|
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) |
$2,523.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,649.59
|
| Rate for Payer: Cash Price |
$3,105.75
|
| Rate for Payer: Cash Price |
$3,261.03
|
| Rate for Payer: Cofinity Commercial |
$2,717.53
|
| Rate for Payer: Cofinity Commercial |
$2,853.40
|
| Rate for Payer: Cofinity Commercial |
$3,505.61
|
| Rate for Payer: Cofinity Commercial |
$3,338.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,853.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,717.53
|
| 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: Multiplan/Beech St/PHCS Commercial |
$3,299.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,464.85
|
| Rate for Payer: PHP Commercial |
$3,299.86
|
| Rate for Payer: PHP Commercial |
$3,464.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,649.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,523.42
|
| 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
|
$4,494.14
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2,831.31 |
| Max. Negotiated Rate |
$4,044.73 |
| Rate for Payer: Aetna Commercial |
$3,820.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,921.19
|
| Rate for Payer: Cash Price |
$3,595.31
|
| Rate for Payer: Cofinity Commercial |
$3,145.90
|
| Rate for Payer: Cofinity Commercial |
$3,864.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,145.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,595.31
|
| Rate for Payer: Healthscope Commercial |
$4,044.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,820.02
|
| Rate for Payer: PHP Commercial |
$3,820.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,921.19
|
| Rate for Payer: Priority Health SBD |
$2,831.31
|
|
|
LEVONORGESTREL 21 MCG/24 HR (UP TO 8 YEARS) 52 MG INTRAUTERINE DEVICE
|
Facility
|
OP
|
$4,494.14
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,797.66 |
| Max. Negotiated Rate |
$4,044.73 |
| Rate for Payer: Aetna Commercial |
$3,820.02
|
| Rate for Payer: Aetna Medicare |
$2,247.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,921.19
|
| Rate for Payer: BCBS Complete |
$1,797.66
|
| Rate for Payer: Cash Price |
$3,595.31
|
| Rate for Payer: Cofinity Commercial |
$3,145.90
|
| Rate for Payer: Cofinity Commercial |
$3,864.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,145.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,595.31
|
| Rate for Payer: Healthscope Commercial |
$4,044.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,820.02
|
| Rate for Payer: PHP Commercial |
$3,820.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,921.19
|
| Rate for Payer: Priority Health SBD |
$2,831.31
|
|
|
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 |
$75.20 |
| Max. Negotiated Rate |
$169.21 |
| Rate for Payer: Aetna Commercial |
$159.81
|
| Rate for Payer: Aetna Commercial |
$247.35
|
| Rate for Payer: Aetna Commercial |
$197.14
|
| Rate for Payer: Aetna Medicare |
$145.50
|
| Rate for Payer: Aetna Medicare |
$94.00
|
| Rate for Payer: Aetna Medicare |
$115.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.75
|
| Rate for Payer: BCBS Complete |
$92.77
|
| Rate for Payer: BCBS Complete |
$75.20
|
| Rate for Payer: BCBS Complete |
$116.40
|
| Rate for Payer: Cash Price |
$232.80
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$250.26
|
| Rate for Payer: Cofinity Commercial |
$161.69
|
| Rate for Payer: Cofinity Commercial |
$131.61
|
| Rate for Payer: Cofinity Commercial |
$199.46
|
| Rate for Payer: Cofinity Commercial |
$162.35
|
| Rate for Payer: Cofinity Commercial |
$203.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.70
|
| 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 |
$208.74
|
| Rate for Payer: Healthscope Commercial |
$169.21
|
| Rate for Payer: Healthscope Commercial |
$261.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: PHP Commercial |
$197.14
|
| Rate for Payer: PHP Commercial |
$159.81
|
| Rate for Payer: PHP Commercial |
$247.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| 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
|
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) |
$150.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.15
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$232.80
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$131.61
|
| Rate for Payer: Cofinity Commercial |
$161.69
|
| Rate for Payer: Cofinity Commercial |
$162.35
|
| Rate for Payer: Cofinity Commercial |
$199.46
|
| Rate for Payer: Cofinity Commercial |
$203.70
|
| Rate for Payer: Cofinity Commercial |
$250.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.80
|
| Rate for Payer: Healthscope Commercial |
$169.21
|
| Rate for Payer: Healthscope Commercial |
$208.74
|
| Rate for Payer: Healthscope Commercial |
$261.90
|
| 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: PHP Commercial |
$197.14
|
| Rate for Payer: PHP Commercial |
$247.35
|
| Rate for Payer: PHP Commercial |
$159.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.21
|
| 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 TABLET
|
Facility
|
IP
|
$396.15
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$249.57 |
| Max. Negotiated Rate |
$356.54 |
| Rate for Payer: Aetna Commercial |
$336.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$257.50
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$277.31
|
| Rate for Payer: Cofinity Commercial |
$340.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$277.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Healthscope Commercial |
$356.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: PHP Commercial |
$336.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: Priority Health SBD |
$249.57
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$93.06
|
|
|
Service Code
|
NDC 16729045115
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.22 |
| Max. Negotiated Rate |
$83.75 |
| Rate for Payer: Aetna Commercial |
$79.10
|
| Rate for Payer: Aetna Medicare |
$46.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.49
|
| Rate for Payer: BCBS Complete |
$37.22
|
| Rate for Payer: Cash Price |
$74.45
|
| Rate for Payer: Cofinity Commercial |
$65.14
|
| Rate for Payer: Cofinity Commercial |
$80.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.45
|
| Rate for Payer: Healthscope Commercial |
$83.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.10
|
| Rate for Payer: PHP Commercial |
$79.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.49
|
| Rate for Payer: Priority Health SBD |
$58.63
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$93.06
|
|
|
Service Code
|
NDC 16729045115
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.63 |
| Max. Negotiated Rate |
$83.75 |
| Rate for Payer: Aetna Commercial |
$79.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.49
|
| Rate for Payer: Cash Price |
$74.45
|
| Rate for Payer: Cofinity Commercial |
$65.14
|
| Rate for Payer: Cofinity Commercial |
$80.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.45
|
| Rate for Payer: Healthscope Commercial |
$83.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.10
|
| Rate for Payer: PHP Commercial |
$79.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$60.49
|
| Rate for Payer: Priority Health SBD |
$58.63
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$396.15
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.46 |
| Max. Negotiated Rate |
$356.54 |
| Rate for Payer: Aetna Commercial |
$336.73
|
| Rate for Payer: Aetna Medicare |
$198.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$257.50
|
| Rate for Payer: BCBS Complete |
$158.46
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$277.31
|
| Rate for Payer: Cofinity Commercial |
$340.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$277.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Healthscope Commercial |
$356.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: PHP Commercial |
$336.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: Priority Health SBD |
$249.57
|
|
|
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 Commercial |
$236.41
|
| Rate for Payer: Cofinity Commercial |
$290.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$236.41
|
| 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: PHP Commercial |
$287.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: Priority Health SBD |
$212.77
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Healthscope Commercial |
$2.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.39
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.77
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$280.32
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.60 |
| Max. Negotiated Rate |
$252.29 |
| Rate for Payer: Aetna Commercial |
$238.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.21
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$196.22
|
| Rate for Payer: Cofinity Commercial |
$241.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.26
|
| Rate for Payer: Healthscope Commercial |
$252.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.27
|
| Rate for Payer: PHP Commercial |
$238.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.21
|
| Rate for Payer: Priority Health SBD |
$176.60
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$280.32
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.13 |
| Max. Negotiated Rate |
$252.29 |
| Rate for Payer: Aetna Commercial |
$238.27
|
| Rate for Payer: Aetna Medicare |
$140.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.21
|
| Rate for Payer: BCBS Complete |
$112.13
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$196.22
|
| Rate for Payer: Cofinity Commercial |
$241.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.26
|
| Rate for Payer: Healthscope Commercial |
$252.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.27
|
| Rate for Payer: PHP Commercial |
$238.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.21
|
| Rate for Payer: Priority Health SBD |
$176.60
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$451.20
|
|
|
Service Code
|
NDC 60793085401
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$284.26 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna Commercial |
$383.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.28
|
| Rate for Payer: Cash Price |
$360.96
|
| Rate for Payer: Cofinity Commercial |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$388.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$315.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$360.96
|
| Rate for Payer: Healthscope Commercial |
$406.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$383.52
|
| Rate for Payer: PHP Commercial |
$383.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.28
|
| Rate for Payer: Priority Health SBD |
$284.26
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$774.72
|
|
|
Service Code
|
NDC 00074662411
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$309.89 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna Medicare |
$387.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.57
|
| Rate for Payer: BCBS Complete |
$309.89
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$542.30
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$697.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: Priority Health SBD |
$488.07
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074662411
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$488.07 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.57
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$542.30
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$697.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: Priority Health SBD |
$488.07
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.09 |
| 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 Commercial |
$236.41
|
| Rate for Payer: Cofinity Commercial |
$290.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$236.41
|
| 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: PHP Commercial |
$287.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: Priority Health SBD |
$212.77
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$2.81
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: Aetna Medicare |
$1.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: BCBS Complete |
$1.12
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Healthscope Commercial |
$2.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.39
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.77
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$451.20
|
|
|
Service Code
|
NDC 60793085401
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.48 |
| Max. Negotiated Rate |
$406.08 |
| Rate for Payer: Aetna Commercial |
$383.52
|
| Rate for Payer: Aetna Medicare |
$225.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.28
|
| Rate for Payer: BCBS Complete |
$180.48
|
| Rate for Payer: Cash Price |
$360.96
|
| Rate for Payer: Cofinity Commercial |
$315.84
|
| Rate for Payer: Cofinity Commercial |
$388.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$315.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$360.96
|
| Rate for Payer: Healthscope Commercial |
$406.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$383.52
|
| Rate for Payer: PHP Commercial |
$383.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.28
|
| Rate for Payer: Priority Health SBD |
$284.26
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$697.25
|
|
|
Service Code
|
NDC 00074662490
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.90 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: Aetna Medicare |
$348.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.21
|
| Rate for Payer: BCBS Complete |
$278.90
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$488.07
|
| Rate for Payer: Cofinity Commercial |
$599.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.80
|
| Rate for Payer: Healthscope Commercial |
$627.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.66
|
| Rate for Payer: PHP Commercial |
$592.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.21
|
| Rate for Payer: Priority Health SBD |
$439.27
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$697.25
|
|
|
Service Code
|
NDC 00074662490
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$439.27 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.21
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$488.07
|
| Rate for Payer: Cofinity Commercial |
$599.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.80
|
| Rate for Payer: Healthscope Commercial |
$627.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.66
|
| Rate for Payer: PHP Commercial |
$592.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.21
|
| Rate for Payer: Priority Health SBD |
$439.27
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$2.93
|
|
|
Service Code
|
NDC 42292003901
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna Commercial |
$2.49
|
| Rate for Payer: Aetna Medicare |
$1.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.90
|
| Rate for Payer: BCBS Complete |
$1.17
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cofinity Commercial |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$2.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.34
|
| Rate for Payer: Healthscope Commercial |
$2.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.49
|
| Rate for Payer: PHP Commercial |
$2.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.90
|
| Rate for Payer: Priority Health SBD |
$1.85
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$697.25
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$439.27 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.21
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$488.07
|
| Rate for Payer: Cofinity Commercial |
$599.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.80
|
| Rate for Payer: Healthscope Commercial |
$627.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.66
|
| Rate for Payer: PHP Commercial |
$592.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.21
|
| Rate for Payer: Priority Health SBD |
$439.27
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$697.25
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.90 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: Aetna Medicare |
$348.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.21
|
| Rate for Payer: BCBS Complete |
$278.90
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$488.07
|
| Rate for Payer: Cofinity Commercial |
$599.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.80
|
| Rate for Payer: Healthscope Commercial |
$627.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.66
|
| Rate for Payer: PHP Commercial |
$592.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.21
|
| Rate for Payer: Priority Health SBD |
$439.27
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$2.93
|
|
|
Service Code
|
NDC 42292003901
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.85 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna Commercial |
$2.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.90
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cofinity Commercial |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$2.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.34
|
| Rate for Payer: Healthscope Commercial |
$2.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.49
|
| Rate for Payer: PHP Commercial |
$2.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.90
|
| Rate for Payer: Priority Health SBD |
$1.85
|
|
