|
SYNTHROID 137MCG TABLET
|
Facility
|
OP
|
$4.92
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
25001476
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Aetna Commercial |
$3.79
|
| Rate for Payer: Anthem Medicaid |
$1.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.84
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: First Health Commercial |
$4.67
|
| Rate for Payer: Humana Commercial |
$4.18
|
| Rate for Payer: Humana KY Medicaid |
$1.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.33
|
| Rate for Payer: Ohio Health Group HMO |
$3.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.72
|
| Rate for Payer: United Healthcare All Payer |
$4.33
|
|
|
SYNTHROID 137MCG TABLET
|
Facility
|
IP
|
$4.92
|
|
|
Service Code
|
NDC 60687056301
|
| Hospital Charge Code |
25001476
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.72 |
| Rate for Payer: Aetna Commercial |
$3.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.84
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: First Health Commercial |
$4.67
|
| Rate for Payer: Humana Commercial |
$4.18
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.63
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.33
|
| Rate for Payer: Ohio Health Group HMO |
$3.69
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.72
|
| Rate for Payer: United Healthcare All Payer |
$4.33
|
|
|
SYNTHROID 75 MCG TAB
|
Facility
|
IP
|
$4.79
|
|
|
Service Code
|
NDC 60687047501
|
| Hospital Charge Code |
25001469
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$3.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.55
|
| Rate for Payer: Humana Commercial |
$4.07
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.60
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
SYNTHROID 75 MCG TAB
|
Facility
|
OP
|
$4.79
|
|
|
Service Code
|
NDC 60687047501
|
| Hospital Charge Code |
25001469
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.60 |
| Rate for Payer: Aetna Commercial |
$3.69
|
| Rate for Payer: Anthem Medicaid |
$1.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.55
|
| Rate for Payer: Humana Commercial |
$4.07
|
| Rate for Payer: Humana KY Medicaid |
$1.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.93
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.59
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.60
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
SYNTHROID (LEVOTHR 112MCG/1TAB
|
Facility
|
IP
|
$4.88
|
|
|
Service Code
|
NDC 60687050801
|
| Hospital Charge Code |
25001470
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
SYNTHROID (LEVOTHR 112MCG/1TAB
|
Facility
|
OP
|
$4.88
|
|
|
Service Code
|
NDC 60687050801
|
| Hospital Charge Code |
25001470
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$3.76
|
| Rate for Payer: Anthem Medicaid |
$1.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.81
|
| Rate for Payer: Cash Price |
$2.44
|
| Rate for Payer: Cigna Commercial |
$4.05
|
| Rate for Payer: First Health Commercial |
$4.64
|
| Rate for Payer: Humana Commercial |
$4.15
|
| Rate for Payer: Humana KY Medicaid |
$1.68
|
| Rate for Payer: Kentucky WC Medicaid |
$1.70
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.00
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.60
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.46
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.29
|
| Rate for Payer: Ohio Health Group HMO |
$3.66
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.63
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.51
|
| Rate for Payer: PHCS Commercial |
$4.68
|
| Rate for Payer: United Healthcare All Payer |
$4.29
|
|
|
SYNTHROID(LEVOTHYRO .05MG/1TAB
|
Facility
|
IP
|
$4.67
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
25001477
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.44
|
| Rate for Payer: Humana Commercial |
$3.97
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.11
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Payer |
$4.11
|
|
|
SYNTHROID(LEVOTHYRO .05MG/1TAB
|
Facility
|
OP
|
$4.67
|
|
|
Service Code
|
NDC 60687046401
|
| Hospital Charge Code |
25001477
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.61 |
| Max. Negotiated Rate |
$4.48 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Anthem Medicaid |
$1.61
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Cash Price |
$2.34
|
| Rate for Payer: Cigna Commercial |
$3.88
|
| Rate for Payer: First Health Commercial |
$4.44
|
| Rate for Payer: Humana Commercial |
$3.97
|
| Rate for Payer: Humana KY Medicaid |
$1.61
|
| Rate for Payer: Kentucky WC Medicaid |
$1.62
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.83
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.45
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.40
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.64
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.11
|
| Rate for Payer: Ohio Health Group HMO |
$3.50
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.93
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.61
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.45
|
| Rate for Payer: PHCS Commercial |
$4.48
|
| Rate for Payer: United Healthcare All Payer |
$4.11
|
|
|
SYNTHROID(LEVOTHYRO .15MG/1TAB
|
Facility
|
IP
|
$4.93
|
|
|
Service Code
|
NDC 60687053001
|
| Hospital Charge Code |
25001478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.85
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.09
|
| Rate for Payer: First Health Commercial |
$4.68
|
| Rate for Payer: Humana Commercial |
$4.19
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.34
|
| Rate for Payer: Ohio Health Group HMO |
$3.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.73
|
| Rate for Payer: United Healthcare All Payer |
$4.34
|
|
|
SYNTHROID(LEVOTHYRO .15MG/1TAB
|
Facility
|
OP
|
$4.93
|
|
|
Service Code
|
NDC 60687053001
|
| Hospital Charge Code |
25001478
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Aetna Commercial |
$3.80
|
| Rate for Payer: Anthem Medicaid |
$1.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.85
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.09
|
| Rate for Payer: First Health Commercial |
$4.68
|
| Rate for Payer: Humana Commercial |
$4.19
|
| Rate for Payer: Humana KY Medicaid |
$1.70
|
| Rate for Payer: Kentucky WC Medicaid |
$1.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.04
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.48
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.73
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.34
|
| Rate for Payer: Ohio Health Group HMO |
$3.70
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.99
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.53
|
| Rate for Payer: PHCS Commercial |
$4.73
|
| Rate for Payer: United Healthcare All Payer |
$4.34
|
|
|
SYNTHROID (LEVOTHYRO .1MG/1TAB
|
Facility
|
IP
|
$4.80
|
|
|
Service Code
|
NDC 60687049701
|
| Hospital Charge Code |
25001471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.56
|
| Rate for Payer: Humana Commercial |
$4.08
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
SYNTHROID (LEVOTHYRO .1MG/1TAB
|
Facility
|
OP
|
$4.80
|
|
|
Service Code
|
NDC 60687049701
|
| Hospital Charge Code |
25001471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.61 |
| Rate for Payer: Aetna Commercial |
$3.70
|
| Rate for Payer: Anthem Medicaid |
$1.65
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.74
|
| Rate for Payer: Cash Price |
$2.40
|
| Rate for Payer: Cigna Commercial |
$3.98
|
| Rate for Payer: First Health Commercial |
$4.56
|
| Rate for Payer: Humana Commercial |
$4.08
|
| Rate for Payer: Humana KY Medicaid |
$1.65
|
| Rate for Payer: Kentucky WC Medicaid |
$1.67
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.94
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.54
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.44
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.22
|
| Rate for Payer: Ohio Health Group HMO |
$3.60
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.49
|
| Rate for Payer: PHCS Commercial |
$4.61
|
| Rate for Payer: United Healthcare All Payer |
$4.22
|
|
|
SYNTHROID (LEVOTHYRO .2MG/1TAB
|
Facility
|
IP
|
$9.00
|
|
|
Service Code
|
NDC 60687055201
|
| Hospital Charge Code |
25001472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$6.93
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.02
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$7.47
|
| Rate for Payer: First Health Commercial |
$8.55
|
| Rate for Payer: Humana Commercial |
$7.65
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.70
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.92
|
| Rate for Payer: Ohio Health Group HMO |
$6.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.79
|
| Rate for Payer: PHCS Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Payer |
$7.92
|
|
|
SYNTHROID (LEVOTHYRO .2MG/1TAB
|
Facility
|
OP
|
$9.00
|
|
|
Service Code
|
NDC 60687055201
|
| Hospital Charge Code |
25001472
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.17 |
| Max. Negotiated Rate |
$8.64 |
| Rate for Payer: Aetna Commercial |
$6.93
|
| Rate for Payer: Anthem Medicaid |
$3.10
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$7.02
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cigna Commercial |
$7.47
|
| Rate for Payer: First Health Commercial |
$8.55
|
| Rate for Payer: Humana Commercial |
$7.65
|
| Rate for Payer: Humana KY Medicaid |
$3.10
|
| Rate for Payer: Kentucky WC Medicaid |
$3.13
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$7.38
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$6.64
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$2.70
|
| Rate for Payer: Molina Healthcare Medicaid |
$3.16
|
| Rate for Payer: Ohio Health Choice Commercial |
$7.92
|
| Rate for Payer: Ohio Health Group HMO |
$6.75
|
| Rate for Payer: Ohio Health Group PPO Differential |
$1.80
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$1.17
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$2.79
|
| Rate for Payer: PHCS Commercial |
$8.64
|
| Rate for Payer: United Healthcare All Payer |
$7.92
|
|
|
SYNTHROID(LEVOTHYROXINE)125MCG
|
Facility
|
IP
|
$4.91
|
|
|
Service Code
|
NDC 60687051901
|
| Hospital Charge Code |
25001474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.71 |
| Rate for Payer: Aetna Commercial |
$3.78
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.32
|
| Rate for Payer: Ohio Health Group HMO |
$3.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: PHCS Commercial |
$4.71
|
| Rate for Payer: United Healthcare All Payer |
$4.32
|
|
|
SYNTHROID(LEVOTHYROXINE)125MCG
|
Facility
|
OP
|
$4.91
|
|
|
Service Code
|
NDC 60687051901
|
| Hospital Charge Code |
25001474
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$4.71 |
| Rate for Payer: Aetna Commercial |
$3.78
|
| Rate for Payer: Anthem Medicaid |
$1.69
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.83
|
| Rate for Payer: Cash Price |
$2.46
|
| Rate for Payer: Cigna Commercial |
$4.08
|
| Rate for Payer: First Health Commercial |
$4.66
|
| Rate for Payer: Humana Commercial |
$4.17
|
| Rate for Payer: Humana KY Medicaid |
$1.69
|
| Rate for Payer: Kentucky WC Medicaid |
$1.71
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$4.03
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.62
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.47
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.72
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.32
|
| Rate for Payer: Ohio Health Group HMO |
$3.68
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.98
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.64
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.52
|
| Rate for Payer: PHCS Commercial |
$4.71
|
| Rate for Payer: United Healthcare All Payer |
$4.32
|
|
|
SYNTHROID (LEVOTHYROXINE)88MCG
|
Facility
|
OP
|
$4.78
|
|
|
Service Code
|
NDC 60687048601
|
| Hospital Charge Code |
25001473
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem Medicaid |
$1.64
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Humana KY Medicaid |
$1.64
|
| Rate for Payer: Kentucky WC Medicaid |
$1.66
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Molina Healthcare Medicaid |
$1.68
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
SYNTHROID (LEVOTHYROXINE)88MCG
|
Facility
|
IP
|
$4.78
|
|
|
Service Code
|
NDC 60687048601
|
| Hospital Charge Code |
25001473
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$4.59 |
| Rate for Payer: Aetna Commercial |
$3.68
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$3.73
|
| Rate for Payer: Cash Price |
$2.39
|
| Rate for Payer: Cigna Commercial |
$3.97
|
| Rate for Payer: First Health Commercial |
$4.54
|
| Rate for Payer: Humana Commercial |
$4.06
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$3.92
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$3.53
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$1.43
|
| Rate for Payer: Ohio Health Choice Commercial |
$4.21
|
| Rate for Payer: Ohio Health Group HMO |
$3.58
|
| Rate for Payer: Ohio Health Group PPO Differential |
$0.96
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$0.62
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$1.48
|
| Rate for Payer: PHCS Commercial |
$4.59
|
| Rate for Payer: United Healthcare All Payer |
$4.21
|
|
|
SYN TI PF FEM COMP SZ 10
|
Facility
|
IP
|
$24,019.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,122.60 |
| Max. Negotiated Rate |
$23,059.19 |
| Rate for Payer: Aetna Commercial |
$18,495.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,735.59
|
| Rate for Payer: Cash Price |
$12,009.99
|
| Rate for Payer: Cigna Commercial |
$19,936.59
|
| Rate for Payer: First Health Commercial |
$22,818.99
|
| Rate for Payer: Humana Commercial |
$20,416.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,696.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,726.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,206.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,137.59
|
| Rate for Payer: Ohio Health Group HMO |
$18,014.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,122.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,446.20
|
| Rate for Payer: PHCS Commercial |
$23,059.19
|
| Rate for Payer: United Healthcare All Payer |
$21,137.59
|
|
|
SYN TI PF FEM COMP SZ 10
|
Facility
|
OP
|
$24,019.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,122.60 |
| Max. Negotiated Rate |
$23,059.19 |
| Rate for Payer: Aetna Commercial |
$18,495.39
|
| Rate for Payer: Anthem Medicaid |
$8,260.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,735.59
|
| Rate for Payer: Cash Price |
$12,009.99
|
| Rate for Payer: Cigna Commercial |
$19,936.59
|
| Rate for Payer: First Health Commercial |
$22,818.99
|
| Rate for Payer: Humana Commercial |
$20,416.99
|
| Rate for Payer: Humana KY Medicaid |
$8,260.47
|
| Rate for Payer: Kentucky WC Medicaid |
$8,344.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,696.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,726.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,206.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,426.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,137.59
|
| Rate for Payer: Ohio Health Group HMO |
$18,014.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,122.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,446.20
|
| Rate for Payer: PHCS Commercial |
$23,059.19
|
| Rate for Payer: United Healthcare All Payer |
$21,137.59
|
|
|
SYN TI PF FEM COMP SZ 11
|
Facility
|
OP
|
$24,019.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,122.60 |
| Max. Negotiated Rate |
$23,059.19 |
| Rate for Payer: Aetna Commercial |
$18,495.39
|
| Rate for Payer: Anthem Medicaid |
$8,260.47
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,735.59
|
| Rate for Payer: Cash Price |
$12,009.99
|
| Rate for Payer: Cigna Commercial |
$19,936.59
|
| Rate for Payer: First Health Commercial |
$22,818.99
|
| Rate for Payer: Humana Commercial |
$20,416.99
|
| Rate for Payer: Humana KY Medicaid |
$8,260.47
|
| Rate for Payer: Kentucky WC Medicaid |
$8,344.54
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,696.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,726.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,206.00
|
| Rate for Payer: Molina Healthcare Medicaid |
$8,426.21
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,137.59
|
| Rate for Payer: Ohio Health Group HMO |
$18,014.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,122.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,446.20
|
| Rate for Payer: PHCS Commercial |
$23,059.19
|
| Rate for Payer: United Healthcare All Payer |
$21,137.59
|
|
|
SYN TI PF FEM COMP SZ 11
|
Facility
|
IP
|
$24,019.99
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$3,122.60 |
| Max. Negotiated Rate |
$23,059.19 |
| Rate for Payer: Aetna Commercial |
$18,495.39
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$18,735.59
|
| Rate for Payer: Cash Price |
$12,009.99
|
| Rate for Payer: Cigna Commercial |
$19,936.59
|
| Rate for Payer: First Health Commercial |
$22,818.99
|
| Rate for Payer: Humana Commercial |
$20,416.99
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$19,696.39
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$17,726.75
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$7,206.00
|
| Rate for Payer: Ohio Health Choice Commercial |
$21,137.59
|
| Rate for Payer: Ohio Health Group HMO |
$18,014.99
|
| Rate for Payer: Ohio Health Group PPO Differential |
$4,804.00
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$3,122.60
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$7,446.20
|
| Rate for Payer: PHCS Commercial |
$23,059.19
|
| Rate for Payer: United Healthcare All Payer |
$21,137.59
|
|
|
SYN TI PF FEM COMP SZ 12
|
Facility
|
OP
|
$15,546.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,021.04 |
| Max. Negotiated Rate |
$14,924.62 |
| Rate for Payer: Aetna Commercial |
$11,970.79
|
| Rate for Payer: Anthem Medicaid |
$5,346.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,126.25
|
| Rate for Payer: Cash Price |
$7,773.24
|
| Rate for Payer: Cigna Commercial |
$12,903.58
|
| Rate for Payer: First Health Commercial |
$14,769.16
|
| Rate for Payer: Humana Commercial |
$13,214.51
|
| Rate for Payer: Humana KY Medicaid |
$5,346.43
|
| Rate for Payer: Kentucky WC Medicaid |
$5,400.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,748.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,473.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,663.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,453.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,680.90
|
| Rate for Payer: Ohio Health Group HMO |
$11,659.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,109.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,021.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,819.41
|
| Rate for Payer: PHCS Commercial |
$14,924.62
|
| Rate for Payer: United Healthcare All Payer |
$13,680.90
|
|
|
SYN TI PF FEM COMP SZ 12
|
Facility
|
IP
|
$15,546.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,021.04 |
| Max. Negotiated Rate |
$14,924.62 |
| Rate for Payer: Aetna Commercial |
$11,970.79
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,126.25
|
| Rate for Payer: Cash Price |
$7,773.24
|
| Rate for Payer: Cigna Commercial |
$12,903.58
|
| Rate for Payer: First Health Commercial |
$14,769.16
|
| Rate for Payer: Humana Commercial |
$13,214.51
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,748.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,473.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,663.94
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,680.90
|
| Rate for Payer: Ohio Health Group HMO |
$11,659.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,109.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,021.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,819.41
|
| Rate for Payer: PHCS Commercial |
$14,924.62
|
| Rate for Payer: United Healthcare All Payer |
$13,680.90
|
|
|
SYN TI PF FEM COMP SZ 13
|
Facility
|
OP
|
$15,546.48
|
|
|
Service Code
|
HCPCS C1776
|
| Hospital Charge Code |
27000011
|
|
Hospital Revenue Code
|
278
|
| Min. Negotiated Rate |
$2,021.04 |
| Max. Negotiated Rate |
$14,924.62 |
| Rate for Payer: Aetna Commercial |
$11,970.79
|
| Rate for Payer: Anthem Medicaid |
$5,346.43
|
| Rate for Payer: Anthem POS/PPO/Traditional |
$12,126.25
|
| Rate for Payer: Cash Price |
$7,773.24
|
| Rate for Payer: Cigna Commercial |
$12,903.58
|
| Rate for Payer: First Health Commercial |
$14,769.16
|
| Rate for Payer: Humana Commercial |
$13,214.51
|
| Rate for Payer: Humana KY Medicaid |
$5,346.43
|
| Rate for Payer: Kentucky WC Medicaid |
$5,400.85
|
| Rate for Payer: Medical Mutual Of Ohio HMO |
$12,748.11
|
| Rate for Payer: Medical Mutual Of Ohio POS/PPO/Traditional |
$11,473.30
|
| Rate for Payer: Molina Healthcare Benefit Exchange |
$4,663.94
|
| Rate for Payer: Molina Healthcare Medicaid |
$5,453.71
|
| Rate for Payer: Ohio Health Choice Commercial |
$13,680.90
|
| Rate for Payer: Ohio Health Group HMO |
$11,659.86
|
| Rate for Payer: Ohio Health Group PPO Differential |
$3,109.30
|
| Rate for Payer: Ohio Health Group PPO No Differential |
$2,021.04
|
| Rate for Payer: Ohio Health Group PPO SOMC Employees |
$4,819.41
|
| Rate for Payer: PHCS Commercial |
$14,924.62
|
| Rate for Payer: United Healthcare All Payer |
$13,680.90
|
|
