Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 100 MCG TABLET

Facility

$813.60

Service Code	NDC 00074662411
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$319.74
Max. Negotiated Rate	$732.24
Rate for Payer: Aetna Commercial	$691.56
Rate for Payer: Aetna Medicare	$406.80
Rate for Payer: Aetna New Business (MI Preferred)	$528.84
Rate for Payer: BCBS Complete	$325.44
Rate for Payer: Cash Price	$650.88
Rate for Payer: Cofinity Advantage	$569.52
Rate for Payer: Cofinity Commercial	$699.70
Rate for Payer: Encore Health Key Benefits Commercial	$650.88
Rate for Payer: Healthscope Commercial	$732.24
Rate for Payer: MI Amish Medical Board Commercial	$650.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$691.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$610.20
Rate for Payer: PHP Commercial	$691.56
Rate for Payer: Priority Health SBD	$512.57
Rate for Payer: UHC All Payor (Choice/PPO)	$528.84
Rate for Payer: UHC Core	$423.89
Rate for Payer: UHC Exchange	$319.74

LEVOTHYROXINE 100 MCG TABLET

Facility

$263.04

Service Code	NDC 51079044220
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$165.72
Max. Negotiated Rate	$236.74
Rate for Payer: Aetna Commercial	$223.58
Rate for Payer: Aetna New Business (MI Preferred)	$170.98
Rate for Payer: Cash Price	$210.43
Rate for Payer: Cofinity Advantage	$184.13
Rate for Payer: Cofinity Commercial	$226.21
Rate for Payer: Encore Health Key Benefits Commercial	$210.43
Rate for Payer: Healthscope Commercial	$236.74
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$223.58
Rate for Payer: Opus (Opus Packaging Group) HMA	$197.28
Rate for Payer: PHP Commercial	$223.58
Rate for Payer: Priority Health SBD	$165.72

LEVOTHYROXINE 100 MCG TABLET

Facility

$813.60

Service Code	NDC 00074662411
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$512.57
Max. Negotiated Rate	$732.24
Rate for Payer: Aetna Commercial	$691.56
Rate for Payer: Aetna New Business (MI Preferred)	$528.84
Rate for Payer: Cash Price	$650.88
Rate for Payer: Cofinity Advantage	$569.52
Rate for Payer: Cofinity Commercial	$699.70
Rate for Payer: Encore Health Key Benefits Commercial	$650.88
Rate for Payer: Healthscope Commercial	$732.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$691.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$610.20
Rate for Payer: PHP Commercial	$691.56
Rate for Payer: Priority Health SBD	$512.57

LEVOTHYROXINE 100 MCG TABLET

Facility

$93.06

Service Code	NDC 16729045115
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$36.57
Max. Negotiated Rate	$83.75
Rate for Payer: Aetna Commercial	$79.10
Rate for Payer: Aetna Medicare	$46.53
Rate for Payer: Aetna New Business (MI Preferred)	$60.49
Rate for Payer: BCBS Complete	$37.22
Rate for Payer: Cash Price	$74.45
Rate for Payer: Cofinity Advantage	$65.14
Rate for Payer: Cofinity Commercial	$80.03
Rate for Payer: Encore Health Key Benefits Commercial	$74.45
Rate for Payer: Healthscope Commercial	$83.75
Rate for Payer: MI Amish Medical Board Commercial	$74.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$79.10
Rate for Payer: Opus (Opus Packaging Group) HMA	$69.80
Rate for Payer: PHP Commercial	$79.10
Rate for Payer: Priority Health SBD	$58.63
Rate for Payer: UHC All Payor (Choice/PPO)	$60.49
Rate for Payer: UHC Core	$48.48
Rate for Payer: UHC Exchange	$36.57

LEVOTHYROXINE 100 MCG TABLET

Facility

$473.76

Service Code	NDC 60793085401
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$298.47
Max. Negotiated Rate	$426.38
Rate for Payer: Aetna Commercial	$402.70
Rate for Payer: Aetna New Business (MI Preferred)	$307.94
Rate for Payer: Cash Price	$379.01
Rate for Payer: Cofinity Advantage	$331.63
Rate for Payer: Cofinity Commercial	$407.43
Rate for Payer: Encore Health Key Benefits Commercial	$379.01
Rate for Payer: Healthscope Commercial	$426.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$402.70
Rate for Payer: Opus (Opus Packaging Group) HMA	$355.32
Rate for Payer: PHP Commercial	$402.70
Rate for Payer: Priority Health SBD	$298.47

LEVOTHYROXINE 100 MCG TABLET

Facility

$732.24

Service Code	NDC 00074662490
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$287.77
Max. Negotiated Rate	$659.02
Rate for Payer: Aetna Commercial	$622.40
Rate for Payer: Aetna Medicare	$366.12
Rate for Payer: Aetna New Business (MI Preferred)	$475.96
Rate for Payer: BCBS Complete	$292.90
Rate for Payer: Cash Price	$585.79
Rate for Payer: Cofinity Advantage	$512.57
Rate for Payer: Cofinity Commercial	$629.73
Rate for Payer: Encore Health Key Benefits Commercial	$585.79
Rate for Payer: Healthscope Commercial	$659.02
Rate for Payer: MI Amish Medical Board Commercial	$585.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$622.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$549.18
Rate for Payer: PHP Commercial	$622.40
Rate for Payer: Priority Health SBD	$461.31
Rate for Payer: UHC All Payor (Choice/PPO)	$475.96
Rate for Payer: UHC Core	$381.50
Rate for Payer: UHC Exchange	$287.77

LEVOTHYROXINE 100 MCG TABLET

Facility

$93.06

Service Code	NDC 16729045115
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$58.63
Max. Negotiated Rate	$83.75
Rate for Payer: Aetna Commercial	$79.10
Rate for Payer: Aetna New Business (MI Preferred)	$60.49
Rate for Payer: Cash Price	$74.45
Rate for Payer: Cofinity Advantage	$65.14
Rate for Payer: Cofinity Commercial	$80.03
Rate for Payer: Encore Health Key Benefits Commercial	$74.45
Rate for Payer: Healthscope Commercial	$83.75
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$79.10
Rate for Payer: Opus (Opus Packaging Group) HMA	$69.80
Rate for Payer: PHP Commercial	$79.10
Rate for Payer: Priority Health SBD	$58.63

LEVOTHYROXINE 100 MCG TABLET

Facility

$416.10

Service Code	NDC 00904695361
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$262.14
Max. Negotiated Rate	$374.49
Rate for Payer: Aetna Commercial	$353.69
Rate for Payer: Aetna New Business (MI Preferred)	$270.46
Rate for Payer: Cash Price	$332.88
Rate for Payer: Cofinity Advantage	$291.27
Rate for Payer: Cofinity Commercial	$357.85
Rate for Payer: Encore Health Key Benefits Commercial	$332.88
Rate for Payer: Healthscope Commercial	$374.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$353.69
Rate for Payer: Opus (Opus Packaging Group) HMA	$312.07
Rate for Payer: PHP Commercial	$353.69
Rate for Payer: Priority Health SBD	$262.14

LEVOTHYROXINE 100 MCG TABLET

Facility

$2.64

Service Code	NDC 51079044201
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$1.66
Max. Negotiated Rate	$2.38
Rate for Payer: Aetna Commercial	$2.24
Rate for Payer: Aetna New Business (MI Preferred)	$1.72
Rate for Payer: Cash Price	$2.11
Rate for Payer: Cofinity Advantage	$1.85
Rate for Payer: Cofinity Commercial	$2.27
Rate for Payer: Encore Health Key Benefits Commercial	$2.11
Rate for Payer: Healthscope Commercial	$2.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.24
Rate for Payer: Opus (Opus Packaging Group) HMA	$1.98
Rate for Payer: PHP Commercial	$2.24
Rate for Payer: Priority Health SBD	$1.66

LEVOTHYROXINE 112 MCG TABLET

Facility

$389.88

Service Code	NDC 00378181177
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$153.22
Max. Negotiated Rate	$350.89
Rate for Payer: Aetna Commercial	$331.40
Rate for Payer: Aetna Medicare	$194.94
Rate for Payer: Aetna New Business (MI Preferred)	$253.42
Rate for Payer: BCBS Complete	$155.95
Rate for Payer: Cash Price	$311.90
Rate for Payer: Cofinity Advantage	$272.92
Rate for Payer: Cofinity Commercial	$335.30
Rate for Payer: Encore Health Key Benefits Commercial	$311.90
Rate for Payer: Healthscope Commercial	$350.89
Rate for Payer: MI Amish Medical Board Commercial	$311.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$331.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$292.41
Rate for Payer: PHP Commercial	$331.40
Rate for Payer: Priority Health SBD	$245.62
Rate for Payer: UHC All Payor (Choice/PPO)	$253.42
Rate for Payer: UHC Core	$203.13
Rate for Payer: UHC Exchange	$153.22

LEVOTHYROXINE 112 MCG TABLET

Facility

$475.00

Service Code	NDC 00904695461
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$186.68
Max. Negotiated Rate	$427.50
Rate for Payer: Aetna Commercial	$403.75
Rate for Payer: Aetna Medicare	$237.50
Rate for Payer: Aetna New Business (MI Preferred)	$308.75
Rate for Payer: BCBS Complete	$190.00
Rate for Payer: Cash Price	$380.00
Rate for Payer: Cofinity Advantage	$332.50
Rate for Payer: Cofinity Commercial	$408.50
Rate for Payer: Encore Health Key Benefits Commercial	$380.00
Rate for Payer: Healthscope Commercial	$427.50
Rate for Payer: MI Amish Medical Board Commercial	$380.00
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$403.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$356.25
Rate for Payer: PHP Commercial	$403.75
Rate for Payer: Priority Health SBD	$299.25
Rate for Payer: UHC All Payor (Choice/PPO)	$308.75
Rate for Payer: UHC Core	$247.47
Rate for Payer: UHC Exchange	$186.68

LEVOTHYROXINE 112 MCG TABLET

Facility

$732.24

Service Code	NDC 00074929690
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$287.77
Max. Negotiated Rate	$659.02
Rate for Payer: Aetna Commercial	$622.40
Rate for Payer: Aetna Medicare	$366.12
Rate for Payer: Aetna New Business (MI Preferred)	$475.96
Rate for Payer: BCBS Complete	$292.90
Rate for Payer: Cash Price	$585.79
Rate for Payer: Cofinity Advantage	$512.57
Rate for Payer: Cofinity Commercial	$629.73
Rate for Payer: Encore Health Key Benefits Commercial	$585.79
Rate for Payer: Healthscope Commercial	$659.02
Rate for Payer: MI Amish Medical Board Commercial	$585.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$622.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$549.18
Rate for Payer: PHP Commercial	$622.40
Rate for Payer: Priority Health SBD	$461.31
Rate for Payer: UHC All Payor (Choice/PPO)	$475.96
Rate for Payer: UHC Core	$381.50
Rate for Payer: UHC Exchange	$287.77

LEVOTHYROXINE 112 MCG TABLET

Facility

$547.68

Service Code	NDC 60793085501
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$215.24
Max. Negotiated Rate	$492.91
Rate for Payer: Aetna Commercial	$465.53
Rate for Payer: Aetna Medicare	$273.84
Rate for Payer: Aetna New Business (MI Preferred)	$355.99
Rate for Payer: BCBS Complete	$219.07
Rate for Payer: Cash Price	$438.14
Rate for Payer: Cofinity Advantage	$383.38
Rate for Payer: Cofinity Commercial	$471.00
Rate for Payer: Encore Health Key Benefits Commercial	$438.14
Rate for Payer: Healthscope Commercial	$492.91
Rate for Payer: MI Amish Medical Board Commercial	$438.14
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$465.53
Rate for Payer: Opus (Opus Packaging Group) HMA	$410.76
Rate for Payer: PHP Commercial	$465.53
Rate for Payer: Priority Health SBD	$345.04
Rate for Payer: UHC All Payor (Choice/PPO)	$355.99
Rate for Payer: UHC Core	$285.34
Rate for Payer: UHC Exchange	$215.24

LEVOTHYROXINE 112 MCG TABLET

Facility

$2.75

Service Code	NDC 42292003901
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.48
Rate for Payer: Aetna Commercial	$2.34
Rate for Payer: Aetna New Business (MI Preferred)	$1.79
Rate for Payer: Cash Price	$2.20
Rate for Payer: Cofinity Advantage	$1.93
Rate for Payer: Cofinity Commercial	$2.37
Rate for Payer: Encore Health Key Benefits Commercial	$2.20
Rate for Payer: Healthscope Commercial	$2.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.06
Rate for Payer: PHP Commercial	$2.34
Rate for Payer: Priority Health SBD	$1.73

LEVOTHYROXINE 112 MCG TABLET

Facility

$547.68

Service Code	NDC 60793085501
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$345.04
Max. Negotiated Rate	$492.91
Rate for Payer: Aetna Commercial	$465.53
Rate for Payer: Aetna New Business (MI Preferred)	$355.99
Rate for Payer: Cash Price	$438.14
Rate for Payer: Cofinity Advantage	$383.38
Rate for Payer: Cofinity Commercial	$471.00
Rate for Payer: Encore Health Key Benefits Commercial	$438.14
Rate for Payer: Healthscope Commercial	$492.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$465.53
Rate for Payer: Opus (Opus Packaging Group) HMA	$410.76
Rate for Payer: PHP Commercial	$465.53
Rate for Payer: Priority Health SBD	$345.04

LEVOTHYROXINE 112 MCG TABLET

Facility

$732.24

Service Code	NDC 00074929690
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$461.31
Max. Negotiated Rate	$659.02
Rate for Payer: Aetna Commercial	$622.40
Rate for Payer: Aetna New Business (MI Preferred)	$475.96
Rate for Payer: Cash Price	$585.79
Rate for Payer: Cofinity Advantage	$512.57
Rate for Payer: Cofinity Commercial	$629.73
Rate for Payer: Encore Health Key Benefits Commercial	$585.79
Rate for Payer: Healthscope Commercial	$659.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$622.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$549.18
Rate for Payer: PHP Commercial	$622.40
Rate for Payer: Priority Health SBD	$461.31

LEVOTHYROXINE 112 MCG TABLET

Facility

$274.56

Service Code	NDC 42292003920
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$172.97
Max. Negotiated Rate	$247.10
Rate for Payer: Aetna Commercial	$233.38
Rate for Payer: Aetna New Business (MI Preferred)	$178.46
Rate for Payer: Cash Price	$219.65
Rate for Payer: Cofinity Advantage	$192.19
Rate for Payer: Cofinity Commercial	$236.12
Rate for Payer: Encore Health Key Benefits Commercial	$219.65
Rate for Payer: Healthscope Commercial	$247.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$233.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$205.92
Rate for Payer: PHP Commercial	$233.38
Rate for Payer: Priority Health SBD	$172.97

LEVOTHYROXINE 112 MCG TABLET

Facility

$167.09

Service Code	NDC 68180097009
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$105.27
Max. Negotiated Rate	$150.38
Rate for Payer: Aetna Commercial	$142.03
Rate for Payer: Aetna New Business (MI Preferred)	$108.61
Rate for Payer: Cash Price	$133.67
Rate for Payer: Cofinity Advantage	$116.96
Rate for Payer: Cofinity Commercial	$143.70
Rate for Payer: Encore Health Key Benefits Commercial	$133.67
Rate for Payer: Healthscope Commercial	$150.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$142.03
Rate for Payer: Opus (Opus Packaging Group) HMA	$125.32
Rate for Payer: PHP Commercial	$142.03
Rate for Payer: Priority Health SBD	$105.27

LEVOTHYROXINE 112 MCG TABLET

Facility

$2.75

Service Code	NDC 42292003901
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$1.08
Max. Negotiated Rate	$2.48
Rate for Payer: Aetna Commercial	$2.34
Rate for Payer: Aetna Medicare	$1.38
Rate for Payer: Aetna New Business (MI Preferred)	$1.79
Rate for Payer: BCBS Complete	$1.10
Rate for Payer: Cash Price	$2.20
Rate for Payer: Cofinity Advantage	$1.93
Rate for Payer: Cofinity Commercial	$2.37
Rate for Payer: Encore Health Key Benefits Commercial	$2.20
Rate for Payer: Healthscope Commercial	$2.48
Rate for Payer: MI Amish Medical Board Commercial	$2.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.06
Rate for Payer: PHP Commercial	$2.34
Rate for Payer: Priority Health SBD	$1.73
Rate for Payer: UHC All Payor (Choice/PPO)	$1.79
Rate for Payer: UHC Core	$1.43
Rate for Payer: UHC Exchange	$1.08

LEVOTHYROXINE 112 MCG TABLET

Facility

$167.09

Service Code	NDC 68180097009
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$65.67
Max. Negotiated Rate	$150.38
Rate for Payer: Aetna Commercial	$142.03
Rate for Payer: Aetna Medicare	$83.55
Rate for Payer: Aetna New Business (MI Preferred)	$108.61
Rate for Payer: BCBS Complete	$66.84
Rate for Payer: Cash Price	$133.67
Rate for Payer: Cofinity Advantage	$116.96
Rate for Payer: Cofinity Commercial	$143.70
Rate for Payer: Encore Health Key Benefits Commercial	$133.67
Rate for Payer: Healthscope Commercial	$150.38
Rate for Payer: MI Amish Medical Board Commercial	$133.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$142.03
Rate for Payer: Opus (Opus Packaging Group) HMA	$125.32
Rate for Payer: PHP Commercial	$142.03
Rate for Payer: Priority Health SBD	$105.27
Rate for Payer: UHC All Payor (Choice/PPO)	$108.61
Rate for Payer: UHC Core	$87.05
Rate for Payer: UHC Exchange	$65.67

LEVOTHYROXINE 112 MCG TABLET

Facility

$475.00

Service Code	NDC 00904695461
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$299.25
Max. Negotiated Rate	$427.50
Rate for Payer: Aetna Commercial	$403.75
Rate for Payer: Aetna New Business (MI Preferred)	$308.75
Rate for Payer: Cash Price	$380.00
Rate for Payer: Cofinity Advantage	$332.50
Rate for Payer: Cofinity Commercial	$408.50
Rate for Payer: Encore Health Key Benefits Commercial	$380.00
Rate for Payer: Healthscope Commercial	$427.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$403.75
Rate for Payer: Opus (Opus Packaging Group) HMA	$356.25
Rate for Payer: PHP Commercial	$403.75
Rate for Payer: Priority Health SBD	$299.25

LEVOTHYROXINE 112 MCG TABLET

Facility

$389.88

Service Code	NDC 00378181177
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$245.62
Max. Negotiated Rate	$350.89
Rate for Payer: Aetna Commercial	$331.40
Rate for Payer: Aetna New Business (MI Preferred)	$253.42
Rate for Payer: Cash Price	$311.90
Rate for Payer: Cofinity Advantage	$272.92
Rate for Payer: Cofinity Commercial	$335.30
Rate for Payer: Encore Health Key Benefits Commercial	$311.90
Rate for Payer: Healthscope Commercial	$350.89
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$331.40
Rate for Payer: Opus (Opus Packaging Group) HMA	$292.41
Rate for Payer: PHP Commercial	$331.40
Rate for Payer: Priority Health SBD	$245.62

LEVOTHYROXINE 112 MCG TABLET

Facility

$274.56

Service Code	NDC 42292003920
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$107.90
Max. Negotiated Rate	$247.10
Rate for Payer: Aetna Commercial	$233.38
Rate for Payer: Aetna Medicare	$137.28
Rate for Payer: Aetna New Business (MI Preferred)	$178.46
Rate for Payer: BCBS Complete	$109.82
Rate for Payer: Cash Price	$219.65
Rate for Payer: Cofinity Advantage	$192.19
Rate for Payer: Cofinity Commercial	$236.12
Rate for Payer: Encore Health Key Benefits Commercial	$219.65
Rate for Payer: Healthscope Commercial	$247.10
Rate for Payer: MI Amish Medical Board Commercial	$219.65
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$233.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$205.92
Rate for Payer: PHP Commercial	$233.38
Rate for Payer: Priority Health SBD	$172.97
Rate for Payer: UHC All Payor (Choice/PPO)	$178.46
Rate for Payer: UHC Core	$143.05
Rate for Payer: UHC Exchange	$107.90

LEVOTHYROXINE 125 MCG TABLET

Facility

$813.60

Service Code	NDC 00074706811
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$512.57
Max. Negotiated Rate	$732.24
Rate for Payer: Aetna Commercial	$691.56
Rate for Payer: Aetna New Business (MI Preferred)	$528.84
Rate for Payer: Cash Price	$650.88
Rate for Payer: Cofinity Advantage	$569.52
Rate for Payer: Cofinity Commercial	$699.70
Rate for Payer: Encore Health Key Benefits Commercial	$650.88
Rate for Payer: Healthscope Commercial	$732.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$691.56
Rate for Payer: Opus (Opus Packaging Group) HMA	$610.20
Rate for Payer: PHP Commercial	$691.56
Rate for Payer: Priority Health SBD	$512.57

LEVOTHYROXINE 125 MCG TABLET

Facility

$4,398.50

Service Code	NDC 00378181310
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$1,728.61
Max. Negotiated Rate	$3,958.65
Rate for Payer: Aetna Commercial	$3,738.72
Rate for Payer: Aetna Medicare	$2,199.25
Rate for Payer: Aetna New Business (MI Preferred)	$2,859.03
Rate for Payer: BCBS Complete	$1,759.40
Rate for Payer: Cash Price	$3,518.80
Rate for Payer: Cofinity Advantage	$3,078.95
Rate for Payer: Cofinity Commercial	$3,782.71
Rate for Payer: Encore Health Key Benefits Commercial	$3,518.80
Rate for Payer: Healthscope Commercial	$3,958.65
Rate for Payer: MI Amish Medical Board Commercial	$3,518.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,738.72
Rate for Payer: Opus (Opus Packaging Group) HMA	$3,298.88
Rate for Payer: PHP Commercial	$3,738.72
Rate for Payer: Priority Health SBD	$2,771.05
Rate for Payer: UHC All Payor (Choice/PPO)	$2,859.03
Rate for Payer: UHC Core	$2,291.62
Rate for Payer: UHC Exchange	$1,728.61

Know your out-of-pocket cost for care.

All Charges