|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$394.80
|
|
|
Service Code
|
NDC 16571078812
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.08 |
| Max. Negotiated Rate |
$355.32 |
| Rate for Payer: Aetna American Axle |
$256.62
|
| Rate for Payer: Aetna Commercial |
$335.58
|
| Rate for Payer: Aetna Medicare |
$197.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$256.62
|
| Rate for Payer: BCBS Complete |
$157.92
|
| Rate for Payer: Cash Price |
$315.84
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$315.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$335.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$296.10
|
| Rate for Payer: PHP Commercial |
$335.58
|
| Rate for Payer: Priority Health SBD |
$248.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$256.62
|
| Rate for Payer: UHC Core |
$205.69
|
| Rate for Payer: UHC Exchange |
$155.16
|
| Rate for Payer: UMR Bronson Commercial |
$146.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$296.10
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$260.78
|
|
|
Service Code
|
NDC 68180011309
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.49 |
| Max. Negotiated Rate |
$234.70 |
| Rate for Payer: Aetna American Axle |
$169.51
|
| Rate for Payer: Aetna Commercial |
$221.66
|
| Rate for Payer: Aetna Medicare |
$130.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.51
|
| Rate for Payer: BCBS Complete |
$104.31
|
| Rate for Payer: Cash Price |
$208.62
|
| Rate for Payer: Cofinity Advantage |
$182.55
|
| Rate for Payer: Cofinity Commercial |
$224.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.62
|
| Rate for Payer: Healthscope Commercial |
$234.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.59
|
| Rate for Payer: PHP Commercial |
$221.66
|
| Rate for Payer: Priority Health SBD |
$164.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$169.51
|
| Rate for Payer: UHC Core |
$135.87
|
| Rate for Payer: UHC Exchange |
$102.49
|
| Rate for Payer: UMR Bronson Commercial |
$96.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.59
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$248.16
|
|
|
Service Code
|
NDC 31722053712
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.19 |
| Max. Negotiated Rate |
$223.34 |
| Rate for Payer: Aetna American Axle |
$161.30
|
| Rate for Payer: Aetna Commercial |
$210.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.30
|
| Rate for Payer: Cash Price |
$198.53
|
| Rate for Payer: Cofinity Advantage |
$173.71
|
| Rate for Payer: Cofinity Commercial |
$213.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$198.53
|
| Rate for Payer: Healthscope Commercial |
$223.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$186.12
|
| Rate for Payer: PHP Commercial |
$210.94
|
| Rate for Payer: Priority Health SBD |
$156.34
|
| Rate for Payer: UMR Bronson Commercial |
$109.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.12
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$248.16
|
|
|
Service Code
|
NDC 31722053712
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.82 |
| Max. Negotiated Rate |
$223.34 |
| Rate for Payer: Aetna American Axle |
$161.30
|
| Rate for Payer: Aetna Commercial |
$210.94
|
| Rate for Payer: Aetna Medicare |
$124.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.30
|
| Rate for Payer: BCBS Complete |
$99.26
|
| Rate for Payer: Cash Price |
$198.53
|
| Rate for Payer: Cofinity Advantage |
$173.71
|
| Rate for Payer: Cofinity Commercial |
$213.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$198.53
|
| Rate for Payer: Healthscope Commercial |
$223.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$198.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$186.12
|
| Rate for Payer: PHP Commercial |
$210.94
|
| Rate for Payer: Priority Health SBD |
$156.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$161.30
|
| Rate for Payer: UHC Core |
$129.29
|
| Rate for Payer: UHC Exchange |
$97.53
|
| Rate for Payer: UMR Bronson Commercial |
$91.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.12
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$188.94
|
|
|
Service Code
|
NDC 65862024608
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.91 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna American Axle |
$122.81
|
| 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 Advantage |
$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 |
$141.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$151.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$141.71
|
| Rate for Payer: PHP Commercial |
$160.60
|
| Rate for Payer: Priority Health SBD |
$119.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$122.81
|
| Rate for Payer: UHC Core |
$98.44
|
| Rate for Payer: UHC Exchange |
$74.25
|
| Rate for Payer: UMR Bronson Commercial |
$69.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.71
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$2.42
|
|
|
Service Code
|
NDC 51079082101
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.06 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Aetna American Axle |
$1.57
|
| Rate for Payer: Aetna Commercial |
$2.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.57
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cofinity Advantage |
$1.69
|
| Rate for Payer: Cofinity Commercial |
$2.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.94
|
| Rate for Payer: Healthscope Commercial |
$2.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.81
|
| Rate for Payer: PHP Commercial |
$2.06
|
| Rate for Payer: Priority Health SBD |
$1.52
|
| Rate for Payer: UMR Bronson Commercial |
$1.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.81
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$376.00
|
|
|
Service Code
|
NDC 63739041110
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$139.12 |
| Max. Negotiated Rate |
$338.40 |
| Rate for Payer: Aetna American Axle |
$244.40
|
| Rate for Payer: Aetna Commercial |
$319.60
|
| Rate for Payer: Aetna Medicare |
$188.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$244.40
|
| Rate for Payer: BCBS Complete |
$150.40
|
| Rate for Payer: Cash Price |
$300.80
|
| Rate for Payer: Cofinity Advantage |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$323.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$300.80
|
| Rate for Payer: Healthscope Commercial |
$338.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$263.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$282.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$300.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$319.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$282.00
|
| Rate for Payer: PHP Commercial |
$319.60
|
| Rate for Payer: Priority Health SBD |
$236.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$244.40
|
| Rate for Payer: UHC Core |
$195.90
|
| Rate for Payer: UHC Exchange |
$147.77
|
| Rate for Payer: UMR Bronson Commercial |
$139.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$282.00
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$188.94
|
|
|
Service Code
|
NDC 68180011316
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$69.91 |
| Max. Negotiated Rate |
$170.05 |
| Rate for Payer: Aetna American Axle |
$122.81
|
| 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 Advantage |
$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 |
$141.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$151.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$141.71
|
| Rate for Payer: PHP Commercial |
$160.60
|
| Rate for Payer: Priority Health SBD |
$119.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$122.81
|
| Rate for Payer: UHC Core |
$98.44
|
| Rate for Payer: UHC Exchange |
$74.25
|
| Rate for Payer: UMR Bronson Commercial |
$69.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.71
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$238.26
|
|
|
Service Code
|
NDC 42385095512
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.16 |
| Max. Negotiated Rate |
$214.43 |
| Rate for Payer: Aetna American Axle |
$154.87
|
| Rate for Payer: Aetna Commercial |
$202.52
|
| Rate for Payer: Aetna Medicare |
$119.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.87
|
| Rate for Payer: BCBS Complete |
$95.30
|
| Rate for Payer: Cash Price |
$190.61
|
| Rate for Payer: Cofinity Advantage |
$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 |
$178.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.69
|
| Rate for Payer: PHP Commercial |
$202.52
|
| Rate for Payer: Priority Health SBD |
$150.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.87
|
| Rate for Payer: UHC Core |
$124.13
|
| Rate for Payer: UHC Exchange |
$93.64
|
| Rate for Payer: UMR Bronson Commercial |
$88.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.69
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$376.00
|
|
|
Service Code
|
NDC 63739041110
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.44 |
| Max. Negotiated Rate |
$338.40 |
| Rate for Payer: Aetna American Axle |
$244.40
|
| Rate for Payer: Aetna Commercial |
$319.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$244.40
|
| Rate for Payer: Cash Price |
$300.80
|
| Rate for Payer: Cofinity Advantage |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$323.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$300.80
|
| Rate for Payer: Healthscope Commercial |
$338.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$263.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$282.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$319.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$282.00
|
| Rate for Payer: PHP Commercial |
$319.60
|
| Rate for Payer: Priority Health SBD |
$236.88
|
| Rate for Payer: UMR Bronson Commercial |
$165.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$282.00
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$361.38
|
|
|
Service Code
|
NDC 71930006315
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.71 |
| Max. Negotiated Rate |
$325.24 |
| Rate for Payer: Aetna American Axle |
$234.90
|
| Rate for Payer: Aetna Commercial |
$307.17
|
| Rate for Payer: Aetna Medicare |
$180.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$234.90
|
| Rate for Payer: BCBS Complete |
$144.55
|
| Rate for Payer: Cash Price |
$289.10
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$289.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$307.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$271.04
|
| Rate for Payer: PHP Commercial |
$307.17
|
| Rate for Payer: Priority Health SBD |
$227.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$234.90
|
| Rate for Payer: UHC Core |
$188.28
|
| Rate for Payer: UHC Exchange |
$142.02
|
| Rate for Payer: UMR Bronson Commercial |
$133.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$271.04
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$390.10
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.64 |
| Max. Negotiated Rate |
$351.09 |
| Rate for Payer: Aetna American Axle |
$253.56
|
| Rate for Payer: Aetna Commercial |
$331.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.56
|
| Rate for Payer: Cash Price |
$312.08
|
| Rate for Payer: Cofinity Advantage |
$273.07
|
| Rate for Payer: Cofinity Commercial |
$335.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$312.08
|
| Rate for Payer: Healthscope Commercial |
$351.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$273.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$292.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.57
|
| Rate for Payer: PHP Commercial |
$331.58
|
| Rate for Payer: Priority Health SBD |
$245.76
|
| Rate for Payer: UMR Bronson Commercial |
$171.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.57
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$394.80
|
|
|
Service Code
|
NDC 16571078812
|
| 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 Advantage |
$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 Commercial |
$335.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$296.10
|
| Rate for Payer: PHP Commercial |
$335.58
|
| 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
|
OP
|
$2.42
|
|
|
Service Code
|
NDC 51079082101
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Aetna American Axle |
$1.57
|
| Rate for Payer: Aetna Commercial |
$2.06
|
| Rate for Payer: Aetna Medicare |
$1.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.57
|
| Rate for Payer: BCBS Complete |
$0.97
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cofinity Advantage |
$1.69
|
| Rate for Payer: Cofinity Commercial |
$2.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.94
|
| Rate for Payer: Healthscope Commercial |
$2.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.81
|
| Rate for Payer: PHP Commercial |
$2.06
|
| Rate for Payer: Priority Health SBD |
$1.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.57
|
| Rate for Payer: UHC Core |
$1.26
|
| Rate for Payer: UHC Exchange |
$0.95
|
| Rate for Payer: UMR Bronson Commercial |
$0.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.81
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$390.10
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.34 |
| Max. Negotiated Rate |
$351.09 |
| Rate for Payer: Aetna American Axle |
$253.56
|
| Rate for Payer: Aetna Commercial |
$331.58
|
| Rate for Payer: Aetna Medicare |
$195.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$253.56
|
| Rate for Payer: BCBS Complete |
$156.04
|
| Rate for Payer: Cash Price |
$312.08
|
| Rate for Payer: Cofinity Advantage |
$273.07
|
| Rate for Payer: Cofinity Commercial |
$335.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$312.08
|
| Rate for Payer: Healthscope Commercial |
$351.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$273.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$292.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$312.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.57
|
| Rate for Payer: PHP Commercial |
$331.58
|
| Rate for Payer: Priority Health SBD |
$245.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$253.56
|
| Rate for Payer: UHC Core |
$203.24
|
| Rate for Payer: UHC Exchange |
$153.31
|
| Rate for Payer: UMR Bronson Commercial |
$144.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.57
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$361.38
|
|
|
Service Code
|
NDC 71930006315
|
| 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 Advantage |
$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 Commercial |
$307.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$271.04
|
| Rate for Payer: PHP Commercial |
$307.17
|
| 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 500 MG TABLET
|
Facility
|
IP
|
$188.94
|
|
|
Service Code
|
NDC 68180011316
|
| 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 Advantage |
$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 |
$141.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$160.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$141.71
|
| Rate for Payer: PHP Commercial |
$160.60
|
| 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 |
$141.71
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$260.78
|
|
|
Service Code
|
NDC 68180011309
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.74 |
| Max. Negotiated Rate |
$234.70 |
| Rate for Payer: Aetna American Axle |
$169.51
|
| Rate for Payer: Aetna Commercial |
$221.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.51
|
| Rate for Payer: Cash Price |
$208.62
|
| Rate for Payer: Cofinity Advantage |
$182.55
|
| Rate for Payer: Cofinity Commercial |
$224.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.62
|
| Rate for Payer: Healthscope Commercial |
$234.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.59
|
| Rate for Payer: PHP Commercial |
$221.66
|
| Rate for Payer: Priority Health SBD |
$164.29
|
| Rate for Payer: UMR Bronson Commercial |
$114.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.59
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$241.30
|
|
|
Service Code
|
NDC 51079082120
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.28 |
| Max. Negotiated Rate |
$217.17 |
| Rate for Payer: Aetna American Axle |
$156.84
|
| Rate for Payer: Aetna Commercial |
$205.10
|
| Rate for Payer: Aetna Medicare |
$120.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$156.84
|
| Rate for Payer: BCBS Complete |
$96.52
|
| Rate for Payer: Cash Price |
$193.04
|
| Rate for Payer: Cofinity Advantage |
$168.91
|
| Rate for Payer: Cofinity Commercial |
$207.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.04
|
| Rate for Payer: Healthscope Commercial |
$217.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$168.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$180.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$193.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$180.97
|
| Rate for Payer: PHP Commercial |
$205.10
|
| Rate for Payer: Priority Health SBD |
$152.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$156.84
|
| Rate for Payer: UHC Core |
$125.72
|
| Rate for Payer: UHC Exchange |
$94.83
|
| Rate for Payer: UMR Bronson Commercial |
$89.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$180.97
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$238.26
|
|
|
Service Code
|
NDC 42385095512
|
| 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 Advantage |
$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 |
$178.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.69
|
| Rate for Payer: PHP Commercial |
$202.52
|
| 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 |
$178.69
|
|
|
LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
IP
|
$221.16
|
|
|
Service Code
|
NDC 68180011707
|
| 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 Advantage |
$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 Commercial |
$187.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$165.87
|
| Rate for Payer: PHP Commercial |
$187.99
|
| 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
|
|
|
LEVETIRACETAM ER 500 MG TABLET,EXTENDED RELEASE 24 HR
|
Facility
|
OP
|
$221.16
|
|
|
Service Code
|
NDC 68180011707
|
| Hospital Charge Code |
93834
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.83 |
| Max. Negotiated Rate |
$199.04 |
| Rate for Payer: Aetna American Axle |
$143.75
|
| Rate for Payer: Aetna Commercial |
$187.99
|
| Rate for Payer: Aetna Medicare |
$110.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.75
|
| Rate for Payer: BCBS Complete |
$88.46
|
| Rate for Payer: Cash Price |
$176.93
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$176.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$165.87
|
| Rate for Payer: PHP Commercial |
$187.99
|
| Rate for Payer: Priority Health SBD |
$139.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$143.75
|
| Rate for Payer: UHC Core |
$115.22
|
| Rate for Payer: UHC Exchange |
$86.92
|
| Rate for Payer: UMR Bronson Commercial |
$81.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$165.87
|
|
|
LEVOBUNOLOL 0.5 % EYE DROPS
|
Facility
|
OP
|
$38.68
|
|
|
Service Code
|
NDC 24208050505
|
| Hospital Charge Code |
10394
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.31 |
| Max. Negotiated Rate |
$34.81 |
| Rate for Payer: Aetna American Axle |
$25.14
|
| Rate for Payer: Aetna Commercial |
$32.88
|
| Rate for Payer: Aetna Medicare |
$19.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.14
|
| Rate for Payer: BCBS Complete |
$15.47
|
| Rate for Payer: Cash Price |
$30.94
|
| Rate for Payer: Cofinity Advantage |
$27.08
|
| Rate for Payer: Cofinity Commercial |
$33.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.94
|
| Rate for Payer: Healthscope Commercial |
$34.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.01
|
| Rate for Payer: PHP Commercial |
$32.88
|
| Rate for Payer: Priority Health SBD |
$24.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.14
|
| Rate for Payer: UHC Core |
$20.15
|
| Rate for Payer: UHC Exchange |
$15.20
|
| Rate for Payer: UMR Bronson Commercial |
$14.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.01
|
|
|
LEVOBUNOLOL 0.5 % EYE DROPS
|
Facility
|
IP
|
$38.68
|
|
|
Service Code
|
NDC 24208050505
|
| Hospital Charge Code |
10394
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.02 |
| Max. Negotiated Rate |
$34.81 |
| Rate for Payer: Aetna American Axle |
$25.14
|
| Rate for Payer: Aetna Commercial |
$32.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.14
|
| Rate for Payer: Cash Price |
$30.94
|
| Rate for Payer: Cofinity Advantage |
$27.08
|
| Rate for Payer: Cofinity Commercial |
$33.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.94
|
| Rate for Payer: Healthscope Commercial |
$34.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.01
|
| Rate for Payer: PHP Commercial |
$32.88
|
| Rate for Payer: Priority Health SBD |
$24.37
|
| Rate for Payer: UMR Bronson Commercial |
$17.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.01
|
|
|
LEVOCARNITINE 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$448.40
|
|
|
Service Code
|
NDC 54482014801
|
| Hospital Charge Code |
108122
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.30 |
| Max. Negotiated Rate |
$403.56 |
| Rate for Payer: Aetna American Axle |
$291.46
|
| Rate for Payer: Aetna Commercial |
$381.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.46
|
| Rate for Payer: Cash Price |
$358.72
|
| Rate for Payer: Cofinity Advantage |
$313.88
|
| Rate for Payer: Cofinity Commercial |
$385.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$358.72
|
| Rate for Payer: Healthscope Commercial |
$403.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$313.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$336.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$381.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$336.30
|
| Rate for Payer: PHP Commercial |
$381.14
|
| Rate for Payer: Priority Health SBD |
$282.49
|
| Rate for Payer: UMR Bronson Commercial |
$197.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$336.30
|
|
