|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$239.70
|
|
|
Service Code
|
NDC 68180097001
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.47 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Aetna American Axle |
$155.80
|
| Rate for Payer: Aetna Commercial |
$203.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.80
|
| 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 |
$105.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.78
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$521.76
|
|
|
Service Code
|
NDC 60793085501
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$229.57 |
| Max. Negotiated Rate |
$469.58 |
| Rate for Payer: Aetna American Axle |
$339.14
|
| Rate for Payer: Aetna Commercial |
$443.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$339.14
|
| Rate for Payer: Cash Price |
$417.41
|
| Rate for Payer: Cofinity Commercial |
$365.23
|
| Rate for Payer: Cofinity Commercial |
$448.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$365.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$417.41
|
| Rate for Payer: Healthscope Commercial |
$469.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$365.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$391.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$443.50
|
| Rate for Payer: PHP Commercial |
$443.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$339.14
|
| Rate for Payer: Priority Health SBD |
$328.71
|
| Rate for Payer: UMR Bronson Commercial |
$229.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$391.32
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$697.25
|
|
|
Service Code
|
NDC 00074929690
|
| Hospital Charge Code |
10404
|
|
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 |
$488.08
|
| 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 |
$257.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$522.94
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$521.76
|
|
|
Service Code
|
NDC 60793085501
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.05 |
| Max. Negotiated Rate |
$469.58 |
| Rate for Payer: Aetna American Axle |
$339.14
|
| Rate for Payer: Aetna Commercial |
$443.50
|
| Rate for Payer: Aetna Medicare |
$260.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$339.14
|
| Rate for Payer: BCBS Complete |
$208.70
|
| Rate for Payer: Cash Price |
$417.41
|
| Rate for Payer: Cofinity Commercial |
$365.23
|
| Rate for Payer: Cofinity Commercial |
$448.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$365.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$417.41
|
| Rate for Payer: Healthscope Commercial |
$469.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$365.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$391.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$443.50
|
| Rate for Payer: PHP Commercial |
$443.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$339.14
|
| Rate for Payer: Priority Health SBD |
$328.71
|
| Rate for Payer: UMR Bronson Commercial |
$193.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$391.32
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
OP
|
$292.80
|
|
|
Service Code
|
NDC 42292003920
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.34 |
| Max. Negotiated Rate |
$263.52 |
| Rate for Payer: Aetna American Axle |
$190.32
|
| Rate for Payer: Aetna Commercial |
$248.88
|
| Rate for Payer: Aetna Medicare |
$146.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.32
|
| Rate for Payer: BCBS Complete |
$117.12
|
| Rate for Payer: Cash Price |
$234.24
|
| Rate for Payer: Cofinity Commercial |
$204.96
|
| Rate for Payer: Cofinity Commercial |
$251.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$204.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.24
|
| Rate for Payer: Healthscope Commercial |
$263.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$219.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.88
|
| Rate for Payer: PHP Commercial |
$248.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.32
|
| Rate for Payer: Priority Health SBD |
$184.46
|
| Rate for Payer: UMR Bronson Commercial |
$108.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$219.60
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$2.93
|
|
|
Service Code
|
NDC 42292003901
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna American Axle |
$1.90
|
| Rate for Payer: Aetna Commercial |
$2.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.90
|
| 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 |
$1.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.20
|
|
|
LEVOTHYROXINE 112 MCG TABLET
|
Facility
|
IP
|
$292.80
|
|
|
Service Code
|
NDC 42292003920
|
| Hospital Charge Code |
10404
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.83 |
| Max. Negotiated Rate |
$263.52 |
| Rate for Payer: Aetna American Axle |
$190.32
|
| Rate for Payer: Aetna Commercial |
$248.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$190.32
|
| Rate for Payer: Cash Price |
$234.24
|
| Rate for Payer: Cofinity Commercial |
$204.96
|
| Rate for Payer: Cofinity Commercial |
$251.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$204.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$234.24
|
| Rate for Payer: Healthscope Commercial |
$263.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$219.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.88
|
| Rate for Payer: PHP Commercial |
$248.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.32
|
| Rate for Payer: Priority Health SBD |
$184.46
|
| Rate for Payer: UMR Bronson Commercial |
$128.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$219.60
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$395.87
|
|
|
Service Code
|
NDC 00378181377
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.47 |
| Max. Negotiated Rate |
$356.28 |
| Rate for Payer: Aetna American Axle |
$257.32
|
| Rate for Payer: Aetna Commercial |
$336.49
|
| Rate for Payer: Aetna Medicare |
$197.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$257.32
|
| Rate for Payer: BCBS Complete |
$158.35
|
| Rate for Payer: Cash Price |
$316.70
|
| Rate for Payer: Cofinity Commercial |
$277.11
|
| Rate for Payer: Cofinity Commercial |
$340.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$277.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.70
|
| Rate for Payer: Healthscope Commercial |
$356.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$296.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.49
|
| Rate for Payer: PHP Commercial |
$336.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.32
|
| Rate for Payer: Priority Health SBD |
$249.40
|
| Rate for Payer: UMR Bronson Commercial |
$146.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$296.90
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$774.72
|
|
|
Service Code
|
NDC 00074706811
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.65 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna American Axle |
$503.57
|
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna Medicare |
$387.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.57
|
| Rate for Payer: BCBS Complete |
$309.89
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$542.30
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$697.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$542.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$581.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: Priority Health SBD |
$488.07
|
| Rate for Payer: UMR Bronson Commercial |
$286.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.04
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$330.24
|
|
|
Service Code
|
NDC 51079044320
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.31 |
| Max. Negotiated Rate |
$297.22 |
| Rate for Payer: Cash Price |
$264.19
|
| Rate for Payer: Aetna American Axle |
$214.66
|
| Rate for Payer: Aetna Commercial |
$280.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.66
|
| Rate for Payer: Cofinity Commercial |
$231.17
|
| Rate for Payer: Cofinity Commercial |
$284.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.19
|
| Rate for Payer: Healthscope Commercial |
$297.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$247.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$280.70
|
| Rate for Payer: PHP Commercial |
$280.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.66
|
| Rate for Payer: Priority Health SBD |
$208.05
|
| Rate for Payer: UMR Bronson Commercial |
$145.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$247.68
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$3.31
|
|
|
Service Code
|
NDC 51079044301
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.46 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna American Axle |
$2.15
|
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.15
|
| Rate for Payer: Cash Price |
$2.65
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.65
|
| Rate for Payer: Healthscope Commercial |
$2.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.81
|
| Rate for Payer: PHP Commercial |
$2.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.15
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.48
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$395.87
|
|
|
Service Code
|
NDC 00378181377
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.18 |
| Max. Negotiated Rate |
$356.28 |
| Rate for Payer: Aetna American Axle |
$257.32
|
| Rate for Payer: Aetna Commercial |
$336.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$257.32
|
| Rate for Payer: Cash Price |
$316.70
|
| Rate for Payer: Cofinity Commercial |
$277.11
|
| Rate for Payer: Cofinity Commercial |
$340.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$277.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.70
|
| Rate for Payer: Healthscope Commercial |
$356.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$277.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$296.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.49
|
| Rate for Payer: PHP Commercial |
$336.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.32
|
| Rate for Payer: Priority Health SBD |
$249.40
|
| Rate for Payer: UMR Bronson Commercial |
$174.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$296.90
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$697.68
|
|
|
Service Code
|
NDC 00074706890
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.98 |
| Max. Negotiated Rate |
$627.91 |
| Rate for Payer: Aetna American Axle |
$453.49
|
| Rate for Payer: Aetna Commercial |
$593.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.49
|
| Rate for Payer: Cash Price |
$558.14
|
| Rate for Payer: Cofinity Commercial |
$488.38
|
| Rate for Payer: Cofinity Commercial |
$600.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$558.14
|
| Rate for Payer: Healthscope Commercial |
$627.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$488.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$523.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$593.03
|
| Rate for Payer: PHP Commercial |
$593.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.49
|
| Rate for Payer: Priority Health SBD |
$439.54
|
| Rate for Payer: UMR Bronson Commercial |
$306.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$523.26
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$256.32
|
|
|
Service Code
|
NDC 60687051901
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.78 |
| Max. Negotiated Rate |
$230.69 |
| Rate for Payer: Aetna American Axle |
$166.61
|
| Rate for Payer: Aetna Commercial |
$217.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.61
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Commercial |
$179.42
|
| Rate for Payer: Cofinity Commercial |
$220.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$179.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Healthscope Commercial |
$230.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.87
|
| Rate for Payer: PHP Commercial |
$217.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.61
|
| Rate for Payer: Priority Health SBD |
$161.48
|
| Rate for Payer: UMR Bronson Commercial |
$112.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.24
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$330.24
|
|
|
Service Code
|
NDC 51079044320
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.19 |
| Max. Negotiated Rate |
$297.22 |
| Rate for Payer: Aetna American Axle |
$214.66
|
| Rate for Payer: Aetna Commercial |
$280.70
|
| Rate for Payer: Aetna Medicare |
$165.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.66
|
| Rate for Payer: BCBS Complete |
$132.10
|
| Rate for Payer: Cash Price |
$264.19
|
| Rate for Payer: Cofinity Commercial |
$231.17
|
| Rate for Payer: Cofinity Commercial |
$284.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.19
|
| Rate for Payer: Healthscope Commercial |
$297.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$247.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$280.70
|
| Rate for Payer: PHP Commercial |
$280.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.66
|
| Rate for Payer: Priority Health SBD |
$208.05
|
| Rate for Payer: UMR Bronson Commercial |
$122.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$247.68
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$2.57
|
|
|
Service Code
|
NDC 60687051911
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna American Axle |
$1.67
|
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.67
|
| Rate for Payer: BCBS Complete |
$1.03
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$1.80
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.67
|
| Rate for Payer: Priority Health SBD |
$1.62
|
| Rate for Payer: UMR Bronson Commercial |
$0.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.93
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$697.68
|
|
|
Service Code
|
NDC 00074706890
|
| Hospital Charge Code |
4424
|
|
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 125 MCG TABLET
|
Facility
|
IP
|
$2.57
|
|
|
Service Code
|
NDC 60687051911
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$2.31 |
| Rate for Payer: Aetna American Axle |
$1.67
|
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.67
|
| Rate for Payer: Cash Price |
$2.06
|
| Rate for Payer: Cofinity Commercial |
$1.80
|
| Rate for Payer: Cofinity Commercial |
$2.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.06
|
| Rate for Payer: Healthscope Commercial |
$2.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.67
|
| Rate for Payer: Priority Health SBD |
$1.62
|
| Rate for Payer: UMR Bronson Commercial |
$1.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.93
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074706811
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$340.88 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna American Axle |
$503.57
|
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.57
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$542.30
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$697.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$542.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$581.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: Priority Health SBD |
$488.07
|
| Rate for Payer: UMR Bronson Commercial |
$340.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.04
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$256.32
|
|
|
Service Code
|
NDC 60687051901
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.84 |
| Max. Negotiated Rate |
$230.69 |
| Rate for Payer: Aetna American Axle |
$166.61
|
| Rate for Payer: Aetna Commercial |
$217.87
|
| Rate for Payer: Aetna Medicare |
$128.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.61
|
| Rate for Payer: BCBS Complete |
$102.53
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Commercial |
$179.42
|
| Rate for Payer: Cofinity Commercial |
$220.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$179.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Healthscope Commercial |
$230.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.87
|
| Rate for Payer: PHP Commercial |
$217.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.61
|
| Rate for Payer: Priority Health SBD |
$161.48
|
| Rate for Payer: UMR Bronson Commercial |
$94.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.24
|
|
|
LEVOTHYROXINE 125 MCG TABLET
|
Facility
|
OP
|
$3.31
|
|
|
Service Code
|
NDC 51079044301
|
| Hospital Charge Code |
4424
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna American Axle |
$2.15
|
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna Medicare |
$1.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.15
|
| Rate for Payer: BCBS Complete |
$1.32
|
| Rate for Payer: Cash Price |
$2.65
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.65
|
| Rate for Payer: Healthscope Commercial |
$2.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.81
|
| Rate for Payer: PHP Commercial |
$2.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.15
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.48
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$697.68
|
|
|
Service Code
|
NDC 00074372790
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.14 |
| Max. Negotiated Rate |
$627.91 |
| Rate for Payer: Aetna American Axle |
$453.49
|
| Rate for Payer: Aetna Commercial |
$593.03
|
| Rate for Payer: Aetna Medicare |
$348.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.49
|
| Rate for Payer: BCBS Complete |
$279.07
|
| Rate for Payer: Cash Price |
$558.14
|
| Rate for Payer: Cofinity Commercial |
$488.38
|
| Rate for Payer: Cofinity Commercial |
$600.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$558.14
|
| Rate for Payer: Healthscope Commercial |
$627.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$488.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$523.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$593.03
|
| Rate for Payer: PHP Commercial |
$593.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.49
|
| Rate for Payer: Priority Health SBD |
$439.54
|
| Rate for Payer: UMR Bronson Commercial |
$258.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$523.26
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$2.56
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.13 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna American Axle |
$1.66
|
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.05
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: UMR Bronson Commercial |
$1.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.92
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
IP
|
$255.36
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.36 |
| Max. Negotiated Rate |
$229.82 |
| Rate for Payer: Aetna American Axle |
$165.98
|
| Rate for Payer: Aetna Commercial |
$217.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$165.98
|
| Rate for Payer: Cash Price |
$204.29
|
| Rate for Payer: Cofinity Commercial |
$178.75
|
| Rate for Payer: Cofinity Commercial |
$219.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$178.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.29
|
| Rate for Payer: Healthscope Commercial |
$229.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$178.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.06
|
| Rate for Payer: PHP Commercial |
$217.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.98
|
| Rate for Payer: Priority Health SBD |
$160.88
|
| Rate for Payer: UMR Bronson Commercial |
$112.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.52
|
|
|
LEVOTHYROXINE 137 MCG TABLET
|
Facility
|
OP
|
$2.56
|
|
|
Service Code
|
NDC 60687056311
|
| Hospital Charge Code |
10405
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$2.30 |
| Rate for Payer: Aetna American Axle |
$1.66
|
| Rate for Payer: Aetna Commercial |
$2.18
|
| Rate for Payer: Aetna Medicare |
$1.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.66
|
| Rate for Payer: BCBS Complete |
$1.02
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$1.79
|
| Rate for Payer: Cofinity Commercial |
$2.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.05
|
| Rate for Payer: Healthscope Commercial |
$2.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: PHP Commercial |
$2.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.61
|
| Rate for Payer: UMR Bronson Commercial |
$0.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.92
|
|
