|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
|
OP
|
$1.08
|
|
|
Service Code
|
NDC 43547-454-41
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.59 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.65
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.65
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.59
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.81
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
|
IP
|
$0.93
|
|
|
Service Code
|
NDC 0409-1886-02
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$0.74 |
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.51
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.70
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 67457-790-05
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.51
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.51
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.89
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 63323-400-05
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$1.13
|
| Rate for Payer: Aetna of CA Government/Medicare |
$1.13
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$1.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.42
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 67457-790-00
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.89
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 67457-790-05
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$1.51
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$1.89
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 65862-246-08
|
| Hospital Charge Code |
1712237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 68180-113-16
|
| Hospital Charge Code |
1712237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 65862-246-08
|
| Hospital Charge Code |
1712237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.07
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
OP
|
$0.23
|
|
|
Service Code
|
NDC 63739-411-10
|
| Hospital Charge Code |
1712237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.14
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.14
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 68001-403-07
|
| Hospital Charge Code |
1712237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0904-7124-61
|
| Hospital Charge Code |
1712237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.19
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
IP
|
$0.23
|
|
|
Service Code
|
NDC 63739-411-10
|
| Hospital Charge Code |
1712237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.13 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.13
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.17
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
OP
|
$0.39
|
|
|
Service Code
|
NDC 68180-113-16
|
| Hospital Charge Code |
1712237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.29 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.23
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
IP
|
$0.39
|
|
|
Service Code
|
NDC 68001-403-07
|
| Hospital Charge Code |
1712237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.21
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.29
|
|
|
LEVETIRACETAM 500 MG TABLET [26817]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0904-7124-61
|
| Hospital Charge Code |
1712237
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.15
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.15
|
| Rate for Payer: Cash Price |
$0.11
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.14
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.19
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 68084-882-01
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.35
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.53
|
|
|
Service Code
|
NDC 68001-404-07
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.42
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.40
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 72205-096-92
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.34
|
|
|
Service Code
|
NDC 0904-7125-61
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.27 |
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.27
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 68084-882-11
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.38
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.35
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.12
|
|
|
Service Code
|
NDC 65862-247-08
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.07
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.09
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.53
|
|
|
Service Code
|
NDC 68001-404-07
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.29 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.32
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.32
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.40
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 68084-882-11
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.28
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.28
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.35
|
|
|
LEVETIRACETAM 750 MG TABLET [26818]
|
Facility
|
OP
|
$0.34
|
|
|
Service Code
|
NDC 0904-7125-61
|
| Hospital Charge Code |
1712308
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$0.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$0.20
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Health Smart Auto/Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$0.26
|
|
