Heights University Hospital

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM

Facility

$390.00

Service Code	HCPCS 80177
Hospital Charge Code	39900013
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

LEVETIRACETAM

Facility

$256.00

Service Code	HCPCS 82542
Hospital Charge Code	3003457
Hospital Revenue Code	301
Min. Negotiated Rate	$38.40
Max. Negotiated Rate	$38.40
Rate for Payer: Qualcare PPO/HMO/WC	$38.40

LEVETIRACETAM 1000MG/100ML

Facility

$398.85

Service Code	HCPCS J1953
Hospital Charge Code	6063943358
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$119.66
Rate for Payer: Aetna Commercial	$119.66
Rate for Payer: Aetna Medicare Advantage	$119.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$101.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$101.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$101.71
Rate for Payer: Cigna Commercial	$0.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$96.52
Rate for Payer: Qualcare PPO/HMO/WC	$59.83

LEVETIRACETAM 1000MG/100ML

Facility

$398.85

Service Code	HCPCS J1953
Hospital Charge Code	6063943358
Hospital Revenue Code	636
Min. Negotiated Rate	$59.83
Max. Negotiated Rate	$96.52
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$96.52
Rate for Payer: Qualcare PPO/HMO/WC	$59.83

LEVETIRACETAM 1500MG/100ML NS

Facility

$175.67

Service Code	HCPCS J1953
Hospital Charge Code	606390213
Hospital Revenue Code	636
Min. Negotiated Rate	$26.35
Max. Negotiated Rate	$42.51
Rate for Payer: Qualcare PPO/HMO/WC	$26.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$42.51

LEVETIRACETAM 1500MG/100ML NS

Facility

$175.67

Service Code	HCPCS J1953
Hospital Charge Code	606390213
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$52.70
Rate for Payer: Aetna Commercial	$52.70
Rate for Payer: Aetna Medicare Advantage	$52.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$44.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$44.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$44.80
Rate for Payer: Cigna Commercial	$0.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$42.51
Rate for Payer: Qualcare PPO/HMO/WC	$26.35

LEVETIRACETAM 250 MG TAB

Facility

$17.35

Service Code	NDC 904605161
Hospital Charge Code	60629263
Hospital Revenue Code	250
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$2.60
Rate for Payer: Qualcare PPO/HMO/WC	$2.60

LEVETIRACETAM 250 MG TAB

Facility

$17.35

Service Code	NDC 904605161
Hospital Charge Code	60629263
Hospital Revenue Code	250
Min. Negotiated Rate	$2.26
Max. Negotiated Rate	$8.68
Rate for Payer: Aetna Commercial	$5.21
Rate for Payer: Aetna Medicare Advantage	$5.21
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$4.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$4.42
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$4.42
Rate for Payer: Cigna Commercial	$8.68
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.26
Rate for Payer: Oxford Commercial	$8.68
Rate for Payer: Qualcare PPO/HMO/WC	$2.60
Rate for Payer: UnitedHealthcare Commercial	$8.68

LEVETIRACETAM 500MG/100ML

Facility

$239.32

Service Code	HCPCS J1953
Hospital Charge Code	6063943357
Hospital Revenue Code	636
Min. Negotiated Rate	$35.90
Max. Negotiated Rate	$57.92
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.92
Rate for Payer: Qualcare PPO/HMO/WC	$35.90

LEVETIRACETAM 500MG/100ML

Facility

$239.32

Service Code	HCPCS J1953
Hospital Charge Code	6063943357
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$71.80
Rate for Payer: Aetna Commercial	$71.80
Rate for Payer: Aetna Medicare Advantage	$71.80
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$61.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$61.03
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$61.03
Rate for Payer: Cigna Commercial	$0.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.92
Rate for Payer: Qualcare PPO/HMO/WC	$35.90

LEVETIRACETAM 500 MG/5 ML INJ

Facility

$310.88

Service Code	HCPCS J1953
Hospital Charge Code	60629890
Hospital Revenue Code	636
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$93.26
Rate for Payer: Aetna Commercial	$93.26
Rate for Payer: Aetna Medicare Advantage	$93.26
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$79.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$79.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$79.27
Rate for Payer: Cigna Commercial	$0.03
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$75.23
Rate for Payer: Qualcare PPO/HMO/WC	$46.63

LEVETIRACETAM 500 MG/5 ML INJ

Facility

$310.88

Service Code	HCPCS J1953
Hospital Charge Code	60629890
Hospital Revenue Code	636
Min. Negotiated Rate	$46.63
Max. Negotiated Rate	$75.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$75.23
Rate for Payer: Qualcare PPO/HMO/WC	$46.63

LEVETIRACETAM 500 MG TAB

Facility

$55.68

Service Code	NDC 50474059540
Hospital Charge Code	60629937
Hospital Revenue Code	250
Min. Negotiated Rate	$8.35
Max. Negotiated Rate	$8.35
Rate for Payer: Qualcare PPO/HMO/WC	$8.35

LEVETIRACETAM 500 MG TAB

Facility

$55.68

Service Code	NDC 50474059540
Hospital Charge Code	60629937
Hospital Revenue Code	250
Min. Negotiated Rate	$7.24
Max. Negotiated Rate	$27.84
Rate for Payer: Aetna Commercial	$16.70
Rate for Payer: Aetna Medicare Advantage	$16.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$14.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$14.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$14.20
Rate for Payer: Cigna Commercial	$27.84
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.24
Rate for Payer: Oxford Commercial	$27.84
Rate for Payer: Qualcare PPO/HMO/WC	$8.35
Rate for Payer: UnitedHealthcare Commercial	$27.84

LEVETIRACETAM (KEPPRA)

Facility

$110.00

Service Code	HCPCS 80299
Hospital Charge Code	38472310
Hospital Revenue Code	301
Min. Negotiated Rate	$9.32
Max. Negotiated Rate	$114.00
Rate for Payer: Aetna Commercial	$60.39
Rate for Payer: Aetna Medicare Advantage	$18.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$68.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$68.30
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$18.64
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$11.24
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$68.30
Rate for Payer: Cigna Commercial	$18.64
Rate for Payer: Cigna Medicare Advantage	$9.32
Rate for Payer: Clover Medicare Advantage	$17.71
Rate for Payer: EmblemHealth Commercial	$55.92
Rate for Payer: Humana Medicare Advantage	$19.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$14.30
Rate for Payer: Oxford Commercial	$101.00
Rate for Payer: Qualcare PPO/HMO/WC	$16.50
Rate for Payer: UnitedHealthcare Commercial	$114.00
Rate for Payer: UnitedHealthcare Medicare Advantage	$18.64
Rate for Payer: Wellcare Ambetter Commercial-Exchange	$19.76
Rate for Payer: Wellcare Medicare Advantage	$18.64

LEVETIRACETAM (KEPPRA)

Facility

$110.00

Service Code	HCPCS 80299
Hospital Charge Code	38472310
Hospital Revenue Code	301
Min. Negotiated Rate	$16.50
Max. Negotiated Rate	$16.50
Rate for Payer: Qualcare PPO/HMO/WC	$16.50

LEVLEUCOVORI FUSILEV 50MG 10ML

Facility

$971.50

Hospital Charge Code	60630110
Hospital Revenue Code	636
Min. Negotiated Rate	$145.72
Max. Negotiated Rate	$235.10
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$235.10
Rate for Payer: Qualcare PPO/HMO/WC	$145.72

LEVLEUCOVORI FUSILEV 50MG 10ML

Facility

$971.50

Hospital Charge Code	60630110
Hospital Revenue Code	636
Min. Negotiated Rate	$145.72
Max. Negotiated Rate	$485.75
Rate for Payer: Aetna Commercial	$291.45
Rate for Payer: Aetna Medicare Advantage	$291.45
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$247.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$247.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$247.73
Rate for Payer: Cigna Commercial	$485.75
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$235.10
Rate for Payer: Qualcare PPO/HMO/WC	$145.72

LEVOBUNOLOL OPH SOL 0.05%

Facility

$93.65

Hospital Charge Code	60628090
Hospital Revenue Code	250
Min. Negotiated Rate	$14.05
Max. Negotiated Rate	$14.05
Rate for Payer: Qualcare PPO/HMO/WC	$14.05

LEVOBUNOLOL OPH SOL 0.05%

Facility

$93.65

Hospital Charge Code	60628090
Hospital Revenue Code	250
Min. Negotiated Rate	$12.17
Max. Negotiated Rate	$46.83
Rate for Payer: Aetna Commercial	$28.09
Rate for Payer: Aetna Medicare Advantage	$28.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$23.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$23.88
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$23.88
Rate for Payer: Cigna Commercial	$46.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$12.17
Rate for Payer: Oxford Commercial	$46.83
Rate for Payer: Qualcare PPO/HMO/WC	$14.05
Rate for Payer: UnitedHealthcare Commercial	$46.83

LEVOBUNOLOL OPH SOL 0.25%

Facility

$265.60

Hospital Charge Code	60628091
Hospital Revenue Code	250
Min. Negotiated Rate	$39.84
Max. Negotiated Rate	$39.84
Rate for Payer: Qualcare PPO/HMO/WC	$39.84

LEVOBUNOLOL OPH SOL 0.25%

Facility

$265.60

Hospital Charge Code	60628091
Hospital Revenue Code	250
Min. Negotiated Rate	$34.53
Max. Negotiated Rate	$132.80
Rate for Payer: Aetna Commercial	$79.68
Rate for Payer: Aetna Medicare Advantage	$79.68
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$67.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$67.73
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$67.73
Rate for Payer: Cigna Commercial	$132.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$34.53
Rate for Payer: Oxford Commercial	$132.80
Rate for Payer: Qualcare PPO/HMO/WC	$39.84
Rate for Payer: UnitedHealthcare Commercial	$132.80

LEVOBUNOLOL OPHT .05% 5ML SOL

Facility

$70.40

Hospital Charge Code	6003230
Hospital Revenue Code	252
Min. Negotiated Rate	$9.15
Max. Negotiated Rate	$35.20
Rate for Payer: Aetna Commercial	$21.12
Rate for Payer: Aetna Medicare Advantage	$21.12
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$17.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$17.95
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$17.95
Rate for Payer: Cigna Commercial	$35.20
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$9.15
Rate for Payer: Oxford Commercial	$35.20
Rate for Payer: Qualcare PPO/HMO/WC	$10.56
Rate for Payer: UnitedHealthcare Commercial	$35.20

LEVOBUNOLOL OPHT .05% 5ML SOL

Facility

$70.40

Hospital Charge Code	6003230
Hospital Revenue Code	252
Min. Negotiated Rate	$10.56
Max. Negotiated Rate	$10.56
Rate for Payer: Qualcare PPO/HMO/WC	$10.56

LEVOBUPIVACAINE 5MG/1ML INJ

Facility

$35.85

Hospital Charge Code	60629249
Hospital Revenue Code	250
Min. Negotiated Rate	$5.38
Max. Negotiated Rate	$5.38
Rate for Payer: Qualcare PPO/HMO/WC	$5.38

Know your out-of-pocket cost for care.

All Charges