|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$732.24
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$509.64 |
| Max. Negotiated Rate |
$659.02 |
| Rate for Payer: Aetna Commercial |
$622.40
|
| Rate for Payer: BCBS Trust/PPO |
$604.76
|
| Rate for Payer: BCN Commercial |
$604.76
|
| Rate for Payer: Cash Price |
$585.79
|
| 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: Lakeland Regional Health Systems Commercial |
$549.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.40
|
| Rate for Payer: Nomi Health Commercial |
$600.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.18
|
| Rate for Payer: PHP Commercial |
$622.40
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$637.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$509.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$644.37
|
| Rate for Payer: UHC Core |
$611.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$549.18
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$389.88
|
|
|
Service Code
|
NDC 00378181177
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.74 |
| Max. Negotiated Rate |
$350.89 |
| Rate for Payer: Aetna Commercial |
$331.40
|
| Rate for Payer: Aetna Medicare |
$101.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$121.84
|
| Rate for Payer: Amish Plain Church Group Commercial |
$121.84
|
| Rate for Payer: BCBS Complete |
$72.17
|
| Rate for Payer: BCBS MAPPO |
$97.47
|
| Rate for Payer: BCBS Trust/PPO |
$320.52
|
| Rate for Payer: BCN Commercial |
$320.52
|
| Rate for Payer: BCN Medicare Advantage |
$97.47
|
| Rate for Payer: Cash Price |
$311.90
|
| Rate for Payer: Cofinity Commercial |
$335.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$311.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$97.47
|
| Rate for Payer: Healthscope Commercial |
$350.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$292.41
|
| Rate for Payer: Mclaren Medicaid |
$68.74
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$102.34
|
| Rate for Payer: Meridian Medicaid |
$72.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$112.09
|
| Rate for Payer: Molina Medicare/Medicaid |
$107.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.40
|
| Rate for Payer: Nomi Health Commercial |
$319.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$292.41
|
| Rate for Payer: PACE Senior Care Partners |
$92.60
|
| Rate for Payer: PACE SWMI |
$97.47
|
| Rate for Payer: PHP Commercial |
$331.40
|
| Rate for Payer: PHP Medicare Advantage |
$97.47
|
| Rate for Payer: Priority Health Choice Medicaid |
$68.74
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$339.20
|
| Rate for Payer: Priority Health Medicare |
$98.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$271.36
|
| Rate for Payer: Railroad Medicare Medicare |
$97.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$343.09
|
| Rate for Payer: UHC Core |
$325.55
|
| Rate for Payer: UHC Exchange |
$97.47
|
| Rate for Payer: UHC Medicaid |
$68.74
|
| Rate for Payer: UHC Medicare Advantage |
$97.47
|
| Rate for Payer: UHCCP Medicaid |
$68.74
|
| Rate for Payer: VA VA |
$97.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.41
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$732.24
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.09 |
| Max. Negotiated Rate |
$659.02 |
| Rate for Payer: Aetna Commercial |
$622.40
|
| Rate for Payer: Aetna Medicare |
$190.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$228.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$228.82
|
| Rate for Payer: BCBS Complete |
$135.54
|
| Rate for Payer: BCBS MAPPO |
$183.06
|
| Rate for Payer: BCBS Trust/PPO |
$601.97
|
| Rate for Payer: BCN Commercial |
$601.97
|
| Rate for Payer: BCN Medicare Advantage |
$183.06
|
| Rate for Payer: Cash Price |
$585.79
|
| Rate for Payer: Cofinity Commercial |
$629.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$585.79
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$183.06
|
| Rate for Payer: Healthscope Commercial |
$659.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$549.18
|
| Rate for Payer: Mclaren Medicaid |
$129.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$192.21
|
| Rate for Payer: Meridian Medicaid |
$135.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$210.52
|
| Rate for Payer: Molina Medicare/Medicaid |
$201.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.40
|
| Rate for Payer: Nomi Health Commercial |
$600.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.18
|
| Rate for Payer: PACE Senior Care Partners |
$173.91
|
| Rate for Payer: PACE SWMI |
$183.06
|
| Rate for Payer: PHP Commercial |
$622.40
|
| Rate for Payer: PHP Medicare Advantage |
$183.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$129.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$637.05
|
| Rate for Payer: Priority Health Medicare |
$184.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$509.64
|
| Rate for Payer: Railroad Medicare Medicare |
$183.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$644.37
|
| Rate for Payer: UHC Core |
$611.42
|
| Rate for Payer: UHC Exchange |
$183.06
|
| Rate for Payer: UHC Medicaid |
$129.09
|
| Rate for Payer: UHC Medicare Advantage |
$183.06
|
| Rate for Payer: UHCCP Medicaid |
$129.09
|
| Rate for Payer: VA VA |
$183.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$549.18
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$466.45
|
|
|
Service Code
|
NDC 00904695561
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.24 |
| Max. Negotiated Rate |
$419.81 |
| Rate for Payer: Aetna Commercial |
$396.48
|
| Rate for Payer: Aetna Medicare |
$121.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$145.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$145.77
|
| Rate for Payer: BCBS Complete |
$86.34
|
| Rate for Payer: BCBS MAPPO |
$116.61
|
| Rate for Payer: BCBS Trust/PPO |
$383.47
|
| Rate for Payer: BCN Commercial |
$383.47
|
| Rate for Payer: BCN Medicare Advantage |
$116.61
|
| Rate for Payer: Cash Price |
$373.16
|
| Rate for Payer: Cofinity Commercial |
$401.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$373.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$116.61
|
| Rate for Payer: Healthscope Commercial |
$419.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$349.84
|
| Rate for Payer: Mclaren Medicaid |
$82.24
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$122.44
|
| Rate for Payer: Meridian Medicaid |
$86.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$134.10
|
| Rate for Payer: Molina Medicare/Medicaid |
$128.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$396.48
|
| Rate for Payer: Nomi Health Commercial |
$382.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$349.84
|
| Rate for Payer: PACE Senior Care Partners |
$110.78
|
| Rate for Payer: PACE SWMI |
$116.61
|
| Rate for Payer: PHP Commercial |
$396.48
|
| Rate for Payer: PHP Medicare Advantage |
$116.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$82.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$405.81
|
| Rate for Payer: Priority Health Medicare |
$117.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$324.65
|
| Rate for Payer: Railroad Medicare Medicare |
$116.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$410.48
|
| Rate for Payer: UHC Core |
$389.49
|
| Rate for Payer: UHC Exchange |
$116.61
|
| Rate for Payer: UHC Medicaid |
$82.24
|
| Rate for Payer: UHC Medicare Advantage |
$116.61
|
| Rate for Payer: UHCCP Medicaid |
$82.24
|
| Rate for Payer: VA VA |
$116.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$349.84
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$466.45
|
|
|
Service Code
|
NDC 00904695561
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$324.65 |
| Max. Negotiated Rate |
$419.81 |
| Rate for Payer: Aetna Commercial |
$396.48
|
| Rate for Payer: BCBS Trust/PPO |
$385.24
|
| Rate for Payer: BCN Commercial |
$385.24
|
| Rate for Payer: Cash Price |
$373.16
|
| Rate for Payer: Cofinity Commercial |
$401.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$373.16
|
| Rate for Payer: Healthscope Commercial |
$419.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$349.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$396.48
|
| Rate for Payer: Nomi Health Commercial |
$382.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$349.84
|
| Rate for Payer: PHP Commercial |
$396.48
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$405.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$324.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$410.48
|
| Rate for Payer: UHC Core |
$389.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$349.84
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$2.87
|
|
|
Service Code
|
NDC 42292004101
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.00 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Aetna Commercial |
$2.44
|
| Rate for Payer: BCBS Trust/PPO |
$2.37
|
| Rate for Payer: BCN Commercial |
$2.37
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cofinity Commercial |
$2.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.30
|
| Rate for Payer: Healthscope Commercial |
$2.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.44
|
| Rate for Payer: Nomi Health Commercial |
$2.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.15
|
| Rate for Payer: PHP Commercial |
$2.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.53
|
| Rate for Payer: UHC Core |
$2.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.15
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$260.16
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.87 |
| Max. Negotiated Rate |
$234.14 |
| Rate for Payer: Aetna Commercial |
$221.14
|
| Rate for Payer: Aetna Medicare |
$67.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$81.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$81.30
|
| Rate for Payer: BCBS Complete |
$48.16
|
| Rate for Payer: BCBS MAPPO |
$65.04
|
| Rate for Payer: BCBS Trust/PPO |
$213.88
|
| Rate for Payer: BCN Commercial |
$213.88
|
| Rate for Payer: BCN Medicare Advantage |
$65.04
|
| Rate for Payer: Cash Price |
$208.13
|
| Rate for Payer: Cofinity Commercial |
$223.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$65.04
|
| Rate for Payer: Healthscope Commercial |
$234.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.12
|
| Rate for Payer: Mclaren Medicaid |
$45.87
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$68.29
|
| Rate for Payer: Meridian Medicaid |
$48.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$74.80
|
| Rate for Payer: Molina Medicare/Medicaid |
$71.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.14
|
| Rate for Payer: Nomi Health Commercial |
$213.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.12
|
| Rate for Payer: PACE Senior Care Partners |
$61.79
|
| Rate for Payer: PACE SWMI |
$65.04
|
| Rate for Payer: PHP Commercial |
$221.14
|
| Rate for Payer: PHP Medicare Advantage |
$65.04
|
| Rate for Payer: Priority Health Choice Medicaid |
$45.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$226.34
|
| Rate for Payer: Priority Health Medicare |
$65.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$181.07
|
| Rate for Payer: Railroad Medicare Medicare |
$65.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$228.94
|
| Rate for Payer: UHC Core |
$217.23
|
| Rate for Payer: UHC Exchange |
$65.04
|
| Rate for Payer: UHC Medicaid |
$45.87
|
| Rate for Payer: UHC Medicare Advantage |
$65.04
|
| Rate for Payer: UHCCP Medicaid |
$45.87
|
| Rate for Payer: VA VA |
$65.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.12
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$2.61
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: Aetna Medicare |
$0.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.82
|
| Rate for Payer: BCBS Complete |
$0.48
|
| Rate for Payer: BCBS MAPPO |
$0.65
|
| Rate for Payer: BCBS Trust/PPO |
$2.15
|
| Rate for Payer: BCN Commercial |
$2.15
|
| Rate for Payer: BCN Medicare Advantage |
$0.65
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.09
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.65
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| Rate for Payer: Mclaren Medicaid |
$0.46
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.69
|
| Rate for Payer: Meridian Medicaid |
$0.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.75
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.22
|
| Rate for Payer: Nomi Health Commercial |
$2.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.96
|
| Rate for Payer: PACE Senior Care Partners |
$0.62
|
| Rate for Payer: PACE SWMI |
$0.65
|
| Rate for Payer: PHP Commercial |
$2.22
|
| Rate for Payer: PHP Medicare Advantage |
$0.65
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.27
|
| Rate for Payer: Priority Health Medicare |
$0.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.82
|
| Rate for Payer: Railroad Medicare Medicare |
$0.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.30
|
| Rate for Payer: UHC Core |
$2.18
|
| Rate for Payer: UHC Exchange |
$0.65
|
| Rate for Payer: UHC Medicaid |
$0.46
|
| Rate for Payer: UHC Medicare Advantage |
$0.65
|
| Rate for Payer: UHCCP Medicaid |
$0.46
|
| Rate for Payer: VA VA |
$0.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$260.16
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$181.07 |
| Max. Negotiated Rate |
$234.14 |
| Rate for Payer: Aetna Commercial |
$221.14
|
| Rate for Payer: BCBS Trust/PPO |
$214.87
|
| Rate for Payer: BCN Commercial |
$214.87
|
| Rate for Payer: Cash Price |
$208.13
|
| Rate for Payer: Cofinity Commercial |
$223.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.13
|
| Rate for Payer: Healthscope Commercial |
$234.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.14
|
| Rate for Payer: Nomi Health Commercial |
$213.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.12
|
| Rate for Payer: PHP Commercial |
$221.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$226.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$181.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$228.94
|
| Rate for Payer: UHC Core |
$217.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.12
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$732.68
|
|
|
Service Code
|
NDC 00074372790
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$509.95 |
| Max. Negotiated Rate |
$659.41 |
| Rate for Payer: Aetna Commercial |
$622.78
|
| Rate for Payer: BCBS Trust/PPO |
$605.12
|
| Rate for Payer: BCN Commercial |
$605.12
|
| Rate for Payer: Cash Price |
$586.14
|
| 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: Lakeland Regional Health Systems Commercial |
$549.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.78
|
| Rate for Payer: Nomi Health Commercial |
$600.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.51
|
| Rate for Payer: PHP Commercial |
$622.78
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$637.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$509.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$644.76
|
| Rate for Payer: UHC Core |
$611.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$549.51
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$286.08
|
|
|
Service Code
|
NDC 42292004120
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$199.11 |
| Max. Negotiated Rate |
$257.47 |
| Rate for Payer: Aetna Commercial |
$243.17
|
| Rate for Payer: BCBS Trust/PPO |
$236.27
|
| Rate for Payer: BCN Commercial |
$236.27
|
| Rate for Payer: Cash Price |
$228.86
|
| Rate for Payer: Cofinity Commercial |
$246.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.86
|
| Rate for Payer: Healthscope Commercial |
$257.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$214.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.17
|
| Rate for Payer: Nomi Health Commercial |
$234.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$214.56
|
| Rate for Payer: PHP Commercial |
$243.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$248.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$251.75
|
| Rate for Payer: UHC Core |
$238.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$214.56
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$286.08
|
|
|
Service Code
|
NDC 42292004120
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.44 |
| Max. Negotiated Rate |
$257.47 |
| Rate for Payer: Aetna Commercial |
$243.17
|
| Rate for Payer: Aetna Medicare |
$74.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$89.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$89.40
|
| Rate for Payer: BCBS Complete |
$52.95
|
| Rate for Payer: BCBS MAPPO |
$71.52
|
| Rate for Payer: BCBS Trust/PPO |
$235.19
|
| Rate for Payer: BCN Commercial |
$235.19
|
| Rate for Payer: BCN Medicare Advantage |
$71.52
|
| Rate for Payer: Cash Price |
$228.86
|
| Rate for Payer: Cofinity Commercial |
$246.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$228.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$71.52
|
| Rate for Payer: Healthscope Commercial |
$257.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$214.56
|
| Rate for Payer: Mclaren Medicaid |
$50.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$75.10
|
| Rate for Payer: Meridian Medicaid |
$52.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$82.25
|
| Rate for Payer: Molina Medicare/Medicaid |
$78.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.17
|
| Rate for Payer: Nomi Health Commercial |
$234.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$214.56
|
| Rate for Payer: PACE Senior Care Partners |
$67.94
|
| Rate for Payer: PACE SWMI |
$71.52
|
| Rate for Payer: PHP Commercial |
$243.17
|
| Rate for Payer: PHP Medicare Advantage |
$71.52
|
| Rate for Payer: Priority Health Choice Medicaid |
$50.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$248.89
|
| Rate for Payer: Priority Health Medicare |
$72.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$199.11
|
| Rate for Payer: Railroad Medicare Medicare |
$71.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$251.75
|
| Rate for Payer: UHC Core |
$238.88
|
| Rate for Payer: UHC Exchange |
$71.52
|
| Rate for Payer: UHC Medicaid |
$50.44
|
| Rate for Payer: UHC Medicare Advantage |
$71.52
|
| Rate for Payer: UHCCP Medicaid |
$50.44
|
| Rate for Payer: VA VA |
$71.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$214.56
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$2.61
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: BCBS Trust/PPO |
$2.16
|
| Rate for Payer: BCN Commercial |
$2.16
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.22
|
| Rate for Payer: Nomi Health Commercial |
$2.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.96
|
| Rate for Payer: PHP Commercial |
$2.22
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.30
|
| Rate for Payer: UHC Core |
$2.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$732.68
|
|
|
Service Code
|
NDC 00074372790
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.17 |
| Max. Negotiated Rate |
$659.41 |
| Rate for Payer: Aetna Commercial |
$622.78
|
| Rate for Payer: Aetna Medicare |
$190.50
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$228.96
|
| Rate for Payer: Amish Plain Church Group Commercial |
$228.96
|
| Rate for Payer: BCBS Complete |
$135.62
|
| Rate for Payer: BCBS MAPPO |
$183.17
|
| Rate for Payer: BCBS Trust/PPO |
$602.34
|
| Rate for Payer: BCN Commercial |
$602.34
|
| Rate for Payer: BCN Medicare Advantage |
$183.17
|
| Rate for Payer: Cash Price |
$586.14
|
| Rate for Payer: Cofinity Commercial |
$630.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$586.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$183.17
|
| Rate for Payer: Healthscope Commercial |
$659.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$549.51
|
| Rate for Payer: Mclaren Medicaid |
$129.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$192.33
|
| Rate for Payer: Meridian Medicaid |
$135.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$210.65
|
| Rate for Payer: Molina Medicare/Medicaid |
$201.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.78
|
| Rate for Payer: Nomi Health Commercial |
$600.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.51
|
| Rate for Payer: PACE Senior Care Partners |
$174.01
|
| Rate for Payer: PACE SWMI |
$183.17
|
| Rate for Payer: PHP Commercial |
$622.78
|
| Rate for Payer: PHP Medicare Advantage |
$183.17
|
| Rate for Payer: Priority Health Choice Medicaid |
$129.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$637.43
|
| Rate for Payer: Priority Health Medicare |
$185.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$509.95
|
| Rate for Payer: Railroad Medicare Medicare |
$183.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$644.76
|
| Rate for Payer: UHC Core |
$611.79
|
| Rate for Payer: UHC Exchange |
$183.17
|
| Rate for Payer: UHC Medicaid |
$129.17
|
| Rate for Payer: UHC Medicare Advantage |
$183.17
|
| Rate for Payer: UHCCP Medicaid |
$129.17
|
| Rate for Payer: VA VA |
$183.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$549.51
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$2.87
|
|
|
Service Code
|
NDC 42292004101
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.51 |
| Max. Negotiated Rate |
$2.58 |
| Rate for Payer: Aetna Commercial |
$2.44
|
| Rate for Payer: Aetna Medicare |
$0.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.90
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.90
|
| Rate for Payer: BCBS Complete |
$0.53
|
| Rate for Payer: BCBS MAPPO |
$0.72
|
| Rate for Payer: BCBS Trust/PPO |
$2.36
|
| Rate for Payer: BCN Commercial |
$2.36
|
| Rate for Payer: BCN Medicare Advantage |
$0.72
|
| Rate for Payer: Cash Price |
$2.30
|
| Rate for Payer: Cofinity Commercial |
$2.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.72
|
| Rate for Payer: Healthscope Commercial |
$2.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.15
|
| Rate for Payer: Mclaren Medicaid |
$0.51
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.75
|
| Rate for Payer: Meridian Medicaid |
$0.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.83
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.44
|
| Rate for Payer: Nomi Health Commercial |
$2.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.15
|
| Rate for Payer: PACE Senior Care Partners |
$0.68
|
| Rate for Payer: PACE SWMI |
$0.72
|
| Rate for Payer: PHP Commercial |
$2.44
|
| Rate for Payer: PHP Medicare Advantage |
$0.72
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.51
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.50
|
| Rate for Payer: Priority Health Medicare |
$0.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.00
|
| Rate for Payer: Railroad Medicare Medicare |
$0.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.53
|
| Rate for Payer: UHC Core |
$2.40
|
| Rate for Payer: UHC Exchange |
$0.72
|
| Rate for Payer: UHC Medicaid |
$0.51
|
| Rate for Payer: UHC Medicare Advantage |
$0.72
|
| Rate for Payer: UHCCP Medicaid |
$0.51
|
| Rate for Payer: VA VA |
$0.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.15
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$250.56
|
|
|
Service Code
|
NDC 00904695661
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.39 |
| Max. Negotiated Rate |
$225.50 |
| Rate for Payer: Aetna Commercial |
$212.98
|
| Rate for Payer: BCBS Trust/PPO |
$206.94
|
| Rate for Payer: BCN Commercial |
$206.94
|
| Rate for Payer: Cash Price |
$200.45
|
| Rate for Payer: Cofinity Commercial |
$215.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.45
|
| Rate for Payer: Healthscope Commercial |
$225.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.98
|
| Rate for Payer: Nomi Health Commercial |
$205.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$187.92
|
| Rate for Payer: PHP Commercial |
$212.98
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$217.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$174.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$220.49
|
| Rate for Payer: UHC Core |
$209.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.92
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$3.19
|
|
|
Service Code
|
NDC 51079044501
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.71
|
| Rate for Payer: Aetna Medicare |
$0.83
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.00
|
| Rate for Payer: BCBS Complete |
$0.59
|
| Rate for Payer: BCBS MAPPO |
$0.80
|
| Rate for Payer: BCBS Trust/PPO |
$2.62
|
| Rate for Payer: BCN Commercial |
$2.62
|
| Rate for Payer: BCN Medicare Advantage |
$0.80
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cofinity Commercial |
$2.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.55
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.80
|
| Rate for Payer: Healthscope Commercial |
$2.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.39
|
| Rate for Payer: Mclaren Medicaid |
$0.56
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.84
|
| Rate for Payer: Meridian Medicaid |
$0.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.92
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.71
|
| Rate for Payer: Nomi Health Commercial |
$2.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.39
|
| Rate for Payer: PACE Senior Care Partners |
$0.76
|
| Rate for Payer: PACE SWMI |
$0.80
|
| Rate for Payer: PHP Commercial |
$2.71
|
| Rate for Payer: PHP Medicare Advantage |
$0.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.78
|
| Rate for Payer: Priority Health Medicare |
$0.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.22
|
| Rate for Payer: Railroad Medicare Medicare |
$0.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.81
|
| Rate for Payer: UHC Core |
$2.66
|
| Rate for Payer: UHC Exchange |
$0.80
|
| Rate for Payer: UHC Medicaid |
$0.56
|
| Rate for Payer: UHC Medicare Advantage |
$0.80
|
| Rate for Payer: UHCCP Medicaid |
$0.56
|
| Rate for Payer: VA VA |
$0.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.39
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$250.56
|
|
|
Service Code
|
NDC 00904695661
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.17 |
| Max. Negotiated Rate |
$225.50 |
| Rate for Payer: Aetna Commercial |
$212.98
|
| Rate for Payer: Aetna Medicare |
$65.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$78.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$78.30
|
| Rate for Payer: BCBS Complete |
$46.38
|
| Rate for Payer: BCBS MAPPO |
$62.64
|
| Rate for Payer: BCBS Trust/PPO |
$205.99
|
| Rate for Payer: BCN Commercial |
$205.99
|
| Rate for Payer: BCN Medicare Advantage |
$62.64
|
| Rate for Payer: Cash Price |
$200.45
|
| Rate for Payer: Cofinity Commercial |
$215.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$62.64
|
| Rate for Payer: Healthscope Commercial |
$225.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.92
|
| Rate for Payer: Mclaren Medicaid |
$44.17
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$65.77
|
| Rate for Payer: Meridian Medicaid |
$46.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$72.04
|
| Rate for Payer: Molina Medicare/Medicaid |
$68.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.98
|
| Rate for Payer: Nomi Health Commercial |
$205.46
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$187.92
|
| Rate for Payer: PACE Senior Care Partners |
$59.51
|
| Rate for Payer: PACE SWMI |
$62.64
|
| Rate for Payer: PHP Commercial |
$212.98
|
| Rate for Payer: PHP Medicare Advantage |
$62.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$44.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$217.99
|
| Rate for Payer: Priority Health Medicare |
$63.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$174.39
|
| Rate for Payer: Railroad Medicare Medicare |
$62.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$220.49
|
| Rate for Payer: UHC Core |
$209.22
|
| Rate for Payer: UHC Exchange |
$62.64
|
| Rate for Payer: UHC Medicaid |
$44.17
|
| Rate for Payer: UHC Medicare Advantage |
$62.64
|
| Rate for Payer: UHCCP Medicaid |
$44.17
|
| Rate for Payer: VA VA |
$62.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.92
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$3.19
|
|
|
Service Code
|
NDC 51079044501
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.22 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna Commercial |
$2.71
|
| Rate for Payer: BCBS Trust/PPO |
$2.63
|
| Rate for Payer: BCN Commercial |
$2.63
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cofinity Commercial |
$2.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.55
|
| Rate for Payer: Healthscope Commercial |
$2.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.71
|
| Rate for Payer: Nomi Health Commercial |
$2.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.39
|
| Rate for Payer: PHP Commercial |
$2.71
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.81
|
| Rate for Payer: UHC Core |
$2.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.39
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$3.51
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Aetna Commercial |
$2.98
|
| Rate for Payer: Aetna Medicare |
$0.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.10
|
| Rate for Payer: BCBS Complete |
$0.65
|
| Rate for Payer: BCBS MAPPO |
$0.88
|
| Rate for Payer: BCBS Trust/PPO |
$2.89
|
| Rate for Payer: BCN Commercial |
$2.89
|
| Rate for Payer: BCN Medicare Advantage |
$0.88
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cofinity Commercial |
$3.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.81
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.88
|
| Rate for Payer: Healthscope Commercial |
$3.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.63
|
| Rate for Payer: Mclaren Medicaid |
$0.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.92
|
| Rate for Payer: Meridian Medicaid |
$0.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.01
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Nomi Health Commercial |
$2.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.63
|
| Rate for Payer: PACE Senior Care Partners |
$0.83
|
| Rate for Payer: PACE SWMI |
$0.88
|
| Rate for Payer: PHP Commercial |
$2.98
|
| Rate for Payer: PHP Medicare Advantage |
$0.88
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.62
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.05
|
| Rate for Payer: Priority Health Medicare |
$0.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.44
|
| Rate for Payer: Railroad Medicare Medicare |
$0.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.09
|
| Rate for Payer: UHC Core |
$2.93
|
| Rate for Payer: UHC Exchange |
$0.88
|
| Rate for Payer: UHC Medicaid |
$0.62
|
| Rate for Payer: UHC Medicare Advantage |
$0.88
|
| Rate for Payer: UHCCP Medicaid |
$0.62
|
| Rate for Payer: VA VA |
$0.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.63
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$4.03
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: BCBS Trust/PPO |
$3.33
|
| Rate for Payer: BCN Commercial |
$3.33
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cofinity Commercial |
$3.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.22
|
| Rate for Payer: Healthscope Commercial |
$3.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.43
|
| Rate for Payer: Nomi Health Commercial |
$3.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.02
|
| Rate for Payer: PHP Commercial |
$3.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.55
|
| Rate for Payer: UHC Core |
$3.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.02
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$319.20
|
|
|
Service Code
|
NDC 00904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$222.16 |
| Max. Negotiated Rate |
$287.28 |
| Rate for Payer: Aetna Commercial |
$271.32
|
| Rate for Payer: BCBS Trust/PPO |
$263.63
|
| Rate for Payer: BCN Commercial |
$263.63
|
| Rate for Payer: Cash Price |
$255.36
|
| Rate for Payer: Cofinity Commercial |
$274.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.36
|
| Rate for Payer: Healthscope Commercial |
$287.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$239.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$271.32
|
| Rate for Payer: Nomi Health Commercial |
$261.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$239.40
|
| Rate for Payer: PHP Commercial |
$271.32
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$277.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$222.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$280.90
|
| Rate for Payer: UHC Core |
$266.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$239.40
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$4.03
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.71 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Aetna Medicare |
$1.05
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.26
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.26
|
| Rate for Payer: BCBS Complete |
$0.75
|
| Rate for Payer: BCBS MAPPO |
$1.01
|
| Rate for Payer: BCBS Trust/PPO |
$3.31
|
| Rate for Payer: BCN Commercial |
$3.31
|
| Rate for Payer: BCN Medicare Advantage |
$1.01
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cofinity Commercial |
$3.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.22
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.01
|
| Rate for Payer: Healthscope Commercial |
$3.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.02
|
| Rate for Payer: Mclaren Medicaid |
$0.71
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.06
|
| Rate for Payer: Meridian Medicaid |
$0.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.16
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.43
|
| Rate for Payer: Nomi Health Commercial |
$3.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.02
|
| Rate for Payer: PACE Senior Care Partners |
$0.96
|
| Rate for Payer: PACE SWMI |
$1.01
|
| Rate for Payer: PHP Commercial |
$3.43
|
| Rate for Payer: PHP Medicare Advantage |
$1.01
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.71
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.51
|
| Rate for Payer: Priority Health Medicare |
$1.02
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.80
|
| Rate for Payer: Railroad Medicare Medicare |
$1.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.55
|
| Rate for Payer: UHC Core |
$3.37
|
| Rate for Payer: UHC Exchange |
$1.01
|
| Rate for Payer: UHC Medicaid |
$0.71
|
| Rate for Payer: UHC Medicare Advantage |
$1.01
|
| Rate for Payer: UHCCP Medicaid |
$0.71
|
| Rate for Payer: VA VA |
$1.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.02
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$3.51
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Aetna Commercial |
$2.98
|
| Rate for Payer: BCBS Trust/PPO |
$2.90
|
| Rate for Payer: BCN Commercial |
$2.90
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cofinity Commercial |
$3.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.81
|
| Rate for Payer: Healthscope Commercial |
$3.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Nomi Health Commercial |
$2.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.63
|
| Rate for Payer: PHP Commercial |
$2.98
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.09
|
| Rate for Payer: UHC Core |
$2.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.63
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$350.55
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.80 |
| Max. Negotiated Rate |
$315.50 |
| Rate for Payer: Aetna Commercial |
$297.97
|
| Rate for Payer: Aetna Medicare |
$91.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$109.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$109.55
|
| Rate for Payer: BCBS Complete |
$64.89
|
| Rate for Payer: BCBS MAPPO |
$87.64
|
| Rate for Payer: BCBS Trust/PPO |
$288.19
|
| Rate for Payer: BCN Commercial |
$288.19
|
| Rate for Payer: BCN Medicare Advantage |
$87.64
|
| Rate for Payer: Cash Price |
$280.44
|
| Rate for Payer: Cofinity Commercial |
$301.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$87.64
|
| Rate for Payer: Healthscope Commercial |
$315.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$262.91
|
| Rate for Payer: Mclaren Medicaid |
$61.80
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$92.02
|
| Rate for Payer: Meridian Medicaid |
$64.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$100.78
|
| Rate for Payer: Molina Medicare/Medicaid |
$96.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.97
|
| Rate for Payer: Nomi Health Commercial |
$287.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$262.91
|
| Rate for Payer: PACE Senior Care Partners |
$83.26
|
| Rate for Payer: PACE SWMI |
$87.64
|
| Rate for Payer: PHP Commercial |
$297.97
|
| Rate for Payer: PHP Medicare Advantage |
$87.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$61.80
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$304.98
|
| Rate for Payer: Priority Health Medicare |
$88.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$243.98
|
| Rate for Payer: Railroad Medicare Medicare |
$87.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$308.48
|
| Rate for Payer: UHC Core |
$292.71
|
| Rate for Payer: UHC Exchange |
$87.64
|
| Rate for Payer: UHC Medicaid |
$61.80
|
| Rate for Payer: UHC Medicare Advantage |
$87.64
|
| Rate for Payer: UHCCP Medicaid |
$61.80
|
| Rate for Payer: VA VA |
$87.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.91
|
|
