|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$732.24
|
|
|
Service Code
|
NDC 00074455290
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$322.19 |
| Max. Negotiated Rate |
$659.02 |
| Rate for Payer: Aetna American Axle |
$475.96
|
| Rate for Payer: Aetna Commercial |
$622.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$475.96
|
| Rate for Payer: Cash Price |
$585.79
|
| Rate for Payer: Cofinity Advantage |
$512.57
|
| Rate for Payer: Cofinity Commercial |
$629.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$585.79
|
| Rate for Payer: Healthscope Commercial |
$659.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$512.57
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$549.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.18
|
| Rate for Payer: PHP Commercial |
$622.40
|
| Rate for Payer: Priority Health SBD |
$461.31
|
| Rate for Payer: UMR Bronson Commercial |
$322.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$549.18
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$3.57
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna American Axle |
$2.32
|
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.32
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cofinity Advantage |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.86
|
| Rate for Payer: Healthscope Commercial |
$3.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.68
|
| Rate for Payer: PHP Commercial |
$3.03
|
| Rate for Payer: Priority Health SBD |
$2.25
|
| Rate for Payer: UMR Bronson Commercial |
$1.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.68
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$3.57
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.21 |
| Rate for Payer: Aetna American Axle |
$2.32
|
| Rate for Payer: Aetna Commercial |
$3.03
|
| Rate for Payer: Aetna Medicare |
$1.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.32
|
| Rate for Payer: BCBS Complete |
$1.43
|
| Rate for Payer: Cash Price |
$2.86
|
| Rate for Payer: Cofinity Advantage |
$2.50
|
| Rate for Payer: Cofinity Commercial |
$3.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.86
|
| Rate for Payer: Healthscope Commercial |
$3.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.68
|
| Rate for Payer: PHP Commercial |
$3.03
|
| Rate for Payer: Priority Health SBD |
$2.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.32
|
| Rate for Payer: UHC Core |
$1.86
|
| Rate for Payer: UHC Exchange |
$1.40
|
| Rate for Payer: UMR Bronson Commercial |
$1.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.68
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$813.60
|
|
|
Service Code
|
NDC 00074518211
|
| Hospital Charge Code |
4422
|
|
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 75 MCG TABLET
|
Facility
|
OP
|
$329.18
|
|
|
Service Code
|
NDC 00378180577
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.80 |
| Max. Negotiated Rate |
$296.26 |
| Rate for Payer: Aetna American Axle |
$213.97
|
| Rate for Payer: Aetna Commercial |
$279.80
|
| Rate for Payer: Aetna Medicare |
$164.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.97
|
| Rate for Payer: BCBS Complete |
$131.67
|
| Rate for Payer: Cash Price |
$263.34
|
| Rate for Payer: Cofinity Advantage |
$230.43
|
| Rate for Payer: Cofinity Commercial |
$283.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.34
|
| Rate for Payer: Healthscope Commercial |
$296.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$263.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$246.88
|
| Rate for Payer: PHP Commercial |
$279.80
|
| Rate for Payer: Priority Health SBD |
$207.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$213.97
|
| Rate for Payer: UHC Core |
$171.50
|
| Rate for Payer: UHC Exchange |
$129.37
|
| Rate for Payer: UMR Bronson Commercial |
$121.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.88
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$813.60
|
|
|
Service Code
|
NDC 00074518211
|
| Hospital Charge Code |
4422
|
|
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 75 MCG TABLET
|
Facility
|
IP
|
$732.68
|
|
|
Service Code
|
NDC 00074518290
|
| Hospital Charge Code |
4422
|
|
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 75 MCG TABLET
|
Facility
|
OP
|
$425.60
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.47 |
| Max. Negotiated Rate |
$383.04 |
| Rate for Payer: Aetna American Axle |
$276.64
|
| Rate for Payer: Aetna Commercial |
$361.76
|
| Rate for Payer: Aetna Medicare |
$212.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.64
|
| Rate for Payer: BCBS Complete |
$170.24
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cofinity Advantage |
$297.92
|
| Rate for Payer: Cofinity Commercial |
$366.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.48
|
| Rate for Payer: Healthscope Commercial |
$383.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$340.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.20
|
| Rate for Payer: PHP Commercial |
$361.76
|
| Rate for Payer: Priority Health SBD |
$268.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$276.64
|
| Rate for Payer: UHC Core |
$221.74
|
| Rate for Payer: UHC Exchange |
$167.26
|
| Rate for Payer: UMR Bronson Commercial |
$157.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.20
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna American Axle |
$1.67
|
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.67
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Advantage |
$1.80
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.93
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health SBD |
$1.62
|
| Rate for Payer: UMR Bronson Commercial |
$1.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.93
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$95.18
|
|
|
Service Code
|
NDC 68180096709
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.22 |
| Max. Negotiated Rate |
$85.66 |
| Rate for Payer: Aetna American Axle |
$61.87
|
| Rate for Payer: Aetna Commercial |
$80.90
|
| Rate for Payer: Aetna Medicare |
$47.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.87
|
| Rate for Payer: BCBS Complete |
$38.07
|
| Rate for Payer: Cash Price |
$76.14
|
| Rate for Payer: Cofinity Advantage |
$66.63
|
| Rate for Payer: Cofinity Commercial |
$81.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.14
|
| Rate for Payer: Healthscope Commercial |
$85.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$76.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.39
|
| Rate for Payer: PHP Commercial |
$80.90
|
| Rate for Payer: Priority Health SBD |
$59.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61.87
|
| Rate for Payer: UHC Core |
$49.59
|
| Rate for Payer: UHC Exchange |
$37.41
|
| Rate for Payer: UMR Bronson Commercial |
$35.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.39
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$732.68
|
|
|
Service Code
|
NDC 00074518290
|
| Hospital Charge Code |
4422
|
|
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 75 MCG TABLET
|
Facility
|
OP
|
$256.32
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.84 |
| Max. Negotiated Rate |
$230.69 |
| Rate for Payer: Aetna American Axle |
$166.61
|
| Rate for Payer: Aetna Commercial |
$217.87
|
| Rate for Payer: Aetna Medicare |
$128.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.61
|
| Rate for Payer: BCBS Complete |
$102.53
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Advantage |
$179.42
|
| Rate for Payer: Cofinity Commercial |
$220.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Healthscope Commercial |
$230.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$205.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$192.24
|
| Rate for Payer: PHP Commercial |
$217.87
|
| Rate for Payer: Priority Health SBD |
$161.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$166.61
|
| Rate for Payer: UHC Core |
$133.54
|
| Rate for Payer: UHC Exchange |
$100.73
|
| Rate for Payer: UMR Bronson Commercial |
$94.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.24
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$329.18
|
|
|
Service Code
|
NDC 00378180577
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.84 |
| Max. Negotiated Rate |
$296.26 |
| Rate for Payer: Aetna American Axle |
$213.97
|
| Rate for Payer: Aetna Commercial |
$279.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.97
|
| Rate for Payer: Cash Price |
$263.34
|
| Rate for Payer: Cofinity Advantage |
$230.43
|
| Rate for Payer: Cofinity Commercial |
$283.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.34
|
| Rate for Payer: Healthscope Commercial |
$296.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$246.88
|
| Rate for Payer: PHP Commercial |
$279.80
|
| Rate for Payer: Priority Health SBD |
$207.38
|
| Rate for Payer: UMR Bronson Commercial |
$144.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.88
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna American Axle |
$1.67
|
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.67
|
| Rate for Payer: BCBS Complete |
$1.03
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Advantage |
$1.80
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.93
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health SBD |
$1.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.67
|
| Rate for Payer: UHC Core |
$1.34
|
| Rate for Payer: UHC Exchange |
$1.01
|
| Rate for Payer: UMR Bronson Commercial |
$0.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.93
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$425.60
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.26 |
| Max. Negotiated Rate |
$383.04 |
| Rate for Payer: Aetna American Axle |
$276.64
|
| Rate for Payer: Aetna Commercial |
$361.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.64
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cofinity Advantage |
$297.92
|
| Rate for Payer: Cofinity Commercial |
$366.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.48
|
| Rate for Payer: Healthscope Commercial |
$383.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$297.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.20
|
| Rate for Payer: PHP Commercial |
$361.76
|
| Rate for Payer: Priority Health SBD |
$268.13
|
| Rate for Payer: UMR Bronson Commercial |
$187.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.20
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$256.32
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.78 |
| Max. Negotiated Rate |
$230.69 |
| Rate for Payer: Aetna American Axle |
$166.61
|
| Rate for Payer: Aetna Commercial |
$217.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.61
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Advantage |
$179.42
|
| Rate for Payer: Cofinity Commercial |
$220.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Healthscope Commercial |
$230.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$192.24
|
| Rate for Payer: PHP Commercial |
$217.87
|
| Rate for Payer: Priority Health SBD |
$161.48
|
| Rate for Payer: UMR Bronson Commercial |
$112.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.24
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$95.18
|
|
|
Service Code
|
NDC 68180096709
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.88 |
| Max. Negotiated Rate |
$85.66 |
| Rate for Payer: Aetna American Axle |
$61.87
|
| Rate for Payer: Aetna Commercial |
$80.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.87
|
| Rate for Payer: Cash Price |
$76.14
|
| Rate for Payer: Cofinity Advantage |
$66.63
|
| Rate for Payer: Cofinity Commercial |
$81.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.14
|
| Rate for Payer: Healthscope Commercial |
$85.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.39
|
| Rate for Payer: PHP Commercial |
$80.90
|
| Rate for Payer: Priority Health SBD |
$59.96
|
| Rate for Payer: UMR Bronson Commercial |
$41.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.39
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$145.94
|
|
|
Service Code
|
NDC 68180096809
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.21 |
| Max. Negotiated Rate |
$131.35 |
| Rate for Payer: Aetna American Axle |
$94.86
|
| Rate for Payer: Aetna Commercial |
$124.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.86
|
| Rate for Payer: Cash Price |
$116.75
|
| Rate for Payer: Cofinity Advantage |
$102.16
|
| Rate for Payer: Cofinity Commercial |
$125.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.75
|
| Rate for Payer: Healthscope Commercial |
$131.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$109.45
|
| Rate for Payer: PHP Commercial |
$124.05
|
| Rate for Payer: Priority Health SBD |
$91.94
|
| Rate for Payer: UMR Bronson Commercial |
$64.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.45
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$334.31
|
|
|
Service Code
|
NDC 00378180777
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.10 |
| Max. Negotiated Rate |
$300.88 |
| Rate for Payer: Aetna American Axle |
$217.30
|
| Rate for Payer: Aetna Commercial |
$284.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.30
|
| Rate for Payer: Cash Price |
$267.45
|
| Rate for Payer: Cofinity Advantage |
$234.02
|
| Rate for Payer: Cofinity Commercial |
$287.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.45
|
| Rate for Payer: Healthscope Commercial |
$300.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$234.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$250.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$284.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$250.73
|
| Rate for Payer: PHP Commercial |
$284.16
|
| Rate for Payer: Priority Health SBD |
$210.62
|
| Rate for Payer: UMR Bronson Commercial |
$147.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$250.73
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$470.40
|
|
|
Service Code
|
NDC 60793085301
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.05 |
| Max. Negotiated Rate |
$423.36 |
| Rate for Payer: Aetna American Axle |
$305.76
|
| Rate for Payer: Aetna Commercial |
$399.84
|
| Rate for Payer: Aetna Medicare |
$235.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.76
|
| Rate for Payer: BCBS Complete |
$188.16
|
| Rate for Payer: Cash Price |
$376.32
|
| Rate for Payer: Cofinity Advantage |
$329.28
|
| Rate for Payer: Cofinity Commercial |
$404.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.32
|
| Rate for Payer: Healthscope Commercial |
$423.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$376.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$352.80
|
| Rate for Payer: PHP Commercial |
$399.84
|
| Rate for Payer: Priority Health SBD |
$296.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$305.76
|
| Rate for Payer: UHC Core |
$245.08
|
| Rate for Payer: UHC Exchange |
$184.87
|
| Rate for Payer: UMR Bronson Commercial |
$174.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.80
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$334.31
|
|
|
Service Code
|
NDC 00378180777
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.69 |
| Max. Negotiated Rate |
$300.88 |
| Rate for Payer: Aetna American Axle |
$217.30
|
| Rate for Payer: Aetna Commercial |
$284.16
|
| Rate for Payer: Aetna Medicare |
$167.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.30
|
| Rate for Payer: BCBS Complete |
$133.72
|
| Rate for Payer: Cash Price |
$267.45
|
| Rate for Payer: Cofinity Advantage |
$234.02
|
| Rate for Payer: Cofinity Commercial |
$287.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.45
|
| Rate for Payer: Healthscope Commercial |
$300.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$234.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$250.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$267.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$284.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$250.73
|
| Rate for Payer: PHP Commercial |
$284.16
|
| Rate for Payer: Priority Health SBD |
$210.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$217.30
|
| Rate for Payer: UHC Core |
$174.18
|
| Rate for Payer: UHC Exchange |
$131.38
|
| Rate for Payer: UMR Bronson Commercial |
$123.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$250.73
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$470.40
|
|
|
Service Code
|
NDC 60793085301
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.98 |
| Max. Negotiated Rate |
$423.36 |
| Rate for Payer: Aetna American Axle |
$305.76
|
| Rate for Payer: Aetna Commercial |
$399.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.76
|
| Rate for Payer: Cash Price |
$376.32
|
| Rate for Payer: Cofinity Advantage |
$329.28
|
| Rate for Payer: Cofinity Commercial |
$404.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.32
|
| Rate for Payer: Healthscope Commercial |
$423.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$399.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$352.80
|
| Rate for Payer: PHP Commercial |
$399.84
|
| Rate for Payer: Priority Health SBD |
$296.35
|
| Rate for Payer: UMR Bronson Commercial |
$206.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.80
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$145.94
|
|
|
Service Code
|
NDC 68180096809
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.00 |
| Max. Negotiated Rate |
$131.35 |
| Rate for Payer: Aetna American Axle |
$94.86
|
| Rate for Payer: Aetna Commercial |
$124.05
|
| Rate for Payer: Aetna Medicare |
$72.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$94.86
|
| Rate for Payer: BCBS Complete |
$58.38
|
| Rate for Payer: Cash Price |
$116.75
|
| Rate for Payer: Cofinity Advantage |
$102.16
|
| Rate for Payer: Cofinity Commercial |
$125.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.75
|
| Rate for Payer: Healthscope Commercial |
$131.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$102.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$109.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$116.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$109.45
|
| Rate for Payer: PHP Commercial |
$124.05
|
| Rate for Payer: Priority Health SBD |
$91.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$94.86
|
| Rate for Payer: UHC Core |
$76.03
|
| Rate for Payer: UHC Exchange |
$57.35
|
| Rate for Payer: UMR Bronson Commercial |
$54.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$109.45
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$732.68
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
10403
|
|
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 88 MCG TABLET
|
Facility
|
IP
|
$732.68
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
10403
|
|
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
|
|
