|
LAPAROSCOPY, SURGICAL; CHOLECYSTECTOMY WITH CHOLANGIOGRAPHY
|
Facility
|
OP
|
$4,339.88
|
|
|
Service Code
|
CPT 47563
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,132.95 |
| Max. Negotiated Rate |
$4,339.88 |
| Rate for Payer: BCBS Complete |
$4,339.88
|
| Rate for Payer: Mclaren Medicaid |
$4,132.95
|
| Rate for Payer: Meridian Medicaid |
$4,339.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,132.95
|
| Rate for Payer: UHCCP Medicaid |
$4,132.95
|
|
|
LAPAROSCOPY, SURGICAL; REPAIR INITIAL INGUINAL HERNIA
|
Facility
|
OP
|
$4,339.88
|
|
|
Service Code
|
CPT 49650
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,132.95 |
| Max. Negotiated Rate |
$4,339.88 |
| Rate for Payer: BCBS Complete |
$4,339.88
|
| Rate for Payer: Mclaren Medicaid |
$4,132.95
|
| Rate for Payer: Meridian Medicaid |
$4,339.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,132.95
|
| Rate for Payer: UHCCP Medicaid |
$4,132.95
|
|
|
LAPAROSCOPY, SURGICAL; REPAIR RECURRENT INGUINAL HERNIA
|
Facility
|
OP
|
$4,339.88
|
|
|
Service Code
|
CPT 49651
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,132.95 |
| Max. Negotiated Rate |
$4,339.88 |
| Rate for Payer: BCBS Complete |
$4,339.88
|
| Rate for Payer: Mclaren Medicaid |
$4,132.95
|
| Rate for Payer: Meridian Medicaid |
$4,339.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,132.95
|
| Rate for Payer: UHCCP Medicaid |
$4,132.95
|
|
|
LAPAROSCOPY, SURGICAL; WITH REMOVAL OF ADNEXAL STRUCTURES (PARTIAL OR TOTAL OOPHORECTOMY AND/OR SALPINGECTOMY)
|
Facility
|
OP
|
$4,339.88
|
|
|
Service Code
|
CPT 58661
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$4,132.95 |
| Max. Negotiated Rate |
$4,339.88 |
| Rate for Payer: BCBS Complete |
$4,339.88
|
| Rate for Payer: Mclaren Medicaid |
$4,132.95
|
| Rate for Payer: Meridian Medicaid |
$4,339.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$4,132.95
|
| Rate for Payer: UHCCP Medicaid |
$4,132.95
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$18.63
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.11 |
| Max. Negotiated Rate |
$16.77 |
| Rate for Payer: Aetna Commercial |
$15.84
|
| Rate for Payer: BCBS Trust/PPO |
$15.21
|
| Rate for Payer: BCN Commercial |
$14.40
|
| Rate for Payer: Cash Price |
$14.90
|
| Rate for Payer: Cofinity Commercial |
$16.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.90
|
| Rate for Payer: Healthscope Commercial |
$16.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.84
|
| Rate for Payer: Nomi Health Commercial |
$15.28
|
| Rate for Payer: PHP Commercial |
$15.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.11
|
| Rate for Payer: Priority Health HMO/PPO |
$16.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.39
|
| Rate for Payer: UHC Core |
$15.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.97
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
IP
|
$26.46
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.20 |
| Max. Negotiated Rate |
$23.81 |
| Rate for Payer: Aetna Commercial |
$22.49
|
| Rate for Payer: BCBS Trust/PPO |
$21.60
|
| Rate for Payer: BCN Commercial |
$20.45
|
| Rate for Payer: Cash Price |
$21.17
|
| Rate for Payer: Cofinity Commercial |
$22.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.17
|
| Rate for Payer: Healthscope Commercial |
$23.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.49
|
| Rate for Payer: Nomi Health Commercial |
$21.70
|
| Rate for Payer: PHP Commercial |
$22.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.20
|
| Rate for Payer: Priority Health HMO/PPO |
$23.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.28
|
| Rate for Payer: UHC Core |
$22.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.84
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$18.63
|
|
|
Service Code
|
NDC 70069042101
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.42 |
| Max. Negotiated Rate |
$16.77 |
| Rate for Payer: Aetna Commercial |
$15.84
|
| Rate for Payer: Aetna Medicare |
$4.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.82
|
| Rate for Payer: BCBS Complete |
$7.45
|
| Rate for Payer: BCBS MAPPO |
$4.66
|
| Rate for Payer: BCBS Trust/PPO |
$15.32
|
| Rate for Payer: BCN Commercial |
$14.48
|
| Rate for Payer: BCN Medicare Advantage |
$4.66
|
| Rate for Payer: Cash Price |
$14.90
|
| Rate for Payer: Cofinity Commercial |
$16.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.66
|
| Rate for Payer: Healthscope Commercial |
$16.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.97
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.84
|
| Rate for Payer: Nomi Health Commercial |
$15.28
|
| Rate for Payer: PACE Senior Care Partners |
$4.42
|
| Rate for Payer: PACE SWMI |
$4.66
|
| Rate for Payer: PHP Commercial |
$15.84
|
| Rate for Payer: PHP Medicare Advantage |
$4.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.11
|
| Rate for Payer: Priority Health HMO/PPO |
$16.21
|
| Rate for Payer: Priority Health Medicare |
$4.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.48
|
| Rate for Payer: Railroad Medicare Medicare |
$4.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.39
|
| Rate for Payer: UHC Core |
$15.56
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.66
|
| Rate for Payer: UHC Exchange |
$4.66
|
| Rate for Payer: UHC Medicare Advantage |
$4.66
|
| Rate for Payer: VA VA |
$4.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.97
|
|
|
LATANOPROST 0.005 % EYE DROPS
|
Facility
|
OP
|
$26.46
|
|
|
Service Code
|
NDC 61314054701
|
| Hospital Charge Code |
18621
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.28 |
| Max. Negotiated Rate |
$23.81 |
| Rate for Payer: Aetna Commercial |
$22.49
|
| Rate for Payer: Aetna Medicare |
$6.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.27
|
| Rate for Payer: BCBS Complete |
$10.58
|
| Rate for Payer: BCBS MAPPO |
$6.62
|
| Rate for Payer: BCBS Trust/PPO |
$21.75
|
| Rate for Payer: BCN Commercial |
$20.57
|
| Rate for Payer: BCN Medicare Advantage |
$6.62
|
| Rate for Payer: Cash Price |
$21.17
|
| Rate for Payer: Cofinity Commercial |
$22.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$6.62
|
| Rate for Payer: Healthscope Commercial |
$23.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$6.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.49
|
| Rate for Payer: Nomi Health Commercial |
$21.70
|
| Rate for Payer: PACE Senior Care Partners |
$6.28
|
| Rate for Payer: PACE SWMI |
$6.62
|
| Rate for Payer: PHP Commercial |
$22.49
|
| Rate for Payer: PHP Medicare Advantage |
$6.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.20
|
| Rate for Payer: Priority Health HMO/PPO |
$23.02
|
| Rate for Payer: Priority Health Medicare |
$6.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.73
|
| Rate for Payer: Railroad Medicare Medicare |
$6.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$23.28
|
| Rate for Payer: UHC Core |
$22.09
|
| Rate for Payer: UHC Dual Complete DSNP |
$6.62
|
| Rate for Payer: UHC Exchange |
$6.62
|
| Rate for Payer: UHC Medicare Advantage |
$6.62
|
| Rate for Payer: VA VA |
$6.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.84
|
|
|
LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER
|
Facility
|
OP
|
$155.35
|
|
|
Service Code
|
NDC 63402051001
|
| Hospital Charge Code |
43472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.90 |
| Max. Negotiated Rate |
$139.82 |
| Rate for Payer: Aetna Commercial |
$132.05
|
| Rate for Payer: Aetna Medicare |
$40.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$48.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$48.55
|
| Rate for Payer: BCBS Complete |
$62.14
|
| Rate for Payer: BCBS MAPPO |
$38.84
|
| Rate for Payer: BCBS Trust/PPO |
$127.71
|
| Rate for Payer: BCN Commercial |
$120.78
|
| Rate for Payer: BCN Medicare Advantage |
$38.84
|
| Rate for Payer: Cash Price |
$124.28
|
| Rate for Payer: Cofinity Commercial |
$133.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$38.84
|
| Rate for Payer: Healthscope Commercial |
$139.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$40.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$44.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.05
|
| Rate for Payer: Nomi Health Commercial |
$127.39
|
| Rate for Payer: PACE Senior Care Partners |
$36.90
|
| Rate for Payer: PACE SWMI |
$38.84
|
| Rate for Payer: PHP Commercial |
$132.05
|
| Rate for Payer: PHP Medicare Advantage |
$38.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.98
|
| Rate for Payer: Priority Health HMO/PPO |
$135.15
|
| Rate for Payer: Priority Health Medicare |
$39.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$104.08
|
| Rate for Payer: Railroad Medicare Medicare |
$38.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$136.71
|
| Rate for Payer: UHC Core |
$129.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$38.84
|
| Rate for Payer: UHC Exchange |
$38.84
|
| Rate for Payer: UHC Medicare Advantage |
$38.84
|
| Rate for Payer: VA VA |
$38.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.51
|
|
|
LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER
|
Facility
|
IP
|
$155.35
|
|
|
Service Code
|
NDC 63402051001
|
| Hospital Charge Code |
43472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$100.98 |
| Max. Negotiated Rate |
$139.82 |
| Rate for Payer: Aetna Commercial |
$132.05
|
| Rate for Payer: BCBS Trust/PPO |
$126.81
|
| Rate for Payer: BCN Commercial |
$120.05
|
| Rate for Payer: Cash Price |
$124.28
|
| Rate for Payer: Cofinity Commercial |
$133.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.28
|
| Rate for Payer: Healthscope Commercial |
$139.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.05
|
| Rate for Payer: Nomi Health Commercial |
$127.39
|
| Rate for Payer: PHP Commercial |
$132.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.98
|
| Rate for Payer: Priority Health HMO/PPO |
$135.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$104.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$136.71
|
| Rate for Payer: UHC Core |
$129.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.51
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
OP
|
$291.40
|
|
|
Service Code
|
NDC 00904712361
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.21 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna Medicare |
$75.76
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$91.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$91.06
|
| Rate for Payer: BCBS Complete |
$116.56
|
| Rate for Payer: BCBS MAPPO |
$72.85
|
| Rate for Payer: BCBS Trust/PPO |
$239.56
|
| Rate for Payer: BCN Commercial |
$226.56
|
| Rate for Payer: BCN Medicare Advantage |
$72.85
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$72.85
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$76.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$83.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Nomi Health Commercial |
$238.95
|
| Rate for Payer: PACE Senior Care Partners |
$69.21
|
| Rate for Payer: PACE SWMI |
$72.85
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: PHP Medicare Advantage |
$72.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health HMO/PPO |
$253.52
|
| Rate for Payer: Priority Health Medicare |
$73.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$195.24
|
| Rate for Payer: Railroad Medicare Medicare |
$72.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$256.43
|
| Rate for Payer: UHC Core |
$243.32
|
| Rate for Payer: UHC Dual Complete DSNP |
$72.85
|
| Rate for Payer: UHC Exchange |
$72.85
|
| Rate for Payer: UHC Medicare Advantage |
$72.85
|
| Rate for Payer: VA VA |
$72.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 00904712361
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.41 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: BCBS Trust/PPO |
$237.87
|
| Rate for Payer: BCN Commercial |
$225.19
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Nomi Health Commercial |
$238.95
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health HMO/PPO |
$253.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$195.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$256.43
|
| Rate for Payer: UHC Core |
$243.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$12.41
|
|
|
Service Code
|
NDC 00904726592
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$11.17 |
| Rate for Payer: Aetna Commercial |
$10.55
|
| Rate for Payer: BCBS Trust/PPO |
$10.13
|
| Rate for Payer: BCN Commercial |
$9.59
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cofinity Commercial |
$10.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.93
|
| Rate for Payer: Healthscope Commercial |
$11.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.55
|
| Rate for Payer: Nomi Health Commercial |
$10.18
|
| Rate for Payer: PHP Commercial |
$10.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.07
|
| Rate for Payer: Priority Health HMO/PPO |
$10.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.92
|
| Rate for Payer: UHC Core |
$10.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.31
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
OP
|
$12.41
|
|
|
Service Code
|
NDC 00904726592
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$11.17 |
| Rate for Payer: Aetna Commercial |
$10.55
|
| Rate for Payer: Aetna Medicare |
$3.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.88
|
| Rate for Payer: BCBS Complete |
$4.96
|
| Rate for Payer: BCBS MAPPO |
$3.10
|
| Rate for Payer: BCBS Trust/PPO |
$10.20
|
| Rate for Payer: BCN Commercial |
$9.65
|
| Rate for Payer: BCN Medicare Advantage |
$3.10
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cofinity Commercial |
$10.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$11.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.55
|
| Rate for Payer: Nomi Health Commercial |
$10.18
|
| Rate for Payer: PACE Senior Care Partners |
$2.95
|
| Rate for Payer: PACE SWMI |
$3.10
|
| Rate for Payer: PHP Commercial |
$10.55
|
| Rate for Payer: PHP Medicare Advantage |
$3.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.07
|
| Rate for Payer: Priority Health HMO/PPO |
$10.80
|
| Rate for Payer: Priority Health Medicare |
$3.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.31
|
| Rate for Payer: Railroad Medicare Medicare |
$3.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.92
|
| Rate for Payer: UHC Core |
$10.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.10
|
| Rate for Payer: UHC Exchange |
$3.10
|
| Rate for Payer: UHC Medicare Advantage |
$3.10
|
| Rate for Payer: VA VA |
$3.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.31
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
OP
|
$12.41
|
|
|
Service Code
|
NDC 00904726541
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.95 |
| Max. Negotiated Rate |
$11.17 |
| Rate for Payer: Aetna Commercial |
$10.55
|
| Rate for Payer: Aetna Medicare |
$3.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.88
|
| Rate for Payer: BCBS Complete |
$4.96
|
| Rate for Payer: BCBS MAPPO |
$3.10
|
| Rate for Payer: BCBS Trust/PPO |
$10.20
|
| Rate for Payer: BCN Commercial |
$9.65
|
| Rate for Payer: BCN Medicare Advantage |
$3.10
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cofinity Commercial |
$10.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.93
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$11.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.31
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.55
|
| Rate for Payer: Nomi Health Commercial |
$10.18
|
| Rate for Payer: PACE Senior Care Partners |
$2.95
|
| Rate for Payer: PACE SWMI |
$3.10
|
| Rate for Payer: PHP Commercial |
$10.55
|
| Rate for Payer: PHP Medicare Advantage |
$3.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.07
|
| Rate for Payer: Priority Health HMO/PPO |
$10.80
|
| Rate for Payer: Priority Health Medicare |
$3.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.31
|
| Rate for Payer: Railroad Medicare Medicare |
$3.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.92
|
| Rate for Payer: UHC Core |
$10.36
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.10
|
| Rate for Payer: UHC Exchange |
$3.10
|
| Rate for Payer: UHC Medicare Advantage |
$3.10
|
| Rate for Payer: VA VA |
$3.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.31
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$12.41
|
|
|
Service Code
|
NDC 00904726541
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$11.17 |
| Rate for Payer: Aetna Commercial |
$10.55
|
| Rate for Payer: BCBS Trust/PPO |
$10.13
|
| Rate for Payer: BCN Commercial |
$9.59
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cofinity Commercial |
$10.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.93
|
| Rate for Payer: Healthscope Commercial |
$11.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.55
|
| Rate for Payer: Nomi Health Commercial |
$10.18
|
| Rate for Payer: PHP Commercial |
$10.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.07
|
| Rate for Payer: Priority Health HMO/PPO |
$10.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$8.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.92
|
| Rate for Payer: UHC Core |
$10.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.31
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$14.36
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
77195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.41 |
| Max. Negotiated Rate |
$12.92 |
| Rate for Payer: Aetna Commercial |
$12.21
|
| Rate for Payer: Aetna Commercial |
$24.28
|
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Aetna Commercial |
$14.98
|
| Rate for Payer: Aetna Medicare |
$4.58
|
| Rate for Payer: Aetna Medicare |
$3.73
|
| Rate for Payer: Aetna Medicare |
$5.36
|
| Rate for Payer: Aetna Medicare |
$7.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.93
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.93
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.44
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.49
|
| Rate for Payer: BCBS Complete |
$5.74
|
| Rate for Payer: BCBS Complete |
$7.05
|
| Rate for Payer: BCBS Complete |
$11.43
|
| Rate for Payer: BCBS Complete |
$8.24
|
| Rate for Payer: BCBS MAPPO |
$3.59
|
| Rate for Payer: BCBS MAPPO |
$4.40
|
| Rate for Payer: BCBS MAPPO |
$7.14
|
| Rate for Payer: BCBS MAPPO |
$5.15
|
| Rate for Payer: BCBS Trust/PPO |
$11.81
|
| Rate for Payer: BCBS Trust/PPO |
$23.49
|
| Rate for Payer: BCBS Trust/PPO |
$14.49
|
| Rate for Payer: BCBS Trust/PPO |
$16.94
|
| Rate for Payer: BCN Commercial |
$11.16
|
| Rate for Payer: BCN Commercial |
$16.02
|
| Rate for Payer: BCN Commercial |
$13.70
|
| Rate for Payer: BCN Commercial |
$22.21
|
| Rate for Payer: BCN Medicare Advantage |
$4.40
|
| Rate for Payer: BCN Medicare Advantage |
$7.14
|
| Rate for Payer: BCN Medicare Advantage |
$3.59
|
| Rate for Payer: BCN Medicare Advantage |
$5.15
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$22.86
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cofinity Commercial |
$24.57
|
| Rate for Payer: Cofinity Commercial |
$15.15
|
| Rate for Payer: Cofinity Commercial |
$12.35
|
| Rate for Payer: Cofinity Commercial |
$17.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3.59
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.15
|
| Rate for Payer: Healthscope Commercial |
$12.92
|
| Rate for Payer: Healthscope Commercial |
$25.71
|
| Rate for Payer: Healthscope Commercial |
$18.55
|
| Rate for Payer: Healthscope Commercial |
$15.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.46
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.77
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.63
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.21
|
| 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 |
$14.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.52
|
| Rate for Payer: Nomi Health Commercial |
$16.90
|
| Rate for Payer: Nomi Health Commercial |
$23.43
|
| Rate for Payer: Nomi Health Commercial |
$11.78
|
| Rate for Payer: Nomi Health Commercial |
$14.45
|
| Rate for Payer: PACE Senior Care Partners |
$3.41
|
| Rate for Payer: PACE Senior Care Partners |
$4.89
|
| Rate for Payer: PACE Senior Care Partners |
$6.79
|
| Rate for Payer: PACE Senior Care Partners |
$4.18
|
| Rate for Payer: PACE SWMI |
$4.40
|
| Rate for Payer: PACE SWMI |
$3.59
|
| Rate for Payer: PACE SWMI |
$5.15
|
| Rate for Payer: PACE SWMI |
$7.14
|
| Rate for Payer: PHP Commercial |
$17.52
|
| Rate for Payer: PHP Commercial |
$24.28
|
| Rate for Payer: PHP Commercial |
$14.98
|
| Rate for Payer: PHP Commercial |
$12.21
|
| Rate for Payer: PHP Medicare Advantage |
$4.40
|
| Rate for Payer: PHP Medicare Advantage |
$3.59
|
| Rate for Payer: PHP Medicare Advantage |
$7.14
|
| Rate for Payer: PHP Medicare Advantage |
$5.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.40
|
| 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 HMO/PPO |
$15.33
|
| Rate for Payer: Priority Health HMO/PPO |
$24.86
|
| Rate for Payer: Priority Health HMO/PPO |
$17.93
|
| Rate for Payer: Priority Health HMO/PPO |
$12.49
|
| Rate for Payer: Priority Health Medicare |
$5.20
|
| Rate for Payer: Priority Health Medicare |
$3.63
|
| Rate for Payer: Priority Health Medicare |
$4.45
|
| Rate for Payer: Priority Health Medicare |
$7.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.62
|
| Rate for Payer: Railroad Medicare Medicare |
$4.40
|
| Rate for Payer: Railroad Medicare Medicare |
$5.15
|
| Rate for Payer: Railroad Medicare Medicare |
$3.59
|
| Rate for Payer: Railroad Medicare Medicare |
$7.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.51
|
| Rate for Payer: UHC Core |
$11.99
|
| Rate for Payer: UHC Core |
$23.86
|
| Rate for Payer: UHC Core |
$14.71
|
| Rate for Payer: UHC Core |
$17.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.15
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.40
|
| Rate for Payer: UHC Exchange |
$7.14
|
| Rate for Payer: UHC Exchange |
$4.40
|
| Rate for Payer: UHC Exchange |
$3.59
|
| Rate for Payer: UHC Exchange |
$5.15
|
| Rate for Payer: UHC Medicare Advantage |
$7.14
|
| Rate for Payer: UHC Medicare Advantage |
$3.59
|
| Rate for Payer: UHC Medicare Advantage |
$5.15
|
| Rate for Payer: UHC Medicare Advantage |
$4.40
|
| Rate for Payer: VA VA |
$4.40
|
| Rate for Payer: VA VA |
$7.14
|
| Rate for Payer: VA VA |
$5.15
|
| Rate for Payer: VA VA |
$3.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.46
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$20.61
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
77195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.40 |
| Max. Negotiated Rate |
$18.55 |
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Aetna Commercial |
$14.98
|
| Rate for Payer: Aetna Commercial |
$12.21
|
| Rate for Payer: Aetna Commercial |
$24.28
|
| Rate for Payer: BCBS Trust/PPO |
$16.82
|
| Rate for Payer: BCBS Trust/PPO |
$23.32
|
| Rate for Payer: BCBS Trust/PPO |
$14.38
|
| Rate for Payer: BCBS Trust/PPO |
$11.72
|
| Rate for Payer: BCN Commercial |
$15.93
|
| Rate for Payer: BCN Commercial |
$11.10
|
| Rate for Payer: BCN Commercial |
$22.08
|
| Rate for Payer: BCN Commercial |
$13.62
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cash Price |
$22.86
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cofinity Commercial |
$12.35
|
| Rate for Payer: Cofinity Commercial |
$24.57
|
| Rate for Payer: Cofinity Commercial |
$17.72
|
| Rate for Payer: Cofinity Commercial |
$15.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.86
|
| Rate for Payer: Healthscope Commercial |
$25.71
|
| Rate for Payer: Healthscope Commercial |
$15.86
|
| Rate for Payer: Healthscope Commercial |
$18.55
|
| Rate for Payer: Healthscope Commercial |
$12.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.28
|
| Rate for Payer: Nomi Health Commercial |
$11.78
|
| Rate for Payer: Nomi Health Commercial |
$14.45
|
| Rate for Payer: Nomi Health Commercial |
$23.43
|
| Rate for Payer: Nomi Health Commercial |
$16.90
|
| Rate for Payer: PHP Commercial |
$14.98
|
| Rate for Payer: PHP Commercial |
$12.21
|
| Rate for Payer: PHP Commercial |
$17.52
|
| Rate for Payer: PHP Commercial |
$24.28
|
| 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 |
$11.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.40
|
| Rate for Payer: Priority Health HMO/PPO |
$17.93
|
| Rate for Payer: Priority Health HMO/PPO |
$24.86
|
| Rate for Payer: Priority Health HMO/PPO |
$12.49
|
| Rate for Payer: Priority Health HMO/PPO |
$15.33
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.14
|
| Rate for Payer: UHC Core |
$17.21
|
| Rate for Payer: UHC Core |
$23.86
|
| Rate for Payer: UHC Core |
$14.71
|
| Rate for Payer: UHC Core |
$11.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.46
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 51079082101
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna Commercial |
$2.21
|
| Rate for Payer: Aetna Medicare |
$0.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.81
|
| Rate for Payer: BCBS Complete |
$1.04
|
| Rate for Payer: BCBS MAPPO |
$0.65
|
| Rate for Payer: BCBS Trust/PPO |
$2.14
|
| Rate for Payer: BCN Commercial |
$2.02
|
| Rate for Payer: BCN Medicare Advantage |
$0.65
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.08
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.65
|
| Rate for Payer: Healthscope Commercial |
$2.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.21
|
| Rate for Payer: Nomi Health Commercial |
$2.13
|
| Rate for Payer: PACE Senior Care Partners |
$0.62
|
| Rate for Payer: PACE SWMI |
$0.65
|
| Rate for Payer: PHP Commercial |
$2.21
|
| Rate for Payer: PHP Medicare Advantage |
$0.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.69
|
| Rate for Payer: Priority Health HMO/PPO |
$2.26
|
| Rate for Payer: Priority Health Medicare |
$0.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.74
|
| Rate for Payer: Railroad Medicare Medicare |
$0.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.29
|
| Rate for Payer: UHC Core |
$2.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.65
|
| Rate for Payer: UHC Exchange |
$0.65
|
| Rate for Payer: UHC Medicare Advantage |
$0.65
|
| Rate for Payer: VA VA |
$0.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.95
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 51079082101
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna Commercial |
$2.21
|
| Rate for Payer: BCBS Trust/PPO |
$2.12
|
| Rate for Payer: BCN Commercial |
$2.01
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.08
|
| Rate for Payer: Healthscope Commercial |
$2.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.21
|
| Rate for Payer: Nomi Health Commercial |
$2.13
|
| Rate for Payer: PHP Commercial |
$2.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.69
|
| Rate for Payer: Priority Health HMO/PPO |
$2.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.29
|
| Rate for Payer: UHC Core |
$2.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.95
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$259.35
|
|
|
Service Code
|
NDC 51079082120
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.60 |
| Max. Negotiated Rate |
$233.42 |
| Rate for Payer: Aetna Commercial |
$220.45
|
| Rate for Payer: Aetna Medicare |
$67.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$81.05
|
| Rate for Payer: Amish Plain Church Group Commercial |
$81.05
|
| Rate for Payer: BCBS Complete |
$103.74
|
| Rate for Payer: BCBS MAPPO |
$64.84
|
| Rate for Payer: BCBS Trust/PPO |
$213.21
|
| Rate for Payer: BCN Commercial |
$201.64
|
| Rate for Payer: BCN Medicare Advantage |
$64.84
|
| Rate for Payer: Cash Price |
$207.48
|
| Rate for Payer: Cofinity Commercial |
$223.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$207.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$64.84
|
| Rate for Payer: Healthscope Commercial |
$233.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$194.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$68.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$74.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$220.45
|
| Rate for Payer: Nomi Health Commercial |
$212.67
|
| Rate for Payer: PACE Senior Care Partners |
$61.60
|
| Rate for Payer: PACE SWMI |
$64.84
|
| Rate for Payer: PHP Commercial |
$220.45
|
| Rate for Payer: PHP Medicare Advantage |
$64.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.58
|
| Rate for Payer: Priority Health HMO/PPO |
$225.63
|
| Rate for Payer: Priority Health Medicare |
$65.49
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$173.76
|
| Rate for Payer: Railroad Medicare Medicare |
$64.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$228.23
|
| Rate for Payer: UHC Core |
$216.56
|
| Rate for Payer: UHC Dual Complete DSNP |
$64.84
|
| Rate for Payer: UHC Exchange |
$64.84
|
| Rate for Payer: UHC Medicare Advantage |
$64.84
|
| Rate for Payer: VA VA |
$64.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$194.51
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$317.25
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.21 |
| Max. Negotiated Rate |
$285.52 |
| Rate for Payer: Aetna Commercial |
$269.66
|
| Rate for Payer: BCBS Trust/PPO |
$258.97
|
| Rate for Payer: BCN Commercial |
$245.17
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cofinity Commercial |
$272.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.80
|
| Rate for Payer: Healthscope Commercial |
$285.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$237.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.66
|
| Rate for Payer: Nomi Health Commercial |
$260.14
|
| Rate for Payer: PHP Commercial |
$269.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.21
|
| Rate for Payer: Priority Health HMO/PPO |
$276.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$212.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$279.18
|
| Rate for Payer: UHC Core |
$264.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$237.94
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$259.35
|
|
|
Service Code
|
NDC 51079082120
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.58 |
| Max. Negotiated Rate |
$233.42 |
| Rate for Payer: Aetna Commercial |
$220.45
|
| Rate for Payer: BCBS Trust/PPO |
$211.71
|
| Rate for Payer: BCN Commercial |
$200.43
|
| Rate for Payer: Cash Price |
$207.48
|
| Rate for Payer: Cofinity Commercial |
$223.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$207.48
|
| Rate for Payer: Healthscope Commercial |
$233.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$194.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$220.45
|
| Rate for Payer: Nomi Health Commercial |
$212.67
|
| Rate for Payer: PHP Commercial |
$220.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.58
|
| Rate for Payer: Priority Health HMO/PPO |
$225.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$173.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$228.23
|
| Rate for Payer: UHC Core |
$216.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$194.51
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$317.25
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.35 |
| Max. Negotiated Rate |
$285.52 |
| Rate for Payer: Aetna Commercial |
$269.66
|
| Rate for Payer: Aetna Medicare |
$82.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$99.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$99.14
|
| Rate for Payer: BCBS Complete |
$126.90
|
| Rate for Payer: BCBS MAPPO |
$79.31
|
| Rate for Payer: BCBS Trust/PPO |
$260.81
|
| Rate for Payer: BCN Commercial |
$246.66
|
| Rate for Payer: BCN Medicare Advantage |
$79.31
|
| Rate for Payer: Cash Price |
$253.80
|
| Rate for Payer: Cofinity Commercial |
$272.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$253.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$79.31
|
| Rate for Payer: Healthscope Commercial |
$285.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$237.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$83.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$91.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$269.66
|
| Rate for Payer: Nomi Health Commercial |
$260.14
|
| Rate for Payer: PACE Senior Care Partners |
$75.35
|
| Rate for Payer: PACE SWMI |
$79.31
|
| Rate for Payer: PHP Commercial |
$269.66
|
| Rate for Payer: PHP Medicare Advantage |
$79.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.21
|
| Rate for Payer: Priority Health HMO/PPO |
$276.01
|
| Rate for Payer: Priority Health Medicare |
$80.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$212.56
|
| Rate for Payer: Railroad Medicare Medicare |
$79.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$279.18
|
| Rate for Payer: UHC Core |
$264.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$79.31
|
| Rate for Payer: UHC Exchange |
$79.31
|
| Rate for Payer: UHC Medicare Advantage |
$79.31
|
| Rate for Payer: VA VA |
$79.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$237.94
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$59.02
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$38.36 |
| Max. Negotiated Rate |
$53.12 |
| Rate for Payer: Aetna Commercial |
$50.17
|
| Rate for Payer: Aetna Commercial |
$53.30
|
| Rate for Payer: BCBS Trust/PPO |
$48.18
|
| Rate for Payer: BCBS Trust/PPO |
$51.19
|
| Rate for Payer: BCN Commercial |
$45.61
|
| Rate for Payer: BCN Commercial |
$48.46
|
| Rate for Payer: Cash Price |
$47.22
|
| Rate for Payer: Cash Price |
$50.17
|
| Rate for Payer: Cofinity Commercial |
$53.93
|
| Rate for Payer: Cofinity Commercial |
$50.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.22
|
| Rate for Payer: Healthscope Commercial |
$53.12
|
| Rate for Payer: Healthscope Commercial |
$56.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.30
|
| Rate for Payer: Nomi Health Commercial |
$48.40
|
| Rate for Payer: Nomi Health Commercial |
$51.42
|
| Rate for Payer: PHP Commercial |
$50.17
|
| Rate for Payer: PHP Commercial |
$53.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.36
|
| Rate for Payer: Priority Health HMO/PPO |
$54.56
|
| Rate for Payer: Priority Health HMO/PPO |
$51.35
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$39.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.18
|
| Rate for Payer: UHC Core |
$49.28
|
| Rate for Payer: UHC Core |
$52.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.03
|
|
