Heights University Hospital

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 500 MCG INJ.

Facility

$161.30

Hospital Charge Code	60629127
Hospital Revenue Code	250
Min. Negotiated Rate	$24.20
Max. Negotiated Rate	$24.20
Rate for Payer: Qualcare PPO/HMO/WC	$24.20

LEVOTHYROXINE INJ 200MCG

Facility

$371.38

Service Code	NDC 63323064710
Hospital Charge Code	6003248
Hospital Revenue Code	250
Min. Negotiated Rate	$55.71
Max. Negotiated Rate	$55.71
Rate for Payer: Qualcare PPO/HMO/WC	$55.71

LEVOTHYROXINE INJ 200MCG

Facility

$371.38

Service Code	NDC 63323064710
Hospital Charge Code	6003248
Hospital Revenue Code	250
Min. Negotiated Rate	$48.28
Max. Negotiated Rate	$185.69
Rate for Payer: Aetna Commercial	$111.41
Rate for Payer: Aetna Medicare Advantage	$111.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$94.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$94.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$94.70
Rate for Payer: Cigna Commercial	$185.69
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$48.28
Rate for Payer: Oxford Commercial	$185.69
Rate for Payer: Qualcare PPO/HMO/WC	$55.71
Rate for Payer: UnitedHealthcare Commercial	$185.69

LEVOTHYROXINE SODIUM 100 MCG P

Facility

$442.20

Service Code	NDC 63323064907
Hospital Charge Code	60630097
Hospital Revenue Code	250
Min. Negotiated Rate	$57.49
Max. Negotiated Rate	$221.10
Rate for Payer: Aetna Commercial	$132.66
Rate for Payer: Aetna Medicare Advantage	$132.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$112.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$112.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$112.76
Rate for Payer: Cigna Commercial	$221.10
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$57.49
Rate for Payer: Oxford Commercial	$221.10
Rate for Payer: Qualcare PPO/HMO/WC	$66.33
Rate for Payer: UnitedHealthcare Commercial	$221.10

LEVOTHYROXINE SODIUM 100 MCG P

Facility

$442.20

Service Code	NDC 63323064907
Hospital Charge Code	60630097
Hospital Revenue Code	250
Min. Negotiated Rate	$66.33
Max. Negotiated Rate	$66.33
Rate for Payer: Qualcare PPO/HMO/WC	$66.33

LEVOTHYROXINE (SYNTHROID) 200

Facility

$5.63

Service Code	NDC 781518992
Hospital Charge Code	60630135
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$0.84
Rate for Payer: Qualcare PPO/HMO/WC	$0.84

LEVOTHYROXINE (SYNTHROID) 200

Facility

$5.63

Service Code	NDC 781518992
Hospital Charge Code	60630135
Hospital Revenue Code	250
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$2.81
Rate for Payer: Aetna Commercial	$1.69
Rate for Payer: Aetna Medicare Advantage	$1.69
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.44
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.44
Rate for Payer: Cigna Commercial	$2.81
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.73
Rate for Payer: Oxford Commercial	$2.81
Rate for Payer: Qualcare PPO/HMO/WC	$0.84
Rate for Payer: UnitedHealthcare Commercial	$2.81

LEVOTHYROXINE TAB 100MCG

Facility

$8.51

Service Code	NDC 74662411
Hospital Charge Code	60628249
Hospital Revenue Code	250
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.28
Rate for Payer: Qualcare PPO/HMO/WC	$1.28

LEVOTHYROXINE TAB 100MCG

Facility

$8.51

Service Code	NDC 74662411
Hospital Charge Code	60628249
Hospital Revenue Code	250
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$4.25
Rate for Payer: Aetna Commercial	$2.55
Rate for Payer: Aetna Medicare Advantage	$2.55
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.17
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.17
Rate for Payer: Cigna Commercial	$4.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.11
Rate for Payer: Oxford Commercial	$4.25
Rate for Payer: Qualcare PPO/HMO/WC	$1.28
Rate for Payer: UnitedHealthcare Commercial	$4.25

LEVOTHYROXINE TAB 112MCG

Facility

$4.36

Service Code	NDC 378181177
Hospital Charge Code	60628250
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna Commercial	$1.31
Rate for Payer: Aetna Medicare Advantage	$1.31
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.11
Rate for Payer: Cigna Commercial	$2.18
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.57
Rate for Payer: Oxford Commercial	$2.18
Rate for Payer: Qualcare PPO/HMO/WC	$0.65
Rate for Payer: UnitedHealthcare Commercial	$2.18

LEVOTHYROXINE TAB 112MCG

Facility

$4.36

Service Code	NDC 378181177
Hospital Charge Code	60628250
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.65
Rate for Payer: Qualcare PPO/HMO/WC	$0.65

LEVOTHYROXINE TAB 125MCG

Facility

$4.00

Service Code	NDC 74706811
Hospital Charge Code	60628251
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.20
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.52
Rate for Payer: Oxford Commercial	$2.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$2.00

LEVOTHYROXINE TAB 125MCG

Facility

$4.00

Service Code	NDC 74706811
Hospital Charge Code	60628251
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

LEVOTHYROXINE TAB 150MCG

Facility

$4.09

Service Code	NDC 74706990
Hospital Charge Code	60628252
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$0.61
Rate for Payer: Qualcare PPO/HMO/WC	$0.61

LEVOTHYROXINE TAB 150MCG

Facility

$4.09

Service Code	NDC 74706990
Hospital Charge Code	60628252
Hospital Revenue Code	250
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$2.04
Rate for Payer: Aetna Commercial	$1.23
Rate for Payer: Aetna Medicare Advantage	$1.23
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.04
Rate for Payer: Cigna Commercial	$2.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.53
Rate for Payer: Oxford Commercial	$2.04
Rate for Payer: Qualcare PPO/HMO/WC	$0.61
Rate for Payer: UnitedHealthcare Commercial	$2.04

LEVOTHYROXINE TAB 175MCG

Facility

$5.43

Service Code	NDC 378181701
Hospital Charge Code	60628253
Hospital Revenue Code	250
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$0.81
Rate for Payer: Qualcare PPO/HMO/WC	$0.81

LEVOTHYROXINE TAB 175MCG

Facility

$5.43

Service Code	NDC 378181701
Hospital Charge Code	60628253
Hospital Revenue Code	250
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$2.71
Rate for Payer: Aetna Commercial	$1.63
Rate for Payer: Aetna Medicare Advantage	$1.63
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.38
Rate for Payer: Cigna Commercial	$2.71
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.71
Rate for Payer: Oxford Commercial	$2.71
Rate for Payer: Qualcare PPO/HMO/WC	$0.81
Rate for Payer: UnitedHealthcare Commercial	$2.71

LEVOTHYROXINE TAB 200MCG

Facility

$3.20

Hospital Charge Code	60628254
Hospital Revenue Code	250
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

LEVOTHYROXINE TAB 200MCG

Facility

$3.20

Hospital Charge Code	60628254
Hospital Revenue Code	250
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna Commercial	$0.96
Rate for Payer: Aetna Medicare Advantage	$0.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.82
Rate for Payer: Cigna Commercial	$1.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.42
Rate for Payer: Oxford Commercial	$1.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.48
Rate for Payer: UnitedHealthcare Commercial	$1.60

LEVOTHYROXINE TAB 25MCG

Facility

$4.00

Service Code	NDC 74434190
Hospital Charge Code	60628255
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

LEVOTHYROXINE TAB 25MCG

Facility

$4.00

Service Code	NDC 74434190
Hospital Charge Code	60628255
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.20
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.52
Rate for Payer: Oxford Commercial	$2.00
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$2.00

LEVOTHYROXINE TAB 50MCG

Facility

$8.04

Service Code	NDC 74455211
Hospital Charge Code	60628256
Hospital Revenue Code	250
Min. Negotiated Rate	$1.05
Max. Negotiated Rate	$4.02
Rate for Payer: Aetna Commercial	$2.41
Rate for Payer: Aetna Medicare Advantage	$2.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.05
Rate for Payer: Cigna Commercial	$4.02
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.05
Rate for Payer: Oxford Commercial	$4.02
Rate for Payer: Qualcare PPO/HMO/WC	$1.21
Rate for Payer: UnitedHealthcare Commercial	$4.02

LEVOTHYROXINE TAB 50MCG

Facility

$8.04

Service Code	NDC 74455211
Hospital Charge Code	60628256
Hospital Revenue Code	250
Min. Negotiated Rate	$1.21
Max. Negotiated Rate	$1.21
Rate for Payer: Qualcare PPO/HMO/WC	$1.21

LEVOTHYROXINE TAB 75MCG

Facility

$8.24

Service Code	NDC 74518211
Hospital Charge Code	60628257
Hospital Revenue Code	250
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.24
Rate for Payer: Qualcare PPO/HMO/WC	$1.24

LEVOTHYROXINE TAB 75MCG

Facility

$8.24

Service Code	NDC 74518211
Hospital Charge Code	60628257
Hospital Revenue Code	250
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$4.12
Rate for Payer: Aetna Commercial	$2.47
Rate for Payer: Aetna Medicare Advantage	$2.47
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.10
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.10
Rate for Payer: Cigna Commercial	$4.12
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.07
Rate for Payer: Oxford Commercial	$4.12
Rate for Payer: Qualcare PPO/HMO/WC	$1.24
Rate for Payer: UnitedHealthcare Commercial	$4.12

Know your out-of-pocket cost for care.

All Charges