|
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 |
$57.48 |
| Max. Negotiated Rate |
$139.81 |
| Rate for Payer: Aetna American Axle |
$100.98
|
| Rate for Payer: Aetna Commercial |
$132.05
|
| Rate for Payer: Aetna Medicare |
$77.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$100.98
|
| Rate for Payer: BCBS Complete |
$62.14
|
| Rate for Payer: Cash Price |
$124.28
|
| Rate for Payer: Cofinity Commercial |
$108.75
|
| Rate for Payer: Cofinity Commercial |
$133.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$108.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.28
|
| Rate for Payer: Healthscope Commercial |
$139.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$108.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$116.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.05
|
| Rate for Payer: PHP Commercial |
$132.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.98
|
| Rate for Payer: Priority Health SBD |
$97.87
|
| Rate for Payer: UMR Bronson Commercial |
$57.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$116.51
|
|
|
LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER
|
Facility
|
OP
|
$202.86
|
|
|
Service Code
|
NDC 00591292754
|
| Hospital Charge Code |
43472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.06 |
| Max. Negotiated Rate |
$182.57 |
| Rate for Payer: Aetna American Axle |
$131.86
|
| Rate for Payer: Aetna Commercial |
$172.43
|
| Rate for Payer: Aetna Medicare |
$101.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.86
|
| Rate for Payer: BCBS Complete |
$81.14
|
| Rate for Payer: Cash Price |
$162.29
|
| Rate for Payer: Cofinity Commercial |
$142.00
|
| Rate for Payer: Cofinity Commercial |
$174.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$142.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$162.29
|
| Rate for Payer: Healthscope Commercial |
$182.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$152.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$172.43
|
| Rate for Payer: PHP Commercial |
$172.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.86
|
| Rate for Payer: Priority Health SBD |
$127.80
|
| Rate for Payer: UMR Bronson Commercial |
$75.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$152.15
|
|
|
LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER
|
Facility
|
OP
|
$163.12
|
|
|
Service Code
|
NDC 27437005601
|
| Hospital Charge Code |
43472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.35 |
| Max. Negotiated Rate |
$146.81 |
| Rate for Payer: Aetna American Axle |
$106.03
|
| Rate for Payer: Aetna Commercial |
$138.65
|
| Rate for Payer: Aetna Medicare |
$81.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.03
|
| Rate for Payer: BCBS Complete |
$65.25
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cofinity Commercial |
$114.18
|
| Rate for Payer: Cofinity Commercial |
$140.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$114.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.50
|
| Rate for Payer: Healthscope Commercial |
$146.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$114.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$122.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.65
|
| Rate for Payer: PHP Commercial |
$138.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.03
|
| Rate for Payer: Priority Health SBD |
$102.77
|
| Rate for Payer: UMR Bronson Commercial |
$60.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$122.34
|
|
|
LEVALBUTEROL HFA 45 MCG/ACTUATION AEROSOL INHALER
|
Facility
|
IP
|
$163.12
|
|
|
Service Code
|
NDC 27437005601
|
| Hospital Charge Code |
43472
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$71.77 |
| Max. Negotiated Rate |
$146.81 |
| Rate for Payer: Aetna American Axle |
$106.03
|
| Rate for Payer: Aetna Commercial |
$138.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.03
|
| Rate for Payer: Cash Price |
$130.50
|
| Rate for Payer: Cofinity Commercial |
$114.18
|
| Rate for Payer: Cofinity Commercial |
$140.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$114.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.50
|
| Rate for Payer: Healthscope Commercial |
$146.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$114.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$122.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.65
|
| Rate for Payer: PHP Commercial |
$138.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$106.03
|
| Rate for Payer: Priority Health SBD |
$102.77
|
| Rate for Payer: UMR Bronson Commercial |
$71.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$122.34
|
|
|
LEVEL IV - SURGICAL PATHOLOGY, GROSS AND MICROSCOPIC EXAMINATION ABORTION - SPONTANEOUS/MISSED ARTERY, BIOPSY BONE MARROW, BIOPSY BONE EXOSTOSIS BRAIN/MENINGES, OTHER THAN FOR TUMOR RESECTION BREAST, BIOPSY, NOT REQUIRING MICROSCOPIC EVALUATION OF SURGICAL MARGINS BREAST, REDUCTION MAMMOPLASTY BRONCHUS, BIOPSY CELL BLOCK, ANY SOURCE CERVIX, BIOPSY COLON, BIOPSY DUODENUM, BIOPSY ENDOCERVIX, CURETTINGS/BIOPSY ENDOMETRIUM, CURETTINGS/BIOPSY ESOPHAGUS, BIOPSY EXTREMITY, AMPUTATION, TRAUMATIC FALLOPIAN TUBE, BIOPSY FALLOPIAN TUBE, ECTOPIC PREGNANCY FEMORAL HEAD, FRACTURE FINGERS/TOES, AMPUTATION, NON-TRAUMATIC GINGIVA/ORAL MUCOSA, BIOPSY HEART VALVE JOINT, RESECTION KIDNEY, BIOPSY LARYNX, BIOPSY LEIOMYOMA(S), UTERINE MYOMECTOMY - WITHOUT UTERUS LIP, BIOPSY/WEDGE RESECTION LUNG, TRANSBRONCHIAL BIOPSY LYMPH NODE, BIOPSY MUSCLE, BIOPSY NASAL MUCOSA, BIOPSY NASOPHARYNX/OROPHARYNX, BIOPSY NERVE, BIOPSY ODONTOGENIC/DENTAL CYST OMENTUM, BIOPSY OVARY WITH OR WITHOUT TUBE, NON-NEOPLASTIC OVARY, BIOPSY/WEDGE RESECTION PARAT
|
Facility
|
OP
|
$146.68
|
|
|
Service Code
|
CPT 88305
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$27.93 |
| Max. Negotiated Rate |
$146.68 |
| Rate for Payer: Aetna Medicare |
$54.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$65.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$65.14
|
| Rate for Payer: BCBS Complete |
$29.33
|
| Rate for Payer: BCBS MAPPO |
$52.11
|
| Rate for Payer: BCN Medicare Advantage |
$52.11
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$52.11
|
| Rate for Payer: Mclaren Medicaid |
$27.93
|
| Rate for Payer: Mclaren Medicare |
$52.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$54.72
|
| Rate for Payer: Meridian Medicaid |
$29.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$59.93
|
| Rate for Payer: PACE Medicare |
$49.50
|
| Rate for Payer: PACE SWMI |
$52.11
|
| Rate for Payer: PHP Medicare Advantage |
$52.11
|
| Rate for Payer: Priority Health Choice Medicaid |
$27.93
|
| Rate for Payer: Priority Health Medicare |
$52.11
|
| Rate for Payer: Railroad Medicare Medicare |
$52.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$146.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$52.11
|
| Rate for Payer: UHC Exchange |
$99.59
|
| Rate for Payer: UHC Medicare Advantage |
$52.11
|
| Rate for Payer: UHCCP Medicaid |
$27.93
|
| Rate for Payer: VA VA |
$52.11
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$422.39
|
|
|
Service Code
|
NDC 00121079916
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.85 |
| Max. Negotiated Rate |
$380.15 |
| Rate for Payer: Aetna American Axle |
$274.55
|
| Rate for Payer: Aetna Commercial |
$359.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.55
|
| Rate for Payer: Cash Price |
$337.91
|
| Rate for Payer: Cofinity Commercial |
$295.67
|
| Rate for Payer: Cofinity Commercial |
$363.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$295.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.91
|
| Rate for Payer: Healthscope Commercial |
$380.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$295.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$316.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.03
|
| Rate for Payer: PHP Commercial |
$359.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.55
|
| Rate for Payer: Priority Health SBD |
$266.11
|
| Rate for Payer: UMR Bronson Commercial |
$185.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$316.79
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$311.24
|
|
|
Service Code
|
NDC 50383024116
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.16 |
| Max. Negotiated Rate |
$280.12 |
| Rate for Payer: Aetna American Axle |
$202.31
|
| Rate for Payer: Aetna Commercial |
$264.55
|
| Rate for Payer: Aetna Medicare |
$155.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.31
|
| Rate for Payer: BCBS Complete |
$124.50
|
| Rate for Payer: Cash Price |
$248.99
|
| Rate for Payer: Cofinity Commercial |
$217.87
|
| Rate for Payer: Cofinity Commercial |
$267.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$217.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.99
|
| Rate for Payer: Healthscope Commercial |
$280.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$217.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$233.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.55
|
| Rate for Payer: PHP Commercial |
$264.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.31
|
| Rate for Payer: Priority Health SBD |
$196.08
|
| Rate for Payer: UMR Bronson Commercial |
$115.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$233.43
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$311.24
|
|
|
Service Code
|
NDC 50383024116
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.95 |
| Max. Negotiated Rate |
$280.12 |
| Rate for Payer: Aetna American Axle |
$202.31
|
| Rate for Payer: Aetna Commercial |
$264.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.31
|
| Rate for Payer: Cash Price |
$248.99
|
| Rate for Payer: Cofinity Commercial |
$217.87
|
| Rate for Payer: Cofinity Commercial |
$267.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$217.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$248.99
|
| Rate for Payer: Healthscope Commercial |
$280.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$217.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$233.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$264.55
|
| Rate for Payer: PHP Commercial |
$264.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$202.31
|
| Rate for Payer: Priority Health SBD |
$196.08
|
| Rate for Payer: UMR Bronson Commercial |
$136.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$233.43
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$4,120.78
|
|
|
Service Code
|
NDC 50474000148
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,524.69 |
| Max. Negotiated Rate |
$3,708.70 |
| Rate for Payer: Aetna American Axle |
$2,678.51
|
| Rate for Payer: Aetna Commercial |
$3,502.66
|
| Rate for Payer: Aetna Medicare |
$2,060.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,678.51
|
| Rate for Payer: BCBS Complete |
$1,648.31
|
| Rate for Payer: Cash Price |
$3,296.62
|
| Rate for Payer: Cofinity Commercial |
$2,884.55
|
| Rate for Payer: Cofinity Commercial |
$3,543.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,884.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,296.62
|
| Rate for Payer: Healthscope Commercial |
$3,708.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,884.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,090.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,502.66
|
| Rate for Payer: PHP Commercial |
$3,502.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,678.51
|
| Rate for Payer: Priority Health SBD |
$2,596.09
|
| Rate for Payer: UMR Bronson Commercial |
$1,524.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,090.59
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$700.28
|
|
|
Service Code
|
NDC 31722057447
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$308.12 |
| Max. Negotiated Rate |
$630.25 |
| Rate for Payer: Aetna American Axle |
$455.18
|
| Rate for Payer: Aetna Commercial |
$595.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$455.18
|
| Rate for Payer: Cash Price |
$560.22
|
| Rate for Payer: Cofinity Commercial |
$490.20
|
| Rate for Payer: Cofinity Commercial |
$602.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$490.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$560.22
|
| Rate for Payer: Healthscope Commercial |
$630.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$490.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$525.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$595.24
|
| Rate for Payer: PHP Commercial |
$595.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$455.18
|
| Rate for Payer: Priority Health SBD |
$441.18
|
| Rate for Payer: UMR Bronson Commercial |
$308.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$525.21
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$700.28
|
|
|
Service Code
|
NDC 31722057447
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$259.10 |
| Max. Negotiated Rate |
$630.25 |
| Rate for Payer: Aetna American Axle |
$455.18
|
| Rate for Payer: Aetna Commercial |
$595.24
|
| Rate for Payer: Aetna Medicare |
$350.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$455.18
|
| Rate for Payer: BCBS Complete |
$280.11
|
| Rate for Payer: Cash Price |
$560.22
|
| Rate for Payer: Cofinity Commercial |
$490.20
|
| Rate for Payer: Cofinity Commercial |
$602.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$490.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$560.22
|
| Rate for Payer: Healthscope Commercial |
$630.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$490.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$525.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$595.24
|
| Rate for Payer: PHP Commercial |
$595.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$455.18
|
| Rate for Payer: Priority Health SBD |
$441.18
|
| Rate for Payer: UMR Bronson Commercial |
$259.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$525.21
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$422.39
|
|
|
Service Code
|
NDC 00121079916
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.28 |
| Max. Negotiated Rate |
$380.15 |
| Rate for Payer: Aetna American Axle |
$274.55
|
| Rate for Payer: Aetna Commercial |
$359.03
|
| Rate for Payer: Aetna Medicare |
$211.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.55
|
| Rate for Payer: BCBS Complete |
$168.96
|
| Rate for Payer: Cash Price |
$337.91
|
| Rate for Payer: Cofinity Commercial |
$295.67
|
| Rate for Payer: Cofinity Commercial |
$363.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$295.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$337.91
|
| Rate for Payer: Healthscope Commercial |
$380.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$295.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$316.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$359.03
|
| Rate for Payer: PHP Commercial |
$359.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.55
|
| Rate for Payer: Priority Health SBD |
$266.11
|
| Rate for Payer: UMR Bronson Commercial |
$156.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$316.79
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$255.66
|
|
|
Service Code
|
NDC 65862025047
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.59 |
| Max. Negotiated Rate |
$230.09 |
| Rate for Payer: Aetna American Axle |
$166.18
|
| Rate for Payer: Aetna Commercial |
$217.31
|
| Rate for Payer: Aetna Medicare |
$127.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.18
|
| Rate for Payer: BCBS Complete |
$102.26
|
| Rate for Payer: Cash Price |
$204.53
|
| Rate for Payer: Cofinity Commercial |
$178.96
|
| Rate for Payer: Cofinity Commercial |
$219.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$178.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.53
|
| Rate for Payer: Healthscope Commercial |
$230.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.31
|
| Rate for Payer: PHP Commercial |
$217.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.18
|
| Rate for Payer: Priority Health SBD |
$161.07
|
| Rate for Payer: UMR Bronson Commercial |
$94.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.75
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$266.78
|
|
|
Service Code
|
NDC 51991065116
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.38 |
| Max. Negotiated Rate |
$240.10 |
| Rate for Payer: Aetna American Axle |
$173.41
|
| Rate for Payer: Aetna Commercial |
$226.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.41
|
| Rate for Payer: Cash Price |
$213.42
|
| Rate for Payer: Cofinity Commercial |
$186.75
|
| Rate for Payer: Cofinity Commercial |
$229.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$186.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.42
|
| Rate for Payer: Healthscope Commercial |
$240.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.76
|
| Rate for Payer: PHP Commercial |
$226.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$173.41
|
| Rate for Payer: Priority Health SBD |
$168.07
|
| Rate for Payer: UMR Bronson Commercial |
$117.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.09
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$255.66
|
|
|
Service Code
|
NDC 65862025047
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.49 |
| Max. Negotiated Rate |
$230.09 |
| Rate for Payer: Aetna American Axle |
$166.18
|
| Rate for Payer: Aetna Commercial |
$217.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.18
|
| Rate for Payer: Cash Price |
$204.53
|
| Rate for Payer: Cofinity Commercial |
$178.96
|
| Rate for Payer: Cofinity Commercial |
$219.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$178.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.53
|
| Rate for Payer: Healthscope Commercial |
$230.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.31
|
| Rate for Payer: PHP Commercial |
$217.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.18
|
| Rate for Payer: Priority Health SBD |
$161.07
|
| Rate for Payer: UMR Bronson Commercial |
$112.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.75
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
OP
|
$266.78
|
|
|
Service Code
|
NDC 51991065116
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.71 |
| Max. Negotiated Rate |
$240.10 |
| Rate for Payer: Aetna American Axle |
$173.41
|
| Rate for Payer: Aetna Commercial |
$226.76
|
| Rate for Payer: Aetna Medicare |
$133.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.41
|
| Rate for Payer: BCBS Complete |
$106.71
|
| Rate for Payer: Cash Price |
$213.42
|
| Rate for Payer: Cofinity Commercial |
$186.75
|
| Rate for Payer: Cofinity Commercial |
$229.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$186.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.42
|
| Rate for Payer: Healthscope Commercial |
$240.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.76
|
| Rate for Payer: PHP Commercial |
$226.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$173.41
|
| Rate for Payer: Priority Health SBD |
$168.07
|
| Rate for Payer: UMR Bronson Commercial |
$98.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.09
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION
|
Facility
|
IP
|
$4,120.78
|
|
|
Service Code
|
NDC 50474000148
|
| Hospital Charge Code |
36590
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,813.14 |
| Max. Negotiated Rate |
$3,708.70 |
| Rate for Payer: Aetna American Axle |
$2,678.51
|
| Rate for Payer: Aetna Commercial |
$3,502.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,678.51
|
| Rate for Payer: Cash Price |
$3,296.62
|
| Rate for Payer: Cofinity Commercial |
$2,884.55
|
| Rate for Payer: Cofinity Commercial |
$3,543.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,884.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,296.62
|
| Rate for Payer: Healthscope Commercial |
$3,708.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,884.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,090.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,502.66
|
| Rate for Payer: PHP Commercial |
$3,502.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,678.51
|
| Rate for Payer: Priority Health SBD |
$2,596.09
|
| Rate for Payer: UMR Bronson Commercial |
$1,813.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,090.59
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
OP
|
$327.12
|
|
|
Service Code
|
NDC 42385095412
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.03 |
| Max. Negotiated Rate |
$294.41 |
| Rate for Payer: Aetna American Axle |
$212.63
|
| Rate for Payer: Aetna Commercial |
$278.05
|
| Rate for Payer: Aetna Medicare |
$163.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$212.63
|
| Rate for Payer: BCBS Complete |
$130.85
|
| Rate for Payer: Cash Price |
$261.70
|
| Rate for Payer: Cofinity Commercial |
$228.98
|
| Rate for Payer: Cofinity Commercial |
$281.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$228.98
|
| 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 Commercial |
$278.05
|
| Rate for Payer: PHP Commercial |
$278.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.63
|
| Rate for Payer: Priority Health SBD |
$206.09
|
| Rate for Payer: UMR Bronson Commercial |
$121.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$245.34
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 00904712361
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.22 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna American Axle |
$189.41
|
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health SBD |
$183.58
|
| Rate for Payer: UMR Bronson Commercial |
$128.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$224.20
|
|
|
Service Code
|
NDC 51079082020
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.65 |
| Max. Negotiated Rate |
$201.78 |
| Rate for Payer: Aetna American Axle |
$145.73
|
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.73
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$156.94
|
| Rate for Payer: Cofinity Commercial |
$192.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$201.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.57
|
| Rate for Payer: PHP Commercial |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.73
|
| Rate for Payer: Priority Health SBD |
$141.25
|
| Rate for Payer: UMR Bronson Commercial |
$98.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.15
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
OP
|
$224.20
|
|
|
Service Code
|
NDC 51079082020
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.95 |
| Max. Negotiated Rate |
$201.78 |
| Rate for Payer: Aetna American Axle |
$145.73
|
| Rate for Payer: Aetna Commercial |
$190.57
|
| Rate for Payer: Aetna Medicare |
$112.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.73
|
| Rate for Payer: BCBS Complete |
$89.68
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$156.94
|
| Rate for Payer: Cofinity Commercial |
$192.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$156.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$201.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$190.57
|
| Rate for Payer: PHP Commercial |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.73
|
| Rate for Payer: Priority Health SBD |
$141.25
|
| Rate for Payer: UMR Bronson Commercial |
$82.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.15
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$345.45
|
|
|
Service Code
|
NDC 68084085901
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$152.00 |
| Max. Negotiated Rate |
$310.90 |
| Rate for Payer: Aetna American Axle |
$224.54
|
| Rate for Payer: Aetna Commercial |
$293.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.54
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$241.81
|
| Rate for Payer: Cofinity Commercial |
$297.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$241.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.36
|
| Rate for Payer: Healthscope Commercial |
$310.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$259.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.63
|
| Rate for Payer: PHP Commercial |
$293.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.54
|
| Rate for Payer: Priority Health SBD |
$217.63
|
| Rate for Payer: UMR Bronson Commercial |
$152.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$259.09
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$327.12
|
|
|
Service Code
|
NDC 42385095412
|
| 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: Cofinity Medicare Advantage |
$228.98
|
| 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 Commercial |
$278.05
|
| Rate for Payer: PHP Commercial |
$278.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.63
|
| 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 250 MG TABLET
|
Facility
|
OP
|
$291.40
|
|
|
Service Code
|
NDC 00904712361
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.82 |
| Max. Negotiated Rate |
$262.26 |
| Rate for Payer: Aetna American Axle |
$189.41
|
| Rate for Payer: Aetna Commercial |
$247.69
|
| Rate for Payer: Aetna Medicare |
$145.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.41
|
| Rate for Payer: BCBS Complete |
$116.56
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$203.98
|
| Rate for Payer: Cofinity Commercial |
$250.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$262.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: PHP Commercial |
$247.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health SBD |
$183.58
|
| Rate for Payer: UMR Bronson Commercial |
$107.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.55
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
OP
|
$345.45
|
|
|
Service Code
|
NDC 68084085901
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.82 |
| Max. Negotiated Rate |
$310.90 |
| Rate for Payer: Aetna American Axle |
$224.54
|
| Rate for Payer: Aetna Commercial |
$293.63
|
| Rate for Payer: Aetna Medicare |
$172.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.54
|
| Rate for Payer: BCBS Complete |
$138.18
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$241.81
|
| Rate for Payer: Cofinity Commercial |
$297.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$241.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.36
|
| Rate for Payer: Healthscope Commercial |
$310.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$259.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.63
|
| Rate for Payer: PHP Commercial |
$293.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.54
|
| Rate for Payer: Priority Health SBD |
$217.63
|
| Rate for Payer: UMR Bronson Commercial |
$127.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$259.09
|
|
