Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LEVOFLOXACIN 250 MG TABLET

Facility

$122.20

Service Code	NDC 55111-279-50
Hospital Charge Code	18918
Hospital Revenue Code	637
Min. Negotiated Rate	$76.99
Max. Negotiated Rate	$109.98
Rate for Payer: Aetna Commercial	$103.87
Rate for Payer: Aetna New Business (MI Preferred)	$79.43
Rate for Payer: Cash Price	$97.76
Rate for Payer: Cofinity Commercial	$105.09
Rate for Payer: Cofinity Commercial	$85.54
Rate for Payer: Healthscope Commercial	$109.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$103.87
Rate for Payer: PHP Commercial	$103.87
Rate for Payer: Priority Health Cigna Priority Health	$85.54
Rate for Payer: Priority Health SBD	$76.99

LEVOFLOXACIN 250 MG TABLET

Facility

$411.25

Service Code	NDC 0904-6351-61
Hospital Charge Code	18918
Hospital Revenue Code	637
Min. Negotiated Rate	$259.09
Max. Negotiated Rate	$370.12
Rate for Payer: Aetna Commercial	$349.56
Rate for Payer: Aetna New Business (MI Preferred)	$267.31
Rate for Payer: Cash Price	$329.00
Rate for Payer: Cofinity Commercial	$287.88
Rate for Payer: Cofinity Commercial	$353.68
Rate for Payer: Healthscope Commercial	$370.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$349.56
Rate for Payer: PHP Commercial	$349.56
Rate for Payer: Priority Health Cigna Priority Health	$287.88
Rate for Payer: Priority Health SBD	$259.09

LEVOFLOXACIN 500 MG/100 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK

Facility

$66.43

Service Code	HCPCS J1956
Hospital Charge Code	18924
Hospital Revenue Code	636
Min. Negotiated Rate	$41.85
Max. Negotiated Rate	$59.79
Rate for Payer: Aetna Commercial	$56.47
Rate for Payer: Aetna Commercial	$62.41
Rate for Payer: Aetna New Business (MI Preferred)	$47.72
Rate for Payer: Aetna New Business (MI Preferred)	$43.18
Rate for Payer: Cash Price	$53.14
Rate for Payer: Cash Price	$58.74
Rate for Payer: Cofinity Commercial	$46.50
Rate for Payer: Cofinity Commercial	$57.13
Rate for Payer: Cofinity Commercial	$51.39
Rate for Payer: Cofinity Commercial	$63.14
Rate for Payer: Healthscope Commercial	$59.79
Rate for Payer: Healthscope Commercial	$66.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$62.41
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$56.47
Rate for Payer: PHP Commercial	$62.41
Rate for Payer: PHP Commercial	$56.47
Rate for Payer: Priority Health Cigna Priority Health	$46.50
Rate for Payer: Priority Health Cigna Priority Health	$51.39
Rate for Payer: Priority Health SBD	$41.85
Rate for Payer: Priority Health SBD	$46.25

LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK

Facility

$111.54

Service Code	HCPCS J1956
Hospital Charge Code	112928
Hospital Revenue Code	636
Min. Negotiated Rate	$2.67
Max. Negotiated Rate	$100.39
Rate for Payer: Aetna Commercial	$94.81
Rate for Payer: Aetna New Business (MI Preferred)	$72.50
Rate for Payer: BCBS Complete	$44.62
Rate for Payer: BCBS Trust/PPO	$2.67
Rate for Payer: Cash Price	$89.23
Rate for Payer: Cash Price	$89.23
Rate for Payer: Cofinity Commercial	$78.08
Rate for Payer: Cofinity Commercial	$95.92
Rate for Payer: Healthscope Commercial	$100.39
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$94.81
Rate for Payer: PHP Commercial	$94.81
Rate for Payer: Priority Health Cigna Priority Health	$78.08
Rate for Payer: Priority Health SBD	$70.27

LEVOFLOXACIN 750 MG/150 ML IN 5 % DEXTROSE INTRAVENOUS PIGGYBACK

Facility

$102.88

Service Code	HCPCS J1956
Hospital Charge Code	112928
Hospital Revenue Code	636
Min. Negotiated Rate	$64.81
Max. Negotiated Rate	$92.59
Rate for Payer: Aetna Commercial	$87.45
Rate for Payer: Aetna Commercial	$94.81
Rate for Payer: Aetna Commercial	$57.95
Rate for Payer: Aetna Commercial	$38.64
Rate for Payer: Aetna Commercial	$50.85
Rate for Payer: Aetna New Business (MI Preferred)	$72.50
Rate for Payer: Aetna New Business (MI Preferred)	$66.87
Rate for Payer: Aetna New Business (MI Preferred)	$44.32
Rate for Payer: Aetna New Business (MI Preferred)	$29.55
Rate for Payer: Aetna New Business (MI Preferred)	$38.88
Rate for Payer: Cash Price	$47.86
Rate for Payer: Cash Price	$89.23
Rate for Payer: Cash Price	$54.54
Rate for Payer: Cash Price	$82.30
Rate for Payer: Cash Price	$36.37
Rate for Payer: Cofinity Commercial	$72.02
Rate for Payer: Cofinity Commercial	$58.63
Rate for Payer: Cofinity Commercial	$88.48
Rate for Payer: Cofinity Commercial	$78.08
Rate for Payer: Cofinity Commercial	$95.92
Rate for Payer: Cofinity Commercial	$47.73
Rate for Payer: Cofinity Commercial	$31.82
Rate for Payer: Cofinity Commercial	$39.10
Rate for Payer: Cofinity Commercial	$51.45
Rate for Payer: Cofinity Commercial	$41.87
Rate for Payer: Healthscope Commercial	$40.91
Rate for Payer: Healthscope Commercial	$53.84
Rate for Payer: Healthscope Commercial	$100.39
Rate for Payer: Healthscope Commercial	$61.36
Rate for Payer: Healthscope Commercial	$92.59
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$57.95
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$87.45
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$94.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$38.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$50.85
Rate for Payer: PHP Commercial	$38.64
Rate for Payer: PHP Commercial	$94.81
Rate for Payer: PHP Commercial	$50.85
Rate for Payer: PHP Commercial	$57.95
Rate for Payer: PHP Commercial	$87.45
Rate for Payer: Priority Health Cigna Priority Health	$31.82
Rate for Payer: Priority Health Cigna Priority Health	$41.87
Rate for Payer: Priority Health Cigna Priority Health	$78.08
Rate for Payer: Priority Health Cigna Priority Health	$72.02
Rate for Payer: Priority Health Cigna Priority Health	$47.73
Rate for Payer: Priority Health SBD	$37.69
Rate for Payer: Priority Health SBD	$28.64
Rate for Payer: Priority Health SBD	$64.81
Rate for Payer: Priority Health SBD	$42.95
Rate for Payer: Priority Health SBD	$70.27

LEVOFLOXACIN 750 MG TABLET

Facility

$324.90

Service Code	NDC 0904-6353-61
Hospital Charge Code	28964
Hospital Revenue Code	637
Min. Negotiated Rate	$204.69
Max. Negotiated Rate	$292.41
Rate for Payer: Aetna Commercial	$276.16
Rate for Payer: Aetna New Business (MI Preferred)	$211.18
Rate for Payer: Cash Price	$259.92
Rate for Payer: Cofinity Commercial	$227.43
Rate for Payer: Cofinity Commercial	$279.41
Rate for Payer: Healthscope Commercial	$292.41
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$276.16
Rate for Payer: PHP Commercial	$276.16
Rate for Payer: Priority Health Cigna Priority Health	$227.43
Rate for Payer: Priority Health SBD	$204.69

LEVOFLOXACIN 750 MG TABLET

Facility

$132.54

Service Code	NDC 55111-281-30
Hospital Charge Code	28964
Hospital Revenue Code	637
Min. Negotiated Rate	$83.50
Max. Negotiated Rate	$119.29
Rate for Payer: Aetna Commercial	$112.66
Rate for Payer: Aetna New Business (MI Preferred)	$86.15
Rate for Payer: Cash Price	$106.03
Rate for Payer: Cofinity Commercial	$113.98
Rate for Payer: Cofinity Commercial	$92.78
Rate for Payer: Healthscope Commercial	$119.29
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$112.66
Rate for Payer: PHP Commercial	$112.66
Rate for Payer: Priority Health Cigna Priority Health	$92.78
Rate for Payer: Priority Health SBD	$83.50

LEVOMILNACIPRAN ER 20 MG CAPSULE,24 HR,EXTENDED RELEASE

Facility

$1,724.17

Service Code	NDC 0456-2220-30
Hospital Charge Code	168790
Hospital Revenue Code	637
Min. Negotiated Rate	$1,086.23
Max. Negotiated Rate	$1,551.75
Rate for Payer: Aetna Commercial	$1,465.54
Rate for Payer: Aetna New Business (MI Preferred)	$1,120.71
Rate for Payer: Cash Price	$1,379.34
Rate for Payer: Cofinity Commercial	$1,206.92
Rate for Payer: Cofinity Commercial	$1,482.79
Rate for Payer: Healthscope Commercial	$1,551.75
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,465.54
Rate for Payer: PHP Commercial	$1,465.54
Rate for Payer: Priority Health Cigna Priority Health	$1,206.92
Rate for Payer: Priority Health SBD	$1,086.23

LEVONORGESTREL 17.5 MCG/24 HRS (5YRS) 19.5MG INTRAUTERINE DEVICE

Facility

$3,882.19

Service Code	HCPCS J7296
Hospital Charge Code	181058
Hospital Revenue Code	636
Min. Negotiated Rate	$2,445.78
Max. Negotiated Rate	$3,493.97
Rate for Payer: Aetna Commercial	$3,299.86
Rate for Payer: Aetna Commercial	$3,464.85
Rate for Payer: Aetna New Business (MI Preferred)	$2,523.42
Rate for Payer: Aetna New Business (MI Preferred)	$2,649.59
Rate for Payer: Cash Price	$3,105.75
Rate for Payer: Cash Price	$3,261.03
Rate for Payer: Cofinity Commercial	$2,853.40
Rate for Payer: Cofinity Commercial	$2,717.53
Rate for Payer: Cofinity Commercial	$3,338.68
Rate for Payer: Cofinity Commercial	$3,505.61
Rate for Payer: Healthscope Commercial	$3,668.66
Rate for Payer: Healthscope Commercial	$3,493.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3,299.86
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3,464.85
Rate for Payer: PHP Commercial	$3,299.86
Rate for Payer: PHP Commercial	$3,464.85
Rate for Payer: Priority Health Cigna Priority Health	$2,853.40
Rate for Payer: Priority Health Cigna Priority Health	$2,717.53
Rate for Payer: Priority Health SBD	$2,445.78
Rate for Payer: Priority Health SBD	$2,568.06

LEVONORGESTREL 21 MCG/24 HOURS (8 YRS) 52 MG INTRAUTERINE DEVICE

Facility

$4,280.13

Service Code	HCPCS J7298
Hospital Charge Code	29280
Hospital Revenue Code	636
Min. Negotiated Rate	$2,696.48
Max. Negotiated Rate	$3,852.12
Rate for Payer: Aetna Commercial	$3,638.11
Rate for Payer: Aetna New Business (MI Preferred)	$2,782.08
Rate for Payer: Cash Price	$3,424.10
Rate for Payer: Cofinity Commercial	$2,996.09
Rate for Payer: Cofinity Commercial	$3,680.91
Rate for Payer: Healthscope Commercial	$3,852.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3,638.11
Rate for Payer: PHP Commercial	$3,638.11
Rate for Payer: Priority Health Cigna Priority Health	$2,996.09
Rate for Payer: Priority Health SBD	$2,696.48

LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION

Facility

$348.58

Service Code	NDC 42023-201-01
Hospital Charge Code	155976
Hospital Revenue Code	250
Min. Negotiated Rate	$219.61
Max. Negotiated Rate	$313.72
Rate for Payer: Aetna Commercial	$296.29
Rate for Payer: Aetna New Business (MI Preferred)	$226.58
Rate for Payer: Cash Price	$278.86
Rate for Payer: Cofinity Commercial	$244.01
Rate for Payer: Cofinity Commercial	$299.78
Rate for Payer: Healthscope Commercial	$313.72
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$296.29
Rate for Payer: PHP Commercial	$296.29
Rate for Payer: Priority Health Cigna Priority Health	$244.01
Rate for Payer: Priority Health SBD	$219.61

LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION

Facility

$277.58

Service Code	NDC 63323-649-16
Hospital Charge Code	155976
Hospital Revenue Code	250
Min. Negotiated Rate	$174.88
Max. Negotiated Rate	$249.82
Rate for Payer: Aetna Commercial	$235.94
Rate for Payer: Aetna New Business (MI Preferred)	$180.43
Rate for Payer: Cash Price	$222.06
Rate for Payer: Cofinity Commercial	$194.31
Rate for Payer: Cofinity Commercial	$238.72
Rate for Payer: Healthscope Commercial	$249.82
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$235.94
Rate for Payer: PHP Commercial	$235.94
Rate for Payer: Priority Health Cigna Priority Health	$194.31
Rate for Payer: Priority Health SBD	$174.88

LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION

Facility

$277.58

Service Code	NDC 63323-649-07
Hospital Charge Code	155976
Hospital Revenue Code	250
Min. Negotiated Rate	$174.88
Max. Negotiated Rate	$249.82
Rate for Payer: Aetna Commercial	$235.94
Rate for Payer: Aetna New Business (MI Preferred)	$180.43
Rate for Payer: Cash Price	$222.06
Rate for Payer: Cofinity Commercial	$238.72
Rate for Payer: Cofinity Commercial	$194.31
Rate for Payer: Healthscope Commercial	$249.82
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$235.94
Rate for Payer: PHP Commercial	$235.94
Rate for Payer: Priority Health Cigna Priority Health	$194.31
Rate for Payer: Priority Health SBD	$174.88

LEVOTHYROXINE 100 MCG INTRAVENOUS POWDER FOR SOLUTION

Facility

$188.01

Service Code	NDC 70860-451-10
Hospital Charge Code	155976
Hospital Revenue Code	250
Min. Negotiated Rate	$118.45
Max. Negotiated Rate	$169.21
Rate for Payer: Aetna Commercial	$159.81
Rate for Payer: Aetna New Business (MI Preferred)	$122.21
Rate for Payer: Cash Price	$150.41
Rate for Payer: Cofinity Commercial	$131.61
Rate for Payer: Cofinity Commercial	$161.69
Rate for Payer: Healthscope Commercial	$169.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$159.81
Rate for Payer: PHP Commercial	$159.81
Rate for Payer: Priority Health Cigna Priority Health	$131.61
Rate for Payer: Priority Health SBD	$118.45

LEVOTHYROXINE 100 MCG TABLET

Facility

$391.40

Service Code	NDC 0904-6953-61
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$246.58
Max. Negotiated Rate	$352.26
Rate for Payer: Aetna Commercial	$332.69
Rate for Payer: Aetna New Business (MI Preferred)	$254.41
Rate for Payer: Cash Price	$313.12
Rate for Payer: Cofinity Commercial	$273.98
Rate for Payer: Cofinity Commercial	$336.60
Rate for Payer: Healthscope Commercial	$352.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$332.69
Rate for Payer: PHP Commercial	$332.69
Rate for Payer: Priority Health Cigna Priority Health	$273.98
Rate for Payer: Priority Health SBD	$246.58

LEVOTHYROXINE 100 MCG TABLET

Facility

$268.80

Service Code	NDC 51079-442-20
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$169.34
Max. Negotiated Rate	$241.92
Rate for Payer: Aetna Commercial	$228.48
Rate for Payer: Aetna New Business (MI Preferred)	$174.72
Rate for Payer: Cash Price	$215.04
Rate for Payer: Cofinity Commercial	$188.16
Rate for Payer: Cofinity Commercial	$231.17
Rate for Payer: Healthscope Commercial	$241.92
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$228.48
Rate for Payer: PHP Commercial	$228.48
Rate for Payer: Priority Health Cigna Priority Health	$188.16
Rate for Payer: Priority Health SBD	$169.34

LEVOTHYROXINE 100 MCG TABLET

Facility

$116.33

Service Code	NDC 16729-451-15
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$73.29
Max. Negotiated Rate	$104.70
Rate for Payer: Aetna Commercial	$98.88
Rate for Payer: Aetna New Business (MI Preferred)	$75.61
Rate for Payer: Cash Price	$93.06
Rate for Payer: Cofinity Commercial	$100.04
Rate for Payer: Cofinity Commercial	$81.43
Rate for Payer: Healthscope Commercial	$104.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$98.88
Rate for Payer: PHP Commercial	$98.88
Rate for Payer: Priority Health Cigna Priority Health	$81.43
Rate for Payer: Priority Health SBD	$73.29

LEVOTHYROXINE 100 MCG TABLET

Facility

$371.93

Service Code	NDC 0378-1809-77
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$234.32
Max. Negotiated Rate	$334.74
Rate for Payer: Aetna Commercial	$316.14
Rate for Payer: Aetna New Business (MI Preferred)	$241.75
Rate for Payer: Cash Price	$297.54
Rate for Payer: Cofinity Commercial	$260.35
Rate for Payer: Cofinity Commercial	$319.86
Rate for Payer: Healthscope Commercial	$334.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$316.14
Rate for Payer: PHP Commercial	$316.14
Rate for Payer: Priority Health Cigna Priority Health	$260.35
Rate for Payer: Priority Health SBD	$234.32

LEVOTHYROXINE 100 MCG TABLET

Facility

$633.75

Service Code	NDC 0074-6624-90
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$399.26
Max. Negotiated Rate	$570.38
Rate for Payer: Aetna Commercial	$538.69
Rate for Payer: Aetna New Business (MI Preferred)	$411.94
Rate for Payer: Cash Price	$507.00
Rate for Payer: Cofinity Commercial	$443.62
Rate for Payer: Cofinity Commercial	$545.02
Rate for Payer: Healthscope Commercial	$570.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$538.69
Rate for Payer: PHP Commercial	$538.69
Rate for Payer: Priority Health Cigna Priority Health	$443.62
Rate for Payer: Priority Health SBD	$399.26

LEVOTHYROXINE 100 MCG TABLET

Facility

$426.24

Service Code	NDC 60793-854-01
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$268.53
Max. Negotiated Rate	$383.62
Rate for Payer: Aetna Commercial	$362.30
Rate for Payer: Aetna New Business (MI Preferred)	$277.06
Rate for Payer: Cash Price	$340.99
Rate for Payer: Cofinity Commercial	$298.37
Rate for Payer: Cofinity Commercial	$366.57
Rate for Payer: Healthscope Commercial	$383.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$362.30
Rate for Payer: PHP Commercial	$362.30
Rate for Payer: Priority Health Cigna Priority Health	$298.37
Rate for Payer: Priority Health SBD	$268.53

LEVOTHYROXINE 100 MCG TABLET

Facility

$2.69

Service Code	NDC 51079-442-01
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.42
Rate for Payer: Aetna Commercial	$2.29
Rate for Payer: Aetna New Business (MI Preferred)	$1.75
Rate for Payer: Cash Price	$2.15
Rate for Payer: Cofinity Commercial	$1.88
Rate for Payer: Cofinity Commercial	$2.31
Rate for Payer: Healthscope Commercial	$2.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.29
Rate for Payer: PHP Commercial	$2.29
Rate for Payer: Priority Health Cigna Priority Health	$1.88
Rate for Payer: Priority Health SBD	$1.69

LEVOTHYROXINE 100 MCG TABLET

Facility

$703.68

Service Code	NDC 0074-6624-11
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$443.32
Max. Negotiated Rate	$633.31
Rate for Payer: Aetna Commercial	$598.13
Rate for Payer: Aetna New Business (MI Preferred)	$457.39
Rate for Payer: Cash Price	$562.94
Rate for Payer: Cofinity Commercial	$492.58
Rate for Payer: Cofinity Commercial	$605.16
Rate for Payer: Healthscope Commercial	$633.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$598.13
Rate for Payer: PHP Commercial	$598.13
Rate for Payer: Priority Health Cigna Priority Health	$492.58
Rate for Payer: Priority Health SBD	$443.32

LEVOTHYROXINE 112 MCG TABLET

Facility

$492.96

Service Code	NDC 60793-855-01
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$310.56
Max. Negotiated Rate	$443.66
Rate for Payer: Aetna Commercial	$419.02
Rate for Payer: Aetna New Business (MI Preferred)	$320.42
Rate for Payer: Cash Price	$394.37
Rate for Payer: Cofinity Commercial	$345.07
Rate for Payer: Cofinity Commercial	$423.95
Rate for Payer: Healthscope Commercial	$443.66
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$419.02
Rate for Payer: PHP Commercial	$419.02
Rate for Payer: Priority Health Cigna Priority Health	$345.07
Rate for Payer: Priority Health SBD	$310.56

LEVOTHYROXINE 112 MCG TABLET

Facility

$217.73

Service Code	NDC 0378-1811-77
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$137.17
Max. Negotiated Rate	$195.96
Rate for Payer: Aetna Commercial	$185.07
Rate for Payer: Aetna New Business (MI Preferred)	$141.52
Rate for Payer: Cash Price	$174.18
Rate for Payer: Cofinity Commercial	$152.41
Rate for Payer: Cofinity Commercial	$187.25
Rate for Payer: Healthscope Commercial	$195.96
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$185.07
Rate for Payer: PHP Commercial	$185.07
Rate for Payer: Priority Health Cigna Priority Health	$152.41
Rate for Payer: Priority Health SBD	$137.17

LEVOTHYROXINE 112 MCG TABLET

Facility

$425.79

Service Code	NDC 0781-5185-92
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$268.25
Max. Negotiated Rate	$383.21
Rate for Payer: Aetna Commercial	$361.92
Rate for Payer: Aetna New Business (MI Preferred)	$276.76
Rate for Payer: Cash Price	$340.63
Rate for Payer: Cofinity Commercial	$298.05
Rate for Payer: Cofinity Commercial	$366.18
Rate for Payer: Healthscope Commercial	$383.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$361.92
Rate for Payer: PHP Commercial	$361.92
Rate for Payer: Priority Health Cigna Priority Health	$298.05
Rate for Payer: Priority Health SBD	$268.25

Know your out-of-pocket cost for care.

All Charges