|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$129.02
|
|
|
Service Code
|
NDC 68180096909
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.74 |
| Max. Negotiated Rate |
$116.12 |
| Rate for Payer: Aetna American Axle |
$83.86
|
| Rate for Payer: Aetna Commercial |
$109.67
|
| Rate for Payer: Aetna Medicare |
$64.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$83.86
|
| Rate for Payer: BCBS Complete |
$51.61
|
| Rate for Payer: Cash Price |
$103.22
|
| Rate for Payer: Cofinity Advantage |
$90.31
|
| Rate for Payer: Cofinity Commercial |
$110.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$103.22
|
| Rate for Payer: Healthscope Commercial |
$116.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$90.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$96.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$103.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$109.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$96.77
|
| Rate for Payer: PHP Commercial |
$109.67
|
| Rate for Payer: Priority Health SBD |
$81.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$83.86
|
| Rate for Payer: UHC Core |
$67.22
|
| Rate for Payer: UHC Exchange |
$50.70
|
| Rate for Payer: UMR Bronson Commercial |
$47.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$96.77
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$813.60
|
|
|
Service Code
|
NDC 00074662411
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$301.03 |
| Max. Negotiated Rate |
$732.24 |
| Rate for Payer: Aetna American Axle |
$528.84
|
| Rate for Payer: Aetna Commercial |
$691.56
|
| Rate for Payer: Aetna Medicare |
$406.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$528.84
|
| Rate for Payer: BCBS Complete |
$325.44
|
| Rate for Payer: Cash Price |
$650.88
|
| Rate for Payer: Cofinity Advantage |
$569.52
|
| Rate for Payer: Cofinity Commercial |
$699.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$650.88
|
| Rate for Payer: Healthscope Commercial |
$732.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$569.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$610.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$650.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$691.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$610.20
|
| Rate for Payer: PHP Commercial |
$691.56
|
| Rate for Payer: Priority Health SBD |
$512.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$528.84
|
| Rate for Payer: UHC Core |
$423.89
|
| Rate for Payer: UHC Exchange |
$319.74
|
| Rate for Payer: UMR Bronson Commercial |
$301.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$610.20
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$813.60
|
|
|
Service Code
|
NDC 00074662411
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$357.98 |
| Max. Negotiated Rate |
$732.24 |
| Rate for Payer: Aetna American Axle |
$528.84
|
| Rate for Payer: Aetna Commercial |
$691.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$528.84
|
| Rate for Payer: Cash Price |
$650.88
|
| Rate for Payer: Cofinity Advantage |
$569.52
|
| Rate for Payer: Cofinity Commercial |
$699.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$650.88
|
| Rate for Payer: Healthscope Commercial |
$732.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$569.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$610.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$691.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$610.20
|
| Rate for Payer: PHP Commercial |
$691.56
|
| Rate for Payer: Priority Health SBD |
$512.57
|
| Rate for Payer: UMR Bronson Commercial |
$357.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$610.20
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$2.75
|
|
|
Service Code
|
NDC 42292003901
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$2.48 |
| Rate for Payer: Aetna American Axle |
$1.79
|
| Rate for Payer: Aetna Commercial |
$2.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.79
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cofinity Advantage |
$1.93
|
| Rate for Payer: Cofinity Commercial |
$2.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.20
|
| Rate for Payer: Healthscope Commercial |
$2.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.06
|
| Rate for Payer: PHP Commercial |
$2.34
|
| Rate for Payer: Priority Health SBD |
$1.73
|
| Rate for Payer: UMR Bronson Commercial |
$1.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.06
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$242.05
|
|
|
Service Code
|
NDC 68180097001
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.56 |
| Max. Negotiated Rate |
$217.84 |
| Rate for Payer: Aetna American Axle |
$157.33
|
| Rate for Payer: Aetna Commercial |
$205.74
|
| Rate for Payer: Aetna Medicare |
$121.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.33
|
| Rate for Payer: BCBS Complete |
$96.82
|
| Rate for Payer: Cash Price |
$193.64
|
| Rate for Payer: Cofinity Advantage |
$169.44
|
| Rate for Payer: Cofinity Commercial |
$208.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.64
|
| Rate for Payer: Healthscope Commercial |
$217.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$169.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$193.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.54
|
| Rate for Payer: PHP Commercial |
$205.74
|
| Rate for Payer: Priority Health SBD |
$152.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.33
|
| Rate for Payer: UHC Core |
$126.11
|
| Rate for Payer: UHC Exchange |
$95.13
|
| Rate for Payer: UMR Bronson Commercial |
$89.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.54
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$547.68
|
|
|
Service Code
|
NDC 60793085501
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$202.64 |
| Max. Negotiated Rate |
$492.91 |
| Rate for Payer: Aetna American Axle |
$355.99
|
| Rate for Payer: Aetna Commercial |
$465.53
|
| Rate for Payer: Aetna Medicare |
$273.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$355.99
|
| Rate for Payer: BCBS Complete |
$219.07
|
| Rate for Payer: Cash Price |
$438.14
|
| Rate for Payer: Cofinity Advantage |
$383.38
|
| Rate for Payer: Cofinity Commercial |
$471.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$438.14
|
| Rate for Payer: Healthscope Commercial |
$492.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$383.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$410.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$438.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$465.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$410.76
|
| Rate for Payer: PHP Commercial |
$465.53
|
| Rate for Payer: Priority Health SBD |
$345.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$355.99
|
| Rate for Payer: UHC Core |
$285.34
|
| Rate for Payer: UHC Exchange |
$215.24
|
| Rate for Payer: UMR Bronson Commercial |
$202.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$410.76
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$2.75
|
|
|
Service Code
|
NDC 42292003901
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.02 |
| Max. Negotiated Rate |
$2.48 |
| Rate for Payer: Aetna American Axle |
$1.79
|
| Rate for Payer: Aetna Commercial |
$2.34
|
| Rate for Payer: Aetna Medicare |
$1.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.79
|
| Rate for Payer: BCBS Complete |
$1.10
|
| Rate for Payer: Cash Price |
$2.20
|
| Rate for Payer: Cofinity Advantage |
$1.93
|
| Rate for Payer: Cofinity Commercial |
$2.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.20
|
| Rate for Payer: Healthscope Commercial |
$2.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.06
|
| Rate for Payer: PHP Commercial |
$2.34
|
| Rate for Payer: Priority Health SBD |
$1.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.79
|
| Rate for Payer: UHC Core |
$1.43
|
| Rate for Payer: UHC Exchange |
$1.08
|
| Rate for Payer: UMR Bronson Commercial |
$1.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.06
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$293.55
|
|
|
Service Code
|
NDC 69238183501
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.16 |
| Max. Negotiated Rate |
$264.19 |
| Rate for Payer: Aetna American Axle |
$190.81
|
| Rate for Payer: Aetna Commercial |
$249.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.81
|
| Rate for Payer: Cash Price |
$234.84
|
| Rate for Payer: Cofinity Advantage |
$205.49
|
| Rate for Payer: Cofinity Commercial |
$252.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.84
|
| Rate for Payer: Healthscope Commercial |
$264.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$205.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$220.16
|
| Rate for Payer: PHP Commercial |
$249.52
|
| Rate for Payer: Priority Health SBD |
$184.94
|
| Rate for Payer: UMR Bronson Commercial |
$129.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.16
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$732.24
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$270.93 |
| Max. Negotiated Rate |
$659.02 |
| Rate for Payer: Aetna American Axle |
$475.96
|
| Rate for Payer: Aetna Commercial |
$622.40
|
| Rate for Payer: Aetna Medicare |
$366.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$475.96
|
| Rate for Payer: BCBS Complete |
$292.90
|
| Rate for Payer: Cash Price |
$585.79
|
| Rate for Payer: Cofinity Advantage |
$512.57
|
| Rate for Payer: Cofinity Commercial |
$629.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$585.79
|
| Rate for Payer: Healthscope Commercial |
$659.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$512.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$549.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$585.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.18
|
| Rate for Payer: PHP Commercial |
$622.40
|
| Rate for Payer: Priority Health SBD |
$461.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$475.96
|
| Rate for Payer: UHC Core |
$381.50
|
| Rate for Payer: UHC Exchange |
$287.77
|
| Rate for Payer: UMR Bronson Commercial |
$270.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$549.18
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$226.31
|
|
|
Service Code
|
NDC 00527328546
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.73 |
| Max. Negotiated Rate |
$203.68 |
| Rate for Payer: Aetna American Axle |
$147.10
|
| Rate for Payer: Aetna Commercial |
$192.36
|
| Rate for Payer: Aetna Medicare |
$113.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.10
|
| Rate for Payer: BCBS Complete |
$90.52
|
| Rate for Payer: Cash Price |
$181.05
|
| Rate for Payer: Cofinity Advantage |
$158.42
|
| Rate for Payer: Cofinity Commercial |
$194.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$181.05
|
| Rate for Payer: Healthscope Commercial |
$203.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$158.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$169.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$181.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$192.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$169.73
|
| Rate for Payer: PHP Commercial |
$192.36
|
| Rate for Payer: Priority Health SBD |
$142.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$147.10
|
| Rate for Payer: UHC Core |
$117.91
|
| Rate for Payer: UHC Exchange |
$88.94
|
| Rate for Payer: UMR Bronson Commercial |
$83.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.73
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$226.31
|
|
|
Service Code
|
NDC 00527328546
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.58 |
| Max. Negotiated Rate |
$203.68 |
| Rate for Payer: Aetna American Axle |
$147.10
|
| Rate for Payer: Aetna Commercial |
$192.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.10
|
| Rate for Payer: Cash Price |
$181.05
|
| Rate for Payer: Cofinity Advantage |
$158.42
|
| Rate for Payer: Cofinity Commercial |
$194.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$181.05
|
| Rate for Payer: Healthscope Commercial |
$203.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$158.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$169.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$192.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$169.73
|
| Rate for Payer: PHP Commercial |
$192.36
|
| Rate for Payer: Priority Health SBD |
$142.58
|
| Rate for Payer: UMR Bronson Commercial |
$99.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$169.73
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$274.56
|
|
|
Service Code
|
NDC 42292003920
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.59 |
| Max. Negotiated Rate |
$247.10 |
| Rate for Payer: Aetna American Axle |
$178.46
|
| Rate for Payer: Aetna Commercial |
$233.38
|
| Rate for Payer: Aetna Medicare |
$137.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$178.46
|
| Rate for Payer: BCBS Complete |
$109.82
|
| Rate for Payer: Cash Price |
$219.65
|
| Rate for Payer: Cofinity Advantage |
$192.19
|
| Rate for Payer: Cofinity Commercial |
$236.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.65
|
| Rate for Payer: Healthscope Commercial |
$247.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$192.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$219.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$233.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$205.92
|
| Rate for Payer: PHP Commercial |
$233.38
|
| Rate for Payer: Priority Health SBD |
$172.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$178.46
|
| Rate for Payer: UHC Core |
$143.05
|
| Rate for Payer: UHC Exchange |
$107.90
|
| Rate for Payer: UMR Bronson Commercial |
$101.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.92
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$547.68
|
|
|
Service Code
|
NDC 60793085501
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$240.98 |
| Max. Negotiated Rate |
$492.91 |
| Rate for Payer: Aetna American Axle |
$355.99
|
| Rate for Payer: Aetna Commercial |
$465.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$355.99
|
| Rate for Payer: Cash Price |
$438.14
|
| Rate for Payer: Cofinity Advantage |
$383.38
|
| Rate for Payer: Cofinity Commercial |
$471.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$438.14
|
| Rate for Payer: Healthscope Commercial |
$492.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$383.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$410.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$465.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$410.76
|
| Rate for Payer: PHP Commercial |
$465.53
|
| Rate for Payer: Priority Health SBD |
$345.04
|
| Rate for Payer: UMR Bronson Commercial |
$240.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$410.76
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$732.24
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$322.19 |
| Max. Negotiated Rate |
$659.02 |
| Rate for Payer: Aetna American Axle |
$475.96
|
| Rate for Payer: Aetna Commercial |
$622.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$475.96
|
| Rate for Payer: Cash Price |
$585.79
|
| Rate for Payer: Cofinity Advantage |
$512.57
|
| Rate for Payer: Cofinity Commercial |
$629.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$585.79
|
| Rate for Payer: Healthscope Commercial |
$659.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$512.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$549.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.18
|
| Rate for Payer: PHP Commercial |
$622.40
|
| Rate for Payer: Priority Health SBD |
$461.31
|
| Rate for Payer: UMR Bronson Commercial |
$322.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$549.18
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$242.05
|
|
|
Service Code
|
NDC 68180097001
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.50 |
| Max. Negotiated Rate |
$217.84 |
| Rate for Payer: Aetna American Axle |
$157.33
|
| Rate for Payer: Aetna Commercial |
$205.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.33
|
| Rate for Payer: Cash Price |
$193.64
|
| Rate for Payer: Cofinity Advantage |
$169.44
|
| Rate for Payer: Cofinity Commercial |
$208.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.64
|
| Rate for Payer: Healthscope Commercial |
$217.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$169.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.54
|
| Rate for Payer: PHP Commercial |
$205.74
|
| Rate for Payer: Priority Health SBD |
$152.49
|
| Rate for Payer: UMR Bronson Commercial |
$106.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.54
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$293.55
|
|
|
Service Code
|
NDC 69238183501
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.61 |
| Max. Negotiated Rate |
$264.19 |
| Rate for Payer: Aetna American Axle |
$190.81
|
| Rate for Payer: Aetna Commercial |
$249.52
|
| Rate for Payer: Aetna Medicare |
$146.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.81
|
| Rate for Payer: BCBS Complete |
$117.42
|
| Rate for Payer: Cash Price |
$234.84
|
| Rate for Payer: Cofinity Advantage |
$205.49
|
| Rate for Payer: Cofinity Commercial |
$252.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.84
|
| Rate for Payer: Healthscope Commercial |
$264.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$205.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$234.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$220.16
|
| Rate for Payer: PHP Commercial |
$249.52
|
| Rate for Payer: Priority Health SBD |
$184.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$190.81
|
| Rate for Payer: UHC Core |
$152.94
|
| Rate for Payer: UHC Exchange |
$115.37
|
| Rate for Payer: UMR Bronson Commercial |
$108.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.16
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$274.56
|
|
|
Service Code
|
NDC 42292003920
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.81 |
| Max. Negotiated Rate |
$247.10 |
| Rate for Payer: Aetna American Axle |
$178.46
|
| Rate for Payer: Aetna Commercial |
$233.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$178.46
|
| Rate for Payer: Cash Price |
$219.65
|
| Rate for Payer: Cofinity Advantage |
$192.19
|
| Rate for Payer: Cofinity Commercial |
$236.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$219.65
|
| Rate for Payer: Healthscope Commercial |
$247.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$192.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$233.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$205.92
|
| Rate for Payer: PHP Commercial |
$233.38
|
| Rate for Payer: Priority Health SBD |
$172.97
|
| Rate for Payer: UMR Bronson Commercial |
$120.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.92
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$309.60
|
|
|
Service Code
|
NDC 51079044320
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.22 |
| Max. Negotiated Rate |
$278.64 |
| Rate for Payer: Aetna American Axle |
$201.24
|
| Rate for Payer: Aetna Commercial |
$263.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.24
|
| Rate for Payer: Cash Price |
$247.68
|
| Rate for Payer: Cofinity Advantage |
$216.72
|
| Rate for Payer: Cofinity Commercial |
$266.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.68
|
| Rate for Payer: Healthscope Commercial |
$278.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.20
|
| Rate for Payer: PHP Commercial |
$263.16
|
| Rate for Payer: Priority Health SBD |
$195.05
|
| Rate for Payer: UMR Bronson Commercial |
$136.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.20
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$732.68
|
|
|
Service Code
|
NDC 00074706890
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$322.38 |
| Max. Negotiated Rate |
$659.41 |
| Rate for Payer: Aetna American Axle |
$476.24
|
| Rate for Payer: Aetna Commercial |
$622.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$476.24
|
| Rate for Payer: Cash Price |
$586.14
|
| Rate for Payer: Cofinity Advantage |
$512.88
|
| Rate for Payer: Cofinity Commercial |
$630.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$586.14
|
| Rate for Payer: Healthscope Commercial |
$659.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$512.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$549.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.51
|
| Rate for Payer: PHP Commercial |
$622.78
|
| Rate for Payer: Priority Health SBD |
$461.59
|
| Rate for Payer: UMR Bronson Commercial |
$322.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$549.51
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$395.87
|
|
|
Service Code
|
NDC 00378181377
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.18 |
| Max. Negotiated Rate |
$356.28 |
| Rate for Payer: Aetna American Axle |
$257.32
|
| Rate for Payer: Aetna Commercial |
$336.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$257.32
|
| Rate for Payer: Cash Price |
$316.70
|
| Rate for Payer: Cofinity Advantage |
$277.11
|
| Rate for Payer: Cofinity Commercial |
$340.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.70
|
| Rate for Payer: Healthscope Commercial |
$356.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$296.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$296.90
|
| Rate for Payer: PHP Commercial |
$336.49
|
| Rate for Payer: Priority Health SBD |
$249.40
|
| Rate for Payer: UMR Bronson Commercial |
$174.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$296.90
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$813.60
|
|
|
Service Code
|
NDC 00074706811
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$301.03 |
| Max. Negotiated Rate |
$732.24 |
| Rate for Payer: Aetna American Axle |
$528.84
|
| Rate for Payer: Aetna Commercial |
$691.56
|
| Rate for Payer: Aetna Medicare |
$406.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$528.84
|
| Rate for Payer: BCBS Complete |
$325.44
|
| Rate for Payer: Cash Price |
$650.88
|
| Rate for Payer: Cofinity Advantage |
$569.52
|
| Rate for Payer: Cofinity Commercial |
$699.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$650.88
|
| Rate for Payer: Healthscope Commercial |
$732.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$569.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$610.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$650.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$691.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$610.20
|
| Rate for Payer: PHP Commercial |
$691.56
|
| Rate for Payer: Priority Health SBD |
$512.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$528.84
|
| Rate for Payer: UHC Core |
$423.89
|
| Rate for Payer: UHC Exchange |
$319.74
|
| Rate for Payer: UMR Bronson Commercial |
$301.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$610.20
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$3.10
|
|
|
Service Code
|
NDC 51079044301
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Aetna American Axle |
$2.02
|
| Rate for Payer: Aetna Commercial |
$2.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.02
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cofinity Advantage |
$2.17
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.48
|
| Rate for Payer: Healthscope Commercial |
$2.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.33
|
| Rate for Payer: PHP Commercial |
$2.63
|
| Rate for Payer: Priority Health SBD |
$1.95
|
| Rate for Payer: UMR Bronson Commercial |
$1.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.33
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$3.10
|
|
|
Service Code
|
NDC 51079044301
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.79 |
| Rate for Payer: Aetna American Axle |
$2.02
|
| Rate for Payer: Aetna Commercial |
$2.63
|
| Rate for Payer: Aetna Medicare |
$1.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.02
|
| Rate for Payer: BCBS Complete |
$1.24
|
| Rate for Payer: Cash Price |
$2.48
|
| Rate for Payer: Cofinity Advantage |
$2.17
|
| Rate for Payer: Cofinity Commercial |
$2.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.48
|
| Rate for Payer: Healthscope Commercial |
$2.79
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.63
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.33
|
| Rate for Payer: PHP Commercial |
$2.63
|
| Rate for Payer: Priority Health SBD |
$1.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.02
|
| Rate for Payer: UHC Core |
$1.62
|
| Rate for Payer: UHC Exchange |
$1.22
|
| Rate for Payer: UMR Bronson Commercial |
$1.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.33
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$259.20
|
|
|
Service Code
|
NDC 60687051901
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.05 |
| Max. Negotiated Rate |
$233.28 |
| Rate for Payer: Aetna American Axle |
$168.48
|
| Rate for Payer: Aetna Commercial |
$220.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.48
|
| Rate for Payer: Cash Price |
$207.36
|
| Rate for Payer: Cofinity Advantage |
$181.44
|
| Rate for Payer: Cofinity Commercial |
$222.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$207.36
|
| Rate for Payer: Healthscope Commercial |
$233.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$181.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$194.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$220.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$194.40
|
| Rate for Payer: PHP Commercial |
$220.32
|
| Rate for Payer: Priority Health SBD |
$163.30
|
| Rate for Payer: UMR Bronson Commercial |
$114.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$194.40
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$309.60
|
|
|
Service Code
|
NDC 51079044320
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.55 |
| Max. Negotiated Rate |
$278.64 |
| Rate for Payer: Aetna American Axle |
$201.24
|
| Rate for Payer: Aetna Commercial |
$263.16
|
| Rate for Payer: Aetna Medicare |
$154.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$201.24
|
| Rate for Payer: BCBS Complete |
$123.84
|
| Rate for Payer: Cash Price |
$247.68
|
| Rate for Payer: Cofinity Advantage |
$216.72
|
| Rate for Payer: Cofinity Commercial |
$266.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.68
|
| Rate for Payer: Healthscope Commercial |
$278.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$247.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$263.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$232.20
|
| Rate for Payer: PHP Commercial |
$263.16
|
| Rate for Payer: Priority Health SBD |
$195.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$201.24
|
| Rate for Payer: UHC Core |
$161.30
|
| Rate for Payer: UHC Exchange |
$121.67
|
| Rate for Payer: UMR Bronson Commercial |
$114.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.20
|
|
