Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 175 MCG TABLET

Facility

$3.32

Service Code	NDC 60687054111
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$2.99
Rate for Payer: Aetna Commercial	$2.82
Rate for Payer: Aetna New Business (MI Preferred)	$2.16
Rate for Payer: Cash Price	$2.66
Rate for Payer: Cofinity Advantage	$2.32
Rate for Payer: Cofinity Commercial	$2.86
Rate for Payer: Encore Health Key Benefits Commercial	$2.66
Rate for Payer: Healthscope Commercial	$2.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.82
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.49
Rate for Payer: PHP Commercial	$2.82
Rate for Payer: Priority Health SBD	$2.09

LEVOTHYROXINE 175 MCG TABLET

Facility

$3.32

Service Code	NDC 60687054111
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$1.30
Max. Negotiated Rate	$2.99
Rate for Payer: Aetna Commercial	$2.82
Rate for Payer: Aetna Medicare	$1.66
Rate for Payer: Aetna New Business (MI Preferred)	$2.16
Rate for Payer: BCBS Complete	$1.33
Rate for Payer: Cash Price	$2.66
Rate for Payer: Cofinity Advantage	$2.32
Rate for Payer: Cofinity Commercial	$2.86
Rate for Payer: Encore Health Key Benefits Commercial	$2.66
Rate for Payer: Healthscope Commercial	$2.99
Rate for Payer: MI Amish Medical Board Commercial	$2.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.82
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.49
Rate for Payer: PHP Commercial	$2.82
Rate for Payer: Priority Health SBD	$2.09
Rate for Payer: UHC All Payor (Choice/PPO)	$2.16
Rate for Payer: UHC Core	$1.73
Rate for Payer: UHC Exchange	$1.30

LEVOTHYROXINE 175 MCG TABLET

Facility

$3.42

Service Code	NDC 42292004001
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$1.34
Max. Negotiated Rate	$3.08
Rate for Payer: Aetna Commercial	$2.91
Rate for Payer: Aetna Medicare	$1.71
Rate for Payer: Aetna New Business (MI Preferred)	$2.22
Rate for Payer: BCBS Complete	$1.37
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: MI Amish Medical Board Commercial	$2.74
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
Rate for Payer: UHC All Payor (Choice/PPO)	$2.22
Rate for Payer: UHC Core	$1.78
Rate for Payer: UHC Exchange	$1.34

LEVOTHYROXINE 175 MCG TABLET

Facility

$331.68

Service Code	NDC 60687054101
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$208.96
Max. Negotiated Rate	$298.51
Rate for Payer: Aetna Commercial	$281.93
Rate for Payer: Aetna New Business (MI Preferred)	$215.59
Rate for Payer: Cash Price	$265.34
Rate for Payer: Cofinity Advantage	$232.18
Rate for Payer: Cofinity Commercial	$285.24
Rate for Payer: Encore Health Key Benefits Commercial	$265.34
Rate for Payer: Healthscope Commercial	$298.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$281.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$248.76
Rate for Payer: PHP Commercial	$281.93
Rate for Payer: Priority Health SBD	$208.96

LEVOTHYROXINE 175 MCG TABLET

Facility

$331.68

Service Code	NDC 60687054101
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$130.35
Max. Negotiated Rate	$298.51
Rate for Payer: Aetna Commercial	$281.93
Rate for Payer: Aetna Medicare	$165.84
Rate for Payer: Aetna New Business (MI Preferred)	$215.59
Rate for Payer: BCBS Complete	$132.67
Rate for Payer: Cash Price	$265.34
Rate for Payer: Cofinity Advantage	$232.18
Rate for Payer: Cofinity Commercial	$285.24
Rate for Payer: Encore Health Key Benefits Commercial	$265.34
Rate for Payer: Healthscope Commercial	$298.51
Rate for Payer: MI Amish Medical Board Commercial	$265.34
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$281.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$248.76
Rate for Payer: PHP Commercial	$281.93
Rate for Payer: Priority Health SBD	$208.96
Rate for Payer: UHC All Payor (Choice/PPO)	$215.59
Rate for Payer: UHC Core	$172.81
Rate for Payer: UHC Exchange	$130.35

LEVOTHYROXINE 25 MCG TABLET

Facility

$319.20

Service Code	NDC 00904694961
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$125.45
Max. Negotiated Rate	$287.28
Rate for Payer: Aetna Commercial	$271.32
Rate for Payer: Aetna Medicare	$159.60
Rate for Payer: Aetna New Business (MI Preferred)	$207.48
Rate for Payer: BCBS Complete	$127.68
Rate for Payer: Cash Price	$255.36
Rate for Payer: Cofinity Advantage	$223.44
Rate for Payer: Cofinity Commercial	$274.51
Rate for Payer: Encore Health Key Benefits Commercial	$255.36
Rate for Payer: Healthscope Commercial	$287.28
Rate for Payer: MI Amish Medical Board Commercial	$255.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$271.32
Rate for Payer: Opus (Opus Packaging Group) HMA	$239.40
Rate for Payer: PHP Commercial	$271.32
Rate for Payer: Priority Health SBD	$201.10
Rate for Payer: UHC All Payor (Choice/PPO)	$207.48
Rate for Payer: UHC Core	$166.30
Rate for Payer: UHC Exchange	$125.45

LEVOTHYROXINE 25 MCG TABLET

Facility

$4.03

Service Code	NDC 51079044401
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$2.54
Max. Negotiated Rate	$3.63
Rate for Payer: Aetna Commercial	$3.43
Rate for Payer: Aetna New Business (MI Preferred)	$2.62
Rate for Payer: Cash Price	$3.22
Rate for Payer: Cofinity Advantage	$2.82
Rate for Payer: Cofinity Commercial	$3.47
Rate for Payer: Encore Health Key Benefits Commercial	$3.22
Rate for Payer: Healthscope Commercial	$3.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.02
Rate for Payer: PHP Commercial	$3.43
Rate for Payer: Priority Health SBD	$2.54

LEVOTHYROXINE 25 MCG TABLET

Facility

$402.80

Service Code	NDC 51079044420
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$253.76
Max. Negotiated Rate	$362.52
Rate for Payer: Aetna Commercial	$342.38
Rate for Payer: Aetna New Business (MI Preferred)	$261.82
Rate for Payer: Cash Price	$322.24
Rate for Payer: Cofinity Advantage	$281.96
Rate for Payer: Cofinity Commercial	$346.41
Rate for Payer: Encore Health Key Benefits Commercial	$322.24
Rate for Payer: Healthscope Commercial	$362.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$342.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$302.10
Rate for Payer: PHP Commercial	$342.38
Rate for Payer: Priority Health SBD	$253.76

LEVOTHYROXINE 25 MCG TABLET

Facility

$402.80

Service Code	NDC 51079044420
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$158.30
Max. Negotiated Rate	$362.52
Rate for Payer: Aetna Commercial	$342.38
Rate for Payer: Aetna Medicare	$201.40
Rate for Payer: Aetna New Business (MI Preferred)	$261.82
Rate for Payer: BCBS Complete	$161.12
Rate for Payer: Cash Price	$322.24
Rate for Payer: Cofinity Advantage	$281.96
Rate for Payer: Cofinity Commercial	$346.41
Rate for Payer: Encore Health Key Benefits Commercial	$322.24
Rate for Payer: Healthscope Commercial	$362.52
Rate for Payer: MI Amish Medical Board Commercial	$322.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$342.38
Rate for Payer: Opus (Opus Packaging Group) HMA	$302.10
Rate for Payer: PHP Commercial	$342.38
Rate for Payer: Priority Health SBD	$253.76
Rate for Payer: UHC All Payor (Choice/PPO)	$261.82
Rate for Payer: UHC Core	$209.86
Rate for Payer: UHC Exchange	$158.30

LEVOTHYROXINE 25 MCG TABLET

Facility

$262.49

Service Code	NDC 00378180077
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$165.37
Max. Negotiated Rate	$236.24
Rate for Payer: Aetna Commercial	$223.12
Rate for Payer: Aetna New Business (MI Preferred)	$170.62
Rate for Payer: Cash Price	$209.99
Rate for Payer: Cofinity Advantage	$183.74
Rate for Payer: Cofinity Commercial	$225.74
Rate for Payer: Encore Health Key Benefits Commercial	$209.99
Rate for Payer: Healthscope Commercial	$236.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$223.12
Rate for Payer: Opus (Opus Packaging Group) HMA	$196.87
Rate for Payer: PHP Commercial	$223.12
Rate for Payer: Priority Health SBD	$165.37

LEVOTHYROXINE 25 MCG TABLET

Facility

$319.20

Service Code	NDC 00904694961
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$201.10
Max. Negotiated Rate	$287.28
Rate for Payer: Aetna Commercial	$271.32
Rate for Payer: Aetna New Business (MI Preferred)	$207.48
Rate for Payer: Cash Price	$255.36
Rate for Payer: Cofinity Advantage	$223.44
Rate for Payer: Cofinity Commercial	$274.51
Rate for Payer: Encore Health Key Benefits Commercial	$255.36
Rate for Payer: Healthscope Commercial	$287.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$271.32
Rate for Payer: Opus (Opus Packaging Group) HMA	$239.40
Rate for Payer: PHP Commercial	$271.32
Rate for Payer: Priority Health SBD	$201.10

LEVOTHYROXINE 25 MCG TABLET

Facility

$3.51

Service Code	NDC 60687045311
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$3.16
Rate for Payer: Aetna Commercial	$2.98
Rate for Payer: Aetna Medicare	$1.75
Rate for Payer: Aetna New Business (MI Preferred)	$2.28
Rate for Payer: BCBS Complete	$1.40
Rate for Payer: Cash Price	$2.81
Rate for Payer: Cofinity Advantage	$2.46
Rate for Payer: Cofinity Commercial	$3.02
Rate for Payer: Encore Health Key Benefits Commercial	$2.81
Rate for Payer: Healthscope Commercial	$3.16
Rate for Payer: MI Amish Medical Board Commercial	$2.81
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.98
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.63
Rate for Payer: PHP Commercial	$2.98
Rate for Payer: Priority Health SBD	$2.21
Rate for Payer: UHC All Payor (Choice/PPO)	$2.28
Rate for Payer: UHC Core	$1.83
Rate for Payer: UHC Exchange	$1.38

LEVOTHYROXINE 25 MCG TABLET

Facility

$3.51

Service Code	NDC 60687045311
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$2.21
Max. Negotiated Rate	$3.16
Rate for Payer: Aetna Commercial	$2.98
Rate for Payer: Aetna New Business (MI Preferred)	$2.28
Rate for Payer: Cash Price	$2.81
Rate for Payer: Cofinity Advantage	$2.46
Rate for Payer: Cofinity Commercial	$3.02
Rate for Payer: Encore Health Key Benefits Commercial	$2.81
Rate for Payer: Healthscope Commercial	$3.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.98
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.63
Rate for Payer: PHP Commercial	$2.98
Rate for Payer: Priority Health SBD	$2.21

LEVOTHYROXINE 25 MCG TABLET

Facility

$350.55

Service Code	NDC 60687045301
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$137.77
Max. Negotiated Rate	$315.50
Rate for Payer: Aetna Commercial	$297.97
Rate for Payer: Aetna Medicare	$175.28
Rate for Payer: Aetna New Business (MI Preferred)	$227.86
Rate for Payer: BCBS Complete	$140.22
Rate for Payer: Cash Price	$280.44
Rate for Payer: Cofinity Advantage	$245.38
Rate for Payer: Cofinity Commercial	$301.47
Rate for Payer: Encore Health Key Benefits Commercial	$280.44
Rate for Payer: Healthscope Commercial	$315.50
Rate for Payer: MI Amish Medical Board Commercial	$280.44
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$297.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$262.91
Rate for Payer: PHP Commercial	$297.97
Rate for Payer: Priority Health SBD	$220.85
Rate for Payer: UHC All Payor (Choice/PPO)	$227.86
Rate for Payer: UHC Core	$182.64
Rate for Payer: UHC Exchange	$137.77

LEVOTHYROXINE 25 MCG TABLET

Facility

$350.55

Service Code	NDC 60687045301
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$220.85
Max. Negotiated Rate	$315.50
Rate for Payer: Aetna Commercial	$297.97
Rate for Payer: Aetna New Business (MI Preferred)	$227.86
Rate for Payer: Cash Price	$280.44
Rate for Payer: Cofinity Advantage	$245.38
Rate for Payer: Cofinity Commercial	$301.47
Rate for Payer: Encore Health Key Benefits Commercial	$280.44
Rate for Payer: Healthscope Commercial	$315.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$297.97
Rate for Payer: Opus (Opus Packaging Group) HMA	$262.91
Rate for Payer: PHP Commercial	$297.97
Rate for Payer: Priority Health SBD	$220.85

LEVOTHYROXINE 25 MCG TABLET

Facility

$262.49

Service Code	NDC 00378180077
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$103.16
Max. Negotiated Rate	$236.24
Rate for Payer: Aetna Commercial	$223.12
Rate for Payer: Aetna Medicare	$131.25
Rate for Payer: Aetna New Business (MI Preferred)	$170.62
Rate for Payer: BCBS Complete	$105.00
Rate for Payer: Cash Price	$209.99
Rate for Payer: Cofinity Advantage	$183.74
Rate for Payer: Cofinity Commercial	$225.74
Rate for Payer: Encore Health Key Benefits Commercial	$209.99
Rate for Payer: Healthscope Commercial	$236.24
Rate for Payer: MI Amish Medical Board Commercial	$209.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$223.12
Rate for Payer: Opus (Opus Packaging Group) HMA	$196.87
Rate for Payer: PHP Commercial	$223.12
Rate for Payer: Priority Health SBD	$165.37
Rate for Payer: UHC All Payor (Choice/PPO)	$170.62
Rate for Payer: UHC Core	$136.76
Rate for Payer: UHC Exchange	$103.16

LEVOTHYROXINE 25 MCG TABLET

Facility

$101.52

Service Code	NDC 68180096509
Hospital Charge Code	4420
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 25 MCG TABLET

Facility

$101.52

Service Code	NDC 68180096509
Hospital Charge Code	4420
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 25 MCG TABLET

Facility

$4.03

Service Code	NDC 51079044401
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$3.63
Rate for Payer: Aetna Commercial	$3.43
Rate for Payer: Aetna Medicare	$2.02
Rate for Payer: Aetna New Business (MI Preferred)	$2.62
Rate for Payer: BCBS Complete	$1.61
Rate for Payer: Cash Price	$3.22
Rate for Payer: Cofinity Advantage	$2.82
Rate for Payer: Cofinity Commercial	$3.47
Rate for Payer: Encore Health Key Benefits Commercial	$3.22
Rate for Payer: Healthscope Commercial	$3.63
Rate for Payer: MI Amish Medical Board Commercial	$3.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.02
Rate for Payer: PHP Commercial	$3.43
Rate for Payer: Priority Health SBD	$2.54
Rate for Payer: UHC All Payor (Choice/PPO)	$2.62
Rate for Payer: UHC Core	$2.10
Rate for Payer: UHC Exchange	$1.58

LEVOTHYROXINE 50 MCG TABLET

Facility

$297.54

Service Code	NDC 00378180377
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$116.93
Max. Negotiated Rate	$267.79
Rate for Payer: Aetna Commercial	$252.91
Rate for Payer: Aetna Medicare	$148.77
Rate for Payer: Aetna New Business (MI Preferred)	$193.40
Rate for Payer: BCBS Complete	$119.02
Rate for Payer: Cash Price	$238.03
Rate for Payer: Cofinity Advantage	$208.28
Rate for Payer: Cofinity Commercial	$255.88
Rate for Payer: Encore Health Key Benefits Commercial	$238.03
Rate for Payer: Healthscope Commercial	$267.79
Rate for Payer: MI Amish Medical Board Commercial	$238.03
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$252.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$223.16
Rate for Payer: PHP Commercial	$252.91
Rate for Payer: Priority Health SBD	$187.45
Rate for Payer: UHC All Payor (Choice/PPO)	$193.40
Rate for Payer: UHC Core	$155.02
Rate for Payer: UHC Exchange	$116.93

LEVOTHYROXINE 50 MCG TABLET

Facility

$457.90

Service Code	NDC 51079044020
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$288.48
Max. Negotiated Rate	$412.11
Rate for Payer: Aetna Commercial	$389.21
Rate for Payer: Aetna New Business (MI Preferred)	$297.63
Rate for Payer: Cash Price	$366.32
Rate for Payer: Cofinity Advantage	$320.53
Rate for Payer: Cofinity Commercial	$393.79
Rate for Payer: Encore Health Key Benefits Commercial	$366.32
Rate for Payer: Healthscope Commercial	$412.11
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$389.21
Rate for Payer: Opus (Opus Packaging Group) HMA	$343.43
Rate for Payer: PHP Commercial	$389.21
Rate for Payer: Priority Health SBD	$288.48

LEVOTHYROXINE 50 MCG TABLET

Facility

$3.57

Service Code	NDC 60687046411
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$2.25
Max. Negotiated Rate	$3.21
Rate for Payer: Aetna Commercial	$3.03
Rate for Payer: Aetna New Business (MI Preferred)	$2.32
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cofinity Advantage	$2.50
Rate for Payer: Cofinity Commercial	$3.07
Rate for Payer: Encore Health Key Benefits Commercial	$2.86
Rate for Payer: Healthscope Commercial	$3.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.03
Rate for Payer: Opus (Opus Packaging Group) HMA	$2.68
Rate for Payer: PHP Commercial	$3.03
Rate for Payer: Priority Health SBD	$2.25

LEVOTHYROXINE 50 MCG TABLET

Facility

$80.37

Service Code	NDC 16729044815
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$50.63
Max. Negotiated Rate	$72.33
Rate for Payer: Aetna Commercial	$68.31
Rate for Payer: Aetna New Business (MI Preferred)	$52.24
Rate for Payer: Cash Price	$64.30
Rate for Payer: Cofinity Advantage	$56.26
Rate for Payer: Cofinity Commercial	$69.12
Rate for Payer: Encore Health Key Benefits Commercial	$64.30
Rate for Payer: Healthscope Commercial	$72.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$68.31
Rate for Payer: Opus (Opus Packaging Group) HMA	$60.28
Rate for Payer: PHP Commercial	$68.31
Rate for Payer: Priority Health SBD	$50.63

LEVOTHYROXINE 50 MCG TABLET

Facility

$732.24

Service Code	NDC 00074455290
Hospital Charge Code	4421
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 50 MCG TABLET

Facility

$4.58

Service Code	NDC 51079044001
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$2.89
Max. Negotiated Rate	$4.12
Rate for Payer: Aetna Commercial	$3.89
Rate for Payer: Aetna New Business (MI Preferred)	$2.98
Rate for Payer: Cash Price	$3.66
Rate for Payer: Cofinity Advantage	$3.21
Rate for Payer: Cofinity Commercial	$3.94
Rate for Payer: Encore Health Key Benefits Commercial	$3.66
Rate for Payer: Healthscope Commercial	$4.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.89
Rate for Payer: Opus (Opus Packaging Group) HMA	$3.44
Rate for Payer: PHP Commercial	$3.89
Rate for Payer: Priority Health SBD	$2.89

Know your out-of-pocket cost for care.

All Charges