Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 175 MCG TABLET

Facility

$3.65

Service Code	NDC 42292004001
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$3.29
Rate for Payer: Aetna Commercial	$3.10
Rate for Payer: Aetna Medicare	$1.82
Rate for Payer: Aetna New Business (MI Preferred)	$2.37
Rate for Payer: BCBS Complete	$1.46
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

LEVOTHYROXINE 175 MCG TABLET

Facility

$364.80

Service Code	NDC 42292004020
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$229.82
Max. Negotiated Rate	$328.32
Rate for Payer: Aetna Commercial	$310.08
Rate for Payer: Aetna New Business (MI Preferred)	$237.12
Rate for Payer: Cash Price	$291.84
Rate for Payer: Cofinity Commercial	$255.36
Rate for Payer: Cofinity Commercial	$313.73
Rate for Payer: Cofinity Medicare Advantage	$255.36
Rate for Payer: Encore Health Key Benefits Commercial	$291.84
Rate for Payer: Healthscope Commercial	$328.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$310.08
Rate for Payer: PHP Commercial	$310.08
Rate for Payer: Priority Health Cigna Priority Health	$237.12
Rate for Payer: Priority Health SBD	$229.82

LEVOTHYROXINE 175 MCG TABLET

Facility

$364.80

Service Code	NDC 42292004020
Hospital Charge Code	10406
Hospital Revenue Code	637
Min. Negotiated Rate	$145.92
Max. Negotiated Rate	$328.32
Rate for Payer: Aetna Commercial	$310.08
Rate for Payer: Aetna Medicare	$182.40
Rate for Payer: Aetna New Business (MI Preferred)	$237.12
Rate for Payer: BCBS Complete	$145.92
Rate for Payer: Cash Price	$291.84
Rate for Payer: Cofinity Commercial	$255.36
Rate for Payer: Cofinity Commercial	$313.73
Rate for Payer: Cofinity Medicare Advantage	$255.36
Rate for Payer: Encore Health Key Benefits Commercial	$291.84
Rate for Payer: Healthscope Commercial	$328.32
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$310.08
Rate for Payer: PHP Commercial	$310.08
Rate for Payer: Priority Health Cigna Priority Health	$237.12
Rate for Payer: Priority Health SBD	$229.82

LEVOTHYROXINE 25 MCG TABLET

Facility

$344.85

Service Code	NDC 60687045301
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$217.26
Max. Negotiated Rate	$310.37
Rate for Payer: Aetna Commercial	$293.12
Rate for Payer: Aetna New Business (MI Preferred)	$224.15
Rate for Payer: Cash Price	$275.88
Rate for Payer: Cofinity Commercial	$241.40
Rate for Payer: Cofinity Commercial	$296.57
Rate for Payer: Cofinity Medicare Advantage	$241.40
Rate for Payer: Encore Health Key Benefits Commercial	$275.88
Rate for Payer: Healthscope Commercial	$310.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$293.12
Rate for Payer: PHP Commercial	$293.12
Rate for Payer: Priority Health Cigna Priority Health	$224.15
Rate for Payer: Priority Health SBD	$217.26

LEVOTHYROXINE 25 MCG TABLET

Facility

$4.30

Service Code	NDC 51079044401
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$2.71
Max. Negotiated Rate	$3.87
Rate for Payer: Aetna Commercial	$3.65
Rate for Payer: Aetna New Business (MI Preferred)	$2.79
Rate for Payer: Cash Price	$3.44
Rate for Payer: Cofinity Commercial	$3.01
Rate for Payer: Cofinity Commercial	$3.70
Rate for Payer: Cofinity Medicare Advantage	$3.01
Rate for Payer: Encore Health Key Benefits Commercial	$3.44
Rate for Payer: Healthscope Commercial	$3.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.65
Rate for Payer: PHP Commercial	$3.65
Rate for Payer: Priority Health Cigna Priority Health	$2.79
Rate for Payer: Priority Health SBD	$2.71

LEVOTHYROXINE 25 MCG TABLET

Facility

$429.40

Service Code	NDC 51079044420
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$171.76
Max. Negotiated Rate	$386.46
Rate for Payer: Aetna Commercial	$364.99
Rate for Payer: Aetna Medicare	$214.70
Rate for Payer: Aetna New Business (MI Preferred)	$279.11
Rate for Payer: BCBS Complete	$171.76
Rate for Payer: Cash Price	$343.52
Rate for Payer: Cofinity Commercial	$300.58
Rate for Payer: Cofinity Commercial	$369.28
Rate for Payer: Cofinity Medicare Advantage	$300.58
Rate for Payer: Encore Health Key Benefits Commercial	$343.52
Rate for Payer: Healthscope Commercial	$386.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$364.99
Rate for Payer: PHP Commercial	$364.99
Rate for Payer: Priority Health Cigna Priority Health	$279.11
Rate for Payer: Priority Health SBD	$270.52

LEVOTHYROXINE 25 MCG TABLET

Facility

$429.40

Service Code	NDC 51079044420
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$270.52
Max. Negotiated Rate	$386.46
Rate for Payer: Aetna Commercial	$364.99
Rate for Payer: Aetna New Business (MI Preferred)	$279.11
Rate for Payer: Cash Price	$343.52
Rate for Payer: Cofinity Commercial	$300.58
Rate for Payer: Cofinity Commercial	$369.28
Rate for Payer: Cofinity Medicare Advantage	$300.58
Rate for Payer: Encore Health Key Benefits Commercial	$343.52
Rate for Payer: Healthscope Commercial	$386.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$364.99
Rate for Payer: PHP Commercial	$364.99
Rate for Payer: Priority Health Cigna Priority Health	$279.11
Rate for Payer: Priority Health SBD	$270.52

LEVOTHYROXINE 25 MCG TABLET

Facility

$4.30

Service Code	NDC 51079044401
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$1.72
Max. Negotiated Rate	$3.87
Rate for Payer: Aetna Commercial	$3.65
Rate for Payer: Aetna Medicare	$2.15
Rate for Payer: Aetna New Business (MI Preferred)	$2.79
Rate for Payer: BCBS Complete	$1.72
Rate for Payer: Cash Price	$3.44
Rate for Payer: Cofinity Commercial	$3.01
Rate for Payer: Cofinity Commercial	$3.70
Rate for Payer: Cofinity Medicare Advantage	$3.01
Rate for Payer: Encore Health Key Benefits Commercial	$3.44
Rate for Payer: Healthscope Commercial	$3.87
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.65
Rate for Payer: PHP Commercial	$3.65
Rate for Payer: Priority Health Cigna Priority Health	$2.79
Rate for Payer: Priority Health SBD	$2.71

LEVOTHYROXINE 25 MCG TABLET

Facility

$313.50

Service Code	NDC 00904694961
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$125.40
Max. Negotiated Rate	$282.15
Rate for Payer: Aetna Commercial	$266.48
Rate for Payer: Aetna Medicare	$156.75
Rate for Payer: Aetna New Business (MI Preferred)	$203.78
Rate for Payer: BCBS Complete	$125.40
Rate for Payer: Cash Price	$250.80
Rate for Payer: Cofinity Commercial	$219.45
Rate for Payer: Cofinity Commercial	$269.61
Rate for Payer: Cofinity Medicare Advantage	$219.45
Rate for Payer: Encore Health Key Benefits Commercial	$250.80
Rate for Payer: Healthscope Commercial	$282.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$266.48
Rate for Payer: PHP Commercial	$266.48
Rate for Payer: Priority Health Cigna Priority Health	$203.78
Rate for Payer: Priority Health SBD	$197.50

LEVOTHYROXINE 25 MCG TABLET

Facility

$3.45

Service Code	NDC 60687045311
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$1.38
Max. Negotiated Rate	$3.10
Rate for Payer: Aetna Commercial	$2.93
Rate for Payer: Aetna Medicare	$1.73
Rate for Payer: Aetna New Business (MI Preferred)	$2.24
Rate for Payer: BCBS Complete	$1.38
Rate for Payer: Cash Price	$2.76
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Cofinity Commercial	$2.97
Rate for Payer: Cofinity Medicare Advantage	$2.42
Rate for Payer: Encore Health Key Benefits Commercial	$2.76
Rate for Payer: Healthscope Commercial	$3.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.93
Rate for Payer: PHP Commercial	$2.93
Rate for Payer: Priority Health Cigna Priority Health	$2.24
Rate for Payer: Priority Health SBD	$2.17

LEVOTHYROXINE 25 MCG TABLET

Facility

$313.50

Service Code	NDC 00904694961
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$197.50
Max. Negotiated Rate	$282.15
Rate for Payer: Aetna Commercial	$266.48
Rate for Payer: Aetna New Business (MI Preferred)	$203.78
Rate for Payer: Cash Price	$250.80
Rate for Payer: Cofinity Commercial	$219.45
Rate for Payer: Cofinity Commercial	$269.61
Rate for Payer: Cofinity Medicare Advantage	$219.45
Rate for Payer: Encore Health Key Benefits Commercial	$250.80
Rate for Payer: Healthscope Commercial	$282.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$266.48
Rate for Payer: PHP Commercial	$266.48
Rate for Payer: Priority Health Cigna Priority Health	$203.78
Rate for Payer: Priority Health SBD	$197.50

LEVOTHYROXINE 25 MCG TABLET

Facility

$344.85

Service Code	NDC 60687045301
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$137.94
Max. Negotiated Rate	$310.37
Rate for Payer: Aetna Commercial	$293.12
Rate for Payer: Aetna Medicare	$172.43
Rate for Payer: Aetna New Business (MI Preferred)	$224.15
Rate for Payer: BCBS Complete	$137.94
Rate for Payer: Cash Price	$275.88
Rate for Payer: Cofinity Commercial	$241.40
Rate for Payer: Cofinity Commercial	$296.57
Rate for Payer: Cofinity Medicare Advantage	$241.40
Rate for Payer: Encore Health Key Benefits Commercial	$275.88
Rate for Payer: Healthscope Commercial	$310.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$293.12
Rate for Payer: PHP Commercial	$293.12
Rate for Payer: Priority Health Cigna Priority Health	$224.15
Rate for Payer: Priority Health SBD	$217.26

LEVOTHYROXINE 25 MCG TABLET

Facility

$3.45

Service Code	NDC 60687045311
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.10
Rate for Payer: Aetna Commercial	$2.93
Rate for Payer: Aetna New Business (MI Preferred)	$2.24
Rate for Payer: Cash Price	$2.76
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Cofinity Commercial	$2.97
Rate for Payer: Cofinity Medicare Advantage	$2.42
Rate for Payer: Encore Health Key Benefits Commercial	$2.76
Rate for Payer: Healthscope Commercial	$3.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.93
Rate for Payer: PHP Commercial	$2.93
Rate for Payer: Priority Health Cigna Priority Health	$2.24
Rate for Payer: Priority Health SBD	$2.17

LEVOTHYROXINE 25 MCG TABLET

Facility

$262.49

Service Code	NDC 00378180077
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$105.00
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 Commercial	$183.74
Rate for Payer: Cofinity Commercial	$225.74
Rate for Payer: Cofinity Medicare Advantage	$183.74
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: PHP Commercial	$223.12
Rate for Payer: Priority Health Cigna Priority Health	$170.62
Rate for Payer: Priority Health SBD	$165.37

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 Commercial	$183.74
Rate for Payer: Cofinity Commercial	$225.74
Rate for Payer: Cofinity Medicare Advantage	$183.74
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: PHP Commercial	$223.12
Rate for Payer: Priority Health Cigna Priority Health	$170.62
Rate for Payer: Priority Health SBD	$165.37

LEVOTHYROXINE 50 MCG TABLET

Facility

$323.95

Service Code	NDC 00904695061
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$204.09
Max. Negotiated Rate	$291.56
Rate for Payer: Aetna Commercial	$275.36
Rate for Payer: Aetna New Business (MI Preferred)	$210.57
Rate for Payer: Cash Price	$259.16
Rate for Payer: Cofinity Commercial	$226.76
Rate for Payer: Cofinity Commercial	$278.60
Rate for Payer: Cofinity Medicare Advantage	$226.76
Rate for Payer: Encore Health Key Benefits Commercial	$259.16
Rate for Payer: Healthscope Commercial	$291.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$275.36
Rate for Payer: PHP Commercial	$275.36
Rate for Payer: Priority Health Cigna Priority Health	$210.57
Rate for Payer: Priority Health SBD	$204.09

LEVOTHYROXINE 50 MCG TABLET

Facility

$2.47

Service Code	NDC 51079044001
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$2.22
Rate for Payer: Aetna Commercial	$2.10
Rate for Payer: Aetna Medicare	$1.24
Rate for Payer: Aetna New Business (MI Preferred)	$1.61
Rate for Payer: BCBS Complete	$0.99
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cofinity Commercial	$1.73
Rate for Payer: Cofinity Commercial	$2.12
Rate for Payer: Cofinity Medicare Advantage	$1.73
Rate for Payer: Encore Health Key Benefits Commercial	$1.98
Rate for Payer: Healthscope Commercial	$2.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.10
Rate for Payer: PHP Commercial	$2.10
Rate for Payer: Priority Health Cigna Priority Health	$1.61
Rate for Payer: Priority Health SBD	$1.56

LEVOTHYROXINE 50 MCG TABLET

Facility

$2.47

Service Code	NDC 51079044001
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.22
Rate for Payer: Aetna Commercial	$2.10
Rate for Payer: Aetna New Business (MI Preferred)	$1.61
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cofinity Commercial	$1.73
Rate for Payer: Cofinity Commercial	$2.12
Rate for Payer: Cofinity Medicare Advantage	$1.73
Rate for Payer: Encore Health Key Benefits Commercial	$1.98
Rate for Payer: Healthscope Commercial	$2.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.10
Rate for Payer: PHP Commercial	$2.10
Rate for Payer: Priority Health Cigna Priority Health	$1.61
Rate for Payer: Priority Health SBD	$1.56

LEVOTHYROXINE 50 MCG TABLET

Facility

$80.37

Service Code	NDC 16729044815
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$32.15
Max. Negotiated Rate	$72.33
Rate for Payer: Aetna Commercial	$68.31
Rate for Payer: Aetna Medicare	$40.19
Rate for Payer: Aetna New Business (MI Preferred)	$52.24
Rate for Payer: BCBS Complete	$32.15
Rate for Payer: Cash Price	$64.30
Rate for Payer: Cofinity Commercial	$56.26
Rate for Payer: Cofinity Commercial	$69.12
Rate for Payer: Cofinity Medicare Advantage	$56.26
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: PHP Commercial	$68.31
Rate for Payer: Priority Health Cigna Priority Health	$52.24
Rate for Payer: Priority Health SBD	$50.63

LEVOTHYROXINE 50 MCG TABLET

Facility

$323.95

Service Code	NDC 00904695061
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$129.58
Max. Negotiated Rate	$291.56
Rate for Payer: Aetna Commercial	$275.36
Rate for Payer: Aetna Medicare	$161.97
Rate for Payer: Aetna New Business (MI Preferred)	$210.57
Rate for Payer: BCBS Complete	$129.58
Rate for Payer: Cash Price	$259.16
Rate for Payer: Cofinity Commercial	$226.76
Rate for Payer: Cofinity Commercial	$278.60
Rate for Payer: Cofinity Medicare Advantage	$226.76
Rate for Payer: Encore Health Key Benefits Commercial	$259.16
Rate for Payer: Healthscope Commercial	$291.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$275.36
Rate for Payer: PHP Commercial	$275.36
Rate for Payer: Priority Health Cigna Priority Health	$210.57
Rate for Payer: Priority Health SBD	$204.09

LEVOTHYROXINE 50 MCG TABLET

Facility

$246.72

Service Code	NDC 51079044020
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$155.43
Max. Negotiated Rate	$222.05
Rate for Payer: Aetna Commercial	$209.71
Rate for Payer: Aetna New Business (MI Preferred)	$160.37
Rate for Payer: Cash Price	$197.38
Rate for Payer: Cofinity Commercial	$172.70
Rate for Payer: Cofinity Commercial	$212.18
Rate for Payer: Cofinity Medicare Advantage	$172.70
Rate for Payer: Encore Health Key Benefits Commercial	$197.38
Rate for Payer: Healthscope Commercial	$222.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$209.71
Rate for Payer: PHP Commercial	$209.71
Rate for Payer: Priority Health Cigna Priority Health	$160.37
Rate for Payer: Priority Health SBD	$155.43

LEVOTHYROXINE 50 MCG TABLET

Facility

$3.45

Service Code	NDC 60687046411
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$2.17
Max. Negotiated Rate	$3.10
Rate for Payer: Aetna Commercial	$2.93
Rate for Payer: Aetna New Business (MI Preferred)	$2.24
Rate for Payer: Cash Price	$2.76
Rate for Payer: Cofinity Commercial	$2.42
Rate for Payer: Cofinity Commercial	$2.97
Rate for Payer: Cofinity Medicare Advantage	$2.42
Rate for Payer: Encore Health Key Benefits Commercial	$2.76
Rate for Payer: Healthscope Commercial	$3.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.93
Rate for Payer: PHP Commercial	$2.93
Rate for Payer: Priority Health Cigna Priority Health	$2.24
Rate for Payer: Priority Health SBD	$2.17

LEVOTHYROXINE 50 MCG TABLET

Facility

$344.85

Service Code	NDC 60687046401
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$137.94
Max. Negotiated Rate	$310.37
Rate for Payer: Aetna Commercial	$293.12
Rate for Payer: Aetna Medicare	$172.43
Rate for Payer: Aetna New Business (MI Preferred)	$224.15
Rate for Payer: BCBS Complete	$137.94
Rate for Payer: Cash Price	$275.88
Rate for Payer: Cofinity Commercial	$241.40
Rate for Payer: Cofinity Commercial	$296.57
Rate for Payer: Cofinity Medicare Advantage	$241.40
Rate for Payer: Encore Health Key Benefits Commercial	$275.88
Rate for Payer: Healthscope Commercial	$310.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$293.12
Rate for Payer: PHP Commercial	$293.12
Rate for Payer: Priority Health Cigna Priority Health	$224.15
Rate for Payer: Priority Health SBD	$217.26

LEVOTHYROXINE 50 MCG TABLET

Facility

$697.25

Service Code	NDC 00074455290
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$439.27
Max. Negotiated Rate	$627.52
Rate for Payer: Aetna Commercial	$592.66
Rate for Payer: Aetna New Business (MI Preferred)	$453.21
Rate for Payer: Cash Price	$557.80
Rate for Payer: Cofinity Commercial	$488.07
Rate for Payer: Cofinity Commercial	$599.63
Rate for Payer: Cofinity Medicare Advantage	$488.07
Rate for Payer: Encore Health Key Benefits Commercial	$557.80
Rate for Payer: Healthscope Commercial	$627.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$592.66
Rate for Payer: PHP Commercial	$592.66
Rate for Payer: Priority Health Cigna Priority Health	$453.21
Rate for Payer: Priority Health SBD	$439.27

LEVOTHYROXINE 50 MCG TABLET

Facility

$697.25

Service Code	NDC 00074455290
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$278.90
Max. Negotiated Rate	$627.52
Rate for Payer: Aetna Commercial	$592.66
Rate for Payer: Aetna Medicare	$348.62
Rate for Payer: Aetna New Business (MI Preferred)	$453.21
Rate for Payer: BCBS Complete	$278.90
Rate for Payer: Cash Price	$557.80
Rate for Payer: Cofinity Commercial	$488.07
Rate for Payer: Cofinity Commercial	$599.63
Rate for Payer: Cofinity Medicare Advantage	$488.07
Rate for Payer: Encore Health Key Benefits Commercial	$557.80
Rate for Payer: Healthscope Commercial	$627.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$592.66
Rate for Payer: PHP Commercial	$592.66
Rate for Payer: Priority Health Cigna Priority Health	$453.21
Rate for Payer: Priority Health SBD	$439.27

Know your out-of-pocket cost for care.

All Charges