|
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 |
$419.80 |
| 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 |
$419.80
|
| 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
|
$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
|
$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
|
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 |
$599.64
|
| 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 |
$571.74
|
| 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 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 |
$419.80 |
| 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 |
$419.80
|
| 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 |
$419.80 |
| 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 |
$419.80
|
| 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
|
OP
|
$2.56
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$2.30 |
| 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 |
$1.02
|
| Rate for Payer: BCBS MAPPO |
$0.64
|
| Rate for Payer: BCBS Trust/PPO |
$2.10
|
| Rate for Payer: BCN Commercial |
$1.99
|
| Rate for Payer: BCN Medicare Advantage |
$0.64
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.64
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: Nomi Health Commercial |
$2.10
|
| 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 Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health HMO/PPO |
$2.23
|
| Rate for Payer: Priority Health Medicare |
$0.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.72
|
| Rate for Payer: Railroad Medicare Medicare |
$0.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.25
|
| Rate for Payer: UHC Core |
$2.14
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.64
|
| Rate for Payer: UHC Exchange |
$0.64
|
| Rate for Payer: UHC Medicare Advantage |
$0.64
|
| Rate for Payer: VA VA |
$0.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.92
|
|
|
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 |
$218.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$218.02
|
| 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
|
IP
|
$255.36
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.98 |
| Max. Negotiated Rate |
$229.82 |
| Rate for Payer: Aetna Commercial |
$217.06
|
| Rate for Payer: BCBS Trust/PPO |
$208.45
|
| Rate for Payer: BCN Commercial |
$197.34
|
| 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: Healthscope Commercial |
$229.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.06
|
| Rate for Payer: Nomi Health Commercial |
$209.40
|
| Rate for Payer: PHP Commercial |
$217.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.98
|
| Rate for Payer: Priority Health HMO/PPO |
$222.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$171.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$224.72
|
| Rate for Payer: UHC Core |
$213.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.52
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$2.56
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.66 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: BCBS Trust/PPO |
$2.09
|
| Rate for Payer: BCN Commercial |
$1.98
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.05
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: Nomi Health Commercial |
$2.10
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health HMO/PPO |
$2.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.25
|
| Rate for Payer: UHC Core |
$2.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.92
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$3.02
|
|
|
Service Code
|
NDC 42292004101
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.72 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Aetna Commercial |
$2.57
|
| Rate for Payer: Aetna Medicare |
$0.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.94
|
| Rate for Payer: BCBS Complete |
$1.21
|
| Rate for Payer: BCBS MAPPO |
$0.76
|
| Rate for Payer: BCBS Trust/PPO |
$2.48
|
| Rate for Payer: BCN Commercial |
$2.35
|
| Rate for Payer: BCN Medicare Advantage |
$0.76
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cofinity Commercial |
$2.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.42
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.76
|
| Rate for Payer: Healthscope Commercial |
$2.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.26
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.79
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.57
|
| Rate for Payer: Nomi Health Commercial |
$2.48
|
| Rate for Payer: PACE Senior Care Partners |
$0.72
|
| Rate for Payer: PACE SWMI |
$0.76
|
| Rate for Payer: PHP Commercial |
$2.57
|
| Rate for Payer: PHP Medicare Advantage |
$0.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.96
|
| Rate for Payer: Priority Health HMO/PPO |
$2.63
|
| Rate for Payer: Priority Health Medicare |
$0.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.02
|
| Rate for Payer: Railroad Medicare Medicare |
$0.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.66
|
| Rate for Payer: UHC Core |
$2.52
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.76
|
| Rate for Payer: UHC Exchange |
$0.76
|
| Rate for Payer: UHC Medicare Advantage |
$0.76
|
| Rate for Payer: VA VA |
$0.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.26
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$3.02
|
|
|
Service Code
|
NDC 42292004101
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$2.72 |
| Rate for Payer: Aetna Commercial |
$2.57
|
| Rate for Payer: BCBS Trust/PPO |
$2.47
|
| Rate for Payer: BCN Commercial |
$2.33
|
| Rate for Payer: Cash Price |
$2.42
|
| Rate for Payer: Cofinity Commercial |
$2.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.42
|
| Rate for Payer: Healthscope Commercial |
$2.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.57
|
| Rate for Payer: Nomi Health Commercial |
$2.48
|
| Rate for Payer: PHP Commercial |
$2.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.96
|
| Rate for Payer: Priority Health HMO/PPO |
$2.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.66
|
| Rate for Payer: UHC Core |
$2.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.26
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$697.68
|
|
|
Service Code
|
NDC 00074372790
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$453.49 |
| Max. Negotiated Rate |
$627.91 |
| Rate for Payer: Aetna Commercial |
$593.03
|
| Rate for Payer: BCBS Trust/PPO |
$569.52
|
| Rate for Payer: BCN Commercial |
$539.17
|
| 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: Healthscope Commercial |
$627.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$523.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$593.03
|
| Rate for Payer: Nomi Health Commercial |
$572.10
|
| Rate for Payer: PHP Commercial |
$593.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.49
|
| Rate for Payer: Priority Health HMO/PPO |
$606.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$467.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$613.96
|
| Rate for Payer: UHC Core |
$582.56
|
| 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
|
|
|
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
|
$301.44
|
|
|
Service Code
|
NDC 42292004120
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.59 |
| Max. Negotiated Rate |
$271.30 |
| Rate for Payer: Aetna Commercial |
$256.22
|
| Rate for Payer: Aetna Medicare |
$78.37
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$94.20
|
| Rate for Payer: Amish Plain Church Group Commercial |
$94.20
|
| Rate for Payer: BCBS Complete |
$120.58
|
| Rate for Payer: BCBS MAPPO |
$75.36
|
| Rate for Payer: BCBS Trust/PPO |
$247.81
|
| Rate for Payer: BCN Commercial |
$234.37
|
| Rate for Payer: BCN Medicare Advantage |
$75.36
|
| 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: Health Alliance Plan Medicare Advantage |
$75.36
|
| Rate for Payer: Healthscope Commercial |
$271.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$226.08
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$79.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$86.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$256.22
|
| Rate for Payer: Nomi Health Commercial |
$247.18
|
| Rate for Payer: PACE Senior Care Partners |
$71.59
|
| Rate for Payer: PACE SWMI |
$75.36
|
| Rate for Payer: PHP Commercial |
$256.22
|
| Rate for Payer: PHP Medicare Advantage |
$75.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.94
|
| Rate for Payer: Priority Health HMO/PPO |
$262.25
|
| Rate for Payer: Priority Health Medicare |
$76.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$201.96
|
| Rate for Payer: Railroad Medicare Medicare |
$75.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$265.27
|
| Rate for Payer: UHC Core |
$251.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$75.36
|
| Rate for Payer: UHC Exchange |
$75.36
|
| Rate for Payer: UHC Medicare Advantage |
$75.36
|
| Rate for Payer: VA VA |
$75.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$226.08
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$248.16
|
|
|
Service Code
|
NDC 00904695661
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.94 |
| Max. Negotiated Rate |
$223.34 |
| Rate for Payer: Aetna Commercial |
$210.94
|
| Rate for Payer: Aetna Medicare |
$64.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$77.55
|
| Rate for Payer: Amish Plain Church Group Commercial |
$77.55
|
| Rate for Payer: BCBS Complete |
$99.26
|
| Rate for Payer: BCBS MAPPO |
$62.04
|
| Rate for Payer: BCBS Trust/PPO |
$204.01
|
| Rate for Payer: BCN Commercial |
$192.94
|
| Rate for Payer: BCN Medicare Advantage |
$62.04
|
| Rate for Payer: Cash Price |
$198.53
|
| Rate for Payer: Cofinity Commercial |
$213.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$198.53
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$223.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$65.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$71.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.94
|
| Rate for Payer: Nomi Health Commercial |
$203.49
|
| Rate for Payer: PACE Senior Care Partners |
$58.94
|
| Rate for Payer: PACE SWMI |
$62.04
|
| Rate for Payer: PHP Commercial |
$210.94
|
| Rate for Payer: PHP Medicare Advantage |
$62.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.30
|
| Rate for Payer: Priority Health HMO/PPO |
$215.90
|
| Rate for Payer: Priority Health Medicare |
$62.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$166.27
|
| Rate for Payer: Railroad Medicare Medicare |
$62.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$218.38
|
| Rate for Payer: UHC Core |
$207.21
|
| Rate for Payer: UHC Dual Complete DSNP |
$62.04
|
| Rate for Payer: UHC Exchange |
$62.04
|
| Rate for Payer: UHC Medicare Advantage |
$62.04
|
| Rate for Payer: VA VA |
$62.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.12
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 51079044501
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna Commercial |
$2.89
|
| Rate for Payer: BCBS Trust/PPO |
$2.78
|
| Rate for Payer: BCN Commercial |
$2.63
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.72
|
| Rate for Payer: Healthscope Commercial |
$3.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.89
|
| Rate for Payer: Nomi Health Commercial |
$2.79
|
| Rate for Payer: PHP Commercial |
$2.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: Priority Health HMO/PPO |
$2.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.99
|
| Rate for Payer: UHC Core |
$2.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.55
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$248.16
|
|
|
Service Code
|
NDC 00904695661
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$161.30 |
| Max. Negotiated Rate |
$223.34 |
| Rate for Payer: Aetna Commercial |
$210.94
|
| Rate for Payer: BCBS Trust/PPO |
$202.57
|
| Rate for Payer: BCN Commercial |
$191.78
|
| Rate for Payer: Cash Price |
$198.53
|
| Rate for Payer: Cofinity Commercial |
$213.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$198.53
|
| Rate for Payer: Healthscope Commercial |
$223.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$186.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.94
|
| Rate for Payer: Nomi Health Commercial |
$203.49
|
| Rate for Payer: PHP Commercial |
$210.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.30
|
| Rate for Payer: Priority Health HMO/PPO |
$215.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$166.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$218.38
|
| Rate for Payer: UHC Core |
$207.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$186.12
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$3.40
|
|
|
Service Code
|
NDC 51079044501
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna Commercial |
$2.89
|
| Rate for Payer: Aetna Medicare |
$0.88
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.06
|
| Rate for Payer: BCBS Complete |
$1.36
|
| Rate for Payer: BCBS MAPPO |
$0.85
|
| Rate for Payer: BCBS Trust/PPO |
$2.80
|
| Rate for Payer: BCN Commercial |
$2.64
|
| Rate for Payer: BCN Medicare Advantage |
$0.85
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.72
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.85
|
| Rate for Payer: Healthscope Commercial |
$3.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.55
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.89
|
| Rate for Payer: Nomi Health Commercial |
$2.79
|
| Rate for Payer: PACE Senior Care Partners |
$0.81
|
| Rate for Payer: PACE SWMI |
$0.85
|
| Rate for Payer: PHP Commercial |
$2.89
|
| Rate for Payer: PHP Medicare Advantage |
$0.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: Priority Health HMO/PPO |
$2.96
|
| Rate for Payer: Priority Health Medicare |
$0.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.28
|
| Rate for Payer: Railroad Medicare Medicare |
$0.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.99
|
| Rate for Payer: UHC Core |
$2.84
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.85
|
| Rate for Payer: UHC Exchange |
$0.85
|
| Rate for Payer: UHC Medicare Advantage |
$0.85
|
| Rate for Payer: VA VA |
$0.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.55
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$313.50
|
|
|
Service Code
|
NDC 00904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.46 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Aetna Commercial |
$266.48
|
| Rate for Payer: Aetna Medicare |
$81.51
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$97.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$97.97
|
| Rate for Payer: BCBS Complete |
$125.40
|
| Rate for Payer: BCBS MAPPO |
$78.38
|
| Rate for Payer: BCBS Trust/PPO |
$257.73
|
| Rate for Payer: BCN Commercial |
$243.75
|
| Rate for Payer: BCN Medicare Advantage |
$78.38
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cofinity Commercial |
$269.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.80
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$78.38
|
| Rate for Payer: Healthscope Commercial |
$282.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$82.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$90.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$266.48
|
| Rate for Payer: Nomi Health Commercial |
$257.07
|
| Rate for Payer: PACE Senior Care Partners |
$74.46
|
| Rate for Payer: PACE SWMI |
$78.38
|
| Rate for Payer: PHP Commercial |
$266.48
|
| Rate for Payer: PHP Medicare Advantage |
$78.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.78
|
| Rate for Payer: Priority Health HMO/PPO |
$272.74
|
| Rate for Payer: Priority Health Medicare |
$79.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$210.04
|
| Rate for Payer: Railroad Medicare Medicare |
$78.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$275.88
|
| Rate for Payer: UHC Core |
$261.77
|
| Rate for Payer: UHC Dual Complete DSNP |
$78.38
|
| Rate for Payer: UHC Exchange |
$78.38
|
| Rate for Payer: UHC Medicare Advantage |
$78.38
|
| Rate for Payer: VA VA |
$78.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.12
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$3.87 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: Aetna Medicare |
$1.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.34
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.34
|
| Rate for Payer: BCBS Complete |
$1.72
|
| Rate for Payer: BCBS MAPPO |
$1.08
|
| Rate for Payer: BCBS Trust/PPO |
$3.54
|
| Rate for Payer: BCN Commercial |
$3.34
|
| Rate for Payer: BCN Medicare Advantage |
$1.08
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cofinity Commercial |
$3.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.08
|
| Rate for Payer: Healthscope Commercial |
$3.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.22
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.66
|
| Rate for Payer: Nomi Health Commercial |
$3.53
|
| Rate for Payer: PACE Senior Care Partners |
$1.02
|
| Rate for Payer: PACE SWMI |
$1.08
|
| Rate for Payer: PHP Commercial |
$3.66
|
| Rate for Payer: PHP Medicare Advantage |
$1.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.80
|
| Rate for Payer: Priority Health HMO/PPO |
$3.74
|
| Rate for Payer: Priority Health Medicare |
$1.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.88
|
| Rate for Payer: Railroad Medicare Medicare |
$1.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.78
|
| Rate for Payer: UHC Core |
$3.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.08
|
| Rate for Payer: UHC Exchange |
$1.08
|
| Rate for Payer: UHC Medicare Advantage |
$1.08
|
| Rate for Payer: VA VA |
$1.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.22
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$344.85
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$310.36 |
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna Medicare |
$89.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$107.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$107.77
|
| Rate for Payer: BCBS Complete |
$137.94
|
| Rate for Payer: BCBS MAPPO |
$86.21
|
| Rate for Payer: BCBS Trust/PPO |
$283.50
|
| Rate for Payer: BCN Commercial |
$268.12
|
| Rate for Payer: BCN Medicare Advantage |
$86.21
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$86.21
|
| Rate for Payer: Healthscope Commercial |
$310.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$90.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$99.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: Nomi Health Commercial |
$282.78
|
| Rate for Payer: PACE Senior Care Partners |
$81.90
|
| Rate for Payer: PACE SWMI |
$86.21
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: PHP Medicare Advantage |
$86.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.15
|
| Rate for Payer: Priority Health HMO/PPO |
$300.02
|
| Rate for Payer: Priority Health Medicare |
$87.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$231.05
|
| Rate for Payer: Railroad Medicare Medicare |
$86.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$303.47
|
| Rate for Payer: UHC Core |
$287.95
|
| Rate for Payer: UHC Dual Complete DSNP |
$86.21
|
| Rate for Payer: UHC Exchange |
$86.21
|
| Rate for Payer: UHC Medicare Advantage |
$86.21
|
| Rate for Payer: VA VA |
$86.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$3.45
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Aetna Commercial |
$2.93
|
| Rate for Payer: BCBS Trust/PPO |
$2.82
|
| Rate for Payer: BCN Commercial |
$2.67
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$2.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.76
|
| Rate for Payer: Healthscope Commercial |
$3.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.93
|
| Rate for Payer: Nomi Health Commercial |
$2.83
|
| Rate for Payer: PHP Commercial |
$2.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.24
|
| Rate for Payer: Priority Health HMO/PPO |
$3.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.04
|
| Rate for Payer: UHC Core |
$2.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.59
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$4.30
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.80 |
| Max. Negotiated Rate |
$3.87 |
| Rate for Payer: Aetna Commercial |
$3.66
|
| Rate for Payer: BCBS Trust/PPO |
$3.51
|
| Rate for Payer: BCN Commercial |
$3.32
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cofinity Commercial |
$3.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.44
|
| Rate for Payer: Healthscope Commercial |
$3.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.66
|
| Rate for Payer: Nomi Health Commercial |
$3.53
|
| Rate for Payer: PHP Commercial |
$3.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.80
|
| Rate for Payer: Priority Health HMO/PPO |
$3.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.78
|
| Rate for Payer: UHC Core |
$3.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.22
|
|
