|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 60432-831-16
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
OP
|
$0.11
|
|
|
Service Code
|
NDC 31722-574-47
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 71093-144-13
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
IP
|
$0.15
|
|
|
Service Code
|
NDC 50383-241-16
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.10
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.04
|
| Rate for Payer: Multiplan Commercial |
$0.11
|
|
|
LEVETIRACETAM 100 MG/ML ORAL SOLUTION [36590]
|
Facility
|
IP
|
$0.08
|
|
|
Service Code
|
NDC 71093-144-13
|
| Hospital Charge Code |
1715766
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.06 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-01
|
| Hospital Charge Code |
1712236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
OP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-11
|
| Hospital Charge Code |
1712236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.23
|
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.26
|
| Rate for Payer: Dignity Health Senior |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.12
|
| Rate for Payer: TriValley Medical Group Senior |
$0.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Vantage Medical Group Senior |
$0.26
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-01
|
| Hospital Charge Code |
1712236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
LEVETIRACETAM 250 MG TABLET [26816]
|
Facility
|
IP
|
$0.30
|
|
|
Service Code
|
NDC 68084-859-11
|
| Hospital Charge Code |
1712236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.21
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.20
|
| Rate for Payer: Heritage Provider Network Senior |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.23
|
|
|
LEVETIRACETAM 500 MG/100 ML IN SODIUM CHLORIDE (ISO-OSM) IV PIGGYBACK [154437]
|
Facility
|
IP
|
$0.22
|
|
|
Service Code
|
CPT J1953
|
| Hospital Charge Code |
NDG154437
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| 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 |
$0.18
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| 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 |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$0.07 |
| Max. Negotiated Rate |
$7.05 |
| Rate for Payer: Adventist Health Commercial |
$0.08
|
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.31
|
| 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: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.09
|
| Rate for Payer: Cash Price |
$0.08
|
| 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 |
$0.18
|
| Rate for Payer: Cash Price |
$0.18
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| 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 |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.35
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.35
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.10
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$7.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| 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 |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Multiplan Commercial |
$0.13
|
| Rate for Payer: Multiplan Commercial |
$0.31
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.09
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.09
|
| Rate for Payer: TriValley Medical Group Senior |
$0.07
|
| Rate for Payer: TriValley Medical Group Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.08
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.03
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| 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 |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.35
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
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 |
$0.34 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.30
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.63
|
|
|
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 |
$0.17 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: Dignity Health Senior |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
| 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
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 67457-790-00
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.48
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.14
|
| Rate for Payer: Dignity Health Senior |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.01
|
| Rate for Payer: TriValley Medical Group Senior |
$1.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.84
|
| 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
|
OP
|
$2.52
|
|
|
Service Code
|
NDC 67457-790-05
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.14 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.89
|
| Rate for Payer: Blue Shield of California Commercial |
$1.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.48
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.14
|
| Rate for Payer: Dignity Health Senior |
$2.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.17
|
| Rate for Payer: Heritage Provider Network Senior |
$1.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.89
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.01
|
| Rate for Payer: TriValley Medical Group Senior |
$1.01
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.84
|
| 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 0409-1886-22
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
|
|
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 |
$0.17 |
| Max. Negotiated Rate |
$0.79 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.70
|
| Rate for Payer: Blue Shield of California Commercial |
$0.58
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.79
|
| Rate for Payer: Dignity Health Senior |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.37
|
| Rate for Payer: TriValley Medical Group Senior |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
| 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
|
$2.52
|
|
|
Service Code
|
NDC 67457-790-00
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.73
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Senior |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.84
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.81
|
| Rate for Payer: Blue Shield of California Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California EPN |
$0.63
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.92
|
| Rate for Payer: Dignity Health Senior |
$0.92
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.69
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.43
|
| Rate for Payer: TriValley Medical Group Senior |
$0.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
| 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
|
$1.89
|
|
|
Service Code
|
NDC 63323-400-05
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.34 |
| Max. Negotiated Rate |
$1.42 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.30
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.28
|
| Rate for Payer: Heritage Provider Network Senior |
$1.28
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.63
|
|
|
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 |
$0.17 |
| Max. Negotiated Rate |
$0.70 |
| Rate for Payer: Adventist Health Commercial |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.64
|
| Rate for Payer: Cash Price |
$0.42
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.23
|
| Rate for Payer: Multiplan Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.31
|
|
|
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 |
$0.34 |
| Max. Negotiated Rate |
$1.61 |
| Rate for Payer: Adventist Health Commercial |
$0.38
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.30
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.61
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.42
|
| Rate for Payer: Blue Shield of California Commercial |
$1.17
|
| Rate for Payer: Blue Shield of California EPN |
$1.11
|
| Rate for Payer: Cash Price |
$0.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.87
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.61
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.61
|
| Rate for Payer: Dignity Health Senior |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.88
|
| Rate for Payer: Heritage Provider Network Senior |
$0.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.47
|
| Rate for Payer: Multiplan Commercial |
$1.42
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Senior |
$0.76
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.69
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.63
|
| 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
|
$2.52
|
|
|
Service Code
|
NDC 67457-790-05
|
| Hospital Charge Code |
1722045
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$1.89 |
| Rate for Payer: Adventist Health Commercial |
$0.50
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.73
|
| Rate for Payer: Cash Price |
$1.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.71
|
| Rate for Payer: Heritage Provider Network Senior |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.46
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.63
|
| Rate for Payer: Multiplan Commercial |
$1.89
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.92
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.84
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.81 |
| Rate for Payer: Adventist Health Commercial |
$0.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.74
|
| Rate for Payer: Cash Price |
$0.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.58
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.73
|
| Rate for Payer: Heritage Provider Network Senior |
$0.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.36
|
|
