|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$350.55
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$262.91 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Aetna Commercial |
$315.50
|
| Rate for Payer: ASR ASR |
$340.03
|
| Rate for Payer: BCBS Trust/PPO |
$287.87
|
| Rate for Payer: BCN Commercial |
$287.87
|
| Rate for Payer: Cash Price |
$280.44
|
| Rate for Payer: Cofinity Commercial |
$329.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.44
|
| Rate for Payer: Healthscope Commercial |
$340.03
|
| Rate for Payer: Healthscope Whirlpool |
$350.55
|
| Rate for Payer: Mclaren Commercial |
$315.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.97
|
| Rate for Payer: Nomi Health Commercial |
$287.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$262.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$308.48
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$3.51
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.30 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Aetna Commercial |
$3.16
|
| Rate for Payer: Aetna Medicare |
$1.30
|
| Rate for Payer: ASR ASR |
$3.40
|
| Rate for Payer: BCBS Complete |
$1.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.89
|
| Rate for Payer: BCN Commercial |
$2.89
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.40
|
| Rate for Payer: Healthscope Whirlpool |
$3.51
|
| Rate for Payer: Mclaren Commercial |
$3.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Nomi Health Commercial |
$2.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.63
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.07
|
| Rate for Payer: Priority Health Narrow Network |
$2.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.09
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$319.20
|
|
|
Service Code
|
NDC 904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$239.40 |
| Max. Negotiated Rate |
$319.20 |
| Rate for Payer: Aetna Commercial |
$287.28
|
| Rate for Payer: ASR ASR |
$309.62
|
| Rate for Payer: BCBS Trust/PPO |
$262.13
|
| Rate for Payer: BCN Commercial |
$262.13
|
| Rate for Payer: Cash Price |
$255.36
|
| Rate for Payer: Cofinity Commercial |
$300.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.36
|
| Rate for Payer: Healthscope Commercial |
$309.62
|
| Rate for Payer: Healthscope Whirlpool |
$319.20
|
| Rate for Payer: Mclaren Commercial |
$287.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$271.32
|
| Rate for Payer: Nomi Health Commercial |
$261.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$239.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$280.90
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$4.03
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.49 |
| Max. Negotiated Rate |
$4.03 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: Aetna Medicare |
$1.49
|
| Rate for Payer: ASR ASR |
$3.91
|
| Rate for Payer: BCBS Complete |
$1.61
|
| Rate for Payer: BCBS Trust/PPO |
$3.32
|
| Rate for Payer: BCN Commercial |
$3.32
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cofinity Commercial |
$3.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.22
|
| Rate for Payer: Healthscope Commercial |
$3.91
|
| Rate for Payer: Healthscope Whirlpool |
$4.03
|
| Rate for Payer: Mclaren Commercial |
$3.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.42
|
| Rate for Payer: Nomi Health Commercial |
$3.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.02
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.53
|
| Rate for Payer: Priority Health Narrow Network |
$2.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.54
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$4.03
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.02 |
| Max. Negotiated Rate |
$4.03 |
| Rate for Payer: Aetna Commercial |
$3.63
|
| Rate for Payer: ASR ASR |
$3.91
|
| Rate for Payer: BCBS Trust/PPO |
$3.31
|
| Rate for Payer: BCN Commercial |
$3.31
|
| Rate for Payer: Cash Price |
$3.22
|
| Rate for Payer: Cofinity Commercial |
$3.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.22
|
| Rate for Payer: Healthscope Commercial |
$3.91
|
| Rate for Payer: Healthscope Whirlpool |
$4.03
|
| Rate for Payer: Mclaren Commercial |
$3.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.42
|
| Rate for Payer: Nomi Health Commercial |
$3.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.54
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$3.51
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.63 |
| Max. Negotiated Rate |
$3.51 |
| Rate for Payer: Aetna Commercial |
$3.16
|
| Rate for Payer: ASR ASR |
$3.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.88
|
| Rate for Payer: BCN Commercial |
$2.88
|
| Rate for Payer: Cash Price |
$2.80
|
| Rate for Payer: Cofinity Commercial |
$3.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.80
|
| Rate for Payer: Healthscope Commercial |
$3.40
|
| Rate for Payer: Healthscope Whirlpool |
$3.51
|
| Rate for Payer: Mclaren Commercial |
$3.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.98
|
| Rate for Payer: Nomi Health Commercial |
$2.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.09
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$319.20
|
|
|
Service Code
|
NDC 904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.10 |
| Max. Negotiated Rate |
$319.20 |
| Rate for Payer: Aetna Commercial |
$287.28
|
| Rate for Payer: Aetna Medicare |
$118.10
|
| Rate for Payer: ASR ASR |
$309.62
|
| Rate for Payer: BCBS Complete |
$127.68
|
| Rate for Payer: BCBS Trust/PPO |
$263.18
|
| Rate for Payer: BCN Commercial |
$263.18
|
| Rate for Payer: Cash Price |
$255.36
|
| Rate for Payer: Cofinity Commercial |
$300.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.36
|
| Rate for Payer: Healthscope Commercial |
$309.62
|
| Rate for Payer: Healthscope Whirlpool |
$319.20
|
| Rate for Payer: Mclaren Commercial |
$287.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$255.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$271.32
|
| Rate for Payer: Nomi Health Commercial |
$261.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$239.40
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$279.68
|
| Rate for Payer: Priority Health Narrow Network |
$223.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$280.90
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$350.55
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.70 |
| Max. Negotiated Rate |
$350.55 |
| Rate for Payer: Aetna Commercial |
$315.50
|
| Rate for Payer: Aetna Medicare |
$129.70
|
| Rate for Payer: ASR ASR |
$340.03
|
| Rate for Payer: BCBS Complete |
$140.22
|
| Rate for Payer: BCBS Trust/PPO |
$289.03
|
| Rate for Payer: BCN Commercial |
$289.03
|
| Rate for Payer: Cash Price |
$280.44
|
| Rate for Payer: Cofinity Commercial |
$329.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.44
|
| Rate for Payer: Healthscope Commercial |
$340.03
|
| Rate for Payer: Healthscope Whirlpool |
$350.55
|
| Rate for Payer: Mclaren Commercial |
$315.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$280.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$297.97
|
| Rate for Payer: Nomi Health Commercial |
$287.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$262.91
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$307.15
|
| Rate for Payer: Priority Health Narrow Network |
$245.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$308.48
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$4.58
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$4.58 |
| Rate for Payer: Aetna Commercial |
$4.12
|
| Rate for Payer: Aetna Medicare |
$1.69
|
| Rate for Payer: ASR ASR |
$4.44
|
| Rate for Payer: BCBS Complete |
$1.83
|
| Rate for Payer: BCBS Trust/PPO |
$3.78
|
| Rate for Payer: BCN Commercial |
$3.78
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cofinity Commercial |
$4.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.66
|
| Rate for Payer: Healthscope Commercial |
$4.44
|
| Rate for Payer: Healthscope Whirlpool |
$4.58
|
| Rate for Payer: Mclaren Commercial |
$4.12
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.89
|
| Rate for Payer: Nomi Health Commercial |
$3.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.01
|
| Rate for Payer: Priority Health Narrow Network |
$3.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.03
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$356.25
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.81 |
| Max. Negotiated Rate |
$356.25 |
| Rate for Payer: Aetna Commercial |
$320.62
|
| Rate for Payer: Aetna Medicare |
$131.81
|
| Rate for Payer: ASR ASR |
$345.56
|
| Rate for Payer: BCBS Complete |
$142.50
|
| Rate for Payer: BCBS Trust/PPO |
$293.73
|
| Rate for Payer: BCN Commercial |
$293.73
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cofinity Commercial |
$334.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.00
|
| Rate for Payer: Healthscope Commercial |
$345.56
|
| Rate for Payer: Healthscope Whirlpool |
$356.25
|
| Rate for Payer: Mclaren Commercial |
$320.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$285.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.81
|
| Rate for Payer: Nomi Health Commercial |
$292.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.19
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$312.15
|
| Rate for Payer: Priority Health Narrow Network |
$249.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$313.50
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$3.56
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.32 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$3.21
|
| Rate for Payer: Aetna Medicare |
$1.32
|
| Rate for Payer: ASR ASR |
$3.46
|
| Rate for Payer: BCBS Complete |
$1.43
|
| Rate for Payer: BCBS Trust/PPO |
$2.94
|
| Rate for Payer: BCN Commercial |
$2.94
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cofinity Commercial |
$3.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.85
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Healthscope Whirlpool |
$3.56
|
| Rate for Payer: Mclaren Commercial |
$3.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Nomi Health Commercial |
$2.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.67
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.12
|
| Rate for Payer: Priority Health Narrow Network |
$2.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.14
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$3.56
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.67 |
| Max. Negotiated Rate |
$3.56 |
| Rate for Payer: Aetna Commercial |
$3.21
|
| Rate for Payer: ASR ASR |
$3.46
|
| Rate for Payer: BCBS Trust/PPO |
$2.93
|
| Rate for Payer: BCN Commercial |
$2.93
|
| Rate for Payer: Cash Price |
$2.85
|
| Rate for Payer: Cofinity Commercial |
$3.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.85
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Healthscope Whirlpool |
$3.56
|
| Rate for Payer: Mclaren Commercial |
$3.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.03
|
| Rate for Payer: Nomi Health Commercial |
$2.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.14
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$323.95
|
|
|
Service Code
|
NDC 904695061
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$242.96 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Aetna Commercial |
$291.56
|
| Rate for Payer: ASR ASR |
$314.23
|
| Rate for Payer: BCBS Trust/PPO |
$266.03
|
| Rate for Payer: BCN Commercial |
$266.03
|
| Rate for Payer: Cash Price |
$259.16
|
| Rate for Payer: Cofinity Commercial |
$304.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.16
|
| Rate for Payer: Healthscope Commercial |
$314.23
|
| Rate for Payer: Healthscope Whirlpool |
$323.95
|
| Rate for Payer: Mclaren Commercial |
$291.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.36
|
| Rate for Payer: Nomi Health Commercial |
$265.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$242.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$285.08
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$4.58
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$4.58 |
| Rate for Payer: Aetna Commercial |
$4.12
|
| Rate for Payer: ASR ASR |
$4.44
|
| Rate for Payer: BCBS Trust/PPO |
$3.76
|
| Rate for Payer: BCN Commercial |
$3.76
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cofinity Commercial |
$4.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.66
|
| Rate for Payer: Healthscope Commercial |
$4.44
|
| Rate for Payer: Healthscope Whirlpool |
$4.58
|
| Rate for Payer: Mclaren Commercial |
$4.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.89
|
| Rate for Payer: Nomi Health Commercial |
$3.75
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.03
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$356.25
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$267.19 |
| Max. Negotiated Rate |
$356.25 |
| Rate for Payer: Aetna Commercial |
$320.62
|
| Rate for Payer: ASR ASR |
$345.56
|
| Rate for Payer: BCBS Trust/PPO |
$292.55
|
| Rate for Payer: BCN Commercial |
$292.55
|
| Rate for Payer: Cash Price |
$285.00
|
| Rate for Payer: Cofinity Commercial |
$334.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.00
|
| Rate for Payer: Healthscope Commercial |
$345.56
|
| Rate for Payer: Healthscope Whirlpool |
$356.25
|
| Rate for Payer: Mclaren Commercial |
$320.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$302.81
|
| Rate for Payer: Nomi Health Commercial |
$292.12
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$267.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$313.50
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$323.95
|
|
|
Service Code
|
NDC 904695061
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.86 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Aetna Commercial |
$291.56
|
| Rate for Payer: Aetna Medicare |
$119.86
|
| Rate for Payer: ASR ASR |
$314.23
|
| Rate for Payer: BCBS Complete |
$129.58
|
| Rate for Payer: BCBS Trust/PPO |
$267.10
|
| Rate for Payer: BCN Commercial |
$267.10
|
| Rate for Payer: Cash Price |
$259.16
|
| Rate for Payer: Cofinity Commercial |
$304.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.16
|
| Rate for Payer: Healthscope Commercial |
$314.23
|
| Rate for Payer: Healthscope Whirlpool |
$323.95
|
| Rate for Payer: Mclaren Commercial |
$291.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$259.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.36
|
| Rate for Payer: Nomi Health Commercial |
$265.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$242.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$283.84
|
| Rate for Payer: Priority Health Narrow Network |
$227.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$285.08
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$95.18
|
|
|
Service Code
|
NDC 68180096709
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.38 |
| Max. Negotiated Rate |
$95.17 |
| Rate for Payer: Aetna Commercial |
$85.66
|
| Rate for Payer: ASR ASR |
$92.32
|
| Rate for Payer: BCBS Trust/PPO |
$78.16
|
| Rate for Payer: BCN Commercial |
$78.16
|
| Rate for Payer: Cash Price |
$76.14
|
| Rate for Payer: Cofinity Commercial |
$89.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.14
|
| Rate for Payer: Healthscope Commercial |
$92.32
|
| Rate for Payer: Healthscope Whirlpool |
$95.17
|
| Rate for Payer: Mclaren Commercial |
$85.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.90
|
| Rate for Payer: Nomi Health Commercial |
$78.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.75
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$425.60
|
|
|
Service Code
|
NDC 904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.47 |
| Max. Negotiated Rate |
$425.60 |
| Rate for Payer: Aetna Commercial |
$383.04
|
| Rate for Payer: Aetna Medicare |
$157.47
|
| Rate for Payer: ASR ASR |
$412.83
|
| Rate for Payer: BCBS Complete |
$170.24
|
| Rate for Payer: BCBS Trust/PPO |
$350.91
|
| Rate for Payer: BCN Commercial |
$350.91
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cofinity Commercial |
$400.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.48
|
| Rate for Payer: Healthscope Commercial |
$412.83
|
| Rate for Payer: Healthscope Whirlpool |
$425.60
|
| Rate for Payer: Mclaren Commercial |
$383.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$340.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.76
|
| Rate for Payer: Nomi Health Commercial |
$348.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$372.91
|
| Rate for Payer: Priority Health Narrow Network |
$298.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$374.53
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$256.32
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.84 |
| Max. Negotiated Rate |
$256.32 |
| Rate for Payer: Aetna Commercial |
$230.69
|
| Rate for Payer: Aetna Medicare |
$94.84
|
| Rate for Payer: ASR ASR |
$248.63
|
| Rate for Payer: BCBS Complete |
$102.53
|
| Rate for Payer: BCBS Trust/PPO |
$211.34
|
| Rate for Payer: BCN Commercial |
$211.34
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Commercial |
$240.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Healthscope Commercial |
$248.63
|
| Rate for Payer: Healthscope Whirlpool |
$256.32
|
| Rate for Payer: Mclaren Commercial |
$230.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$205.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.87
|
| Rate for Payer: Nomi Health Commercial |
$210.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$192.24
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$224.59
|
| Rate for Payer: Priority Health Narrow Network |
$179.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$225.56
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$95.18
|
|
|
Service Code
|
NDC 68180096709
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.21 |
| Max. Negotiated Rate |
$95.17 |
| Rate for Payer: Aetna Commercial |
$85.66
|
| Rate for Payer: Aetna Medicare |
$35.21
|
| Rate for Payer: ASR ASR |
$92.32
|
| Rate for Payer: BCBS Complete |
$38.07
|
| Rate for Payer: BCBS Trust/PPO |
$78.47
|
| Rate for Payer: BCN Commercial |
$78.47
|
| Rate for Payer: Cash Price |
$76.14
|
| Rate for Payer: Cofinity Commercial |
$89.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.14
|
| Rate for Payer: Healthscope Commercial |
$92.32
|
| Rate for Payer: Healthscope Whirlpool |
$95.17
|
| Rate for Payer: Mclaren Commercial |
$85.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$76.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.90
|
| Rate for Payer: Nomi Health Commercial |
$78.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.38
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$83.39
|
| Rate for Payer: Priority Health Narrow Network |
$66.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$83.75
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$2.56
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.95 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna Commercial |
$2.31
|
| Rate for Payer: Aetna Medicare |
$0.95
|
| Rate for Payer: ASR ASR |
$2.49
|
| Rate for Payer: BCBS Complete |
$1.03
|
| Rate for Payer: BCBS Trust/PPO |
$2.11
|
| Rate for Payer: BCN Commercial |
$2.11
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$2.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.05
|
| Rate for Payer: Healthscope Commercial |
$2.49
|
| Rate for Payer: Healthscope Whirlpool |
$2.56
|
| Rate for Payer: Mclaren Commercial |
$2.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: Nomi Health Commercial |
$2.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.92
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.25
|
| Rate for Payer: Priority Health Narrow Network |
$1.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.26
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$425.60
|
|
|
Service Code
|
NDC 904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$319.20 |
| Max. Negotiated Rate |
$425.60 |
| Rate for Payer: Aetna Commercial |
$383.04
|
| Rate for Payer: ASR ASR |
$412.83
|
| Rate for Payer: BCBS Trust/PPO |
$349.50
|
| Rate for Payer: BCN Commercial |
$349.50
|
| Rate for Payer: Cash Price |
$340.48
|
| Rate for Payer: Cofinity Commercial |
$400.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.48
|
| Rate for Payer: Healthscope Commercial |
$412.83
|
| Rate for Payer: Healthscope Whirlpool |
$425.60
|
| Rate for Payer: Mclaren Commercial |
$383.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.76
|
| Rate for Payer: Nomi Health Commercial |
$348.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$374.53
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$2.56
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.92 |
| Max. Negotiated Rate |
$2.56 |
| Rate for Payer: Aetna Commercial |
$2.31
|
| Rate for Payer: ASR ASR |
$2.49
|
| Rate for Payer: BCBS Trust/PPO |
$2.11
|
| Rate for Payer: BCN Commercial |
$2.11
|
| Rate for Payer: Cash Price |
$2.05
|
| Rate for Payer: Cofinity Commercial |
$2.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.05
|
| Rate for Payer: Healthscope Commercial |
$2.49
|
| Rate for Payer: Healthscope Whirlpool |
$2.56
|
| Rate for Payer: Mclaren Commercial |
$2.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.18
|
| Rate for Payer: Nomi Health Commercial |
$2.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.26
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$256.32
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.24 |
| Max. Negotiated Rate |
$256.32 |
| Rate for Payer: Aetna Commercial |
$230.69
|
| Rate for Payer: ASR ASR |
$248.63
|
| Rate for Payer: BCBS Trust/PPO |
$210.49
|
| Rate for Payer: BCN Commercial |
$210.49
|
| Rate for Payer: Cash Price |
$205.06
|
| Rate for Payer: Cofinity Commercial |
$240.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$205.06
|
| Rate for Payer: Healthscope Commercial |
$248.63
|
| Rate for Payer: Healthscope Whirlpool |
$256.32
|
| Rate for Payer: Mclaren Commercial |
$230.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$217.87
|
| Rate for Payer: Nomi Health Commercial |
$210.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$192.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$225.56
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$4.66
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$4.19
|
| Rate for Payer: ASR ASR |
$4.52
|
| Rate for Payer: BCBS Trust/PPO |
$3.82
|
| Rate for Payer: BCN Commercial |
$3.82
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Cofinity Commercial |
$4.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.72
|
| Rate for Payer: Healthscope Commercial |
$4.52
|
| Rate for Payer: Healthscope Whirlpool |
$4.66
|
| Rate for Payer: Mclaren Commercial |
$4.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.96
|
| Rate for Payer: Nomi Health Commercial |
$3.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.10
|
|
