|
LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$19,492.67
|
|
|
Service Code
|
HCPCS J1950
|
| Hospital Charge Code |
21044
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12,670.24 |
| Max. Negotiated Rate |
$19,492.67 |
| Rate for Payer: Aetna Commercial |
$17,543.40
|
| Rate for Payer: ASR ASR |
$18,907.89
|
| Rate for Payer: ASR Commercial |
$18,907.89
|
| Rate for Payer: BCBS Trust/PPO |
$15,884.58
|
| Rate for Payer: BCN Commercial |
$15,112.67
|
| Rate for Payer: Cash Price |
$15,594.14
|
| Rate for Payer: Cofinity Commercial |
$18,323.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15,594.14
|
| Rate for Payer: Healthscope Commercial |
$19,492.67
|
| Rate for Payer: Healthscope Whirlpool |
$18,907.89
|
| Rate for Payer: Mclaren Commercial |
$17,543.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16,568.77
|
| Rate for Payer: Nomi Health Commercial |
$15,983.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12,670.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17,153.55
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$16,322.57
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$16,322.57 |
| Rate for Payer: Aetna Commercial |
$14,690.31
|
| Rate for Payer: Aetna Medicare |
$180.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$225.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$225.99
|
| Rate for Payer: ASR ASR |
$15,832.89
|
| Rate for Payer: ASR Commercial |
$15,832.89
|
| Rate for Payer: BCBS Complete |
$101.75
|
| Rate for Payer: BCBS MAPPO |
$180.79
|
| Rate for Payer: BCBS Trust/PPO |
$13,366.55
|
| Rate for Payer: BCN Commercial |
$12,654.89
|
| Rate for Payer: BCN Medicare Advantage |
$180.79
|
| Rate for Payer: Cash Price |
$13,058.05
|
| Rate for Payer: Cash Price |
$13,058.05
|
| Rate for Payer: Cofinity Commercial |
$15,343.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,058.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$180.79
|
| Rate for Payer: Healthscope Commercial |
$16,322.57
|
| Rate for Payer: Healthscope Whirlpool |
$15,832.89
|
| Rate for Payer: Humana Choice PPO Medicare |
$180.79
|
| Rate for Payer: Mclaren Commercial |
$14,690.31
|
| Rate for Payer: Mclaren Medicaid |
$96.90
|
| Rate for Payer: Mclaren Medicare |
$180.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$189.83
|
| Rate for Payer: Meridian Medicaid |
$101.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,874.18
|
| Rate for Payer: Nomi Health Commercial |
$13,384.51
|
| Rate for Payer: PACE Medicare |
$171.75
|
| Rate for Payer: PACE SWMI |
$180.79
|
| Rate for Payer: PHP Commercial |
$198.87
|
| Rate for Payer: PHP Medicaid |
$96.90
|
| Rate for Payer: PHP Medicare Advantage |
$180.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,609.67
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$178.79
|
| Rate for Payer: Priority Health Medicare |
$180.79
|
| Rate for Payer: Priority Health Narrow Network |
$143.03
|
| Rate for Payer: Railroad Medicare Medicare |
$180.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14,363.86
|
| Rate for Payer: UHC Dual Complete DSNP |
$180.79
|
| Rate for Payer: UHC Exchange |
$280.22
|
| Rate for Payer: UHC Medicare Advantage |
$180.79
|
| Rate for Payer: UHCCP DNSP |
$180.79
|
| Rate for Payer: UHCCP Medicaid |
$96.90
|
| Rate for Payer: VA VA |
$180.79
|
|
|
LEUPROLIDE 22.5 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$16,322.57
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
21045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10,609.67 |
| Max. Negotiated Rate |
$16,322.57 |
| Rate for Payer: Aetna Commercial |
$14,690.31
|
| Rate for Payer: ASR ASR |
$15,832.89
|
| Rate for Payer: ASR Commercial |
$15,832.89
|
| Rate for Payer: BCBS Trust/PPO |
$13,301.26
|
| Rate for Payer: BCN Commercial |
$12,654.89
|
| Rate for Payer: Cash Price |
$13,058.05
|
| Rate for Payer: Cofinity Commercial |
$15,343.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13,058.06
|
| Rate for Payer: Healthscope Commercial |
$16,322.57
|
| Rate for Payer: Healthscope Whirlpool |
$15,832.89
|
| Rate for Payer: Mclaren Commercial |
$14,690.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13,874.18
|
| Rate for Payer: Nomi Health Commercial |
$13,384.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10,609.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14,363.86
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
OP
|
$2,188.80
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
40801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$2,188.80 |
| Rate for Payer: Aetna Commercial |
$1,969.92
|
| Rate for Payer: Aetna Medicare |
$180.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$225.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$225.99
|
| Rate for Payer: ASR ASR |
$2,123.14
|
| Rate for Payer: ASR Commercial |
$2,123.14
|
| Rate for Payer: BCBS Complete |
$101.75
|
| Rate for Payer: BCBS MAPPO |
$180.79
|
| Rate for Payer: BCBS Trust/PPO |
$1,792.41
|
| Rate for Payer: BCN Commercial |
$1,696.98
|
| Rate for Payer: BCN Medicare Advantage |
$180.79
|
| Rate for Payer: Cash Price |
$1,751.04
|
| Rate for Payer: Cash Price |
$1,751.04
|
| Rate for Payer: Cofinity Commercial |
$2,057.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,751.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$180.79
|
| Rate for Payer: Healthscope Commercial |
$2,188.80
|
| Rate for Payer: Healthscope Whirlpool |
$2,123.14
|
| Rate for Payer: Humana Choice PPO Medicare |
$180.79
|
| Rate for Payer: Mclaren Commercial |
$1,969.92
|
| Rate for Payer: Mclaren Medicaid |
$96.90
|
| Rate for Payer: Mclaren Medicare |
$180.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$189.83
|
| Rate for Payer: Meridian Medicaid |
$101.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,860.48
|
| Rate for Payer: Nomi Health Commercial |
$1,794.82
|
| Rate for Payer: PACE Medicare |
$171.75
|
| Rate for Payer: PACE SWMI |
$180.79
|
| Rate for Payer: PHP Commercial |
$198.87
|
| Rate for Payer: PHP Medicaid |
$96.90
|
| Rate for Payer: PHP Medicare Advantage |
$180.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,422.72
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$178.79
|
| Rate for Payer: Priority Health Medicare |
$180.79
|
| Rate for Payer: Priority Health Narrow Network |
$143.03
|
| Rate for Payer: Railroad Medicare Medicare |
$180.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,926.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$180.79
|
| Rate for Payer: UHC Exchange |
$280.22
|
| Rate for Payer: UHC Medicare Advantage |
$180.79
|
| Rate for Payer: UHCCP DNSP |
$180.79
|
| Rate for Payer: UHCCP Medicaid |
$96.90
|
| Rate for Payer: VA VA |
$180.79
|
|
|
LEUPROLIDE ACETATE 45 MG (6 MONTH) SUBCUTANEOUS SYRINGE
|
Facility
|
IP
|
$2,188.80
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
40801
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,422.72 |
| Max. Negotiated Rate |
$2,188.80 |
| Rate for Payer: Aetna Commercial |
$1,969.92
|
| Rate for Payer: ASR ASR |
$2,123.14
|
| Rate for Payer: ASR Commercial |
$2,123.14
|
| Rate for Payer: BCBS Trust/PPO |
$1,783.65
|
| Rate for Payer: BCN Commercial |
$1,696.98
|
| Rate for Payer: Cash Price |
$1,751.04
|
| Rate for Payer: Cofinity Commercial |
$2,057.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,751.04
|
| Rate for Payer: Healthscope Commercial |
$2,188.80
|
| Rate for Payer: Healthscope Whirlpool |
$2,123.14
|
| Rate for Payer: Mclaren Commercial |
$1,969.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,860.48
|
| Rate for Payer: Nomi Health Commercial |
$1,794.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,422.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1,926.14
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
IP
|
$32,645.70
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152942
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21,219.70 |
| Max. Negotiated Rate |
$32,645.70 |
| Rate for Payer: Aetna Commercial |
$29,381.13
|
| Rate for Payer: ASR ASR |
$31,666.33
|
| Rate for Payer: ASR Commercial |
$31,666.33
|
| Rate for Payer: BCBS Trust/PPO |
$26,602.98
|
| Rate for Payer: BCN Commercial |
$25,310.21
|
| Rate for Payer: Cash Price |
$26,116.56
|
| Rate for Payer: Cofinity Commercial |
$30,686.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26,116.56
|
| Rate for Payer: Healthscope Commercial |
$32,645.70
|
| Rate for Payer: Healthscope Whirlpool |
$31,666.33
|
| Rate for Payer: Mclaren Commercial |
$29,381.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27,748.84
|
| Rate for Payer: Nomi Health Commercial |
$26,769.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21,219.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28,728.22
|
|
|
LEUPROLIDE ACETATE (6 MONTH) 45 MG INTRAMUSCULAR SYRINGE KIT
|
Facility
|
OP
|
$32,645.70
|
|
|
Service Code
|
HCPCS J9217
|
| Hospital Charge Code |
152942
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$96.90 |
| Max. Negotiated Rate |
$32,645.70 |
| Rate for Payer: Aetna Commercial |
$29,381.13
|
| Rate for Payer: Aetna Medicare |
$180.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$225.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$225.99
|
| Rate for Payer: ASR ASR |
$31,666.33
|
| Rate for Payer: ASR Commercial |
$31,666.33
|
| Rate for Payer: BCBS Complete |
$101.75
|
| Rate for Payer: BCBS MAPPO |
$180.79
|
| Rate for Payer: BCBS Trust/PPO |
$26,733.56
|
| Rate for Payer: BCN Commercial |
$25,310.21
|
| Rate for Payer: BCN Medicare Advantage |
$180.79
|
| Rate for Payer: Cash Price |
$26,116.56
|
| Rate for Payer: Cash Price |
$26,116.56
|
| Rate for Payer: Cofinity Commercial |
$30,686.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26,116.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$180.79
|
| Rate for Payer: Healthscope Commercial |
$32,645.70
|
| Rate for Payer: Healthscope Whirlpool |
$31,666.33
|
| Rate for Payer: Humana Choice PPO Medicare |
$180.79
|
| Rate for Payer: Mclaren Commercial |
$29,381.13
|
| Rate for Payer: Mclaren Medicaid |
$96.90
|
| Rate for Payer: Mclaren Medicare |
$180.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$189.83
|
| Rate for Payer: Meridian Medicaid |
$101.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$207.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27,748.84
|
| Rate for Payer: Nomi Health Commercial |
$26,769.47
|
| Rate for Payer: PACE Medicare |
$171.75
|
| Rate for Payer: PACE SWMI |
$180.79
|
| Rate for Payer: PHP Commercial |
$198.87
|
| Rate for Payer: PHP Medicaid |
$96.90
|
| Rate for Payer: PHP Medicare Advantage |
$180.79
|
| Rate for Payer: Priority Health Choice Medicaid |
$96.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21,219.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$178.79
|
| Rate for Payer: Priority Health Medicare |
$180.79
|
| Rate for Payer: Priority Health Narrow Network |
$143.03
|
| Rate for Payer: Railroad Medicare Medicare |
$180.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28,728.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$180.79
|
| Rate for Payer: UHC Exchange |
$280.22
|
| Rate for Payer: UHC Medicare Advantage |
$180.79
|
| Rate for Payer: UHCCP DNSP |
$180.79
|
| Rate for Payer: UHCCP Medicaid |
$96.90
|
| Rate for Payer: VA VA |
$180.79
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
OP
|
$345.45
|
|
|
Service Code
|
NDC 68084085901
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.18 |
| Max. Negotiated Rate |
$345.45 |
| Rate for Payer: Aetna Commercial |
$310.90
|
| Rate for Payer: Aetna Medicare |
$172.72
|
| Rate for Payer: ASR ASR |
$335.09
|
| Rate for Payer: ASR Commercial |
$335.09
|
| Rate for Payer: BCBS Complete |
$138.18
|
| Rate for Payer: BCBS Trust/PPO |
$282.89
|
| Rate for Payer: BCN Commercial |
$267.83
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$324.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.36
|
| Rate for Payer: Healthscope Commercial |
$345.45
|
| Rate for Payer: Healthscope Whirlpool |
$335.09
|
| Rate for Payer: Mclaren Commercial |
$310.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.63
|
| Rate for Payer: Nomi Health Commercial |
$283.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$302.68
|
| Rate for Payer: Priority Health Narrow Network |
$242.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$304.00
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
OP
|
$291.40
|
|
|
Service Code
|
NDC 00904712361
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.56 |
| Max. Negotiated Rate |
$291.40 |
| Rate for Payer: Aetna Commercial |
$262.26
|
| Rate for Payer: Aetna Medicare |
$145.70
|
| Rate for Payer: ASR ASR |
$282.66
|
| Rate for Payer: ASR Commercial |
$282.66
|
| Rate for Payer: BCBS Complete |
$116.56
|
| Rate for Payer: BCBS Trust/PPO |
$238.63
|
| Rate for Payer: BCN Commercial |
$225.92
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$273.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$291.40
|
| Rate for Payer: Healthscope Whirlpool |
$282.66
|
| Rate for Payer: Mclaren Commercial |
$262.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Nomi Health Commercial |
$238.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$255.32
|
| Rate for Payer: Priority Health Narrow Network |
$204.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$256.43
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
OP
|
$3.46
|
|
|
Service Code
|
NDC 68084085911
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Aetna Commercial |
$3.11
|
| Rate for Payer: Aetna Medicare |
$1.73
|
| Rate for Payer: ASR ASR |
$3.36
|
| Rate for Payer: ASR Commercial |
$3.36
|
| Rate for Payer: BCBS Complete |
$1.38
|
| Rate for Payer: BCBS Trust/PPO |
$2.83
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$3.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.77
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Healthscope Whirlpool |
$3.36
|
| Rate for Payer: Mclaren Commercial |
$3.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.94
|
| Rate for Payer: Nomi Health Commercial |
$2.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.03
|
| Rate for Payer: Priority Health Narrow Network |
$2.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.04
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$3.46
|
|
|
Service Code
|
NDC 68084085911
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.25 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Aetna Commercial |
$3.11
|
| Rate for Payer: ASR ASR |
$3.36
|
| Rate for Payer: ASR Commercial |
$3.36
|
| Rate for Payer: BCBS Trust/PPO |
$2.82
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$3.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.77
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Healthscope Whirlpool |
$3.36
|
| Rate for Payer: Mclaren Commercial |
$3.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.94
|
| Rate for Payer: Nomi Health Commercial |
$2.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.04
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$345.45
|
|
|
Service Code
|
NDC 68084085901
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.54 |
| Max. Negotiated Rate |
$345.45 |
| Rate for Payer: Aetna Commercial |
$310.90
|
| Rate for Payer: ASR ASR |
$335.09
|
| Rate for Payer: ASR Commercial |
$335.09
|
| Rate for Payer: BCBS Trust/PPO |
$281.51
|
| Rate for Payer: BCN Commercial |
$267.83
|
| Rate for Payer: Cash Price |
$276.36
|
| Rate for Payer: Cofinity Commercial |
$324.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$276.36
|
| Rate for Payer: Healthscope Commercial |
$345.45
|
| Rate for Payer: Healthscope Whirlpool |
$335.09
|
| Rate for Payer: Mclaren Commercial |
$310.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.63
|
| Rate for Payer: Nomi Health Commercial |
$283.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$304.00
|
|
|
LEVETIRACETAM 250 MG TABLET
|
Facility
|
IP
|
$291.40
|
|
|
Service Code
|
NDC 00904712361
|
| Hospital Charge Code |
26816
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$189.41 |
| Max. Negotiated Rate |
$291.40 |
| Rate for Payer: Aetna Commercial |
$262.26
|
| Rate for Payer: ASR ASR |
$282.66
|
| Rate for Payer: ASR Commercial |
$282.66
|
| Rate for Payer: BCBS Trust/PPO |
$237.46
|
| Rate for Payer: BCN Commercial |
$225.92
|
| Rate for Payer: Cash Price |
$233.12
|
| Rate for Payer: Cofinity Commercial |
$273.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.12
|
| Rate for Payer: Healthscope Commercial |
$291.40
|
| Rate for Payer: Healthscope Whirlpool |
$282.66
|
| Rate for Payer: Mclaren Commercial |
$262.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.69
|
| Rate for Payer: Nomi Health Commercial |
$238.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$256.43
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$12.38
|
|
|
Service Code
|
NDC 00121479905
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.05 |
| Max. Negotiated Rate |
$12.38 |
| Rate for Payer: Aetna Commercial |
$11.14
|
| Rate for Payer: ASR ASR |
$12.01
|
| Rate for Payer: ASR Commercial |
$12.01
|
| Rate for Payer: BCBS Trust/PPO |
$10.09
|
| Rate for Payer: BCN Commercial |
$9.60
|
| Rate for Payer: Cash Price |
$9.91
|
| Rate for Payer: Cofinity Commercial |
$11.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.90
|
| Rate for Payer: Healthscope Commercial |
$12.38
|
| Rate for Payer: Healthscope Whirlpool |
$12.01
|
| Rate for Payer: Mclaren Commercial |
$11.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.52
|
| Rate for Payer: Nomi Health Commercial |
$10.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.89
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
OP
|
$12.41
|
|
|
Service Code
|
NDC 00904726592
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$12.41 |
| Rate for Payer: Aetna Commercial |
$11.17
|
| Rate for Payer: Aetna Medicare |
$6.20
|
| Rate for Payer: ASR ASR |
$12.04
|
| Rate for Payer: ASR Commercial |
$12.04
|
| Rate for Payer: BCBS Complete |
$4.96
|
| Rate for Payer: BCBS Trust/PPO |
$10.16
|
| Rate for Payer: BCN Commercial |
$9.62
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cofinity Commercial |
$11.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.93
|
| Rate for Payer: Healthscope Commercial |
$12.41
|
| Rate for Payer: Healthscope Whirlpool |
$12.04
|
| Rate for Payer: Mclaren Commercial |
$11.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.55
|
| Rate for Payer: Nomi Health Commercial |
$10.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.87
|
| Rate for Payer: Priority Health Narrow Network |
$8.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.92
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
OP
|
$12.02
|
|
|
Service Code
|
NDC 00904706093
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.81 |
| Max. Negotiated Rate |
$12.02 |
| Rate for Payer: Aetna Commercial |
$10.82
|
| Rate for Payer: Aetna Medicare |
$6.01
|
| Rate for Payer: ASR ASR |
$11.66
|
| Rate for Payer: ASR Commercial |
$11.66
|
| Rate for Payer: BCBS Complete |
$4.81
|
| Rate for Payer: BCBS Trust/PPO |
$9.84
|
| Rate for Payer: BCN Commercial |
$9.32
|
| Rate for Payer: Cash Price |
$9.62
|
| Rate for Payer: Cofinity Commercial |
$11.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.62
|
| Rate for Payer: Healthscope Commercial |
$12.02
|
| Rate for Payer: Healthscope Whirlpool |
$11.66
|
| Rate for Payer: Mclaren Commercial |
$10.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.22
|
| Rate for Payer: Nomi Health Commercial |
$9.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.53
|
| Rate for Payer: Priority Health Narrow Network |
$8.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.58
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$15.53
|
|
|
Service Code
|
NDC 50268047013
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.09 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna Commercial |
$13.98
|
| Rate for Payer: ASR ASR |
$15.06
|
| Rate for Payer: ASR Commercial |
$15.06
|
| Rate for Payer: BCBS Trust/PPO |
$12.66
|
| Rate for Payer: BCN Commercial |
$12.04
|
| Rate for Payer: Cash Price |
$12.42
|
| Rate for Payer: Cofinity Commercial |
$14.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.42
|
| Rate for Payer: Healthscope Commercial |
$15.53
|
| Rate for Payer: Healthscope Whirlpool |
$15.06
|
| Rate for Payer: Mclaren Commercial |
$13.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.20
|
| Rate for Payer: Nomi Health Commercial |
$12.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.67
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
OP
|
$15.53
|
|
|
Service Code
|
NDC 50268047013
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.21 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna Commercial |
$13.98
|
| Rate for Payer: Aetna Medicare |
$7.76
|
| Rate for Payer: ASR ASR |
$15.06
|
| Rate for Payer: ASR Commercial |
$15.06
|
| Rate for Payer: BCBS Complete |
$6.21
|
| Rate for Payer: BCBS Trust/PPO |
$12.72
|
| Rate for Payer: BCN Commercial |
$12.04
|
| Rate for Payer: Cash Price |
$12.42
|
| Rate for Payer: Cofinity Commercial |
$14.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.42
|
| Rate for Payer: Healthscope Commercial |
$15.53
|
| Rate for Payer: Healthscope Whirlpool |
$15.06
|
| Rate for Payer: Mclaren Commercial |
$13.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.20
|
| Rate for Payer: Nomi Health Commercial |
$12.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.61
|
| Rate for Payer: Priority Health Narrow Network |
$10.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.67
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$12.02
|
|
|
Service Code
|
NDC 00904706093
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.81 |
| Max. Negotiated Rate |
$12.02 |
| Rate for Payer: Aetna Commercial |
$10.82
|
| Rate for Payer: ASR ASR |
$11.66
|
| Rate for Payer: ASR Commercial |
$11.66
|
| Rate for Payer: BCBS Trust/PPO |
$9.80
|
| Rate for Payer: BCN Commercial |
$9.32
|
| Rate for Payer: Cash Price |
$9.62
|
| Rate for Payer: Cofinity Commercial |
$11.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.62
|
| Rate for Payer: Healthscope Commercial |
$12.02
|
| Rate for Payer: Healthscope Whirlpool |
$11.66
|
| Rate for Payer: Mclaren Commercial |
$10.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.22
|
| Rate for Payer: Nomi Health Commercial |
$9.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.58
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
OP
|
$12.41
|
|
|
Service Code
|
NDC 00904726541
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.96 |
| Max. Negotiated Rate |
$12.41 |
| Rate for Payer: Aetna Commercial |
$11.17
|
| Rate for Payer: Aetna Medicare |
$6.20
|
| Rate for Payer: ASR ASR |
$12.04
|
| Rate for Payer: ASR Commercial |
$12.04
|
| Rate for Payer: BCBS Complete |
$4.96
|
| Rate for Payer: BCBS Trust/PPO |
$10.16
|
| Rate for Payer: BCN Commercial |
$9.62
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cofinity Commercial |
$11.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.93
|
| Rate for Payer: Healthscope Commercial |
$12.41
|
| Rate for Payer: Healthscope Whirlpool |
$12.04
|
| Rate for Payer: Mclaren Commercial |
$11.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.55
|
| Rate for Payer: Nomi Health Commercial |
$10.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.87
|
| Rate for Payer: Priority Health Narrow Network |
$8.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.92
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
OP
|
$20.24
|
|
|
Service Code
|
NDC 00904706041
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.10 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: Aetna Medicare |
$10.12
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: ASR Commercial |
$19.63
|
| Rate for Payer: BCBS Complete |
$8.10
|
| Rate for Payer: BCBS Trust/PPO |
$16.57
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.20
|
| Rate for Payer: Nomi Health Commercial |
$16.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.73
|
| Rate for Payer: Priority Health Narrow Network |
$14.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$20.24
|
|
|
Service Code
|
NDC 00904706041
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.16 |
| Max. Negotiated Rate |
$20.24 |
| Rate for Payer: Aetna Commercial |
$18.22
|
| Rate for Payer: ASR ASR |
$19.63
|
| Rate for Payer: ASR Commercial |
$19.63
|
| Rate for Payer: BCBS Trust/PPO |
$16.49
|
| Rate for Payer: BCN Commercial |
$15.69
|
| Rate for Payer: Cash Price |
$16.19
|
| Rate for Payer: Cofinity Commercial |
$19.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.19
|
| Rate for Payer: Healthscope Commercial |
$20.24
|
| Rate for Payer: Healthscope Whirlpool |
$19.63
|
| Rate for Payer: Mclaren Commercial |
$18.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.20
|
| Rate for Payer: Nomi Health Commercial |
$16.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.81
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$15.53
|
|
|
Service Code
|
NDC 50268047011
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.09 |
| Max. Negotiated Rate |
$15.53 |
| Rate for Payer: Aetna Commercial |
$13.98
|
| Rate for Payer: ASR ASR |
$15.06
|
| Rate for Payer: ASR Commercial |
$15.06
|
| Rate for Payer: BCBS Trust/PPO |
$12.66
|
| Rate for Payer: BCN Commercial |
$12.04
|
| Rate for Payer: Cash Price |
$12.42
|
| Rate for Payer: Cofinity Commercial |
$14.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.42
|
| Rate for Payer: Healthscope Commercial |
$15.53
|
| Rate for Payer: Healthscope Whirlpool |
$15.06
|
| Rate for Payer: Mclaren Commercial |
$13.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.20
|
| Rate for Payer: Nomi Health Commercial |
$12.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.67
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$13.68
|
|
|
Service Code
|
NDC 00121479950
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.89 |
| Max. Negotiated Rate |
$13.68 |
| Rate for Payer: Aetna Commercial |
$12.31
|
| Rate for Payer: ASR ASR |
$13.27
|
| Rate for Payer: ASR Commercial |
$13.27
|
| Rate for Payer: BCBS Trust/PPO |
$11.15
|
| Rate for Payer: BCN Commercial |
$10.61
|
| Rate for Payer: Cash Price |
$10.94
|
| Rate for Payer: Cofinity Commercial |
$12.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.94
|
| Rate for Payer: Healthscope Commercial |
$13.68
|
| Rate for Payer: Healthscope Whirlpool |
$13.27
|
| Rate for Payer: Mclaren Commercial |
$12.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.63
|
| Rate for Payer: Nomi Health Commercial |
$11.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$12.04
|
|
|
LEVETIRACETAM 500 MG/5 ML (5 ML) ORAL SOLUTION
|
Facility
|
IP
|
$12.41
|
|
|
Service Code
|
NDC 00904726592
|
| Hospital Charge Code |
118734
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.07 |
| Max. Negotiated Rate |
$12.41 |
| Rate for Payer: Aetna Commercial |
$11.17
|
| Rate for Payer: ASR ASR |
$12.04
|
| Rate for Payer: ASR Commercial |
$12.04
|
| Rate for Payer: BCBS Trust/PPO |
$10.11
|
| Rate for Payer: BCN Commercial |
$9.62
|
| Rate for Payer: Cash Price |
$9.93
|
| Rate for Payer: Cofinity Commercial |
$11.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.93
|
| Rate for Payer: Healthscope Commercial |
$12.41
|
| Rate for Payer: Healthscope Whirlpool |
$12.04
|
| Rate for Payer: Mclaren Commercial |
$11.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.55
|
| Rate for Payer: Nomi Health Commercial |
$10.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.92
|
|
