|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$813.60
|
|
|
Service Code
|
NDC 00074706811
|
| Hospital Charge Code |
4424
|
|
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 125 MCG TABLET
|
Facility
|
OP
|
$2.60
|
|
|
Service Code
|
NDC 60687051911
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.96 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna American Axle |
$1.69
|
| Rate for Payer: Aetna Commercial |
$2.21
|
| Rate for Payer: Aetna Medicare |
$1.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.69
|
| Rate for Payer: BCBS Complete |
$1.04
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cofinity Advantage |
$1.82
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.08
|
| Rate for Payer: Healthscope Commercial |
$2.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.95
|
| Rate for Payer: PHP Commercial |
$2.21
|
| Rate for Payer: Priority Health SBD |
$1.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.69
|
| Rate for Payer: UHC Core |
$1.35
|
| Rate for Payer: UHC Exchange |
$1.02
|
| Rate for Payer: UMR Bronson Commercial |
$0.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.95
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$259.20
|
|
|
Service Code
|
NDC 60687051901
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.90 |
| Max. Negotiated Rate |
$233.28 |
| Rate for Payer: Aetna American Axle |
$168.48
|
| Rate for Payer: Aetna Commercial |
$220.32
|
| Rate for Payer: Aetna Medicare |
$129.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$168.48
|
| Rate for Payer: BCBS Complete |
$103.68
|
| 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: MI Amish Medical Board Commercial |
$207.36
|
| 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: UHC All Payor (Choice/PPO) |
$168.48
|
| Rate for Payer: UHC Core |
$135.04
|
| Rate for Payer: UHC Exchange |
$101.87
|
| Rate for Payer: UMR Bronson Commercial |
$95.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$194.40
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$2.60
|
|
|
Service Code
|
NDC 60687051911
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.14 |
| Max. Negotiated Rate |
$2.34 |
| Rate for Payer: Aetna American Axle |
$1.69
|
| Rate for Payer: Aetna Commercial |
$2.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.69
|
| Rate for Payer: Cash Price |
$2.08
|
| Rate for Payer: Cofinity Advantage |
$1.82
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.08
|
| Rate for Payer: Healthscope Commercial |
$2.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.95
|
| Rate for Payer: PHP Commercial |
$2.21
|
| Rate for Payer: Priority Health SBD |
$1.64
|
| Rate for Payer: UMR Bronson Commercial |
$1.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.95
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$395.87
|
|
|
Service Code
|
NDC 00378181377
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.47 |
| Max. Negotiated Rate |
$356.28 |
| Rate for Payer: Aetna American Axle |
$257.32
|
| Rate for Payer: Aetna Commercial |
$336.49
|
| Rate for Payer: Aetna Medicare |
$197.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$257.32
|
| Rate for Payer: BCBS Complete |
$158.35
|
| 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: MI Amish Medical Board Commercial |
$316.70
|
| 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: UHC All Payor (Choice/PPO) |
$257.32
|
| Rate for Payer: UHC Core |
$206.25
|
| Rate for Payer: UHC Exchange |
$155.58
|
| Rate for Payer: UMR Bronson Commercial |
$146.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$296.90
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$732.68
|
|
|
Service Code
|
NDC 00074706890
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.09 |
| Max. Negotiated Rate |
$659.41 |
| Rate for Payer: Aetna American Axle |
$476.24
|
| Rate for Payer: Aetna Commercial |
$622.78
|
| Rate for Payer: Aetna Medicare |
$366.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$476.24
|
| Rate for Payer: BCBS Complete |
$293.07
|
| 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: MI Amish Medical Board Commercial |
$586.14
|
| 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: UHC All Payor (Choice/PPO) |
$476.24
|
| Rate for Payer: UHC Core |
$381.73
|
| Rate for Payer: UHC Exchange |
$287.94
|
| Rate for Payer: UMR Bronson Commercial |
$271.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$549.51
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$2.61
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.97 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna American Axle |
$1.70
|
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: Aetna Medicare |
$1.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: BCBS Complete |
$1.04
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cofinity Advantage |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.96
|
| Rate for Payer: PHP Commercial |
$2.22
|
| Rate for Payer: Priority Health SBD |
$1.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.70
|
| Rate for Payer: UHC Core |
$1.36
|
| Rate for Payer: UHC Exchange |
$1.03
|
| Rate for Payer: UMR Bronson Commercial |
$0.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$260.16
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.47 |
| Max. Negotiated Rate |
$234.14 |
| Rate for Payer: Aetna American Axle |
$169.10
|
| Rate for Payer: Aetna Commercial |
$221.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.10
|
| Rate for Payer: Cash Price |
$208.13
|
| Rate for Payer: Cofinity Advantage |
$182.11
|
| Rate for Payer: Cofinity Commercial |
$223.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.13
|
| Rate for Payer: Healthscope Commercial |
$234.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.12
|
| Rate for Payer: PHP Commercial |
$221.14
|
| Rate for Payer: Priority Health SBD |
$163.90
|
| Rate for Payer: UMR Bronson Commercial |
$114.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.12
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$260.16
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.26 |
| Max. Negotiated Rate |
$234.14 |
| Rate for Payer: Aetna American Axle |
$169.10
|
| Rate for Payer: Aetna Commercial |
$221.14
|
| Rate for Payer: Aetna Medicare |
$130.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$169.10
|
| Rate for Payer: BCBS Complete |
$104.06
|
| Rate for Payer: Cash Price |
$208.13
|
| Rate for Payer: Cofinity Advantage |
$182.11
|
| Rate for Payer: Cofinity Commercial |
$223.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$208.13
|
| Rate for Payer: Healthscope Commercial |
$234.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$182.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$195.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$208.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$221.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$195.12
|
| Rate for Payer: PHP Commercial |
$221.14
|
| Rate for Payer: Priority Health SBD |
$163.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$169.10
|
| Rate for Payer: UHC Core |
$135.54
|
| Rate for Payer: UHC Exchange |
$102.24
|
| Rate for Payer: UMR Bronson Commercial |
$96.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$195.12
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$132.54
|
|
|
Service Code
|
NDC 72305013730
|
| Hospital Charge Code |
10405
|
|
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 Advantage |
$92.78
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| 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 |
$99.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$99.41
|
| Rate for Payer: PHP Commercial |
$112.66
|
| 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 |
$99.41
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$2.61
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.15 |
| Max. Negotiated Rate |
$2.35 |
| Rate for Payer: Aetna American Axle |
$1.70
|
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.70
|
| Rate for Payer: Cash Price |
$2.09
|
| Rate for Payer: Cofinity Advantage |
$1.83
|
| Rate for Payer: Cofinity Commercial |
$2.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.09
|
| Rate for Payer: Healthscope Commercial |
$2.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.96
|
| Rate for Payer: PHP Commercial |
$2.22
|
| Rate for Payer: Priority Health SBD |
$1.64
|
| Rate for Payer: UMR Bronson Commercial |
$1.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.96
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
NDC 00378182377
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.37 |
| Max. Negotiated Rate |
$360.90 |
| Rate for Payer: Aetna American Axle |
$260.65
|
| Rate for Payer: Aetna Commercial |
$340.85
|
| Rate for Payer: Aetna Medicare |
$200.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.65
|
| Rate for Payer: BCBS Complete |
$160.40
|
| Rate for Payer: Cash Price |
$320.80
|
| Rate for Payer: Cofinity Advantage |
$280.70
|
| Rate for Payer: Cofinity Commercial |
$344.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.80
|
| Rate for Payer: Healthscope Commercial |
$360.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$280.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$300.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$320.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$300.75
|
| Rate for Payer: PHP Commercial |
$340.85
|
| Rate for Payer: Priority Health SBD |
$252.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$260.65
|
| Rate for Payer: UHC Core |
$208.92
|
| Rate for Payer: UHC Exchange |
$157.59
|
| Rate for Payer: UMR Bronson Commercial |
$148.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$300.75
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
NDC 00378182377
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.44 |
| Max. Negotiated Rate |
$360.90 |
| Rate for Payer: Aetna American Axle |
$260.65
|
| Rate for Payer: Aetna Commercial |
$340.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.65
|
| Rate for Payer: Cash Price |
$320.80
|
| Rate for Payer: Cofinity Advantage |
$280.70
|
| Rate for Payer: Cofinity Commercial |
$344.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.80
|
| Rate for Payer: Healthscope Commercial |
$360.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$280.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$300.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$300.75
|
| Rate for Payer: PHP Commercial |
$340.85
|
| Rate for Payer: Priority Health SBD |
$252.63
|
| Rate for Payer: UMR Bronson Commercial |
$176.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$300.75
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$132.54
|
|
|
Service Code
|
NDC 72305013730
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.04 |
| Max. Negotiated Rate |
$119.29 |
| Rate for Payer: Aetna American Axle |
$86.15
|
| Rate for Payer: Aetna Commercial |
$112.66
|
| Rate for Payer: Aetna Medicare |
$66.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.15
|
| Rate for Payer: BCBS Complete |
$53.02
|
| Rate for Payer: Cash Price |
$106.03
|
| Rate for Payer: Cofinity Advantage |
$92.78
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| 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 |
$99.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$106.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$99.41
|
| Rate for Payer: PHP Commercial |
$112.66
|
| Rate for Payer: Priority Health SBD |
$83.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$86.15
|
| Rate for Payer: UHC Core |
$69.05
|
| Rate for Payer: UHC Exchange |
$52.09
|
| Rate for Payer: UMR Bronson Commercial |
$49.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.41
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$289.76
|
|
|
Service Code
|
NDC 68180097209
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.21 |
| Max. Negotiated Rate |
$260.78 |
| Rate for Payer: Aetna American Axle |
$188.34
|
| Rate for Payer: Aetna Commercial |
$246.30
|
| Rate for Payer: Aetna Medicare |
$144.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.34
|
| Rate for Payer: BCBS Complete |
$115.90
|
| Rate for Payer: Cash Price |
$231.81
|
| Rate for Payer: Cofinity Advantage |
$202.83
|
| Rate for Payer: Cofinity Commercial |
$249.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.81
|
| Rate for Payer: Healthscope Commercial |
$260.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$217.32
|
| Rate for Payer: MI Amish Medical Board Commercial |
$231.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$246.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$217.32
|
| Rate for Payer: PHP Commercial |
$246.30
|
| Rate for Payer: Priority Health SBD |
$182.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$188.34
|
| Rate for Payer: UHC Core |
$150.96
|
| Rate for Payer: UHC Exchange |
$113.88
|
| Rate for Payer: UMR Bronson Commercial |
$107.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$217.32
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$732.68
|
|
|
Service Code
|
NDC 00074372790
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.09 |
| Max. Negotiated Rate |
$659.41 |
| Rate for Payer: Aetna American Axle |
$476.24
|
| Rate for Payer: Aetna Commercial |
$622.78
|
| Rate for Payer: Aetna Medicare |
$366.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$476.24
|
| Rate for Payer: BCBS Complete |
$293.07
|
| 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: MI Amish Medical Board Commercial |
$586.14
|
| 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: UHC All Payor (Choice/PPO) |
$476.24
|
| Rate for Payer: UHC Core |
$381.73
|
| Rate for Payer: UHC Exchange |
$287.94
|
| Rate for Payer: UMR Bronson Commercial |
$271.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$549.51
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$732.68
|
|
|
Service Code
|
NDC 00074372790
|
| Hospital Charge Code |
10405
|
|
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 137 MCG TABLET
|
Facility
|
IP
|
$289.76
|
|
|
Service Code
|
NDC 68180097209
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.49 |
| Max. Negotiated Rate |
$260.78 |
| Rate for Payer: Aetna American Axle |
$188.34
|
| Rate for Payer: Aetna Commercial |
$246.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$188.34
|
| Rate for Payer: Cash Price |
$231.81
|
| Rate for Payer: Cofinity Advantage |
$202.83
|
| Rate for Payer: Cofinity Commercial |
$249.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$231.81
|
| Rate for Payer: Healthscope Commercial |
$260.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$202.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$217.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$246.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$217.32
|
| Rate for Payer: PHP Commercial |
$246.30
|
| Rate for Payer: Priority Health SBD |
$182.55
|
| Rate for Payer: UMR Bronson Commercial |
$127.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$217.32
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$732.68
|
|
|
Service Code
|
NDC 00074706990
|
| Hospital Charge Code |
4425
|
|
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 150 MCG TABLET
|
Facility
|
OP
|
$318.24
|
|
|
Service Code
|
NDC 51079044520
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.75 |
| Max. Negotiated Rate |
$286.42 |
| Rate for Payer: Aetna American Axle |
$206.86
|
| Rate for Payer: Aetna Commercial |
$270.50
|
| Rate for Payer: Aetna Medicare |
$159.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.86
|
| Rate for Payer: BCBS Complete |
$127.30
|
| Rate for Payer: Cash Price |
$254.59
|
| Rate for Payer: Cofinity Advantage |
$222.77
|
| Rate for Payer: Cofinity Commercial |
$273.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.59
|
| Rate for Payer: Healthscope Commercial |
$286.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$222.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$238.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$254.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$238.68
|
| Rate for Payer: PHP Commercial |
$270.50
|
| Rate for Payer: Priority Health SBD |
$200.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$206.86
|
| Rate for Payer: UHC Core |
$165.80
|
| Rate for Payer: UHC Exchange |
$125.07
|
| Rate for Payer: UMR Bronson Commercial |
$117.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.68
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$3.19
|
|
|
Service Code
|
NDC 51079044501
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna American Axle |
$2.07
|
| Rate for Payer: Aetna Commercial |
$2.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.07
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cofinity Advantage |
$2.23
|
| Rate for Payer: Cofinity Commercial |
$2.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.55
|
| Rate for Payer: Healthscope Commercial |
$2.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.39
|
| Rate for Payer: PHP Commercial |
$2.71
|
| Rate for Payer: Priority Health SBD |
$2.01
|
| Rate for Payer: UMR Bronson Commercial |
$1.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.39
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$406.98
|
|
|
Service Code
|
NDC 00378181577
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.07 |
| Max. Negotiated Rate |
$366.28 |
| Rate for Payer: Aetna American Axle |
$264.54
|
| Rate for Payer: Aetna Commercial |
$345.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.54
|
| Rate for Payer: Cash Price |
$325.58
|
| Rate for Payer: Cofinity Advantage |
$284.89
|
| Rate for Payer: Cofinity Commercial |
$350.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.58
|
| Rate for Payer: Healthscope Commercial |
$366.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$305.24
|
| Rate for Payer: PHP Commercial |
$345.93
|
| Rate for Payer: Priority Health SBD |
$256.40
|
| Rate for Payer: UMR Bronson Commercial |
$179.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.24
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$3.19
|
|
|
Service Code
|
NDC 51079044501
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$2.87 |
| Rate for Payer: Aetna American Axle |
$2.07
|
| Rate for Payer: Aetna Commercial |
$2.71
|
| Rate for Payer: Aetna Medicare |
$1.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.07
|
| Rate for Payer: BCBS Complete |
$1.28
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cofinity Advantage |
$2.23
|
| Rate for Payer: Cofinity Commercial |
$2.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.55
|
| Rate for Payer: Healthscope Commercial |
$2.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.39
|
| Rate for Payer: PHP Commercial |
$2.71
|
| Rate for Payer: Priority Health SBD |
$2.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.07
|
| Rate for Payer: UHC Core |
$1.66
|
| Rate for Payer: UHC Exchange |
$1.25
|
| Rate for Payer: UMR Bronson Commercial |
$1.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.39
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$774.72
|
|
|
Service Code
|
NDC 00074706911
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.65 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna American Axle |
$503.57
|
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna Medicare |
$387.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.57
|
| Rate for Payer: BCBS Complete |
$309.89
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Advantage |
$542.30
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$697.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$542.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$581.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$619.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$581.04
|
| Rate for Payer: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health SBD |
$488.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$503.57
|
| Rate for Payer: UHC Core |
$403.63
|
| Rate for Payer: UHC Exchange |
$304.46
|
| Rate for Payer: UMR Bronson Commercial |
$286.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.04
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$408.90
|
|
|
Service Code
|
NDC 68180097301
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.29 |
| Max. Negotiated Rate |
$368.01 |
| Rate for Payer: Aetna American Axle |
$265.79
|
| Rate for Payer: Aetna Commercial |
$347.56
|
| Rate for Payer: Aetna Medicare |
$204.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$265.79
|
| Rate for Payer: BCBS Complete |
$163.56
|
| Rate for Payer: Cash Price |
$327.12
|
| Rate for Payer: Cofinity Advantage |
$286.23
|
| Rate for Payer: Cofinity Commercial |
$351.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$327.12
|
| Rate for Payer: Healthscope Commercial |
$368.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$286.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$306.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$327.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$347.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$306.68
|
| Rate for Payer: PHP Commercial |
$347.56
|
| Rate for Payer: Priority Health SBD |
$257.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$265.79
|
| Rate for Payer: UHC Core |
$213.04
|
| Rate for Payer: UHC Exchange |
$160.70
|
| Rate for Payer: UMR Bronson Commercial |
$151.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$306.68
|
|
