|
LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK
|
Facility
|
IP
|
$7.80
|
|
|
Service Code
|
HCPCS J1956
|
| Hospital Charge Code |
112928
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$7.80 |
| Rate for Payer: Aetna Commercial |
$7.02
|
| Rate for Payer: Aetna Commercial |
$19.98
|
| Rate for Payer: ASR ASR |
$7.57
|
| Rate for Payer: ASR ASR |
$21.53
|
| Rate for Payer: ASR Commercial |
$21.53
|
| Rate for Payer: ASR Commercial |
$7.57
|
| Rate for Payer: BCBS Trust/PPO |
$18.09
|
| Rate for Payer: BCBS Trust/PPO |
$6.36
|
| Rate for Payer: BCN Commercial |
$6.05
|
| Rate for Payer: BCN Commercial |
$17.21
|
| Rate for Payer: Cash Price |
$6.24
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$20.87
|
| Rate for Payer: Cofinity Commercial |
$7.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.24
|
| Rate for Payer: Healthscope Commercial |
$22.20
|
| Rate for Payer: Healthscope Commercial |
$7.80
|
| Rate for Payer: Healthscope Whirlpool |
$21.53
|
| Rate for Payer: Healthscope Whirlpool |
$7.57
|
| Rate for Payer: Mclaren Commercial |
$19.98
|
| Rate for Payer: Mclaren Commercial |
$7.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.63
|
| Rate for Payer: Nomi Health Commercial |
$18.20
|
| Rate for Payer: Nomi Health Commercial |
$6.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.86
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$231.92
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$150.75 |
| Max. Negotiated Rate |
$231.92 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Commercial |
$169.21
|
| Rate for Payer: ASR ASR |
$224.96
|
| Rate for Payer: ASR ASR |
$182.37
|
| Rate for Payer: ASR Commercial |
$182.37
|
| Rate for Payer: ASR Commercial |
$224.96
|
| Rate for Payer: BCBS Trust/PPO |
$153.21
|
| Rate for Payer: BCBS Trust/PPO |
$188.99
|
| Rate for Payer: BCN Commercial |
$179.81
|
| Rate for Payer: BCN Commercial |
$145.76
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cofinity Commercial |
$176.73
|
| Rate for Payer: Cofinity Commercial |
$218.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Healthscope Commercial |
$188.01
|
| Rate for Payer: Healthscope Commercial |
$231.92
|
| Rate for Payer: Healthscope Whirlpool |
$182.37
|
| Rate for Payer: Healthscope Whirlpool |
$224.96
|
| Rate for Payer: Mclaren Commercial |
$169.21
|
| Rate for Payer: Mclaren Commercial |
$208.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.13
|
| Rate for Payer: Nomi Health Commercial |
$154.17
|
| Rate for Payer: Nomi Health Commercial |
$190.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$165.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$204.09
|
|
|
LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$231.92
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
155976
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.03 |
| Max. Negotiated Rate |
$231.92 |
| Rate for Payer: Aetna Commercial |
$208.73
|
| Rate for Payer: Aetna Commercial |
$169.21
|
| Rate for Payer: Aetna Medicare |
$94.00
|
| Rate for Payer: Aetna Medicare |
$115.96
|
| Rate for Payer: ASR ASR |
$224.96
|
| Rate for Payer: ASR ASR |
$182.37
|
| Rate for Payer: ASR Commercial |
$182.37
|
| Rate for Payer: ASR Commercial |
$224.96
|
| Rate for Payer: BCBS Complete |
$92.77
|
| Rate for Payer: BCBS Complete |
$75.20
|
| Rate for Payer: BCBS Trust/PPO |
$189.92
|
| Rate for Payer: BCBS Trust/PPO |
$153.96
|
| Rate for Payer: BCN Commercial |
$145.76
|
| Rate for Payer: BCN Commercial |
$179.81
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$150.41
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cash Price |
$185.54
|
| Rate for Payer: Cofinity Commercial |
$176.73
|
| Rate for Payer: Cofinity Commercial |
$218.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$185.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$150.41
|
| Rate for Payer: Healthscope Commercial |
$231.92
|
| Rate for Payer: Healthscope Commercial |
$188.01
|
| Rate for Payer: Healthscope Whirlpool |
$224.96
|
| Rate for Payer: Healthscope Whirlpool |
$182.37
|
| Rate for Payer: Mclaren Commercial |
$169.21
|
| Rate for Payer: Mclaren Commercial |
$208.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$197.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$159.81
|
| Rate for Payer: Nomi Health Commercial |
$190.17
|
| Rate for Payer: Nomi Health Commercial |
$154.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$122.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.54
|
| Rate for Payer: Priority Health Narrow Network |
$6.03
|
| Rate for Payer: Priority Health Narrow Network |
$6.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$165.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$204.09
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$280.32
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.13 |
| Max. Negotiated Rate |
$280.32 |
| Rate for Payer: Aetna Commercial |
$252.29
|
| Rate for Payer: Aetna Medicare |
$140.16
|
| Rate for Payer: ASR ASR |
$271.91
|
| Rate for Payer: ASR Commercial |
$271.91
|
| Rate for Payer: BCBS Complete |
$112.13
|
| Rate for Payer: BCBS Trust/PPO |
$229.55
|
| Rate for Payer: BCN Commercial |
$217.33
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$263.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.26
|
| Rate for Payer: Healthscope Commercial |
$280.32
|
| Rate for Payer: Healthscope Whirlpool |
$271.91
|
| Rate for Payer: Mclaren Commercial |
$252.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.27
|
| Rate for Payer: Nomi Health Commercial |
$229.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$245.62
|
| Rate for Payer: Priority Health Narrow Network |
$196.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$246.68
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$2.80
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.82 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: ASR ASR |
$2.72
|
| Rate for Payer: ASR Commercial |
$2.72
|
| Rate for Payer: BCBS Trust/PPO |
$2.28
|
| Rate for Payer: BCN Commercial |
$2.17
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cofinity Commercial |
$2.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.24
|
| Rate for Payer: Healthscope Commercial |
$2.80
|
| Rate for Payer: Healthscope Whirlpool |
$2.72
|
| Rate for Payer: Mclaren Commercial |
$2.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.38
|
| Rate for Payer: Nomi Health Commercial |
$2.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.46
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$774.72
|
|
|
Service Code
|
NDC 00074662411
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$309.89 |
| Max. Negotiated Rate |
$774.72 |
| Rate for Payer: Aetna Commercial |
$697.25
|
| Rate for Payer: Aetna Medicare |
$387.36
|
| Rate for Payer: ASR ASR |
$751.48
|
| Rate for Payer: ASR Commercial |
$751.48
|
| Rate for Payer: BCBS Complete |
$309.89
|
| Rate for Payer: BCBS Trust/PPO |
$634.42
|
| Rate for Payer: BCN Commercial |
$600.64
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$728.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$774.72
|
| Rate for Payer: Healthscope Whirlpool |
$751.48
|
| Rate for Payer: Mclaren Commercial |
$697.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: Nomi Health Commercial |
$635.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$678.81
|
| Rate for Payer: Priority Health Narrow Network |
$543.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$681.75
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$337.72
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.09 |
| Max. Negotiated Rate |
$337.72 |
| Rate for Payer: Aetna Commercial |
$303.95
|
| Rate for Payer: Aetna Medicare |
$168.86
|
| Rate for Payer: ASR ASR |
$327.59
|
| Rate for Payer: ASR Commercial |
$327.59
|
| Rate for Payer: BCBS Complete |
$135.09
|
| Rate for Payer: BCBS Trust/PPO |
$276.56
|
| Rate for Payer: BCN Commercial |
$261.83
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$317.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$337.72
|
| Rate for Payer: Healthscope Whirlpool |
$327.59
|
| Rate for Payer: Mclaren Commercial |
$303.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.06
|
| Rate for Payer: Nomi Health Commercial |
$276.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$295.91
|
| Rate for Payer: Priority Health Narrow Network |
$236.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$297.19
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$774.72
|
|
|
Service Code
|
NDC 00074662411
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$503.57 |
| Max. Negotiated Rate |
$774.72 |
| Rate for Payer: Aetna Commercial |
$697.25
|
| Rate for Payer: ASR ASR |
$751.48
|
| Rate for Payer: ASR Commercial |
$751.48
|
| Rate for Payer: BCBS Trust/PPO |
$631.32
|
| Rate for Payer: BCN Commercial |
$600.64
|
| Rate for Payer: Cash Price |
$619.78
|
| Rate for Payer: Cofinity Commercial |
$728.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$619.78
|
| Rate for Payer: Healthscope Commercial |
$774.72
|
| Rate for Payer: Healthscope Whirlpool |
$751.48
|
| Rate for Payer: Mclaren Commercial |
$697.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$658.51
|
| Rate for Payer: Nomi Health Commercial |
$635.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$503.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$681.75
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$396.15
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.46 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Aetna Commercial |
$356.54
|
| Rate for Payer: Aetna Medicare |
$198.08
|
| Rate for Payer: ASR ASR |
$384.27
|
| Rate for Payer: ASR Commercial |
$384.27
|
| Rate for Payer: BCBS Complete |
$158.46
|
| Rate for Payer: BCBS Trust/PPO |
$324.41
|
| Rate for Payer: BCN Commercial |
$307.14
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$372.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Healthscope Commercial |
$396.15
|
| Rate for Payer: Healthscope Whirlpool |
$384.27
|
| Rate for Payer: Mclaren Commercial |
$356.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: Nomi Health Commercial |
$324.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$347.11
|
| Rate for Payer: Priority Health Narrow Network |
$277.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$348.61
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$337.72
|
|
|
Service Code
|
NDC 00378180977
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$219.52 |
| Max. Negotiated Rate |
$337.72 |
| Rate for Payer: Aetna Commercial |
$303.95
|
| Rate for Payer: ASR ASR |
$327.59
|
| Rate for Payer: ASR Commercial |
$327.59
|
| Rate for Payer: BCBS Trust/PPO |
$275.21
|
| Rate for Payer: BCN Commercial |
$261.83
|
| Rate for Payer: Cash Price |
$270.18
|
| Rate for Payer: Cofinity Commercial |
$317.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$270.18
|
| Rate for Payer: Healthscope Commercial |
$337.72
|
| Rate for Payer: Healthscope Whirlpool |
$327.59
|
| Rate for Payer: Mclaren Commercial |
$303.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$287.06
|
| Rate for Payer: Nomi Health Commercial |
$276.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$297.19
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
OP
|
$2.80
|
|
|
Service Code
|
NDC 51079044201
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.12 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: Aetna Medicare |
$1.40
|
| Rate for Payer: ASR ASR |
$2.72
|
| Rate for Payer: ASR Commercial |
$2.72
|
| Rate for Payer: BCBS Complete |
$1.12
|
| Rate for Payer: BCBS Trust/PPO |
$2.29
|
| Rate for Payer: BCN Commercial |
$2.17
|
| Rate for Payer: Cash Price |
$2.24
|
| Rate for Payer: Cofinity Commercial |
$2.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.24
|
| Rate for Payer: Healthscope Commercial |
$2.80
|
| Rate for Payer: Healthscope Whirlpool |
$2.72
|
| Rate for Payer: Mclaren Commercial |
$2.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.38
|
| Rate for Payer: Nomi Health Commercial |
$2.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.82
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.45
|
| Rate for Payer: Priority Health Narrow Network |
$1.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.46
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$396.15
|
|
|
Service Code
|
NDC 00904695361
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.50 |
| Max. Negotiated Rate |
$396.15 |
| Rate for Payer: Aetna Commercial |
$356.54
|
| Rate for Payer: ASR ASR |
$384.27
|
| Rate for Payer: ASR Commercial |
$384.27
|
| Rate for Payer: BCBS Trust/PPO |
$322.82
|
| Rate for Payer: BCN Commercial |
$307.14
|
| Rate for Payer: Cash Price |
$316.92
|
| Rate for Payer: Cofinity Commercial |
$372.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$316.92
|
| Rate for Payer: Healthscope Commercial |
$396.15
|
| Rate for Payer: Healthscope Whirlpool |
$384.27
|
| Rate for Payer: Mclaren Commercial |
$356.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$336.73
|
| Rate for Payer: Nomi Health Commercial |
$324.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$257.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$348.61
|
|
|
LEVOTHYROXINE 100 MCG TABLET
|
Facility
|
IP
|
$280.32
|
|
|
Service Code
|
NDC 51079044220
|
| Hospital Charge Code |
4423
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$182.21 |
| Max. Negotiated Rate |
$280.32 |
| Rate for Payer: Aetna Commercial |
$252.29
|
| Rate for Payer: ASR ASR |
$271.91
|
| Rate for Payer: ASR Commercial |
$271.91
|
| Rate for Payer: BCBS Trust/PPO |
$228.43
|
| Rate for Payer: BCN Commercial |
$217.33
|
| Rate for Payer: Cash Price |
$224.26
|
| Rate for Payer: Cofinity Commercial |
$263.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.26
|
| Rate for Payer: Healthscope Commercial |
$280.32
|
| Rate for Payer: Healthscope Whirlpool |
$271.91
|
| Rate for Payer: Mclaren Commercial |
$252.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$238.27
|
| Rate for Payer: Nomi Health Commercial |
$229.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$182.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$246.68
|
|
|
LEVOTHYROXINE 200 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$541.73
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$352.12 |
| Max. Negotiated Rate |
$541.73 |
| Rate for Payer: Aetna Commercial |
$487.56
|
| Rate for Payer: ASR ASR |
$525.48
|
| Rate for Payer: ASR Commercial |
$525.48
|
| Rate for Payer: BCBS Trust/PPO |
$441.46
|
| Rate for Payer: BCN Commercial |
$420.00
|
| Rate for Payer: Cash Price |
$433.38
|
| Rate for Payer: Cofinity Commercial |
$509.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$433.38
|
| Rate for Payer: Healthscope Commercial |
$541.73
|
| Rate for Payer: Healthscope Whirlpool |
$525.48
|
| Rate for Payer: Mclaren Commercial |
$487.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$460.47
|
| Rate for Payer: Nomi Health Commercial |
$444.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$352.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$476.72
|
|
|
LEVOTHYROXINE 200 MCG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
OP
|
$541.73
|
|
|
Service Code
|
HCPCS J0650
|
| Hospital Charge Code |
4418
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.03 |
| Max. Negotiated Rate |
$541.73 |
| Rate for Payer: Aetna Commercial |
$487.56
|
| Rate for Payer: Aetna Medicare |
$270.86
|
| Rate for Payer: ASR ASR |
$525.48
|
| Rate for Payer: ASR Commercial |
$525.48
|
| Rate for Payer: BCBS Complete |
$216.69
|
| Rate for Payer: BCBS Trust/PPO |
$443.62
|
| Rate for Payer: BCN Commercial |
$420.00
|
| Rate for Payer: Cash Price |
$433.38
|
| Rate for Payer: Cash Price |
$433.38
|
| Rate for Payer: Cofinity Commercial |
$509.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$433.38
|
| Rate for Payer: Healthscope Commercial |
$541.73
|
| Rate for Payer: Healthscope Whirlpool |
$525.48
|
| Rate for Payer: Mclaren Commercial |
$487.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$460.47
|
| Rate for Payer: Nomi Health Commercial |
$444.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$352.12
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$7.54
|
| Rate for Payer: Priority Health Narrow Network |
$6.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$476.72
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
OP
|
$7,752.00
|
|
|
Service Code
|
NDC 00074714819
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3,100.80 |
| Max. Negotiated Rate |
$7,752.00 |
| Rate for Payer: Aetna Commercial |
$6,976.80
|
| Rate for Payer: Aetna Medicare |
$3,876.00
|
| Rate for Payer: ASR ASR |
$7,519.44
|
| Rate for Payer: ASR Commercial |
$7,519.44
|
| Rate for Payer: BCBS Complete |
$3,100.80
|
| Rate for Payer: BCBS Trust/PPO |
$6,348.11
|
| Rate for Payer: BCN Commercial |
$6,010.13
|
| Rate for Payer: Cash Price |
$6,201.60
|
| Rate for Payer: Cofinity Commercial |
$7,286.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,201.60
|
| Rate for Payer: Healthscope Commercial |
$7,752.00
|
| Rate for Payer: Healthscope Whirlpool |
$7,519.44
|
| Rate for Payer: Mclaren Commercial |
$6,976.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,589.20
|
| Rate for Payer: Nomi Health Commercial |
$6,356.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,038.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6,792.30
|
| Rate for Payer: Priority Health Narrow Network |
$5,434.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6,821.76
|
|
|
LEVOTHYROXINE 200 MCG TABLET
|
Facility
|
IP
|
$7,752.00
|
|
|
Service Code
|
NDC 00074714819
|
| Hospital Charge Code |
4426
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5,038.80 |
| Max. Negotiated Rate |
$7,752.00 |
| Rate for Payer: Aetna Commercial |
$6,976.80
|
| Rate for Payer: ASR ASR |
$7,519.44
|
| Rate for Payer: ASR Commercial |
$7,519.44
|
| Rate for Payer: BCBS Trust/PPO |
$6,317.10
|
| Rate for Payer: BCN Commercial |
$6,010.13
|
| Rate for Payer: Cash Price |
$6,201.60
|
| Rate for Payer: Cofinity Commercial |
$7,286.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6,201.60
|
| Rate for Payer: Healthscope Commercial |
$7,752.00
|
| Rate for Payer: Healthscope Whirlpool |
$7,519.44
|
| Rate for Payer: Mclaren Commercial |
$6,976.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6,589.20
|
| Rate for Payer: Nomi Health Commercial |
$6,356.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$5,038.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6,821.76
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$4.29
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.86
|
| Rate for Payer: Aetna Medicare |
$2.14
|
| Rate for Payer: ASR ASR |
$4.16
|
| Rate for Payer: ASR Commercial |
$4.16
|
| Rate for Payer: BCBS Complete |
$1.72
|
| Rate for Payer: BCBS Trust/PPO |
$3.51
|
| Rate for Payer: BCN Commercial |
$3.33
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cofinity Commercial |
$4.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.43
|
| Rate for Payer: Healthscope Commercial |
$4.29
|
| Rate for Payer: Healthscope Whirlpool |
$4.16
|
| Rate for Payer: Mclaren Commercial |
$3.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.65
|
| Rate for Payer: Nomi Health Commercial |
$3.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.76
|
| Rate for Payer: Priority Health Narrow Network |
$3.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.78
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$344.85
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.94 |
| Max. Negotiated Rate |
$344.85 |
| Rate for Payer: Aetna Commercial |
$310.36
|
| Rate for Payer: Aetna Medicare |
$172.42
|
| Rate for Payer: ASR ASR |
$334.50
|
| Rate for Payer: ASR Commercial |
$334.50
|
| Rate for Payer: BCBS Complete |
$137.94
|
| Rate for Payer: BCBS Trust/PPO |
$282.40
|
| Rate for Payer: BCN Commercial |
$267.36
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$324.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$344.85
|
| Rate for Payer: Healthscope Whirlpool |
$334.50
|
| Rate for Payer: Mclaren Commercial |
$310.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: Nomi Health Commercial |
$282.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$302.16
|
| Rate for Payer: Priority Health Narrow Network |
$241.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$303.47
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$344.85
|
|
|
Service Code
|
NDC 60687045301
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.15 |
| Max. Negotiated Rate |
$344.85 |
| Rate for Payer: Aetna Commercial |
$310.36
|
| Rate for Payer: ASR ASR |
$334.50
|
| Rate for Payer: ASR Commercial |
$334.50
|
| Rate for Payer: BCBS Trust/PPO |
$281.02
|
| Rate for Payer: BCN Commercial |
$267.36
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$324.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$344.85
|
| Rate for Payer: Healthscope Whirlpool |
$334.50
|
| Rate for Payer: Mclaren Commercial |
$310.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$293.12
|
| Rate for Payer: Nomi Health Commercial |
$282.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$224.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$303.47
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$4.29
|
|
|
Service Code
|
NDC 51079044401
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.79 |
| Max. Negotiated Rate |
$4.29 |
| Rate for Payer: Aetna Commercial |
$3.86
|
| Rate for Payer: ASR ASR |
$4.16
|
| Rate for Payer: ASR Commercial |
$4.16
|
| Rate for Payer: BCBS Trust/PPO |
$3.50
|
| Rate for Payer: BCN Commercial |
$3.33
|
| Rate for Payer: Cash Price |
$3.44
|
| Rate for Payer: Cofinity Commercial |
$4.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.43
|
| Rate for Payer: Healthscope Commercial |
$4.29
|
| Rate for Payer: Healthscope Whirlpool |
$4.16
|
| Rate for Payer: Mclaren Commercial |
$3.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.65
|
| Rate for Payer: Nomi Health Commercial |
$3.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.78
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$313.50
|
|
|
Service Code
|
NDC 00904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.40 |
| Max. Negotiated Rate |
$313.50 |
| Rate for Payer: Aetna Commercial |
$282.15
|
| Rate for Payer: Aetna Medicare |
$156.75
|
| Rate for Payer: ASR ASR |
$304.10
|
| Rate for Payer: ASR Commercial |
$304.10
|
| Rate for Payer: BCBS Complete |
$125.40
|
| Rate for Payer: BCBS Trust/PPO |
$256.73
|
| Rate for Payer: BCN Commercial |
$243.06
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cofinity Commercial |
$294.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.80
|
| Rate for Payer: Healthscope Commercial |
$313.50
|
| Rate for Payer: Healthscope Whirlpool |
$304.10
|
| Rate for Payer: Mclaren Commercial |
$282.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$266.48
|
| Rate for Payer: Nomi Health Commercial |
$257.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$274.69
|
| Rate for Payer: Priority Health Narrow Network |
$219.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$275.88
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$3.45
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Aetna Commercial |
$3.10
|
| Rate for Payer: ASR ASR |
$3.35
|
| Rate for Payer: ASR Commercial |
$3.35
|
| Rate for Payer: BCBS Trust/PPO |
$2.81
|
| Rate for Payer: BCN Commercial |
$2.67
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$3.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.76
|
| Rate for Payer: Healthscope Commercial |
$3.45
|
| Rate for Payer: Healthscope Whirlpool |
$3.35
|
| Rate for Payer: Mclaren Commercial |
$3.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.93
|
| Rate for Payer: Nomi Health Commercial |
$2.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.04
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
IP
|
$313.50
|
|
|
Service Code
|
NDC 00904694961
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.78 |
| Max. Negotiated Rate |
$313.50 |
| Rate for Payer: Aetna Commercial |
$282.15
|
| Rate for Payer: ASR ASR |
$304.10
|
| Rate for Payer: ASR Commercial |
$304.10
|
| Rate for Payer: BCBS Trust/PPO |
$255.47
|
| Rate for Payer: BCN Commercial |
$243.06
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cofinity Commercial |
$294.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.80
|
| Rate for Payer: Healthscope Commercial |
$313.50
|
| Rate for Payer: Healthscope Whirlpool |
$304.10
|
| Rate for Payer: Mclaren Commercial |
$282.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$266.48
|
| Rate for Payer: Nomi Health Commercial |
$257.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$275.88
|
|
|
LEVOTHYROXINE 25 MCG TABLET
|
Facility
|
OP
|
$3.45
|
|
|
Service Code
|
NDC 60687045311
|
| Hospital Charge Code |
4420
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.38 |
| Max. Negotiated Rate |
$3.45 |
| Rate for Payer: Aetna Commercial |
$3.10
|
| Rate for Payer: Aetna Medicare |
$1.72
|
| Rate for Payer: ASR ASR |
$3.35
|
| Rate for Payer: ASR Commercial |
$3.35
|
| Rate for Payer: BCBS Complete |
$1.38
|
| Rate for Payer: BCBS Trust/PPO |
$2.83
|
| Rate for Payer: BCN Commercial |
$2.67
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$3.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.76
|
| Rate for Payer: Healthscope Commercial |
$3.45
|
| Rate for Payer: Healthscope Whirlpool |
$3.35
|
| Rate for Payer: Mclaren Commercial |
$3.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.93
|
| Rate for Payer: Nomi Health Commercial |
$2.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.24
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.02
|
| Rate for Payer: Priority Health Narrow Network |
$2.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.04
|
|
