|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$88.53
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$21.03 |
| Max. Negotiated Rate |
$79.68 |
| Rate for Payer: Aetna Commercial |
$75.25
|
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Medicare |
$23.02
|
| Rate for Payer: Aetna Medicare |
$17.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.31
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27.67
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27.67
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.31
|
| Rate for Payer: BCBS Complete |
$27.27
|
| Rate for Payer: BCBS Complete |
$35.41
|
| Rate for Payer: BCBS MAPPO |
$17.05
|
| Rate for Payer: BCBS MAPPO |
$22.13
|
| Rate for Payer: BCBS Trust/PPO |
$72.78
|
| Rate for Payer: BCBS Trust/PPO |
$56.05
|
| Rate for Payer: BCN Commercial |
$68.83
|
| Rate for Payer: BCN Commercial |
$53.01
|
| Rate for Payer: BCN Medicare Advantage |
$22.13
|
| Rate for Payer: BCN Medicare Advantage |
$17.05
|
| Rate for Payer: Cash Price |
$70.82
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Cofinity Commercial |
$76.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$17.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.13
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Healthscope Commercial |
$79.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.13
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.90
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.95
|
| Rate for Payer: Nomi Health Commercial |
$72.59
|
| Rate for Payer: Nomi Health Commercial |
$55.91
|
| Rate for Payer: PACE Senior Care Partners |
$21.03
|
| Rate for Payer: PACE Senior Care Partners |
$16.19
|
| Rate for Payer: PACE SWMI |
$22.13
|
| Rate for Payer: PACE SWMI |
$17.05
|
| Rate for Payer: PHP Commercial |
$75.25
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: PHP Medicare Advantage |
$17.05
|
| Rate for Payer: PHP Medicare Advantage |
$22.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.32
|
| Rate for Payer: Priority Health HMO/PPO |
$59.32
|
| Rate for Payer: Priority Health HMO/PPO |
$77.02
|
| Rate for Payer: Priority Health Medicare |
$22.35
|
| Rate for Payer: Priority Health Medicare |
$17.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$59.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.68
|
| Rate for Payer: Railroad Medicare Medicare |
$17.05
|
| Rate for Payer: Railroad Medicare Medicare |
$22.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.91
|
| Rate for Payer: UHC Core |
$73.92
|
| Rate for Payer: UHC Core |
$56.93
|
| Rate for Payer: UHC Dual Complete DSNP |
$22.13
|
| Rate for Payer: UHC Dual Complete DSNP |
$17.05
|
| Rate for Payer: UHC Exchange |
$17.05
|
| Rate for Payer: UHC Exchange |
$22.13
|
| Rate for Payer: UHC Medicare Advantage |
$17.05
|
| Rate for Payer: UHC Medicare Advantage |
$22.13
|
| Rate for Payer: VA VA |
$17.05
|
| Rate for Payer: VA VA |
$22.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.13
|
|
|
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 |
$44.32 |
| Max. Negotiated Rate |
$61.36 |
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Commercial |
$75.25
|
| Rate for Payer: BCBS Trust/PPO |
$55.66
|
| Rate for Payer: BCBS Trust/PPO |
$72.27
|
| Rate for Payer: BCN Commercial |
$52.69
|
| Rate for Payer: BCN Commercial |
$68.42
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cash Price |
$70.82
|
| Rate for Payer: Cofinity Commercial |
$76.14
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Healthscope Commercial |
$79.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.25
|
| Rate for Payer: Nomi Health Commercial |
$55.91
|
| Rate for Payer: Nomi Health Commercial |
$72.59
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: PHP Commercial |
$75.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.32
|
| Rate for Payer: Priority Health HMO/PPO |
$77.02
|
| Rate for Payer: Priority Health HMO/PPO |
$59.32
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$59.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.91
|
| Rate for Payer: UHC Core |
$56.93
|
| Rate for Payer: UHC Core |
$73.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.40
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
OP
|
$336.30
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.87 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna Medicare |
$87.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$105.09
|
| Rate for Payer: Amish Plain Church Group Commercial |
$105.09
|
| Rate for Payer: BCBS Complete |
$134.52
|
| Rate for Payer: BCBS MAPPO |
$84.08
|
| Rate for Payer: BCBS Trust/PPO |
$276.47
|
| Rate for Payer: BCN Commercial |
$261.47
|
| Rate for Payer: BCN Medicare Advantage |
$84.08
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$84.08
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$88.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$96.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: Nomi Health Commercial |
$275.77
|
| Rate for Payer: PACE Senior Care Partners |
$79.87
|
| Rate for Payer: PACE SWMI |
$84.08
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: PHP Medicare Advantage |
$84.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.59
|
| Rate for Payer: Priority Health HMO/PPO |
$292.58
|
| Rate for Payer: Priority Health Medicare |
$84.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$225.32
|
| Rate for Payer: Railroad Medicare Medicare |
$84.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$295.94
|
| Rate for Payer: UHC Core |
$280.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$84.08
|
| Rate for Payer: UHC Exchange |
$84.08
|
| Rate for Payer: UHC Medicare Advantage |
$84.08
|
| Rate for Payer: VA VA |
$84.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$336.30
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$218.59 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: BCBS Trust/PPO |
$274.52
|
| Rate for Payer: BCN Commercial |
$259.89
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: Nomi Health Commercial |
$275.77
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.59
|
| Rate for Payer: Priority Health HMO/PPO |
$292.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$225.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$295.94
|
| Rate for Payer: UHC Core |
$280.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
LEVONORGESTREL 1.5 MG TABLET
|
Facility
|
OP
|
$38.52
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.15 |
| Max. Negotiated Rate |
$34.67 |
| Rate for Payer: Aetna Commercial |
$32.74
|
| Rate for Payer: Aetna Medicare |
$10.02
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$12.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$12.04
|
| Rate for Payer: BCBS Complete |
$15.41
|
| Rate for Payer: BCBS MAPPO |
$9.63
|
| Rate for Payer: BCBS Trust/PPO |
$31.67
|
| Rate for Payer: BCN Commercial |
$29.95
|
| Rate for Payer: BCN Medicare Advantage |
$9.63
|
| Rate for Payer: Cash Price |
$30.82
|
| Rate for Payer: Cofinity Commercial |
$33.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.82
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$9.63
|
| Rate for Payer: Healthscope Commercial |
$34.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.89
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$10.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.74
|
| Rate for Payer: Nomi Health Commercial |
$31.59
|
| Rate for Payer: PACE Senior Care Partners |
$9.15
|
| Rate for Payer: PACE SWMI |
$9.63
|
| Rate for Payer: PHP Commercial |
$32.74
|
| Rate for Payer: PHP Medicare Advantage |
$9.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.04
|
| Rate for Payer: Priority Health HMO/PPO |
$33.51
|
| Rate for Payer: Priority Health Medicare |
$9.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.81
|
| Rate for Payer: Railroad Medicare Medicare |
$9.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.90
|
| Rate for Payer: UHC Core |
$32.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$9.63
|
| Rate for Payer: UHC Exchange |
$9.63
|
| Rate for Payer: UHC Medicare Advantage |
$9.63
|
| Rate for Payer: VA VA |
$9.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.89
|
|
|
LEVONORGESTREL 1.5 MG TABLET
|
Facility
|
IP
|
$38.52
|
|
|
Service Code
|
NDC 68180085211
|
| Hospital Charge Code |
99445
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.04 |
| Max. Negotiated Rate |
$34.67 |
| Rate for Payer: Aetna Commercial |
$32.74
|
| Rate for Payer: BCBS Trust/PPO |
$31.44
|
| Rate for Payer: BCN Commercial |
$29.77
|
| Rate for Payer: Cash Price |
$30.82
|
| Rate for Payer: Cofinity Commercial |
$33.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.82
|
| Rate for Payer: Healthscope Commercial |
$34.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.74
|
| Rate for Payer: Nomi Health Commercial |
$31.59
|
| Rate for Payer: PHP Commercial |
$32.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.04
|
| Rate for Payer: Priority Health HMO/PPO |
$33.51
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$33.90
|
| Rate for Payer: UHC Core |
$32.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.89
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$231.93
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.75 |
| Max. Negotiated Rate |
$208.74 |
| Rate for Payer: Aetna Commercial |
$197.14
|
| Rate for Payer: BCBS Trust/PPO |
$189.32
|
| Rate for Payer: BCN Commercial |
$179.24
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$199.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Healthscope Commercial |
$208.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.14
|
| Rate for Payer: Nomi Health Commercial |
$190.18
|
| Rate for Payer: PHP Commercial |
$197.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| Rate for Payer: Priority Health HMO/PPO |
$201.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$155.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$204.10
|
| Rate for Payer: UHC Core |
$193.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.95
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$231.93
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$55.08 |
| Max. Negotiated Rate |
$208.74 |
| Rate for Payer: Aetna Commercial |
$197.14
|
| Rate for Payer: Aetna Medicare |
$60.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$72.48
|
| Rate for Payer: Amish Plain Church Group Commercial |
$72.48
|
| Rate for Payer: BCBS Complete |
$92.77
|
| Rate for Payer: BCBS MAPPO |
$57.98
|
| Rate for Payer: BCBS Trust/PPO |
$190.67
|
| Rate for Payer: BCN Commercial |
$180.33
|
| Rate for Payer: BCN Medicare Advantage |
$57.98
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$199.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$57.98
|
| Rate for Payer: Healthscope Commercial |
$208.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.95
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$60.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$66.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.14
|
| Rate for Payer: Nomi Health Commercial |
$190.18
|
| Rate for Payer: PACE Senior Care Partners |
$55.08
|
| Rate for Payer: PACE SWMI |
$57.98
|
| Rate for Payer: PHP Commercial |
$197.14
|
| Rate for Payer: PHP Medicare Advantage |
$57.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| Rate for Payer: Priority Health HMO/PPO |
$201.78
|
| Rate for Payer: Priority Health Medicare |
$58.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$155.39
|
| Rate for Payer: Railroad Medicare Medicare |
$57.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$204.10
|
| Rate for Payer: UHC Core |
$193.66
|
| Rate for Payer: UHC Dual Complete DSNP |
$57.98
|
| Rate for Payer: UHC Exchange |
$57.98
|
| Rate for Payer: UHC Medicare Advantage |
$57.98
|
| Rate for Payer: VA VA |
$57.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.95
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: BCBS Trust/PPO |
$2.29
|
| Rate for Payer: BCN Commercial |
$2.17
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Healthscope Commercial |
$2.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.39
|
| Rate for Payer: Nomi Health Commercial |
$2.30
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health HMO/PPO |
$2.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.47
|
| Rate for Payer: UHC Core |
$2.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$396.15
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.50 |
| Max. Negotiated Rate |
$356.54 |
| Rate for Payer: Aetna Commercial |
$336.73
|
| Rate for Payer: BCBS Trust/PPO |
$323.38
|
| Rate for Payer: BCN Commercial |
$306.14
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$340.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Healthscope Commercial |
$356.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: Nomi Health Commercial |
$324.84
|
| Rate for Payer: PHP Commercial |
$336.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: Priority Health HMO/PPO |
$344.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$265.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$348.61
|
| Rate for Payer: UHC Core |
$330.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$2.81
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: Aetna Medicare |
$0.73
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.88
|
| Rate for Payer: BCBS Complete |
$1.12
|
| Rate for Payer: BCBS MAPPO |
$0.70
|
| Rate for Payer: BCBS Trust/PPO |
$2.31
|
| Rate for Payer: BCN Commercial |
$2.18
|
| Rate for Payer: BCN Medicare Advantage |
$0.70
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.70
|
| Rate for Payer: Healthscope Commercial |
$2.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.39
|
| Rate for Payer: Nomi Health Commercial |
$2.30
|
| Rate for Payer: PACE Senior Care Partners |
$0.67
|
| Rate for Payer: PACE SWMI |
$0.70
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: PHP Medicare Advantage |
$0.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health HMO/PPO |
$2.44
|
| Rate for Payer: Priority Health Medicare |
$0.71
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.88
|
| Rate for Payer: Railroad Medicare Medicare |
$0.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.47
|
| Rate for Payer: UHC Core |
$2.35
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.70
|
| Rate for Payer: UHC Exchange |
$0.70
|
| Rate for Payer: UHC Medicare Advantage |
$0.70
|
| Rate for Payer: VA VA |
$0.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$219.52 |
| Max. Negotiated Rate |
$303.96 |
| Rate for Payer: Aetna Commercial |
$287.07
|
| Rate for Payer: BCBS Trust/PPO |
$275.69
|
| Rate for Payer: BCN Commercial |
$261.00
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$290.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$303.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$253.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: Nomi Health Commercial |
$276.94
|
| Rate for Payer: PHP Commercial |
$287.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: Priority Health HMO/PPO |
$293.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$226.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$297.20
|
| Rate for Payer: UHC Core |
$282.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$253.30
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$396.15
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.09 |
| Max. Negotiated Rate |
$356.54 |
| Rate for Payer: Aetna Commercial |
$336.73
|
| Rate for Payer: Aetna Medicare |
$103.00
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$123.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$123.80
|
| Rate for Payer: BCBS Complete |
$158.46
|
| Rate for Payer: BCBS MAPPO |
$99.04
|
| Rate for Payer: BCBS Trust/PPO |
$325.67
|
| Rate for Payer: BCN Commercial |
$308.01
|
| Rate for Payer: BCN Medicare Advantage |
$99.04
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$340.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$99.04
|
| Rate for Payer: Healthscope Commercial |
$356.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$297.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$103.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$113.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: Nomi Health Commercial |
$324.84
|
| Rate for Payer: PACE Senior Care Partners |
$94.09
|
| Rate for Payer: PACE SWMI |
$99.04
|
| Rate for Payer: PHP Commercial |
$336.73
|
| Rate for Payer: PHP Medicare Advantage |
$99.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: Priority Health HMO/PPO |
$344.65
|
| Rate for Payer: Priority Health Medicare |
$100.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$265.42
|
| Rate for Payer: Railroad Medicare Medicare |
$99.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$348.61
|
| Rate for Payer: UHC Core |
$330.79
|
| Rate for Payer: UHC Dual Complete DSNP |
$99.04
|
| Rate for Payer: UHC Exchange |
$99.04
|
| Rate for Payer: UHC Medicare Advantage |
$99.04
|
| Rate for Payer: VA VA |
$99.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$297.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.21 |
| Max. Negotiated Rate |
$303.96 |
| Rate for Payer: Aetna Commercial |
$287.07
|
| Rate for Payer: Aetna Medicare |
$87.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$105.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$105.54
|
| Rate for Payer: BCBS Complete |
$135.09
|
| Rate for Payer: BCBS MAPPO |
$84.43
|
| Rate for Payer: BCBS Trust/PPO |
$277.65
|
| Rate for Payer: BCN Commercial |
$262.59
|
| Rate for Payer: BCN Medicare Advantage |
$84.43
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$290.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$84.43
|
| Rate for Payer: Healthscope Commercial |
$303.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$253.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$88.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$97.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: Nomi Health Commercial |
$276.94
|
| Rate for Payer: PACE Senior Care Partners |
$80.21
|
| Rate for Payer: PACE SWMI |
$84.43
|
| Rate for Payer: PHP Commercial |
$287.07
|
| Rate for Payer: PHP Medicare Advantage |
$84.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: Priority Health HMO/PPO |
$293.83
|
| Rate for Payer: Priority Health Medicare |
$85.28
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$226.28
|
| Rate for Payer: Railroad Medicare Medicare |
$84.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$297.20
|
| Rate for Payer: UHC Core |
$282.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$84.43
|
| Rate for Payer: UHC Exchange |
$84.43
|
| Rate for Payer: UHC Medicare Advantage |
$84.43
|
| Rate for Payer: VA VA |
$84.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$253.30
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$389.88
|
|
|
Service Code
|
NDC 00378181177
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.60 |
| 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 |
$155.95
|
| Rate for Payer: BCBS MAPPO |
$97.47
|
| Rate for Payer: BCBS Trust/PPO |
$320.52
|
| Rate for Payer: BCN Commercial |
$303.13
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$102.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$112.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.40
|
| Rate for Payer: Nomi Health Commercial |
$319.70
|
| 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 Cigna Priority Health |
$253.42
|
| Rate for Payer: Priority Health HMO/PPO |
$339.20
|
| Rate for Payer: Priority Health Medicare |
$98.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$261.22
|
| 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 Dual Complete DSNP |
$97.47
|
| Rate for Payer: UHC Exchange |
$97.47
|
| Rate for Payer: UHC Medicare Advantage |
$97.47
|
| Rate for Payer: VA VA |
$97.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.41
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$389.88
|
|
|
Service Code
|
NDC 00378181177
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$253.42 |
| Max. Negotiated Rate |
$350.89 |
| Rate for Payer: Aetna Commercial |
$331.40
|
| Rate for Payer: BCBS Trust/PPO |
$318.26
|
| Rate for Payer: BCN Commercial |
$301.30
|
| 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: Healthscope Commercial |
$350.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$292.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$331.40
|
| Rate for Payer: Nomi Health Commercial |
$319.70
|
| Rate for Payer: PHP Commercial |
$331.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$253.42
|
| Rate for Payer: Priority Health HMO/PPO |
$339.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$261.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$343.09
|
| Rate for Payer: UHC Core |
$325.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$292.41
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$697.25
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.60 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: Aetna Medicare |
$181.28
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$217.89
|
| Rate for Payer: Amish Plain Church Group Commercial |
$217.89
|
| Rate for Payer: BCBS Complete |
$278.90
|
| Rate for Payer: BCBS MAPPO |
$174.31
|
| Rate for Payer: BCBS Trust/PPO |
$573.21
|
| Rate for Payer: BCN Commercial |
$542.11
|
| Rate for Payer: BCN Medicare Advantage |
$174.31
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$599.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$174.31
|
| Rate for Payer: Healthscope Commercial |
$627.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$522.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$183.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$200.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.66
|
| Rate for Payer: Nomi Health Commercial |
$571.75
|
| Rate for Payer: PACE Senior Care Partners |
$165.60
|
| Rate for Payer: PACE SWMI |
$174.31
|
| Rate for Payer: PHP Commercial |
$592.66
|
| Rate for Payer: PHP Medicare Advantage |
$174.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.21
|
| Rate for Payer: Priority Health HMO/PPO |
$606.61
|
| Rate for Payer: Priority Health Medicare |
$176.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$467.16
|
| Rate for Payer: Railroad Medicare Medicare |
$174.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$613.58
|
| Rate for Payer: UHC Core |
$582.20
|
| Rate for Payer: UHC Dual Complete DSNP |
$174.31
|
| Rate for Payer: UHC Exchange |
$174.31
|
| Rate for Payer: UHC Medicare Advantage |
$174.31
|
| Rate for Payer: VA VA |
$174.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$522.94
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$697.25
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$453.21 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: BCBS Trust/PPO |
$569.17
|
| Rate for Payer: BCN Commercial |
$538.83
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$599.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.80
|
| Rate for Payer: Healthscope Commercial |
$627.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$522.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.66
|
| Rate for Payer: Nomi Health Commercial |
$571.75
|
| Rate for Payer: PHP Commercial |
$592.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.21
|
| Rate for Payer: Priority Health HMO/PPO |
$606.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$467.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$613.58
|
| Rate for Payer: UHC Core |
$582.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$522.94
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$466.45
|
|
|
Service Code
|
NDC 00904695461
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.78 |
| 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 |
$186.58
|
| Rate for Payer: BCBS MAPPO |
$116.61
|
| Rate for Payer: BCBS Trust/PPO |
$383.47
|
| Rate for Payer: BCN Commercial |
$362.66
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$122.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$134.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$396.48
|
| Rate for Payer: Nomi Health Commercial |
$382.49
|
| 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 Cigna Priority Health |
$303.19
|
| Rate for Payer: Priority Health HMO/PPO |
$405.81
|
| Rate for Payer: Priority Health Medicare |
$117.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$312.52
|
| 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 Dual Complete DSNP |
$116.61
|
| Rate for Payer: UHC Exchange |
$116.61
|
| Rate for Payer: UHC Medicare Advantage |
$116.61
|
| Rate for Payer: VA VA |
$116.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$349.84
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$466.45
|
|
|
Service Code
|
NDC 00904695461
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$303.19 |
| Max. Negotiated Rate |
$419.81 |
| Rate for Payer: Aetna Commercial |
$396.48
|
| Rate for Payer: BCBS Trust/PPO |
$380.76
|
| Rate for Payer: BCN Commercial |
$360.47
|
| 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: PHP Commercial |
$396.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$303.19
|
| Rate for Payer: Priority Health HMO/PPO |
$405.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$312.52
|
| 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 125 MCG TABLET
|
Facility
|
OP
|
$466.45
|
|
|
Service Code
|
NDC 00904695561
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.78 |
| 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 |
$186.58
|
| Rate for Payer: BCBS MAPPO |
$116.61
|
| Rate for Payer: BCBS Trust/PPO |
$383.47
|
| Rate for Payer: BCN Commercial |
$362.66
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$122.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$134.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$396.48
|
| Rate for Payer: Nomi Health Commercial |
$382.49
|
| 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 Cigna Priority Health |
$303.19
|
| Rate for Payer: Priority Health HMO/PPO |
$405.81
|
| Rate for Payer: Priority Health Medicare |
$117.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$312.52
|
| 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 Dual Complete DSNP |
$116.61
|
| Rate for Payer: UHC Exchange |
$116.61
|
| Rate for Payer: UHC Medicare Advantage |
$116.61
|
| 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 |
$303.19 |
| Max. Negotiated Rate |
$419.81 |
| Rate for Payer: Aetna Commercial |
$396.48
|
| Rate for Payer: BCBS Trust/PPO |
$380.76
|
| Rate for Payer: BCN Commercial |
$360.47
|
| 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: PHP Commercial |
$396.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$303.19
|
| Rate for Payer: Priority Health HMO/PPO |
$405.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$312.52
|
| 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
|
$301.44
|
|
|
Service Code
|
NDC 42292004120
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$195.94 |
| Max. Negotiated Rate |
$271.30 |
| Rate for Payer: Aetna Commercial |
$256.22
|
| Rate for Payer: BCBS Trust/PPO |
$246.07
|
| Rate for Payer: BCN Commercial |
$232.95
|
| Rate for Payer: Cash Price |
$241.15
|
| Rate for Payer: Cofinity Commercial |
$259.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.15
|
| Rate for Payer: Healthscope Commercial |
$271.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$226.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$256.22
|
| Rate for Payer: Nomi Health Commercial |
$247.18
|
| Rate for Payer: PHP Commercial |
$256.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.94
|
| Rate for Payer: Priority Health HMO/PPO |
$262.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$201.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$265.27
|
| Rate for Payer: UHC Core |
$251.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$226.08
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$697.68
|
|
|
Service Code
|
NDC 00074372790
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.70 |
| Max. Negotiated Rate |
$627.91 |
| Rate for Payer: Aetna Commercial |
$593.03
|
| Rate for Payer: Aetna Medicare |
$181.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$218.03
|
| Rate for Payer: Amish Plain Church Group Commercial |
$218.03
|
| Rate for Payer: BCBS Complete |
$279.07
|
| Rate for Payer: BCBS MAPPO |
$174.42
|
| Rate for Payer: BCBS Trust/PPO |
$573.56
|
| Rate for Payer: BCN Commercial |
$542.45
|
| Rate for Payer: BCN Medicare Advantage |
$174.42
|
| Rate for Payer: Cash Price |
$558.14
|
| Rate for Payer: Cofinity Commercial |
$600.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$558.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$174.42
|
| Rate for Payer: Healthscope Commercial |
$627.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$523.26
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$183.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$200.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$593.03
|
| Rate for Payer: Nomi Health Commercial |
$572.10
|
| Rate for Payer: PACE Senior Care Partners |
$165.70
|
| Rate for Payer: PACE SWMI |
$174.42
|
| Rate for Payer: PHP Commercial |
$593.03
|
| Rate for Payer: PHP Medicare Advantage |
$174.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.49
|
| Rate for Payer: Priority Health HMO/PPO |
$606.98
|
| Rate for Payer: Priority Health Medicare |
$176.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$467.45
|
| Rate for Payer: Railroad Medicare Medicare |
$174.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$613.96
|
| Rate for Payer: UHC Core |
$582.56
|
| Rate for Payer: UHC Dual Complete DSNP |
$174.42
|
| Rate for Payer: UHC Exchange |
$174.42
|
| Rate for Payer: UHC Medicare Advantage |
$174.42
|
| Rate for Payer: VA VA |
$174.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$523.26
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$255.36
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.65 |
| Max. Negotiated Rate |
$229.82 |
| Rate for Payer: Aetna Commercial |
$217.06
|
| Rate for Payer: Aetna Medicare |
$66.39
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$79.80
|
| Rate for Payer: Amish Plain Church Group Commercial |
$79.80
|
| Rate for Payer: BCBS Complete |
$102.14
|
| Rate for Payer: BCBS MAPPO |
$63.84
|
| Rate for Payer: BCBS Trust/PPO |
$209.93
|
| Rate for Payer: BCN Commercial |
$198.54
|
| Rate for Payer: BCN Medicare Advantage |
$63.84
|
| Rate for Payer: Cash Price |
$204.29
|
| Rate for Payer: Cofinity Commercial |
$219.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$63.84
|
| Rate for Payer: Healthscope Commercial |
$229.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$67.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$73.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.06
|
| Rate for Payer: Nomi Health Commercial |
$209.40
|
| Rate for Payer: PACE Senior Care Partners |
$60.65
|
| Rate for Payer: PACE SWMI |
$63.84
|
| Rate for Payer: PHP Commercial |
$217.06
|
| Rate for Payer: PHP Medicare Advantage |
$63.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.98
|
| Rate for Payer: Priority Health HMO/PPO |
$222.16
|
| Rate for Payer: Priority Health Medicare |
$64.48
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$171.09
|
| Rate for Payer: Railroad Medicare Medicare |
$63.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$224.72
|
| Rate for Payer: UHC Core |
$213.23
|
| Rate for Payer: UHC Dual Complete DSNP |
$63.84
|
| Rate for Payer: UHC Exchange |
$63.84
|
| Rate for Payer: UHC Medicare Advantage |
$63.84
|
| Rate for Payer: VA VA |
$63.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.52
|
|
