|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
OP
|
$258.50
|
|
|
Service Code
|
NDC 63739079510
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.64 |
| Max. Negotiated Rate |
$232.65 |
| Rate for Payer: Aetna American Axle |
$168.03
|
| Rate for Payer: Aetna Commercial |
$219.72
|
| Rate for Payer: Aetna Medicare |
$129.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.03
|
| Rate for Payer: BCBS Complete |
$103.40
|
| Rate for Payer: Cash Price |
$206.80
|
| Rate for Payer: Cofinity Commercial |
$180.95
|
| Rate for Payer: Cofinity Commercial |
$222.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$180.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.80
|
| Rate for Payer: Healthscope Commercial |
$232.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.72
|
| Rate for Payer: PHP Commercial |
$219.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.03
|
| Rate for Payer: Priority Health SBD |
$162.85
|
| Rate for Payer: UMR Bronson Commercial |
$95.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.88
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$258.50
|
|
|
Service Code
|
NDC 63739079510
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$113.74 |
| Max. Negotiated Rate |
$232.65 |
| Rate for Payer: Aetna American Axle |
$168.03
|
| Rate for Payer: Aetna Commercial |
$219.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.03
|
| Rate for Payer: Cash Price |
$206.80
|
| Rate for Payer: Cofinity Commercial |
$180.95
|
| Rate for Payer: Cofinity Commercial |
$222.31
|
| Rate for Payer: Cofinity Medicare Advantage |
$180.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.80
|
| Rate for Payer: Healthscope Commercial |
$232.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$180.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$193.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.72
|
| Rate for Payer: PHP Commercial |
$219.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.03
|
| Rate for Payer: Priority Health SBD |
$162.85
|
| Rate for Payer: UMR Bronson Commercial |
$113.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$193.88
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
OP
|
$3.46
|
|
|
Service Code
|
NDC 68084085911
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Aetna American Axle |
$2.25
|
| Rate for Payer: Aetna Commercial |
$2.94
|
| Rate for Payer: Aetna Medicare |
$1.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.25
|
| Rate for Payer: BCBS Complete |
$1.38
|
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Commercial |
$2.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.42
|
| 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 Commercial |
$2.94
|
| Rate for Payer: PHP Commercial |
$2.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.25
|
| Rate for Payer: Priority Health SBD |
$2.18
|
| Rate for Payer: UMR Bronson Commercial |
$1.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.60
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$3.46
|
|
|
Service Code
|
NDC 68084085911
|
| 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: Cofinity Medicare Advantage |
$2.42
|
| 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 Commercial |
$2.94
|
| Rate for Payer: PHP Commercial |
$2.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.25
|
| 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 500 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$15.51
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
77195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$13.96 |
| Rate for Payer: Aetna American Axle |
$10.08
|
| Rate for Payer: Aetna American Axle |
$11.45
|
| Rate for Payer: Aetna American Axle |
$9.33
|
| Rate for Payer: Aetna American Axle |
$12.82
|
| Rate for Payer: Aetna American Axle |
$13.40
|
| Rate for Payer: Aetna American Axle |
$11.78
|
| Rate for Payer: Aetna American Axle |
$146.41
|
| Rate for Payer: Aetna American Axle |
$16.11
|
| Rate for Payer: Aetna American Axle |
$18.57
|
| Rate for Payer: Aetna American Axle |
$48.84
|
| Rate for Payer: Aetna American Axle |
$10.37
|
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Aetna Commercial |
$191.46
|
| Rate for Payer: Aetna Commercial |
$13.56
|
| Rate for Payer: Aetna Commercial |
$63.87
|
| Rate for Payer: Aetna Commercial |
$16.76
|
| Rate for Payer: Aetna Commercial |
$14.98
|
| Rate for Payer: Aetna Commercial |
$13.18
|
| Rate for Payer: Aetna Commercial |
$12.21
|
| Rate for Payer: Aetna Commercial |
$24.28
|
| Rate for Payer: Aetna Commercial |
$15.41
|
| Rate for Payer: Aetna Commercial |
$21.07
|
| 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) |
$11.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.37
|
| Rate for Payer: Cash Price |
$15.78
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cash Price |
$12.76
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cash Price |
$60.11
|
| Rate for Payer: Cash Price |
$22.86
|
| Rate for Payer: Cash Price |
$19.83
|
| Rate for Payer: Cash Price |
$180.20
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cofinity Commercial |
$12.33
|
| Rate for Payer: Cofinity Commercial |
$157.68
|
| Rate for Payer: Cofinity Commercial |
$12.35
|
| Rate for Payer: Cofinity Commercial |
$13.72
|
| Rate for Payer: Cofinity Commercial |
$13.34
|
| Rate for Payer: Cofinity Commercial |
$10.86
|
| Rate for Payer: Cofinity Commercial |
$11.16
|
| Rate for Payer: Cofinity Commercial |
$16.96
|
| Rate for Payer: Cofinity Commercial |
$12.69
|
| Rate for Payer: Cofinity Commercial |
$15.59
|
| Rate for Payer: Cofinity Commercial |
$20.00
|
| Rate for Payer: Cofinity Commercial |
$10.05
|
| Rate for Payer: Cofinity Commercial |
$17.72
|
| Rate for Payer: Cofinity Commercial |
$14.43
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Commercial |
$64.62
|
| Rate for Payer: Cofinity Commercial |
$52.60
|
| Rate for Payer: Cofinity Commercial |
$15.15
|
| Rate for Payer: Cofinity Commercial |
$21.32
|
| Rate for Payer: Cofinity Commercial |
$17.35
|
| Rate for Payer: Cofinity Commercial |
$24.57
|
| Rate for Payer: Cofinity Commercial |
$193.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.16
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$52.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.86
|
| Rate for Payer: Healthscope Commercial |
$17.75
|
| Rate for Payer: Healthscope Commercial |
$12.92
|
| Rate for Payer: Healthscope Commercial |
$13.96
|
| Rate for Payer: Healthscope Commercial |
$14.36
|
| Rate for Payer: Healthscope Commercial |
$15.86
|
| Rate for Payer: Healthscope Commercial |
$16.32
|
| Rate for Payer: Healthscope Commercial |
$18.55
|
| Rate for Payer: Healthscope Commercial |
$202.72
|
| Rate for Payer: Healthscope Commercial |
$22.31
|
| Rate for Payer: Healthscope Commercial |
$25.71
|
| Rate for Payer: Healthscope Commercial |
$67.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.60
|
| 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 |
$11.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.87
|
| Rate for Payer: PHP Commercial |
$12.21
|
| Rate for Payer: PHP Commercial |
$15.41
|
| Rate for Payer: PHP Commercial |
$21.07
|
| Rate for Payer: PHP Commercial |
$14.98
|
| Rate for Payer: PHP Commercial |
$16.76
|
| Rate for Payer: PHP Commercial |
$24.28
|
| Rate for Payer: PHP Commercial |
$17.52
|
| Rate for Payer: PHP Commercial |
$63.87
|
| Rate for Payer: PHP Commercial |
$13.18
|
| Rate for Payer: PHP Commercial |
$13.56
|
| Rate for Payer: PHP Commercial |
$191.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.82
|
| Rate for Payer: Priority Health SBD |
$9.77
|
| Rate for Payer: Priority Health SBD |
$10.05
|
| Rate for Payer: Priority Health SBD |
$18.00
|
| Rate for Payer: Priority Health SBD |
$47.34
|
| Rate for Payer: Priority Health SBD |
$11.42
|
| Rate for Payer: Priority Health SBD |
$12.42
|
| Rate for Payer: Priority Health SBD |
$12.98
|
| Rate for Payer: Priority Health SBD |
$11.10
|
| Rate for Payer: Priority Health SBD |
$15.62
|
| Rate for Payer: Priority Health SBD |
$9.05
|
| Rate for Payer: Priority Health SBD |
$141.91
|
| Rate for Payer: UMR Bronson Commercial |
$10.91
|
| Rate for Payer: UMR Bronson Commercial |
$6.82
|
| Rate for Payer: UMR Bronson Commercial |
$33.06
|
| Rate for Payer: UMR Bronson Commercial |
$99.11
|
| Rate for Payer: UMR Bronson Commercial |
$7.02
|
| Rate for Payer: UMR Bronson Commercial |
$8.68
|
| Rate for Payer: UMR Bronson Commercial |
$12.57
|
| Rate for Payer: UMR Bronson Commercial |
$6.32
|
| Rate for Payer: UMR Bronson Commercial |
$7.75
|
| Rate for Payer: UMR Bronson Commercial |
$9.07
|
| Rate for Payer: UMR Bronson Commercial |
$7.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.79
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$18.13
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
77195
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$16.32 |
| Rate for Payer: Aetna American Axle |
$11.78
|
| Rate for Payer: Aetna American Axle |
$13.40
|
| Rate for Payer: Aetna American Axle |
$10.08
|
| Rate for Payer: Aetna American Axle |
$12.82
|
| Rate for Payer: Aetna American Axle |
$11.45
|
| Rate for Payer: Aetna American Axle |
$9.33
|
| Rate for Payer: Aetna American Axle |
$48.84
|
| Rate for Payer: Aetna American Axle |
$10.37
|
| Rate for Payer: Aetna American Axle |
$18.57
|
| Rate for Payer: Aetna American Axle |
$16.11
|
| Rate for Payer: Aetna American Axle |
$146.41
|
| Rate for Payer: Aetna Commercial |
$17.52
|
| Rate for Payer: Aetna Commercial |
$13.18
|
| Rate for Payer: Aetna Commercial |
$12.21
|
| Rate for Payer: Aetna Commercial |
$16.76
|
| Rate for Payer: Aetna Commercial |
$63.87
|
| Rate for Payer: Aetna Commercial |
$14.98
|
| Rate for Payer: Aetna Commercial |
$15.41
|
| Rate for Payer: Aetna Commercial |
$191.46
|
| Rate for Payer: Aetna Commercial |
$13.56
|
| Rate for Payer: Aetna Commercial |
$21.07
|
| Rate for Payer: Aetna Commercial |
$24.28
|
| Rate for Payer: Aetna Medicare |
$8.81
|
| Rate for Payer: Aetna Medicare |
$7.97
|
| Rate for Payer: Aetna Medicare |
$112.62
|
| Rate for Payer: Aetna Medicare |
$37.57
|
| Rate for Payer: Aetna Medicare |
$9.86
|
| Rate for Payer: Aetna Medicare |
$7.18
|
| Rate for Payer: Aetna Medicare |
$10.30
|
| Rate for Payer: Aetna Medicare |
$14.29
|
| Rate for Payer: Aetna Medicare |
$9.06
|
| Rate for Payer: Aetna Medicare |
$12.39
|
| Rate for Payer: Aetna Medicare |
$7.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.40
|
| Rate for Payer: BCBS Complete |
$90.10
|
| Rate for Payer: BCBS Complete |
$9.92
|
| Rate for Payer: BCBS Complete |
$30.06
|
| Rate for Payer: BCBS Complete |
$7.05
|
| Rate for Payer: BCBS Complete |
$7.89
|
| Rate for Payer: BCBS Complete |
$8.24
|
| Rate for Payer: BCBS Complete |
$5.74
|
| Rate for Payer: BCBS Complete |
$11.43
|
| Rate for Payer: BCBS Complete |
$6.38
|
| Rate for Payer: BCBS Complete |
$7.25
|
| Rate for Payer: BCBS Complete |
$6.20
|
| Rate for Payer: Cash Price |
$12.76
|
| Rate for Payer: Cash Price |
$22.86
|
| Rate for Payer: Cash Price |
$19.83
|
| Rate for Payer: Cash Price |
$180.20
|
| Rate for Payer: Cash Price |
$14.10
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cash Price |
$11.49
|
| Rate for Payer: Cash Price |
$15.78
|
| Rate for Payer: Cash Price |
$14.50
|
| Rate for Payer: Cash Price |
$16.49
|
| Rate for Payer: Cash Price |
$60.11
|
| Rate for Payer: Cofinity Commercial |
$15.15
|
| Rate for Payer: Cofinity Commercial |
$12.69
|
| Rate for Payer: Cofinity Commercial |
$15.59
|
| Rate for Payer: Cofinity Commercial |
$17.72
|
| Rate for Payer: Cofinity Commercial |
$14.43
|
| Rate for Payer: Cofinity Commercial |
$21.32
|
| Rate for Payer: Cofinity Commercial |
$17.35
|
| Rate for Payer: Cofinity Commercial |
$20.00
|
| Rate for Payer: Cofinity Commercial |
$16.96
|
| Rate for Payer: Cofinity Commercial |
$11.16
|
| Rate for Payer: Cofinity Commercial |
$13.72
|
| Rate for Payer: Cofinity Commercial |
$10.05
|
| Rate for Payer: Cofinity Commercial |
$193.72
|
| Rate for Payer: Cofinity Commercial |
$157.68
|
| Rate for Payer: Cofinity Commercial |
$24.57
|
| Rate for Payer: Cofinity Commercial |
$12.33
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Cofinity Commercial |
$13.34
|
| Rate for Payer: Cofinity Commercial |
$64.62
|
| Rate for Payer: Cofinity Commercial |
$12.35
|
| Rate for Payer: Cofinity Commercial |
$52.60
|
| Rate for Payer: Cofinity Commercial |
$10.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$157.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.80
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.05
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$52.60
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.11
|
| Rate for Payer: Healthscope Commercial |
$14.36
|
| Rate for Payer: Healthscope Commercial |
$16.32
|
| Rate for Payer: Healthscope Commercial |
$202.72
|
| 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 |
$12.92
|
| Rate for Payer: Healthscope Commercial |
$15.86
|
| Rate for Payer: Healthscope Commercial |
$13.96
|
| Rate for Payer: Healthscope Commercial |
$25.71
|
| Rate for Payer: Healthscope Commercial |
$67.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.00
|
| 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 |
$11.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$157.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.43
|
| 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: Lakeland Regional Health Systems Commercial |
$18.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$168.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.52
|
| Rate for Payer: PHP Commercial |
$21.07
|
| Rate for Payer: PHP Commercial |
$13.56
|
| Rate for Payer: PHP Commercial |
$191.46
|
| Rate for Payer: PHP Commercial |
$15.41
|
| Rate for Payer: PHP Commercial |
$16.76
|
| Rate for Payer: PHP Commercial |
$12.21
|
| Rate for Payer: PHP Commercial |
$63.87
|
| Rate for Payer: PHP Commercial |
$24.28
|
| Rate for Payer: PHP Commercial |
$13.18
|
| Rate for Payer: PHP Commercial |
$14.98
|
| Rate for Payer: PHP Commercial |
$17.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$146.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.57
|
| Rate for Payer: Priority Health SBD |
$9.77
|
| Rate for Payer: Priority Health SBD |
$12.98
|
| Rate for Payer: Priority Health SBD |
$11.42
|
| Rate for Payer: Priority Health SBD |
$12.42
|
| Rate for Payer: Priority Health SBD |
$18.00
|
| Rate for Payer: Priority Health SBD |
$15.62
|
| Rate for Payer: Priority Health SBD |
$47.34
|
| Rate for Payer: Priority Health SBD |
$10.05
|
| Rate for Payer: Priority Health SBD |
$9.05
|
| Rate for Payer: Priority Health SBD |
$141.91
|
| Rate for Payer: Priority Health SBD |
$11.10
|
| Rate for Payer: UMR Bronson Commercial |
$83.34
|
| Rate for Payer: UMR Bronson Commercial |
$5.90
|
| Rate for Payer: UMR Bronson Commercial |
$5.31
|
| Rate for Payer: UMR Bronson Commercial |
$7.63
|
| Rate for Payer: UMR Bronson Commercial |
$10.57
|
| Rate for Payer: UMR Bronson Commercial |
$27.80
|
| Rate for Payer: UMR Bronson Commercial |
$6.71
|
| Rate for Payer: UMR Bronson Commercial |
$5.74
|
| Rate for Payer: UMR Bronson Commercial |
$6.52
|
| Rate for Payer: UMR Bronson Commercial |
$7.30
|
| Rate for Payer: UMR Bronson Commercial |
$9.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$168.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.79
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 51079082101
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna American Axle |
$1.69
|
| Rate for Payer: Aetna Commercial |
$2.21
|
| Rate for Payer: Aetna Medicare |
$1.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.69
|
| Rate for Payer: BCBS Complete |
$1.04
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cofinity Commercial |
$1.82
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.08
|
| Rate for Payer: Healthscope Commercial |
$2.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.21
|
| Rate for Payer: PHP Commercial |
$2.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.69
|
| Rate for Payer: Priority Health SBD |
$1.64
|
| Rate for Payer: UMR Bronson Commercial |
$0.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.95
|
|
|
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 Commercial |
$166.78
|
| Rate for Payer: Cofinity Commercial |
$204.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$166.78
|
| 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: PHP Commercial |
$202.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.87
|
| Rate for Payer: Priority Health SBD |
$150.10
|
| Rate for Payer: UMR Bronson Commercial |
$88.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.69
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
OP
|
$298.92
|
|
|
Service Code
|
NDC 31722053712
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.60 |
| Max. Negotiated Rate |
$269.03 |
| Rate for Payer: Aetna American Axle |
$194.30
|
| Rate for Payer: Aetna Commercial |
$254.08
|
| Rate for Payer: Aetna Medicare |
$149.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$194.30
|
| Rate for Payer: BCBS Complete |
$119.57
|
| Rate for Payer: Cash Price |
$239.14
|
| Rate for Payer: Cofinity Commercial |
$209.24
|
| Rate for Payer: Cofinity Commercial |
$257.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$209.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$239.14
|
| Rate for Payer: Healthscope Commercial |
$269.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$209.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$224.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$254.08
|
| Rate for Payer: PHP Commercial |
$254.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.30
|
| Rate for Payer: Priority Health SBD |
$188.32
|
| Rate for Payer: UMR Bronson Commercial |
$110.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$224.19
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$259.35
|
|
|
Service Code
|
NDC 51079082120
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.11 |
| Max. Negotiated Rate |
$233.41 |
| Rate for Payer: Aetna American Axle |
$168.58
|
| Rate for Payer: Aetna Commercial |
$220.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.58
|
| Rate for Payer: Cash Price |
$207.48
|
| Rate for Payer: Cofinity Commercial |
$181.54
|
| Rate for Payer: Cofinity Commercial |
$223.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$181.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$207.48
|
| Rate for Payer: Healthscope Commercial |
$233.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$181.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$194.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$220.45
|
| Rate for Payer: PHP Commercial |
$220.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.58
|
| Rate for Payer: Priority Health SBD |
$163.39
|
| Rate for Payer: UMR Bronson Commercial |
$114.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$194.51
|
|
|
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 Commercial |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$323.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$263.20
|
| 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: PHP Commercial |
$319.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$244.40
|
| Rate for Payer: Priority Health SBD |
$236.88
|
| Rate for Payer: UMR Bronson Commercial |
$139.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$282.00
|
|
|
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 Commercial |
$166.78
|
| Rate for Payer: Cofinity Commercial |
$204.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$166.78
|
| 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: PHP Commercial |
$202.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.87
|
| 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 500 MG TABLET
|
Facility
|
OP
|
$197.40
|
|
|
Service Code
|
NDC 68180011316
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.04 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna American Axle |
$128.31
|
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna Medicare |
$98.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: BCBS Complete |
$78.96
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| Rate for Payer: UMR Bronson Commercial |
$73.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
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 Commercial |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$339.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$276.36
|
| 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: PHP Commercial |
$335.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.62
|
| 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
|
$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 Commercial |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$339.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$276.36
|
| 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: PHP Commercial |
$335.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$256.62
|
| Rate for Payer: Priority Health SBD |
$248.72
|
| Rate for Payer: UMR Bronson Commercial |
$146.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$296.10
|
|
|
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 Commercial |
$252.97
|
| Rate for Payer: Cofinity Commercial |
$310.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$252.97
|
| 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: PHP Commercial |
$307.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.90
|
| 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
|
$2.60
|
|
|
Service Code
|
NDC 51079082101
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna American Axle |
$1.69
|
| Rate for Payer: Aetna Commercial |
$2.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.69
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cofinity Commercial |
$1.82
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.08
|
| Rate for Payer: Healthscope Commercial |
$2.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.21
|
| Rate for Payer: PHP Commercial |
$2.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.69
|
| Rate for Payer: Priority Health SBD |
$1.64
|
| Rate for Payer: UMR Bronson Commercial |
$1.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.95
|
|
|
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 Commercial |
$132.26
|
| Rate for Payer: Cofinity Commercial |
$162.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$132.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.15
|
| Rate for Payer: Healthscope Commercial |
$170.05
|
| Rate for Payer: 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: PHP Commercial |
$160.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.81
|
| Rate for Payer: Priority Health SBD |
$119.03
|
| 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
|
$197.40
|
|
|
Service Code
|
NDC 68180011316
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.86 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna American Axle |
$128.31
|
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| Rate for Payer: UMR Bronson Commercial |
$86.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
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 Commercial |
$252.97
|
| Rate for Payer: Cofinity Commercial |
$310.79
|
| Rate for Payer: Cofinity Medicare Advantage |
$252.97
|
| 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: PHP Commercial |
$307.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$234.90
|
| Rate for Payer: Priority Health SBD |
$227.67
|
| 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
|
$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 Commercial |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$323.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$263.20
|
| 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: PHP Commercial |
$319.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$244.40
|
| 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
|
$259.35
|
|
|
Service Code
|
NDC 51079082120
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.96 |
| Max. Negotiated Rate |
$233.41 |
| Rate for Payer: Aetna American Axle |
$168.58
|
| Rate for Payer: Aetna Commercial |
$220.45
|
| Rate for Payer: Aetna Medicare |
$129.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.58
|
| Rate for Payer: BCBS Complete |
$103.74
|
| Rate for Payer: Cash Price |
$207.48
|
| Rate for Payer: Cofinity Commercial |
$181.54
|
| Rate for Payer: Cofinity Commercial |
$223.04
|
| Rate for Payer: Cofinity Medicare Advantage |
$181.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$207.48
|
| Rate for Payer: Healthscope Commercial |
$233.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$181.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$194.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$220.45
|
| Rate for Payer: PHP Commercial |
$220.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.58
|
| Rate for Payer: Priority Health SBD |
$163.39
|
| Rate for Payer: UMR Bronson Commercial |
$95.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$194.51
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$298.92
|
|
|
Service Code
|
NDC 31722053712
|
| Hospital Charge Code |
26817
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.52 |
| Max. Negotiated Rate |
$269.03 |
| Rate for Payer: Aetna American Axle |
$194.30
|
| Rate for Payer: Aetna Commercial |
$254.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$194.30
|
| Rate for Payer: Cash Price |
$239.14
|
| Rate for Payer: Cofinity Commercial |
$209.24
|
| Rate for Payer: Cofinity Commercial |
$257.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$209.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$239.14
|
| Rate for Payer: Healthscope Commercial |
$269.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$209.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$224.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$254.08
|
| Rate for Payer: PHP Commercial |
$254.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.30
|
| Rate for Payer: Priority Health SBD |
$188.32
|
| Rate for Payer: UMR Bronson Commercial |
$131.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$224.19
|
|
|
LEVETIRACETAM 500 MG TABLET
|
Facility
|
IP
|
$188.94
|
|
|
Service Code
|
NDC 65862024608
|
| 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: Cofinity Medicare Advantage |
$132.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.15
|
| Rate for Payer: Healthscope Commercial |
$170.05
|
| Rate for Payer: 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: PHP Commercial |
$160.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.81
|
| 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 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 Commercial |
$154.81
|
| Rate for Payer: Cofinity Commercial |
$190.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$154.81
|
| 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: PHP Commercial |
$187.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$143.75
|
| Rate for Payer: Priority Health SBD |
$139.33
|
| Rate for Payer: UMR Bronson Commercial |
$81.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$165.87
|
|
