|
LEVOTHYROXINE 500 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$1,182.05
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$520.10 |
| Max. Negotiated Rate |
$1,063.84 |
| Rate for Payer: Aetna American Axle |
$768.33
|
| Rate for Payer: Aetna Commercial |
$1,004.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$768.33
|
| Rate for Payer: Cash Price |
$945.64
|
| Rate for Payer: Cofinity Commercial |
$1,016.56
|
| Rate for Payer: Cofinity Commercial |
$827.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$827.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$945.64
|
| Rate for Payer: Healthscope Commercial |
$1,063.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$827.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$886.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,004.74
|
| Rate for Payer: PHP Commercial |
$1,004.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$768.33
|
| Rate for Payer: Priority Health SBD |
$744.69
|
| Rate for Payer: UMR Bronson Commercial |
$520.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$886.54
|
|
|
LEVOTHYROXINE 500 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$1,182.05
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4419
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$1,063.84 |
| Rate for Payer: Aetna American Axle |
$768.33
|
| Rate for Payer: Aetna Commercial |
$1,004.74
|
| Rate for Payer: Aetna Medicare |
$591.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$768.33
|
| Rate for Payer: BCBS Complete |
$472.82
|
| Rate for Payer: BCBS Trust/PPO |
$14.53
|
| Rate for Payer: BCN Commercial |
$14.53
|
| Rate for Payer: Cash Price |
$945.64
|
| Rate for Payer: Cash Price |
$945.64
|
| Rate for Payer: Cofinity Commercial |
$1,016.56
|
| Rate for Payer: Cofinity Commercial |
$827.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$827.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$945.64
|
| Rate for Payer: Healthscope Commercial |
$1,063.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$827.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$886.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,004.74
|
| Rate for Payer: PHP Commercial |
$1,004.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$768.33
|
| Rate for Payer: Priority Health SBD |
$744.69
|
| Rate for Payer: UMR Bronson Commercial |
$437.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$886.54
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$2.47
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.91 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Aetna American Axle |
$1.61
|
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.61
|
| Rate for Payer: BCBS Complete |
$0.99
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cofinity Commercial |
$1.73
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.10
|
| Rate for Payer: PHP Commercial |
$2.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: Priority Health SBD |
$1.56
|
| Rate for Payer: UMR Bronson Commercial |
$0.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.85
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$246.72
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.56 |
| Max. Negotiated Rate |
$222.05 |
| Rate for Payer: Aetna American Axle |
$160.37
|
| Rate for Payer: Aetna Commercial |
$209.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.37
|
| Rate for Payer: Cash Price |
$197.38
|
| Rate for Payer: Cofinity Commercial |
$172.70
|
| Rate for Payer: Cofinity Commercial |
$212.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.38
|
| Rate for Payer: Healthscope Commercial |
$222.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.71
|
| Rate for Payer: PHP Commercial |
$209.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.37
|
| Rate for Payer: Priority Health SBD |
$155.43
|
| Rate for Payer: UMR Bronson Commercial |
$108.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.04
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$697.25
|
|
|
Service Code
|
NDC 00074455290
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.98 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna American Axle |
$453.21
|
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: Aetna Medicare |
$348.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.21
|
| Rate for Payer: BCBS Complete |
$278.90
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$488.08
|
| 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 50 MCG TABLET
|
Facility
|
OP
|
$774.72
|
|
|
Service Code
|
NDC 00074455211
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$286.65 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna American Axle |
$503.57
|
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna Medicare |
$387.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.57
|
| Rate for Payer: BCBS Complete |
$309.89
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$542.30
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$697.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$542.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$581.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: Priority Health SBD |
$488.07
|
| Rate for Payer: UMR Bronson Commercial |
$286.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.04
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$344.85
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.73 |
| Max. Negotiated Rate |
$310.36 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$241.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.15
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UMR Bronson Commercial |
$151.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$3.45
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Aetna American Axle |
$2.24
|
| Rate for Payer: Aetna Commercial |
$2.93
|
| Rate for Payer: Aetna Medicare |
$1.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.24
|
| Rate for Payer: BCBS Complete |
$1.38
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Commercial |
$2.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.76
|
| Rate for Payer: Healthscope Commercial |
$3.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.93
|
| Rate for Payer: PHP Commercial |
$2.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.24
|
| Rate for Payer: Priority Health SBD |
$2.17
|
| Rate for Payer: UMR Bronson Commercial |
$1.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.59
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$3.45
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Aetna American Axle |
$2.24
|
| Rate for Payer: Aetna Commercial |
$2.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.24
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Commercial |
$2.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.76
|
| Rate for Payer: Healthscope Commercial |
$3.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.93
|
| Rate for Payer: PHP Commercial |
$2.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.24
|
| Rate for Payer: Priority Health SBD |
$2.17
|
| Rate for Payer: UMR Bronson Commercial |
$1.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.59
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$697.25
|
|
|
Service Code
|
NDC 00074455290
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.79 |
| Max. Negotiated Rate |
$627.52 |
| Rate for Payer: Aetna American Axle |
$453.21
|
| Rate for Payer: Aetna Commercial |
$592.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.21
|
| Rate for Payer: Cash Price |
$557.80
|
| Rate for Payer: Cofinity Commercial |
$488.08
|
| 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 50 MCG TABLET
|
Facility
|
OP
|
$246.72
|
|
|
Service Code
|
NDC 51079044020
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.29 |
| Max. Negotiated Rate |
$222.05 |
| Rate for Payer: Aetna American Axle |
$160.37
|
| Rate for Payer: Aetna Commercial |
$209.71
|
| Rate for Payer: Aetna Medicare |
$123.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.37
|
| Rate for Payer: BCBS Complete |
$98.69
|
| Rate for Payer: Cash Price |
$197.38
|
| Rate for Payer: Cofinity Commercial |
$172.70
|
| Rate for Payer: Cofinity Commercial |
$212.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.38
|
| Rate for Payer: Healthscope Commercial |
$222.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.71
|
| Rate for Payer: PHP Commercial |
$209.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.37
|
| Rate for Payer: Priority Health SBD |
$155.43
|
| Rate for Payer: UMR Bronson Commercial |
$91.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.04
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$344.85
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.59 |
| Max. Negotiated Rate |
$310.36 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna Medicare |
$172.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: BCBS Complete |
$137.94
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$241.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.15
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UMR Bronson Commercial |
$127.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074455211
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$340.88 |
| Max. Negotiated Rate |
$697.25 |
| Rate for Payer: Aetna American Axle |
$503.57
|
| Rate for Payer: Aetna Commercial |
$658.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$503.57
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$542.30
|
| Rate for Payer: Cofinity Commercial |
$666.26
|
| Rate for Payer: Cofinity Medicare Advantage |
$542.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$697.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$542.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$581.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: PHP Commercial |
$658.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: Priority Health SBD |
$488.07
|
| Rate for Payer: UMR Bronson Commercial |
$340.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$581.04
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$2.47
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Aetna American Axle |
$1.61
|
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.61
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cofinity Commercial |
$1.73
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.10
|
| Rate for Payer: PHP Commercial |
$2.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: Priority Health SBD |
$1.56
|
| Rate for Payer: UMR Bronson Commercial |
$1.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.85
|
|
|
LEVOTHYROXINE 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
|
$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
|
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 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
|
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
|
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
|
$697.68
|
|
|
Service Code
|
NDC 00074518290
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$306.98 |
| Max. Negotiated Rate |
$627.91 |
| Rate for Payer: Aetna American Axle |
$453.49
|
| Rate for Payer: Aetna Commercial |
$593.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$453.49
|
| Rate for Payer: Cash Price |
$558.14
|
| Rate for Payer: Cofinity Commercial |
$488.38
|
| Rate for Payer: Cofinity Commercial |
$600.00
|
| Rate for Payer: Cofinity Medicare Advantage |
$488.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$558.14
|
| Rate for Payer: Healthscope Commercial |
$627.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$488.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$523.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$593.03
|
| Rate for Payer: PHP Commercial |
$593.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$453.49
|
| Rate for Payer: Priority Health SBD |
$439.54
|
| Rate for Payer: UMR Bronson Commercial |
$306.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$523.26
|
|
|
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 |
$347.98 |
| 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 |
$270.66
|
| Rate for Payer: Cofinity Commercial |
$332.52
|
| Rate for Payer: Cofinity Medicare Advantage |
$270.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Healthscope Commercial |
$347.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$270.66
|
| 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
|
$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
|
|
