|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$774.72
|
|
|
Service Code
|
NDC 00074518211
|
| Hospital Charge Code |
4422
|
|
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 75 MCG TABLET
|
Facility
|
IP
|
$273.60
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.38 |
| Max. Negotiated Rate |
$246.24 |
| Rate for Payer: Aetna American Axle |
$177.84
|
| Rate for Payer: Aetna Commercial |
$232.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.84
|
| Rate for Payer: Cash Price |
$218.88
|
| Rate for Payer: Cofinity Commercial |
$191.52
|
| Rate for Payer: Cofinity Commercial |
$235.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$191.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.88
|
| Rate for Payer: Healthscope Commercial |
$246.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.56
|
| Rate for Payer: PHP Commercial |
$232.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.84
|
| Rate for Payer: Priority Health SBD |
$172.37
|
| Rate for Payer: UMR Bronson Commercial |
$120.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.20
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$2.74
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna American Axle |
$1.78
|
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.78
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$1.92
|
| Rate for Payer: Cofinity Commercial |
$2.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$2.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.33
|
| Rate for Payer: PHP Commercial |
$2.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: Priority Health SBD |
$1.73
|
| Rate for Payer: UMR Bronson Commercial |
$1.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.06
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$386.65
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$143.06 |
| Max. Negotiated Rate |
$347.99 |
| Rate for Payer: Aetna American Axle |
$251.32
|
| Rate for Payer: Aetna Commercial |
$328.65
|
| Rate for Payer: Aetna Medicare |
$193.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$251.32
|
| Rate for Payer: BCBS Complete |
$154.66
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$270.65
|
| Rate for Payer: Cofinity Commercial |
$332.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$270.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Healthscope Commercial |
$347.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$270.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: PHP Commercial |
$328.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: Priority Health SBD |
$243.59
|
| Rate for Payer: UMR Bronson Commercial |
$143.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.99
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$697.68
|
|
|
Service Code
|
NDC 00074518290
|
| Hospital Charge Code |
4422
|
|
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 75 MCG TABLET
|
Facility
|
OP
|
$329.18
|
|
|
Service Code
|
NDC 00378180577
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.80 |
| Max. Negotiated Rate |
$296.26 |
| Rate for Payer: Aetna American Axle |
$213.97
|
| Rate for Payer: Aetna Commercial |
$279.80
|
| Rate for Payer: Aetna Medicare |
$164.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.97
|
| Rate for Payer: BCBS Complete |
$131.67
|
| Rate for Payer: Cash Price |
$263.34
|
| Rate for Payer: Cofinity Commercial |
$230.43
|
| Rate for Payer: Cofinity Commercial |
$283.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$230.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.34
|
| Rate for Payer: Healthscope Commercial |
$296.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.80
|
| Rate for Payer: PHP Commercial |
$279.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.97
|
| Rate for Payer: Priority Health SBD |
$207.38
|
| Rate for Payer: UMR Bronson Commercial |
$121.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.88
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$329.18
|
|
|
Service Code
|
NDC 00378180577
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$144.84 |
| Max. Negotiated Rate |
$296.26 |
| Rate for Payer: Aetna American Axle |
$213.97
|
| Rate for Payer: Aetna Commercial |
$279.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.97
|
| Rate for Payer: Cash Price |
$263.34
|
| Rate for Payer: Cofinity Commercial |
$230.43
|
| Rate for Payer: Cofinity Commercial |
$283.09
|
| Rate for Payer: Cofinity Medicare Advantage |
$230.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.34
|
| Rate for Payer: Healthscope Commercial |
$296.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.80
|
| Rate for Payer: PHP Commercial |
$279.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.97
|
| Rate for Payer: Priority Health SBD |
$207.38
|
| Rate for Payer: UMR Bronson Commercial |
$144.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.88
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$386.65
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.13 |
| Max. Negotiated Rate |
$347.99 |
| Rate for Payer: Aetna American Axle |
$251.32
|
| Rate for Payer: Aetna Commercial |
$328.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$251.32
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$270.65
|
| Rate for Payer: Cofinity Commercial |
$332.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$270.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Healthscope Commercial |
$347.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$270.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: PHP Commercial |
$328.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: Priority Health SBD |
$243.59
|
| Rate for Payer: UMR Bronson Commercial |
$170.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.99
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$273.60
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.23 |
| Max. Negotiated Rate |
$246.24 |
| Rate for Payer: Aetna American Axle |
$177.84
|
| Rate for Payer: Aetna Commercial |
$232.56
|
| Rate for Payer: Aetna Medicare |
$136.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.84
|
| Rate for Payer: BCBS Complete |
$109.44
|
| Rate for Payer: Cash Price |
$218.88
|
| Rate for Payer: Cofinity Commercial |
$191.52
|
| Rate for Payer: Cofinity Commercial |
$235.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$191.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.88
|
| Rate for Payer: Healthscope Commercial |
$246.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.56
|
| Rate for Payer: PHP Commercial |
$232.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.84
|
| Rate for Payer: Priority Health SBD |
$172.37
|
| Rate for Payer: UMR Bronson Commercial |
$101.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.20
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$2.74
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna American Axle |
$1.78
|
| Rate for Payer: Aetna Commercial |
$2.33
|
| Rate for Payer: Aetna Medicare |
$1.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.78
|
| Rate for Payer: BCBS Complete |
$1.10
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$1.92
|
| Rate for Payer: Cofinity Commercial |
$2.36
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$2.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.33
|
| Rate for Payer: PHP Commercial |
$2.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: Priority Health SBD |
$1.73
|
| Rate for Payer: UMR Bronson Commercial |
$1.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.06
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074518211
|
| Hospital Charge Code |
4422
|
|
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 88 MCG TABLET
|
Facility
|
IP
|
$141.71
|
|
|
Service Code
|
NDC 68180096809
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.35 |
| Max. Negotiated Rate |
$127.54 |
| Rate for Payer: Aetna American Axle |
$92.11
|
| Rate for Payer: Aetna Commercial |
$120.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.11
|
| Rate for Payer: Cash Price |
$113.37
|
| Rate for Payer: Cofinity Commercial |
$121.87
|
| Rate for Payer: Cofinity Commercial |
$99.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$99.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.37
|
| Rate for Payer: Healthscope Commercial |
$127.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.45
|
| Rate for Payer: PHP Commercial |
$120.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.11
|
| Rate for Payer: Priority Health SBD |
$89.28
|
| Rate for Payer: UMR Bronson Commercial |
$62.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.28
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$447.84
|
|
|
Service Code
|
NDC 60793085301
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.70 |
| Max. Negotiated Rate |
$403.06 |
| Rate for Payer: Aetna American Axle |
$291.10
|
| Rate for Payer: Aetna Commercial |
$380.66
|
| Rate for Payer: Aetna Medicare |
$223.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.10
|
| Rate for Payer: BCBS Complete |
$179.14
|
| Rate for Payer: Cash Price |
$358.27
|
| Rate for Payer: Cofinity Commercial |
$313.49
|
| Rate for Payer: Cofinity Commercial |
$385.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$313.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$358.27
|
| Rate for Payer: Healthscope Commercial |
$403.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$313.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$335.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$380.66
|
| Rate for Payer: PHP Commercial |
$380.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.10
|
| Rate for Payer: Priority Health SBD |
$282.14
|
| Rate for Payer: UMR Bronson Commercial |
$165.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$335.88
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$447.84
|
|
|
Service Code
|
NDC 60793085301
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.05 |
| Max. Negotiated Rate |
$403.06 |
| Rate for Payer: Aetna American Axle |
$291.10
|
| Rate for Payer: Aetna Commercial |
$380.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$291.10
|
| Rate for Payer: Cash Price |
$358.27
|
| Rate for Payer: Cofinity Commercial |
$313.49
|
| Rate for Payer: Cofinity Commercial |
$385.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$313.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$358.27
|
| Rate for Payer: Healthscope Commercial |
$403.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$313.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$335.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$380.66
|
| Rate for Payer: PHP Commercial |
$380.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.10
|
| Rate for Payer: Priority Health SBD |
$282.14
|
| Rate for Payer: UMR Bronson Commercial |
$197.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$335.88
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$697.68
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
10403
|
|
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 88 MCG TABLET
|
Facility
|
IP
|
$697.68
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
10403
|
|
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 88 MCG TABLET
|
Facility
|
OP
|
$141.71
|
|
|
Service Code
|
NDC 68180096809
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.43 |
| Max. Negotiated Rate |
$127.54 |
| Rate for Payer: Aetna American Axle |
$92.11
|
| Rate for Payer: Aetna Commercial |
$120.45
|
| Rate for Payer: Aetna Medicare |
$70.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.11
|
| Rate for Payer: BCBS Complete |
$56.68
|
| Rate for Payer: Cash Price |
$113.37
|
| Rate for Payer: Cofinity Commercial |
$121.87
|
| Rate for Payer: Cofinity Commercial |
$99.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$99.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.37
|
| Rate for Payer: Healthscope Commercial |
$127.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.45
|
| Rate for Payer: PHP Commercial |
$120.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.11
|
| Rate for Payer: Priority Health SBD |
$89.28
|
| Rate for Payer: UMR Bronson Commercial |
$52.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.28
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$334.31
|
|
|
Service Code
|
NDC 00378180777
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.69 |
| Max. Negotiated Rate |
$300.88 |
| Rate for Payer: Aetna American Axle |
$217.30
|
| Rate for Payer: Aetna Commercial |
$284.16
|
| Rate for Payer: Aetna Medicare |
$167.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.30
|
| Rate for Payer: BCBS Complete |
$133.72
|
| Rate for Payer: Cash Price |
$267.45
|
| Rate for Payer: Cofinity Commercial |
$234.02
|
| Rate for Payer: Cofinity Commercial |
$287.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$234.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.45
|
| Rate for Payer: Healthscope Commercial |
$300.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$234.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$250.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$284.16
|
| Rate for Payer: PHP Commercial |
$284.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$217.30
|
| Rate for Payer: Priority Health SBD |
$210.62
|
| Rate for Payer: UMR Bronson Commercial |
$123.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$250.73
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$334.31
|
|
|
Service Code
|
NDC 00378180777
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.10 |
| Max. Negotiated Rate |
$300.88 |
| Rate for Payer: Aetna American Axle |
$217.30
|
| Rate for Payer: Aetna Commercial |
$284.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.30
|
| Rate for Payer: Cash Price |
$267.45
|
| Rate for Payer: Cofinity Commercial |
$234.02
|
| Rate for Payer: Cofinity Commercial |
$287.51
|
| Rate for Payer: Cofinity Medicare Advantage |
$234.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.45
|
| Rate for Payer: Healthscope Commercial |
$300.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$234.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$250.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$284.16
|
| Rate for Payer: PHP Commercial |
$284.16
|
| Rate for Payer: Priority Health Cigna Priority Health |
$217.30
|
| Rate for Payer: Priority Health SBD |
$210.62
|
| Rate for Payer: UMR Bronson Commercial |
$147.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$250.73
|
|
|
LICE AND NIT COMB
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 25715067323
|
| Hospital Charge Code |
167001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna American Axle |
$0.57
|
| Rate for Payer: Aetna Commercial |
$0.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.57
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cofinity Commercial |
$0.61
|
| Rate for Payer: Cofinity Commercial |
$0.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.70
|
| Rate for Payer: Healthscope Commercial |
$0.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.74
|
| Rate for Payer: PHP Commercial |
$0.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.57
|
| Rate for Payer: Priority Health SBD |
$0.55
|
| Rate for Payer: UMR Bronson Commercial |
$0.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.65
|
|
|
LICE AND NIT COMB
|
Facility
|
IP
|
$3.45
|
|
|
Service Code
|
NDC 55128270000
|
| Hospital Charge Code |
167001
|
|
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
|
|
|
LICE AND NIT COMB
|
Facility
|
OP
|
$3.45
|
|
|
Service Code
|
NDC 55128270000
|
| Hospital Charge Code |
167001
|
|
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
|
|
|
LICE AND NIT COMB
|
Facility
|
IP
|
$8.75
|
|
|
Service Code
|
NDC 64442650197
|
| Hospital Charge Code |
167001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$7.88 |
| Rate for Payer: Aetna American Axle |
$5.69
|
| Rate for Payer: Aetna Commercial |
$7.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.69
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Cofinity Commercial |
$6.12
|
| Rate for Payer: Cofinity Commercial |
$7.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.00
|
| Rate for Payer: Healthscope Commercial |
$7.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.44
|
| Rate for Payer: PHP Commercial |
$7.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.69
|
| Rate for Payer: Priority Health SBD |
$5.51
|
| Rate for Payer: UMR Bronson Commercial |
$3.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.56
|
|
|
LICE AND NIT COMB
|
Facility
|
OP
|
$0.87
|
|
|
Service Code
|
NDC 25715067323
|
| Hospital Charge Code |
167001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.32 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna American Axle |
$0.57
|
| Rate for Payer: Aetna Commercial |
$0.74
|
| Rate for Payer: Aetna Medicare |
$0.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.57
|
| Rate for Payer: BCBS Complete |
$0.35
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cofinity Commercial |
$0.61
|
| Rate for Payer: Cofinity Commercial |
$0.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$0.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.70
|
| Rate for Payer: Healthscope Commercial |
$0.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$0.74
|
| Rate for Payer: PHP Commercial |
$0.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.57
|
| Rate for Payer: Priority Health SBD |
$0.55
|
| Rate for Payer: UMR Bronson Commercial |
$0.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.65
|
|
|
LICE AND NIT COMB
|
Facility
|
OP
|
$4.25
|
|
|
Service Code
|
NDC 63736024793
|
| Hospital Charge Code |
167001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$3.83 |
| Rate for Payer: Aetna American Axle |
$2.76
|
| Rate for Payer: Aetna Commercial |
$3.61
|
| Rate for Payer: Aetna Medicare |
$2.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.76
|
| Rate for Payer: BCBS Complete |
$1.70
|
| Rate for Payer: Cash Price |
$3.40
|
| Rate for Payer: Cofinity Commercial |
$2.98
|
| Rate for Payer: Cofinity Commercial |
$3.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.40
|
| Rate for Payer: Healthscope Commercial |
$3.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.61
|
| Rate for Payer: PHP Commercial |
$3.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.76
|
| Rate for Payer: Priority Health SBD |
$2.68
|
| Rate for Payer: UMR Bronson Commercial |
$1.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.19
|
|
