|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$406.98
|
|
|
Service Code
|
NDC 00378181577
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.58 |
| Max. Negotiated Rate |
$366.28 |
| Rate for Payer: Aetna American Axle |
$264.54
|
| Rate for Payer: Aetna Commercial |
$345.93
|
| Rate for Payer: Aetna Medicare |
$203.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.54
|
| Rate for Payer: BCBS Complete |
$162.79
|
| 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: MI Amish Medical Board Commercial |
$325.58
|
| 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: UHC All Payor (Choice/PPO) |
$264.54
|
| Rate for Payer: UHC Core |
$212.04
|
| Rate for Payer: UHC Exchange |
$159.94
|
| Rate for Payer: UMR Bronson Commercial |
$150.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$305.24
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074706911
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$340.88 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna American Axle |
$503.57
|
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.57
|
| 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: 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: UMR Bronson Commercial |
$340.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.04
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$732.68
|
|
|
Service Code
|
NDC 00074706990
|
| Hospital Charge Code |
4425
|
|
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 150 MCG TABLET
|
Facility
|
IP
|
$318.24
|
|
|
Service Code
|
NDC 51079044520
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.03 |
| Max. Negotiated Rate |
$286.42 |
| Rate for Payer: Aetna American Axle |
$206.86
|
| Rate for Payer: Aetna Commercial |
$270.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$206.86
|
| 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: 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: UMR Bronson Commercial |
$140.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$238.68
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$408.90
|
|
|
Service Code
|
NDC 68180097301
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.92 |
| Max. Negotiated Rate |
$368.01 |
| Rate for Payer: Aetna American Axle |
$265.79
|
| Rate for Payer: Aetna Commercial |
$347.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$265.79
|
| 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: 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: UMR Bronson Commercial |
$179.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$306.68
|
|
|
LEVOTHYROXINE 175 MCG TABLET
|
Facility
|
OP
|
$731.38
|
|
|
Service Code
|
NDC 00074707090
|
| Hospital Charge Code |
10406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$270.61 |
| Max. Negotiated Rate |
$658.24 |
| Rate for Payer: Aetna American Axle |
$475.40
|
| Rate for Payer: Aetna Commercial |
$621.67
|
| Rate for Payer: Aetna Medicare |
$365.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$475.40
|
| Rate for Payer: BCBS Complete |
$292.55
|
| Rate for Payer: Cash Price |
$585.10
|
| Rate for Payer: Cofinity Advantage |
$511.97
|
| Rate for Payer: Cofinity Commercial |
$628.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$585.10
|
| Rate for Payer: Healthscope Commercial |
$658.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$511.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$548.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$585.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$621.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$548.53
|
| Rate for Payer: PHP Commercial |
$621.67
|
| Rate for Payer: Priority Health SBD |
$460.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$475.40
|
| Rate for Payer: UHC Core |
$381.05
|
| Rate for Payer: UHC Exchange |
$287.43
|
| Rate for Payer: UMR Bronson Commercial |
$270.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$548.53
|
|
|
LEVOTHYROXINE 175 MCG TABLET
|
Facility
|
IP
|
$731.38
|
|
|
Service Code
|
NDC 00074707090
|
| Hospital Charge Code |
10406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$321.81 |
| Max. Negotiated Rate |
$658.24 |
| Rate for Payer: Aetna American Axle |
$475.40
|
| Rate for Payer: Aetna Commercial |
$621.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$475.40
|
| Rate for Payer: Cash Price |
$585.10
|
| Rate for Payer: Cofinity Advantage |
$511.97
|
| Rate for Payer: Cofinity Commercial |
$628.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$585.10
|
| Rate for Payer: Healthscope Commercial |
$658.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$511.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$548.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$621.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$548.53
|
| Rate for Payer: PHP Commercial |
$621.67
|
| Rate for Payer: Priority Health SBD |
$460.77
|
| Rate for Payer: UMR Bronson Commercial |
$321.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$548.53
|
|
|
LEVOTHYROXINE 175 MCG TABLET
|
Facility
|
OP
|
$321.48
|
|
|
Service Code
|
NDC 00527328946
|
| Hospital Charge Code |
10406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.95 |
| Max. Negotiated Rate |
$289.33 |
| Rate for Payer: Aetna American Axle |
$208.96
|
| Rate for Payer: Aetna Commercial |
$273.26
|
| Rate for Payer: Aetna Medicare |
$160.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$208.96
|
| Rate for Payer: BCBS Complete |
$128.59
|
| Rate for Payer: Cash Price |
$257.18
|
| Rate for Payer: Cofinity Advantage |
$225.04
|
| Rate for Payer: Cofinity Commercial |
$276.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.18
|
| Rate for Payer: Healthscope Commercial |
$289.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$257.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$241.11
|
| Rate for Payer: PHP Commercial |
$273.26
|
| Rate for Payer: Priority Health SBD |
$202.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$208.96
|
| Rate for Payer: UHC Core |
$167.49
|
| Rate for Payer: UHC Exchange |
$126.34
|
| Rate for Payer: UMR Bronson Commercial |
$118.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.11
|
|
|
LEVOTHYROXINE 175 MCG TABLET
|
Facility
|
IP
|
$321.48
|
|
|
Service Code
|
NDC 00527328946
|
| Hospital Charge Code |
10406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.45 |
| Max. Negotiated Rate |
$289.33 |
| Rate for Payer: Aetna American Axle |
$208.96
|
| Rate for Payer: Aetna Commercial |
$273.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$208.96
|
| Rate for Payer: Cash Price |
$257.18
|
| Rate for Payer: Cofinity Advantage |
$225.04
|
| Rate for Payer: Cofinity Commercial |
$276.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.18
|
| Rate for Payer: Healthscope Commercial |
$289.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.26
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$241.11
|
| Rate for Payer: PHP Commercial |
$273.26
|
| Rate for Payer: Priority Health SBD |
$202.53
|
| Rate for Payer: UMR Bronson Commercial |
$141.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.11
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$244.95
|
|
|
Service Code
|
NDC 00378181977
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.63 |
| Max. Negotiated Rate |
$220.46 |
| Rate for Payer: Aetna American Axle |
$159.22
|
| Rate for Payer: Aetna Commercial |
$208.21
|
| Rate for Payer: Aetna Medicare |
$122.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.22
|
| Rate for Payer: BCBS Complete |
$97.98
|
| Rate for Payer: Cash Price |
$195.96
|
| Rate for Payer: Cofinity Advantage |
$171.47
|
| Rate for Payer: Cofinity Commercial |
$210.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.96
|
| Rate for Payer: Healthscope Commercial |
$220.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$195.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$183.71
|
| Rate for Payer: PHP Commercial |
$208.21
|
| Rate for Payer: Priority Health SBD |
$154.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$159.22
|
| Rate for Payer: UHC Core |
$127.62
|
| Rate for Payer: UHC Exchange |
$96.27
|
| Rate for Payer: UMR Bronson Commercial |
$90.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.71
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$609.60
|
|
|
Service Code
|
NDC 00074714811
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$225.55 |
| Max. Negotiated Rate |
$548.64 |
| Rate for Payer: Aetna American Axle |
$396.24
|
| Rate for Payer: Aetna Commercial |
$518.16
|
| Rate for Payer: Aetna Medicare |
$304.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.24
|
| Rate for Payer: BCBS Complete |
$243.84
|
| Rate for Payer: Cash Price |
$487.68
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$487.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$518.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$457.20
|
| Rate for Payer: PHP Commercial |
$518.16
|
| Rate for Payer: Priority Health SBD |
$384.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$396.24
|
| Rate for Payer: UHC Core |
$317.60
|
| Rate for Payer: UHC Exchange |
$239.57
|
| Rate for Payer: UMR Bronson Commercial |
$225.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$457.20
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$4.15
|
|
|
Service Code
|
NDC 60687055211
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$3.73 |
| Rate for Payer: Aetna American Axle |
$2.70
|
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Aetna Medicare |
$2.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.70
|
| Rate for Payer: BCBS Complete |
$1.66
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cofinity Advantage |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$3.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.32
|
| Rate for Payer: Healthscope Commercial |
$3.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.11
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.11
|
| Rate for Payer: PHP Commercial |
$3.53
|
| Rate for Payer: Priority Health SBD |
$2.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.70
|
| Rate for Payer: UHC Core |
$2.16
|
| Rate for Payer: UHC Exchange |
$1.63
|
| Rate for Payer: UMR Bronson Commercial |
$1.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.11
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$364.80
|
|
|
Service Code
|
NDC 69238184001
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.98 |
| Max. Negotiated Rate |
$328.32 |
| Rate for Payer: Aetna American Axle |
$237.12
|
| Rate for Payer: Aetna Commercial |
$310.08
|
| Rate for Payer: Aetna Medicare |
$182.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.12
|
| Rate for Payer: BCBS Complete |
$145.92
|
| Rate for Payer: Cash Price |
$291.84
|
| Rate for Payer: Cofinity Advantage |
$255.36
|
| Rate for Payer: Cofinity Commercial |
$313.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.84
|
| Rate for Payer: Healthscope Commercial |
$328.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$255.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$273.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$291.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.60
|
| Rate for Payer: PHP Commercial |
$310.08
|
| Rate for Payer: Priority Health SBD |
$229.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$237.12
|
| Rate for Payer: UHC Core |
$190.06
|
| Rate for Payer: UHC Exchange |
$143.37
|
| Rate for Payer: UMR Bronson Commercial |
$134.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$273.60
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$414.72
|
|
|
Service Code
|
NDC 60687055201
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.48 |
| Max. Negotiated Rate |
$373.25 |
| Rate for Payer: Aetna American Axle |
$269.57
|
| Rate for Payer: Aetna Commercial |
$352.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$269.57
|
| Rate for Payer: Cash Price |
$331.78
|
| Rate for Payer: Cofinity Advantage |
$290.30
|
| Rate for Payer: Cofinity Commercial |
$356.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$331.78
|
| Rate for Payer: Healthscope Commercial |
$373.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$290.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$311.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$352.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$311.04
|
| Rate for Payer: PHP Commercial |
$352.51
|
| Rate for Payer: Priority Health SBD |
$261.27
|
| Rate for Payer: UMR Bronson Commercial |
$182.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$311.04
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$4.15
|
|
|
Service Code
|
NDC 60687055211
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$3.73 |
| Rate for Payer: Aetna American Axle |
$2.70
|
| Rate for Payer: Aetna Commercial |
$3.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.70
|
| Rate for Payer: Cash Price |
$3.32
|
| Rate for Payer: Cofinity Advantage |
$2.90
|
| Rate for Payer: Cofinity Commercial |
$3.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.32
|
| Rate for Payer: Healthscope Commercial |
$3.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.11
|
| Rate for Payer: PHP Commercial |
$3.53
|
| Rate for Payer: Priority Health SBD |
$2.61
|
| Rate for Payer: UMR Bronson Commercial |
$1.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.11
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$212.80
|
|
|
Service Code
|
NDC 68180097501
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.74 |
| Max. Negotiated Rate |
$191.52 |
| Rate for Payer: Aetna American Axle |
$138.32
|
| Rate for Payer: Aetna Commercial |
$180.88
|
| Rate for Payer: Aetna Medicare |
$106.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.32
|
| Rate for Payer: BCBS Complete |
$85.12
|
| Rate for Payer: Cash Price |
$170.24
|
| Rate for Payer: Cofinity Advantage |
$148.96
|
| Rate for Payer: Cofinity Commercial |
$183.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.24
|
| Rate for Payer: Healthscope Commercial |
$191.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$170.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$159.60
|
| Rate for Payer: PHP Commercial |
$180.88
|
| Rate for Payer: Priority Health SBD |
$134.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$138.32
|
| Rate for Payer: UHC Core |
$110.87
|
| Rate for Payer: UHC Exchange |
$83.63
|
| Rate for Payer: UMR Bronson Commercial |
$78.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.60
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$414.72
|
|
|
Service Code
|
NDC 60687055201
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.45 |
| Max. Negotiated Rate |
$373.25 |
| Rate for Payer: Aetna American Axle |
$269.57
|
| Rate for Payer: Aetna Commercial |
$352.51
|
| Rate for Payer: Aetna Medicare |
$207.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$269.57
|
| Rate for Payer: BCBS Complete |
$165.89
|
| Rate for Payer: Cash Price |
$331.78
|
| Rate for Payer: Cofinity Advantage |
$290.30
|
| Rate for Payer: Cofinity Commercial |
$356.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$331.78
|
| Rate for Payer: Healthscope Commercial |
$373.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$290.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$311.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$331.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$352.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$311.04
|
| Rate for Payer: PHP Commercial |
$352.51
|
| Rate for Payer: Priority Health SBD |
$261.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$269.57
|
| Rate for Payer: UHC Core |
$216.07
|
| Rate for Payer: UHC Exchange |
$162.98
|
| Rate for Payer: UMR Bronson Commercial |
$153.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$311.04
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$212.80
|
|
|
Service Code
|
NDC 68180097501
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$93.63 |
| Max. Negotiated Rate |
$191.52 |
| Rate for Payer: Aetna American Axle |
$138.32
|
| Rate for Payer: Aetna Commercial |
$180.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.32
|
| Rate for Payer: Cash Price |
$170.24
|
| Rate for Payer: Cofinity Advantage |
$148.96
|
| Rate for Payer: Cofinity Commercial |
$183.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.24
|
| Rate for Payer: Healthscope Commercial |
$191.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$148.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$159.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$180.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$159.60
|
| Rate for Payer: PHP Commercial |
$180.88
|
| Rate for Payer: Priority Health SBD |
$134.06
|
| Rate for Payer: UMR Bronson Commercial |
$93.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$159.60
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$364.80
|
|
|
Service Code
|
NDC 69238184001
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.51 |
| Max. Negotiated Rate |
$328.32 |
| Rate for Payer: Aetna American Axle |
$237.12
|
| Rate for Payer: Aetna Commercial |
$310.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.12
|
| Rate for Payer: Cash Price |
$291.84
|
| Rate for Payer: Cofinity Advantage |
$255.36
|
| Rate for Payer: Cofinity Commercial |
$313.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$291.84
|
| Rate for Payer: Healthscope Commercial |
$328.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$255.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$273.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$310.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$273.60
|
| Rate for Payer: PHP Commercial |
$310.08
|
| Rate for Payer: Priority Health SBD |
$229.82
|
| Rate for Payer: UMR Bronson Commercial |
$160.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$273.60
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$313.02
|
|
|
Service Code
|
NDC 68180097509
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.73 |
| Max. Negotiated Rate |
$281.72 |
| Rate for Payer: Aetna American Axle |
$203.46
|
| Rate for Payer: Aetna Commercial |
$266.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.46
|
| Rate for Payer: Cash Price |
$250.42
|
| Rate for Payer: Cofinity Advantage |
$219.11
|
| Rate for Payer: Cofinity Commercial |
$269.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.42
|
| Rate for Payer: Healthscope Commercial |
$281.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$219.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$266.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.76
|
| Rate for Payer: PHP Commercial |
$266.07
|
| Rate for Payer: Priority Health SBD |
$197.20
|
| Rate for Payer: UMR Bronson Commercial |
$137.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.76
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$609.60
|
|
|
Service Code
|
NDC 00074714811
|
| 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 Advantage |
$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 Commercial |
$518.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$457.20
|
| Rate for Payer: PHP Commercial |
$518.16
|
| 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
|
OP
|
$313.02
|
|
|
Service Code
|
NDC 68180097509
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.82 |
| Max. Negotiated Rate |
$281.72 |
| Rate for Payer: Aetna American Axle |
$203.46
|
| Rate for Payer: Aetna Commercial |
$266.07
|
| Rate for Payer: Aetna Medicare |
$156.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.46
|
| Rate for Payer: BCBS Complete |
$125.21
|
| Rate for Payer: Cash Price |
$250.42
|
| Rate for Payer: Cofinity Advantage |
$219.11
|
| Rate for Payer: Cofinity Commercial |
$269.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.42
|
| Rate for Payer: Healthscope Commercial |
$281.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$219.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$234.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$250.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$266.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$234.76
|
| Rate for Payer: PHP Commercial |
$266.07
|
| Rate for Payer: Priority Health SBD |
$197.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$203.46
|
| Rate for Payer: UHC Core |
$163.08
|
| Rate for Payer: UHC Exchange |
$123.02
|
| Rate for Payer: UMR Bronson Commercial |
$115.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$234.76
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$244.95
|
|
|
Service Code
|
NDC 00378181977
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.78 |
| Max. Negotiated Rate |
$220.46 |
| Rate for Payer: Aetna American Axle |
$159.22
|
| Rate for Payer: Aetna Commercial |
$208.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.22
|
| Rate for Payer: Cash Price |
$195.96
|
| Rate for Payer: Cofinity Advantage |
$171.47
|
| Rate for Payer: Cofinity Commercial |
$210.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.96
|
| Rate for Payer: Healthscope Commercial |
$220.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$183.71
|
| Rate for Payer: PHP Commercial |
$208.21
|
| Rate for Payer: Priority Health SBD |
$154.32
|
| Rate for Payer: UMR Bronson Commercial |
$107.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.71
|
|
|
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$246.98
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
190375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$222.28 |
| Rate for Payer: Aetna American Axle |
$160.54
|
| Rate for Payer: Aetna Commercial |
$209.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.54
|
| Rate for Payer: Cash Price |
$197.58
|
| Rate for Payer: Cofinity Advantage |
$172.89
|
| Rate for Payer: Cofinity Commercial |
$212.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.58
|
| Rate for Payer: Healthscope Commercial |
$222.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$185.24
|
| Rate for Payer: PHP Commercial |
$209.93
|
| Rate for Payer: Priority Health SBD |
$155.60
|
| Rate for Payer: UMR Bronson Commercial |
$108.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.24
|
|
|
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$246.98
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
190375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$222.28 |
| Rate for Payer: Aetna American Axle |
$160.54
|
| Rate for Payer: Aetna Commercial |
$209.93
|
| Rate for Payer: Aetna Medicare |
$123.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.54
|
| Rate for Payer: BCBS Complete |
$98.79
|
| Rate for Payer: BCBS Trust/PPO |
$19.38
|
| Rate for Payer: BCN Commercial |
$19.38
|
| Rate for Payer: Cash Price |
$197.58
|
| Rate for Payer: Cash Price |
$197.58
|
| Rate for Payer: Cofinity Advantage |
$172.89
|
| Rate for Payer: Cofinity Commercial |
$212.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.58
|
| Rate for Payer: Healthscope Commercial |
$222.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$197.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$185.24
|
| Rate for Payer: PHP Commercial |
$209.93
|
| Rate for Payer: Priority Health SBD |
$155.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.87
|
| Rate for Payer: UHC Core |
$9.87
|
| Rate for Payer: UHC Exchange |
$9.87
|
| Rate for Payer: UMR Bronson Commercial |
$91.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.24
|
|
