|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
OP
|
$150.40
|
|
|
Service Code
|
NDC 55111027950
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.11 |
| Max. Negotiated Rate |
$135.36 |
| Rate for Payer: Aetna Commercial |
$127.84
|
| Rate for Payer: Aetna Medicare |
$75.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$97.76
|
| Rate for Payer: BCBS Complete |
$60.16
|
| Rate for Payer: Cash Price |
$120.32
|
| Rate for Payer: Cofinity Advantage |
$105.28
|
| Rate for Payer: Cofinity Commercial |
$129.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$120.32
|
| Rate for Payer: Healthscope Commercial |
$135.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$120.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$112.80
|
| Rate for Payer: PHP Commercial |
$127.84
|
| Rate for Payer: Priority Health SBD |
$94.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.76
|
| Rate for Payer: UHC Core |
$78.36
|
| Rate for Payer: UHC Exchange |
$59.11
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
OP
|
$195.70
|
|
|
Service Code
|
NDC 00904635161
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.91 |
| Max. Negotiated Rate |
$176.13 |
| Rate for Payer: Aetna Commercial |
$166.34
|
| Rate for Payer: Aetna Medicare |
$97.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$127.20
|
| Rate for Payer: BCBS Complete |
$78.28
|
| Rate for Payer: Cash Price |
$156.56
|
| Rate for Payer: Cofinity Advantage |
$136.99
|
| Rate for Payer: Cofinity Commercial |
$168.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.56
|
| Rate for Payer: Healthscope Commercial |
$176.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$156.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$166.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.78
|
| Rate for Payer: PHP Commercial |
$166.34
|
| Rate for Payer: Priority Health SBD |
$123.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$127.20
|
| Rate for Payer: UHC Core |
$101.96
|
| Rate for Payer: UHC Exchange |
$76.91
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$89.32
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.27 |
| Max. Negotiated Rate |
$80.39 |
| Rate for Payer: Aetna Commercial |
$75.92
|
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.06
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cash Price |
$71.46
|
| Rate for Payer: Cofinity Advantage |
$62.52
|
| Rate for Payer: Cofinity Advantage |
$55.83
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Cofinity Commercial |
$76.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.46
|
| Rate for Payer: Healthscope Commercial |
$71.78
|
| Rate for Payer: Healthscope Commercial |
$80.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.81
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: PHP Commercial |
$75.92
|
| Rate for Payer: Priority Health SBD |
$50.24
|
| Rate for Payer: Priority Health SBD |
$56.27
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$89.32
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$80.39 |
| Rate for Payer: Aetna Commercial |
$75.92
|
| Rate for Payer: Aetna Commercial |
$67.79
|
| Rate for Payer: Aetna Medicare |
$39.88
|
| Rate for Payer: Aetna Medicare |
$44.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.84
|
| Rate for Payer: BCBS Complete |
$31.90
|
| Rate for Payer: BCBS Complete |
$35.73
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: Cash Price |
$71.46
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cash Price |
$71.46
|
| Rate for Payer: Cash Price |
$63.80
|
| Rate for Payer: Cofinity Advantage |
$62.52
|
| Rate for Payer: Cofinity Advantage |
$55.83
|
| Rate for Payer: Cofinity Commercial |
$76.82
|
| Rate for Payer: Cofinity Commercial |
$68.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.46
|
| Rate for Payer: Healthscope Commercial |
$71.78
|
| Rate for Payer: Healthscope Commercial |
$80.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$63.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$67.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$66.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.81
|
| Rate for Payer: PHP Commercial |
$75.92
|
| Rate for Payer: PHP Commercial |
$67.79
|
| Rate for Payer: Priority Health SBD |
$56.27
|
| Rate for Payer: Priority Health SBD |
$50.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$90.92
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$81.83 |
| Rate for Payer: Aetna Commercial |
$77.28
|
| Rate for Payer: Aetna Commercial |
$50.85
|
| Rate for Payer: Aetna Commercial |
$94.81
|
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Commercial |
$87.45
|
| Rate for Payer: Aetna Medicare |
$51.44
|
| Rate for Payer: Aetna Medicare |
$55.77
|
| Rate for Payer: Aetna Medicare |
$29.91
|
| Rate for Payer: Aetna Medicare |
$45.46
|
| Rate for Payer: Aetna Medicare |
$34.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.87
|
| Rate for Payer: BCBS Complete |
$36.37
|
| Rate for Payer: BCBS Complete |
$44.62
|
| Rate for Payer: BCBS Complete |
$23.93
|
| Rate for Payer: BCBS Complete |
$41.15
|
| Rate for Payer: BCBS Complete |
$27.27
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCBS Trust/PPO |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: BCN Commercial |
$5.42
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$82.30
|
| Rate for Payer: Cash Price |
$82.30
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cofinity Advantage |
$63.64
|
| Rate for Payer: Cofinity Advantage |
$47.73
|
| Rate for Payer: Cofinity Advantage |
$78.08
|
| Rate for Payer: Cofinity Advantage |
$72.02
|
| Rate for Payer: Cofinity Advantage |
$41.87
|
| Rate for Payer: Cofinity Commercial |
$51.45
|
| Rate for Payer: Cofinity Commercial |
$95.92
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Cofinity Commercial |
$78.19
|
| Rate for Payer: Cofinity Commercial |
$88.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.23
|
| Rate for Payer: Healthscope Commercial |
$100.39
|
| Rate for Payer: Healthscope Commercial |
$81.83
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Healthscope Commercial |
$53.84
|
| Rate for Payer: Healthscope Commercial |
$92.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$54.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$82.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$89.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$72.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$83.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$51.13
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: PHP Commercial |
$94.81
|
| Rate for Payer: PHP Commercial |
$87.45
|
| Rate for Payer: PHP Commercial |
$77.28
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: Priority Health SBD |
$37.69
|
| Rate for Payer: Priority Health SBD |
$42.95
|
| Rate for Payer: Priority Health SBD |
$57.28
|
| Rate for Payer: Priority Health SBD |
$70.27
|
| Rate for Payer: Priority Health SBD |
$64.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Core |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
| Rate for Payer: UHC Exchange |
$3.56
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$90.92
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$57.28 |
| Max. Negotiated Rate |
$81.83 |
| Rate for Payer: Aetna Commercial |
$77.28
|
| Rate for Payer: Aetna Commercial |
$94.81
|
| Rate for Payer: Aetna Commercial |
$87.45
|
| Rate for Payer: Aetna Commercial |
$50.85
|
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.10
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cash Price |
$72.74
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$82.30
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cofinity Advantage |
$47.73
|
| Rate for Payer: Cofinity Advantage |
$41.87
|
| Rate for Payer: Cofinity Advantage |
$63.64
|
| Rate for Payer: Cofinity Advantage |
$72.02
|
| Rate for Payer: Cofinity Advantage |
$78.08
|
| Rate for Payer: Cofinity Commercial |
$78.19
|
| Rate for Payer: Cofinity Commercial |
$51.45
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Cofinity Commercial |
$95.92
|
| Rate for Payer: Cofinity Commercial |
$88.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.74
|
| Rate for Payer: Healthscope Commercial |
$53.84
|
| Rate for Payer: Healthscope Commercial |
$81.83
|
| Rate for Payer: Healthscope Commercial |
$100.39
|
| Rate for Payer: Healthscope Commercial |
$92.59
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$77.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$83.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$51.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$68.19
|
| Rate for Payer: PHP Commercial |
$87.45
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: PHP Commercial |
$77.28
|
| Rate for Payer: PHP Commercial |
$94.81
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: Priority Health SBD |
$42.95
|
| Rate for Payer: Priority Health SBD |
$37.69
|
| Rate for Payer: Priority Health SBD |
$70.27
|
| Rate for Payer: Priority Health SBD |
$64.81
|
| Rate for Payer: Priority Health SBD |
$57.28
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$385.70
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.99 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna Commercial |
$327.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.71
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Advantage |
$269.99
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.27
|
| Rate for Payer: PHP Commercial |
$327.85
|
| Rate for Payer: Priority Health SBD |
$242.99
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
OP
|
$385.70
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.58 |
| Max. Negotiated Rate |
$347.13 |
| Rate for Payer: Aetna Commercial |
$327.85
|
| Rate for Payer: Aetna Medicare |
$192.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$250.71
|
| Rate for Payer: BCBS Complete |
$154.28
|
| Rate for Payer: Cash Price |
$308.56
|
| Rate for Payer: Cofinity Advantage |
$269.99
|
| Rate for Payer: Cofinity Commercial |
$331.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.56
|
| Rate for Payer: Healthscope Commercial |
$347.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$308.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$327.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.27
|
| Rate for Payer: PHP Commercial |
$327.85
|
| Rate for Payer: Priority Health SBD |
$242.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$250.71
|
| Rate for Payer: UHC Core |
$200.95
|
| Rate for Payer: UHC Exchange |
$151.58
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
OP
|
$65.55
|
|
|
Service Code
|
NDC 55111028130
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.76 |
| Max. Negotiated Rate |
$58.99 |
| Rate for Payer: Aetna Commercial |
$55.72
|
| Rate for Payer: Aetna Medicare |
$32.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.61
|
| Rate for Payer: BCBS Complete |
$26.22
|
| Rate for Payer: Cash Price |
$52.44
|
| Rate for Payer: Cofinity Advantage |
$45.88
|
| Rate for Payer: Cofinity Commercial |
$56.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.44
|
| Rate for Payer: Healthscope Commercial |
$58.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$52.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$49.16
|
| Rate for Payer: PHP Commercial |
$55.72
|
| Rate for Payer: Priority Health SBD |
$41.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$42.61
|
| Rate for Payer: UHC Core |
$34.15
|
| Rate for Payer: UHC Exchange |
$25.76
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$65.55
|
|
|
Service Code
|
NDC 55111028130
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.30 |
| Max. Negotiated Rate |
$58.99 |
| Rate for Payer: Aetna Commercial |
$55.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.61
|
| Rate for Payer: Cash Price |
$52.44
|
| Rate for Payer: Cofinity Advantage |
$45.88
|
| Rate for Payer: Cofinity Commercial |
$56.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.44
|
| Rate for Payer: Healthscope Commercial |
$58.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$55.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$49.16
|
| Rate for Payer: PHP Commercial |
$55.72
|
| Rate for Payer: Priority Health SBD |
$41.30
|
|
|
LEVOMILNACIPRAN ER 20 MG CAPSULE,24 HR,EXTENDED RELEASE
|
Facility
|
OP
|
$1,900.88
|
|
|
Service Code
|
NDC 00456222030
|
| Hospital Charge Code |
168790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$747.05 |
| Max. Negotiated Rate |
$1,710.79 |
| Rate for Payer: Aetna Commercial |
$1,615.75
|
| Rate for Payer: Aetna Medicare |
$950.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,235.57
|
| Rate for Payer: BCBS Complete |
$760.35
|
| Rate for Payer: Cash Price |
$1,520.70
|
| Rate for Payer: Cofinity Advantage |
$1,330.62
|
| Rate for Payer: Cofinity Commercial |
$1,634.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,520.70
|
| Rate for Payer: Healthscope Commercial |
$1,710.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,520.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,615.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,425.66
|
| Rate for Payer: PHP Commercial |
$1,615.75
|
| Rate for Payer: Priority Health SBD |
$1,197.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,235.57
|
| Rate for Payer: UHC Core |
$990.36
|
| Rate for Payer: UHC Exchange |
$747.05
|
|
|
LEVOMILNACIPRAN ER 20 MG CAPSULE,24 HR,EXTENDED RELEASE
|
Facility
|
IP
|
$1,900.88
|
|
|
Service Code
|
NDC 00456222030
|
| Hospital Charge Code |
168790
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,197.55 |
| Max. Negotiated Rate |
$1,710.79 |
| Rate for Payer: Aetna Commercial |
$1,615.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,235.57
|
| Rate for Payer: Cash Price |
$1,520.70
|
| Rate for Payer: Cofinity Advantage |
$1,330.62
|
| Rate for Payer: Cofinity Commercial |
$1,634.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,520.70
|
| Rate for Payer: Healthscope Commercial |
$1,710.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,615.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,425.66
|
| Rate for Payer: PHP Commercial |
$1,615.75
|
| Rate for Payer: Priority Health SBD |
$1,197.55
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE
|
Facility
|
OP
|
$4,076.29
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
181058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,030.01 |
| Max. Negotiated Rate |
$3,668.66 |
| Rate for Payer: Aetna Commercial |
$3,464.85
|
| Rate for Payer: Aetna Commercial |
$3,299.86
|
| Rate for Payer: Aetna Medicare |
$1,941.10
|
| Rate for Payer: Aetna Medicare |
$2,038.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,523.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,649.59
|
| Rate for Payer: BCBS Complete |
$1,552.88
|
| Rate for Payer: BCBS Complete |
$1,630.52
|
| Rate for Payer: BCBS Trust/PPO |
$3,042.47
|
| Rate for Payer: BCBS Trust/PPO |
$3,042.47
|
| Rate for Payer: BCN Commercial |
$3,042.47
|
| Rate for Payer: BCN Commercial |
$3,042.47
|
| Rate for Payer: Cash Price |
$3,105.75
|
| Rate for Payer: Cash Price |
$3,105.75
|
| Rate for Payer: Cash Price |
$3,261.03
|
| Rate for Payer: Cash Price |
$3,261.03
|
| Rate for Payer: Cofinity Advantage |
$2,717.53
|
| Rate for Payer: Cofinity Advantage |
$2,853.40
|
| Rate for Payer: Cofinity Commercial |
$3,338.68
|
| Rate for Payer: Cofinity Commercial |
$3,505.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,105.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,261.03
|
| Rate for Payer: Healthscope Commercial |
$3,493.97
|
| Rate for Payer: Healthscope Commercial |
$3,668.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,105.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,261.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,299.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,464.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,911.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,057.22
|
| Rate for Payer: PHP Commercial |
$3,299.86
|
| Rate for Payer: PHP Commercial |
$3,464.85
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,287.51
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,287.51
|
| Rate for Payer: Priority Health SBD |
$2,568.06
|
| Rate for Payer: Priority Health SBD |
$2,445.78
|
| Rate for Payer: Priority Health Tiered Network |
$1,030.01
|
| Rate for Payer: Priority Health Tiered Network |
$1,030.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,519.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,519.43
|
| Rate for Payer: UHC Core |
$2,519.43
|
| Rate for Payer: UHC Core |
$2,519.43
|
| Rate for Payer: UHC Exchange |
$2,519.43
|
| Rate for Payer: UHC Exchange |
$2,519.43
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE
|
Facility
|
IP
|
$4,076.29
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
181058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,568.06 |
| Max. Negotiated Rate |
$3,668.66 |
| Rate for Payer: Aetna Commercial |
$3,464.85
|
| Rate for Payer: Aetna Commercial |
$3,299.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,649.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,523.42
|
| Rate for Payer: Cash Price |
$3,261.03
|
| Rate for Payer: Cash Price |
$3,105.75
|
| Rate for Payer: Cofinity Advantage |
$2,717.53
|
| Rate for Payer: Cofinity Advantage |
$2,853.40
|
| Rate for Payer: Cofinity Commercial |
$3,338.68
|
| Rate for Payer: Cofinity Commercial |
$3,505.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,261.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,105.75
|
| Rate for Payer: Healthscope Commercial |
$3,668.66
|
| Rate for Payer: Healthscope Commercial |
$3,493.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,299.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,464.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,911.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,057.22
|
| Rate for Payer: PHP Commercial |
$3,464.85
|
| Rate for Payer: PHP Commercial |
$3,299.86
|
| Rate for Payer: Priority Health SBD |
$2,568.06
|
| Rate for Payer: Priority Health SBD |
$2,445.78
|
|
|
LEVONORGESTREL 21 MCG/24 HR (UP TO 8 YEARS) 52 MG INTRAUTERINE DEVICE
|
Facility
|
IP
|
$4,708.03
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,966.06 |
| Max. Negotiated Rate |
$4,237.23 |
| Rate for Payer: Aetna Commercial |
$4,001.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,060.22
|
| Rate for Payer: Cash Price |
$3,766.42
|
| Rate for Payer: Cofinity Advantage |
$3,295.62
|
| Rate for Payer: Cofinity Commercial |
$4,048.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,766.42
|
| Rate for Payer: Healthscope Commercial |
$4,237.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,001.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,531.02
|
| Rate for Payer: PHP Commercial |
$4,001.83
|
| Rate for Payer: Priority Health SBD |
$2,966.06
|
|
|
LEVONORGESTREL 21 MCG/24 HR (UP TO 8 YEARS) 52 MG INTRAUTERINE DEVICE
|
Facility
|
OP
|
$4,708.03
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,030.01 |
| Max. Negotiated Rate |
$4,237.23 |
| Rate for Payer: Aetna Commercial |
$4,001.83
|
| Rate for Payer: Aetna Medicare |
$2,354.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,060.22
|
| Rate for Payer: BCBS Complete |
$1,883.21
|
| Rate for Payer: BCBS Trust/PPO |
$3,003.00
|
| Rate for Payer: BCN Commercial |
$3,003.00
|
| Rate for Payer: Cash Price |
$3,766.42
|
| Rate for Payer: Cash Price |
$3,766.42
|
| Rate for Payer: Cofinity Advantage |
$3,295.62
|
| Rate for Payer: Cofinity Commercial |
$4,048.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,766.42
|
| Rate for Payer: Healthscope Commercial |
$4,237.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,766.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,001.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3,531.02
|
| Rate for Payer: PHP Commercial |
$4,001.83
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$1,287.51
|
| Rate for Payer: Priority Health SBD |
$2,966.06
|
| Rate for Payer: Priority Health Tiered Network |
$1,030.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2,519.43
|
| Rate for Payer: UHC Core |
$2,519.43
|
| Rate for Payer: UHC Exchange |
$2,519.43
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$231.93
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$146.12 |
| Max. Negotiated Rate |
$208.74 |
| Rate for Payer: Aetna Commercial |
$197.14
|
| Rate for Payer: Aetna Commercial |
$159.81
|
| Rate for Payer: Aetna Commercial |
$247.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.21
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$232.80
|
| Rate for Payer: Cofinity Advantage |
$203.70
|
| Rate for Payer: Cofinity Advantage |
$131.61
|
| Rate for Payer: Cofinity Advantage |
$162.35
|
| Rate for Payer: Cofinity Commercial |
$199.46
|
| Rate for Payer: Cofinity Commercial |
$161.69
|
| Rate for Payer: Cofinity Commercial |
$250.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Healthscope Commercial |
$261.90
|
| Rate for Payer: Healthscope Commercial |
$169.21
|
| Rate for Payer: Healthscope Commercial |
$208.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$141.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$218.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$173.95
|
| Rate for Payer: PHP Commercial |
$159.81
|
| Rate for Payer: PHP Commercial |
$247.35
|
| Rate for Payer: PHP Commercial |
$197.14
|
| Rate for Payer: Priority Health SBD |
$183.33
|
| Rate for Payer: Priority Health SBD |
$146.12
|
| Rate for Payer: Priority Health SBD |
$118.45
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$188.01
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$169.21 |
| Rate for Payer: Aetna Commercial |
$159.81
|
| Rate for Payer: Aetna Commercial |
$197.14
|
| Rate for Payer: Aetna Commercial |
$247.35
|
| Rate for Payer: Aetna Medicare |
$94.00
|
| Rate for Payer: Aetna Medicare |
$115.97
|
| Rate for Payer: Aetna Medicare |
$145.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.15
|
| Rate for Payer: BCBS Complete |
$116.40
|
| Rate for Payer: BCBS Complete |
$75.20
|
| Rate for Payer: BCBS Complete |
$92.77
|
| Rate for Payer: BCBS Trust/PPO |
$15.00
|
| Rate for Payer: BCBS Trust/PPO |
$15.00
|
| Rate for Payer: BCBS Trust/PPO |
$15.00
|
| Rate for Payer: BCN Commercial |
$15.00
|
| Rate for Payer: BCN Commercial |
$15.00
|
| Rate for Payer: BCN Commercial |
$15.00
|
| Rate for Payer: Cash Price |
$232.80
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$232.80
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cofinity Advantage |
$162.35
|
| Rate for Payer: Cofinity Advantage |
$131.61
|
| Rate for Payer: Cofinity Advantage |
$203.70
|
| Rate for Payer: Cofinity Commercial |
$161.69
|
| Rate for Payer: Cofinity Commercial |
$199.46
|
| Rate for Payer: Cofinity Commercial |
$250.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Healthscope Commercial |
$261.90
|
| Rate for Payer: Healthscope Commercial |
$208.74
|
| Rate for Payer: Healthscope Commercial |
$169.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$150.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$232.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$185.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$173.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$141.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$218.25
|
| Rate for Payer: PHP Commercial |
$159.81
|
| Rate for Payer: PHP Commercial |
$197.14
|
| Rate for Payer: PHP Commercial |
$247.35
|
| Rate for Payer: Priority Health SBD |
$118.45
|
| Rate for Payer: Priority Health SBD |
$183.33
|
| Rate for Payer: Priority Health SBD |
$146.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.87
|
| Rate for Payer: UHC Core |
$9.87
|
| Rate for Payer: UHC Core |
$9.87
|
| Rate for Payer: UHC Core |
$9.87
|
| Rate for Payer: UHC Exchange |
$9.87
|
| Rate for Payer: UHC Exchange |
$9.87
|
| Rate for Payer: UHC Exchange |
$9.87
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$263.04
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.37 |
| Max. Negotiated Rate |
$236.74 |
| Rate for Payer: Aetna Commercial |
$223.58
|
| Rate for Payer: Aetna Medicare |
$131.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.98
|
| Rate for Payer: BCBS Complete |
$105.22
|
| Rate for Payer: Cash Price |
$210.43
|
| Rate for Payer: Cofinity Advantage |
$184.13
|
| Rate for Payer: Cofinity Commercial |
$226.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.43
|
| Rate for Payer: Healthscope Commercial |
$236.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$210.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$223.58
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$197.28
|
| Rate for Payer: PHP Commercial |
$223.58
|
| Rate for Payer: Priority Health SBD |
$165.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.98
|
| Rate for Payer: UHC Core |
$137.04
|
| Rate for Payer: UHC Exchange |
$103.37
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$732.24
|
|
|
Service Code
|
NDC 00074662490
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$461.31 |
| Max. Negotiated Rate |
$659.02 |
| Rate for Payer: Aetna Commercial |
$622.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$475.96
|
| Rate for Payer: Cash Price |
$585.79
|
| Rate for Payer: Cofinity Advantage |
$512.57
|
| Rate for Payer: Cofinity Commercial |
$629.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$585.79
|
| Rate for Payer: Healthscope Commercial |
$659.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.18
|
| Rate for Payer: PHP Commercial |
$622.40
|
| Rate for Payer: Priority Health SBD |
$461.31
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$2.64
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.72
|
| Rate for Payer: BCBS Complete |
$1.06
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cofinity Advantage |
$1.85
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.11
|
| Rate for Payer: Healthscope Commercial |
$2.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.98
|
| Rate for Payer: PHP Commercial |
$2.24
|
| Rate for Payer: Priority Health SBD |
$1.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.72
|
| Rate for Payer: UHC Core |
$1.38
|
| Rate for Payer: UHC Exchange |
$1.04
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.73 |
| Max. Negotiated Rate |
$303.96 |
| Rate for Payer: Aetna Commercial |
$287.07
|
| Rate for Payer: Aetna Medicare |
$168.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$219.52
|
| Rate for Payer: BCBS Complete |
$135.09
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Advantage |
$236.41
|
| Rate for Payer: Cofinity Commercial |
$290.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$303.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$270.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$253.30
|
| Rate for Payer: PHP Commercial |
$287.07
|
| Rate for Payer: Priority Health SBD |
$212.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$219.52
|
| Rate for Payer: UHC Core |
$175.96
|
| Rate for Payer: UHC Exchange |
$132.73
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$473.76
|
|
|
Service Code
|
NDC 60793085401
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.19 |
| Max. Negotiated Rate |
$426.38 |
| Rate for Payer: Aetna Commercial |
$402.70
|
| Rate for Payer: Aetna Medicare |
$236.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$307.94
|
| Rate for Payer: BCBS Complete |
$189.50
|
| Rate for Payer: Cash Price |
$379.01
|
| Rate for Payer: Cofinity Advantage |
$331.63
|
| Rate for Payer: Cofinity Commercial |
$407.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$379.01
|
| Rate for Payer: Healthscope Commercial |
$426.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$379.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$402.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$355.32
|
| Rate for Payer: PHP Commercial |
$402.70
|
| Rate for Payer: Priority Health SBD |
$298.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$307.94
|
| Rate for Payer: UHC Core |
$246.83
|
| Rate for Payer: UHC Exchange |
$186.19
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$416.10
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.53 |
| Max. Negotiated Rate |
$374.49 |
| Rate for Payer: Aetna Commercial |
$353.69
|
| Rate for Payer: Aetna Medicare |
$208.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$270.46
|
| Rate for Payer: BCBS Complete |
$166.44
|
| Rate for Payer: Cash Price |
$332.88
|
| Rate for Payer: Cofinity Advantage |
$291.27
|
| Rate for Payer: Cofinity Commercial |
$357.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$332.88
|
| Rate for Payer: Healthscope Commercial |
$374.49
|
| Rate for Payer: MI Amish Medical Board Commercial |
$332.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$353.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$312.07
|
| Rate for Payer: PHP Commercial |
$353.69
|
| Rate for Payer: Priority Health SBD |
$262.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$270.46
|
| Rate for Payer: UHC Core |
$216.79
|
| Rate for Payer: UHC Exchange |
$163.53
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$212.77 |
| Max. Negotiated Rate |
$303.96 |
| Rate for Payer: Aetna Commercial |
$287.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$219.52
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Advantage |
$236.41
|
| Rate for Payer: Cofinity Commercial |
$290.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$303.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$253.30
|
| Rate for Payer: PHP Commercial |
$287.07
|
| Rate for Payer: Priority Health SBD |
$212.77
|
|
