|
levETIRAcetam 100 mg/mL Oral Sol [HMC]
|
Facility
|
IP
|
$493.89
|
|
|
Service Code
|
NDC 00904726594
|
| Hospital Charge Code |
3800085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$444.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$444.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$469.20
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 100 mg/mL Oral Sol [HMC]
|
Facility
|
OP
|
$399.07
|
|
|
Service Code
|
NDC 16714035801
|
| Hospital Charge Code |
3800085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$159.63 |
| Max. Negotiated Rate |
$379.12 |
| Rate for Payer: Aetna Commercial |
$359.16
|
| Rate for Payer: Humana Medicare Advantage |
$167.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$379.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$159.63
|
| Rate for Payer: WPPA Medicare Advantage |
$239.44
|
|
|
levETIRAcetam 100 mg/mL Oral Sol [HMC]
|
Facility
|
IP
|
$443.24
|
|
|
Service Code
|
NDC 00781614116
|
| Hospital Charge Code |
3800085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$398.92 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$398.92
|
| Rate for Payer: UnitedHealthcare Commercial |
$421.08
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 100 mg/mL Oral Sol [HMC]
|
Facility
|
IP
|
$399.07
|
|
|
Service Code
|
NDC 16714035801
|
| Hospital Charge Code |
3800085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$359.16 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$359.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$379.12
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 100 mg/mL Oral Sol [HMC]
|
Facility
|
OP
|
$443.24
|
|
|
Service Code
|
NDC 00781614116
|
| Hospital Charge Code |
3800085
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$177.30 |
| Max. Negotiated Rate |
$421.08 |
| Rate for Payer: Aetna Commercial |
$398.92
|
| Rate for Payer: Humana Medicare Advantage |
$186.16
|
| Rate for Payer: UnitedHealthcare Commercial |
$421.08
|
| Rate for Payer: UnitedHealthcare Medicaid |
$177.30
|
| Rate for Payer: WPPA Medicare Advantage |
$265.94
|
|
|
levETIRAcetam 100 mg/mL Sol
|
Facility
|
IP
|
$38.33
|
|
|
Service Code
|
NDC 00409188602
|
| Hospital Charge Code |
3800132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$34.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.41
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 100 mg/mL Sol
|
Facility
|
OP
|
$38.33
|
|
|
Service Code
|
NDC 00409188602
|
| Hospital Charge Code |
3800132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.33 |
| Max. Negotiated Rate |
$36.41 |
| Rate for Payer: Aetna Commercial |
$34.50
|
| Rate for Payer: Humana Medicare Advantage |
$16.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.33
|
| Rate for Payer: WPPA Medicare Advantage |
$23.00
|
|
|
levETIRAcetam 100 mg/mL Sol
|
Facility
|
IP
|
$38.33
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
3800132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.50 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$34.50
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.41
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 100 mg/mL Sol
|
Facility
|
OP
|
$38.33
|
|
|
Service Code
|
HCPCS J1953
|
| Hospital Charge Code |
3800132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$36.41 |
| Rate for Payer: Aetna Commercial |
$34.50
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$0.11
|
| Rate for Payer: Humana Medicare Advantage |
$16.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.41
|
| Rate for Payer: UnitedHealthcare Medicaid |
$0.04
|
| Rate for Payer: WPPA Medicare Advantage |
$23.00
|
|
|
levETIRAcetam 250 mg Tab [HMC]
|
Facility
|
IP
|
$13.63
|
|
|
Service Code
|
NDC 31722053612
|
| Hospital Charge Code |
3809478
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.27 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$12.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.95
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 250 mg Tab [HMC]
|
Facility
|
IP
|
$6.80
|
|
|
Service Code
|
NDC 68084033601
|
| Hospital Charge Code |
3809478
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.12 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$6.12
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.46
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 250 mg Tab [HMC]
|
Facility
|
OP
|
$6.80
|
|
|
Service Code
|
NDC 68084033601
|
| Hospital Charge Code |
3809478
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$6.46 |
| Rate for Payer: Aetna Commercial |
$6.12
|
| Rate for Payer: Humana Medicare Advantage |
$2.86
|
| Rate for Payer: UnitedHealthcare Commercial |
$6.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.72
|
| Rate for Payer: WPPA Medicare Advantage |
$4.08
|
|
|
levETIRAcetam 250 mg Tab [HMC]
|
Facility
|
OP
|
$13.63
|
|
|
Service Code
|
NDC 31722053612
|
| Hospital Charge Code |
3809478
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.45 |
| Max. Negotiated Rate |
$12.95 |
| Rate for Payer: Aetna Commercial |
$12.27
|
| Rate for Payer: Humana Medicare Advantage |
$5.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$12.95
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.45
|
| Rate for Payer: WPPA Medicare Advantage |
$8.18
|
|
|
levETIRAcetam 250 mg Tab [HMC]
|
Facility
|
OP
|
$5.67
|
|
|
Service Code
|
NDC 00904712361
|
| Hospital Charge Code |
3809478
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.27 |
| Max. Negotiated Rate |
$5.39 |
| Rate for Payer: Aetna Commercial |
$5.10
|
| Rate for Payer: Humana Medicare Advantage |
$2.38
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.27
|
| Rate for Payer: WPPA Medicare Advantage |
$3.40
|
|
|
levETIRAcetam 250 mg Tab [HMC]
|
Facility
|
IP
|
$5.67
|
|
|
Service Code
|
NDC 00904712361
|
| Hospital Charge Code |
3809478
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.10 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.10
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.39
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 500 mg Tab [HMC]
|
Facility
|
OP
|
$15.54
|
|
|
Service Code
|
NDC 31722053712
|
| Hospital Charge Code |
3801214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.22 |
| Max. Negotiated Rate |
$14.76 |
| Rate for Payer: Aetna Commercial |
$13.99
|
| Rate for Payer: Humana Medicare Advantage |
$6.53
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.76
|
| Rate for Payer: UnitedHealthcare Medicaid |
$6.22
|
| Rate for Payer: WPPA Medicare Advantage |
$9.32
|
|
|
levETIRAcetam 500 mg Tab [HMC]
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
NDC 31722053712
|
| Hospital Charge Code |
3801214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.99 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.99
|
| Rate for Payer: UnitedHealthcare Commercial |
$14.76
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 500 mg Tab [HMC]
|
Facility
|
IP
|
$5.75
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
3801214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.17 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$5.17
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.46
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 500 mg Tab [HMC]
|
Facility
|
IP
|
$14.49
|
|
|
Service Code
|
NDC 00904605261
|
| Hospital Charge Code |
3801214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.04 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$13.04
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.77
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
levETIRAcetam 500 mg Tab [HMC]
|
Facility
|
OP
|
$5.75
|
|
|
Service Code
|
NDC 00904712461
|
| Hospital Charge Code |
3801214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.30 |
| Max. Negotiated Rate |
$5.46 |
| Rate for Payer: Aetna Commercial |
$5.17
|
| Rate for Payer: Humana Medicare Advantage |
$2.42
|
| Rate for Payer: UnitedHealthcare Commercial |
$5.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$2.30
|
| Rate for Payer: WPPA Medicare Advantage |
$3.45
|
|
|
levETIRAcetam 500 mg Tab [HMC]
|
Facility
|
OP
|
$14.49
|
|
|
Service Code
|
NDC 00904605261
|
| Hospital Charge Code |
3801214
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.80 |
| Max. Negotiated Rate |
$13.77 |
| Rate for Payer: Aetna Commercial |
$13.04
|
| Rate for Payer: Humana Medicare Advantage |
$6.09
|
| Rate for Payer: UnitedHealthcare Commercial |
$13.77
|
| Rate for Payer: UnitedHealthcare Medicaid |
$5.80
|
| Rate for Payer: WPPA Medicare Advantage |
$8.69
|
|
|
Levetiracetam, Immunoassay QST
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS 80177
|
| Hospital Charge Code |
3550177
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Aetna Commercial |
$162.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$36.45
|
| Rate for Payer: Humana Medicare Advantage |
$75.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$171.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.25
|
| Rate for Payer: WPPA Medicare Advantage |
$108.00
|
|
|
Levetiracetam, Immunoassay QST
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS 80177
|
| Hospital Charge Code |
3550177
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$162.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$162.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$171.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Levetiracetam QST
|
Facility
|
IP
|
$180.00
|
|
|
Service Code
|
HCPCS 80177
|
| Hospital Charge Code |
3550177
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$162.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$162.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$171.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
Levetiracetam QST
|
Facility
|
OP
|
$180.00
|
|
|
Service Code
|
HCPCS 80177
|
| Hospital Charge Code |
3550177
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$13.25 |
| Max. Negotiated Rate |
$171.00 |
| Rate for Payer: Aetna Commercial |
$162.00
|
| Rate for Payer: Blue Cross Blue Shield of Kansas Commercial |
$36.45
|
| Rate for Payer: Humana Medicare Advantage |
$75.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$171.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.25
|
| Rate for Payer: WPPA Medicare Advantage |
$108.00
|
|
