|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$3.31
|
|
|
Service Code
|
NDC 51079044301
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna American Axle |
$2.15
|
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna Medicare |
$1.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.15
|
| Rate for Payer: BCBS Complete |
$1.32
|
| Rate for Payer: Cash Price |
$2.65
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.65
|
| Rate for Payer: Healthscope Commercial |
$2.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.81
|
| Rate for Payer: PHP Commercial |
$2.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.15
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.48
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074706811
|
| Hospital Charge Code |
4424
|
|
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 Commercial |
$542.30
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.30
|
| 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: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| 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 125 MCG TABLET
|
Facility
|
IP
|
$697.68
|
|
|
Service Code
|
NDC 00074706890
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.98 |
| Max. Negotiated Rate |
$627.91 |
| Rate for Payer: Aetna American Axle |
$453.49
|
| Rate for Payer: Aetna Commercial |
$593.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.49
|
| Rate for Payer: Cash Price |
$558.14
|
| Rate for Payer: Cofinity Commercial |
$488.38
|
| Rate for Payer: Cofinity Commercial |
$600.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$558.14
|
| Rate for Payer: Healthscope Commercial |
$627.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$488.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$523.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$593.03
|
| Rate for Payer: PHP Commercial |
$593.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.49
|
| Rate for Payer: Priority Health SBD |
$439.54
|
| Rate for Payer: UMR Bronson Commercial |
$306.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$523.26
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$774.72
|
|
|
Service Code
|
NDC 00074706811
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.65 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna American Axle |
$503.57
|
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna Medicare |
$387.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.57
|
| Rate for Payer: BCBS Complete |
$309.89
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$542.30
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.30
|
| 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: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: Priority Health SBD |
$488.07
|
| Rate for Payer: UMR Bronson Commercial |
$286.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.04
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$395.87
|
|
|
Service Code
|
NDC 00378181377
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.18 |
| Max. Negotiated Rate |
$356.28 |
| Rate for Payer: Aetna American Axle |
$257.32
|
| Rate for Payer: Aetna Commercial |
$336.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$257.32
|
| Rate for Payer: Cash Price |
$316.70
|
| Rate for Payer: Cofinity Commercial |
$277.11
|
| Rate for Payer: Cofinity Commercial |
$340.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$277.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.70
|
| Rate for Payer: Healthscope Commercial |
$356.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$296.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.49
|
| Rate for Payer: PHP Commercial |
$336.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.32
|
| Rate for Payer: Priority Health SBD |
$249.40
|
| Rate for Payer: UMR Bronson Commercial |
$174.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$296.90
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 60687051911
|
| Hospital Charge Code |
4424
|
|
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 Commercial |
$1.80
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.80
|
| 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: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.67
|
| 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 137 MCG TABLET
|
Facility
|
OP
|
$2.56
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna American Axle |
$1.66
|
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: BCBS Complete |
$1.02
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.05
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: UMR Bronson Commercial |
$0.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.92
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$132.54
|
|
|
Service Code
|
NDC 72305013730
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.04 |
| Max. Negotiated Rate |
$119.29 |
| Rate for Payer: Aetna American Axle |
$86.15
|
| Rate for Payer: Aetna Commercial |
$112.66
|
| Rate for Payer: Aetna Medicare |
$66.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.15
|
| Rate for Payer: BCBS Complete |
$53.02
|
| Rate for Payer: Cash Price |
$106.03
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| Rate for Payer: Cofinity Commercial |
$92.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.03
|
| Rate for Payer: Healthscope Commercial |
$119.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.66
|
| Rate for Payer: PHP Commercial |
$112.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.15
|
| Rate for Payer: Priority Health SBD |
$83.50
|
| Rate for Payer: UMR Bronson Commercial |
$49.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.41
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$255.36
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.36 |
| Max. Negotiated Rate |
$229.82 |
| Rate for Payer: Aetna American Axle |
$165.98
|
| Rate for Payer: Aetna Commercial |
$217.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.98
|
| Rate for Payer: Cash Price |
$204.29
|
| Rate for Payer: Cofinity Commercial |
$178.75
|
| Rate for Payer: Cofinity Commercial |
$219.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$178.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.29
|
| Rate for Payer: Healthscope Commercial |
$229.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.06
|
| Rate for Payer: PHP Commercial |
$217.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.98
|
| Rate for Payer: Priority Health SBD |
$160.88
|
| Rate for Payer: UMR Bronson Commercial |
$112.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.52
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$255.36
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.48 |
| Max. Negotiated Rate |
$229.82 |
| Rate for Payer: Aetna American Axle |
$165.98
|
| Rate for Payer: Aetna Commercial |
$217.06
|
| Rate for Payer: Aetna Medicare |
$127.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.98
|
| Rate for Payer: BCBS Complete |
$102.14
|
| Rate for Payer: Cash Price |
$204.29
|
| Rate for Payer: Cofinity Commercial |
$178.75
|
| Rate for Payer: Cofinity Commercial |
$219.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$178.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.29
|
| Rate for Payer: Healthscope Commercial |
$229.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.06
|
| Rate for Payer: PHP Commercial |
$217.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.98
|
| Rate for Payer: Priority Health SBD |
$160.88
|
| Rate for Payer: UMR Bronson Commercial |
$94.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.52
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$697.68
|
|
|
Service Code
|
NDC 00074372790
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.98 |
| Max. Negotiated Rate |
$627.91 |
| Rate for Payer: Aetna American Axle |
$453.49
|
| Rate for Payer: Aetna Commercial |
$593.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.49
|
| Rate for Payer: Cash Price |
$558.14
|
| Rate for Payer: Cofinity Commercial |
$488.38
|
| Rate for Payer: Cofinity Commercial |
$600.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$558.14
|
| Rate for Payer: Healthscope Commercial |
$627.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$488.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$523.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$593.03
|
| Rate for Payer: PHP Commercial |
$593.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.49
|
| Rate for Payer: Priority Health SBD |
$439.54
|
| Rate for Payer: UMR Bronson Commercial |
$306.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$523.26
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$697.68
|
|
|
Service Code
|
NDC 00074372790
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.14 |
| Max. Negotiated Rate |
$627.91 |
| Rate for Payer: Aetna American Axle |
$453.49
|
| Rate for Payer: Aetna Commercial |
$593.03
|
| Rate for Payer: Aetna Medicare |
$348.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.49
|
| Rate for Payer: BCBS Complete |
$279.07
|
| Rate for Payer: Cash Price |
$558.14
|
| Rate for Payer: Cofinity Commercial |
$488.38
|
| Rate for Payer: Cofinity Commercial |
$600.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$558.14
|
| Rate for Payer: Healthscope Commercial |
$627.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$488.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$523.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$593.03
|
| Rate for Payer: PHP Commercial |
$593.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.49
|
| Rate for Payer: Priority Health SBD |
$439.54
|
| Rate for Payer: UMR Bronson Commercial |
$258.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$523.26
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$401.00
|
|
|
Service Code
|
NDC 00378182377
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.44 |
| Max. Negotiated Rate |
$360.90 |
| Rate for Payer: Aetna American Axle |
$260.65
|
| Rate for Payer: Aetna Commercial |
$340.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.65
|
| Rate for Payer: Cash Price |
$320.80
|
| Rate for Payer: Cofinity Commercial |
$280.70
|
| Rate for Payer: Cofinity Commercial |
$344.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$280.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.80
|
| Rate for Payer: Healthscope Commercial |
$360.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$280.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$300.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.85
|
| Rate for Payer: PHP Commercial |
$340.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.65
|
| Rate for Payer: Priority Health SBD |
$252.63
|
| Rate for Payer: UMR Bronson Commercial |
$176.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$300.75
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$401.00
|
|
|
Service Code
|
NDC 00378182377
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.37 |
| Max. Negotiated Rate |
$360.90 |
| Rate for Payer: Aetna American Axle |
$260.65
|
| Rate for Payer: Aetna Commercial |
$340.85
|
| Rate for Payer: Aetna Medicare |
$200.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$260.65
|
| Rate for Payer: BCBS Complete |
$160.40
|
| Rate for Payer: Cash Price |
$320.80
|
| Rate for Payer: Cofinity Commercial |
$280.70
|
| Rate for Payer: Cofinity Commercial |
$344.86
|
| Rate for Payer: Cofinity Medicare Advantage |
$280.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$320.80
|
| Rate for Payer: Healthscope Commercial |
$360.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$280.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$300.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$340.85
|
| Rate for Payer: PHP Commercial |
$340.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.65
|
| Rate for Payer: Priority Health SBD |
$252.63
|
| Rate for Payer: UMR Bronson Commercial |
$148.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$300.75
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$132.54
|
|
|
Service Code
|
NDC 72305013730
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.32 |
| Max. Negotiated Rate |
$119.29 |
| Rate for Payer: Aetna American Axle |
$86.15
|
| Rate for Payer: Aetna Commercial |
$112.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.15
|
| Rate for Payer: Cash Price |
$106.03
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| Rate for Payer: Cofinity Commercial |
$92.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.03
|
| Rate for Payer: Healthscope Commercial |
$119.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.66
|
| Rate for Payer: PHP Commercial |
$112.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.15
|
| Rate for Payer: Priority Health SBD |
$83.50
|
| Rate for Payer: UMR Bronson Commercial |
$58.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.41
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$287.64
|
|
|
Service Code
|
NDC 68180097209
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.56 |
| Max. Negotiated Rate |
$258.88 |
| Rate for Payer: Aetna American Axle |
$186.97
|
| Rate for Payer: Aetna Commercial |
$244.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.97
|
| Rate for Payer: Cash Price |
$230.11
|
| Rate for Payer: Cofinity Commercial |
$201.35
|
| Rate for Payer: Cofinity Commercial |
$247.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$201.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$230.11
|
| Rate for Payer: Healthscope Commercial |
$258.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$201.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$244.49
|
| Rate for Payer: PHP Commercial |
$244.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.97
|
| Rate for Payer: Priority Health SBD |
$181.21
|
| Rate for Payer: UMR Bronson Commercial |
$126.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.73
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$2.56
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna American Axle |
$1.66
|
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.05
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: UMR Bronson Commercial |
$1.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.92
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$287.64
|
|
|
Service Code
|
NDC 68180097209
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.43 |
| Max. Negotiated Rate |
$258.88 |
| Rate for Payer: Aetna American Axle |
$186.97
|
| Rate for Payer: Aetna Commercial |
$244.49
|
| Rate for Payer: Aetna Medicare |
$143.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.97
|
| Rate for Payer: BCBS Complete |
$115.06
|
| Rate for Payer: Cash Price |
$230.11
|
| Rate for Payer: Cofinity Commercial |
$201.35
|
| Rate for Payer: Cofinity Commercial |
$247.37
|
| Rate for Payer: Cofinity Medicare Advantage |
$201.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$230.11
|
| Rate for Payer: Healthscope Commercial |
$258.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$201.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$244.49
|
| Rate for Payer: PHP Commercial |
$244.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.97
|
| Rate for Payer: Priority Health SBD |
$181.21
|
| Rate for Payer: UMR Bronson Commercial |
$106.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.73
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$339.36
|
|
|
Service Code
|
NDC 51079044520
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.56 |
| Max. Negotiated Rate |
$305.42 |
| Rate for Payer: Aetna American Axle |
$220.58
|
| Rate for Payer: Aetna Commercial |
$288.46
|
| Rate for Payer: Aetna Medicare |
$169.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$220.58
|
| Rate for Payer: BCBS Complete |
$135.74
|
| Rate for Payer: Cash Price |
$271.49
|
| Rate for Payer: Cofinity Commercial |
$237.55
|
| Rate for Payer: Cofinity Commercial |
$291.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$237.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.49
|
| Rate for Payer: Healthscope Commercial |
$305.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$237.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$254.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.46
|
| Rate for Payer: PHP Commercial |
$288.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$220.58
|
| Rate for Payer: Priority Health SBD |
$213.80
|
| Rate for Payer: UMR Bronson Commercial |
$125.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$254.52
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 51079044501
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.50 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna American Axle |
$2.21
|
| Rate for Payer: Aetna Commercial |
$2.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.21
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$2.38
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.72
|
| Rate for Payer: Healthscope Commercial |
$3.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.89
|
| Rate for Payer: PHP Commercial |
$2.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: Priority Health SBD |
$2.14
|
| Rate for Payer: UMR Bronson Commercial |
$1.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.55
|
|
|
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 Commercial |
$284.89
|
| Rate for Payer: Cofinity Commercial |
$350.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$284.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.58
|
| Rate for Payer: Healthscope Commercial |
$366.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$284.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$305.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.93
|
| Rate for Payer: PHP Commercial |
$345.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$264.54
|
| Rate for Payer: Priority Health SBD |
$256.40
|
| 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
|
$339.36
|
|
|
Service Code
|
NDC 51079044520
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.32 |
| Max. Negotiated Rate |
$305.42 |
| Rate for Payer: Aetna American Axle |
$220.58
|
| Rate for Payer: Aetna Commercial |
$288.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$220.58
|
| Rate for Payer: Cash Price |
$271.49
|
| Rate for Payer: Cofinity Commercial |
$237.55
|
| Rate for Payer: Cofinity Commercial |
$291.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$237.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$271.49
|
| Rate for Payer: Healthscope Commercial |
$305.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$237.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$254.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$288.46
|
| Rate for Payer: PHP Commercial |
$288.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$220.58
|
| Rate for Payer: Priority Health SBD |
$213.80
|
| Rate for Payer: UMR Bronson Commercial |
$149.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$254.52
|
|
|
LEVOTHYROXINE 150 MCG TABLET
|
Facility
|
OP
|
$3.40
|
|
|
Service Code
|
NDC 51079044501
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$3.06 |
| Rate for Payer: Aetna American Axle |
$2.21
|
| Rate for Payer: Aetna Commercial |
$2.89
|
| Rate for Payer: Aetna Medicare |
$1.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.21
|
| Rate for Payer: BCBS Complete |
$1.36
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$2.38
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.72
|
| Rate for Payer: Healthscope Commercial |
$3.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.89
|
| Rate for Payer: PHP Commercial |
$2.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: Priority Health SBD |
$2.14
|
| Rate for Payer: UMR Bronson Commercial |
$1.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.55
|
|
|
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 Commercial |
$542.30
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.30
|
| 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: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| 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
|
IP
|
$697.68
|
|
|
Service Code
|
NDC 00074706990
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.98 |
| Max. Negotiated Rate |
$627.91 |
| Rate for Payer: Aetna American Axle |
$453.49
|
| Rate for Payer: Aetna Commercial |
$593.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.49
|
| Rate for Payer: Cash Price |
$558.14
|
| Rate for Payer: Cofinity Commercial |
$488.38
|
| Rate for Payer: Cofinity Commercial |
$600.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$558.14
|
| Rate for Payer: Healthscope Commercial |
$627.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$488.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$523.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$593.03
|
| Rate for Payer: PHP Commercial |
$593.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.49
|
| Rate for Payer: Priority Health SBD |
$439.54
|
| Rate for Payer: UMR Bronson Commercial |
$306.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$523.26
|
|
