|
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
|
$774.72
|
|
|
Service Code
|
NDC 00074706911
|
| Hospital Charge Code |
4425
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.65 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna American Axle |
$503.57
|
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna Medicare |
$387.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.57
|
| Rate for Payer: BCBS Complete |
$309.89
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity 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 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 175 MCG TABLET
|
Facility
|
OP
|
$696.82
|
|
|
Service Code
|
NDC 00074707090
|
| Hospital Charge Code |
10406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.82 |
| Max. Negotiated Rate |
$627.14 |
| Rate for Payer: Aetna American Axle |
$452.93
|
| Rate for Payer: Aetna Commercial |
$592.30
|
| Rate for Payer: Aetna Medicare |
$348.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$452.93
|
| Rate for Payer: BCBS Complete |
$278.73
|
| Rate for Payer: Cash Price |
$557.46
|
| Rate for Payer: Cofinity Commercial |
$487.77
|
| Rate for Payer: Cofinity Commercial |
$599.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$487.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.46
|
| Rate for Payer: Healthscope Commercial |
$627.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$487.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$522.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.30
|
| Rate for Payer: PHP Commercial |
$592.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$452.93
|
| Rate for Payer: Priority Health SBD |
$439.00
|
| Rate for Payer: UMR Bronson Commercial |
$257.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$522.62
|
|
|
LEVOTHYROXINE 175 MCG TABLET
|
Facility
|
IP
|
$696.82
|
|
|
Service Code
|
NDC 00074707090
|
| Hospital Charge Code |
10406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.60 |
| Max. Negotiated Rate |
$627.14 |
| Rate for Payer: Aetna American Axle |
$452.93
|
| Rate for Payer: Aetna Commercial |
$592.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$452.93
|
| Rate for Payer: Cash Price |
$557.46
|
| Rate for Payer: Cofinity Commercial |
$487.77
|
| Rate for Payer: Cofinity Commercial |
$599.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$487.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.46
|
| Rate for Payer: Healthscope Commercial |
$627.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$487.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$522.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.30
|
| Rate for Payer: PHP Commercial |
$592.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$452.93
|
| Rate for Payer: Priority Health SBD |
$439.00
|
| Rate for Payer: UMR Bronson Commercial |
$306.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$522.62
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$3.87
|
|
|
Service Code
|
NDC 60687055211
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.43 |
| Max. Negotiated Rate |
$3.48 |
| Rate for Payer: Aetna American Axle |
$2.52
|
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Aetna Medicare |
$1.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.52
|
| Rate for Payer: BCBS Complete |
$1.55
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Commercial |
$2.71
|
| Rate for Payer: Cofinity Commercial |
$3.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$3.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.29
|
| Rate for Payer: PHP Commercial |
$3.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.52
|
| Rate for Payer: Priority Health SBD |
$2.44
|
| Rate for Payer: UMR Bronson Commercial |
$1.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.90
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$372.40
|
|
|
Service Code
|
NDC 69238184001
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.79 |
| Max. Negotiated Rate |
$335.16 |
| Rate for Payer: Aetna American Axle |
$242.06
|
| Rate for Payer: Aetna Commercial |
$316.54
|
| Rate for Payer: Aetna Medicare |
$186.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.06
|
| Rate for Payer: BCBS Complete |
$148.96
|
| Rate for Payer: Cash Price |
$297.92
|
| Rate for Payer: Cofinity Commercial |
$260.68
|
| Rate for Payer: Cofinity Commercial |
$320.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$260.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.92
|
| Rate for Payer: Healthscope Commercial |
$335.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$260.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$316.54
|
| Rate for Payer: PHP Commercial |
$316.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.06
|
| Rate for Payer: Priority Health SBD |
$234.61
|
| Rate for Payer: UMR Bronson Commercial |
$137.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.30
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$609.60
|
|
|
Service Code
|
NDC 00074714811
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$268.22 |
| Max. Negotiated Rate |
$548.64 |
| Rate for Payer: Aetna American Axle |
$396.24
|
| Rate for Payer: Aetna Commercial |
$518.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.24
|
| Rate for Payer: Cash Price |
$487.68
|
| Rate for Payer: Cofinity Commercial |
$426.72
|
| Rate for Payer: Cofinity Commercial |
$524.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$426.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$487.68
|
| Rate for Payer: Healthscope Commercial |
$548.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$426.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$457.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$518.16
|
| Rate for Payer: PHP Commercial |
$518.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$396.24
|
| Rate for Payer: Priority Health SBD |
$384.05
|
| Rate for Payer: UMR Bronson Commercial |
$268.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$457.20
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$609.60
|
|
|
Service Code
|
NDC 00074714811
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$225.55 |
| Max. Negotiated Rate |
$548.64 |
| Rate for Payer: Aetna American Axle |
$396.24
|
| Rate for Payer: Aetna Commercial |
$518.16
|
| Rate for Payer: Aetna Medicare |
$304.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$396.24
|
| Rate for Payer: BCBS Complete |
$243.84
|
| Rate for Payer: Cash Price |
$487.68
|
| Rate for Payer: Cofinity Commercial |
$426.72
|
| Rate for Payer: Cofinity Commercial |
$524.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$426.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$487.68
|
| Rate for Payer: Healthscope Commercial |
$548.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$426.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$457.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$518.16
|
| Rate for Payer: PHP Commercial |
$518.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$396.24
|
| Rate for Payer: Priority Health SBD |
$384.05
|
| Rate for Payer: UMR Bronson Commercial |
$225.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$457.20
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$244.95
|
|
|
Service Code
|
NDC 00378181977
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.63 |
| Max. Negotiated Rate |
$220.46 |
| Rate for Payer: Aetna American Axle |
$159.22
|
| Rate for Payer: Aetna Commercial |
$208.21
|
| Rate for Payer: Aetna Medicare |
$122.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.22
|
| Rate for Payer: BCBS Complete |
$97.98
|
| Rate for Payer: Cash Price |
$195.96
|
| Rate for Payer: Cofinity Commercial |
$171.47
|
| Rate for Payer: Cofinity Commercial |
$210.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.96
|
| Rate for Payer: Healthscope Commercial |
$220.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.21
|
| Rate for Payer: PHP Commercial |
$208.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.22
|
| Rate for Payer: Priority Health SBD |
$154.32
|
| Rate for Payer: UMR Bronson Commercial |
$90.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.71
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$244.95
|
|
|
Service Code
|
NDC 00378181977
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.78 |
| Max. Negotiated Rate |
$220.46 |
| Rate for Payer: Aetna American Axle |
$159.22
|
| Rate for Payer: Aetna Commercial |
$208.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.22
|
| Rate for Payer: Cash Price |
$195.96
|
| Rate for Payer: Cofinity Commercial |
$171.47
|
| Rate for Payer: Cofinity Commercial |
$210.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.96
|
| Rate for Payer: Healthscope Commercial |
$220.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.21
|
| Rate for Payer: PHP Commercial |
$208.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.22
|
| Rate for Payer: Priority Health SBD |
$154.32
|
| Rate for Payer: UMR Bronson Commercial |
$107.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.71
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$372.40
|
|
|
Service Code
|
NDC 69238184001
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.86 |
| Max. Negotiated Rate |
$335.16 |
| Rate for Payer: Aetna American Axle |
$242.06
|
| Rate for Payer: Aetna Commercial |
$316.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.06
|
| Rate for Payer: Cash Price |
$297.92
|
| Rate for Payer: Cofinity Commercial |
$260.68
|
| Rate for Payer: Cofinity Commercial |
$320.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$260.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$297.92
|
| Rate for Payer: Healthscope Commercial |
$335.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$260.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$316.54
|
| Rate for Payer: PHP Commercial |
$316.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$242.06
|
| Rate for Payer: Priority Health SBD |
$234.61
|
| Rate for Payer: UMR Bronson Commercial |
$163.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.30
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$386.88
|
|
|
Service Code
|
NDC 60687055201
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.23 |
| Max. Negotiated Rate |
$348.19 |
| Rate for Payer: Aetna American Axle |
$251.47
|
| Rate for Payer: Aetna Commercial |
$328.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$251.47
|
| Rate for Payer: Cash Price |
$309.50
|
| Rate for Payer: Cofinity Commercial |
$270.82
|
| Rate for Payer: Cofinity Commercial |
$332.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$270.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.50
|
| Rate for Payer: Healthscope Commercial |
$348.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$270.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.85
|
| Rate for Payer: PHP Commercial |
$328.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.47
|
| Rate for Payer: Priority Health SBD |
$243.73
|
| Rate for Payer: UMR Bronson Commercial |
$170.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.16
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$209.00
|
|
|
Service Code
|
NDC 68180097501
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.96 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna American Axle |
$135.85
|
| Rate for Payer: Aetna Commercial |
$177.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.85
|
| Rate for Payer: Cash Price |
$167.20
|
| Rate for Payer: Cofinity Commercial |
$146.30
|
| Rate for Payer: Cofinity Commercial |
$179.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.20
|
| Rate for Payer: Healthscope Commercial |
$188.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.65
|
| Rate for Payer: PHP Commercial |
$177.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.85
|
| Rate for Payer: Priority Health SBD |
$131.67
|
| Rate for Payer: UMR Bronson Commercial |
$91.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.75
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$209.00
|
|
|
Service Code
|
NDC 68180097501
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.33 |
| Max. Negotiated Rate |
$188.10 |
| Rate for Payer: Aetna American Axle |
$135.85
|
| Rate for Payer: Aetna Commercial |
$177.65
|
| Rate for Payer: Aetna Medicare |
$104.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.85
|
| Rate for Payer: BCBS Complete |
$83.60
|
| Rate for Payer: Cash Price |
$167.20
|
| Rate for Payer: Cofinity Commercial |
$146.30
|
| Rate for Payer: Cofinity Commercial |
$179.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$146.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$167.20
|
| Rate for Payer: Healthscope Commercial |
$188.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$146.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$177.65
|
| Rate for Payer: PHP Commercial |
$177.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.85
|
| Rate for Payer: Priority Health SBD |
$131.67
|
| Rate for Payer: UMR Bronson Commercial |
$77.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.75
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$308.79
|
|
|
Service Code
|
NDC 68180097509
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.87 |
| Max. Negotiated Rate |
$277.91 |
| Rate for Payer: Aetna American Axle |
$200.71
|
| Rate for Payer: Aetna Commercial |
$262.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.71
|
| Rate for Payer: Cash Price |
$247.03
|
| Rate for Payer: Cofinity Commercial |
$216.15
|
| Rate for Payer: Cofinity Commercial |
$265.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.03
|
| Rate for Payer: Healthscope Commercial |
$277.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$262.47
|
| Rate for Payer: PHP Commercial |
$262.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.71
|
| Rate for Payer: Priority Health SBD |
$194.54
|
| Rate for Payer: UMR Bronson Commercial |
$135.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.59
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$308.79
|
|
|
Service Code
|
NDC 68180097509
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.25 |
| Max. Negotiated Rate |
$277.91 |
| Rate for Payer: Aetna American Axle |
$200.71
|
| Rate for Payer: Aetna Commercial |
$262.47
|
| Rate for Payer: Aetna Medicare |
$154.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.71
|
| Rate for Payer: BCBS Complete |
$123.52
|
| Rate for Payer: Cash Price |
$247.03
|
| Rate for Payer: Cofinity Commercial |
$216.15
|
| Rate for Payer: Cofinity Commercial |
$265.56
|
| Rate for Payer: Cofinity Medicare Advantage |
$216.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$247.03
|
| Rate for Payer: Healthscope Commercial |
$277.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$216.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$262.47
|
| Rate for Payer: PHP Commercial |
$262.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.71
|
| Rate for Payer: Priority Health SBD |
$194.54
|
| Rate for Payer: UMR Bronson Commercial |
$114.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.59
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$386.88
|
|
|
Service Code
|
NDC 60687055201
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.15 |
| Max. Negotiated Rate |
$348.19 |
| Rate for Payer: Aetna American Axle |
$251.47
|
| Rate for Payer: Aetna Commercial |
$328.85
|
| Rate for Payer: Aetna Medicare |
$193.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$251.47
|
| Rate for Payer: BCBS Complete |
$154.75
|
| Rate for Payer: Cash Price |
$309.50
|
| Rate for Payer: Cofinity Commercial |
$270.82
|
| Rate for Payer: Cofinity Commercial |
$332.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$270.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.50
|
| Rate for Payer: Healthscope Commercial |
$348.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$270.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$290.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.85
|
| Rate for Payer: PHP Commercial |
$328.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.47
|
| Rate for Payer: Priority Health SBD |
$243.73
|
| Rate for Payer: UMR Bronson Commercial |
$143.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$290.16
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$3.87
|
|
|
Service Code
|
NDC 60687055211
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.70 |
| Max. Negotiated Rate |
$3.48 |
| Rate for Payer: Aetna American Axle |
$2.52
|
| Rate for Payer: Aetna Commercial |
$3.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.52
|
| Rate for Payer: Cash Price |
$3.10
|
| Rate for Payer: Cofinity Commercial |
$2.71
|
| Rate for Payer: Cofinity Commercial |
$3.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.10
|
| Rate for Payer: Healthscope Commercial |
$3.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.29
|
| Rate for Payer: PHP Commercial |
$3.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.52
|
| Rate for Payer: Priority Health SBD |
$2.44
|
| Rate for Payer: UMR Bronson Commercial |
$1.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.90
|
|
|
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$246.98
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
190375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$91.38 |
| Max. Negotiated Rate |
$222.28 |
| Rate for Payer: Aetna American Axle |
$160.54
|
| Rate for Payer: Aetna Commercial |
$209.93
|
| Rate for Payer: Aetna Medicare |
$123.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.54
|
| Rate for Payer: BCBS Complete |
$98.79
|
| Rate for Payer: Cash Price |
$197.58
|
| Rate for Payer: Cofinity Commercial |
$172.89
|
| Rate for Payer: Cofinity Commercial |
$212.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.58
|
| Rate for Payer: Healthscope Commercial |
$222.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.93
|
| Rate for Payer: PHP Commercial |
$209.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.54
|
| Rate for Payer: Priority Health SBD |
$155.60
|
| Rate for Payer: UMR Bronson Commercial |
$91.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.24
|
|
|
LEVOTHYROXINE 20 MCG/ML INTRAVENOUS SOLUTION
|
Facility
|
IP
|
$246.98
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
190375
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$108.67 |
| Max. Negotiated Rate |
$222.28 |
| Rate for Payer: Aetna American Axle |
$160.54
|
| Rate for Payer: Aetna Commercial |
$209.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.54
|
| Rate for Payer: Cash Price |
$197.58
|
| Rate for Payer: Cofinity Commercial |
$172.89
|
| Rate for Payer: Cofinity Commercial |
$212.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.58
|
| Rate for Payer: Healthscope Commercial |
$222.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.93
|
| Rate for Payer: PHP Commercial |
$209.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.54
|
| Rate for Payer: Priority Health SBD |
$155.60
|
| Rate for Payer: UMR Bronson Commercial |
$108.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.24
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$3.45
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Aetna American Axle |
$2.24
|
| Rate for Payer: Aetna Commercial |
$2.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.24
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Commercial |
$2.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.76
|
| Rate for Payer: Healthscope Commercial |
$3.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.93
|
| Rate for Payer: PHP Commercial |
$2.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.24
|
| Rate for Payer: Priority Health SBD |
$2.17
|
| Rate for Payer: UMR Bronson Commercial |
$1.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.59
|
|
|
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 Commercial |
$51.82
|
| Rate for Payer: Cofinity Commercial |
$63.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.82
|
| 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: PHP Commercial |
$62.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.12
|
| 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
|
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 Commercial |
$51.82
|
| Rate for Payer: Cofinity Commercial |
$63.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.82
|
| 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: PHP Commercial |
$62.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.12
|
| Rate for Payer: Priority Health SBD |
$46.64
|
| 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
|
$4.30
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.89 |
| Max. Negotiated Rate |
$3.87 |
| Rate for Payer: Aetna American Axle |
$2.79
|
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.79
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cofinity Commercial |
$3.01
|
| Rate for Payer: Cofinity Commercial |
$3.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.44
|
| Rate for Payer: Healthscope Commercial |
$3.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.65
|
| Rate for Payer: PHP Commercial |
$3.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.79
|
| Rate for Payer: Priority Health SBD |
$2.71
|
| Rate for Payer: UMR Bronson Commercial |
$1.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.23
|
|
