|
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
|
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 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 |
$216.69 |
| Max. Negotiated Rate |
$541.73 |
| Rate for Payer: Aetna Commercial |
$487.56
|
| Rate for Payer: Aetna Medicare |
$270.87
|
| 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: 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 |
$474.66
|
| Rate for Payer: Priority Health Narrow Network |
$379.75
|
| 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
|
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
|
$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 |
$2.15
|
| 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
|
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
|
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 |
$1.73
|
| 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
|
|
|
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 |
$310.37
|
| 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 |
$310.37
|
| 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
|
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 |
$310.37
|
| Rate for Payer: Aetna Medicare |
$172.43
|
| 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 |
$310.37
|
| 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
|
$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 50 MCG TABLET
|
Facility
|
IP
|
$344.85
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.15 |
| Max. Negotiated Rate |
$344.85 |
| Rate for Payer: Aetna Commercial |
$310.37
|
| 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 |
$310.37
|
| 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 50 MCG TABLET
|
Facility
|
IP
|
$3.45
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
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 50 MCG TABLET
|
Facility
|
OP
|
$3.45
|
|
|
Service Code
|
NDC 60687046411
|
| Hospital Charge Code |
4421
|
|
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 |
$1.73
|
| 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
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$2.47
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: Aetna Medicare |
$1.24
|
| Rate for Payer: ASR ASR |
$2.40
|
| Rate for Payer: ASR Commercial |
$2.40
|
| Rate for Payer: BCBS Complete |
$0.99
|
| Rate for Payer: BCBS Trust/PPO |
$2.02
|
| Rate for Payer: BCN Commercial |
$1.91
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.47
|
| Rate for Payer: Healthscope Whirlpool |
$2.40
|
| Rate for Payer: Mclaren Commercial |
$2.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.10
|
| Rate for Payer: Nomi Health Commercial |
$2.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.16
|
| Rate for Payer: Priority Health Narrow Network |
$1.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.17
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
OP
|
$323.95
|
|
|
Service Code
|
NDC 00904695061
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.58 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Aetna Commercial |
$291.56
|
| Rate for Payer: Aetna Medicare |
$161.97
|
| Rate for Payer: ASR ASR |
$314.23
|
| Rate for Payer: ASR Commercial |
$314.23
|
| Rate for Payer: BCBS Complete |
$129.58
|
| Rate for Payer: BCBS Trust/PPO |
$265.28
|
| Rate for Payer: BCN Commercial |
$251.16
|
| 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 |
$323.95
|
| Rate for Payer: Healthscope Whirlpool |
$314.23
|
| 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: Priority Health Cigna Priority Health |
$210.57
|
| Rate for Payer: 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 50 MCG TABLET
|
Facility
|
OP
|
$344.85
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.94 |
| Max. Negotiated Rate |
$344.85 |
| Rate for Payer: Aetna Commercial |
$310.37
|
| Rate for Payer: Aetna Medicare |
$172.43
|
| 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 |
$310.37
|
| 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 50 MCG TABLET
|
Facility
|
IP
|
$323.95
|
|
|
Service Code
|
NDC 00904695061
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.57 |
| Max. Negotiated Rate |
$323.95 |
| Rate for Payer: Aetna Commercial |
$291.56
|
| Rate for Payer: ASR ASR |
$314.23
|
| Rate for Payer: ASR Commercial |
$314.23
|
| Rate for Payer: BCBS Trust/PPO |
$263.99
|
| Rate for Payer: BCN Commercial |
$251.16
|
| 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 |
$323.95
|
| Rate for Payer: Healthscope Whirlpool |
$314.23
|
| 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: Priority Health Cigna Priority Health |
$210.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$285.08
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$2.47
|
|
|
Service Code
|
NDC 51079044001
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$2.47 |
| Rate for Payer: Aetna Commercial |
$2.22
|
| Rate for Payer: ASR ASR |
$2.40
|
| Rate for Payer: ASR Commercial |
$2.40
|
| Rate for Payer: BCBS Trust/PPO |
$2.01
|
| Rate for Payer: BCN Commercial |
$1.91
|
| Rate for Payer: Cash Price |
$1.97
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.47
|
| Rate for Payer: Healthscope Whirlpool |
$2.40
|
| Rate for Payer: Mclaren Commercial |
$2.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.10
|
| Rate for Payer: Nomi Health Commercial |
$2.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.17
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$386.65
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.66 |
| Max. Negotiated Rate |
$386.65 |
| Rate for Payer: Aetna Commercial |
$347.99
|
| Rate for Payer: Aetna Medicare |
$193.32
|
| Rate for Payer: ASR ASR |
$375.05
|
| Rate for Payer: ASR Commercial |
$375.05
|
| Rate for Payer: BCBS Complete |
$154.66
|
| Rate for Payer: BCBS Trust/PPO |
$316.63
|
| Rate for Payer: BCN Commercial |
$299.77
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$363.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Healthscope Commercial |
$386.65
|
| Rate for Payer: Healthscope Whirlpool |
$375.05
|
| Rate for Payer: Mclaren Commercial |
$347.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: Nomi Health Commercial |
$317.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$338.78
|
| Rate for Payer: Priority Health Narrow Network |
$271.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$340.25
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
OP
|
$273.60
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.44 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$246.24
|
| Rate for Payer: Aetna Medicare |
$136.80
|
| Rate for Payer: ASR ASR |
$265.39
|
| Rate for Payer: ASR Commercial |
$265.39
|
| Rate for Payer: BCBS Complete |
$109.44
|
| Rate for Payer: BCBS Trust/PPO |
$224.05
|
| Rate for Payer: BCN Commercial |
$212.12
|
| Rate for Payer: Cash Price |
$218.88
|
| Rate for Payer: Cofinity Commercial |
$257.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.88
|
| Rate for Payer: Healthscope Commercial |
$273.60
|
| Rate for Payer: Healthscope Whirlpool |
$265.39
|
| Rate for Payer: Mclaren Commercial |
$246.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.56
|
| Rate for Payer: Nomi Health Commercial |
$224.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$239.73
|
| Rate for Payer: Priority Health Narrow Network |
$191.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$240.77
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$386.65
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$251.32 |
| Max. Negotiated Rate |
$386.65 |
| Rate for Payer: Aetna Commercial |
$347.99
|
| Rate for Payer: ASR ASR |
$375.05
|
| Rate for Payer: ASR Commercial |
$375.05
|
| Rate for Payer: BCBS Trust/PPO |
$315.08
|
| Rate for Payer: BCN Commercial |
$299.77
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$363.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Healthscope Commercial |
$386.65
|
| Rate for Payer: Healthscope Whirlpool |
$375.05
|
| Rate for Payer: Mclaren Commercial |
$347.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: Nomi Health Commercial |
$317.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$340.25
|
|
