|
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK [154437]
|
Facility
IP
|
$0.17
|
|
|
Service Code
|
CPT J1953
|
| Hospital Charge Code |
NDG154437
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
|
|
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK [154437]
|
Facility
OP
|
$0.41
|
|
|
Service Code
|
CPT J1953
|
| Hospital Charge Code |
NDG154437
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$8.59 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: BCBS Transplant Transplant |
$0.06
|
| Rate for Payer: BCBS Transplant Transplant |
$0.13
|
| Rate for Payer: BCBS Transplant Transplant |
$0.25
|
| Rate for Payer: BCBS Transplant Transplant |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.30
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA HMO |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.15
|
| Rate for Payer: Cigna of CA PPO |
$0.29
|
| Rate for Payer: Cigna of CA PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Media |
$0.19
|
| Rate for Payer: Dignity Health Media |
$0.35
|
| Rate for Payer: Dignity Health Media |
$0.14
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.07
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.35
|
| Rate for Payer: Galaxy Health WC |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.10
|
| Rate for Payer: Global Benefits Group Commercial |
$0.25
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Global Benefits Group Commercial |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.08
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Networks By Design Commercial |
$0.21
|
| Rate for Payer: Networks By Design Commercial |
$0.05
|
| Rate for Payer: Networks By Design Commercial |
$0.09
|
| Rate for Payer: Networks By Design Commercial |
$0.11
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Prime Health Services Commercial |
$0.14
|
| Rate for Payer: Prime Health Services Commercial |
$0.19
|
| Rate for Payer: Prime Health Services Commercial |
$0.35
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.25
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.13
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.25
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.11
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.09
|
| Rate for Payer: United Healthcare All Other HMO |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO |
$0.21
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.09
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.11
|
| Rate for Payer: United Healthcare HMO Rider |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.11
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.21
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.14
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
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 |
$0.60 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.76
|
| Rate for Payer: Cigna of CA PPO |
$1.76
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.50
|
| Rate for Payer: BCBS Transplant Transplant |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.14
|
| Rate for Payer: Dignity Health Media |
$2.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.01
|
| Rate for Payer: Galaxy Health WC |
$2.14
|
| Rate for Payer: Global Benefits Group Commercial |
$1.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Networks By Design Commercial |
$1.26
|
| Rate for Payer: Prime Health Services Commercial |
$2.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO |
$1.26
|
| Rate for Payer: United Healthcare HMO Rider |
$1.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.14
|
| Rate for Payer: Vantage Medical Group Senior |
$2.14
|
|
|
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 |
$0.60 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Blue Shield of California Commercial |
$1.79
|
| Rate for Payer: Blue Shield of California EPN |
$1.29
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.76
|
| Rate for Payer: Cigna of CA PPO |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.01
|
| Rate for Payer: Galaxy Health WC |
$2.14
|
| Rate for Payer: Global Benefits Group Commercial |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Networks By Design Commercial |
$1.26
|
| Rate for Payer: Prime Health Services Commercial |
$2.14
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
OP
|
$2.52
|
|
|
Service Code
|
NDC 67457-790-00
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.65
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.14
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.50
|
| Rate for Payer: BCBS Transplant Transplant |
$1.51
|
| Rate for Payer: Blue Shield of California Commercial |
$1.86
|
| Rate for Payer: Blue Shield of California EPN |
$1.47
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.76
|
| Rate for Payer: Cigna of CA PPO |
$1.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.14
|
| Rate for Payer: Dignity Health Media |
$2.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.01
|
| Rate for Payer: Galaxy Health WC |
$2.14
|
| Rate for Payer: Global Benefits Group Commercial |
$1.51
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Networks By Design Commercial |
$1.26
|
| Rate for Payer: Prime Health Services Commercial |
$2.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.51
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.51
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.26
|
| Rate for Payer: United Healthcare All Other HMO |
$1.26
|
| Rate for Payer: United Healthcare HMO Rider |
$1.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.14
|
| Rate for Payer: Vantage Medical Group Senior |
$2.14
|
|
|
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 |
$0.22 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
OP
|
$0.93
|
|
|
Service Code
|
NDC 0409-1886-22
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: BCBS Transplant Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Media |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
IP
|
$1.89
|
|
|
Service Code
|
NDC 63323-400-01
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$0.95
|
| Rate for Payer: Prime Health Services Commercial |
$1.61
|
|
|
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 |
$0.60 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Blue Shield of California Commercial |
$1.79
|
| Rate for Payer: Blue Shield of California EPN |
$1.29
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO |
$1.76
|
| Rate for Payer: Cigna of CA PPO |
$1.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.01
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.01
|
| Rate for Payer: Galaxy Health WC |
$2.14
|
| Rate for Payer: Global Benefits Group Commercial |
$1.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.60
|
| Rate for Payer: Multiplan Commercial |
$2.02
|
| Rate for Payer: Networks By Design Commercial |
$1.26
|
| Rate for Payer: Prime Health Services Commercial |
$2.14
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
OP
|
$0.93
|
|
|
Service Code
|
NDC 0409-1886-02
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.61
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.55
|
| Rate for Payer: BCBS Transplant Transplant |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California EPN |
$0.54
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Media |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.47
|
| Rate for Payer: United Healthcare All Other HMO |
$0.47
|
| Rate for Payer: United Healthcare HMO Rider |
$0.47
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.47
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.79
|
| Rate for Payer: Vantage Medical Group Senior |
$0.79
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
IP
|
$1.08
|
|
|
Service Code
|
NDC 43547-454-10
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
OP
|
$1.89
|
|
|
Service Code
|
NDC 63323-400-01
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: BCBS Transplant Transplant |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.10
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.61
|
| Rate for Payer: Dignity Health Media |
$1.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$0.95
|
| Rate for Payer: Prime Health Services Commercial |
$1.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO |
$0.95
|
| Rate for Payer: United Healthcare HMO Rider |
$0.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.61
|
| Rate for Payer: Vantage Medical Group Senior |
$1.61
|
|
|
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 |
$0.26 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.64
|
| Rate for Payer: BCBS Transplant Transplant |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Media |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO |
$0.54
|
| Rate for Payer: United Healthcare HMO Rider |
$0.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
|
|
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 |
$0.45 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.24
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.04
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.13
|
| Rate for Payer: BCBS Transplant Transplant |
$1.13
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.10
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.61
|
| Rate for Payer: Dignity Health Media |
$1.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$0.95
|
| Rate for Payer: Prime Health Services Commercial |
$1.61
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.13
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.13
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.95
|
| Rate for Payer: United Healthcare All Other HMO |
$0.95
|
| Rate for Payer: United Healthcare HMO Rider |
$0.95
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.61
|
| Rate for Payer: Vantage Medical Group Senior |
$1.61
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
IP
|
$0.93
|
|
|
Service Code
|
NDC 0409-1886-22
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.22 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Cigna of CA PPO |
$0.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.37
|
| Rate for Payer: Galaxy Health WC |
$0.79
|
| Rate for Payer: Blue Shield of California Commercial |
$0.66
|
| Rate for Payer: Blue Shield of California EPN |
$0.48
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO |
$0.65
|
| Rate for Payer: Global Benefits Group Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.22
|
| Rate for Payer: Multiplan Commercial |
$0.74
|
| Rate for Payer: Networks By Design Commercial |
$0.47
|
| Rate for Payer: Prime Health Services Commercial |
$0.79
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
IP
|
$1.89
|
|
|
Service Code
|
NDC 63323-400-05
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Blue Shield of California Commercial |
$1.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.97
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO |
$1.32
|
| Rate for Payer: Cigna of CA PPO |
$1.32
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.76
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.76
|
| Rate for Payer: Galaxy Health WC |
$1.61
|
| Rate for Payer: Global Benefits Group Commercial |
$1.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.45
|
| Rate for Payer: Multiplan Commercial |
$1.51
|
| Rate for Payer: Networks By Design Commercial |
$0.95
|
| Rate for Payer: Prime Health Services Commercial |
$1.61
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
OP
|
$1.08
|
|
|
Service Code
|
NDC 43547-454-10
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.64
|
| Rate for Payer: BCBS Transplant Transplant |
$0.65
|
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Media |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.65
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.65
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.54
|
| Rate for Payer: United Healthcare All Other HMO |
$0.54
|
| Rate for Payer: United Healthcare HMO Rider |
$0.54
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.54
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.92
|
| Rate for Payer: Vantage Medical Group Senior |
$0.92
|
|
|
LEVETIRACETAM 500 MG/5 ML INTRAVENOUS SOLUTION [77195]
|
Facility
IP
|
$1.08
|
|
|
Service Code
|
NDC 43547-454-41
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Blue Shield of California Commercial |
$0.77
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO |
$0.76
|
| Rate for Payer: Cigna of CA PPO |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.43
|
| Rate for Payer: Galaxy Health WC |
$0.92
|
| Rate for Payer: Global Benefits Group Commercial |
$0.65
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.26
|
| Rate for Payer: Multiplan Commercial |
$0.86
|
| Rate for Payer: Networks By Design Commercial |
$0.54
|
| Rate for Payer: Prime Health Services Commercial |
$0.92
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.20
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.33 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.23
|
| Rate for Payer: BCBS Transplant Transplant |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cigna of CA HMO |
$0.27
|
| Rate for Payer: Cigna of CA PPO |
$0.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.33
|
| Rate for Payer: Dignity Health Media |
$0.33
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.16
|
| Rate for Payer: Galaxy Health WC |
$0.33
|
| Rate for Payer: Global Benefits Group Commercial |
$0.23
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Networks By Design Commercial |
$0.25
|
| Rate for Payer: Prime Health Services Commercial |
$0.33
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.23
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.20
|
| Rate for Payer: United Healthcare All Other HMO |
$0.20
|
| Rate for Payer: United Healthcare HMO Rider |
$0.20
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.20
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.33
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.33
|
| Rate for Payer: Vantage Medical Group Senior |
$0.33
|
|
|
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 |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.05
|
| Rate for Payer: BCBS Transplant Transplant |
$0.05
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Media |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
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 |
$0.06 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Galaxy Health WC |
$0.20
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.13
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.14
|
| Rate for Payer: BCBS Transplant Transplant |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO |
$0.16
|
| Rate for Payer: Cigna of CA PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.20
|
| Rate for Payer: Dignity Health Media |
$0.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.14
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.18
|
| Rate for Payer: Networks By Design Commercial |
$0.15
|
| Rate for Payer: Prime Health Services Commercial |
$0.20
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.12
|
| Rate for Payer: United Healthcare All Other HMO |
$0.12
|
| Rate for Payer: United Healthcare HMO Rider |
$0.12
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Vantage Medical Group Senior |
$0.20
|
|
|
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 |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO |
$0.06
|
| Rate for Payer: Cigna of CA PPO |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.08
|
| Rate for Payer: Global Benefits Group Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Networks By Design Commercial |
$0.06
|
| Rate for Payer: Prime Health Services Commercial |
$0.08
|
|
