|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$323.95
|
|
|
Service Code
|
NDC 00904695061
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.94 |
| 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 |
$129.58
|
| Rate for Payer: BCBS MAPPO |
$80.99
|
| Rate for Payer: BCBS Trust/PPO |
$266.32
|
| Rate for Payer: BCN Commercial |
$251.87
|
| 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: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$85.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.36
|
| Rate for Payer: Nomi Health Commercial |
$265.64
|
| 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 Cigna Priority Health |
$210.57
|
| Rate for Payer: Priority Health HMO/PPO |
$281.84
|
| Rate for Payer: Priority Health Medicare |
$81.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$217.05
|
| 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 Dual Complete DSNP |
$80.99
|
| Rate for Payer: UHC Exchange |
$80.99
|
| Rate for Payer: UHC Medicare Advantage |
$80.99
|
| Rate for Payer: VA VA |
$80.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$242.96
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$344.85
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.90 |
| Max. Negotiated Rate |
$310.37 |
| 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 |
$310.37
|
| 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 75 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074518211
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$503.57 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: BCBS Trust/PPO |
$632.40
|
| Rate for Payer: BCN Commercial |
$598.70
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$697.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$581.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: Nomi Health Commercial |
$635.27
|
| Rate for Payer: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: Priority Health HMO/PPO |
$674.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$519.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$681.75
|
| Rate for Payer: UHC Core |
$646.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.04
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$774.72
|
|
|
Service Code
|
NDC 00074518211
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$184.00 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna Medicare |
$201.43
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$242.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$242.10
|
| Rate for Payer: BCBS Complete |
$309.89
|
| Rate for Payer: BCBS MAPPO |
$193.68
|
| Rate for Payer: BCBS Trust/PPO |
$636.90
|
| Rate for Payer: BCN Commercial |
$602.34
|
| Rate for Payer: BCN Medicare Advantage |
$193.68
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$193.68
|
| Rate for Payer: Healthscope Commercial |
$697.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$581.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$203.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$222.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: Nomi Health Commercial |
$635.27
|
| Rate for Payer: PACE Senior Care Partners |
$184.00
|
| Rate for Payer: PACE SWMI |
$193.68
|
| Rate for Payer: PHP Commercial |
$658.51
|
| Rate for Payer: PHP Medicare Advantage |
$193.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: Priority Health HMO/PPO |
$674.01
|
| Rate for Payer: Priority Health Medicare |
$195.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$519.06
|
| Rate for Payer: Railroad Medicare Medicare |
$193.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$681.75
|
| Rate for Payer: UHC Core |
$646.89
|
| Rate for Payer: UHC Dual Complete DSNP |
$193.68
|
| Rate for Payer: UHC Exchange |
$193.68
|
| Rate for Payer: UHC Medicare Advantage |
$193.68
|
| Rate for Payer: VA VA |
$193.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.04
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$273.60
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.84 |
| Max. Negotiated Rate |
$246.24 |
| Rate for Payer: Aetna Commercial |
$232.56
|
| Rate for Payer: BCBS Trust/PPO |
$223.34
|
| Rate for Payer: BCN Commercial |
$211.44
|
| Rate for Payer: Cash Price |
$218.88
|
| Rate for Payer: Cofinity Commercial |
$235.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.88
|
| Rate for Payer: Healthscope Commercial |
$246.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.56
|
| Rate for Payer: Nomi Health Commercial |
$224.35
|
| Rate for Payer: PHP Commercial |
$232.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.84
|
| Rate for Payer: Priority Health HMO/PPO |
$238.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$183.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$240.77
|
| Rate for Payer: UHC Core |
$228.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.20
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: Aetna Medicare |
$0.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.86
|
| Rate for Payer: BCBS Complete |
$1.10
|
| Rate for Payer: BCBS MAPPO |
$0.69
|
| Rate for Payer: BCBS Trust/PPO |
$2.25
|
| Rate for Payer: BCN Commercial |
$2.13
|
| Rate for Payer: BCN Medicare Advantage |
$0.69
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.69
|
| Rate for Payer: Healthscope Commercial |
$2.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.33
|
| Rate for Payer: Nomi Health Commercial |
$2.25
|
| Rate for Payer: PACE Senior Care Partners |
$0.65
|
| Rate for Payer: PACE SWMI |
$0.69
|
| Rate for Payer: PHP Commercial |
$2.33
|
| Rate for Payer: PHP Medicare Advantage |
$0.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: Priority Health HMO/PPO |
$2.38
|
| Rate for Payer: Priority Health Medicare |
$0.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.84
|
| Rate for Payer: Railroad Medicare Medicare |
$0.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.41
|
| Rate for Payer: UHC Core |
$2.29
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.69
|
| Rate for Payer: UHC Exchange |
$0.69
|
| Rate for Payer: UHC Medicare Advantage |
$0.69
|
| Rate for Payer: VA VA |
$0.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.06
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$386.65
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$251.32 |
| Max. Negotiated Rate |
$347.99 |
| Rate for Payer: Aetna Commercial |
$328.65
|
| Rate for Payer: BCBS Trust/PPO |
$315.62
|
| Rate for Payer: BCN Commercial |
$298.80
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$332.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Healthscope Commercial |
$347.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: Nomi Health Commercial |
$317.05
|
| Rate for Payer: PHP Commercial |
$328.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: Priority Health HMO/PPO |
$336.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$259.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.25
|
| Rate for Payer: UHC Core |
$322.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.99
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$273.60
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.98 |
| Max. Negotiated Rate |
$246.24 |
| Rate for Payer: Aetna Commercial |
$232.56
|
| Rate for Payer: Aetna Medicare |
$71.14
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$85.50
|
| Rate for Payer: Amish Plain Church Group Commercial |
$85.50
|
| Rate for Payer: BCBS Complete |
$109.44
|
| Rate for Payer: BCBS MAPPO |
$68.40
|
| Rate for Payer: BCBS Trust/PPO |
$224.93
|
| Rate for Payer: BCN Commercial |
$212.72
|
| Rate for Payer: BCN Medicare Advantage |
$68.40
|
| Rate for Payer: Cash Price |
$218.88
|
| Rate for Payer: Cofinity Commercial |
$235.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$68.40
|
| Rate for Payer: Healthscope Commercial |
$246.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$71.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$78.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.56
|
| Rate for Payer: Nomi Health Commercial |
$224.35
|
| Rate for Payer: PACE Senior Care Partners |
$64.98
|
| Rate for Payer: PACE SWMI |
$68.40
|
| Rate for Payer: PHP Commercial |
$232.56
|
| Rate for Payer: PHP Medicare Advantage |
$68.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.84
|
| Rate for Payer: Priority Health HMO/PPO |
$238.03
|
| Rate for Payer: Priority Health Medicare |
$69.08
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$183.31
|
| Rate for Payer: Railroad Medicare Medicare |
$68.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$240.77
|
| Rate for Payer: UHC Core |
$228.46
|
| Rate for Payer: UHC Dual Complete DSNP |
$68.40
|
| Rate for Payer: UHC Exchange |
$68.40
|
| Rate for Payer: UHC Medicare Advantage |
$68.40
|
| Rate for Payer: VA VA |
$68.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.20
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$386.65
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.83 |
| Max. Negotiated Rate |
$347.99 |
| Rate for Payer: Aetna Commercial |
$328.65
|
| Rate for Payer: Aetna Medicare |
$100.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$120.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$120.83
|
| Rate for Payer: BCBS Complete |
$154.66
|
| Rate for Payer: BCBS MAPPO |
$96.66
|
| Rate for Payer: BCBS Trust/PPO |
$317.86
|
| Rate for Payer: BCN Commercial |
$300.62
|
| Rate for Payer: BCN Medicare Advantage |
$96.66
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$332.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$96.66
|
| Rate for Payer: Healthscope Commercial |
$347.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.99
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$101.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$111.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: Nomi Health Commercial |
$317.05
|
| Rate for Payer: PACE Senior Care Partners |
$91.83
|
| Rate for Payer: PACE SWMI |
$96.66
|
| Rate for Payer: PHP Commercial |
$328.65
|
| Rate for Payer: PHP Medicare Advantage |
$96.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: Priority Health HMO/PPO |
$336.39
|
| Rate for Payer: Priority Health Medicare |
$97.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$259.06
|
| Rate for Payer: Railroad Medicare Medicare |
$96.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.25
|
| Rate for Payer: UHC Core |
$322.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$96.66
|
| Rate for Payer: UHC Exchange |
$96.66
|
| Rate for Payer: UHC Medicare Advantage |
$96.66
|
| Rate for Payer: VA VA |
$96.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.99
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$2.74
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: BCBS Trust/PPO |
$2.24
|
| Rate for Payer: BCN Commercial |
$2.12
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$2.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.33
|
| Rate for Payer: Nomi Health Commercial |
$2.25
|
| Rate for Payer: PHP Commercial |
$2.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: Priority Health HMO/PPO |
$2.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.41
|
| Rate for Payer: UHC Core |
$2.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.06
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$4.18
|
|
|
Service Code
|
NDC 60687048611
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$3.76 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Aetna Medicare |
$1.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.31
|
| Rate for Payer: BCBS Complete |
$1.67
|
| Rate for Payer: BCBS MAPPO |
$1.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.44
|
| Rate for Payer: BCN Commercial |
$3.25
|
| Rate for Payer: BCN Medicare Advantage |
$1.04
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cofinity Commercial |
$3.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.04
|
| Rate for Payer: Healthscope Commercial |
$3.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.13
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.55
|
| Rate for Payer: Nomi Health Commercial |
$3.43
|
| Rate for Payer: PACE Senior Care Partners |
$0.99
|
| Rate for Payer: PACE SWMI |
$1.04
|
| Rate for Payer: PHP Commercial |
$3.55
|
| Rate for Payer: PHP Medicare Advantage |
$1.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health HMO/PPO |
$3.64
|
| Rate for Payer: Priority Health Medicare |
$1.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.80
|
| Rate for Payer: Railroad Medicare Medicare |
$1.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.68
|
| Rate for Payer: UHC Core |
$3.49
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.04
|
| Rate for Payer: UHC Exchange |
$1.04
|
| Rate for Payer: UHC Medicare Advantage |
$1.04
|
| Rate for Payer: VA VA |
$1.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.13
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$4.18
|
|
|
Service Code
|
NDC 60687048611
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.72 |
| Max. Negotiated Rate |
$3.76 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: BCBS Trust/PPO |
$3.41
|
| Rate for Payer: BCN Commercial |
$3.23
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cofinity Commercial |
$3.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.34
|
| Rate for Payer: Healthscope Commercial |
$3.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.55
|
| Rate for Payer: Nomi Health Commercial |
$3.43
|
| Rate for Payer: PHP Commercial |
$3.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health HMO/PPO |
$3.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.68
|
| Rate for Payer: UHC Core |
$3.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.13
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$418.00
|
|
|
Service Code
|
NDC 60687048601
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.28 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna Commercial |
$355.30
|
| Rate for Payer: Aetna Medicare |
$108.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$130.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$130.62
|
| Rate for Payer: BCBS Complete |
$167.20
|
| Rate for Payer: BCBS MAPPO |
$104.50
|
| Rate for Payer: BCBS Trust/PPO |
$343.64
|
| Rate for Payer: BCN Commercial |
$325.00
|
| Rate for Payer: BCN Medicare Advantage |
$104.50
|
| Rate for Payer: Cash Price |
$334.40
|
| Rate for Payer: Cofinity Commercial |
$359.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$104.50
|
| Rate for Payer: Healthscope Commercial |
$376.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$109.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$120.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.30
|
| Rate for Payer: Nomi Health Commercial |
$342.76
|
| Rate for Payer: PACE Senior Care Partners |
$99.28
|
| Rate for Payer: PACE SWMI |
$104.50
|
| Rate for Payer: PHP Commercial |
$355.30
|
| Rate for Payer: PHP Medicare Advantage |
$104.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.70
|
| Rate for Payer: Priority Health HMO/PPO |
$363.66
|
| Rate for Payer: Priority Health Medicare |
$105.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$280.06
|
| Rate for Payer: Railroad Medicare Medicare |
$104.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$367.84
|
| Rate for Payer: UHC Core |
$349.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$104.50
|
| Rate for Payer: UHC Exchange |
$104.50
|
| Rate for Payer: UHC Medicare Advantage |
$104.50
|
| Rate for Payer: VA VA |
$104.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.50
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$418.00
|
|
|
Service Code
|
NDC 60687048601
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.70 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna Commercial |
$355.30
|
| Rate for Payer: BCBS Trust/PPO |
$341.21
|
| Rate for Payer: BCN Commercial |
$323.03
|
| Rate for Payer: Cash Price |
$334.40
|
| Rate for Payer: Cofinity Commercial |
$359.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.40
|
| Rate for Payer: Healthscope Commercial |
$376.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.30
|
| Rate for Payer: Nomi Health Commercial |
$342.76
|
| Rate for Payer: PHP Commercial |
$355.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.70
|
| Rate for Payer: Priority Health HMO/PPO |
$363.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$280.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$367.84
|
| Rate for Payer: UHC Core |
$349.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.50
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$697.68
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
10403
|
|
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 88 MCG TABLET
|
Facility
|
IP
|
$697.68
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
10403
|
|
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 88 MCG TABLET
|
Facility
|
IP
|
$250.56
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.86 |
| Max. Negotiated Rate |
$225.50 |
| Rate for Payer: Aetna Commercial |
$212.98
|
| Rate for Payer: BCBS Trust/PPO |
$204.53
|
| Rate for Payer: BCN Commercial |
$193.63
|
| Rate for Payer: Cash Price |
$200.45
|
| Rate for Payer: Cofinity Commercial |
$215.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.45
|
| Rate for Payer: Healthscope Commercial |
$225.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.98
|
| Rate for Payer: Nomi Health Commercial |
$205.46
|
| Rate for Payer: PHP Commercial |
$212.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.86
|
| Rate for Payer: Priority Health HMO/PPO |
$217.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$167.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$220.49
|
| Rate for Payer: UHC Core |
$209.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.92
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$2.51
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna Commercial |
$2.13
|
| Rate for Payer: BCBS Trust/PPO |
$2.05
|
| Rate for Payer: BCN Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cofinity Commercial |
$2.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.01
|
| Rate for Payer: Healthscope Commercial |
$2.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.13
|
| Rate for Payer: Nomi Health Commercial |
$2.06
|
| Rate for Payer: PHP Commercial |
$2.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.63
|
| Rate for Payer: Priority Health HMO/PPO |
$2.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.21
|
| Rate for Payer: UHC Core |
$2.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.88
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$386.65
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.83 |
| Max. Negotiated Rate |
$347.99 |
| Rate for Payer: Aetna Commercial |
$328.65
|
| Rate for Payer: Aetna Medicare |
$100.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$120.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$120.83
|
| Rate for Payer: BCBS Complete |
$154.66
|
| Rate for Payer: BCBS MAPPO |
$96.66
|
| Rate for Payer: BCBS Trust/PPO |
$317.86
|
| Rate for Payer: BCN Commercial |
$300.62
|
| Rate for Payer: BCN Medicare Advantage |
$96.66
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$332.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$96.66
|
| Rate for Payer: Healthscope Commercial |
$347.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.99
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$101.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$111.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: Nomi Health Commercial |
$317.05
|
| Rate for Payer: PACE Senior Care Partners |
$91.83
|
| Rate for Payer: PACE SWMI |
$96.66
|
| Rate for Payer: PHP Commercial |
$328.65
|
| Rate for Payer: PHP Medicare Advantage |
$96.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: Priority Health HMO/PPO |
$336.39
|
| Rate for Payer: Priority Health Medicare |
$97.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$259.06
|
| Rate for Payer: Railroad Medicare Medicare |
$96.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.25
|
| Rate for Payer: UHC Core |
$322.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$96.66
|
| Rate for Payer: UHC Exchange |
$96.66
|
| Rate for Payer: UHC Medicare Advantage |
$96.66
|
| Rate for Payer: VA VA |
$96.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.99
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$386.65
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$251.32 |
| Max. Negotiated Rate |
$347.99 |
| Rate for Payer: Aetna Commercial |
$328.65
|
| Rate for Payer: BCBS Trust/PPO |
$315.62
|
| Rate for Payer: BCN Commercial |
$298.80
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$332.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Healthscope Commercial |
$347.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: Nomi Health Commercial |
$317.05
|
| Rate for Payer: PHP Commercial |
$328.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: Priority Health HMO/PPO |
$336.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$259.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.25
|
| Rate for Payer: UHC Core |
$322.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.99
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$250.56
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$225.50 |
| Rate for Payer: Aetna Commercial |
$212.98
|
| Rate for Payer: Aetna Medicare |
$65.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$78.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$78.30
|
| Rate for Payer: BCBS Complete |
$100.22
|
| Rate for Payer: BCBS MAPPO |
$62.64
|
| Rate for Payer: BCBS Trust/PPO |
$205.99
|
| Rate for Payer: BCN Commercial |
$194.81
|
| Rate for Payer: BCN Medicare Advantage |
$62.64
|
| Rate for Payer: Cash Price |
$200.45
|
| Rate for Payer: Cofinity Commercial |
$215.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$62.64
|
| Rate for Payer: Healthscope Commercial |
$225.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$65.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$72.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.98
|
| Rate for Payer: Nomi Health Commercial |
$205.46
|
| Rate for Payer: PACE Senior Care Partners |
$59.51
|
| Rate for Payer: PACE SWMI |
$62.64
|
| Rate for Payer: PHP Commercial |
$212.98
|
| Rate for Payer: PHP Medicare Advantage |
$62.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.86
|
| Rate for Payer: Priority Health HMO/PPO |
$217.99
|
| Rate for Payer: Priority Health Medicare |
$63.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$167.88
|
| Rate for Payer: Railroad Medicare Medicare |
$62.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$220.49
|
| Rate for Payer: UHC Core |
$209.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$62.64
|
| Rate for Payer: UHC Exchange |
$62.64
|
| Rate for Payer: UHC Medicare Advantage |
$62.64
|
| Rate for Payer: VA VA |
$62.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.92
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$2.51
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.60 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna Commercial |
$2.13
|
| Rate for Payer: Aetna Medicare |
$0.65
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.78
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.78
|
| Rate for Payer: BCBS Complete |
$1.00
|
| Rate for Payer: BCBS MAPPO |
$0.63
|
| Rate for Payer: BCBS Trust/PPO |
$2.06
|
| Rate for Payer: BCN Commercial |
$1.95
|
| Rate for Payer: BCN Medicare Advantage |
$0.63
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cofinity Commercial |
$2.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.01
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.63
|
| Rate for Payer: Healthscope Commercial |
$2.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.88
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.13
|
| Rate for Payer: Nomi Health Commercial |
$2.06
|
| Rate for Payer: PACE Senior Care Partners |
$0.60
|
| Rate for Payer: PACE SWMI |
$0.63
|
| Rate for Payer: PHP Commercial |
$2.13
|
| Rate for Payer: PHP Medicare Advantage |
$0.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.63
|
| Rate for Payer: Priority Health HMO/PPO |
$2.18
|
| Rate for Payer: Priority Health Medicare |
$0.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.68
|
| Rate for Payer: Railroad Medicare Medicare |
$0.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.21
|
| Rate for Payer: UHC Core |
$2.10
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.63
|
| Rate for Payer: UHC Exchange |
$0.63
|
| Rate for Payer: UHC Medicare Advantage |
$0.63
|
| Rate for Payer: VA VA |
$0.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.88
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$17.40
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: BCBS Trust/PPO |
$14.20
|
| Rate for Payer: BCBS Trust/PPO |
$15.70
|
| Rate for Payer: BCN Commercial |
$13.45
|
| Rate for Payer: BCN Commercial |
$14.86
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cofinity Commercial |
$16.54
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.92
|
| Rate for Payer: Healthscope Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$17.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.35
|
| Rate for Payer: Nomi Health Commercial |
$14.27
|
| Rate for Payer: Nomi Health Commercial |
$15.77
|
| Rate for Payer: PHP Commercial |
$14.79
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.31
|
| Rate for Payer: Priority Health HMO/PPO |
$16.73
|
| Rate for Payer: Priority Health HMO/PPO |
$15.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.92
|
| Rate for Payer: UHC Core |
$14.53
|
| Rate for Payer: UHC Core |
$16.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.42
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
OP
|
$19.23
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.57 |
| Max. Negotiated Rate |
$17.31 |
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Aetna Medicare |
$5.00
|
| Rate for Payer: Aetna Medicare |
$4.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.44
|
| Rate for Payer: BCBS Complete |
$6.96
|
| Rate for Payer: BCBS Complete |
$7.69
|
| Rate for Payer: BCBS MAPPO |
$4.35
|
| Rate for Payer: BCBS MAPPO |
$4.81
|
| Rate for Payer: BCBS Trust/PPO |
$15.81
|
| Rate for Payer: BCBS Trust/PPO |
$14.30
|
| Rate for Payer: BCN Commercial |
$14.95
|
| Rate for Payer: BCN Commercial |
$13.53
|
| Rate for Payer: BCN Medicare Advantage |
$4.81
|
| Rate for Payer: BCN Medicare Advantage |
$4.35
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Cofinity Commercial |
$16.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.81
|
| Rate for Payer: Healthscope Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$17.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.79
|
| Rate for Payer: Nomi Health Commercial |
$15.77
|
| Rate for Payer: Nomi Health Commercial |
$14.27
|
| Rate for Payer: PACE Senior Care Partners |
$4.57
|
| Rate for Payer: PACE Senior Care Partners |
$4.13
|
| Rate for Payer: PACE SWMI |
$4.81
|
| Rate for Payer: PACE SWMI |
$4.35
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: PHP Commercial |
$14.79
|
| Rate for Payer: PHP Medicare Advantage |
$4.35
|
| Rate for Payer: PHP Medicare Advantage |
$4.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.31
|
| Rate for Payer: Priority Health HMO/PPO |
$15.14
|
| Rate for Payer: Priority Health HMO/PPO |
$16.73
|
| Rate for Payer: Priority Health Medicare |
$4.86
|
| Rate for Payer: Priority Health Medicare |
$4.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.66
|
| Rate for Payer: Railroad Medicare Medicare |
$4.35
|
| Rate for Payer: Railroad Medicare Medicare |
$4.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.92
|
| Rate for Payer: UHC Core |
$16.06
|
| Rate for Payer: UHC Core |
$14.53
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.35
|
| Rate for Payer: UHC Exchange |
$4.35
|
| Rate for Payer: UHC Exchange |
$4.81
|
| Rate for Payer: UHC Medicare Advantage |
$4.35
|
| Rate for Payer: UHC Medicare Advantage |
$4.81
|
| Rate for Payer: VA VA |
$4.35
|
| Rate for Payer: VA VA |
$4.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.05
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$19.50
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.68 |
| Max. Negotiated Rate |
$17.55 |
| Rate for Payer: Aetna Commercial |
$16.57
|
| Rate for Payer: Aetna Commercial |
$19.23
|
| Rate for Payer: BCBS Trust/PPO |
$15.92
|
| Rate for Payer: BCBS Trust/PPO |
$18.46
|
| Rate for Payer: BCN Commercial |
$15.07
|
| Rate for Payer: BCN Commercial |
$17.48
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cofinity Commercial |
$19.45
|
| Rate for Payer: Cofinity Commercial |
$16.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.60
|
| Rate for Payer: Healthscope Commercial |
$17.55
|
| Rate for Payer: Healthscope Commercial |
$20.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.23
|
| Rate for Payer: Nomi Health Commercial |
$15.99
|
| Rate for Payer: Nomi Health Commercial |
$18.55
|
| Rate for Payer: PHP Commercial |
$16.57
|
| Rate for Payer: PHP Commercial |
$19.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.68
|
| Rate for Payer: Priority Health HMO/PPO |
$19.68
|
| Rate for Payer: Priority Health HMO/PPO |
$16.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.91
|
| Rate for Payer: UHC Core |
$16.28
|
| Rate for Payer: UHC Core |
$18.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.96
|
|
