|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$697.68
|
|
|
Service Code
|
NDC 00074434190
|
| Hospital Charge Code |
4420
|
|
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 25 MCG TABLET
|
Facility
|
OP
|
$4.30
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.59 |
| Max. Negotiated Rate |
$3.87 |
| Rate for Payer: Aetna American Axle |
$2.79
|
| Rate for Payer: Aetna Commercial |
$3.65
|
| Rate for Payer: Aetna Medicare |
$2.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.79
|
| Rate for Payer: BCBS Complete |
$1.72
|
| 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 |
$1.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.23
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$429.40
|
|
|
Service Code
|
NDC 51079044420
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.94 |
| Max. Negotiated Rate |
$386.46 |
| Rate for Payer: Aetna American Axle |
$279.11
|
| Rate for Payer: Aetna Commercial |
$364.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$279.11
|
| Rate for Payer: Cash Price |
$343.52
|
| Rate for Payer: Cofinity Commercial |
$300.58
|
| Rate for Payer: Cofinity Commercial |
$369.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$300.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.52
|
| Rate for Payer: Healthscope Commercial |
$386.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$300.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$322.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.99
|
| Rate for Payer: PHP Commercial |
$364.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$279.11
|
| Rate for Payer: Priority Health SBD |
$270.52
|
| Rate for Payer: UMR Bronson Commercial |
$188.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$322.05
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$697.68
|
|
|
Service Code
|
NDC 00074434190
|
| Hospital Charge Code |
4420
|
|
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 25 MCG TABLET
|
Facility
|
OP
|
$429.40
|
|
|
Service Code
|
NDC 51079044420
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.88 |
| Max. Negotiated Rate |
$386.46 |
| Rate for Payer: Aetna American Axle |
$279.11
|
| Rate for Payer: Aetna Commercial |
$364.99
|
| Rate for Payer: Aetna Medicare |
$214.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$279.11
|
| Rate for Payer: BCBS Complete |
$171.76
|
| Rate for Payer: Cash Price |
$343.52
|
| Rate for Payer: Cofinity Commercial |
$300.58
|
| Rate for Payer: Cofinity Commercial |
$369.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$300.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$343.52
|
| Rate for Payer: Healthscope Commercial |
$386.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$300.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$322.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$364.99
|
| Rate for Payer: PHP Commercial |
$364.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$279.11
|
| Rate for Payer: Priority Health SBD |
$270.52
|
| Rate for Payer: UMR Bronson Commercial |
$158.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$322.05
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$313.50
|
|
|
Service Code
|
NDC 00904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.00 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Aetna American Axle |
$203.78
|
| Rate for Payer: Aetna Commercial |
$266.48
|
| Rate for Payer: Aetna Medicare |
$156.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.78
|
| Rate for Payer: BCBS Complete |
$125.40
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cofinity Commercial |
$219.45
|
| Rate for Payer: Cofinity Commercial |
$269.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$219.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.80
|
| Rate for Payer: Healthscope Commercial |
$282.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$219.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$266.48
|
| Rate for Payer: PHP Commercial |
$266.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.78
|
| Rate for Payer: Priority Health SBD |
$197.50
|
| Rate for Payer: UMR Bronson Commercial |
$116.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.12
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$344.85
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.73 |
| Max. Negotiated Rate |
$310.37 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$241.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.15
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UMR Bronson Commercial |
$151.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$313.50
|
|
|
Service Code
|
NDC 00904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.94 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Aetna American Axle |
$203.78
|
| Rate for Payer: Aetna Commercial |
$266.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$203.78
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cofinity Commercial |
$219.45
|
| Rate for Payer: Cofinity Commercial |
$269.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$219.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.80
|
| Rate for Payer: Healthscope Commercial |
$282.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$219.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$266.48
|
| Rate for Payer: PHP Commercial |
$266.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.78
|
| Rate for Payer: Priority Health SBD |
$197.50
|
| Rate for Payer: UMR Bronson Commercial |
$137.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.12
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$344.85
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.59 |
| Max. Negotiated Rate |
$310.37 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna Medicare |
$172.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: BCBS Complete |
$137.94
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$241.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.15
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UMR Bronson Commercial |
$127.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$3.45
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Aetna American Axle |
$2.24
|
| Rate for Payer: Aetna Commercial |
$2.93
|
| Rate for Payer: Aetna Medicare |
$1.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.24
|
| Rate for Payer: BCBS Complete |
$1.38
|
| 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 |
$1.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.59
|
|
|
LEVOTHYROXINE 500 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$1,182.05
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$520.10 |
| Max. Negotiated Rate |
$1,063.85 |
| Rate for Payer: Aetna American Axle |
$768.33
|
| Rate for Payer: Aetna Commercial |
$1,004.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$768.33
|
| Rate for Payer: Cash Price |
$945.64
|
| Rate for Payer: Cofinity Commercial |
$1,016.56
|
| Rate for Payer: Cofinity Commercial |
$827.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$827.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$945.64
|
| Rate for Payer: Healthscope Commercial |
$1,063.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$827.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$886.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,004.74
|
| Rate for Payer: PHP Commercial |
$1,004.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$768.33
|
| Rate for Payer: Priority Health SBD |
$744.69
|
| Rate for Payer: UMR Bronson Commercial |
$520.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$886.54
|
|
|
LEVOTHYROXINE 500 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$1,182.05
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$437.36 |
| Max. Negotiated Rate |
$1,063.85 |
| Rate for Payer: Aetna American Axle |
$768.33
|
| Rate for Payer: Aetna Commercial |
$1,004.74
|
| Rate for Payer: Aetna Medicare |
$591.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$768.33
|
| Rate for Payer: BCBS Complete |
$472.82
|
| Rate for Payer: Cash Price |
$945.64
|
| Rate for Payer: Cofinity Commercial |
$1,016.56
|
| Rate for Payer: Cofinity Commercial |
$827.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$827.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$945.64
|
| Rate for Payer: Healthscope Commercial |
$1,063.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$827.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$886.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,004.74
|
| Rate for Payer: PHP Commercial |
$1,004.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$768.33
|
| Rate for Payer: Priority Health SBD |
$744.69
|
| Rate for Payer: UMR Bronson Commercial |
$437.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$886.54
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$3.45
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
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 50 MCG TABLET
|
Facility
|
OP
|
$344.85
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.59 |
| Max. Negotiated Rate |
$310.37 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna Medicare |
$172.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: BCBS Complete |
$137.94
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$241.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.15
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UMR Bronson Commercial |
$127.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$2.47
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Aetna American Axle |
$1.61
|
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.61
|
| Rate for Payer: BCBS Complete |
$0.99
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cofinity Commercial |
$1.73
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.10
|
| Rate for Payer: PHP Commercial |
$2.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: Priority Health SBD |
$1.56
|
| Rate for Payer: UMR Bronson Commercial |
$0.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.85
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$697.25
|
|
|
Service Code
|
NDC 00074455290
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.98 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna American Axle |
$453.21
|
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: Aetna Medicare |
$348.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.21
|
| Rate for Payer: BCBS Complete |
$278.90
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$488.07
|
| Rate for Payer: Cofinity Commercial |
$599.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.80
|
| Rate for Payer: Healthscope Commercial |
$627.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$488.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$522.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.66
|
| Rate for Payer: PHP Commercial |
$592.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.21
|
| Rate for Payer: Priority Health SBD |
$439.27
|
| Rate for Payer: UMR Bronson Commercial |
$257.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$522.94
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$2.47
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Aetna American Axle |
$1.61
|
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.61
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cofinity Commercial |
$1.73
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.10
|
| Rate for Payer: PHP Commercial |
$2.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: Priority Health SBD |
$1.56
|
| Rate for Payer: UMR Bronson Commercial |
$1.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.85
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$697.25
|
|
|
Service Code
|
NDC 00074455290
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.79 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna American Axle |
$453.21
|
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.21
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$488.07
|
| Rate for Payer: Cofinity Commercial |
$599.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$557.80
|
| Rate for Payer: Healthscope Commercial |
$627.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$488.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$522.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$592.66
|
| Rate for Payer: PHP Commercial |
$592.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.21
|
| Rate for Payer: Priority Health SBD |
$439.27
|
| Rate for Payer: UMR Bronson Commercial |
$306.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$522.94
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$3.45
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Aetna American Axle |
$2.24
|
| Rate for Payer: Aetna Commercial |
$2.93
|
| Rate for Payer: Aetna Medicare |
$1.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.24
|
| Rate for Payer: BCBS Complete |
$1.38
|
| 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 |
$1.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.59
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074455211
|
| Hospital Charge Code |
4421
|
|
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 50 MCG TABLET
|
Facility
|
IP
|
$246.72
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.56 |
| Max. Negotiated Rate |
$222.05 |
| Rate for Payer: Aetna American Axle |
$160.37
|
| Rate for Payer: Aetna Commercial |
$209.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.37
|
| Rate for Payer: Cash Price |
$197.38
|
| Rate for Payer: Cofinity Commercial |
$172.70
|
| Rate for Payer: Cofinity Commercial |
$212.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.38
|
| Rate for Payer: Healthscope Commercial |
$222.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.71
|
| Rate for Payer: PHP Commercial |
$209.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.37
|
| Rate for Payer: Priority Health SBD |
$155.43
|
| Rate for Payer: UMR Bronson Commercial |
$108.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.04
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$246.72
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.29 |
| Max. Negotiated Rate |
$222.05 |
| Rate for Payer: Aetna American Axle |
$160.37
|
| Rate for Payer: Aetna Commercial |
$209.71
|
| Rate for Payer: Aetna Medicare |
$123.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.37
|
| Rate for Payer: BCBS Complete |
$98.69
|
| Rate for Payer: Cash Price |
$197.38
|
| Rate for Payer: Cofinity Commercial |
$172.70
|
| Rate for Payer: Cofinity Commercial |
$212.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.38
|
| Rate for Payer: Healthscope Commercial |
$222.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.71
|
| Rate for Payer: PHP Commercial |
$209.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.37
|
| Rate for Payer: Priority Health SBD |
$155.43
|
| Rate for Payer: UMR Bronson Commercial |
$91.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.04
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$774.72
|
|
|
Service Code
|
NDC 00074455211
|
| Hospital Charge Code |
4421
|
|
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 50 MCG TABLET
|
Facility
|
IP
|
$344.85
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.73 |
| Max. Negotiated Rate |
$310.37 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$241.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.15
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UMR Bronson Commercial |
$151.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$697.68
|
|
|
Service Code
|
NDC 00074518290
|
| Hospital Charge Code |
4422
|
|
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
|
|
