|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$319.20
|
|
|
Service Code
|
NDC 00904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.27 |
| Max. Negotiated Rate |
$287.28 |
| Rate for Payer: Aetna Commercial |
$271.32
|
| Rate for Payer: Aetna Medicare |
$82.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$99.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$99.75
|
| Rate for Payer: BCBS Complete |
$59.08
|
| Rate for Payer: BCBS MAPPO |
$79.80
|
| Rate for Payer: BCBS Trust/PPO |
$262.41
|
| Rate for Payer: BCN Commercial |
$262.41
|
| Rate for Payer: BCN Medicare Advantage |
$79.80
|
| 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: Health Alliance Plan Medicare Advantage |
$79.80
|
| Rate for Payer: Healthscope Commercial |
$287.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$239.40
|
| Rate for Payer: Mclaren Medicaid |
$56.27
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$83.79
|
| Rate for Payer: Meridian Medicaid |
$59.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$91.77
|
| Rate for Payer: Molina Medicare/Medicaid |
$87.78
|
| 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: PACE Senior Care Partners |
$75.81
|
| Rate for Payer: PACE SWMI |
$79.80
|
| Rate for Payer: PHP Commercial |
$271.32
|
| Rate for Payer: PHP Medicare Advantage |
$79.80
|
| Rate for Payer: Priority Health Choice Medicaid |
$56.27
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$277.70
|
| Rate for Payer: Priority Health Medicare |
$80.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$222.16
|
| Rate for Payer: Railroad Medicare Medicare |
$79.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$280.90
|
| Rate for Payer: UHC Core |
$266.53
|
| Rate for Payer: UHC Exchange |
$79.80
|
| Rate for Payer: UHC Medicaid |
$56.27
|
| Rate for Payer: UHC Medicare Advantage |
$79.80
|
| Rate for Payer: UHCCP Medicaid |
$56.27
|
| Rate for Payer: VA VA |
$79.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$239.40
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$350.55
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$243.98 |
| Max. Negotiated Rate |
$315.50 |
| Rate for Payer: Aetna Commercial |
$297.97
|
| Rate for Payer: BCBS Trust/PPO |
$289.52
|
| Rate for Payer: BCN Commercial |
$289.52
|
| 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: Healthscope Commercial |
$315.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$262.91
|
| 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: PHP Commercial |
$297.97
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$304.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$243.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$308.48
|
| Rate for Payer: UHC Core |
$292.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.91
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$356.25
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.81 |
| Max. Negotiated Rate |
$320.62 |
| Rate for Payer: Aetna Commercial |
$302.81
|
| Rate for Payer: Aetna Medicare |
$92.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$111.33
|
| Rate for Payer: Amish Plain Church Group Commercial |
$111.33
|
| Rate for Payer: BCBS Complete |
$65.94
|
| Rate for Payer: BCBS MAPPO |
$89.06
|
| Rate for Payer: BCBS Trust/PPO |
$292.87
|
| Rate for Payer: BCN Commercial |
$292.87
|
| Rate for Payer: BCN Medicare Advantage |
$89.06
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cofinity Commercial |
$306.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.00
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$89.06
|
| Rate for Payer: Healthscope Commercial |
$320.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.19
|
| Rate for Payer: Mclaren Medicaid |
$62.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$93.52
|
| Rate for Payer: Meridian Medicaid |
$65.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$102.42
|
| Rate for Payer: Molina Medicare/Medicaid |
$97.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.81
|
| Rate for Payer: Nomi Health Commercial |
$292.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.19
|
| Rate for Payer: PACE Senior Care Partners |
$84.61
|
| Rate for Payer: PACE SWMI |
$89.06
|
| Rate for Payer: PHP Commercial |
$302.81
|
| Rate for Payer: PHP Medicare Advantage |
$89.06
|
| Rate for Payer: Priority Health Choice Medicaid |
$62.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$309.94
|
| Rate for Payer: Priority Health Medicare |
$89.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$247.95
|
| Rate for Payer: Railroad Medicare Medicare |
$89.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$313.50
|
| Rate for Payer: UHC Core |
$297.47
|
| Rate for Payer: UHC Exchange |
$89.06
|
| Rate for Payer: UHC Medicaid |
$62.81
|
| Rate for Payer: UHC Medicare Advantage |
$89.06
|
| Rate for Payer: UHCCP Medicaid |
$62.81
|
| Rate for Payer: VA VA |
$89.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.19
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$3.57
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.48 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: BCBS Trust/PPO |
$2.95
|
| Rate for Payer: BCN Commercial |
$2.95
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.86
|
| Rate for Payer: Healthscope Commercial |
$3.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Nomi Health Commercial |
$2.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.68
|
| Rate for Payer: PHP Commercial |
$3.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.14
|
| Rate for Payer: UHC Core |
$2.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.68
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$3.57
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: Aetna Medicare |
$0.93
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.12
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.12
|
| Rate for Payer: BCBS Complete |
$0.66
|
| Rate for Payer: BCBS MAPPO |
$0.89
|
| Rate for Payer: BCBS Trust/PPO |
$2.93
|
| Rate for Payer: BCN Commercial |
$2.93
|
| Rate for Payer: BCN Medicare Advantage |
$0.89
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.89
|
| Rate for Payer: Healthscope Commercial |
$3.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.68
|
| Rate for Payer: Mclaren Medicaid |
$0.63
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.94
|
| Rate for Payer: Meridian Medicaid |
$0.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.03
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Nomi Health Commercial |
$2.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.68
|
| Rate for Payer: PACE Senior Care Partners |
$0.85
|
| Rate for Payer: PACE SWMI |
$0.89
|
| Rate for Payer: PHP Commercial |
$3.03
|
| Rate for Payer: PHP Medicare Advantage |
$0.89
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.63
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.11
|
| Rate for Payer: Priority Health Medicare |
$0.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.48
|
| Rate for Payer: Railroad Medicare Medicare |
$0.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.14
|
| Rate for Payer: UHC Core |
$2.98
|
| Rate for Payer: UHC Exchange |
$0.89
|
| Rate for Payer: UHC Medicaid |
$0.63
|
| Rate for Payer: UHC Medicare Advantage |
$0.89
|
| Rate for Payer: UHCCP Medicaid |
$0.63
|
| Rate for Payer: VA VA |
$0.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.68
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$323.95
|
|
|
Service Code
|
NDC 00904695061
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$225.47 |
| Max. Negotiated Rate |
$291.56 |
| Rate for Payer: Aetna Commercial |
$275.36
|
| Rate for Payer: BCBS Trust/PPO |
$267.55
|
| Rate for Payer: BCN Commercial |
$267.55
|
| Rate for Payer: Cash Price |
$259.16
|
| Rate for Payer: Cofinity Commercial |
$278.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.16
|
| Rate for Payer: Healthscope Commercial |
$291.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$242.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.36
|
| Rate for Payer: Nomi Health Commercial |
$265.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$242.96
|
| Rate for Payer: PHP Commercial |
$275.36
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$281.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$225.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$285.08
|
| Rate for Payer: UHC Core |
$270.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$242.96
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$4.58
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: Aetna Medicare |
$1.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.43
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.43
|
| Rate for Payer: BCBS Complete |
$0.85
|
| Rate for Payer: BCBS MAPPO |
$1.15
|
| Rate for Payer: BCBS Trust/PPO |
$3.77
|
| Rate for Payer: BCN Commercial |
$3.77
|
| Rate for Payer: BCN Medicare Advantage |
$1.15
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cofinity Commercial |
$3.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.15
|
| Rate for Payer: Healthscope Commercial |
$4.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.44
|
| Rate for Payer: Mclaren Medicaid |
$0.81
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.20
|
| Rate for Payer: Meridian Medicaid |
$0.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.32
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.89
|
| Rate for Payer: Nomi Health Commercial |
$3.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.44
|
| Rate for Payer: PACE Senior Care Partners |
$1.09
|
| Rate for Payer: PACE SWMI |
$1.15
|
| Rate for Payer: PHP Commercial |
$3.89
|
| Rate for Payer: PHP Medicare Advantage |
$1.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.98
|
| Rate for Payer: Priority Health Medicare |
$1.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.19
|
| Rate for Payer: Railroad Medicare Medicare |
$1.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.03
|
| Rate for Payer: UHC Core |
$3.82
|
| Rate for Payer: UHC Exchange |
$1.15
|
| Rate for Payer: UHC Medicaid |
$0.81
|
| Rate for Payer: UHC Medicare Advantage |
$1.15
|
| Rate for Payer: UHCCP Medicaid |
$0.81
|
| Rate for Payer: VA VA |
$1.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.44
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$4.58
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.19 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: BCBS Trust/PPO |
$3.78
|
| Rate for Payer: BCN Commercial |
$3.78
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cofinity Commercial |
$3.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.66
|
| Rate for Payer: Healthscope Commercial |
$4.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.89
|
| Rate for Payer: Nomi Health Commercial |
$3.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.89
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.03
|
| Rate for Payer: UHC Core |
$3.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.44
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$323.95
|
|
|
Service Code
|
NDC 00904695061
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.11 |
| Max. Negotiated Rate |
$291.56 |
| Rate for Payer: Aetna Commercial |
$275.36
|
| Rate for Payer: Aetna Medicare |
$84.23
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$101.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$101.23
|
| Rate for Payer: BCBS Complete |
$59.96
|
| Rate for Payer: BCBS MAPPO |
$80.99
|
| Rate for Payer: BCBS Trust/PPO |
$266.32
|
| Rate for Payer: BCN Commercial |
$266.32
|
| Rate for Payer: BCN Medicare Advantage |
$80.99
|
| Rate for Payer: Cash Price |
$259.16
|
| Rate for Payer: Cofinity Commercial |
$278.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$80.99
|
| Rate for Payer: Healthscope Commercial |
$291.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$242.96
|
| Rate for Payer: Mclaren Medicaid |
$57.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$85.04
|
| Rate for Payer: Meridian Medicaid |
$59.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.14
|
| Rate for Payer: Molina Medicare/Medicaid |
$89.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.36
|
| Rate for Payer: Nomi Health Commercial |
$265.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$242.96
|
| Rate for Payer: PACE Senior Care Partners |
$76.94
|
| Rate for Payer: PACE SWMI |
$80.99
|
| Rate for Payer: PHP Commercial |
$275.36
|
| Rate for Payer: PHP Medicare Advantage |
$80.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$57.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$281.84
|
| Rate for Payer: Priority Health Medicare |
$81.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$225.47
|
| Rate for Payer: Railroad Medicare Medicare |
$80.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$285.08
|
| Rate for Payer: UHC Core |
$270.50
|
| Rate for Payer: UHC Exchange |
$80.99
|
| Rate for Payer: UHC Medicaid |
$57.11
|
| Rate for Payer: UHC Medicare Advantage |
$80.99
|
| Rate for Payer: UHCCP Medicaid |
$57.11
|
| Rate for Payer: VA VA |
$80.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$242.96
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$356.25
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$247.95 |
| Max. Negotiated Rate |
$320.62 |
| Rate for Payer: Aetna Commercial |
$302.81
|
| Rate for Payer: BCBS Trust/PPO |
$294.23
|
| Rate for Payer: BCN Commercial |
$294.23
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cofinity Commercial |
$306.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.00
|
| Rate for Payer: Healthscope Commercial |
$320.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.81
|
| Rate for Payer: Nomi Health Commercial |
$292.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.19
|
| Rate for Payer: PHP Commercial |
$302.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$309.94
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$247.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$313.50
|
| Rate for Payer: UHC Core |
$297.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.19
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna Medicare |
$0.67
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.80
|
| Rate for Payer: BCBS Complete |
$0.48
|
| Rate for Payer: BCBS MAPPO |
$0.64
|
| Rate for Payer: BCBS Trust/PPO |
$2.11
|
| Rate for Payer: BCN Commercial |
$2.11
|
| Rate for Payer: BCN Medicare Advantage |
$0.64
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.64
|
| Rate for Payer: Healthscope Commercial |
$2.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.93
|
| Rate for Payer: Mclaren Medicaid |
$0.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.67
|
| Rate for Payer: Meridian Medicaid |
$0.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.74
|
| Rate for Payer: Molina Medicare/Medicaid |
$0.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: Nomi Health Commercial |
$2.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.93
|
| Rate for Payer: PACE Senior Care Partners |
$0.61
|
| Rate for Payer: PACE SWMI |
$0.64
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: PHP Medicare Advantage |
$0.64
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.45
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.24
|
| Rate for Payer: Priority Health Medicare |
$0.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.79
|
| Rate for Payer: Railroad Medicare Medicare |
$0.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.26
|
| Rate for Payer: UHC Core |
$2.15
|
| Rate for Payer: UHC Exchange |
$0.64
|
| Rate for Payer: UHC Medicaid |
$0.45
|
| Rate for Payer: UHC Medicare Advantage |
$0.64
|
| Rate for Payer: UHCCP Medicaid |
$0.45
|
| Rate for Payer: VA VA |
$0.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.93
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$256.32
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.40 |
| Max. Negotiated Rate |
$230.69 |
| Rate for Payer: Aetna Commercial |
$217.87
|
| Rate for Payer: BCBS Trust/PPO |
$211.69
|
| Rate for Payer: BCN Commercial |
$211.69
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Commercial |
$220.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Healthscope Commercial |
$230.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.87
|
| Rate for Payer: Nomi Health Commercial |
$210.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$192.24
|
| Rate for Payer: PHP Commercial |
$217.87
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$223.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$178.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$225.56
|
| Rate for Payer: UHC Core |
$214.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.24
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$425.60
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$296.22 |
| Max. Negotiated Rate |
$383.04 |
| Rate for Payer: Aetna Commercial |
$361.76
|
| Rate for Payer: BCBS Trust/PPO |
$351.50
|
| Rate for Payer: BCN Commercial |
$351.50
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cofinity Commercial |
$366.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.48
|
| Rate for Payer: Healthscope Commercial |
$383.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.76
|
| Rate for Payer: Nomi Health Commercial |
$348.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.20
|
| Rate for Payer: PHP Commercial |
$361.76
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$370.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$296.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$374.53
|
| Rate for Payer: UHC Core |
$355.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.20
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$813.60
|
|
|
Service Code
|
NDC 00074518211
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.44 |
| Max. Negotiated Rate |
$732.24 |
| Rate for Payer: Aetna Commercial |
$691.56
|
| Rate for Payer: Aetna Medicare |
$211.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$254.25
|
| Rate for Payer: Amish Plain Church Group Commercial |
$254.25
|
| Rate for Payer: BCBS Complete |
$150.60
|
| Rate for Payer: BCBS MAPPO |
$203.40
|
| Rate for Payer: BCBS Trust/PPO |
$668.86
|
| Rate for Payer: BCN Commercial |
$668.86
|
| Rate for Payer: BCN Medicare Advantage |
$203.40
|
| Rate for Payer: Cash Price |
$650.88
|
| Rate for Payer: Cofinity Commercial |
$699.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$650.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$203.40
|
| Rate for Payer: Healthscope Commercial |
$732.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$610.20
|
| Rate for Payer: Mclaren Medicaid |
$143.44
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$213.57
|
| Rate for Payer: Meridian Medicaid |
$150.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$233.91
|
| Rate for Payer: Molina Medicare/Medicaid |
$223.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$691.56
|
| Rate for Payer: Nomi Health Commercial |
$667.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$610.20
|
| Rate for Payer: PACE Senior Care Partners |
$193.23
|
| Rate for Payer: PACE SWMI |
$203.40
|
| Rate for Payer: PHP Commercial |
$691.56
|
| Rate for Payer: PHP Medicare Advantage |
$203.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$143.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$707.83
|
| Rate for Payer: Priority Health Medicare |
$205.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$566.27
|
| Rate for Payer: Railroad Medicare Medicare |
$203.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$715.97
|
| Rate for Payer: UHC Core |
$679.36
|
| Rate for Payer: UHC Exchange |
$203.40
|
| Rate for Payer: UHC Medicaid |
$143.44
|
| Rate for Payer: UHC Medicare Advantage |
$203.40
|
| Rate for Payer: UHCCP Medicaid |
$143.44
|
| Rate for Payer: VA VA |
$203.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$610.20
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$425.60
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.03 |
| Max. Negotiated Rate |
$383.04 |
| Rate for Payer: Aetna Commercial |
$361.76
|
| Rate for Payer: Aetna Medicare |
$110.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$133.00
|
| Rate for Payer: Amish Plain Church Group Commercial |
$133.00
|
| Rate for Payer: BCBS Complete |
$78.78
|
| Rate for Payer: BCBS MAPPO |
$106.40
|
| Rate for Payer: BCBS Trust/PPO |
$349.89
|
| Rate for Payer: BCN Commercial |
$349.89
|
| Rate for Payer: BCN Medicare Advantage |
$106.40
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cofinity Commercial |
$366.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$106.40
|
| Rate for Payer: Healthscope Commercial |
$383.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.20
|
| Rate for Payer: Mclaren Medicaid |
$75.03
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$111.72
|
| Rate for Payer: Meridian Medicaid |
$78.78
|
| Rate for Payer: MI Amish Medical Board Commercial |
$122.36
|
| Rate for Payer: Molina Medicare/Medicaid |
$117.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.76
|
| Rate for Payer: Nomi Health Commercial |
$348.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.20
|
| Rate for Payer: PACE Senior Care Partners |
$101.08
|
| Rate for Payer: PACE SWMI |
$106.40
|
| Rate for Payer: PHP Commercial |
$361.76
|
| Rate for Payer: PHP Medicare Advantage |
$106.40
|
| Rate for Payer: Priority Health Choice Medicaid |
$75.03
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$370.27
|
| Rate for Payer: Priority Health Medicare |
$107.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$296.22
|
| Rate for Payer: Railroad Medicare Medicare |
$106.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$374.53
|
| Rate for Payer: UHC Core |
$355.38
|
| Rate for Payer: UHC Exchange |
$106.40
|
| Rate for Payer: UHC Medicaid |
$75.03
|
| Rate for Payer: UHC Medicare Advantage |
$106.40
|
| Rate for Payer: UHCCP Medicaid |
$75.03
|
| Rate for Payer: VA VA |
$106.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.20
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.79 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: BCBS Trust/PPO |
$2.12
|
| Rate for Payer: BCN Commercial |
$2.12
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: Nomi Health Commercial |
$2.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.93
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$2.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.26
|
| Rate for Payer: UHC Core |
$2.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.93
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$813.60
|
|
|
Service Code
|
NDC 00074518211
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$566.27 |
| Max. Negotiated Rate |
$732.24 |
| Rate for Payer: Aetna Commercial |
$691.56
|
| Rate for Payer: BCBS Trust/PPO |
$671.95
|
| Rate for Payer: BCN Commercial |
$671.95
|
| Rate for Payer: Cash Price |
$650.88
|
| Rate for Payer: Cofinity Commercial |
$699.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$650.88
|
| Rate for Payer: Healthscope Commercial |
$732.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$610.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$691.56
|
| Rate for Payer: Nomi Health Commercial |
$667.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$610.20
|
| Rate for Payer: PHP Commercial |
$691.56
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$707.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$566.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$715.97
|
| Rate for Payer: UHC Core |
$679.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$610.20
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$256.32
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.19 |
| Max. Negotiated Rate |
$230.69 |
| Rate for Payer: Aetna Commercial |
$217.87
|
| Rate for Payer: Aetna Medicare |
$66.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$80.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$80.10
|
| Rate for Payer: BCBS Complete |
$47.44
|
| Rate for Payer: BCBS MAPPO |
$64.08
|
| Rate for Payer: BCBS Trust/PPO |
$210.72
|
| Rate for Payer: BCN Commercial |
$210.72
|
| Rate for Payer: BCN Medicare Advantage |
$64.08
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Commercial |
$220.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$64.08
|
| Rate for Payer: Healthscope Commercial |
$230.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.24
|
| Rate for Payer: Mclaren Medicaid |
$45.19
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$67.28
|
| Rate for Payer: Meridian Medicaid |
$47.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$73.69
|
| Rate for Payer: Molina Medicare/Medicaid |
$70.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.87
|
| Rate for Payer: Nomi Health Commercial |
$210.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$192.24
|
| Rate for Payer: PACE Senior Care Partners |
$60.88
|
| Rate for Payer: PACE SWMI |
$64.08
|
| Rate for Payer: PHP Commercial |
$217.87
|
| Rate for Payer: PHP Medicare Advantage |
$64.08
|
| Rate for Payer: Priority Health Choice Medicaid |
$45.19
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$223.00
|
| Rate for Payer: Priority Health Medicare |
$64.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$178.40
|
| Rate for Payer: Railroad Medicare Medicare |
$64.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$225.56
|
| Rate for Payer: UHC Core |
$214.03
|
| Rate for Payer: UHC Exchange |
$64.08
|
| Rate for Payer: UHC Medicaid |
$45.19
|
| Rate for Payer: UHC Medicare Advantage |
$64.08
|
| Rate for Payer: UHCCP Medicaid |
$45.19
|
| Rate for Payer: VA VA |
$64.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.24
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$732.68
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
10403
|
|
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 88 MCG TABLET
|
Facility
|
IP
|
$4.66
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.24 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Aetna Commercial |
$3.96
|
| Rate for Payer: BCBS Trust/PPO |
$3.85
|
| Rate for Payer: BCN Commercial |
$3.85
|
| Rate for Payer: Cash Price |
$3.73
|
| Rate for Payer: Cofinity Commercial |
$4.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.73
|
| Rate for Payer: Healthscope Commercial |
$4.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.96
|
| Rate for Payer: Nomi Health Commercial |
$3.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.50
|
| Rate for Payer: PHP Commercial |
$3.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$4.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.10
|
| Rate for Payer: UHC Core |
$3.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.50
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$447.45
|
|
|
Service Code
|
NDC 60687048601
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$311.43 |
| Max. Negotiated Rate |
$402.70 |
| Rate for Payer: Aetna Commercial |
$380.33
|
| Rate for Payer: BCBS Trust/PPO |
$369.55
|
| Rate for Payer: BCN Commercial |
$369.55
|
| Rate for Payer: Cash Price |
$357.96
|
| Rate for Payer: Cofinity Commercial |
$384.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$357.96
|
| Rate for Payer: Healthscope Commercial |
$402.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$335.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$380.33
|
| Rate for Payer: Nomi Health Commercial |
$366.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$335.59
|
| Rate for Payer: PHP Commercial |
$380.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$389.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$311.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$393.76
|
| Rate for Payer: UHC Core |
$373.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$335.59
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$4.48
|
|
|
Service Code
|
NDC 60687048611
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.79 |
| Max. Negotiated Rate |
$4.03 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: Aetna Medicare |
$1.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.40
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.40
|
| Rate for Payer: BCBS Complete |
$0.83
|
| Rate for Payer: BCBS MAPPO |
$1.12
|
| Rate for Payer: BCBS Trust/PPO |
$3.68
|
| Rate for Payer: BCN Commercial |
$3.68
|
| Rate for Payer: BCN Medicare Advantage |
$1.12
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Cofinity Commercial |
$3.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.12
|
| Rate for Payer: Healthscope Commercial |
$4.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.36
|
| Rate for Payer: Mclaren Medicaid |
$0.79
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.18
|
| Rate for Payer: Meridian Medicaid |
$0.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.29
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.81
|
| Rate for Payer: Nomi Health Commercial |
$3.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.36
|
| Rate for Payer: PACE Senior Care Partners |
$1.06
|
| Rate for Payer: PACE SWMI |
$1.12
|
| Rate for Payer: PHP Commercial |
$3.81
|
| Rate for Payer: PHP Medicare Advantage |
$1.12
|
| Rate for Payer: Priority Health Choice Medicaid |
$0.79
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.90
|
| Rate for Payer: Priority Health Medicare |
$1.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.12
|
| Rate for Payer: Railroad Medicare Medicare |
$1.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.94
|
| Rate for Payer: UHC Core |
$3.74
|
| Rate for Payer: UHC Exchange |
$1.12
|
| Rate for Payer: UHC Medicaid |
$0.79
|
| Rate for Payer: UHC Medicare Advantage |
$1.12
|
| Rate for Payer: UHCCP Medicaid |
$0.79
|
| Rate for Payer: VA VA |
$1.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.36
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$732.68
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
10403
|
|
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 88 MCG TABLET
|
Facility
|
IP
|
$4.48
|
|
|
Service Code
|
NDC 60687048611
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.12 |
| Max. Negotiated Rate |
$4.03 |
| Rate for Payer: Aetna Commercial |
$3.81
|
| Rate for Payer: BCBS Trust/PPO |
$3.70
|
| Rate for Payer: BCN Commercial |
$3.70
|
| Rate for Payer: Cash Price |
$3.58
|
| Rate for Payer: Cofinity Commercial |
$3.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.58
|
| Rate for Payer: Healthscope Commercial |
$4.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.81
|
| Rate for Payer: Nomi Health Commercial |
$3.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.36
|
| Rate for Payer: PHP Commercial |
$3.81
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$3.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.94
|
| Rate for Payer: UHC Core |
$3.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.36
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$406.60
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$282.99 |
| Max. Negotiated Rate |
$365.94 |
| Rate for Payer: Aetna Commercial |
$345.61
|
| Rate for Payer: BCBS Trust/PPO |
$335.81
|
| Rate for Payer: BCN Commercial |
$335.81
|
| Rate for Payer: Cash Price |
$325.28
|
| Rate for Payer: Cofinity Commercial |
$349.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.28
|
| Rate for Payer: Healthscope Commercial |
$365.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$304.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.61
|
| Rate for Payer: Nomi Health Commercial |
$333.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$304.95
|
| Rate for Payer: PHP Commercial |
$345.61
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$353.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$282.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$357.81
|
| Rate for Payer: UHC Core |
$339.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$304.95
|
|
