|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$633.75
|
|
|
Service Code
|
NDC 0074-9296-90
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.85 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna American Axle |
$411.94
|
| Rate for Payer: Aetna Commercial |
$538.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.94
|
| Rate for Payer: Cash Price |
$507.00
|
| Rate for Payer: Cofinity Commercial |
$443.62
|
| Rate for Payer: Cofinity Commercial |
$545.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$507.00
|
| Rate for Payer: Healthscope Commercial |
$570.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$443.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$475.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$538.69
|
| Rate for Payer: PHP Commercial |
$538.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$443.62
|
| Rate for Payer: Priority Health SBD |
$399.26
|
| Rate for Payer: UMR Bronson Commercial |
$278.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$475.31
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$281.76
|
|
|
Service Code
|
NDC 42292-039-20
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.97 |
| Max. Negotiated Rate |
$253.58 |
| Rate for Payer: Aetna American Axle |
$183.14
|
| Rate for Payer: Aetna Commercial |
$239.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$183.14
|
| Rate for Payer: Cash Price |
$225.41
|
| Rate for Payer: Cofinity Commercial |
$197.23
|
| Rate for Payer: Cofinity Commercial |
$242.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.41
|
| Rate for Payer: Healthscope Commercial |
$253.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$197.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$211.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.50
|
| Rate for Payer: PHP Commercial |
$239.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.23
|
| Rate for Payer: Priority Health SBD |
$177.51
|
| Rate for Payer: UMR Bronson Commercial |
$123.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$211.32
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$2.82
|
|
|
Service Code
|
NDC 42292-039-01
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$2.54 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.40
|
| Rate for Payer: PHP Commercial |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.97
|
| Rate for Payer: Priority Health SBD |
$1.78
|
| Rate for Payer: UMR Bronson Commercial |
$1.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.12
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$235.00
|
|
|
Service Code
|
NDC 68180-970-01
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.40 |
| Max. Negotiated Rate |
$211.50 |
| Rate for Payer: Aetna American Axle |
$152.75
|
| Rate for Payer: Aetna Commercial |
$199.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$152.75
|
| Rate for Payer: Cash Price |
$188.00
|
| Rate for Payer: Cofinity Commercial |
$164.50
|
| Rate for Payer: Cofinity Commercial |
$202.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.00
|
| Rate for Payer: Healthscope Commercial |
$211.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$164.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$176.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$199.75
|
| Rate for Payer: PHP Commercial |
$199.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.50
|
| Rate for Payer: Priority Health SBD |
$148.05
|
| Rate for Payer: UMR Bronson Commercial |
$103.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$176.25
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$242.88
|
|
|
Service Code
|
NDC 0527-1346-01
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.87 |
| Max. Negotiated Rate |
$218.59 |
| Rate for Payer: Aetna American Axle |
$157.87
|
| Rate for Payer: Aetna Commercial |
$206.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.87
|
| Rate for Payer: Cash Price |
$194.30
|
| Rate for Payer: Cofinity Commercial |
$170.02
|
| Rate for Payer: Cofinity Commercial |
$208.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$194.30
|
| Rate for Payer: Healthscope Commercial |
$218.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$170.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$182.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$206.45
|
| Rate for Payer: PHP Commercial |
$206.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.02
|
| Rate for Payer: Priority Health SBD |
$153.01
|
| Rate for Payer: UMR Bronson Commercial |
$106.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$182.16
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$2.45
|
|
|
Service Code
|
NDC 60687-519-11
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$2.20 |
| Rate for Payer: Aetna American Axle |
$1.59
|
| Rate for Payer: Aetna Commercial |
$2.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.59
|
| Rate for Payer: Cash Price |
$1.96
|
| Rate for Payer: Cofinity Commercial |
$1.72
|
| Rate for Payer: Cofinity Commercial |
$2.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.96
|
| Rate for Payer: Healthscope Commercial |
$2.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.08
|
| Rate for Payer: PHP Commercial |
$2.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.72
|
| Rate for Payer: Priority Health SBD |
$1.54
|
| Rate for Payer: UMR Bronson Commercial |
$1.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.84
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$315.84
|
|
|
Service Code
|
NDC 51079-443-20
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$138.97 |
| Max. Negotiated Rate |
$284.26 |
| Rate for Payer: Aetna American Axle |
$205.30
|
| Rate for Payer: Aetna Commercial |
$268.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$205.30
|
| Rate for Payer: Cash Price |
$252.67
|
| Rate for Payer: Cofinity Commercial |
$221.09
|
| Rate for Payer: Cofinity Commercial |
$271.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$252.67
|
| Rate for Payer: Healthscope Commercial |
$284.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$221.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$236.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$268.46
|
| Rate for Payer: PHP Commercial |
$268.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.09
|
| Rate for Payer: Priority Health SBD |
$198.98
|
| Rate for Payer: UMR Bronson Commercial |
$138.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$236.88
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$244.80
|
|
|
Service Code
|
NDC 60687-519-01
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.71 |
| Max. Negotiated Rate |
$220.32 |
| Rate for Payer: Aetna American Axle |
$159.12
|
| Rate for Payer: Aetna Commercial |
$208.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.12
|
| Rate for Payer: Cash Price |
$195.84
|
| Rate for Payer: Cofinity Commercial |
$171.36
|
| Rate for Payer: Cofinity Commercial |
$210.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.84
|
| Rate for Payer: Healthscope Commercial |
$220.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$208.08
|
| Rate for Payer: PHP Commercial |
$208.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.36
|
| Rate for Payer: Priority Health SBD |
$154.22
|
| Rate for Payer: UMR Bronson Commercial |
$107.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.60
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$703.68
|
|
|
Service Code
|
NDC 0074-7068-11
|
| Hospital Charge Code |
4424
|
|
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 125 MCG TABLET
|
Facility
|
IP
|
$633.75
|
|
|
Service Code
|
NDC 0074-7068-90
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.85 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna American Axle |
$411.94
|
| Rate for Payer: Aetna Commercial |
$538.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.94
|
| Rate for Payer: Cash Price |
$507.00
|
| Rate for Payer: Cofinity Commercial |
$443.62
|
| Rate for Payer: Cofinity Commercial |
$545.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$507.00
|
| Rate for Payer: Healthscope Commercial |
$570.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$443.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$475.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$538.69
|
| Rate for Payer: PHP Commercial |
$538.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$443.62
|
| Rate for Payer: Priority Health SBD |
$399.26
|
| Rate for Payer: UMR Bronson Commercial |
$278.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$475.31
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$3.16
|
|
|
Service Code
|
NDC 51079-443-01
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.39 |
| Max. Negotiated Rate |
$2.84 |
| Rate for Payer: Aetna American Axle |
$2.05
|
| Rate for Payer: Aetna Commercial |
$2.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.05
|
| Rate for Payer: Cash Price |
$2.53
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Cofinity Commercial |
$2.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.53
|
| Rate for Payer: Healthscope Commercial |
$2.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.69
|
| Rate for Payer: PHP Commercial |
$2.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: Priority Health SBD |
$1.99
|
| Rate for Payer: UMR Bronson Commercial |
$1.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.37
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$220.32
|
|
|
Service Code
|
NDC 0378-1813-77
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.94 |
| Max. Negotiated Rate |
$198.29 |
| Rate for Payer: Aetna American Axle |
$143.21
|
| Rate for Payer: Aetna Commercial |
$187.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.21
|
| Rate for Payer: Cash Price |
$176.26
|
| Rate for Payer: Cofinity Commercial |
$154.22
|
| Rate for Payer: Cofinity Commercial |
$189.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.26
|
| Rate for Payer: Healthscope Commercial |
$198.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$154.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$165.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$187.27
|
| Rate for Payer: PHP Commercial |
$187.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.22
|
| Rate for Payer: Priority Health SBD |
$138.80
|
| Rate for Payer: UMR Bronson Commercial |
$96.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$165.24
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$423.23
|
|
|
Service Code
|
NDC 0781-5186-92
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.22 |
| Max. Negotiated Rate |
$380.91 |
| Rate for Payer: Aetna American Axle |
$275.10
|
| Rate for Payer: Aetna Commercial |
$359.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.10
|
| Rate for Payer: Cash Price |
$338.58
|
| Rate for Payer: Cofinity Commercial |
$296.26
|
| Rate for Payer: Cofinity Commercial |
$363.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.58
|
| Rate for Payer: Healthscope Commercial |
$380.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$359.75
|
| Rate for Payer: PHP Commercial |
$359.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.26
|
| Rate for Payer: Priority Health SBD |
$266.63
|
| Rate for Payer: UMR Bronson Commercial |
$186.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.42
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$181.89
|
|
|
Service Code
|
NDC 68180-972-09
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.03 |
| Max. Negotiated Rate |
$163.70 |
| Rate for Payer: Aetna American Axle |
$118.23
|
| Rate for Payer: Aetna Commercial |
$154.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.23
|
| Rate for Payer: Cash Price |
$145.51
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Cofinity Commercial |
$156.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.51
|
| Rate for Payer: Healthscope Commercial |
$163.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$127.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$154.61
|
| Rate for Payer: PHP Commercial |
$154.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$127.32
|
| Rate for Payer: Priority Health SBD |
$114.59
|
| Rate for Payer: UMR Bronson Commercial |
$80.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.42
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$223.78
|
|
|
Service Code
|
NDC 0378-1823-77
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.46 |
| Max. Negotiated Rate |
$201.40 |
| Rate for Payer: Aetna American Axle |
$145.46
|
| Rate for Payer: Aetna Commercial |
$190.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$145.46
|
| Rate for Payer: Cash Price |
$179.02
|
| Rate for Payer: Cofinity Commercial |
$156.65
|
| Rate for Payer: Cofinity Commercial |
$192.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.02
|
| Rate for Payer: Healthscope Commercial |
$201.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$156.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$167.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$190.21
|
| Rate for Payer: PHP Commercial |
$190.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.65
|
| Rate for Payer: Priority Health SBD |
$140.98
|
| Rate for Payer: UMR Bronson Commercial |
$98.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$167.84
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$633.75
|
|
|
Service Code
|
NDC 0074-3727-90
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.85 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna American Axle |
$411.94
|
| Rate for Payer: Aetna Commercial |
$538.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.94
|
| Rate for Payer: Cash Price |
$507.00
|
| Rate for Payer: Cofinity Commercial |
$443.62
|
| Rate for Payer: Cofinity Commercial |
$545.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$507.00
|
| Rate for Payer: Healthscope Commercial |
$570.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$443.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$475.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$538.69
|
| Rate for Payer: PHP Commercial |
$538.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$443.62
|
| Rate for Payer: Priority Health SBD |
$399.26
|
| Rate for Payer: UMR Bronson Commercial |
$278.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$475.31
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$114.92
|
|
|
Service Code
|
NDC 72305-137-30
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.56 |
| Max. Negotiated Rate |
$103.43 |
| Rate for Payer: Aetna American Axle |
$74.70
|
| Rate for Payer: Aetna Commercial |
$97.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$74.70
|
| Rate for Payer: Cash Price |
$91.94
|
| Rate for Payer: Cofinity Commercial |
$80.44
|
| Rate for Payer: Cofinity Commercial |
$98.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$91.94
|
| Rate for Payer: Healthscope Commercial |
$103.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$80.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$86.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$97.68
|
| Rate for Payer: PHP Commercial |
$97.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$80.44
|
| Rate for Payer: Priority Health SBD |
$72.40
|
| Rate for Payer: UMR Bronson Commercial |
$50.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$86.19
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$251.04
|
|
|
Service Code
|
NDC 60687-563-01
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.46 |
| Max. Negotiated Rate |
$225.94 |
| Rate for Payer: Aetna American Axle |
$163.18
|
| Rate for Payer: Aetna Commercial |
$213.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$163.18
|
| Rate for Payer: Cash Price |
$200.83
|
| Rate for Payer: Cofinity Commercial |
$175.73
|
| Rate for Payer: Cofinity Commercial |
$215.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.83
|
| Rate for Payer: Healthscope Commercial |
$225.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$175.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$188.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$213.38
|
| Rate for Payer: PHP Commercial |
$213.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.73
|
| Rate for Payer: Priority Health SBD |
$158.16
|
| Rate for Payer: UMR Bronson Commercial |
$110.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$188.28
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$2.52
|
|
|
Service Code
|
NDC 60687-563-11
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$2.27 |
| Rate for Payer: Aetna American Axle |
$1.64
|
| Rate for Payer: Aetna Commercial |
$2.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.64
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cofinity Commercial |
$1.76
|
| Rate for Payer: Cofinity Commercial |
$2.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.02
|
| Rate for Payer: Healthscope Commercial |
$2.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.14
|
| Rate for Payer: PHP Commercial |
$2.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.76
|
| Rate for Payer: Priority Health SBD |
$1.59
|
| Rate for Payer: UMR Bronson Commercial |
$1.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.89
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$703.68
|
|
|
Service Code
|
NDC 0074-7069-11
|
| Hospital Charge Code |
4425
|
|
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 150 MCG TABLET
|
Facility
|
IP
|
$633.75
|
|
|
Service Code
|
NDC 0074-7069-90
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.85 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna American Axle |
$411.94
|
| Rate for Payer: Aetna Commercial |
$538.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.94
|
| Rate for Payer: Cash Price |
$507.00
|
| Rate for Payer: Cofinity Commercial |
$443.62
|
| Rate for Payer: Cofinity Commercial |
$545.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$507.00
|
| Rate for Payer: Healthscope Commercial |
$570.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$443.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$475.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$538.69
|
| Rate for Payer: PHP Commercial |
$538.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$443.62
|
| Rate for Payer: Priority Health SBD |
$399.26
|
| Rate for Payer: UMR Bronson Commercial |
$278.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$475.31
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$325.92
|
|
|
Service Code
|
NDC 51079-445-20
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.40 |
| Max. Negotiated Rate |
$293.33 |
| Rate for Payer: Aetna American Axle |
$211.85
|
| Rate for Payer: Aetna Commercial |
$277.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$211.85
|
| Rate for Payer: Cash Price |
$260.74
|
| Rate for Payer: Cofinity Commercial |
$228.14
|
| Rate for Payer: Cofinity Commercial |
$280.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$260.74
|
| Rate for Payer: Healthscope Commercial |
$293.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$228.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$244.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$277.03
|
| Rate for Payer: PHP Commercial |
$277.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.14
|
| Rate for Payer: Priority Health SBD |
$205.33
|
| Rate for Payer: UMR Bronson Commercial |
$143.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$244.44
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$3.26
|
|
|
Service Code
|
NDC 51079-445-01
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$2.93 |
| Rate for Payer: Aetna American Axle |
$2.12
|
| Rate for Payer: Aetna Commercial |
$2.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.12
|
| Rate for Payer: Cash Price |
$2.61
|
| Rate for Payer: Cofinity Commercial |
$2.28
|
| Rate for Payer: Cofinity Commercial |
$2.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.61
|
| Rate for Payer: Healthscope Commercial |
$2.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.77
|
| Rate for Payer: PHP Commercial |
$2.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.28
|
| Rate for Payer: Priority Health SBD |
$2.05
|
| Rate for Payer: UMR Bronson Commercial |
$1.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.44
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$226.80
|
|
|
Service Code
|
NDC 0378-1815-77
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.79 |
| Max. Negotiated Rate |
$204.12 |
| Rate for Payer: Aetna American Axle |
$147.42
|
| Rate for Payer: Aetna Commercial |
$192.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.42
|
| Rate for Payer: Cash Price |
$181.44
|
| Rate for Payer: Cofinity Commercial |
$158.76
|
| Rate for Payer: Cofinity Commercial |
$195.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$181.44
|
| Rate for Payer: Healthscope Commercial |
$204.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$158.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$170.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$192.78
|
| Rate for Payer: PHP Commercial |
$192.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.76
|
| Rate for Payer: Priority Health SBD |
$142.88
|
| Rate for Payer: UMR Bronson Commercial |
$99.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$170.10
|
|
|
LEVOTHYROXINE 175 MCG TABLET
|
Facility
|
IP
|
$632.88
|
|
|
Service Code
|
NDC 0074-7070-90
|
| Hospital Charge Code |
10406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.47 |
| Max. Negotiated Rate |
$569.59 |
| Rate for Payer: Aetna American Axle |
$411.37
|
| Rate for Payer: Aetna Commercial |
$537.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.37
|
| Rate for Payer: Cash Price |
$506.30
|
| Rate for Payer: Cofinity Commercial |
$443.02
|
| Rate for Payer: Cofinity Commercial |
$544.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$506.30
|
| Rate for Payer: Healthscope Commercial |
$569.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$443.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$474.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$537.95
|
| Rate for Payer: PHP Commercial |
$537.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$443.02
|
| Rate for Payer: Priority Health SBD |
$398.71
|
| Rate for Payer: UMR Bronson Commercial |
$278.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$474.66
|
|
