|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$4.58
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.80 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: Aetna Medicare |
$2.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.98
|
| Rate for Payer: BCBS Complete |
$1.83
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cofinity Advantage |
$3.21
|
| Rate for Payer: Cofinity Commercial |
$3.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.66
|
| Rate for Payer: Healthscope Commercial |
$4.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.89
|
| Rate for Payer: Priority Health SBD |
$2.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.98
|
| Rate for Payer: UHC Core |
$2.39
|
| Rate for Payer: UHC Exchange |
$1.80
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$323.95
|
|
|
Service Code
|
NDC 00904695061
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.31 |
| Max. Negotiated Rate |
$291.56 |
| Rate for Payer: Aetna Commercial |
$275.36
|
| Rate for Payer: Aetna Medicare |
$161.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.57
|
| Rate for Payer: BCBS Complete |
$129.58
|
| Rate for Payer: Cash Price |
$259.16
|
| Rate for Payer: Cofinity Advantage |
$226.76
|
| Rate for Payer: Cofinity Commercial |
$278.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.16
|
| Rate for Payer: Healthscope Commercial |
$291.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$259.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$242.96
|
| Rate for Payer: PHP Commercial |
$275.36
|
| Rate for Payer: Priority Health SBD |
$204.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$210.57
|
| Rate for Payer: UHC Core |
$168.78
|
| Rate for Payer: UHC Exchange |
$127.31
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$297.54
|
|
|
Service Code
|
NDC 00378180377
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.45 |
| Max. Negotiated Rate |
$267.79 |
| Rate for Payer: Aetna Commercial |
$252.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$193.40
|
| Rate for Payer: Cash Price |
$238.03
|
| Rate for Payer: Cofinity Advantage |
$208.28
|
| Rate for Payer: Cofinity Commercial |
$255.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$238.03
|
| Rate for Payer: Healthscope Commercial |
$267.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$252.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$223.16
|
| Rate for Payer: PHP Commercial |
$252.91
|
| Rate for Payer: Priority Health SBD |
$187.45
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$80.37
|
|
|
Service Code
|
NDC 16729044815
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.59 |
| Max. Negotiated Rate |
$72.33 |
| Rate for Payer: Aetna Commercial |
$68.31
|
| Rate for Payer: Aetna Medicare |
$40.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.24
|
| Rate for Payer: BCBS Complete |
$32.15
|
| Rate for Payer: Cash Price |
$64.30
|
| Rate for Payer: Cofinity Advantage |
$56.26
|
| Rate for Payer: Cofinity Commercial |
$69.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.30
|
| Rate for Payer: Healthscope Commercial |
$72.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$64.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$60.28
|
| Rate for Payer: PHP Commercial |
$68.31
|
| Rate for Payer: Priority Health SBD |
$50.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$52.24
|
| Rate for Payer: UHC Core |
$41.87
|
| Rate for Payer: UHC Exchange |
$31.59
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$356.25
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.44 |
| Max. Negotiated Rate |
$320.62 |
| Rate for Payer: Aetna Commercial |
$302.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$231.56
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cofinity Advantage |
$249.38
|
| Rate for Payer: Cofinity Commercial |
$306.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.00
|
| Rate for Payer: Healthscope Commercial |
$320.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.19
|
| Rate for Payer: PHP Commercial |
$302.81
|
| Rate for Payer: Priority Health SBD |
$224.44
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$732.24
|
|
|
Service Code
|
NDC 00074455290
|
| Hospital Charge Code |
4421
|
|
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 50 MCG TABLET
|
Facility
|
OP
|
$457.90
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.95 |
| Max. Negotiated Rate |
$412.11 |
| Rate for Payer: Aetna Commercial |
$389.21
|
| Rate for Payer: Aetna Medicare |
$228.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.63
|
| Rate for Payer: BCBS Complete |
$183.16
|
| Rate for Payer: Cash Price |
$366.32
|
| Rate for Payer: Cofinity Advantage |
$320.53
|
| Rate for Payer: Cofinity Commercial |
$393.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.32
|
| Rate for Payer: Healthscope Commercial |
$412.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$366.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$389.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$343.43
|
| Rate for Payer: PHP Commercial |
$389.21
|
| Rate for Payer: Priority Health SBD |
$288.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$297.63
|
| Rate for Payer: UHC Core |
$238.57
|
| Rate for Payer: UHC Exchange |
$179.95
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$323.95
|
|
|
Service Code
|
NDC 00904695061
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$204.09 |
| Max. Negotiated Rate |
$291.56 |
| Rate for Payer: Aetna Commercial |
$275.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.57
|
| Rate for Payer: Cash Price |
$259.16
|
| Rate for Payer: Cofinity Advantage |
$226.76
|
| Rate for Payer: Cofinity Commercial |
$278.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.16
|
| Rate for Payer: Healthscope Commercial |
$291.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$242.96
|
| Rate for Payer: PHP Commercial |
$275.36
|
| Rate for Payer: Priority Health SBD |
$204.09
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$356.25
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.01 |
| Max. Negotiated Rate |
$320.62 |
| Rate for Payer: Aetna Commercial |
$302.81
|
| Rate for Payer: Aetna Medicare |
$178.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$231.56
|
| Rate for Payer: BCBS Complete |
$142.50
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cofinity Advantage |
$249.38
|
| Rate for Payer: Cofinity Commercial |
$306.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.00
|
| Rate for Payer: Healthscope Commercial |
$320.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$285.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.19
|
| Rate for Payer: PHP Commercial |
$302.81
|
| Rate for Payer: Priority Health SBD |
$224.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$231.56
|
| Rate for Payer: UHC Core |
$185.61
|
| Rate for Payer: UHC Exchange |
$140.01
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$3.57
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: Aetna Medicare |
$1.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.32
|
| Rate for Payer: BCBS Complete |
$1.43
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cofinity Advantage |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.86
|
| Rate for Payer: Healthscope Commercial |
$3.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.68
|
| Rate for Payer: PHP Commercial |
$3.03
|
| Rate for Payer: Priority Health SBD |
$2.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.32
|
| Rate for Payer: UHC Core |
$1.86
|
| Rate for Payer: UHC Exchange |
$1.40
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$256.32
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.73 |
| Max. Negotiated Rate |
$230.69 |
| Rate for Payer: Aetna Commercial |
$217.87
|
| Rate for Payer: Aetna Medicare |
$128.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.61
|
| Rate for Payer: BCBS Complete |
$102.53
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Advantage |
$179.42
|
| Rate for Payer: Cofinity Commercial |
$220.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Healthscope Commercial |
$230.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$205.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$192.24
|
| Rate for Payer: PHP Commercial |
$217.87
|
| Rate for Payer: Priority Health SBD |
$161.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$166.61
|
| Rate for Payer: UHC Core |
$133.54
|
| Rate for Payer: UHC Exchange |
$100.73
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.67
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Advantage |
$1.80
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.93
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health SBD |
$1.62
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$732.68
|
|
|
Service Code
|
NDC 00074518290
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$461.59 |
| Max. Negotiated Rate |
$659.41 |
| Rate for Payer: Aetna Commercial |
$622.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$476.24
|
| Rate for Payer: Cash Price |
$586.14
|
| Rate for Payer: Cofinity Advantage |
$512.88
|
| Rate for Payer: Cofinity Commercial |
$630.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$586.14
|
| Rate for Payer: Healthscope Commercial |
$659.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.51
|
| Rate for Payer: PHP Commercial |
$622.78
|
| Rate for Payer: Priority Health SBD |
$461.59
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$84.60
|
|
|
Service Code
|
NDC 16729044915
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.30 |
| Max. Negotiated Rate |
$76.14 |
| Rate for Payer: Aetna Commercial |
$71.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.99
|
| Rate for Payer: Cash Price |
$67.68
|
| Rate for Payer: Cofinity Advantage |
$59.22
|
| Rate for Payer: Cofinity Commercial |
$72.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$67.68
|
| Rate for Payer: Healthscope Commercial |
$76.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$63.45
|
| Rate for Payer: PHP Commercial |
$71.91
|
| Rate for Payer: Priority Health SBD |
$53.30
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$425.60
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.26 |
| Max. Negotiated Rate |
$383.04 |
| Rate for Payer: Aetna Commercial |
$361.76
|
| Rate for Payer: Aetna Medicare |
$212.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.64
|
| Rate for Payer: BCBS Complete |
$170.24
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cofinity Advantage |
$297.92
|
| Rate for Payer: Cofinity Commercial |
$366.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.48
|
| Rate for Payer: Healthscope Commercial |
$383.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$340.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.20
|
| Rate for Payer: PHP Commercial |
$361.76
|
| Rate for Payer: Priority Health SBD |
$268.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$276.64
|
| Rate for Payer: UHC Core |
$221.74
|
| Rate for Payer: UHC Exchange |
$167.26
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.67
|
| Rate for Payer: BCBS Complete |
$1.03
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Advantage |
$1.80
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.93
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health SBD |
$1.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.67
|
| Rate for Payer: UHC Core |
$1.34
|
| Rate for Payer: UHC Exchange |
$1.01
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$425.60
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.13 |
| Max. Negotiated Rate |
$383.04 |
| Rate for Payer: Aetna Commercial |
$361.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.64
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cofinity Advantage |
$297.92
|
| Rate for Payer: Cofinity Commercial |
$366.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.48
|
| Rate for Payer: Healthscope Commercial |
$383.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.20
|
| Rate for Payer: PHP Commercial |
$361.76
|
| Rate for Payer: Priority Health SBD |
$268.13
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$256.32
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.48 |
| Max. Negotiated Rate |
$230.69 |
| Rate for Payer: Aetna Commercial |
$217.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.61
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Advantage |
$179.42
|
| Rate for Payer: Cofinity Commercial |
$220.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Healthscope Commercial |
$230.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$192.24
|
| Rate for Payer: PHP Commercial |
$217.87
|
| Rate for Payer: Priority Health SBD |
$161.48
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$329.18
|
|
|
Service Code
|
NDC 00378180577
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.38 |
| Max. Negotiated Rate |
$296.26 |
| Rate for Payer: Aetna Commercial |
$279.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.97
|
| Rate for Payer: Cash Price |
$263.34
|
| Rate for Payer: Cofinity Advantage |
$230.43
|
| Rate for Payer: Cofinity Commercial |
$283.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.34
|
| Rate for Payer: Healthscope Commercial |
$296.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$246.88
|
| Rate for Payer: PHP Commercial |
$279.80
|
| Rate for Payer: Priority Health SBD |
$207.38
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$732.68
|
|
|
Service Code
|
NDC 00074518290
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.94 |
| Max. Negotiated Rate |
$659.41 |
| Rate for Payer: Aetna Commercial |
$622.78
|
| Rate for Payer: Aetna Medicare |
$366.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$476.24
|
| Rate for Payer: BCBS Complete |
$293.07
|
| Rate for Payer: Cash Price |
$586.14
|
| Rate for Payer: Cofinity Advantage |
$512.88
|
| Rate for Payer: Cofinity Commercial |
$630.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$586.14
|
| Rate for Payer: Healthscope Commercial |
$659.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$586.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.51
|
| Rate for Payer: PHP Commercial |
$622.78
|
| Rate for Payer: Priority Health SBD |
$461.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$476.24
|
| Rate for Payer: UHC Core |
$381.73
|
| Rate for Payer: UHC Exchange |
$287.94
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$329.18
|
|
|
Service Code
|
NDC 00378180577
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.37 |
| Max. Negotiated Rate |
$296.26 |
| Rate for Payer: Aetna Commercial |
$279.80
|
| Rate for Payer: Aetna Medicare |
$164.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.97
|
| Rate for Payer: BCBS Complete |
$131.67
|
| Rate for Payer: Cash Price |
$263.34
|
| Rate for Payer: Cofinity Advantage |
$230.43
|
| Rate for Payer: Cofinity Commercial |
$283.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.34
|
| Rate for Payer: Healthscope Commercial |
$296.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$263.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$246.88
|
| Rate for Payer: PHP Commercial |
$279.80
|
| Rate for Payer: Priority Health SBD |
$207.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$213.97
|
| Rate for Payer: UHC Core |
$171.50
|
| Rate for Payer: UHC Exchange |
$129.37
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$84.60
|
|
|
Service Code
|
NDC 16729044915
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.25 |
| Max. Negotiated Rate |
$76.14 |
| Rate for Payer: Aetna Commercial |
$71.91
|
| Rate for Payer: Aetna Medicare |
$42.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$54.99
|
| Rate for Payer: BCBS Complete |
$33.84
|
| Rate for Payer: Cash Price |
$67.68
|
| Rate for Payer: Cofinity Advantage |
$59.22
|
| Rate for Payer: Cofinity Commercial |
$72.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$67.68
|
| Rate for Payer: Healthscope Commercial |
$76.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$67.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$71.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$63.45
|
| Rate for Payer: PHP Commercial |
$71.91
|
| Rate for Payer: Priority Health SBD |
$53.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$54.99
|
| Rate for Payer: UHC Core |
$44.08
|
| Rate for Payer: UHC Exchange |
$33.25
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$465.50
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.94 |
| Max. Negotiated Rate |
$418.95 |
| Rate for Payer: Aetna Commercial |
$395.68
|
| Rate for Payer: Aetna Medicare |
$232.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$302.57
|
| Rate for Payer: BCBS Complete |
$186.20
|
| Rate for Payer: Cash Price |
$372.40
|
| Rate for Payer: Cofinity Advantage |
$325.85
|
| Rate for Payer: Cofinity Commercial |
$400.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$372.40
|
| Rate for Payer: Healthscope Commercial |
$418.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$372.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$349.12
|
| Rate for Payer: PHP Commercial |
$395.68
|
| Rate for Payer: Priority Health SBD |
$293.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$302.57
|
| Rate for Payer: UHC Core |
$242.53
|
| Rate for Payer: UHC Exchange |
$182.94
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$406.60
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.79 |
| Max. Negotiated Rate |
$365.94 |
| Rate for Payer: Aetna Commercial |
$345.61
|
| Rate for Payer: Aetna Medicare |
$203.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.29
|
| Rate for Payer: BCBS Complete |
$162.64
|
| Rate for Payer: Cash Price |
$325.28
|
| Rate for Payer: Cofinity Advantage |
$284.62
|
| Rate for Payer: Cofinity Commercial |
$349.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.28
|
| Rate for Payer: Healthscope Commercial |
$365.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$325.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$304.95
|
| Rate for Payer: PHP Commercial |
$345.61
|
| Rate for Payer: Priority Health SBD |
$256.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$264.29
|
| Rate for Payer: UHC Core |
$211.84
|
| Rate for Payer: UHC Exchange |
$159.79
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$732.68
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$287.94 |
| Max. Negotiated Rate |
$659.41 |
| Rate for Payer: Aetna Commercial |
$622.78
|
| Rate for Payer: Aetna Medicare |
$366.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$476.24
|
| Rate for Payer: BCBS Complete |
$293.07
|
| Rate for Payer: Cash Price |
$586.14
|
| Rate for Payer: Cofinity Advantage |
$512.88
|
| Rate for Payer: Cofinity Commercial |
$630.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$586.14
|
| Rate for Payer: Healthscope Commercial |
$659.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$586.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.51
|
| Rate for Payer: PHP Commercial |
$622.78
|
| Rate for Payer: Priority Health SBD |
$461.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$476.24
|
| Rate for Payer: UHC Core |
$381.73
|
| Rate for Payer: UHC Exchange |
$287.94
|
|
