|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$352.50
|
|
|
Service Code
|
NDC 63739-795-10
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$155.10 |
| Max. Negotiated Rate |
$317.25 |
| Rate for Payer: Aetna American Axle |
$229.12
|
| Rate for Payer: Aetna Commercial |
$299.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$229.12
|
| Rate for Payer: Cash Price |
$282.00
|
| Rate for Payer: Cofinity Commercial |
$246.75
|
| Rate for Payer: Cofinity Commercial |
$303.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$282.00
|
| Rate for Payer: Healthscope Commercial |
$317.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$246.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$264.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$299.62
|
| Rate for Payer: PHP Commercial |
$299.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$246.75
|
| Rate for Payer: Priority Health SBD |
$222.08
|
| Rate for Payer: UMR Bronson Commercial |
$155.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$264.38
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$3.46
|
|
|
Service Code
|
NDC 68084-859-11
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Aetna American Axle |
$2.25
|
| 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: Encore Health Key Benefits Commercial |
$2.77
|
| Rate for Payer: Healthscope Commercial |
$3.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.94
|
| Rate for Payer: PHP Commercial |
$2.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.42
|
| Rate for Payer: Priority Health SBD |
$2.18
|
| Rate for Payer: UMR Bronson Commercial |
$1.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.60
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$327.12
|
|
|
Service Code
|
NDC 42385-954-12
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.93 |
| Max. Negotiated Rate |
$294.41 |
| Rate for Payer: Aetna American Axle |
$212.63
|
| Rate for Payer: Aetna Commercial |
$278.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.63
|
| Rate for Payer: Cash Price |
$261.70
|
| Rate for Payer: Cofinity Commercial |
$228.98
|
| Rate for Payer: Cofinity Commercial |
$281.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.70
|
| Rate for Payer: Healthscope Commercial |
$294.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$228.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$245.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$278.05
|
| Rate for Payer: PHP Commercial |
$278.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.98
|
| Rate for Payer: Priority Health SBD |
$206.09
|
| Rate for Payer: UMR Bronson Commercial |
$143.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.34
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$14.36
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
77195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.32 |
| Max. Negotiated Rate |
$12.92 |
| Rate for Payer: Aetna American Axle |
$9.33
|
| Rate for Payer: Aetna American Axle |
$16.11
|
| Rate for Payer: Aetna American Axle |
$11.45
|
| Rate for Payer: Aetna American Axle |
$48.84
|
| Rate for Payer: Aetna American Axle |
$17.53
|
| Rate for Payer: Aetna American Axle |
$10.08
|
| Rate for Payer: Aetna American Axle |
$9.99
|
| Rate for Payer: Aetna American Axle |
$17.37
|
| Rate for Payer: Aetna American Axle |
$142.85
|
| Rate for Payer: Aetna American Axle |
$13.40
|
| Rate for Payer: Aetna American Axle |
$12.82
|
| Rate for Payer: Aetna American Axle |
$9.94
|
| Rate for Payer: Aetna Commercial |
$13.18
|
| Rate for Payer: Aetna Commercial |
$13.06
|
| Rate for Payer: Aetna Commercial |
$12.21
|
| Rate for Payer: Aetna Commercial |
$22.71
|
| Rate for Payer: Aetna Commercial |
$21.07
|
| Rate for Payer: Aetna Commercial |
$22.92
|
| Rate for Payer: Aetna Commercial |
$186.80
|
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Aetna Commercial |
$16.76
|
| Rate for Payer: Aetna Commercial |
$13.00
|
| Rate for Payer: Aetna Commercial |
$14.98
|
| Rate for Payer: Aetna Commercial |
$63.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.11
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$60.11
|
| Rate for Payer: Cash Price |
$15.78
|
| Rate for Payer: Cash Price |
$21.58
|
| Rate for Payer: Cash Price |
$12.23
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cash Price |
$19.83
|
| Rate for Payer: Cash Price |
$175.82
|
| Rate for Payer: Cash Price |
$21.38
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cofinity Commercial |
$13.22
|
| Rate for Payer: Cofinity Commercial |
$18.88
|
| Rate for Payer: Cofinity Commercial |
$23.19
|
| Rate for Payer: Cofinity Commercial |
$17.72
|
| Rate for Payer: Cofinity Commercial |
$14.43
|
| Rate for Payer: Cofinity Commercial |
$10.76
|
| Rate for Payer: Cofinity Commercial |
$13.15
|
| Rate for Payer: Cofinity Commercial |
$10.70
|
| Rate for Payer: Cofinity Commercial |
$12.33
|
| Rate for Payer: Cofinity Commercial |
$15.15
|
| Rate for Payer: Cofinity Commercial |
$21.32
|
| Rate for Payer: Cofinity Commercial |
$18.70
|
| Rate for Payer: Cofinity Commercial |
$10.05
|
| Rate for Payer: Cofinity Commercial |
$16.96
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Commercial |
$22.98
|
| Rate for Payer: Cofinity Commercial |
$17.35
|
| Rate for Payer: Cofinity Commercial |
$12.35
|
| Rate for Payer: Cofinity Commercial |
$64.62
|
| Rate for Payer: Cofinity Commercial |
$52.60
|
| Rate for Payer: Cofinity Commercial |
$189.00
|
| Rate for Payer: Cofinity Commercial |
$153.84
|
| Rate for Payer: Cofinity Commercial |
$10.86
|
| Rate for Payer: Cofinity Commercial |
$13.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$175.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.11
|
| Rate for Payer: Healthscope Commercial |
$197.79
|
| Rate for Payer: Healthscope Commercial |
$24.05
|
| Rate for Payer: Healthscope Commercial |
$12.92
|
| Rate for Payer: Healthscope Commercial |
$24.27
|
| Rate for Payer: Healthscope Commercial |
$67.63
|
| Rate for Payer: Healthscope Commercial |
$15.86
|
| Rate for Payer: Healthscope Commercial |
$13.83
|
| Rate for Payer: Healthscope Commercial |
$18.55
|
| Rate for Payer: Healthscope Commercial |
$17.75
|
| Rate for Payer: Healthscope Commercial |
$22.31
|
| Rate for Payer: Healthscope Commercial |
$13.96
|
| Rate for Payer: Healthscope Commercial |
$13.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$153.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$164.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$186.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.87
|
| Rate for Payer: PHP Commercial |
$22.71
|
| Rate for Payer: PHP Commercial |
$12.21
|
| Rate for Payer: PHP Commercial |
$17.52
|
| Rate for Payer: PHP Commercial |
$13.00
|
| Rate for Payer: PHP Commercial |
$13.18
|
| Rate for Payer: PHP Commercial |
$22.92
|
| Rate for Payer: PHP Commercial |
$21.07
|
| Rate for Payer: PHP Commercial |
$63.87
|
| Rate for Payer: PHP Commercial |
$16.76
|
| Rate for Payer: PHP Commercial |
$186.80
|
| Rate for Payer: PHP Commercial |
$13.06
|
| Rate for Payer: PHP Commercial |
$14.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$153.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.60
|
| Rate for Payer: Priority Health SBD |
$12.42
|
| Rate for Payer: Priority Health SBD |
$16.99
|
| Rate for Payer: Priority Health SBD |
$9.63
|
| Rate for Payer: Priority Health SBD |
$11.10
|
| Rate for Payer: Priority Health SBD |
$15.62
|
| Rate for Payer: Priority Health SBD |
$47.34
|
| Rate for Payer: Priority Health SBD |
$138.46
|
| Rate for Payer: Priority Health SBD |
$9.68
|
| Rate for Payer: Priority Health SBD |
$9.05
|
| Rate for Payer: Priority Health SBD |
$12.98
|
| Rate for Payer: Priority Health SBD |
$9.77
|
| Rate for Payer: Priority Health SBD |
$16.83
|
| Rate for Payer: UMR Bronson Commercial |
$11.76
|
| Rate for Payer: UMR Bronson Commercial |
$96.70
|
| Rate for Payer: UMR Bronson Commercial |
$9.07
|
| Rate for Payer: UMR Bronson Commercial |
$8.68
|
| Rate for Payer: UMR Bronson Commercial |
$7.75
|
| Rate for Payer: UMR Bronson Commercial |
$11.87
|
| Rate for Payer: UMR Bronson Commercial |
$6.82
|
| Rate for Payer: UMR Bronson Commercial |
$6.76
|
| Rate for Payer: UMR Bronson Commercial |
$6.73
|
| Rate for Payer: UMR Bronson Commercial |
$6.32
|
| Rate for Payer: UMR Bronson Commercial |
$10.91
|
| Rate for Payer: UMR Bronson Commercial |
$33.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$164.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.59
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$257.45
|
|
|
Service Code
|
NDC 51079-821-20
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.28 |
| Max. Negotiated Rate |
$231.70 |
| Rate for Payer: Aetna American Axle |
$167.34
|
| Rate for Payer: Aetna Commercial |
$218.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.34
|
| Rate for Payer: Cash Price |
$205.96
|
| Rate for Payer: Cofinity Commercial |
$180.22
|
| Rate for Payer: Cofinity Commercial |
$221.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.96
|
| Rate for Payer: Healthscope Commercial |
$231.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$218.83
|
| Rate for Payer: PHP Commercial |
$218.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$180.22
|
| Rate for Payer: Priority Health SBD |
$162.19
|
| Rate for Payer: UMR Bronson Commercial |
$113.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.09
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$188.94
|
|
|
Service Code
|
NDC 65862-246-08
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.13 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna American Axle |
$122.81
|
| 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: Encore Health Key Benefits Commercial |
$151.15
|
| Rate for Payer: Healthscope Commercial |
$170.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$132.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$160.60
|
| Rate for Payer: PHP Commercial |
$160.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.26
|
| Rate for Payer: Priority Health SBD |
$119.03
|
| Rate for Payer: UMR Bronson Commercial |
$83.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.70
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$2.58
|
|
|
Service Code
|
NDC 51079-821-01
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$2.32 |
| Rate for Payer: Aetna American Axle |
$1.68
|
| Rate for Payer: Aetna Commercial |
$2.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.68
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$1.81
|
| Rate for Payer: Cofinity Commercial |
$2.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.19
|
| Rate for Payer: PHP Commercial |
$2.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.81
|
| Rate for Payer: Priority Health SBD |
$1.63
|
| Rate for Payer: UMR Bronson Commercial |
$1.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.94
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$394.80
|
|
|
Service Code
|
NDC 16571-788-12
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$173.71 |
| Max. Negotiated Rate |
$355.32 |
| Rate for Payer: Aetna American Axle |
$256.62
|
| Rate for Payer: Aetna Commercial |
$335.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$256.62
|
| Rate for Payer: Cash Price |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$339.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$315.84
|
| Rate for Payer: Healthscope Commercial |
$355.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$276.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$296.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$335.58
|
| Rate for Payer: PHP Commercial |
$335.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.36
|
| Rate for Payer: Priority Health SBD |
$248.72
|
| Rate for Payer: UMR Bronson Commercial |
$173.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$296.10
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$238.26
|
|
|
Service Code
|
NDC 42385-955-12
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.83 |
| Max. Negotiated Rate |
$214.43 |
| Rate for Payer: Aetna American Axle |
$154.87
|
| Rate for Payer: Aetna Commercial |
$202.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.87
|
| Rate for Payer: Cash Price |
$190.61
|
| Rate for Payer: Cofinity Commercial |
$166.78
|
| Rate for Payer: Cofinity Commercial |
$204.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.61
|
| Rate for Payer: Healthscope Commercial |
$214.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.52
|
| Rate for Payer: PHP Commercial |
$202.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.78
|
| Rate for Payer: Priority Health SBD |
$150.10
|
| Rate for Payer: UMR Bronson Commercial |
$104.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.70
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$371.30
|
|
|
Service Code
|
NDC 63739-411-10
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.37 |
| Max. Negotiated Rate |
$334.17 |
| Rate for Payer: Aetna American Axle |
$241.34
|
| Rate for Payer: Aetna Commercial |
$315.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.34
|
| Rate for Payer: Cash Price |
$297.04
|
| Rate for Payer: Cofinity Commercial |
$259.91
|
| Rate for Payer: Cofinity Commercial |
$319.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.04
|
| Rate for Payer: Healthscope Commercial |
$334.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$259.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$315.60
|
| Rate for Payer: PHP Commercial |
$315.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$259.91
|
| Rate for Payer: Priority Health SBD |
$233.92
|
| Rate for Payer: UMR Bronson Commercial |
$163.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.48
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$279.65
|
|
|
Service Code
|
NDC 0904-6052-61
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.05 |
| Max. Negotiated Rate |
$251.68 |
| Rate for Payer: Aetna American Axle |
$181.77
|
| Rate for Payer: Aetna Commercial |
$237.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$181.77
|
| Rate for Payer: Cash Price |
$223.72
|
| Rate for Payer: Cofinity Commercial |
$195.76
|
| Rate for Payer: Cofinity Commercial |
$240.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.72
|
| Rate for Payer: Healthscope Commercial |
$251.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$195.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$209.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$237.70
|
| Rate for Payer: PHP Commercial |
$237.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.76
|
| Rate for Payer: Priority Health SBD |
$176.18
|
| Rate for Payer: UMR Bronson Commercial |
$123.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$209.74
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$361.38
|
|
|
Service Code
|
NDC 71930-063-15
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.01 |
| Max. Negotiated Rate |
$325.24 |
| Rate for Payer: Aetna American Axle |
$234.90
|
| Rate for Payer: Aetna Commercial |
$307.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$234.90
|
| Rate for Payer: Cash Price |
$289.10
|
| Rate for Payer: Cofinity Commercial |
$252.97
|
| Rate for Payer: Cofinity Commercial |
$310.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$289.10
|
| Rate for Payer: Healthscope Commercial |
$325.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$252.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$271.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$307.17
|
| Rate for Payer: PHP Commercial |
$307.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$252.97
|
| Rate for Payer: Priority Health SBD |
$227.67
|
| Rate for Payer: UMR Bronson Commercial |
$159.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$271.04
|
|
|
LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$221.16
|
|
|
Service Code
|
NDC 68180-117-07
|
| Hospital Charge Code |
93834
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.31 |
| Max. Negotiated Rate |
$199.04 |
| Rate for Payer: Aetna American Axle |
$143.75
|
| Rate for Payer: Aetna Commercial |
$187.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.75
|
| Rate for Payer: Cash Price |
$176.93
|
| Rate for Payer: Cofinity Commercial |
$154.81
|
| Rate for Payer: Cofinity Commercial |
$190.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.93
|
| Rate for Payer: Healthscope Commercial |
$199.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$154.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$165.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$187.99
|
| Rate for Payer: PHP Commercial |
$187.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.81
|
| Rate for Payer: Priority Health SBD |
$139.33
|
| Rate for Payer: UMR Bronson Commercial |
$97.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$165.87
|
|
|
LEVOBUNOLOL 0.5 % EYE DROPS
|
Facility
|
IP
|
$16.02
|
|
|
Service Code
|
NDC 24208-505-05
|
| Hospital Charge Code |
10394
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.05 |
| Max. Negotiated Rate |
$14.42 |
| Rate for Payer: Aetna American Axle |
$10.41
|
| Rate for Payer: Aetna Commercial |
$13.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.41
|
| Rate for Payer: Cash Price |
$12.82
|
| Rate for Payer: Cofinity Commercial |
$11.21
|
| Rate for Payer: Cofinity Commercial |
$13.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.82
|
| Rate for Payer: Healthscope Commercial |
$14.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.62
|
| Rate for Payer: PHP Commercial |
$13.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.21
|
| Rate for Payer: Priority Health SBD |
$10.09
|
| Rate for Payer: UMR Bronson Commercial |
$7.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.02
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$271.29
|
|
|
Service Code
|
NDC 70954-140-10
|
| Hospital Charge Code |
108122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.37 |
| Max. Negotiated Rate |
$244.16 |
| Rate for Payer: Aetna American Axle |
$176.34
|
| Rate for Payer: Aetna Commercial |
$230.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$176.34
|
| Rate for Payer: Cash Price |
$217.03
|
| Rate for Payer: Cofinity Commercial |
$189.90
|
| Rate for Payer: Cofinity Commercial |
$233.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$217.03
|
| Rate for Payer: Healthscope Commercial |
$244.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$189.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$203.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$230.60
|
| Rate for Payer: PHP Commercial |
$230.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.90
|
| Rate for Payer: Priority Health SBD |
$170.91
|
| Rate for Payer: UMR Bronson Commercial |
$119.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$203.47
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$437.19
|
|
|
Service Code
|
NDC 54482-148-01
|
| Hospital Charge Code |
108122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.36 |
| Max. Negotiated Rate |
$393.47 |
| Rate for Payer: Aetna American Axle |
$284.17
|
| Rate for Payer: Aetna Commercial |
$371.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$284.17
|
| Rate for Payer: Cash Price |
$349.75
|
| Rate for Payer: Cofinity Commercial |
$306.03
|
| Rate for Payer: Cofinity Commercial |
$375.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$349.75
|
| Rate for Payer: Healthscope Commercial |
$393.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$306.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$327.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$371.61
|
| Rate for Payer: PHP Commercial |
$371.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$306.03
|
| Rate for Payer: Priority Health SBD |
$275.43
|
| Rate for Payer: UMR Bronson Commercial |
$192.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$327.89
|
|
|
LEVOCARNITINE 200 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$113.90
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
20954
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$50.12 |
| Max. Negotiated Rate |
$102.51 |
| Rate for Payer: Aetna American Axle |
$74.04
|
| Rate for Payer: Aetna American Axle |
$65.10
|
| Rate for Payer: Aetna American Axle |
$233.47
|
| Rate for Payer: Aetna American Axle |
$63.87
|
| Rate for Payer: Aetna Commercial |
$85.13
|
| Rate for Payer: Aetna Commercial |
$96.82
|
| Rate for Payer: Aetna Commercial |
$83.52
|
| Rate for Payer: Aetna Commercial |
$305.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$233.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$65.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.04
|
| Rate for Payer: Cash Price |
$78.61
|
| Rate for Payer: Cash Price |
$287.35
|
| Rate for Payer: Cash Price |
$80.12
|
| Rate for Payer: Cash Price |
$91.12
|
| Rate for Payer: Cofinity Commercial |
$84.50
|
| Rate for Payer: Cofinity Commercial |
$86.13
|
| Rate for Payer: Cofinity Commercial |
$70.10
|
| Rate for Payer: Cofinity Commercial |
$68.78
|
| Rate for Payer: Cofinity Commercial |
$79.73
|
| Rate for Payer: Cofinity Commercial |
$308.90
|
| Rate for Payer: Cofinity Commercial |
$251.43
|
| Rate for Payer: Cofinity Commercial |
$97.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$80.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.61
|
| Rate for Payer: Healthscope Commercial |
$90.14
|
| Rate for Payer: Healthscope Commercial |
$88.43
|
| Rate for Payer: Healthscope Commercial |
$102.51
|
| Rate for Payer: Healthscope Commercial |
$323.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$70.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$79.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$251.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$85.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$305.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$85.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$96.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$83.52
|
| Rate for Payer: PHP Commercial |
$96.82
|
| Rate for Payer: PHP Commercial |
$305.31
|
| Rate for Payer: PHP Commercial |
$83.52
|
| Rate for Payer: PHP Commercial |
$85.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$79.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.78
|
| Rate for Payer: Priority Health SBD |
$226.29
|
| Rate for Payer: Priority Health SBD |
$61.90
|
| Rate for Payer: Priority Health SBD |
$63.09
|
| Rate for Payer: Priority Health SBD |
$71.76
|
| Rate for Payer: UMR Bronson Commercial |
$158.04
|
| Rate for Payer: UMR Bronson Commercial |
$44.07
|
| Rate for Payer: UMR Bronson Commercial |
$43.23
|
| Rate for Payer: UMR Bronson Commercial |
$50.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$269.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$85.42
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$342.58
|
|
|
Service Code
|
NDC 50383-172-90
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.74 |
| Max. Negotiated Rate |
$308.32 |
| Rate for Payer: Aetna American Axle |
$222.68
|
| Rate for Payer: Aetna Commercial |
$291.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$222.68
|
| Rate for Payer: Cash Price |
$274.06
|
| Rate for Payer: Cofinity Commercial |
$239.81
|
| Rate for Payer: Cofinity Commercial |
$294.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$274.06
|
| Rate for Payer: Healthscope Commercial |
$308.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$239.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$256.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$291.19
|
| Rate for Payer: PHP Commercial |
$291.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$239.81
|
| Rate for Payer: Priority Health SBD |
$215.83
|
| Rate for Payer: UMR Bronson Commercial |
$150.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$256.94
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$3.50
|
|
|
Service Code
|
NDC 9900-0008-79
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$3.15 |
| Rate for Payer: Aetna American Axle |
$2.28
|
| Rate for Payer: Aetna Commercial |
$2.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.28
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$2.45
|
| Rate for Payer: Cofinity Commercial |
$3.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.98
|
| Rate for Payer: PHP Commercial |
$2.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.45
|
| Rate for Payer: Priority Health SBD |
$2.20
|
| Rate for Payer: UMR Bronson Commercial |
$1.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.62
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$491.62
|
|
|
Service Code
|
NDC 54482-144-07
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$216.31 |
| Max. Negotiated Rate |
$442.46 |
| Rate for Payer: Aetna American Axle |
$319.55
|
| Rate for Payer: Aetna Commercial |
$417.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$319.55
|
| Rate for Payer: Cash Price |
$393.30
|
| Rate for Payer: Cofinity Commercial |
$344.13
|
| Rate for Payer: Cofinity Commercial |
$422.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$393.30
|
| Rate for Payer: Healthscope Commercial |
$442.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$344.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$368.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$417.88
|
| Rate for Payer: PHP Commercial |
$417.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$344.13
|
| Rate for Payer: Priority Health SBD |
$309.72
|
| Rate for Payer: UMR Bronson Commercial |
$216.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$368.72
|
|
|
LEVOCARNITINE 330 MG TABLET
|
Facility
|
IP
|
$324.44
|
|
|
Service Code
|
NDC 70954-492-10
|
| Hospital Charge Code |
20952
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.75 |
| Max. Negotiated Rate |
$292.00 |
| Rate for Payer: Aetna American Axle |
$210.89
|
| Rate for Payer: Aetna Commercial |
$275.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.89
|
| Rate for Payer: Cash Price |
$259.55
|
| Rate for Payer: Cofinity Commercial |
$227.11
|
| Rate for Payer: Cofinity Commercial |
$279.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.55
|
| Rate for Payer: Healthscope Commercial |
$292.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$275.77
|
| Rate for Payer: PHP Commercial |
$275.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.11
|
| Rate for Payer: Priority Health SBD |
$204.40
|
| Rate for Payer: UMR Bronson Commercial |
$142.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.33
|
|
|
LEVOCARNITINE SD 20 MG/ML IV
|
Facility
|
IP
|
$65.00
|
|
|
Service Code
|
HCPCS J1955
|
| Hospital Charge Code |
157117
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$28.60 |
| Max. Negotiated Rate |
$58.50 |
| Rate for Payer: Aetna American Axle |
$42.25
|
| Rate for Payer: Aetna Commercial |
$55.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.25
|
| Rate for Payer: Cash Price |
$52.00
|
| Rate for Payer: Cofinity Commercial |
$45.50
|
| Rate for Payer: Cofinity Commercial |
$55.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.00
|
| Rate for Payer: Healthscope Commercial |
$58.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.25
|
| Rate for Payer: PHP Commercial |
$55.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.50
|
| Rate for Payer: Priority Health SBD |
$40.95
|
| Rate for Payer: UMR Bronson Commercial |
$28.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.75
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
IP
|
$810.72
|
|
|
Service Code
|
NDC 0527-1948-66
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$356.72 |
| Max. Negotiated Rate |
$729.65 |
| Rate for Payer: Aetna American Axle |
$526.97
|
| Rate for Payer: Aetna Commercial |
$689.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$526.97
|
| Rate for Payer: Cash Price |
$648.58
|
| Rate for Payer: Cofinity Commercial |
$567.50
|
| Rate for Payer: Cofinity Commercial |
$697.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$648.58
|
| Rate for Payer: Healthscope Commercial |
$729.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$567.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$608.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$689.11
|
| Rate for Payer: PHP Commercial |
$689.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$567.50
|
| Rate for Payer: Priority Health SBD |
$510.75
|
| Rate for Payer: UMR Bronson Commercial |
$356.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$608.04
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
IP
|
$996.48
|
|
|
Service Code
|
NDC 50383-286-08
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$438.45 |
| Max. Negotiated Rate |
$896.83 |
| Rate for Payer: Aetna American Axle |
$647.71
|
| Rate for Payer: Aetna Commercial |
$847.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$647.71
|
| Rate for Payer: Cash Price |
$797.18
|
| Rate for Payer: Cofinity Commercial |
$697.54
|
| Rate for Payer: Cofinity Commercial |
$856.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$797.18
|
| Rate for Payer: Healthscope Commercial |
$896.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$697.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$747.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$847.01
|
| Rate for Payer: PHP Commercial |
$847.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$697.54
|
| Rate for Payer: Priority Health SBD |
$627.78
|
| Rate for Payer: UMR Bronson Commercial |
$438.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$747.36
|
|
|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,209.60
|
|
|
Service Code
|
NDC 0527-1948-68
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$532.22 |
| Max. Negotiated Rate |
$1,088.64 |
| Rate for Payer: Aetna American Axle |
$786.24
|
| Rate for Payer: Aetna Commercial |
$1,028.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$786.24
|
| Rate for Payer: Cash Price |
$967.68
|
| Rate for Payer: Cofinity Commercial |
$1,040.26
|
| Rate for Payer: Cofinity Commercial |
$846.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$967.68
|
| Rate for Payer: Healthscope Commercial |
$1,088.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$846.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$907.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,028.16
|
| Rate for Payer: PHP Commercial |
$1,028.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$846.72
|
| Rate for Payer: Priority Health SBD |
$762.05
|
| Rate for Payer: UMR Bronson Commercial |
$532.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$907.20
|
|
