Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 112 MCG TABLET

Facility

$521.76

Service Code	NDC 60793085501
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$328.71
Max. Negotiated Rate	$469.58
Rate for Payer: Aetna Commercial	$443.50
Rate for Payer: Aetna New Business (MI Preferred)	$339.14
Rate for Payer: Cash Price	$417.41
Rate for Payer: Cofinity Commercial	$365.23
Rate for Payer: Cofinity Commercial	$448.71
Rate for Payer: Cofinity Medicare Advantage	$365.23
Rate for Payer: Encore Health Key Benefits Commercial	$417.41
Rate for Payer: Healthscope Commercial	$469.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$443.50
Rate for Payer: PHP Commercial	$443.50
Rate for Payer: Priority Health Cigna Priority Health	$339.14
Rate for Payer: Priority Health SBD	$328.71

LEVOTHYROXINE 112 MCG TABLET

Facility

$292.80

Service Code	NDC 42292003920
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$117.12
Max. Negotiated Rate	$263.52
Rate for Payer: Aetna Commercial	$248.88
Rate for Payer: Aetna Medicare	$146.40
Rate for Payer: Aetna New Business (MI Preferred)	$190.32
Rate for Payer: BCBS Complete	$117.12
Rate for Payer: Cash Price	$234.24
Rate for Payer: Cofinity Commercial	$204.96
Rate for Payer: Cofinity Commercial	$251.81
Rate for Payer: Cofinity Medicare Advantage	$204.96
Rate for Payer: Encore Health Key Benefits Commercial	$234.24
Rate for Payer: Healthscope Commercial	$263.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$248.88
Rate for Payer: PHP Commercial	$248.88
Rate for Payer: Priority Health Cigna Priority Health	$190.32
Rate for Payer: Priority Health SBD	$184.46

LEVOTHYROXINE 112 MCG TABLET

Facility

$521.76

Service Code	NDC 60793085501
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$208.70
Max. Negotiated Rate	$469.58
Rate for Payer: Aetna Commercial	$443.50
Rate for Payer: Aetna Medicare	$260.88
Rate for Payer: Aetna New Business (MI Preferred)	$339.14
Rate for Payer: BCBS Complete	$208.70
Rate for Payer: Cash Price	$417.41
Rate for Payer: Cofinity Commercial	$365.23
Rate for Payer: Cofinity Commercial	$448.71
Rate for Payer: Cofinity Medicare Advantage	$365.23
Rate for Payer: Encore Health Key Benefits Commercial	$417.41
Rate for Payer: Healthscope Commercial	$469.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$443.50
Rate for Payer: PHP Commercial	$443.50
Rate for Payer: Priority Health Cigna Priority Health	$339.14
Rate for Payer: Priority Health SBD	$328.71

LEVOTHYROXINE 112 MCG TABLET

Facility

$389.88

Service Code	NDC 00378181177
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$155.95
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 Commercial	$272.92
Rate for Payer: Cofinity Commercial	$335.30
Rate for Payer: Cofinity Medicare Advantage	$272.92
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: PHP Commercial	$331.40
Rate for Payer: Priority Health Cigna Priority Health	$253.42
Rate for Payer: Priority Health SBD	$245.62

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 Commercial	$272.92
Rate for Payer: Cofinity Commercial	$335.30
Rate for Payer: Cofinity Medicare Advantage	$272.92
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: PHP Commercial	$331.40
Rate for Payer: Priority Health Cigna Priority Health	$253.42
Rate for Payer: Priority Health SBD	$245.62

LEVOTHYROXINE 112 MCG TABLET

Facility

$292.80

Service Code	NDC 42292003920
Hospital Charge Code	10404
Hospital Revenue Code	637
Min. Negotiated Rate	$184.46
Max. Negotiated Rate	$263.52
Rate for Payer: Aetna Commercial	$248.88
Rate for Payer: Aetna New Business (MI Preferred)	$190.32
Rate for Payer: Cash Price	$234.24
Rate for Payer: Cofinity Commercial	$204.96
Rate for Payer: Cofinity Commercial	$251.81
Rate for Payer: Cofinity Medicare Advantage	$204.96
Rate for Payer: Encore Health Key Benefits Commercial	$234.24
Rate for Payer: Healthscope Commercial	$263.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$248.88
Rate for Payer: PHP Commercial	$248.88
Rate for Payer: Priority Health Cigna Priority Health	$190.32
Rate for Payer: Priority Health SBD	$184.46

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 Commercial	$3,078.95
Rate for Payer: Cofinity Commercial	$3,782.71
Rate for Payer: Cofinity Medicare Advantage	$3,078.95
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: PHP Commercial	$3,738.72
Rate for Payer: Priority Health Cigna Priority Health	$2,859.03
Rate for Payer: Priority Health SBD	$2,771.05

LEVOTHYROXINE 125 MCG TABLET

Facility

$330.24

Service Code	NDC 51079044320
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$132.10
Max. Negotiated Rate	$297.22
Rate for Payer: Aetna Commercial	$280.70
Rate for Payer: Aetna Medicare	$165.12
Rate for Payer: Aetna New Business (MI Preferred)	$214.66
Rate for Payer: BCBS Complete	$132.10
Rate for Payer: Cash Price	$264.19
Rate for Payer: Cofinity Commercial	$231.17
Rate for Payer: Cofinity Commercial	$284.01
Rate for Payer: Cofinity Medicare Advantage	$231.17
Rate for Payer: Encore Health Key Benefits Commercial	$264.19
Rate for Payer: Healthscope Commercial	$297.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$280.70
Rate for Payer: PHP Commercial	$280.70
Rate for Payer: Priority Health Cigna Priority Health	$214.66
Rate for Payer: Priority Health SBD	$208.05

LEVOTHYROXINE 125 MCG TABLET

Facility

$774.72

Service Code	NDC 00074706811
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$309.89
Max. Negotiated Rate	$697.25
Rate for Payer: Aetna Commercial	$658.51
Rate for Payer: Aetna Medicare	$387.36
Rate for Payer: Aetna New Business (MI Preferred)	$503.57
Rate for Payer: BCBS Complete	$309.89
Rate for Payer: Cash Price	$619.78
Rate for Payer: Cofinity Commercial	$542.30
Rate for Payer: Cofinity Commercial	$666.26
Rate for Payer: Cofinity Medicare Advantage	$542.30
Rate for Payer: Encore Health Key Benefits Commercial	$619.78
Rate for Payer: Healthscope Commercial	$697.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$658.51
Rate for Payer: PHP Commercial	$658.51
Rate for Payer: Priority Health Cigna Priority Health	$503.57
Rate for Payer: Priority Health SBD	$488.07

LEVOTHYROXINE 125 MCG TABLET

Facility

$3.31

Service Code	NDC 51079044301
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna Commercial	$2.81
Rate for Payer: Aetna Medicare	$1.66
Rate for Payer: Aetna New Business (MI Preferred)	$2.15
Rate for Payer: BCBS Complete	$1.32
Rate for Payer: Cash Price	$2.65
Rate for Payer: Cofinity Commercial	$2.32
Rate for Payer: Cofinity Commercial	$2.85
Rate for Payer: Cofinity Medicare Advantage	$2.32
Rate for Payer: Encore Health Key Benefits Commercial	$2.65
Rate for Payer: Healthscope Commercial	$2.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.81
Rate for Payer: PHP Commercial	$2.81
Rate for Payer: Priority Health Cigna Priority Health	$2.15
Rate for Payer: Priority Health SBD	$2.09

LEVOTHYROXINE 125 MCG TABLET

Facility

$330.24

Service Code	NDC 51079044320
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$208.05
Max. Negotiated Rate	$297.22
Rate for Payer: Aetna Commercial	$280.70
Rate for Payer: Aetna New Business (MI Preferred)	$214.66
Rate for Payer: Cash Price	$264.19
Rate for Payer: Cofinity Commercial	$231.17
Rate for Payer: Cofinity Commercial	$284.01
Rate for Payer: Cofinity Medicare Advantage	$231.17
Rate for Payer: Encore Health Key Benefits Commercial	$264.19
Rate for Payer: Healthscope Commercial	$297.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$280.70
Rate for Payer: PHP Commercial	$280.70
Rate for Payer: Priority Health Cigna Priority Health	$214.66
Rate for Payer: Priority Health SBD	$208.05

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 Commercial	$326.51
Rate for Payer: Cofinity Commercial	$401.15
Rate for Payer: Cofinity Medicare Advantage	$326.51
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: PHP Commercial	$396.48
Rate for Payer: Priority Health Cigna Priority Health	$303.19
Rate for Payer: Priority Health SBD	$293.86

LEVOTHYROXINE 125 MCG TABLET

Facility

$4,398.50

Service Code	NDC 00378181310
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$1,759.40
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 Commercial	$3,078.95
Rate for Payer: Cofinity Commercial	$3,782.71
Rate for Payer: Cofinity Medicare Advantage	$3,078.95
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: PHP Commercial	$3,738.72
Rate for Payer: Priority Health Cigna Priority Health	$2,859.03
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 Commercial	$277.11
Rate for Payer: Cofinity Commercial	$340.45
Rate for Payer: Cofinity Medicare Advantage	$277.11
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: PHP Commercial	$336.49
Rate for Payer: Priority Health Cigna Priority Health	$257.32
Rate for Payer: Priority Health SBD	$249.40

LEVOTHYROXINE 125 MCG TABLET

Facility

$466.45

Service Code	NDC 00904695561
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$186.58
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 Commercial	$326.51
Rate for Payer: Cofinity Commercial	$401.15
Rate for Payer: Cofinity Medicare Advantage	$326.51
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: PHP Commercial	$396.48
Rate for Payer: Priority Health Cigna Priority Health	$303.19
Rate for Payer: Priority Health SBD	$293.86

LEVOTHYROXINE 125 MCG TABLET

Facility

$774.72

Service Code	NDC 00074706811
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$488.07
Max. Negotiated Rate	$697.25
Rate for Payer: Aetna Commercial	$658.51
Rate for Payer: Aetna New Business (MI Preferred)	$503.57
Rate for Payer: Cash Price	$619.78
Rate for Payer: Cofinity Commercial	$542.30
Rate for Payer: Cofinity Commercial	$666.26
Rate for Payer: Cofinity Medicare Advantage	$542.30
Rate for Payer: Encore Health Key Benefits Commercial	$619.78
Rate for Payer: Healthscope Commercial	$697.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$658.51
Rate for Payer: PHP Commercial	$658.51
Rate for Payer: Priority Health Cigna Priority Health	$503.57
Rate for Payer: Priority Health SBD	$488.07

LEVOTHYROXINE 125 MCG TABLET

Facility

$3.31

Service Code	NDC 51079044301
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna Commercial	$2.81
Rate for Payer: Aetna New Business (MI Preferred)	$2.15
Rate for Payer: Cash Price	$2.65
Rate for Payer: Cofinity Commercial	$2.32
Rate for Payer: Cofinity Commercial	$2.85
Rate for Payer: Cofinity Medicare Advantage	$2.32
Rate for Payer: Encore Health Key Benefits Commercial	$2.65
Rate for Payer: Healthscope Commercial	$2.98
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.81
Rate for Payer: PHP Commercial	$2.81
Rate for Payer: Priority Health Cigna Priority Health	$2.15
Rate for Payer: Priority Health SBD	$2.09

LEVOTHYROXINE 125 MCG TABLET

Facility

$395.87

Service Code	NDC 00378181377
Hospital Charge Code	4424
Hospital Revenue Code	637
Min. Negotiated Rate	$158.35
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 Commercial	$277.11
Rate for Payer: Cofinity Commercial	$340.45
Rate for Payer: Cofinity Medicare Advantage	$277.11
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: PHP Commercial	$336.49
Rate for Payer: Priority Health Cigna Priority Health	$257.32
Rate for Payer: Priority Health SBD	$249.40

LEVOTHYROXINE 150 MCG TABLET

Facility

$3.40

Service Code	NDC 51079044501
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$3.06
Rate for Payer: Aetna Commercial	$2.89
Rate for Payer: Aetna Medicare	$1.70
Rate for Payer: Aetna New Business (MI Preferred)	$2.21
Rate for Payer: BCBS Complete	$1.36
Rate for Payer: Cash Price	$2.72
Rate for Payer: Cofinity Commercial	$2.38
Rate for Payer: Cofinity Commercial	$2.92
Rate for Payer: Cofinity Medicare Advantage	$2.38
Rate for Payer: Encore Health Key Benefits Commercial	$2.72
Rate for Payer: Healthscope Commercial	$3.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.89
Rate for Payer: PHP Commercial	$2.89
Rate for Payer: Priority Health Cigna Priority Health	$2.21
Rate for Payer: Priority Health SBD	$2.14

LEVOTHYROXINE 150 MCG TABLET

Facility

$339.36

Service Code	NDC 51079044520
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$213.80
Max. Negotiated Rate	$305.42
Rate for Payer: Aetna Commercial	$288.46
Rate for Payer: Aetna New Business (MI Preferred)	$220.58
Rate for Payer: Cash Price	$271.49
Rate for Payer: Cofinity Commercial	$237.55
Rate for Payer: Cofinity Commercial	$291.85
Rate for Payer: Cofinity Medicare Advantage	$237.55
Rate for Payer: Encore Health Key Benefits Commercial	$271.49
Rate for Payer: Healthscope Commercial	$305.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$288.46
Rate for Payer: PHP Commercial	$288.46
Rate for Payer: Priority Health Cigna Priority Health	$220.58
Rate for Payer: Priority Health SBD	$213.80

LEVOTHYROXINE 150 MCG TABLET

Facility

$3.40

Service Code	NDC 51079044501
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$3.06
Rate for Payer: Aetna Commercial	$2.89
Rate for Payer: Aetna New Business (MI Preferred)	$2.21
Rate for Payer: Cash Price	$2.72
Rate for Payer: Cofinity Commercial	$2.38
Rate for Payer: Cofinity Commercial	$2.92
Rate for Payer: Cofinity Medicare Advantage	$2.38
Rate for Payer: Encore Health Key Benefits Commercial	$2.72
Rate for Payer: Healthscope Commercial	$3.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.89
Rate for Payer: PHP Commercial	$2.89
Rate for Payer: Priority Health Cigna Priority Health	$2.21
Rate for Payer: Priority Health SBD	$2.14

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 Commercial	$284.89
Rate for Payer: Cofinity Commercial	$350.00
Rate for Payer: Cofinity Medicare Advantage	$284.89
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: PHP Commercial	$345.93
Rate for Payer: Priority Health Cigna Priority Health	$264.54
Rate for Payer: Priority Health SBD	$256.40

LEVOTHYROXINE 150 MCG TABLET

Facility

$406.98

Service Code	NDC 00378181577
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$162.79
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 Commercial	$284.89
Rate for Payer: Cofinity Commercial	$350.00
Rate for Payer: Cofinity Medicare Advantage	$284.89
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: PHP Commercial	$345.93
Rate for Payer: Priority Health Cigna Priority Health	$264.54
Rate for Payer: Priority Health SBD	$256.40

LEVOTHYROXINE 150 MCG TABLET

Facility

$339.36

Service Code	NDC 51079044520
Hospital Charge Code	4425
Hospital Revenue Code	637
Min. Negotiated Rate	$135.74
Max. Negotiated Rate	$305.42
Rate for Payer: Aetna Commercial	$288.46
Rate for Payer: Aetna Medicare	$169.68
Rate for Payer: Aetna New Business (MI Preferred)	$220.58
Rate for Payer: BCBS Complete	$135.74
Rate for Payer: Cash Price	$271.49
Rate for Payer: Cofinity Commercial	$237.55
Rate for Payer: Cofinity Commercial	$291.85
Rate for Payer: Cofinity Medicare Advantage	$237.55
Rate for Payer: Encore Health Key Benefits Commercial	$271.49
Rate for Payer: Healthscope Commercial	$305.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$288.46
Rate for Payer: PHP Commercial	$288.46
Rate for Payer: Priority Health Cigna Priority Health	$220.58
Rate for Payer: Priority Health SBD	$213.80

LEVOTHYROXINE 175 MCG TABLET

Facility

$3.65

Service Code	NDC 42292004001
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$3.29
Rate for Payer: Aetna Commercial	$3.10
Rate for Payer: Aetna New Business (MI Preferred)	$2.37
Rate for Payer: Cash Price	$2.92
Rate for Payer: Cofinity Commercial	$2.56
Rate for Payer: Cofinity Commercial	$3.14
Rate for Payer: Cofinity Medicare Advantage	$2.56
Rate for Payer: Encore Health Key Benefits Commercial	$2.92
Rate for Payer: Healthscope Commercial	$3.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.10
Rate for Payer: PHP Commercial	$3.10
Rate for Payer: Priority Health Cigna Priority Health	$2.37
Rate for Payer: Priority Health SBD	$2.30

Know your out-of-pocket cost for care.

All Charges