|
LEVOFLOXACIN 250 MG/10 ML ORAL SOLUTION
|
Facility
|
IP
|
$1,209.60
|
|
|
Service Code
|
NDC 0527-1948-68
|
| Hospital Charge Code |
39970
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$532.22 |
| Max. Negotiated Rate |
$1,088.64 |
| Rate for Payer: Aetna American Axle |
$786.24
|
| Rate for Payer: Aetna Commercial |
$1,028.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$786.24
|
| Rate for Payer: Cash Price |
$967.68
|
| Rate for Payer: Cofinity Commercial |
$1,040.26
|
| Rate for Payer: Cofinity Commercial |
$846.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$967.68
|
| Rate for Payer: Healthscope Commercial |
$1,088.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$846.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$907.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,028.16
|
| Rate for Payer: PHP Commercial |
$1,028.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$846.72
|
| Rate for Payer: Priority Health SBD |
$762.05
|
| Rate for Payer: UMR Bronson Commercial |
$532.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$907.20
|
|
|
LEVOFLOXACIN 250 MG/50 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$73.42
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112929
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$66.08 |
| Rate for Payer: Aetna American Axle |
$47.72
|
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cofinity Commercial |
$51.39
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.39
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.41
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.39
|
| Rate for Payer: Priority Health SBD |
$46.25
|
| Rate for Payer: UMR Bronson Commercial |
$32.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.06
|
|
|
LEVOFLOXACIN 250 MG TABLET
|
Facility
|
IP
|
$411.25
|
|
|
Service Code
|
NDC 0904-6351-61
|
| Hospital Charge Code |
18918
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.95 |
| Max. Negotiated Rate |
$370.12 |
| Rate for Payer: Aetna American Axle |
$267.31
|
| Rate for Payer: Aetna Commercial |
$349.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$267.31
|
| Rate for Payer: Cash Price |
$329.00
|
| Rate for Payer: Cofinity Commercial |
$287.88
|
| Rate for Payer: Cofinity Commercial |
$353.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$329.00
|
| Rate for Payer: Healthscope Commercial |
$370.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$287.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$308.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$349.56
|
| Rate for Payer: PHP Commercial |
$349.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.88
|
| Rate for Payer: Priority Health SBD |
$259.09
|
| Rate for Payer: UMR Bronson Commercial |
$180.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$308.44
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$80.41
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$72.37 |
| Rate for Payer: Aetna American Axle |
$52.27
|
| Rate for Payer: Aetna Commercial |
$68.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.27
|
| Rate for Payer: BCBS Complete |
$32.16
|
| Rate for Payer: BCBS Trust/PPO |
$2.92
|
| Rate for Payer: Cash Price |
$64.33
|
| Rate for Payer: Cash Price |
$64.33
|
| Rate for Payer: Cofinity Commercial |
$56.29
|
| Rate for Payer: Cofinity Commercial |
$69.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.33
|
| Rate for Payer: Healthscope Commercial |
$72.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.35
|
| Rate for Payer: PHP Commercial |
$68.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.29
|
| Rate for Payer: Priority Health SBD |
$50.66
|
| Rate for Payer: UMR Bronson Commercial |
$29.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.31
|
|
|
LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$73.42
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
18924
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$32.30 |
| Max. Negotiated Rate |
$66.08 |
| Rate for Payer: Aetna American Axle |
$47.72
|
| Rate for Payer: Aetna American Axle |
$52.27
|
| Rate for Payer: Aetna Commercial |
$62.41
|
| Rate for Payer: Aetna Commercial |
$68.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.72
|
| Rate for Payer: Cash Price |
$64.33
|
| Rate for Payer: Cash Price |
$58.74
|
| Rate for Payer: Cofinity Commercial |
$56.29
|
| Rate for Payer: Cofinity Commercial |
$69.15
|
| Rate for Payer: Cofinity Commercial |
$63.14
|
| Rate for Payer: Cofinity Commercial |
$51.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.74
|
| Rate for Payer: Healthscope Commercial |
$72.37
|
| Rate for Payer: Healthscope Commercial |
$66.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.06
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.41
|
| Rate for Payer: PHP Commercial |
$68.35
|
| Rate for Payer: PHP Commercial |
$62.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.39
|
| Rate for Payer: Priority Health SBD |
$50.66
|
| Rate for Payer: Priority Health SBD |
$46.25
|
| Rate for Payer: UMR Bronson Commercial |
$35.38
|
| Rate for Payer: UMR Bronson Commercial |
$32.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.31
|
|
|
LEVOFLOXACIN 500 MG TABLET
|
Facility
|
IP
|
$213.75
|
|
|
Service Code
|
NDC 0904-6352-61
|
| Hospital Charge Code |
18919
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.05 |
| Max. Negotiated Rate |
$192.38 |
| Rate for Payer: Aetna American Axle |
$138.94
|
| Rate for Payer: Aetna Commercial |
$181.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.94
|
| Rate for Payer: Cash Price |
$171.00
|
| Rate for Payer: Cofinity Commercial |
$149.62
|
| Rate for Payer: Cofinity Commercial |
$183.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$171.00
|
| Rate for Payer: Healthscope Commercial |
$192.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$149.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$160.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$181.69
|
| Rate for Payer: PHP Commercial |
$181.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.62
|
| Rate for Payer: Priority Health SBD |
$134.66
|
| Rate for Payer: UMR Bronson Commercial |
$94.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$160.31
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$111.54
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.08 |
| Max. Negotiated Rate |
$100.39 |
| Rate for Payer: Aetna American Axle |
$72.50
|
| Rate for Payer: Aetna American Axle |
$66.87
|
| Rate for Payer: Aetna American Axle |
$38.88
|
| Rate for Payer: Aetna Commercial |
$50.85
|
| Rate for Payer: Aetna Commercial |
$87.45
|
| Rate for Payer: Aetna Commercial |
$94.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.87
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cash Price |
$82.30
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cofinity Commercial |
$78.08
|
| Rate for Payer: Cofinity Commercial |
$88.48
|
| Rate for Payer: Cofinity Commercial |
$72.02
|
| Rate for Payer: Cofinity Commercial |
$95.92
|
| Rate for Payer: Cofinity Commercial |
$51.45
|
| Rate for Payer: Cofinity Commercial |
$41.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.86
|
| Rate for Payer: Healthscope Commercial |
$53.84
|
| Rate for Payer: Healthscope Commercial |
$92.59
|
| Rate for Payer: Healthscope Commercial |
$100.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$87.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$94.81
|
| Rate for Payer: PHP Commercial |
$87.45
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: PHP Commercial |
$94.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.02
|
| Rate for Payer: Priority Health SBD |
$70.27
|
| Rate for Payer: Priority Health SBD |
$37.69
|
| Rate for Payer: Priority Health SBD |
$64.81
|
| Rate for Payer: UMR Bronson Commercial |
$49.08
|
| Rate for Payer: UMR Bronson Commercial |
$45.27
|
| Rate for Payer: UMR Bronson Commercial |
$26.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.66
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$59.82
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.92 |
| Max. Negotiated Rate |
$53.84 |
| Rate for Payer: Aetna American Axle |
$38.88
|
| Rate for Payer: Aetna American Axle |
$72.50
|
| Rate for Payer: Aetna Commercial |
$50.85
|
| Rate for Payer: Aetna Commercial |
$94.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.88
|
| Rate for Payer: BCBS Complete |
$44.62
|
| Rate for Payer: BCBS Complete |
$23.93
|
| Rate for Payer: BCBS Trust/PPO |
$2.92
|
| Rate for Payer: BCBS Trust/PPO |
$2.92
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cash Price |
$47.86
|
| Rate for Payer: Cofinity Commercial |
$41.87
|
| Rate for Payer: Cofinity Commercial |
$95.92
|
| Rate for Payer: Cofinity Commercial |
$78.08
|
| Rate for Payer: Cofinity Commercial |
$51.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.23
|
| Rate for Payer: Healthscope Commercial |
$53.84
|
| Rate for Payer: Healthscope Commercial |
$100.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$94.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.85
|
| Rate for Payer: PHP Commercial |
$94.81
|
| Rate for Payer: PHP Commercial |
$50.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.08
|
| Rate for Payer: Priority Health SBD |
$37.69
|
| Rate for Payer: Priority Health SBD |
$70.27
|
| Rate for Payer: UMR Bronson Commercial |
$41.27
|
| Rate for Payer: UMR Bronson Commercial |
$22.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.66
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$132.54
|
|
|
Service Code
|
NDC 55111-281-30
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.32 |
| Max. Negotiated Rate |
$119.29 |
| Rate for Payer: Aetna American Axle |
$86.15
|
| Rate for Payer: Aetna Commercial |
$112.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.15
|
| Rate for Payer: Cash Price |
$106.03
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| Rate for Payer: Cofinity Commercial |
$92.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.03
|
| Rate for Payer: Healthscope Commercial |
$119.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$112.66
|
| Rate for Payer: PHP Commercial |
$112.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.78
|
| Rate for Payer: Priority Health SBD |
$83.50
|
| Rate for Payer: UMR Bronson Commercial |
$58.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.40
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$324.90
|
|
|
Service Code
|
NDC 0904-6353-61
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$142.96 |
| Max. Negotiated Rate |
$292.41 |
| Rate for Payer: Aetna American Axle |
$211.18
|
| Rate for Payer: Aetna Commercial |
$276.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.18
|
| Rate for Payer: Cash Price |
$259.92
|
| Rate for Payer: Cofinity Commercial |
$227.43
|
| Rate for Payer: Cofinity Commercial |
$279.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.92
|
| Rate for Payer: Healthscope Commercial |
$292.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$227.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$243.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$276.16
|
| Rate for Payer: PHP Commercial |
$276.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$227.43
|
| Rate for Payer: Priority Health SBD |
$204.69
|
| Rate for Payer: UMR Bronson Commercial |
$142.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$243.68
|
|
|
LEVONORGESTREL 17.5 MCG/24 HRS (5YRS) 19.5MG INTRAUTERINE DEVICE
|
Facility
|
IP
|
$4,076.29
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
181058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,793.57 |
| Max. Negotiated Rate |
$3,668.66 |
| Rate for Payer: Aetna American Axle |
$2,649.59
|
| Rate for Payer: Aetna American Axle |
$2,523.42
|
| Rate for Payer: Aetna Commercial |
$3,299.86
|
| Rate for Payer: Aetna Commercial |
$3,464.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,523.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,649.59
|
| Rate for Payer: Cash Price |
$3,261.03
|
| Rate for Payer: Cash Price |
$3,105.75
|
| Rate for Payer: Cofinity Commercial |
$2,853.40
|
| Rate for Payer: Cofinity Commercial |
$3,505.61
|
| Rate for Payer: Cofinity Commercial |
$3,338.68
|
| Rate for Payer: Cofinity Commercial |
$2,717.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,105.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,261.03
|
| Rate for Payer: Healthscope Commercial |
$3,493.97
|
| Rate for Payer: Healthscope Commercial |
$3,668.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,717.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,853.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,911.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,057.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,464.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,299.86
|
| Rate for Payer: PHP Commercial |
$3,299.86
|
| Rate for Payer: PHP Commercial |
$3,464.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,853.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,717.53
|
| Rate for Payer: Priority Health SBD |
$2,568.06
|
| Rate for Payer: Priority Health SBD |
$2,445.78
|
| Rate for Payer: UMR Bronson Commercial |
$1,708.16
|
| Rate for Payer: UMR Bronson Commercial |
$1,793.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,911.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,057.22
|
|
|
LEVONORGESTREL 21 MCG/24 HOURS (8 YRS) 52 MG INTRAUTERINE DEVICE
|
Facility
|
IP
|
$4,280.13
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,883.26 |
| Max. Negotiated Rate |
$3,852.12 |
| Rate for Payer: Aetna American Axle |
$2,782.08
|
| Rate for Payer: Aetna Commercial |
$3,638.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,782.08
|
| Rate for Payer: Cash Price |
$3,424.10
|
| Rate for Payer: Cofinity Commercial |
$2,996.09
|
| Rate for Payer: Cofinity Commercial |
$3,680.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,424.10
|
| Rate for Payer: Healthscope Commercial |
$3,852.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,996.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,210.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3,638.11
|
| Rate for Payer: PHP Commercial |
$3,638.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,996.09
|
| Rate for Payer: Priority Health SBD |
$2,696.48
|
| Rate for Payer: UMR Bronson Commercial |
$1,883.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,210.10
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$188.01
|
|
|
Service Code
|
NDC 70860-451-10
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.72 |
| Max. Negotiated Rate |
$169.21 |
| Rate for Payer: Aetna American Axle |
$122.21
|
| Rate for Payer: Aetna Commercial |
$159.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.21
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cofinity Commercial |
$131.61
|
| Rate for Payer: Cofinity Commercial |
$161.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Healthscope Commercial |
$169.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$159.81
|
| Rate for Payer: PHP Commercial |
$159.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.61
|
| Rate for Payer: Priority Health SBD |
$118.45
|
| Rate for Payer: UMR Bronson Commercial |
$82.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.01
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$277.58
|
|
|
Service Code
|
NDC 63323-649-07
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.70 |
| Max. Negotiated Rate |
$249.82 |
| Rate for Payer: Aetna American Axle |
$180.43
|
| Rate for Payer: Aetna Commercial |
$235.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.43
|
| Rate for Payer: BCBS Complete |
$111.03
|
| Rate for Payer: Cash Price |
$222.06
|
| Rate for Payer: Cofinity Commercial |
$194.31
|
| Rate for Payer: Cofinity Commercial |
$238.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.06
|
| Rate for Payer: Healthscope Commercial |
$249.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$235.94
|
| Rate for Payer: PHP Commercial |
$235.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.31
|
| Rate for Payer: Priority Health SBD |
$174.88
|
| Rate for Payer: UMR Bronson Commercial |
$102.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.18
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$411.20
|
|
|
Service Code
|
NDC 66794-649-02
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$152.14 |
| Max. Negotiated Rate |
$370.08 |
| Rate for Payer: Aetna American Axle |
$267.28
|
| Rate for Payer: Aetna Commercial |
$349.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$267.28
|
| Rate for Payer: BCBS Complete |
$164.48
|
| Rate for Payer: Cash Price |
$328.96
|
| Rate for Payer: Cofinity Commercial |
$287.84
|
| Rate for Payer: Cofinity Commercial |
$353.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$328.96
|
| Rate for Payer: Healthscope Commercial |
$370.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$287.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$308.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$349.52
|
| Rate for Payer: PHP Commercial |
$349.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.84
|
| Rate for Payer: Priority Health SBD |
$259.06
|
| Rate for Payer: UMR Bronson Commercial |
$152.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$308.40
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$348.58
|
|
|
Service Code
|
NDC 42023-201-01
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$153.38 |
| Max. Negotiated Rate |
$313.72 |
| Rate for Payer: Aetna American Axle |
$226.58
|
| Rate for Payer: Aetna Commercial |
$296.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.58
|
| Rate for Payer: Cash Price |
$278.86
|
| Rate for Payer: Cofinity Commercial |
$244.01
|
| Rate for Payer: Cofinity Commercial |
$299.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$278.86
|
| Rate for Payer: Healthscope Commercial |
$313.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$244.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$261.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$296.29
|
| Rate for Payer: PHP Commercial |
$296.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$244.01
|
| Rate for Payer: Priority Health SBD |
$219.61
|
| Rate for Payer: UMR Bronson Commercial |
$153.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$261.44
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$348.58
|
|
|
Service Code
|
NDC 42023-201-01
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$128.97 |
| Max. Negotiated Rate |
$313.72 |
| Rate for Payer: Aetna American Axle |
$226.58
|
| Rate for Payer: Aetna Commercial |
$296.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$226.58
|
| Rate for Payer: BCBS Complete |
$139.43
|
| Rate for Payer: Cash Price |
$278.86
|
| Rate for Payer: Cofinity Commercial |
$244.01
|
| Rate for Payer: Cofinity Commercial |
$299.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$278.86
|
| Rate for Payer: Healthscope Commercial |
$313.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$244.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$261.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$296.29
|
| Rate for Payer: PHP Commercial |
$296.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$244.01
|
| Rate for Payer: Priority Health SBD |
$219.61
|
| Rate for Payer: UMR Bronson Commercial |
$128.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$261.44
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$277.58
|
|
|
Service Code
|
NDC 63323-649-16
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$102.70 |
| Max. Negotiated Rate |
$249.82 |
| Rate for Payer: Aetna American Axle |
$180.43
|
| Rate for Payer: Aetna Commercial |
$235.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.43
|
| Rate for Payer: BCBS Complete |
$111.03
|
| Rate for Payer: Cash Price |
$222.06
|
| Rate for Payer: Cofinity Commercial |
$194.31
|
| Rate for Payer: Cofinity Commercial |
$238.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.06
|
| Rate for Payer: Healthscope Commercial |
$249.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$235.94
|
| Rate for Payer: PHP Commercial |
$235.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.31
|
| Rate for Payer: Priority Health SBD |
$174.88
|
| Rate for Payer: UMR Bronson Commercial |
$102.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.18
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$277.58
|
|
|
Service Code
|
NDC 63323-649-07
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$122.14 |
| Max. Negotiated Rate |
$249.82 |
| Rate for Payer: Aetna American Axle |
$180.43
|
| Rate for Payer: Aetna Commercial |
$235.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.43
|
| Rate for Payer: Cash Price |
$222.06
|
| Rate for Payer: Cofinity Commercial |
$194.31
|
| Rate for Payer: Cofinity Commercial |
$238.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.06
|
| Rate for Payer: Healthscope Commercial |
$249.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$235.94
|
| Rate for Payer: PHP Commercial |
$235.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.31
|
| Rate for Payer: Priority Health SBD |
$174.88
|
| Rate for Payer: UMR Bronson Commercial |
$122.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.18
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$268.80
|
|
|
Service Code
|
NDC 51079-442-20
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.27 |
| Max. Negotiated Rate |
$241.92 |
| Rate for Payer: Aetna American Axle |
$174.72
|
| Rate for Payer: Aetna Commercial |
$228.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.72
|
| Rate for Payer: Cash Price |
$215.04
|
| Rate for Payer: Cofinity Commercial |
$188.16
|
| Rate for Payer: Cofinity Commercial |
$231.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.04
|
| Rate for Payer: Healthscope Commercial |
$241.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$188.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$201.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$228.48
|
| Rate for Payer: PHP Commercial |
$228.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.16
|
| Rate for Payer: Priority Health SBD |
$169.34
|
| Rate for Payer: UMR Bronson Commercial |
$118.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$201.60
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$703.68
|
|
|
Service Code
|
NDC 0074-6624-11
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$309.62 |
| Max. Negotiated Rate |
$633.31 |
| Rate for Payer: Aetna American Axle |
$457.39
|
| Rate for Payer: Aetna Commercial |
$598.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$457.39
|
| Rate for Payer: Cash Price |
$562.94
|
| Rate for Payer: Cofinity Commercial |
$492.58
|
| Rate for Payer: Cofinity Commercial |
$605.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$562.94
|
| Rate for Payer: Healthscope Commercial |
$633.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$492.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$527.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$598.13
|
| Rate for Payer: PHP Commercial |
$598.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$492.58
|
| Rate for Payer: Priority Health SBD |
$443.32
|
| Rate for Payer: UMR Bronson Commercial |
$309.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$527.76
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.69
|
|
|
Service Code
|
NDC 51079-442-01
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$2.42 |
| Rate for Payer: Aetna American Axle |
$1.75
|
| Rate for Payer: Aetna Commercial |
$2.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.75
|
| Rate for Payer: Cash Price |
$2.15
|
| Rate for Payer: Cofinity Commercial |
$1.88
|
| Rate for Payer: Cofinity Commercial |
$2.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.15
|
| Rate for Payer: Healthscope Commercial |
$2.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.29
|
| Rate for Payer: PHP Commercial |
$2.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.88
|
| Rate for Payer: Priority Health SBD |
$1.69
|
| Rate for Payer: UMR Bronson Commercial |
$1.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.02
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$371.93
|
|
|
Service Code
|
NDC 0378-1809-77
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.65 |
| Max. Negotiated Rate |
$334.74 |
| Rate for Payer: Aetna American Axle |
$241.75
|
| Rate for Payer: Aetna Commercial |
$316.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$241.75
|
| Rate for Payer: Cash Price |
$297.54
|
| Rate for Payer: Cofinity Commercial |
$260.35
|
| Rate for Payer: Cofinity Commercial |
$319.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.54
|
| Rate for Payer: Healthscope Commercial |
$334.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$260.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$278.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$316.14
|
| Rate for Payer: PHP Commercial |
$316.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.35
|
| Rate for Payer: Priority Health SBD |
$234.32
|
| Rate for Payer: UMR Bronson Commercial |
$163.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$278.95
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$492.96
|
|
|
Service Code
|
NDC 60793-855-01
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$216.90 |
| Max. Negotiated Rate |
$443.66 |
| Rate for Payer: Aetna American Axle |
$320.42
|
| Rate for Payer: Aetna Commercial |
$419.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$320.42
|
| Rate for Payer: Cash Price |
$394.37
|
| Rate for Payer: Cofinity Commercial |
$345.07
|
| Rate for Payer: Cofinity Commercial |
$423.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$394.37
|
| Rate for Payer: Healthscope Commercial |
$443.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$345.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$369.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$419.02
|
| Rate for Payer: PHP Commercial |
$419.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$345.07
|
| Rate for Payer: Priority Health SBD |
$310.56
|
| Rate for Payer: UMR Bronson Commercial |
$216.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$369.72
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$300.20
|
|
|
Service Code
|
NDC 69238-1835-1
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.09 |
| Max. Negotiated Rate |
$270.18 |
| Rate for Payer: Aetna American Axle |
$195.13
|
| Rate for Payer: Aetna Commercial |
$255.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.13
|
| Rate for Payer: Cash Price |
$240.16
|
| Rate for Payer: Cofinity Commercial |
$210.14
|
| Rate for Payer: Cofinity Commercial |
$258.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.16
|
| Rate for Payer: Healthscope Commercial |
$270.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$210.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$255.17
|
| Rate for Payer: PHP Commercial |
$255.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$210.14
|
| Rate for Payer: Priority Health SBD |
$189.13
|
| Rate for Payer: UMR Bronson Commercial |
$132.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.15
|
|
