rate for Payer: PHP Commercial |
$24.28
|
| Rate for Payer: PHP Commercial |
$18.73
|
| Rate for Payer: PHP Commercial |
$12.21
|
| Rate for Payer: PHP Commercial |
$15.28
|
| Rate for Payer: PHP Commercial |
$13.56
|
| Rate for Payer: PHP Commercial |
$14.98
|
| Rate for Payer: PHP Commercial |
$21.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.40
|
| Rate for Payer: Priority Health SBD |
$11.10
|
| Rate for Payer: Priority Health SBD |
$15.62
|
| Rate for Payer: Priority Health SBD |
$9.05
|
| Rate for Payer: Priority Health SBD |
$18.00
|
| Rate for Payer: Priority Health SBD |
$10.05
|
| Rate for Payer: Priority Health SBD |
$11.33
|
| Rate for Payer: Priority Health SBD |
$12.98
|
| Rate for Payer: Priority Health SBD |
$13.89
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$24.79
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
77195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.62 |
| Max. Negotiated Rate |
$22.31 |
| Rate for Payer: Aetna Commercial |
$21.07
|
| Rate for Payer: Aetna Commercial |
$18.73
|
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Aetna Commercial |
$13.56
|
| Rate for Payer: Aetna Commercial |
$12.21
|
| Rate for Payer: Aetna Commercial |
$15.28
|
| Rate for Payer: Aetna Commercial |
$14.98
|
| Rate for Payer: Aetna Commercial |
$24.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.37
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cash Price |
$12.76
|
| Rate for Payer: Cash Price |
$17.63
|
| Rate for Payer: Cash Price |
$19.83
|
| Rate for Payer: Cash Price |
$22.86
|
| Rate for Payer: Cofinity Commercial |
$10.05
|
| Rate for Payer: Cofinity Commercial |
$12.35
|
| Rate for Payer: Cofinity Commercial |
$15.15
|
| Rate for Payer: Cofinity Commercial |
$11.16
|
| Rate for Payer: Cofinity Commercial |
$13.72
|
| Rate for Payer: Cofinity Commercial |
$12.33
|
| Rate for Payer: Cofinity Commercial |
$12.59
|
| Rate for Payer: Cofinity Commercial |
$15.46
|
| Rate for Payer: Cofinity Commercial |
$14.43
|
| Rate for Payer: Cofinity Commercial |
$17.72
|
| Rate for Payer: Cofinity Commercial |
$15.43
|
| Rate for Payer: Cofinity Commercial |
$18.95
|
| Rate for Payer: Cofinity Commercial |
$17.35
|
| Rate for Payer: Cofinity Commercial |
$21.32
|
| Rate for Payer: Cofinity Commercial |
$20.00
|
| Rate for Payer: Cofinity Commercial |
$24.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.59
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.83
|
| Rate for Payer: Healthscope Commercial |
$18.55
|
| Rate for Payer: Healthscope Commercial |
$22.31
|
| Rate for Payer: Healthscope Commercial |
$12.92
|
| Rate for Payer: Healthscope Commercial |
$14.36
|
| Rate for Payer: Healthscope Commercial |
$15.86
|
| Rate for Payer: Healthscope Commercial |
$16.18
|
| Rate for Payer: Healthscope Commercial |
$25.71
|
| Rate for Payer: Healthscope Commercial |
$19.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.98
|
| Rate for Payer: PHP Commercial |
$14.98
|
| Rate for Payer: PHP Commercial |
$15.28
|
| Rate for Payer: PHP Commercial |
$17.52
|
| Rate for Payer: PHP Commercial |
$18.73
|
| Rate for Payer: PHP Commercial |
$24.28
|
| Rate for Payer: PHP Commercial |
$21.07
|
| Rate for Payer: PHP Commercial |
$12.21
|
| Rate for Payer: PHP Commercial |
$13.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.33
|
| Rate for Payer: Priority Health SBD |
$12.98
|
| Rate for Payer: Priority Health SBD |
$11.10
|
| Rate for Payer: Priority Health SBD |
$9.05
|
| Rate for Payer: Priority Health SBD |
$15.62
|
| Rate for Payer: Priority Health SBD |
$18.00
|
| Rate for Payer: Priority Health SBD |
$11.33
|
| Rate for Payer: Priority Health SBD |
$10.05
|
| Rate for Payer: Priority Health SBD |
$13.89
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$2.39
|
|
|
Service Code
|
NDC 68084087011
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.51 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna Commercial |
$2.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.55
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cofinity Commercial |
$1.67
|
| Rate for Payer: Cofinity Commercial |
$2.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.91
|
| Rate for Payer: Healthscope Commercial |
$2.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.03
|
| Rate for Payer: PHP Commercial |
$2.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.55
|
| Rate for Payer: Priority Health SBD |
$1.51
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$2.39
|
|
|
Service Code
|
NDC 68084087011
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.15 |
| Rate for Payer: Aetna Commercial |
$2.03
|
| Rate for Payer: Aetna Medicare |
$1.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.55
|
| Rate for Payer: BCBS Complete |
$0.96
|
| Rate for Payer: Cash Price |
$1.91
|
| Rate for Payer: Cofinity Commercial |
$1.67
|
| Rate for Payer: Cofinity Commercial |
$2.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.91
|
| Rate for Payer: Healthscope Commercial |
$2.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.03
|
| Rate for Payer: PHP Commercial |
$2.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.55
|
| Rate for Payer: Priority Health SBD |
$1.51
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$413.60
|
|
|
Service Code
|
NDC 60687065701
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.44 |
| Max. Negotiated Rate |
$372.24 |
| Rate for Payer: Aetna Commercial |
$351.56
|
| Rate for Payer: Aetna Medicare |
$206.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$268.84
|
| Rate for Payer: BCBS Complete |
$165.44
|
| Rate for Payer: Cash Price |
$330.88
|
| Rate for Payer: Cofinity Commercial |
$289.52
|
| Rate for Payer: Cofinity Commercial |
$355.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$289.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$330.88
|
| Rate for Payer: Healthscope Commercial |
$372.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$351.56
|
| Rate for Payer: PHP Commercial |
$351.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$268.84
|
| Rate for Payer: Priority Health SBD |
$260.57
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$238.45
|
|
|
Service Code
|
NDC 68084087001
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.38 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna Medicare |
$119.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: BCBS Complete |
$95.38
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$166.91
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$166.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.99
|
| Rate for Payer: Priority Health SBD |
$150.22
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$188.94
|
|
|
Service Code
|
NDC 72205009592
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.03 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna Commercial |
$160.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.81
|
| Rate for Payer: Cash Price |
$151.15
|
| Rate for Payer: Cofinity Commercial |
$132.26
|
| Rate for Payer: Cofinity Commercial |
$162.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$132.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.15
|
| Rate for Payer: Healthscope Commercial |
$170.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.60
|
| Rate for Payer: PHP Commercial |
$160.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.81
|
| Rate for Payer: Priority Health SBD |
$119.03
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$298.92
|
|
|
Service Code
|
NDC 31722053712
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.32 |
| Max. Negotiated Rate |
$269.03 |
| Rate for Payer: Aetna Commercial |
$254.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$194.30
|
| Rate for Payer: Cash Price |
$239.14
|
| Rate for Payer: Cofinity Commercial |
$209.24
|
| Rate for Payer: Cofinity Commercial |
$257.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$209.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$239.14
|
| Rate for Payer: Healthscope Commercial |
$269.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$254.08
|
| Rate for Payer: PHP Commercial |
$254.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.30
|
| Rate for Payer: Priority Health SBD |
$188.32
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$298.92
|
|
|
Service Code
|
NDC 31722053712
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.57 |
| Max. Negotiated Rate |
$269.03 |
| Rate for Payer: Aetna Commercial |
$254.08
|
| Rate for Payer: Aetna Medicare |
$149.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$194.30
|
| Rate for Payer: BCBS Complete |
$119.57
|
| Rate for Payer: Cash Price |
$239.14
|
| Rate for Payer: Cofinity Commercial |
$209.24
|
| Rate for Payer: Cofinity Commercial |
$257.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$209.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$239.14
|
| Rate for Payer: Healthscope Commercial |
$269.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$254.08
|
| Rate for Payer: PHP Commercial |
$254.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.30
|
| Rate for Payer: Priority Health SBD |
$188.32
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$4.14
|
|
|
Service Code
|
NDC 60687065711
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.61 |
| Max. Negotiated Rate |
$3.73 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.69
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cofinity Commercial |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$3.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.31
|
| Rate for Payer: Healthscope Commercial |
$3.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.52
|
| Rate for Payer: PHP Commercial |
$3.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.69
|
| Rate for Payer: Priority Health SBD |
$2.61
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$317.25
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.87 |
| Max. Negotiated Rate |
$285.52 |
| Rate for Payer: Aetna Commercial |
$269.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.21
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cofinity Commercial |
$222.07
|
| Rate for Payer: Cofinity Commercial |
$272.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$222.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.80
|
| Rate for Payer: Healthscope Commercial |
$285.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.66
|
| Rate for Payer: PHP Commercial |
$269.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.21
|
| Rate for Payer: Priority Health SBD |
$199.87
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$4.14
|
|
|
Service Code
|
NDC 60687065711
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$3.73 |
| Rate for Payer: Aetna Commercial |
$3.52
|
| Rate for Payer: Aetna Medicare |
$2.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.69
|
| Rate for Payer: BCBS Complete |
$1.66
|
| Rate for Payer: Cash Price |
$3.31
|
| Rate for Payer: Cofinity Commercial |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$3.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.31
|
| Rate for Payer: Healthscope Commercial |
$3.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.52
|
| Rate for Payer: PHP Commercial |
$3.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.69
|
| Rate for Payer: Priority Health SBD |
$2.61
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$259.35
|
|
|
Service Code
|
NDC 51079082120
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.39 |
| Max. Negotiated Rate |
$233.41 |
| Rate for Payer: Aetna Commercial |
$220.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.58
|
| Rate for Payer: Cash Price |
$207.48
|
| Rate for Payer: Cofinity Commercial |
$181.54
|
| Rate for Payer: Cofinity Commercial |
$223.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$181.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$207.48
|
| Rate for Payer: Healthscope Commercial |
$233.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$220.45
|
| Rate for Payer: PHP Commercial |
$220.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.58
|
| Rate for Payer: Priority Health SBD |
$163.39
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 51079082101
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna Commercial |
$2.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.69
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cofinity Commercial |
$1.82
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.08
|
| Rate for Payer: Healthscope Commercial |
$2.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.21
|
| Rate for Payer: PHP Commercial |
$2.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.69
|
| Rate for Payer: Priority Health SBD |
$1.64
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 51079082101
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna Commercial |
$2.21
|
| Rate for Payer: Aetna Medicare |
$1.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.69
|
| Rate for Payer: BCBS Complete |
$1.04
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cofinity Commercial |
$1.82
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.08
|
| Rate for Payer: Healthscope Commercial |
$2.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.21
|
| Rate for Payer: PHP Commercial |
$2.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.69
|
| Rate for Payer: Priority Health SBD |
$1.64
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$259.35
|
|
|
Service Code
|
NDC 51079082120
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.74 |
| Max. Negotiated Rate |
$233.41 |
| Rate for Payer: Aetna Commercial |
$220.45
|
| Rate for Payer: Aetna Medicare |
$129.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.58
|
| Rate for Payer: BCBS Complete |
$103.74
|
| Rate for Payer: Cash Price |
$207.48
|
| Rate for Payer: Cofinity Commercial |
$181.54
|
| Rate for Payer: Cofinity Commercial |
$223.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$181.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$207.48
|
| Rate for Payer: Healthscope Commercial |
$233.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$220.45
|
| Rate for Payer: PHP Commercial |
$220.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.58
|
| Rate for Payer: Priority Health SBD |
$163.39
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$317.25
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.90 |
| Max. Negotiated Rate |
$285.52 |
| Rate for Payer: Aetna Commercial |
$269.66
|
| Rate for Payer: Aetna Medicare |
$158.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.21
|
| Rate for Payer: BCBS Complete |
$126.90
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cofinity Commercial |
$222.07
|
| Rate for Payer: Cofinity Commercial |
$272.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$222.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.80
|
| Rate for Payer: Healthscope Commercial |
$285.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.66
|
| Rate for Payer: PHP Commercial |
$269.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.21
|
| Rate for Payer: Priority Health SBD |
$199.87
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$188.94
|
|
|
Service Code
|
NDC 72205009592
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.58 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna Commercial |
$160.60
|
| Rate for Payer: Aetna Medicare |
$94.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.81
|
| Rate for Payer: BCBS Complete |
$75.58
|
| Rate for Payer: Cash Price |
$151.15
|
| Rate for Payer: Cofinity Commercial |
$132.26
|
| Rate for Payer: Cofinity Commercial |
$162.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$132.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.15
|
| Rate for Payer: Healthscope Commercial |
$170.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.60
|
| Rate for Payer: PHP Commercial |
$160.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.81
|
| Rate for Payer: Priority Health SBD |
$119.03
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 68084087001
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.22 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$166.91
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$166.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.99
|
| Rate for Payer: Priority Health SBD |
$150.22
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$413.60
|
|
|
Service Code
|
NDC 60687065701
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$260.57 |
| Max. Negotiated Rate |
$372.24 |
| Rate for Payer: Aetna Commercial |
$351.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$268.84
|
| Rate for Payer: Cash Price |
$330.88
|
| Rate for Payer: Cofinity Commercial |
$289.52
|
| Rate for Payer: Cofinity Commercial |
$355.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$289.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$330.88
|
| Rate for Payer: Healthscope Commercial |
$372.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$351.56
|
| Rate for Payer: PHP Commercial |
$351.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$268.84
|
| Rate for Payer: Priority Health SBD |
$260.57
|
|
|
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 Commercial |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$187.53
|
| 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: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.13
|
| Rate for Payer: Priority Health SBD |
$168.78
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
OP
|
$267.90
|
|
|
Service Code
|
NDC 65862024708
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.16 |
| 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 Commercial |
$187.53
|
| Rate for Payer: Cofinity Commercial |
$230.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$187.53
|
| 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: PHP Commercial |
$227.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$174.13
|
| Rate for Payer: Priority Health SBD |
$168.78
|
|
|
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 Commercial |
$182.88
|
| Rate for Payer: Cofinity Commercial |
$224.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$182.88
|
| 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: PHP Commercial |
$222.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.81
|
| Rate for Payer: Priority Health SBD |
$164.59
|
|
|
LEVETIRACETAM 750 MG TABLET
|
Facility
|
OP
|
$261.25
|
|
|
Service Code
|
NDC 68084088201
|
| Hospital Charge Code |
26818
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.50 |
| 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 Commercial |
$182.88
|
| Rate for Payer: Cofinity Commercial |
$224.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$182.88
|
| 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: PHP Commercial |
$222.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.81
|
| Rate for Payer: Priority Health SBD |
$164.59
|
|
