|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$3.51
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.54 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Aetna American Axle |
$2.28
|
| Rate for Payer: Aetna Commercial |
$2.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.28
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cofinity Advantage |
$2.46
|
| Rate for Payer: Cofinity Commercial |
$3.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.81
|
| Rate for Payer: Healthscope Commercial |
$3.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.63
|
| Rate for Payer: PHP Commercial |
$2.98
|
| Rate for Payer: Priority Health SBD |
$2.21
|
| Rate for Payer: UMR Bronson Commercial |
$1.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.63
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$732.68
|
|
|
Service Code
|
NDC 00074434190
|
| Hospital Charge Code |
4420
|
|
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 25 MCG TABLET
|
Facility
|
OP
|
$319.20
|
|
|
Service Code
|
NDC 00904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.10 |
| Max. Negotiated Rate |
$287.28 |
| Rate for Payer: Aetna American Axle |
$207.48
|
| Rate for Payer: Aetna Commercial |
$271.32
|
| Rate for Payer: Aetna Medicare |
$159.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.48
|
| Rate for Payer: BCBS Complete |
$127.68
|
| Rate for Payer: Cash Price |
$255.36
|
| Rate for Payer: Cofinity Advantage |
$223.44
|
| Rate for Payer: Cofinity Commercial |
$274.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.36
|
| Rate for Payer: Healthscope Commercial |
$287.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$239.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$255.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$271.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$239.40
|
| Rate for Payer: PHP Commercial |
$271.32
|
| Rate for Payer: Priority Health SBD |
$201.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$207.48
|
| Rate for Payer: UHC Core |
$166.30
|
| Rate for Payer: UHC Exchange |
$125.45
|
| Rate for Payer: UMR Bronson Commercial |
$118.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$239.40
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$350.55
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.70 |
| Max. Negotiated Rate |
$315.50 |
| Rate for Payer: Aetna American Axle |
$227.86
|
| Rate for Payer: Aetna Commercial |
$297.97
|
| Rate for Payer: Aetna Medicare |
$175.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$227.86
|
| Rate for Payer: BCBS Complete |
$140.22
|
| Rate for Payer: Cash Price |
$280.44
|
| Rate for Payer: Cofinity Advantage |
$245.38
|
| Rate for Payer: Cofinity Commercial |
$301.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.44
|
| Rate for Payer: Healthscope Commercial |
$315.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$245.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$262.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$280.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$262.91
|
| Rate for Payer: PHP Commercial |
$297.97
|
| Rate for Payer: Priority Health SBD |
$220.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$227.86
|
| Rate for Payer: UHC Core |
$182.64
|
| Rate for Payer: UHC Exchange |
$137.77
|
| Rate for Payer: UMR Bronson Commercial |
$129.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.91
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$3.51
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$3.16 |
| Rate for Payer: Aetna American Axle |
$2.28
|
| Rate for Payer: Aetna Commercial |
$2.98
|
| Rate for Payer: Aetna Medicare |
$1.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.28
|
| Rate for Payer: BCBS Complete |
$1.40
|
| Rate for Payer: Cash Price |
$2.81
|
| Rate for Payer: Cofinity Advantage |
$2.46
|
| Rate for Payer: Cofinity Commercial |
$3.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.81
|
| Rate for Payer: Healthscope Commercial |
$3.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.63
|
| Rate for Payer: PHP Commercial |
$2.98
|
| Rate for Payer: Priority Health SBD |
$2.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.28
|
| Rate for Payer: UHC Core |
$1.83
|
| Rate for Payer: UHC Exchange |
$1.38
|
| Rate for Payer: UMR Bronson Commercial |
$1.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.63
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$4.03
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Aetna American Axle |
$2.62
|
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Aetna Medicare |
$2.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.62
|
| Rate for Payer: BCBS Complete |
$1.61
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cofinity Advantage |
$2.82
|
| Rate for Payer: Cofinity Commercial |
$3.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.22
|
| Rate for Payer: Healthscope Commercial |
$3.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.02
|
| Rate for Payer: PHP Commercial |
$3.43
|
| Rate for Payer: Priority Health SBD |
$2.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.62
|
| Rate for Payer: UHC Core |
$2.10
|
| Rate for Payer: UHC Exchange |
$1.58
|
| Rate for Payer: UMR Bronson Commercial |
$1.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.02
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$350.55
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.24 |
| Max. Negotiated Rate |
$315.50 |
| Rate for Payer: Aetna American Axle |
$227.86
|
| Rate for Payer: Aetna Commercial |
$297.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$227.86
|
| Rate for Payer: Cash Price |
$280.44
|
| Rate for Payer: Cofinity Advantage |
$245.38
|
| Rate for Payer: Cofinity Commercial |
$301.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.44
|
| Rate for Payer: Healthscope Commercial |
$315.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$245.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$262.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$262.91
|
| Rate for Payer: PHP Commercial |
$297.97
|
| Rate for Payer: Priority Health SBD |
$220.85
|
| Rate for Payer: UMR Bronson Commercial |
$154.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$262.91
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$402.80
|
|
|
Service Code
|
NDC 51079044420
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.23 |
| Max. Negotiated Rate |
$362.52 |
| Rate for Payer: Aetna American Axle |
$261.82
|
| Rate for Payer: Aetna Commercial |
$342.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.82
|
| Rate for Payer: Cash Price |
$322.24
|
| Rate for Payer: Cofinity Advantage |
$281.96
|
| Rate for Payer: Cofinity Commercial |
$346.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.24
|
| Rate for Payer: Healthscope Commercial |
$362.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$302.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$342.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$302.10
|
| Rate for Payer: PHP Commercial |
$342.38
|
| Rate for Payer: Priority Health SBD |
$253.76
|
| Rate for Payer: UMR Bronson Commercial |
$177.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$302.10
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$74.03
|
|
|
Service Code
|
NDC 16729044715
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.57 |
| Max. Negotiated Rate |
$66.63 |
| Rate for Payer: Aetna American Axle |
$48.12
|
| Rate for Payer: Aetna Commercial |
$62.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.12
|
| Rate for Payer: Cash Price |
$59.22
|
| Rate for Payer: Cofinity Advantage |
$51.82
|
| Rate for Payer: Cofinity Commercial |
$63.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.22
|
| Rate for Payer: Healthscope Commercial |
$66.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.52
|
| Rate for Payer: PHP Commercial |
$62.93
|
| Rate for Payer: Priority Health SBD |
$46.64
|
| Rate for Payer: UMR Bronson Commercial |
$32.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.52
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$319.20
|
|
|
Service Code
|
NDC 00904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.45 |
| Max. Negotiated Rate |
$287.28 |
| Rate for Payer: Aetna American Axle |
$207.48
|
| Rate for Payer: Aetna Commercial |
$271.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.48
|
| Rate for Payer: Cash Price |
$255.36
|
| Rate for Payer: Cofinity Advantage |
$223.44
|
| Rate for Payer: Cofinity Commercial |
$274.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.36
|
| Rate for Payer: Healthscope Commercial |
$287.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$223.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$239.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$271.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$239.40
|
| Rate for Payer: PHP Commercial |
$271.32
|
| Rate for Payer: Priority Health SBD |
$201.10
|
| Rate for Payer: UMR Bronson Commercial |
$140.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$239.40
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$74.03
|
|
|
Service Code
|
NDC 16729044715
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.39 |
| Max. Negotiated Rate |
$66.63 |
| Rate for Payer: Aetna American Axle |
$48.12
|
| Rate for Payer: Aetna Commercial |
$62.93
|
| Rate for Payer: Aetna Medicare |
$37.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.12
|
| Rate for Payer: BCBS Complete |
$29.61
|
| Rate for Payer: Cash Price |
$59.22
|
| Rate for Payer: Cofinity Advantage |
$51.82
|
| Rate for Payer: Cofinity Commercial |
$63.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.22
|
| Rate for Payer: Healthscope Commercial |
$66.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$55.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$59.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$62.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$55.52
|
| Rate for Payer: PHP Commercial |
$62.93
|
| Rate for Payer: Priority Health SBD |
$46.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$48.12
|
| Rate for Payer: UHC Core |
$38.57
|
| Rate for Payer: UHC Exchange |
$29.09
|
| Rate for Payer: UMR Bronson Commercial |
$27.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$55.52
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$732.68
|
|
|
Service Code
|
NDC 00074434190
|
| Hospital Charge Code |
4420
|
|
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 25 MCG TABLET
|
Facility
|
OP
|
$402.80
|
|
|
Service Code
|
NDC 51079044420
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.04 |
| Max. Negotiated Rate |
$362.52 |
| Rate for Payer: Aetna American Axle |
$261.82
|
| Rate for Payer: Aetna Commercial |
$342.38
|
| Rate for Payer: Aetna Medicare |
$201.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.82
|
| Rate for Payer: BCBS Complete |
$161.12
|
| Rate for Payer: Cash Price |
$322.24
|
| Rate for Payer: Cofinity Advantage |
$281.96
|
| Rate for Payer: Cofinity Commercial |
$346.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$322.24
|
| Rate for Payer: Healthscope Commercial |
$362.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$302.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$322.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$342.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$302.10
|
| Rate for Payer: PHP Commercial |
$342.38
|
| Rate for Payer: Priority Health SBD |
$253.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$261.82
|
| Rate for Payer: UHC Core |
$209.86
|
| Rate for Payer: UHC Exchange |
$158.30
|
| Rate for Payer: UMR Bronson Commercial |
$149.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$302.10
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$4.03
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.77 |
| Max. Negotiated Rate |
$3.63 |
| Rate for Payer: Aetna American Axle |
$2.62
|
| Rate for Payer: Aetna Commercial |
$3.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.62
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cofinity Advantage |
$2.82
|
| Rate for Payer: Cofinity Commercial |
$3.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.22
|
| Rate for Payer: Healthscope Commercial |
$3.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.02
|
| Rate for Payer: PHP Commercial |
$3.43
|
| Rate for Payer: Priority Health SBD |
$2.54
|
| Rate for Payer: UMR Bronson Commercial |
$1.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.02
|
|
|
LEVOTHYROXINE 500 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$1,232.23
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.87 |
| Max. Negotiated Rate |
$1,109.01 |
| Rate for Payer: Aetna American Axle |
$800.95
|
| Rate for Payer: Aetna Commercial |
$1,047.40
|
| Rate for Payer: Aetna Medicare |
$616.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$800.95
|
| Rate for Payer: BCBS Complete |
$492.89
|
| Rate for Payer: BCBS Trust/PPO |
$19.38
|
| Rate for Payer: BCN Commercial |
$19.38
|
| Rate for Payer: Cash Price |
$985.78
|
| Rate for Payer: Cash Price |
$985.78
|
| Rate for Payer: Cofinity Advantage |
$862.56
|
| Rate for Payer: Cofinity Commercial |
$1,059.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$985.78
|
| Rate for Payer: Healthscope Commercial |
$1,109.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$862.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$924.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$985.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,047.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$924.17
|
| Rate for Payer: PHP Commercial |
$1,047.40
|
| Rate for Payer: Priority Health SBD |
$776.30
|
| 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 |
$455.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$924.17
|
|
|
LEVOTHYROXINE 500 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$1,232.23
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$542.18 |
| Max. Negotiated Rate |
$1,109.01 |
| Rate for Payer: Aetna American Axle |
$800.95
|
| Rate for Payer: Aetna Commercial |
$1,047.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$800.95
|
| Rate for Payer: Cash Price |
$985.78
|
| Rate for Payer: Cofinity Advantage |
$862.56
|
| Rate for Payer: Cofinity Commercial |
$1,059.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$985.78
|
| Rate for Payer: Healthscope Commercial |
$1,109.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$862.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$924.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,047.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$924.17
|
| Rate for Payer: PHP Commercial |
$1,047.40
|
| Rate for Payer: Priority Health SBD |
$776.30
|
| Rate for Payer: UMR Bronson Commercial |
$542.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$924.17
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$732.24
|
|
|
Service Code
|
NDC 00074455290
|
| Hospital Charge Code |
4421
|
|
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 50 MCG TABLET
|
Facility
|
IP
|
$813.60
|
|
|
Service Code
|
NDC 00074455211
|
| Hospital Charge Code |
4421
|
|
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 50 MCG TABLET
|
Facility
|
OP
|
$813.60
|
|
|
Service Code
|
NDC 00074455211
|
| Hospital Charge Code |
4421
|
|
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 50 MCG TABLET
|
Facility
|
IP
|
$4.58
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna American Axle |
$2.98
|
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.98
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cofinity Advantage |
$3.21
|
| Rate for Payer: Cofinity Commercial |
$3.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.66
|
| Rate for Payer: Healthscope Commercial |
$4.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.89
|
| Rate for Payer: Priority Health SBD |
$2.89
|
| Rate for Payer: UMR Bronson Commercial |
$2.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.44
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$356.25
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.81 |
| Max. Negotiated Rate |
$320.62 |
| Rate for Payer: Aetna American Axle |
$231.56
|
| Rate for Payer: Aetna Commercial |
$302.81
|
| Rate for Payer: Aetna Medicare |
$178.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$231.56
|
| Rate for Payer: BCBS Complete |
$142.50
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cofinity Advantage |
$249.38
|
| Rate for Payer: Cofinity Commercial |
$306.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.00
|
| Rate for Payer: Healthscope Commercial |
$320.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$249.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$285.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.19
|
| Rate for Payer: PHP Commercial |
$302.81
|
| Rate for Payer: Priority Health SBD |
$224.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$231.56
|
| Rate for Payer: UHC Core |
$185.61
|
| Rate for Payer: UHC Exchange |
$140.01
|
| Rate for Payer: UMR Bronson Commercial |
$131.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.19
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$457.90
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$201.48 |
| Max. Negotiated Rate |
$412.11 |
| Rate for Payer: Aetna American Axle |
$297.63
|
| Rate for Payer: Aetna Commercial |
$389.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.63
|
| Rate for Payer: Cash Price |
$366.32
|
| Rate for Payer: Cofinity Advantage |
$320.53
|
| Rate for Payer: Cofinity Commercial |
$393.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.32
|
| Rate for Payer: Healthscope Commercial |
$412.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$320.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$343.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$389.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$343.43
|
| Rate for Payer: PHP Commercial |
$389.21
|
| Rate for Payer: Priority Health SBD |
$288.48
|
| Rate for Payer: UMR Bronson Commercial |
$201.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$343.43
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$4.58
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$4.12 |
| Rate for Payer: Aetna American Axle |
$2.98
|
| Rate for Payer: Aetna Commercial |
$3.89
|
| Rate for Payer: Aetna Medicare |
$2.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.98
|
| Rate for Payer: BCBS Complete |
$1.83
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cofinity Advantage |
$3.21
|
| Rate for Payer: Cofinity Commercial |
$3.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.66
|
| Rate for Payer: Healthscope Commercial |
$4.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.44
|
| Rate for Payer: PHP Commercial |
$3.89
|
| Rate for Payer: Priority Health SBD |
$2.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.98
|
| Rate for Payer: UHC Core |
$2.39
|
| Rate for Payer: UHC Exchange |
$1.80
|
| Rate for Payer: UMR Bronson Commercial |
$1.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.44
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$457.90
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.42 |
| Max. Negotiated Rate |
$412.11 |
| Rate for Payer: Aetna American Axle |
$297.63
|
| Rate for Payer: Aetna Commercial |
$389.21
|
| Rate for Payer: Aetna Medicare |
$228.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$297.63
|
| Rate for Payer: BCBS Complete |
$183.16
|
| Rate for Payer: Cash Price |
$366.32
|
| Rate for Payer: Cofinity Advantage |
$320.53
|
| Rate for Payer: Cofinity Commercial |
$393.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$366.32
|
| Rate for Payer: Healthscope Commercial |
$412.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$320.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$343.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$366.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$389.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$343.43
|
| Rate for Payer: PHP Commercial |
$389.21
|
| Rate for Payer: Priority Health SBD |
$288.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$297.63
|
| Rate for Payer: UHC Core |
$238.57
|
| Rate for Payer: UHC Exchange |
$179.95
|
| Rate for Payer: UMR Bronson Commercial |
$169.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$343.43
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$356.25
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.75 |
| Max. Negotiated Rate |
$320.62 |
| Rate for Payer: Aetna American Axle |
$231.56
|
| Rate for Payer: Aetna Commercial |
$302.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$231.56
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cofinity Advantage |
$249.38
|
| Rate for Payer: Cofinity Commercial |
$306.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.00
|
| Rate for Payer: Healthscope Commercial |
$320.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$249.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.19
|
| Rate for Payer: PHP Commercial |
$302.81
|
| Rate for Payer: Priority Health SBD |
$224.44
|
| Rate for Payer: UMR Bronson Commercial |
$156.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.19
|
|
