Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

LEVETIRACETAM 500MG/100ML PREMIX

Facility

OP

$0.65

Service Code	HCPCS J1953
Hospital Charge Code	41647939
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.37
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.07
Rate for Payer: SOMOS Essential	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

LEVETIRACETAM 500MG/100ML PREMIX

Facility

OP

$0.65

Service Code	HCPCS J1953
Hospital Charge Code	41657939
Hospital Revenue Code	636
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.42
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.39
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.33
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.37
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: SOMOS CHP/HARP/Medicaid	$0.07
Rate for Payer: SOMOS Essential	$0.07
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

OP

$0.93

Service Code	HCPCS J1953
Hospital Charge Code	00409188602
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.98
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.51
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.56
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.47
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.54
Rate for Payer: EmblemHealth Commercial	$0.47
Rate for Payer: Fidelis Medicare Advantage	$0.98
Rate for Payer: Group Health Inc Commercial	$0.47
Rate for Payer: Group Health Inc Medicare	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.47
Rate for Payer: Hamaspik Choice Inc Medicare	$0.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.61

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

IP

$1.38

Service Code	HCPCS J1953
Hospital Charge Code	51224001325
Hospital Revenue Code	278
Min. Negotiated Rate	$0.69
Max. Negotiated Rate	$0.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.69
Rate for Payer: Hamaspik Choice Inc Medicare	$0.69

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

OP

$3.00

Service Code	HCPCS J1953
Hospital Charge Code	55150017705
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$3.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.65
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$1.80
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.50
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.72
Rate for Payer: EmblemHealth Commercial	$1.50
Rate for Payer: Fidelis Medicare Advantage	$3.15
Rate for Payer: Group Health Inc Commercial	$1.50
Rate for Payer: Group Health Inc Medicare	$1.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.95

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

IP

$0.60

Service Code	HCPCS J1953
Hospital Charge Code	72485010610
Hospital Revenue Code	278
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.30
Rate for Payer: Hamaspik Choice Inc Medicare	$0.30

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

IP

$3.00

Service Code	HCPCS J1953
Hospital Charge Code	55150017705
Hospital Revenue Code	278
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$1.50
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.50
Rate for Payer: Hamaspik Choice Inc Medicare	$1.50

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

IP

$0.93

Service Code	HCPCS J1953
Hospital Charge Code	00409188602
Hospital Revenue Code	278
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.47
Rate for Payer: Hamaspik Choice Inc Medicare	$0.47

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

OP

$1.38

Service Code	HCPCS J1953
Hospital Charge Code	51224001325
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$1.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.76
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.83
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.69
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.79
Rate for Payer: EmblemHealth Commercial	$0.69
Rate for Payer: Fidelis Medicare Advantage	$1.44
Rate for Payer: Group Health Inc Commercial	$0.69
Rate for Payer: Group Health Inc Medicare	$0.48
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.69
Rate for Payer: Hamaspik Choice Inc Medicare	$0.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.89

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

OP

$0.60

Service Code	HCPCS J1953
Hospital Charge Code	72485010610
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.63
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.33
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.36
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.35
Rate for Payer: EmblemHealth Commercial	$0.30
Rate for Payer: Fidelis Medicare Advantage	$0.63
Rate for Payer: Group Health Inc Commercial	$0.30
Rate for Payer: Group Health Inc Medicare	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.30
Rate for Payer: Hamaspik Choice Inc Medicare	$0.30
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.39

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

IP

$2.52

Service Code	HCPCS J1953
Hospital Charge Code	67457079005
Hospital Revenue Code	278
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$1.26
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.26
Rate for Payer: Hamaspik Choice Inc Medicare	$1.26

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

OP

$1.41

Service Code	HCPCS J1953
Hospital Charge Code	51224001310
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$1.48
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.78
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.85
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.81
Rate for Payer: EmblemHealth Commercial	$0.71
Rate for Payer: Fidelis Medicare Advantage	$1.48
Rate for Payer: Group Health Inc Commercial	$0.71
Rate for Payer: Group Health Inc Medicare	$0.49
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.71
Rate for Payer: Hamaspik Choice Inc Medicare	$0.71
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.92

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

IP

$1.41

Service Code	HCPCS J1953
Hospital Charge Code	51224001310
Hospital Revenue Code	278
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$0.71
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.71
Rate for Payer: Hamaspik Choice Inc Medicare	$0.71

LEVETIRACETAM 500 MG/5ML IV SOLN [77195]

Facility

OP

$2.52

Service Code	HCPCS J1953
Hospital Charge Code	67457079005
Hospital Revenue Code	278
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$2.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$1.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.26
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.45
Rate for Payer: EmblemHealth Commercial	$1.26
Rate for Payer: Fidelis Medicare Advantage	$2.65
Rate for Payer: Group Health Inc Commercial	$1.26
Rate for Payer: Group Health Inc Medicare	$0.88
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.26
Rate for Payer: Hamaspik Choice Inc Medicare	$1.26
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.64

LEVETIRACETAM 500 MG PO TABS [26817]

Facility

OP

$0.25

Service Code	NDC 00904712461
Hospital Charge Code	00904712461
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.14
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.13
Rate for Payer: Aetna Government	$0.13
Rate for Payer: Brighton Health Commercial	$0.19
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.17
Rate for Payer: Group Health Inc Commercial	$0.13
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.13
Rate for Payer: Hamaspik Choice Inc Medicare	$0.13
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

LEVETIRACETAM 500 MG PO TABS [26817]

Facility

OP

$3.51

Service Code	NDC 68180011302
Hospital Charge Code	68180011302
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$2.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.76
Rate for Payer: Aetna Government	$1.76
Rate for Payer: Brighton Health Commercial	$2.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.39
Rate for Payer: Group Health Inc Commercial	$1.76
Rate for Payer: Group Health Inc Medicare	$1.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.76
Rate for Payer: Hamaspik Choice Inc Medicare	$1.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.28

LEVETIRACETAM 500 MG PO TABS [26817]

Facility

OP

$3.51

Service Code	NDC 31722053712
Hospital Charge Code	31722053712
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$2.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.76
Rate for Payer: Aetna Government	$1.76
Rate for Payer: Brighton Health Commercial	$2.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.39
Rate for Payer: Group Health Inc Commercial	$1.76
Rate for Payer: Group Health Inc Medicare	$1.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.76
Rate for Payer: Hamaspik Choice Inc Medicare	$1.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.28

LEVETIRACETAM 500 MG PO TABS [26817]

Facility

OP

$3.51

Service Code	NDC 31722053705
Hospital Charge Code	31722053705
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$2.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.93
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$1.76
Rate for Payer: Aetna Government	$1.76
Rate for Payer: Brighton Health Commercial	$2.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$2.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$2.39
Rate for Payer: Group Health Inc Commercial	$1.76
Rate for Payer: Group Health Inc Medicare	$1.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$1.76
Rate for Payer: Hamaspik Choice Inc Medicare	$1.76
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$2.28

LEVETIRACETAM 500MG TAB

Facility

OP

$0.15

Hospital Charge Code	41648436
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.10
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.10

LEVETIRACETAM 500MG TAB

Facility

OP

$0.15

Hospital Charge Code	41658436
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.12
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.08
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.08
Rate for Payer: Aetna Government	$0.08
Rate for Payer: Brighton Health Commercial	$0.11
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.12
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.10
Rate for Payer: Group Health Inc Commercial	$0.08
Rate for Payer: Group Health Inc Medicare	$0.05
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.08
Rate for Payer: Hamaspik Choice Inc Medicare	$0.08
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.10

LEVETIRACETAM 500 MG TAB CR

Facility

OP

$0.91

Hospital Charge Code	41655047
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.46
Rate for Payer: Aetna Government	$0.46
Rate for Payer: Brighton Health Commercial	$0.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.62
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.59

LEVETIRACETAM 500 MG TAB CR

Facility

OP

$0.91

Hospital Charge Code	41645047
Hospital Revenue Code	250
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.73
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.50
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.46
Rate for Payer: Aetna Government	$0.46
Rate for Payer: Brighton Health Commercial	$0.68
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.73
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.62
Rate for Payer: Group Health Inc Commercial	$0.46
Rate for Payer: Group Health Inc Medicare	$0.32
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.46
Rate for Payer: Hamaspik Choice Inc Medicare	$0.46
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.59

LEVETIRACETAM 750 MG PO TABS [26818]

Facility

OP

$0.34

Service Code	NDC 00904712561
Hospital Charge Code	00904712561
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.27
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.17
Rate for Payer: Aetna Government	$0.17
Rate for Payer: Brighton Health Commercial	$0.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.27
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.23
Rate for Payer: Group Health Inc Commercial	$0.17
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.22

LEVETIRACETAM 750 MG PO TABS [26818]

Facility

OP

$0.34

Service Code	NDC 63739078710
Hospital Charge Code	63739078710
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.27
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.17
Rate for Payer: Aetna Government	$0.17
Rate for Payer: Brighton Health Commercial	$0.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.27
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.23
Rate for Payer: Group Health Inc Commercial	$0.17
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.17
Rate for Payer: Hamaspik Choice Inc Medicare	$0.17
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.22

LEVETIRACETAM 750 MG PO TABS [26818]

Facility

OP

$4.76

Service Code	NDC 00378561778
Hospital Charge Code	00378561778
Hospital Revenue Code	250
Min. Negotiated Rate	$1.67
Max. Negotiated Rate	$3.81
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$2.62
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$2.38
Rate for Payer: Aetna Government	$2.38
Rate for Payer: Brighton Health Commercial	$3.57
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$3.81
Rate for Payer: Cigna LocalPlus Benefit Plan	$3.24
Rate for Payer: Group Health Inc Commercial	$2.38
Rate for Payer: Group Health Inc Medicare	$1.67
Rate for Payer: Hamaspik Choice Inc Medicaid	$2.38
Rate for Payer: Hamaspik Choice Inc Medicare	$2.38
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$3.09