|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$68.18
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$30.00 |
| Max. Negotiated Rate |
$61.36 |
| Rate for Payer: Aetna American Axle |
$44.32
|
| Rate for Payer: Aetna American Axle |
$66.87
|
| Rate for Payer: Aetna American Axle |
$72.50
|
| Rate for Payer: Aetna American Axle |
$57.54
|
| Rate for Payer: Aetna American Axle |
$32.66
|
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Commercial |
$94.81
|
| Rate for Payer: Aetna Commercial |
$87.45
|
| Rate for Payer: Aetna Commercial |
$75.25
|
| Rate for Payer: Aetna Commercial |
$42.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.50
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cash Price |
$70.82
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$82.30
|
| Rate for Payer: Cofinity Commercial |
$61.97
|
| Rate for Payer: Cofinity Commercial |
$72.02
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Cofinity Commercial |
$47.73
|
| Rate for Payer: Cofinity Commercial |
$35.18
|
| Rate for Payer: Cofinity Commercial |
$78.08
|
| Rate for Payer: Cofinity Commercial |
$95.92
|
| Rate for Payer: Cofinity Commercial |
$43.22
|
| Rate for Payer: Cofinity Commercial |
$88.48
|
| Rate for Payer: Cofinity Commercial |
$76.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.20
|
| Rate for Payer: Healthscope Commercial |
$100.39
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Healthscope Commercial |
$45.22
|
| Rate for Payer: Healthscope Commercial |
$79.68
|
| Rate for Payer: Healthscope Commercial |
$92.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.45
|
| Rate for Payer: PHP Commercial |
$87.45
|
| Rate for Payer: PHP Commercial |
$75.25
|
| Rate for Payer: PHP Commercial |
$42.71
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: PHP Commercial |
$94.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.87
|
| Rate for Payer: Priority Health SBD |
$55.77
|
| Rate for Payer: Priority Health SBD |
$31.66
|
| Rate for Payer: Priority Health SBD |
$70.27
|
| Rate for Payer: Priority Health SBD |
$64.81
|
| Rate for Payer: Priority Health SBD |
$42.95
|
| Rate for Payer: UMR Bronson Commercial |
$45.27
|
| Rate for Payer: UMR Bronson Commercial |
$49.08
|
| Rate for Payer: UMR Bronson Commercial |
$30.00
|
| Rate for Payer: UMR Bronson Commercial |
$38.95
|
| Rate for Payer: UMR Bronson Commercial |
$22.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.14
|
|
|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
OP
|
$111.54
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.10 |
| Max. Negotiated Rate |
$100.39 |
| Rate for Payer: Aetna American Axle |
$72.50
|
| Rate for Payer: Aetna American Axle |
$44.32
|
| Rate for Payer: Aetna American Axle |
$32.66
|
| Rate for Payer: Aetna American Axle |
$66.87
|
| Rate for Payer: Aetna American Axle |
$57.54
|
| Rate for Payer: Aetna Commercial |
$94.81
|
| Rate for Payer: Aetna Commercial |
$87.45
|
| Rate for Payer: Aetna Commercial |
$75.25
|
| Rate for Payer: Aetna Commercial |
$42.71
|
| Rate for Payer: Aetna Commercial |
$57.95
|
| Rate for Payer: Aetna Medicare |
$25.12
|
| Rate for Payer: Aetna Medicare |
$34.09
|
| Rate for Payer: Aetna Medicare |
$55.77
|
| Rate for Payer: Aetna Medicare |
$51.44
|
| Rate for Payer: Aetna Medicare |
$44.26
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$44.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$57.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$32.66
|
| Rate for Payer: BCBS Complete |
$44.62
|
| Rate for Payer: BCBS Complete |
$41.15
|
| Rate for Payer: BCBS Complete |
$27.27
|
| Rate for Payer: BCBS Complete |
$35.41
|
| Rate for Payer: BCBS Complete |
$20.10
|
| Rate for Payer: BCBS Trust/PPO |
$3.10
|
| Rate for Payer: BCBS Trust/PPO |
$3.10
|
| Rate for Payer: BCBS Trust/PPO |
$3.10
|
| Rate for Payer: BCBS Trust/PPO |
$3.10
|
| Rate for Payer: BCBS Trust/PPO |
$3.10
|
| Rate for Payer: BCN Commercial |
$3.10
|
| Rate for Payer: BCN Commercial |
$3.10
|
| Rate for Payer: BCN Commercial |
$3.10
|
| Rate for Payer: BCN Commercial |
$3.10
|
| Rate for Payer: BCN Commercial |
$3.10
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$82.30
|
| Rate for Payer: Cash Price |
$89.23
|
| Rate for Payer: Cash Price |
$82.30
|
| Rate for Payer: Cash Price |
$40.20
|
| Rate for Payer: Cash Price |
$70.82
|
| Rate for Payer: Cash Price |
$70.82
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cash Price |
$54.54
|
| Rate for Payer: Cofinity Commercial |
$78.08
|
| Rate for Payer: Cofinity Commercial |
$76.14
|
| Rate for Payer: Cofinity Commercial |
$72.02
|
| Rate for Payer: Cofinity Commercial |
$43.22
|
| Rate for Payer: Cofinity Commercial |
$35.18
|
| Rate for Payer: Cofinity Commercial |
$61.97
|
| Rate for Payer: Cofinity Commercial |
$58.63
|
| Rate for Payer: Cofinity Commercial |
$47.73
|
| Rate for Payer: Cofinity Commercial |
$95.92
|
| Rate for Payer: Cofinity Commercial |
$88.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$61.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$35.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$78.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$40.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.54
|
| Rate for Payer: Healthscope Commercial |
$61.36
|
| Rate for Payer: Healthscope Commercial |
$92.59
|
| Rate for Payer: Healthscope Commercial |
$100.39
|
| Rate for Payer: Healthscope Commercial |
$45.22
|
| Rate for Payer: Healthscope Commercial |
$79.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.08
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$35.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$61.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$37.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$42.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$75.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.45
|
| Rate for Payer: PHP Commercial |
$75.25
|
| Rate for Payer: PHP Commercial |
$57.95
|
| Rate for Payer: PHP Commercial |
$94.81
|
| Rate for Payer: PHP Commercial |
$87.45
|
| Rate for Payer: PHP Commercial |
$42.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.50
|
| Rate for Payer: Priority Health SBD |
$70.27
|
| Rate for Payer: Priority Health SBD |
$55.77
|
| Rate for Payer: Priority Health SBD |
$42.95
|
| Rate for Payer: Priority Health SBD |
$64.81
|
| Rate for Payer: Priority Health SBD |
$31.66
|
| Rate for Payer: UMR Bronson Commercial |
$38.07
|
| Rate for Payer: UMR Bronson Commercial |
$18.59
|
| Rate for Payer: UMR Bronson Commercial |
$41.27
|
| Rate for Payer: UMR Bronson Commercial |
$25.23
|
| Rate for Payer: UMR Bronson Commercial |
$32.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$37.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.16
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
OP
|
$135.36
|
|
|
Service Code
|
NDC 55111028130
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.08 |
| Max. Negotiated Rate |
$121.82 |
| Rate for Payer: Aetna American Axle |
$87.98
|
| Rate for Payer: Aetna Commercial |
$115.06
|
| Rate for Payer: Aetna Medicare |
$67.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.98
|
| Rate for Payer: BCBS Complete |
$54.14
|
| Rate for Payer: Cash Price |
$108.29
|
| Rate for Payer: Cofinity Commercial |
$116.41
|
| Rate for Payer: Cofinity Commercial |
$94.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$94.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.29
|
| Rate for Payer: Healthscope Commercial |
$121.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.06
|
| Rate for Payer: PHP Commercial |
$115.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.98
|
| Rate for Payer: Priority Health SBD |
$85.28
|
| Rate for Payer: UMR Bronson Commercial |
$50.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.52
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$135.36
|
|
|
Service Code
|
NDC 55111028130
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.56 |
| Max. Negotiated Rate |
$121.82 |
| Rate for Payer: Aetna American Axle |
$87.98
|
| Rate for Payer: Aetna Commercial |
$115.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.98
|
| Rate for Payer: Cash Price |
$108.29
|
| Rate for Payer: Cofinity Commercial |
$116.41
|
| Rate for Payer: Cofinity Commercial |
$94.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$94.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.29
|
| Rate for Payer: Healthscope Commercial |
$121.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$94.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$115.06
|
| Rate for Payer: PHP Commercial |
$115.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$87.98
|
| Rate for Payer: Priority Health SBD |
$85.28
|
| Rate for Payer: UMR Bronson Commercial |
$59.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.52
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
OP
|
$336.30
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.43 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna American Axle |
$218.60
|
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna Medicare |
$168.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.60
|
| Rate for Payer: BCBS Complete |
$134.52
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$235.41
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$235.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$235.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.60
|
| Rate for Payer: Priority Health SBD |
$211.87
|
| Rate for Payer: UMR Bronson Commercial |
$124.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
LEVOFLOXACIN 750 MG TABLET
|
Facility
|
IP
|
$336.30
|
|
|
Service Code
|
NDC 00904635361
|
| Hospital Charge Code |
28964
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.97 |
| Max. Negotiated Rate |
$302.67 |
| Rate for Payer: Aetna American Axle |
$218.60
|
| Rate for Payer: Aetna Commercial |
$285.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$218.60
|
| Rate for Payer: Cash Price |
$269.04
|
| Rate for Payer: Cofinity Commercial |
$235.41
|
| Rate for Payer: Cofinity Commercial |
$289.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$235.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$269.04
|
| Rate for Payer: Healthscope Commercial |
$302.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$235.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$252.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.86
|
| Rate for Payer: PHP Commercial |
$285.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.60
|
| Rate for Payer: Priority Health SBD |
$211.87
|
| Rate for Payer: UMR Bronson Commercial |
$147.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$252.22
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE
|
Facility
|
IP
|
$3,882.19
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
181058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,708.16 |
| Max. Negotiated Rate |
$3,493.97 |
| Rate for Payer: Aetna American Axle |
$2,523.42
|
| Rate for Payer: Aetna American Axle |
$2,649.59
|
| Rate for Payer: Aetna Commercial |
$3,299.86
|
| Rate for Payer: Aetna Commercial |
$3,464.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,523.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,649.59
|
| Rate for Payer: Cash Price |
$3,105.75
|
| Rate for Payer: Cash Price |
$3,261.03
|
| Rate for Payer: Cofinity Commercial |
$3,505.61
|
| Rate for Payer: Cofinity Commercial |
$2,853.40
|
| Rate for Payer: Cofinity Commercial |
$2,717.53
|
| Rate for Payer: Cofinity Commercial |
$3,338.68
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,717.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,853.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,105.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,261.03
|
| Rate for Payer: Healthscope Commercial |
$3,493.97
|
| Rate for Payer: Healthscope Commercial |
$3,668.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,717.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,853.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,911.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,057.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,464.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,299.86
|
| Rate for Payer: PHP Commercial |
$3,464.85
|
| Rate for Payer: PHP Commercial |
$3,299.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,523.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,649.59
|
| Rate for Payer: Priority Health SBD |
$2,445.78
|
| Rate for Payer: Priority Health SBD |
$2,568.06
|
| Rate for Payer: UMR Bronson Commercial |
$1,708.16
|
| Rate for Payer: UMR Bronson Commercial |
$1,793.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,911.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,057.22
|
|
|
LEVONORGESTREL 17.5 MCG/24 HR (UP TO 5 YRS) 19.5MG INTRAUTERINE DEVICE
|
Facility
|
OP
|
$4,076.29
|
|
|
Service Code
|
HCPCS J7296
|
| Hospital Charge Code |
181058
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$980.96 |
| Max. Negotiated Rate |
$3,668.66 |
| Rate for Payer: Aetna American Axle |
$2,649.59
|
| Rate for Payer: Aetna American Axle |
$2,523.42
|
| Rate for Payer: Aetna Commercial |
$3,299.86
|
| Rate for Payer: Aetna Commercial |
$3,464.85
|
| Rate for Payer: Aetna Medicare |
$2,038.14
|
| Rate for Payer: Aetna Medicare |
$1,941.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,649.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,523.42
|
| Rate for Payer: BCBS Complete |
$1,630.52
|
| Rate for Payer: BCBS Complete |
$1,552.88
|
| Rate for Payer: BCBS Trust/PPO |
$3,272.88
|
| Rate for Payer: BCBS Trust/PPO |
$3,272.88
|
| Rate for Payer: BCN Commercial |
$3,272.88
|
| Rate for Payer: BCN Commercial |
$3,272.88
|
| Rate for Payer: Cash Price |
$3,261.03
|
| Rate for Payer: Cash Price |
$3,105.75
|
| Rate for Payer: Cash Price |
$3,105.75
|
| Rate for Payer: Cash Price |
$3,261.03
|
| Rate for Payer: Cofinity Commercial |
$3,338.68
|
| Rate for Payer: Cofinity Commercial |
$2,853.40
|
| Rate for Payer: Cofinity Commercial |
$3,505.61
|
| Rate for Payer: Cofinity Commercial |
$2,717.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,717.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$2,853.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,105.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,261.03
|
| Rate for Payer: Healthscope Commercial |
$3,668.66
|
| Rate for Payer: Healthscope Commercial |
$3,493.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,717.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2,853.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,057.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2,911.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,299.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,464.85
|
| Rate for Payer: PHP Commercial |
$3,299.86
|
| Rate for Payer: PHP Commercial |
$3,464.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,523.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,649.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,226.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,226.20
|
| Rate for Payer: Priority Health Narrow Network |
$980.96
|
| Rate for Payer: Priority Health Narrow Network |
$980.96
|
| Rate for Payer: Priority Health SBD |
$2,445.78
|
| Rate for Payer: Priority Health SBD |
$2,568.06
|
| Rate for Payer: UMR Bronson Commercial |
$1,508.23
|
| Rate for Payer: UMR Bronson Commercial |
$1,436.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,057.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2,911.64
|
|
|
LEVONORGESTREL 21 MCG/24 HR (UP TO 8 YEARS) 52 MG INTRAUTERINE DEVICE
|
Facility
|
OP
|
$4,494.14
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$980.96 |
| Max. Negotiated Rate |
$4,044.73 |
| Rate for Payer: Aetna American Axle |
$2,921.19
|
| Rate for Payer: Aetna Commercial |
$3,820.02
|
| Rate for Payer: Aetna Medicare |
$2,247.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,921.19
|
| Rate for Payer: BCBS Complete |
$1,797.66
|
| Rate for Payer: BCBS Trust/PPO |
$3,230.46
|
| Rate for Payer: BCN Commercial |
$3,230.46
|
| Rate for Payer: Cash Price |
$3,595.31
|
| Rate for Payer: Cash Price |
$3,595.31
|
| Rate for Payer: Cofinity Commercial |
$3,145.90
|
| Rate for Payer: Cofinity Commercial |
$3,864.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,145.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,595.31
|
| Rate for Payer: Healthscope Commercial |
$4,044.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,145.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,370.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,820.02
|
| Rate for Payer: PHP Commercial |
$3,820.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,921.19
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1,226.20
|
| Rate for Payer: Priority Health Narrow Network |
$980.96
|
| Rate for Payer: Priority Health SBD |
$2,831.31
|
| Rate for Payer: UMR Bronson Commercial |
$1,662.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,370.60
|
|
|
LEVONORGESTREL 21 MCG/24 HR (UP TO 8 YEARS) 52 MG INTRAUTERINE DEVICE
|
Facility
|
IP
|
$4,494.14
|
|
|
Service Code
|
HCPCS J7298
|
| Hospital Charge Code |
29280
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,977.42 |
| Max. Negotiated Rate |
$4,044.73 |
| Rate for Payer: PHP Commercial |
$3,820.02
|
| Rate for Payer: Aetna American Axle |
$2,921.19
|
| Rate for Payer: Aetna Commercial |
$3,820.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2,921.19
|
| Rate for Payer: Cash Price |
$3,595.31
|
| Rate for Payer: Cofinity Commercial |
$3,145.90
|
| Rate for Payer: Cofinity Commercial |
$3,864.96
|
| Rate for Payer: Cofinity Medicare Advantage |
$3,145.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3,595.31
|
| Rate for Payer: Healthscope Commercial |
$4,044.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3,145.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3,370.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3,820.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2,921.19
|
| Rate for Payer: Priority Health SBD |
$2,831.31
|
| Rate for Payer: UMR Bronson Commercial |
$1,977.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3,370.60
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$188.01
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$82.72 |
| Max. Negotiated Rate |
$169.21 |
| Rate for Payer: Aetna American Axle |
$122.21
|
| Rate for Payer: Aetna American Axle |
$150.75
|
| Rate for Payer: Aetna American Axle |
$189.15
|
| Rate for Payer: Aetna Commercial |
$197.14
|
| Rate for Payer: Aetna Commercial |
$159.81
|
| Rate for Payer: Aetna Commercial |
$247.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.75
|
| Rate for Payer: Cash Price |
$232.80
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cofinity Commercial |
$161.69
|
| Rate for Payer: Cofinity Commercial |
$199.46
|
| Rate for Payer: Cofinity Commercial |
$162.35
|
| Rate for Payer: Cofinity Commercial |
$250.26
|
| Rate for Payer: Cofinity Commercial |
$203.70
|
| Rate for Payer: Cofinity Commercial |
$131.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Healthscope Commercial |
$208.74
|
| Rate for Payer: Healthscope Commercial |
$169.21
|
| Rate for Payer: Healthscope Commercial |
$261.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.14
|
| Rate for Payer: PHP Commercial |
$247.35
|
| Rate for Payer: PHP Commercial |
$197.14
|
| Rate for Payer: PHP Commercial |
$159.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.21
|
| Rate for Payer: Priority Health SBD |
$183.33
|
| Rate for Payer: Priority Health SBD |
$146.12
|
| Rate for Payer: Priority Health SBD |
$118.45
|
| Rate for Payer: UMR Bronson Commercial |
$82.72
|
| Rate for Payer: UMR Bronson Commercial |
$128.04
|
| Rate for Payer: UMR Bronson Commercial |
$102.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.95
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$411.20
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$370.08 |
| Rate for Payer: Aetna American Axle |
$267.28
|
| Rate for Payer: Aetna American Axle |
$189.15
|
| Rate for Payer: Aetna American Axle |
$122.21
|
| Rate for Payer: Aetna American Axle |
$150.75
|
| Rate for Payer: Aetna Commercial |
$349.52
|
| Rate for Payer: Aetna Commercial |
$197.14
|
| Rate for Payer: Aetna Commercial |
$159.81
|
| Rate for Payer: Aetna Commercial |
$247.35
|
| Rate for Payer: Aetna Medicare |
$145.50
|
| Rate for Payer: Aetna Medicare |
$115.96
|
| Rate for Payer: Aetna Medicare |
$94.00
|
| Rate for Payer: Aetna Medicare |
$205.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$267.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$122.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.75
|
| Rate for Payer: BCBS Complete |
$116.40
|
| Rate for Payer: BCBS Complete |
$75.20
|
| Rate for Payer: BCBS Complete |
$164.48
|
| Rate for Payer: BCBS Complete |
$92.77
|
| Rate for Payer: BCBS Trust/PPO |
$14.53
|
| Rate for Payer: BCBS Trust/PPO |
$14.53
|
| Rate for Payer: BCBS Trust/PPO |
$14.53
|
| Rate for Payer: BCBS Trust/PPO |
$14.53
|
| Rate for Payer: BCN Commercial |
$14.53
|
| Rate for Payer: BCN Commercial |
$14.53
|
| Rate for Payer: BCN Commercial |
$14.53
|
| Rate for Payer: BCN Commercial |
$14.53
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$328.96
|
| Rate for Payer: Cash Price |
$232.80
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$232.80
|
| Rate for Payer: Cash Price |
$328.96
|
| Rate for Payer: Cofinity Commercial |
$353.63
|
| Rate for Payer: Cofinity Commercial |
$199.46
|
| Rate for Payer: Cofinity Commercial |
$131.61
|
| Rate for Payer: Cofinity Commercial |
$161.69
|
| Rate for Payer: Cofinity Commercial |
$162.35
|
| Rate for Payer: Cofinity Commercial |
$203.70
|
| Rate for Payer: Cofinity Commercial |
$250.26
|
| Rate for Payer: Cofinity Commercial |
$287.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$162.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$131.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$287.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$328.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Healthscope Commercial |
$169.21
|
| Rate for Payer: Healthscope Commercial |
$370.08
|
| Rate for Payer: Healthscope Commercial |
$261.90
|
| Rate for Payer: Healthscope Commercial |
$208.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$131.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$287.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$308.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$141.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$349.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: PHP Commercial |
$349.52
|
| Rate for Payer: PHP Commercial |
$197.14
|
| Rate for Payer: PHP Commercial |
$159.81
|
| Rate for Payer: PHP Commercial |
$247.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$267.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.15
|
| Rate for Payer: Priority Health SBD |
$118.45
|
| Rate for Payer: Priority Health SBD |
$183.33
|
| Rate for Payer: Priority Health SBD |
$146.12
|
| Rate for Payer: Priority Health SBD |
$259.06
|
| Rate for Payer: UMR Bronson Commercial |
$69.56
|
| Rate for Payer: UMR Bronson Commercial |
$107.67
|
| Rate for Payer: UMR Bronson Commercial |
$152.14
|
| Rate for Payer: UMR Bronson Commercial |
$85.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$141.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$308.40
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$2.81
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: Aetna Medicare |
$1.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: BCBS Complete |
$1.12
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Healthscope Commercial |
$2.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.39
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.77
|
| Rate for Payer: UMR Bronson Commercial |
$1.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$774.72
|
|
|
Service Code
|
NDC 00074662411
|
| Hospital Charge Code |
4423
|
|
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 100 MCG TABLET
|
Facility
|
IP
|
$280.32
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.34 |
| Max. Negotiated Rate |
$252.29 |
| Rate for Payer: Aetna American Axle |
$182.21
|
| Rate for Payer: Aetna Commercial |
$238.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.21
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$196.22
|
| Rate for Payer: Cofinity Commercial |
$241.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.26
|
| Rate for Payer: Healthscope Commercial |
$252.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.27
|
| Rate for Payer: PHP Commercial |
$238.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.21
|
| Rate for Payer: Priority Health SBD |
$176.60
|
| Rate for Payer: UMR Bronson Commercial |
$123.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.24
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Aetna American Axle |
$1.83
|
| Rate for Payer: Aetna Commercial |
$2.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.83
|
| Rate for Payer: Cash Price |
$2.25
|
| Rate for Payer: Cofinity Commercial |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.25
|
| Rate for Payer: Healthscope Commercial |
$2.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.39
|
| Rate for Payer: PHP Commercial |
$2.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.83
|
| Rate for Payer: Priority Health SBD |
$1.77
|
| Rate for Payer: UMR Bronson Commercial |
$1.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.11
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$148.60 |
| Max. Negotiated Rate |
$303.96 |
| Rate for Payer: Aetna American Axle |
$219.52
|
| Rate for Payer: Aetna Commercial |
$287.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$219.52
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$236.41
|
| Rate for Payer: Cofinity Commercial |
$290.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$236.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$303.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$236.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$253.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: PHP Commercial |
$287.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: Priority Health SBD |
$212.77
|
| Rate for Payer: UMR Bronson Commercial |
$148.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$253.30
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074662411
|
| Hospital Charge Code |
4423
|
|
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 100 MCG TABLET
|
Facility
|
OP
|
$337.73
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.96 |
| Max. Negotiated Rate |
$303.96 |
| Rate for Payer: Aetna American Axle |
$219.52
|
| Rate for Payer: Aetna Commercial |
$287.07
|
| Rate for Payer: Aetna Medicare |
$168.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$219.52
|
| Rate for Payer: BCBS Complete |
$135.09
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$236.41
|
| Rate for Payer: Cofinity Commercial |
$290.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$236.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$303.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$236.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$253.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.07
|
| Rate for Payer: PHP Commercial |
$287.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: Priority Health SBD |
$212.77
|
| Rate for Payer: UMR Bronson Commercial |
$124.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$253.30
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$280.32
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.72 |
| Max. Negotiated Rate |
$252.29 |
| Rate for Payer: Aetna American Axle |
$182.21
|
| Rate for Payer: Aetna Commercial |
$238.27
|
| Rate for Payer: Aetna Medicare |
$140.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.21
|
| Rate for Payer: BCBS Complete |
$112.13
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$196.22
|
| Rate for Payer: Cofinity Commercial |
$241.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$196.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.26
|
| Rate for Payer: Healthscope Commercial |
$252.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.27
|
| Rate for Payer: PHP Commercial |
$238.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.21
|
| Rate for Payer: Priority Health SBD |
$176.60
|
| Rate for Payer: UMR Bronson Commercial |
$103.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.24
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$2.93
|
|
|
Service Code
|
NDC 42292003901
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna American Axle |
$1.90
|
| Rate for Payer: Aetna Commercial |
$2.49
|
| Rate for Payer: Aetna Medicare |
$1.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.90
|
| Rate for Payer: BCBS Complete |
$1.17
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cofinity Commercial |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$2.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.34
|
| Rate for Payer: Healthscope Commercial |
$2.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.49
|
| Rate for Payer: PHP Commercial |
$2.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.90
|
| Rate for Payer: Priority Health SBD |
$1.85
|
| Rate for Payer: UMR Bronson Commercial |
$1.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.20
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$239.70
|
|
|
Service Code
|
NDC 68180097001
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.69 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Aetna American Axle |
$155.80
|
| Rate for Payer: Aetna Commercial |
$203.74
|
| Rate for Payer: Aetna Medicare |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.80
|
| Rate for Payer: BCBS Complete |
$95.88
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$167.79
|
| Rate for Payer: Cofinity Commercial |
$206.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$167.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.76
|
| Rate for Payer: Healthscope Commercial |
$215.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.74
|
| Rate for Payer: PHP Commercial |
$203.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.80
|
| Rate for Payer: Priority Health SBD |
$151.01
|
| Rate for Payer: UMR Bronson Commercial |
$88.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.78
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$300.20
|
|
|
Service Code
|
NDC 69238183501
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.07 |
| Max. Negotiated Rate |
$270.18 |
| Rate for Payer: Aetna American Axle |
$195.13
|
| Rate for Payer: Aetna Commercial |
$255.17
|
| Rate for Payer: Aetna Medicare |
$150.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.13
|
| Rate for Payer: BCBS Complete |
$120.08
|
| Rate for Payer: Cash Price |
$240.16
|
| Rate for Payer: Cofinity Commercial |
$210.14
|
| Rate for Payer: Cofinity Commercial |
$258.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$210.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.16
|
| Rate for Payer: Healthscope Commercial |
$270.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$210.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.17
|
| Rate for Payer: PHP Commercial |
$255.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.13
|
| Rate for Payer: Priority Health SBD |
$189.13
|
| Rate for Payer: UMR Bronson Commercial |
$111.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.15
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$697.25
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
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 |
$488.08
|
| Rate for Payer: Cofinity Commercial |
$599.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.08
|
| 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 |
$488.08
|
| 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 112 MCG TABLET
|
Facility
|
IP
|
$300.20
|
|
|
Service Code
|
NDC 69238183501
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.09 |
| Max. Negotiated Rate |
$270.18 |
| Rate for Payer: Aetna American Axle |
$195.13
|
| Rate for Payer: Aetna Commercial |
$255.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$195.13
|
| Rate for Payer: Cash Price |
$240.16
|
| Rate for Payer: Cofinity Commercial |
$210.14
|
| Rate for Payer: Cofinity Commercial |
$258.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$210.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$240.16
|
| Rate for Payer: Healthscope Commercial |
$270.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$210.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$225.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$255.17
|
| Rate for Payer: PHP Commercial |
$255.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$195.13
|
| Rate for Payer: Priority Health SBD |
$189.13
|
| Rate for Payer: UMR Bronson Commercial |
$132.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$225.15
|
|
