|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$68.18
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$41.58 |
| Max. Negotiated Rate |
$61.36 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Commercial |
$50.85
|
| Rate for Payer: BCBS Trust/PPO |
$52.69
|
| Rate for Payer: BCBS Trust/PPO |
$46.23
|
| Rate for Payer: BCN Commercial |
$46.23
|
| Rate for Payer: BCN Commercial |
$52.69
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Cofinity Commercial |
$51.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Healthscope Commercial |
$53.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.95
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.87
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$52.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$59.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$41.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$36.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$52.64
|
| Rate for Payer: UHC Core |
$49.95
|
| Rate for Payer: UHC Core |
$56.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.14
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$324.90
|
|
|
Service Code
|
NDC 0904-6353-61
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.16 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: BCBS Trust/PPO |
$251.08
|
| Rate for Payer: BCN Commercial |
$251.08
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.92
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.16
|
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.43
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$282.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$198.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$285.91
|
| Rate for Payer: UHC Core |
$271.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.68
|
|
|
LEVONORGESTREL 1.5 MG TABLET
|
Facility
|
IP
|
$37.74
|
|
|
Service Code
|
NDC 68180-852-11
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.02 |
| Max. Negotiated Rate |
$33.97 |
| Rate for Payer: Aetna Commercial |
$32.08
|
| Rate for Payer: BCBS Trust/PPO |
$29.17
|
| Rate for Payer: BCN Commercial |
$29.17
|
| Rate for Payer: Cash Price |
$30.19
|
| Rate for Payer: Cofinity Commercial |
$32.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.19
|
| Rate for Payer: Healthscope Commercial |
$33.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$32.08
|
| Rate for Payer: PHP Commercial |
$32.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$23.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.21
|
| Rate for Payer: UHC Core |
$31.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.30
|
|
|
LEVONORGESTREL 1.5 MG TABLET
|
Facility
|
IP
|
$146.71
|
|
|
Service Code
|
NDC 51285-162-88
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.48 |
| Max. Negotiated Rate |
$132.04 |
| Rate for Payer: Aetna Commercial |
$124.70
|
| Rate for Payer: BCBS Trust/PPO |
$113.38
|
| Rate for Payer: BCN Commercial |
$113.38
|
| Rate for Payer: Cash Price |
$117.37
|
| Rate for Payer: Cofinity Commercial |
$126.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$117.37
|
| Rate for Payer: Healthscope Commercial |
$132.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$110.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$124.70
|
| Rate for Payer: PHP Commercial |
$124.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$102.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$127.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$89.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$129.10
|
| Rate for Payer: UHC Core |
$122.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$110.03
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$371.93
|
|
|
Service Code
|
NDC 0378-1809-77
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$226.84 |
| Max. Negotiated Rate |
$334.74 |
| Rate for Payer: Aetna Commercial |
$316.14
|
| Rate for Payer: BCBS Trust/PPO |
$287.43
|
| Rate for Payer: BCN Commercial |
$287.43
|
| Rate for Payer: Cash Price |
$297.54
|
| Rate for Payer: Cofinity Commercial |
$319.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.54
|
| Rate for Payer: Healthscope Commercial |
$334.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$316.14
|
| Rate for Payer: PHP Commercial |
$316.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.35
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$323.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$226.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$327.30
|
| Rate for Payer: UHC Core |
$310.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.95
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.69
|
|
|
Service Code
|
NDC 51079-442-01
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.64 |
| Max. Negotiated Rate |
$2.42 |
| Rate for Payer: Aetna Commercial |
$2.29
|
| Rate for Payer: BCBS Trust/PPO |
$2.08
|
| Rate for Payer: BCN Commercial |
$2.08
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cofinity Commercial |
$2.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.15
|
| Rate for Payer: Healthscope Commercial |
$2.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.29
|
| Rate for Payer: PHP Commercial |
$2.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.37
|
| Rate for Payer: UHC Core |
$2.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.02
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$391.40
|
|
|
Service Code
|
NDC 0904-6953-61
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$238.71 |
| Max. Negotiated Rate |
$352.26 |
| Rate for Payer: Aetna Commercial |
$332.69
|
| Rate for Payer: BCBS Trust/PPO |
$302.47
|
| Rate for Payer: BCN Commercial |
$302.47
|
| Rate for Payer: Cash Price |
$313.12
|
| Rate for Payer: Cofinity Commercial |
$336.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$313.12
|
| Rate for Payer: Healthscope Commercial |
$352.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$293.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$332.69
|
| Rate for Payer: PHP Commercial |
$332.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$273.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$340.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$238.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$344.43
|
| Rate for Payer: UHC Core |
$326.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$293.55
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$633.75
|
|
|
Service Code
|
NDC 0074-9296-90
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$386.52 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna Commercial |
$538.69
|
| Rate for Payer: BCBS Trust/PPO |
$489.76
|
| Rate for Payer: BCN Commercial |
$489.76
|
| Rate for Payer: Cash Price |
$507.00
|
| Rate for Payer: Cofinity Commercial |
$545.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$507.00
|
| Rate for Payer: Healthscope Commercial |
$570.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$475.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$538.69
|
| Rate for Payer: PHP Commercial |
$538.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$443.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$551.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$386.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$557.70
|
| Rate for Payer: UHC Core |
$529.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$475.31
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$460.75
|
|
|
Service Code
|
NDC 0904-6954-61
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.01 |
| Max. Negotiated Rate |
$414.68 |
| Rate for Payer: Aetna Commercial |
$391.64
|
| Rate for Payer: BCBS Trust/PPO |
$356.07
|
| Rate for Payer: BCN Commercial |
$356.07
|
| Rate for Payer: Cash Price |
$368.60
|
| Rate for Payer: Cofinity Commercial |
$396.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$368.60
|
| Rate for Payer: Healthscope Commercial |
$414.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$345.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$391.64
|
| Rate for Payer: PHP Commercial |
$391.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$322.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$400.85
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$281.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$405.46
|
| Rate for Payer: UHC Core |
$384.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$345.56
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$217.73
|
|
|
Service Code
|
NDC 0378-1811-77
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.79 |
| Max. Negotiated Rate |
$195.96 |
| Rate for Payer: Aetna Commercial |
$185.07
|
| Rate for Payer: BCBS Trust/PPO |
$168.26
|
| Rate for Payer: BCN Commercial |
$168.26
|
| Rate for Payer: Cash Price |
$174.18
|
| Rate for Payer: Cofinity Commercial |
$187.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.18
|
| Rate for Payer: Healthscope Commercial |
$195.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$185.07
|
| Rate for Payer: PHP Commercial |
$185.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$152.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$189.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$132.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$191.60
|
| Rate for Payer: UHC Core |
$181.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.30
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$460.75
|
|
|
Service Code
|
NDC 0904-6955-61
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$281.01 |
| Max. Negotiated Rate |
$414.68 |
| Rate for Payer: Aetna Commercial |
$391.64
|
| Rate for Payer: BCBS Trust/PPO |
$356.07
|
| Rate for Payer: BCN Commercial |
$356.07
|
| Rate for Payer: Cash Price |
$368.60
|
| Rate for Payer: Cofinity Commercial |
$396.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$368.60
|
| Rate for Payer: Healthscope Commercial |
$414.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$345.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$391.64
|
| Rate for Payer: PHP Commercial |
$391.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$322.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$400.85
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$281.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$405.46
|
| Rate for Payer: UHC Core |
$384.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$345.56
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$2.71
|
|
|
Service Code
|
NDC 42292-041-01
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$2.44 |
| Rate for Payer: Aetna Commercial |
$2.30
|
| Rate for Payer: BCBS Trust/PPO |
$2.09
|
| Rate for Payer: BCN Commercial |
$2.09
|
| Rate for Payer: Cash Price |
$2.17
|
| Rate for Payer: Cofinity Commercial |
$2.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.17
|
| Rate for Payer: Healthscope Commercial |
$2.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.30
|
| Rate for Payer: PHP Commercial |
$2.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.38
|
| Rate for Payer: UHC Core |
$2.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.03
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$251.04
|
|
|
Service Code
|
NDC 60687-563-01
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.11 |
| Max. Negotiated Rate |
$225.94 |
| Rate for Payer: Aetna Commercial |
$213.38
|
| Rate for Payer: BCBS Trust/PPO |
$194.00
|
| Rate for Payer: BCN Commercial |
$194.00
|
| Rate for Payer: Cash Price |
$200.83
|
| Rate for Payer: Cofinity Commercial |
$215.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.83
|
| Rate for Payer: Healthscope Commercial |
$225.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.38
|
| Rate for Payer: PHP Commercial |
$213.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$218.40
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$153.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$220.92
|
| Rate for Payer: UHC Core |
$209.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.28
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 60687-563-11
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna Commercial |
$2.14
|
| Rate for Payer: BCBS Trust/PPO |
$1.95
|
| Rate for Payer: BCN Commercial |
$1.95
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.02
|
| Rate for Payer: Healthscope Commercial |
$2.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.14
|
| Rate for Payer: PHP Commercial |
$2.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.76
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.22
|
| Rate for Payer: UHC Core |
$2.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.89
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$633.75
|
|
|
Service Code
|
NDC 0074-3727-90
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$386.52 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna Commercial |
$538.69
|
| Rate for Payer: BCBS Trust/PPO |
$489.76
|
| Rate for Payer: BCN Commercial |
$489.76
|
| Rate for Payer: Cash Price |
$507.00
|
| Rate for Payer: Cofinity Commercial |
$545.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$507.00
|
| Rate for Payer: Healthscope Commercial |
$570.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$475.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$538.69
|
| Rate for Payer: PHP Commercial |
$538.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$443.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$551.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$386.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$557.70
|
| Rate for Payer: UHC Core |
$529.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$475.31
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$270.24
|
|
|
Service Code
|
NDC 42292-041-20
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$164.82 |
| Max. Negotiated Rate |
$243.22 |
| Rate for Payer: Aetna Commercial |
$229.70
|
| Rate for Payer: BCBS Trust/PPO |
$208.84
|
| Rate for Payer: BCN Commercial |
$208.84
|
| Rate for Payer: Cash Price |
$216.19
|
| Rate for Payer: Cofinity Commercial |
$232.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.19
|
| Rate for Payer: Healthscope Commercial |
$243.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$229.70
|
| Rate for Payer: PHP Commercial |
$229.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.17
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$235.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$164.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$237.81
|
| Rate for Payer: UHC Core |
$225.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.68
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$242.88
|
|
|
Service Code
|
NDC 0904-6956-61
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.13 |
| Max. Negotiated Rate |
$218.59 |
| Rate for Payer: Aetna Commercial |
$206.45
|
| Rate for Payer: BCBS Trust/PPO |
$187.70
|
| Rate for Payer: BCN Commercial |
$187.70
|
| Rate for Payer: Cash Price |
$194.30
|
| Rate for Payer: Cofinity Commercial |
$208.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.30
|
| Rate for Payer: Healthscope Commercial |
$218.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$182.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$206.45
|
| Rate for Payer: PHP Commercial |
$206.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$211.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$148.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$213.73
|
| Rate for Payer: UHC Core |
$202.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$182.16
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$3.26
|
|
|
Service Code
|
NDC 51079-445-01
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.93 |
| Rate for Payer: Aetna Commercial |
$2.77
|
| Rate for Payer: BCBS Trust/PPO |
$2.52
|
| Rate for Payer: BCN Commercial |
$2.52
|
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Cofinity Commercial |
$2.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.61
|
| Rate for Payer: Healthscope Commercial |
$2.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.77
|
| Rate for Payer: PHP Commercial |
$2.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.87
|
| Rate for Payer: UHC Core |
$2.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.44
|
|
|
LEVOTHYROXINE 200 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$443.22
|
|
|
Service Code
|
NDC 70860-452-10
|
| Hospital Charge Code |
4418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$270.32 |
| Max. Negotiated Rate |
$398.90 |
| Rate for Payer: Aetna Commercial |
$376.74
|
| Rate for Payer: BCBS Trust/PPO |
$342.52
|
| Rate for Payer: BCN Commercial |
$342.52
|
| Rate for Payer: Cash Price |
$354.58
|
| Rate for Payer: Cofinity Commercial |
$381.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$354.58
|
| Rate for Payer: Healthscope Commercial |
$398.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$332.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$376.74
|
| Rate for Payer: PHP Commercial |
$376.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$310.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$385.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$270.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$390.03
|
| Rate for Payer: UHC Core |
$370.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$332.42
|
|
|
LEVOTHYROXINE 200 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$538.61
|
|
|
Service Code
|
NDC 63323-647-10
|
| Hospital Charge Code |
4418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$328.50 |
| Max. Negotiated Rate |
$484.75 |
| Rate for Payer: Aetna Commercial |
$457.82
|
| Rate for Payer: BCBS Trust/PPO |
$416.24
|
| Rate for Payer: BCN Commercial |
$416.24
|
| Rate for Payer: Cash Price |
$430.89
|
| Rate for Payer: Cofinity Commercial |
$463.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$430.89
|
| Rate for Payer: Healthscope Commercial |
$484.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$403.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$457.82
|
| Rate for Payer: PHP Commercial |
$457.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$377.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$468.59
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$328.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$473.98
|
| Rate for Payer: UHC Core |
$449.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$403.96
|
|
|
LEVOTHYROXINE 200 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$697.15
|
|
|
Service Code
|
NDC 42023-202-01
|
| Hospital Charge Code |
4418
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$425.19 |
| Max. Negotiated Rate |
$627.44 |
| Rate for Payer: Aetna Commercial |
$592.58
|
| Rate for Payer: BCBS Trust/PPO |
$538.76
|
| Rate for Payer: BCN Commercial |
$538.76
|
| Rate for Payer: Cash Price |
$557.72
|
| Rate for Payer: Cofinity Commercial |
$599.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.72
|
| Rate for Payer: Healthscope Commercial |
$627.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$522.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$592.58
|
| Rate for Payer: PHP Commercial |
$592.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$488.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$606.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$425.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$613.49
|
| Rate for Payer: UHC Core |
$582.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$522.86
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$304.95
|
|
|
Service Code
|
NDC 60687-453-01
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.99 |
| Max. Negotiated Rate |
$274.46 |
| Rate for Payer: Aetna Commercial |
$259.21
|
| Rate for Payer: BCBS Trust/PPO |
$235.67
|
| Rate for Payer: BCN Commercial |
$235.67
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$262.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$274.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$259.21
|
| Rate for Payer: PHP Commercial |
$259.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$265.31
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$185.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$268.36
|
| Rate for Payer: UHC Core |
$254.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.71
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$4.12
|
|
|
Service Code
|
NDC 51079-444-01
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.51 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: BCBS Trust/PPO |
$3.18
|
| Rate for Payer: BCN Commercial |
$3.18
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cofinity Commercial |
$3.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.30
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.50
|
| Rate for Payer: PHP Commercial |
$3.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.88
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.63
|
| Rate for Payer: UHC Core |
$3.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.09
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 60687-453-11
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: BCBS Trust/PPO |
$2.36
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$2.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.59
|
| Rate for Payer: PHP Commercial |
$2.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.14
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.68
|
| Rate for Payer: UHC Core |
$2.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.29
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
NDC 0904-6949-61
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$185.41 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: BCBS Trust/PPO |
$234.93
|
| Rate for Payer: BCN Commercial |
$234.93
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Cofinity Commercial |
$261.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.20
|
| Rate for Payer: Healthscope Commercial |
$273.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$258.40
|
| Rate for Payer: PHP Commercial |
$258.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$264.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$185.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$267.52
|
| Rate for Payer: UHC Core |
$253.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.00
|
|
