Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 125 MCG TABLET

Facility

$309.60

Service Code	NDC 51079044320
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$195.05
Max. Negotiated Rate	$278.64
Rate for Payer: Aetna Commercial	$263.16
Rate for Payer: Aetna New Business (MI Preferred)	$201.24
Rate for Payer: Cash Price	$247.68
Rate for Payer: Cofinity Advantage	$216.72
Rate for Payer: Cofinity Commercial	$266.26
Rate for Payer: Encore Health Key Benefits Commercial	$247.68
Rate for Payer: Healthscope Commercial	$278.64
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$263.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$232.20
Rate for Payer: PHP Commercial	$263.16
Rate for Payer: Priority Health SBD	$195.05

LEVOTHYROXINE 125 MCG TABLET

Facility

$3.10

Service Code	NDC 51079044301
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$1.95
Max. Negotiated Rate	$2.79
Rate for Payer: Aetna Commercial	$2.63
Rate for Payer: Aetna New Business (MI Preferred)	$2.02
Rate for Payer: Cash Price	$2.48
Rate for Payer: Cofinity Advantage	$2.17
Rate for Payer: Cofinity Commercial	$2.67
Rate for Payer: Encore Health Key Benefits Commercial	$2.48
Rate for Payer: Healthscope Commercial	$2.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.33
Rate for Payer: PHP Commercial	$2.63
Rate for Payer: Priority Health SBD	$1.95

LEVOTHYROXINE 125 MCG TABLET

Facility

$3.10

Service Code	NDC 51079044301
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$2.79
Rate for Payer: Aetna Commercial	$2.63
Rate for Payer: Aetna Medicare	$1.55
Rate for Payer: Aetna New Business (MI Preferred)	$2.02
Rate for Payer: BCBS Complete	$1.24
Rate for Payer: Cash Price	$2.48
Rate for Payer: Cofinity Advantage	$2.17
Rate for Payer: Cofinity Commercial	$2.67
Rate for Payer: Encore Health Key Benefits Commercial	$2.48
Rate for Payer: Healthscope Commercial	$2.79
Rate for Payer: MI Amish Medical Board Commercial	$2.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.33
Rate for Payer: PHP Commercial	$2.63
Rate for Payer: Priority Health SBD	$1.95
Rate for Payer: UHC All Payor (Choice/PPO)	$2.02
Rate for Payer: UHC Core	$1.62
Rate for Payer: UHC Exchange	$1.22

LEVOTHYROXINE 125 MCG TABLET

Facility

$466.45

Service Code	NDC 00904695561
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$293.86
Max. Negotiated Rate	$419.81
Rate for Payer: Aetna Commercial	$396.48
Rate for Payer: Aetna New Business (MI Preferred)	$303.19
Rate for Payer: Cash Price	$373.16
Rate for Payer: Cofinity Advantage	$326.51
Rate for Payer: Cofinity Commercial	$401.15
Rate for Payer: Encore Health Key Benefits Commercial	$373.16
Rate for Payer: Healthscope Commercial	$419.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$396.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$349.84
Rate for Payer: PHP Commercial	$396.48
Rate for Payer: Priority Health SBD	$293.86

LEVOTHYROXINE 125 MCG TABLET

Facility

$309.60

Service Code	NDC 51079044320
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$121.67
Max. Negotiated Rate	$278.64
Rate for Payer: Aetna Commercial	$263.16
Rate for Payer: Aetna Medicare	$154.80
Rate for Payer: Aetna New Business (MI Preferred)	$201.24
Rate for Payer: BCBS Complete	$123.84
Rate for Payer: Cash Price	$247.68
Rate for Payer: Cofinity Advantage	$216.72
Rate for Payer: Cofinity Commercial	$266.26
Rate for Payer: Encore Health Key Benefits Commercial	$247.68
Rate for Payer: Healthscope Commercial	$278.64
Rate for Payer: MI Amish Medical Board Commercial	$247.68
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$263.16
Rate for Payer: Opus (Opus Packaging Group) HMA	$232.20
Rate for Payer: PHP Commercial	$263.16
Rate for Payer: Priority Health SBD	$195.05
Rate for Payer: UHC All Payor (Choice/PPO)	$201.24
Rate for Payer: UHC Core	$161.30
Rate for Payer: UHC Exchange	$121.67

LEVOTHYROXINE 125 MCG TABLET

Facility

$466.45

Service Code	NDC 00904695561
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$183.31
Max. Negotiated Rate	$419.81
Rate for Payer: Aetna Commercial	$396.48
Rate for Payer: Aetna Medicare	$233.22
Rate for Payer: Aetna New Business (MI Preferred)	$303.19
Rate for Payer: BCBS Complete	$186.58
Rate for Payer: Cash Price	$373.16
Rate for Payer: Cofinity Advantage	$326.51
Rate for Payer: Cofinity Commercial	$401.15
Rate for Payer: Encore Health Key Benefits Commercial	$373.16
Rate for Payer: Healthscope Commercial	$419.81
Rate for Payer: MI Amish Medical Board Commercial	$373.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$396.48
Rate for Payer: Opus (Opus Packaging Group) HMA	$349.84
Rate for Payer: PHP Commercial	$396.48
Rate for Payer: Priority Health SBD	$293.86
Rate for Payer: UHC All Payor (Choice/PPO)	$303.19
Rate for Payer: UHC Core	$243.02
Rate for Payer: UHC Exchange	$183.31

LEVOTHYROXINE 125 MCG TABLET

Facility

$4,398.50

Service Code	NDC 00378181310
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$2,771.05
Max. Negotiated Rate	$3,958.65
Rate for Payer: Aetna Commercial	$3,738.72
Rate for Payer: Aetna New Business (MI Preferred)	$2,859.03
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: 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

LEVOTHYROXINE 125 MCG TABLET

Facility

$395.87

Service Code	NDC 00378181377
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$249.40
Max. Negotiated Rate	$356.28
Rate for Payer: Aetna Commercial	$336.49
Rate for Payer: Aetna New Business (MI Preferred)	$257.32
Rate for Payer: Cash Price	$316.70
Rate for Payer: Cofinity Advantage	$277.11
Rate for Payer: Cofinity Commercial	$340.45
Rate for Payer: Encore Health Key Benefits Commercial	$316.70
Rate for Payer: Healthscope Commercial	$356.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$336.49
Rate for Payer: Opus (Opus Packaging Group) HMA	$296.90
Rate for Payer: PHP Commercial	$336.49
Rate for Payer: Priority Health SBD	$249.40

LEVOTHYROXINE 125 MCG TABLET

Facility

$395.87

Service Code	NDC 00378181377
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$155.58
Max. Negotiated Rate	$356.28
Rate for Payer: Aetna Commercial	$336.49
Rate for Payer: Aetna Medicare	$197.94
Rate for Payer: Aetna New Business (MI Preferred)	$257.32
Rate for Payer: BCBS Complete	$158.35
Rate for Payer: Cash Price	$316.70
Rate for Payer: Cofinity Advantage	$277.11
Rate for Payer: Cofinity Commercial	$340.45
Rate for Payer: Encore Health Key Benefits Commercial	$316.70
Rate for Payer: Healthscope Commercial	$356.28
Rate for Payer: MI Amish Medical Board Commercial	$316.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$336.49
Rate for Payer: Opus (Opus Packaging Group) HMA	$296.90
Rate for Payer: PHP Commercial	$336.49
Rate for Payer: Priority Health SBD	$249.40
Rate for Payer: UHC All Payor (Choice/PPO)	$257.32
Rate for Payer: UHC Core	$206.25
Rate for Payer: UHC Exchange	$155.58

LEVOTHYROXINE 125 MCG TABLET

Facility

$813.60

Service Code	NDC 00074706811
Hospital Charge Code	4424
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 150 MCG TABLET

Facility

$3.19

Service Code	NDC 51079044501
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$2.01
Max. Negotiated Rate	$2.87
Rate for Payer: Aetna Commercial	$2.71
Rate for Payer: Aetna New Business (MI Preferred)	$2.07
Rate for Payer: Cash Price	$2.55
Rate for Payer: Cofinity Advantage	$2.23
Rate for Payer: Cofinity Commercial	$2.74
Rate for Payer: Encore Health Key Benefits Commercial	$2.55
Rate for Payer: Healthscope Commercial	$2.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.71
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.39
Rate for Payer: PHP Commercial	$2.71
Rate for Payer: Priority Health SBD	$2.01

LEVOTHYROXINE 150 MCG TABLET

Facility

$250.56

Service Code	NDC 00904695661
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$98.47
Max. Negotiated Rate	$225.50
Rate for Payer: Aetna Commercial	$212.98
Rate for Payer: Aetna Medicare	$125.28
Rate for Payer: Aetna New Business (MI Preferred)	$162.86
Rate for Payer: BCBS Complete	$100.22
Rate for Payer: Cash Price	$200.45
Rate for Payer: Cofinity Advantage	$175.39
Rate for Payer: Cofinity Commercial	$215.48
Rate for Payer: Encore Health Key Benefits Commercial	$200.45
Rate for Payer: Healthscope Commercial	$225.50
Rate for Payer: MI Amish Medical Board Commercial	$200.45
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$212.98
Rate for Payer: Opus (Opus Packaging Group) HMA	$187.92
Rate for Payer: PHP Commercial	$212.98
Rate for Payer: Priority Health SBD	$157.85
Rate for Payer: UHC All Payor (Choice/PPO)	$162.86
Rate for Payer: UHC Core	$130.54
Rate for Payer: UHC Exchange	$98.47

LEVOTHYROXINE 150 MCG TABLET

Facility

$101.52

Service Code	NDC 16729045515
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$39.90
Max. Negotiated Rate	$91.37
Rate for Payer: Aetna Commercial	$86.29
Rate for Payer: Aetna Medicare	$50.76
Rate for Payer: Aetna New Business (MI Preferred)	$65.99
Rate for Payer: BCBS Complete	$40.61
Rate for Payer: Cash Price	$81.22
Rate for Payer: Cofinity Advantage	$71.06
Rate for Payer: Cofinity Commercial	$87.31
Rate for Payer: Encore Health Key Benefits Commercial	$81.22
Rate for Payer: Healthscope Commercial	$91.37
Rate for Payer: MI Amish Medical Board Commercial	$81.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.29
Rate for Payer: Opus (Opus Packaging Group) HMA	$76.14
Rate for Payer: PHP Commercial	$86.29
Rate for Payer: Priority Health SBD	$63.96
Rate for Payer: UHC All Payor (Choice/PPO)	$65.99
Rate for Payer: UHC Core	$52.89
Rate for Payer: UHC Exchange	$39.90

LEVOTHYROXINE 150 MCG TABLET

Facility

$250.56

Service Code	NDC 00904695661
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$157.85
Max. Negotiated Rate	$225.50
Rate for Payer: Aetna Commercial	$212.98
Rate for Payer: Aetna New Business (MI Preferred)	$162.86
Rate for Payer: Cash Price	$200.45
Rate for Payer: Cofinity Advantage	$175.39
Rate for Payer: Cofinity Commercial	$215.48
Rate for Payer: Encore Health Key Benefits Commercial	$200.45
Rate for Payer: Healthscope Commercial	$225.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$212.98
Rate for Payer: Opus (Opus Packaging Group) HMA	$187.92
Rate for Payer: PHP Commercial	$212.98
Rate for Payer: Priority Health SBD	$157.85

LEVOTHYROXINE 150 MCG TABLET

Facility

$101.52

Service Code	NDC 16729045515
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$63.96
Max. Negotiated Rate	$91.37
Rate for Payer: Aetna Commercial	$86.29
Rate for Payer: Aetna New Business (MI Preferred)	$65.99
Rate for Payer: Cash Price	$81.22
Rate for Payer: Cofinity Advantage	$71.06
Rate for Payer: Cofinity Commercial	$87.31
Rate for Payer: Encore Health Key Benefits Commercial	$81.22
Rate for Payer: Healthscope Commercial	$91.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.29
Rate for Payer: Opus (Opus Packaging Group) HMA	$76.14
Rate for Payer: PHP Commercial	$86.29
Rate for Payer: Priority Health SBD	$63.96

LEVOTHYROXINE 150 MCG TABLET

Facility

$318.24

Service Code	NDC 51079044520
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$125.07
Max. Negotiated Rate	$286.42
Rate for Payer: Aetna Commercial	$270.50
Rate for Payer: Aetna Medicare	$159.12
Rate for Payer: Aetna New Business (MI Preferred)	$206.86
Rate for Payer: BCBS Complete	$127.30
Rate for Payer: Cash Price	$254.59
Rate for Payer: Cofinity Advantage	$222.77
Rate for Payer: Cofinity Commercial	$273.69
Rate for Payer: Encore Health Key Benefits Commercial	$254.59
Rate for Payer: Healthscope Commercial	$286.42
Rate for Payer: MI Amish Medical Board Commercial	$254.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$270.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$238.68
Rate for Payer: PHP Commercial	$270.50
Rate for Payer: Priority Health SBD	$200.49
Rate for Payer: UHC All Payor (Choice/PPO)	$206.86
Rate for Payer: UHC Core	$165.80
Rate for Payer: UHC Exchange	$125.07

LEVOTHYROXINE 150 MCG TABLET

Facility

$406.98

Service Code	NDC 00378181577
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$159.94
Max. Negotiated Rate	$366.28
Rate for Payer: Aetna Commercial	$345.93
Rate for Payer: Aetna Medicare	$203.49
Rate for Payer: Aetna New Business (MI Preferred)	$264.54
Rate for Payer: BCBS Complete	$162.79
Rate for Payer: Cash Price	$325.58
Rate for Payer: Cofinity Advantage	$284.89
Rate for Payer: Cofinity Commercial	$350.00
Rate for Payer: Encore Health Key Benefits Commercial	$325.58
Rate for Payer: Healthscope Commercial	$366.28
Rate for Payer: MI Amish Medical Board Commercial	$325.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$345.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$305.24
Rate for Payer: PHP Commercial	$345.93
Rate for Payer: Priority Health SBD	$256.40
Rate for Payer: UHC All Payor (Choice/PPO)	$264.54
Rate for Payer: UHC Core	$212.04
Rate for Payer: UHC Exchange	$159.94

LEVOTHYROXINE 150 MCG TABLET

Facility

$406.98

Service Code	NDC 00378181577
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$256.40
Max. Negotiated Rate	$366.28
Rate for Payer: Aetna Commercial	$345.93
Rate for Payer: Aetna New Business (MI Preferred)	$264.54
Rate for Payer: Cash Price	$325.58
Rate for Payer: Cofinity Advantage	$284.89
Rate for Payer: Cofinity Commercial	$350.00
Rate for Payer: Encore Health Key Benefits Commercial	$325.58
Rate for Payer: Healthscope Commercial	$366.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$345.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$305.24
Rate for Payer: PHP Commercial	$345.93
Rate for Payer: Priority Health SBD	$256.40

LEVOTHYROXINE 150 MCG TABLET

Facility

$3.19

Service Code	NDC 51079044501
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$2.87
Rate for Payer: Aetna Commercial	$2.71
Rate for Payer: Aetna Medicare	$1.59
Rate for Payer: Aetna New Business (MI Preferred)	$2.07
Rate for Payer: BCBS Complete	$1.28
Rate for Payer: Cash Price	$2.55
Rate for Payer: Cofinity Advantage	$2.23
Rate for Payer: Cofinity Commercial	$2.74
Rate for Payer: Encore Health Key Benefits Commercial	$2.55
Rate for Payer: Healthscope Commercial	$2.87
Rate for Payer: MI Amish Medical Board Commercial	$2.55
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.71
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.39
Rate for Payer: PHP Commercial	$2.71
Rate for Payer: Priority Health SBD	$2.01
Rate for Payer: UHC All Payor (Choice/PPO)	$2.07
Rate for Payer: UHC Core	$1.66
Rate for Payer: UHC Exchange	$1.25

LEVOTHYROXINE 150 MCG TABLET

Facility

$318.24

Service Code	NDC 51079044520
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$200.49
Max. Negotiated Rate	$286.42
Rate for Payer: Aetna Commercial	$270.50
Rate for Payer: Aetna New Business (MI Preferred)	$206.86
Rate for Payer: Cash Price	$254.59
Rate for Payer: Cofinity Advantage	$222.77
Rate for Payer: Cofinity Commercial	$273.69
Rate for Payer: Encore Health Key Benefits Commercial	$254.59
Rate for Payer: Healthscope Commercial	$286.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$270.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$238.68
Rate for Payer: PHP Commercial	$270.50
Rate for Payer: Priority Health SBD	$200.49

LEVOTHYROXINE 175 MCG TABLET

Facility

$301.92

Service Code	NDC 00904695761
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$190.21
Max. Negotiated Rate	$271.73
Rate for Payer: Aetna Commercial	$256.63
Rate for Payer: Aetna New Business (MI Preferred)	$196.25
Rate for Payer: Cash Price	$241.54
Rate for Payer: Cofinity Advantage	$211.34
Rate for Payer: Cofinity Commercial	$259.65
Rate for Payer: Encore Health Key Benefits Commercial	$241.54
Rate for Payer: Healthscope Commercial	$271.73
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$256.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$226.44
Rate for Payer: PHP Commercial	$256.63
Rate for Payer: Priority Health SBD	$190.21

LEVOTHYROXINE 175 MCG TABLET

Facility

$301.92

Service Code	NDC 00904695761
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$118.65
Max. Negotiated Rate	$271.73
Rate for Payer: Aetna Commercial	$256.63
Rate for Payer: Aetna Medicare	$150.96
Rate for Payer: Aetna New Business (MI Preferred)	$196.25
Rate for Payer: BCBS Complete	$120.77
Rate for Payer: Cash Price	$241.54
Rate for Payer: Cofinity Advantage	$211.34
Rate for Payer: Cofinity Commercial	$259.65
Rate for Payer: Encore Health Key Benefits Commercial	$241.54
Rate for Payer: Healthscope Commercial	$271.73
Rate for Payer: MI Amish Medical Board Commercial	$241.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$256.63
Rate for Payer: Opus (Opus Packaging Group) HMA	$226.44
Rate for Payer: PHP Commercial	$256.63
Rate for Payer: Priority Health SBD	$190.21
Rate for Payer: UHC All Payor (Choice/PPO)	$196.25
Rate for Payer: UHC Core	$157.30
Rate for Payer: UHC Exchange	$118.65

LEVOTHYROXINE 175 MCG TABLET

Facility

$3.42

Service Code	NDC 42292004001
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$2.15
Max. Negotiated Rate	$3.08
Rate for Payer: Aetna Commercial	$2.91
Rate for Payer: Aetna New Business (MI Preferred)	$2.22
Rate for Payer: Cash Price	$2.74
Rate for Payer: Cofinity Advantage	$2.39
Rate for Payer: Cofinity Commercial	$2.94
Rate for Payer: Encore Health Key Benefits Commercial	$2.74
Rate for Payer: Healthscope Commercial	$3.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.56
Rate for Payer: PHP Commercial	$2.91
Rate for Payer: Priority Health SBD	$2.15

LEVOTHYROXINE 175 MCG TABLET

Facility

$341.76

Service Code	NDC 42292004020
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$215.31
Max. Negotiated Rate	$307.58
Rate for Payer: Aetna Commercial	$290.50
Rate for Payer: Aetna New Business (MI Preferred)	$222.14
Rate for Payer: Cash Price	$273.41
Rate for Payer: Cofinity Advantage	$239.23
Rate for Payer: Cofinity Commercial	$293.91
Rate for Payer: Encore Health Key Benefits Commercial	$273.41
Rate for Payer: Healthscope Commercial	$307.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$290.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$256.32
Rate for Payer: PHP Commercial	$290.50
Rate for Payer: Priority Health SBD	$215.31

LEVOTHYROXINE 175 MCG TABLET

Facility

$341.76

Service Code	NDC 42292004020
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$134.31
Max. Negotiated Rate	$307.58
Rate for Payer: Aetna Commercial	$290.50
Rate for Payer: Aetna Medicare	$170.88
Rate for Payer: Aetna New Business (MI Preferred)	$222.14
Rate for Payer: BCBS Complete	$136.70
Rate for Payer: Cash Price	$273.41
Rate for Payer: Cofinity Advantage	$239.23
Rate for Payer: Cofinity Commercial	$293.91
Rate for Payer: Encore Health Key Benefits Commercial	$273.41
Rate for Payer: Healthscope Commercial	$307.58
Rate for Payer: MI Amish Medical Board Commercial	$273.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$290.50
Rate for Payer: Opus (Opus Packaging Group) HMA	$256.32
Rate for Payer: PHP Commercial	$290.50
Rate for Payer: Priority Health SBD	$215.31
Rate for Payer: UHC All Payor (Choice/PPO)	$222.14
Rate for Payer: UHC Core	$178.06
Rate for Payer: UHC Exchange	$134.31

Know your out-of-pocket cost for care.

All Charges