|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$270.44
|
|
|
Service Code
|
NDC 0378-1819-77
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.99 |
| Max. Negotiated Rate |
$243.40 |
| Rate for Payer: Aetna American Axle |
$175.79
|
| Rate for Payer: Aetna Commercial |
$229.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.79
|
| Rate for Payer: Cash Price |
$216.35
|
| Rate for Payer: Cofinity Commercial |
$189.31
|
| Rate for Payer: Cofinity Commercial |
$232.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.35
|
| Rate for Payer: Healthscope Commercial |
$243.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$189.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$229.87
|
| Rate for Payer: PHP Commercial |
$229.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.31
|
| Rate for Payer: Priority Health SBD |
$170.38
|
| Rate for Payer: UMR Bronson Commercial |
$118.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.83
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$609.60
|
|
|
Service Code
|
NDC 0074-7148-11
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.22 |
| Max. Negotiated Rate |
$548.64 |
| Rate for Payer: Aetna American Axle |
$396.24
|
| Rate for Payer: Aetna Commercial |
$518.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.24
|
| Rate for Payer: Cash Price |
$487.68
|
| Rate for Payer: Cofinity Commercial |
$426.72
|
| Rate for Payer: Cofinity Commercial |
$524.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$487.68
|
| Rate for Payer: Healthscope Commercial |
$548.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$426.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$457.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$518.16
|
| Rate for Payer: PHP Commercial |
$518.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$426.72
|
| Rate for Payer: Priority Health SBD |
$384.05
|
| Rate for Payer: UMR Bronson Commercial |
$268.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$457.20
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$302.45
|
|
|
Service Code
|
NDC 68180-975-09
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.08 |
| Max. Negotiated Rate |
$272.20 |
| Rate for Payer: Aetna American Axle |
$196.59
|
| Rate for Payer: Aetna Commercial |
$257.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$196.59
|
| Rate for Payer: Cash Price |
$241.96
|
| Rate for Payer: Cofinity Commercial |
$211.72
|
| Rate for Payer: Cofinity Commercial |
$260.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$241.96
|
| Rate for Payer: Healthscope Commercial |
$272.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$211.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$226.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$257.08
|
| Rate for Payer: PHP Commercial |
$257.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$211.72
|
| Rate for Payer: Priority Health SBD |
$190.54
|
| Rate for Payer: UMR Bronson Commercial |
$133.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$226.84
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$381.12
|
|
|
Service Code
|
NDC 60687-552-01
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$167.69 |
| Max. Negotiated Rate |
$343.01 |
| Rate for Payer: Aetna American Axle |
$247.73
|
| Rate for Payer: Aetna Commercial |
$323.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$247.73
|
| Rate for Payer: Cash Price |
$304.90
|
| Rate for Payer: Cofinity Commercial |
$327.76
|
| Rate for Payer: Cofinity Commercial |
$266.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$304.90
|
| Rate for Payer: Healthscope Commercial |
$343.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$266.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$285.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$323.95
|
| Rate for Payer: PHP Commercial |
$323.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.78
|
| Rate for Payer: Priority Health SBD |
$240.11
|
| Rate for Payer: UMR Bronson Commercial |
$167.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$285.84
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$206.15
|
|
|
Service Code
|
NDC 68180-975-01
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.71 |
| Max. Negotiated Rate |
$185.54 |
| Rate for Payer: Aetna American Axle |
$134.00
|
| Rate for Payer: Aetna Commercial |
$175.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$134.00
|
| Rate for Payer: Cash Price |
$164.92
|
| Rate for Payer: Cofinity Commercial |
$144.30
|
| Rate for Payer: Cofinity Commercial |
$177.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$164.92
|
| Rate for Payer: Healthscope Commercial |
$185.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$144.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$154.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$175.23
|
| Rate for Payer: PHP Commercial |
$175.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$144.30
|
| Rate for Payer: Priority Health SBD |
$129.87
|
| Rate for Payer: UMR Bronson Commercial |
$90.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$154.61
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$3.82
|
|
|
Service Code
|
NDC 60687-552-11
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$3.44 |
| Rate for Payer: Aetna American Axle |
$2.48
|
| Rate for Payer: Aetna Commercial |
$3.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.48
|
| Rate for Payer: Cash Price |
$3.06
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Cofinity Commercial |
$3.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.06
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.25
|
| Rate for Payer: PHP Commercial |
$3.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.67
|
| Rate for Payer: Priority Health SBD |
$2.41
|
| Rate for Payer: UMR Bronson Commercial |
$1.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.86
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$267.41
|
|
|
Service Code
|
NDC 0781-5189-92
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.66 |
| Max. Negotiated Rate |
$240.67 |
| Rate for Payer: Aetna American Axle |
$173.82
|
| Rate for Payer: Aetna Commercial |
$227.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$173.82
|
| Rate for Payer: Cash Price |
$213.93
|
| Rate for Payer: Cofinity Commercial |
$187.19
|
| Rate for Payer: Cofinity Commercial |
$229.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$213.93
|
| Rate for Payer: Healthscope Commercial |
$240.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$187.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$227.30
|
| Rate for Payer: PHP Commercial |
$227.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$187.19
|
| Rate for Payer: Priority Health SBD |
$168.47
|
| Rate for Payer: UMR Bronson Commercial |
$117.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.56
|
|
|
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$235.58
|
|
|
Service Code
|
NDC 63323-885-10
|
| Hospital Charge Code |
190375
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$103.66 |
| Max. Negotiated Rate |
$212.02 |
| Rate for Payer: Aetna American Axle |
$153.13
|
| Rate for Payer: Aetna Commercial |
$200.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.13
|
| Rate for Payer: Cash Price |
$188.46
|
| Rate for Payer: Cofinity Commercial |
$164.91
|
| Rate for Payer: Cofinity Commercial |
$202.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.46
|
| Rate for Payer: Healthscope Commercial |
$212.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$164.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$176.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$200.24
|
| Rate for Payer: PHP Commercial |
$200.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$164.91
|
| Rate for Payer: Priority Health SBD |
$148.42
|
| Rate for Payer: UMR Bronson Commercial |
$103.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$176.68
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$93.06
|
|
|
Service Code
|
NDC 16729-447-15
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.95 |
| Max. Negotiated Rate |
$83.75 |
| Rate for Payer: Aetna American Axle |
$60.49
|
| Rate for Payer: Aetna Commercial |
$79.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$60.49
|
| Rate for Payer: Cash Price |
$74.45
|
| Rate for Payer: Cofinity Commercial |
$65.14
|
| Rate for Payer: Cofinity Commercial |
$80.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$74.45
|
| Rate for Payer: Healthscope Commercial |
$83.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$69.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$79.10
|
| Rate for Payer: PHP Commercial |
$79.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.14
|
| Rate for Payer: Priority Health SBD |
$58.63
|
| Rate for Payer: UMR Bronson Commercial |
$40.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$69.80
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
NDC 0904-6949-61
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.76 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna American Axle |
$197.60
|
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.60
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Cofinity Commercial |
$212.80
|
| Rate for Payer: Cofinity Commercial |
$261.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.20
|
| Rate for Payer: Healthscope Commercial |
$273.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$212.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$258.40
|
| Rate for Payer: PHP Commercial |
$258.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$212.80
|
| Rate for Payer: Priority Health SBD |
$191.52
|
| Rate for Payer: UMR Bronson Commercial |
$133.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.00
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$304.95
|
|
|
Service Code
|
NDC 60687-453-01
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.18 |
| Max. Negotiated Rate |
$274.46 |
| Rate for Payer: Aetna American Axle |
$198.22
|
| Rate for Payer: Aetna Commercial |
$259.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$198.22
|
| Rate for Payer: Cash Price |
$243.96
|
| Rate for Payer: Cofinity Commercial |
$213.46
|
| Rate for Payer: Cofinity Commercial |
$262.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.96
|
| Rate for Payer: Healthscope Commercial |
$274.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$213.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$259.21
|
| Rate for Payer: PHP Commercial |
$259.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.46
|
| Rate for Payer: Priority Health SBD |
$192.12
|
| Rate for Payer: UMR Bronson Commercial |
$134.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.71
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$633.75
|
|
|
Service Code
|
NDC 0074-4341-90
|
| Hospital Charge Code |
4420
|
|
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 25 MCG TABLET
|
Facility
|
IP
|
$3.05
|
|
|
Service Code
|
NDC 60687-453-11
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.34 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna American Axle |
$1.98
|
| Rate for Payer: Aetna Commercial |
$2.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.98
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cofinity Commercial |
$2.14
|
| Rate for Payer: Cofinity Commercial |
$2.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.44
|
| Rate for Payer: Healthscope Commercial |
$2.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.59
|
| Rate for Payer: PHP Commercial |
$2.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.14
|
| Rate for Payer: Priority Health SBD |
$1.92
|
| Rate for Payer: UMR Bronson Commercial |
$1.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.29
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$4.12
|
|
|
Service Code
|
NDC 51079-444-01
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna American Axle |
$2.68
|
| Rate for Payer: Aetna Commercial |
$3.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.68
|
| Rate for Payer: Cash Price |
$3.30
|
| Rate for Payer: Cofinity Commercial |
$2.88
|
| Rate for Payer: Cofinity Commercial |
$3.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.30
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.50
|
| Rate for Payer: PHP Commercial |
$3.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.88
|
| Rate for Payer: Priority Health SBD |
$2.60
|
| Rate for Payer: UMR Bronson Commercial |
$1.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.09
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$411.35
|
|
|
Service Code
|
NDC 51079-444-20
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$180.99 |
| Max. Negotiated Rate |
$370.22 |
| Rate for Payer: Aetna American Axle |
$267.38
|
| Rate for Payer: Aetna Commercial |
$349.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$267.38
|
| Rate for Payer: Cash Price |
$329.08
|
| Rate for Payer: Cofinity Commercial |
$287.94
|
| Rate for Payer: Cofinity Commercial |
$353.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$329.08
|
| Rate for Payer: Healthscope Commercial |
$370.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$287.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$308.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$349.65
|
| Rate for Payer: PHP Commercial |
$349.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$287.94
|
| Rate for Payer: Priority Health SBD |
$259.15
|
| Rate for Payer: UMR Bronson Commercial |
$180.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$308.51
|
|
|
LEVOTHYROXINE 500 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$1,182.05
|
|
|
Service Code
|
NDC 63323-648-10
|
| Hospital Charge Code |
4419
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$437.36 |
| Max. Negotiated Rate |
$1,063.84 |
| Rate for Payer: Aetna American Axle |
$768.33
|
| Rate for Payer: Aetna Commercial |
$1,004.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$768.33
|
| Rate for Payer: BCBS Complete |
$472.82
|
| Rate for Payer: Cash Price |
$945.64
|
| Rate for Payer: Cofinity Commercial |
$1,016.56
|
| Rate for Payer: Cofinity Commercial |
$827.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$945.64
|
| Rate for Payer: Healthscope Commercial |
$1,063.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$827.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$886.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,004.74
|
| Rate for Payer: PHP Commercial |
$1,004.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$827.44
|
| Rate for Payer: Priority Health SBD |
$744.69
|
| Rate for Payer: UMR Bronson Commercial |
$437.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$886.54
|
|
|
LEVOTHYROXINE 500 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$1,182.05
|
|
|
Service Code
|
NDC 63323-648-10
|
| Hospital Charge Code |
4419
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$520.10 |
| Max. Negotiated Rate |
$1,063.84 |
| Rate for Payer: Aetna American Axle |
$768.33
|
| Rate for Payer: Aetna Commercial |
$1,004.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$768.33
|
| Rate for Payer: Cash Price |
$945.64
|
| Rate for Payer: Cofinity Commercial |
$1,016.56
|
| Rate for Payer: Cofinity Commercial |
$827.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$945.64
|
| Rate for Payer: Healthscope Commercial |
$1,063.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$827.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$886.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,004.74
|
| Rate for Payer: PHP Commercial |
$1,004.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$827.44
|
| Rate for Payer: Priority Health SBD |
$744.69
|
| Rate for Payer: UMR Bronson Commercial |
$520.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$886.54
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$467.40
|
|
|
Service Code
|
NDC 51079-440-20
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$205.66 |
| Max. Negotiated Rate |
$420.66 |
| Rate for Payer: Aetna American Axle |
$303.81
|
| Rate for Payer: Aetna Commercial |
$397.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$303.81
|
| Rate for Payer: Cash Price |
$373.92
|
| Rate for Payer: Cofinity Commercial |
$327.18
|
| Rate for Payer: Cofinity Commercial |
$401.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$373.92
|
| Rate for Payer: Healthscope Commercial |
$420.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$327.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$350.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$397.29
|
| Rate for Payer: PHP Commercial |
$397.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$327.18
|
| Rate for Payer: Priority Health SBD |
$294.46
|
| Rate for Payer: UMR Bronson Commercial |
$205.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$350.55
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$328.70
|
|
|
Service Code
|
NDC 60687-464-01
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.63 |
| Max. Negotiated Rate |
$295.83 |
| Rate for Payer: Aetna American Axle |
$213.66
|
| Rate for Payer: Aetna Commercial |
$279.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.66
|
| Rate for Payer: Cash Price |
$262.96
|
| Rate for Payer: Cofinity Commercial |
$230.09
|
| Rate for Payer: Cofinity Commercial |
$282.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.96
|
| Rate for Payer: Healthscope Commercial |
$295.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$279.40
|
| Rate for Payer: PHP Commercial |
$279.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.09
|
| Rate for Payer: Priority Health SBD |
$207.08
|
| Rate for Payer: UMR Bronson Commercial |
$144.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.52
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$633.75
|
|
|
Service Code
|
NDC 0074-4552-90
|
| Hospital Charge Code |
4421
|
|
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 50 MCG TABLET
|
Facility
|
IP
|
$703.68
|
|
|
Service Code
|
NDC 0074-4552-11
|
| Hospital Charge Code |
4421
|
|
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 50 MCG TABLET
|
Facility
|
IP
|
$4.68
|
|
|
Service Code
|
NDC 51079-440-01
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.06 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna American Axle |
$3.04
|
| Rate for Payer: Aetna Commercial |
$3.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.04
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cofinity Commercial |
$3.28
|
| Rate for Payer: Cofinity Commercial |
$4.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.74
|
| Rate for Payer: Healthscope Commercial |
$4.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.98
|
| Rate for Payer: PHP Commercial |
$3.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.28
|
| Rate for Payer: Priority Health SBD |
$2.95
|
| Rate for Payer: UMR Bronson Commercial |
$2.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.51
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$3.29
|
|
|
Service Code
|
NDC 60687-464-11
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.45 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna American Axle |
$2.14
|
| Rate for Payer: Aetna Commercial |
$2.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.14
|
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Cofinity Commercial |
$2.30
|
| Rate for Payer: Cofinity Commercial |
$2.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.63
|
| Rate for Payer: Healthscope Commercial |
$2.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.80
|
| Rate for Payer: PHP Commercial |
$2.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.30
|
| Rate for Payer: Priority Health SBD |
$2.07
|
| Rate for Payer: UMR Bronson Commercial |
$1.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.47
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$703.68
|
|
|
Service Code
|
NDC 0074-5182-11
|
| Hospital Charge Code |
4422
|
|
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 75 MCG TABLET
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 51079-441-01
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Aetna American Axle |
$1.71
|
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.71
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$1.84
|
| Rate for Payer: Cofinity Commercial |
$2.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.24
|
| Rate for Payer: PHP Commercial |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.84
|
| Rate for Payer: Priority Health SBD |
$1.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.97
|
|
