Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE (SYNTHROID) 200

Facility

$5.63

Service Code	NDC 781518992
Hospital Charge Code	60630135
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$2.81
Rate for Payer: Aetna Commercial	$2.14
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	$1.46
Rate for Payer: Oxford Commercial	$1.13
Rate for Payer: Qualcare PPO/HMO/WC	$0.84
Rate for Payer: UnitedHealthcare Commercial	$1.13
Rate for Payer: UnitedHealthcare Community & State	$0.18
Rate for Payer: Wellpoint Medicaid Managed Care	$0.16

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	$0.24
Max. Negotiated Rate	$4.25
Rate for Payer: Aetna Commercial	$3.23
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	$2.21
Rate for Payer: Oxford Commercial	$1.70
Rate for Payer: Qualcare PPO/HMO/WC	$1.28
Rate for Payer: UnitedHealthcare Commercial	$1.70
Rate for Payer: UnitedHealthcare Community & State	$0.27
Rate for Payer: Wellpoint Medicaid Managed Care	$0.24

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 112MCG

Facility

$4.36

Service Code	NDC 378181177
Hospital Charge Code	60628250
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna Commercial	$1.66
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	$1.13
Rate for Payer: Oxford Commercial	$0.87
Rate for Payer: Qualcare PPO/HMO/WC	$0.65
Rate for Payer: UnitedHealthcare Commercial	$0.87
Rate for Payer: UnitedHealthcare Community & State	$0.14
Rate for Payer: Wellpoint Medicaid Managed Care	$0.12

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 125MCG

Facility

$4.00

Service Code	NDC 74706811
Hospital Charge Code	60628251
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
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	$1.04
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

LEVOTHYROXINE TAB 150MCG

Facility

$4.09

Service Code	NDC 74706990
Hospital Charge Code	60628252
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$2.04
Rate for Payer: Aetna Commercial	$1.55
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	$1.06
Rate for Payer: Oxford Commercial	$0.82
Rate for Payer: Qualcare PPO/HMO/WC	$0.61
Rate for Payer: UnitedHealthcare Commercial	$0.82
Rate for Payer: UnitedHealthcare Community & State	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.12

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 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	$0.15
Max. Negotiated Rate	$2.71
Rate for Payer: Aetna Commercial	$2.06
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	$1.41
Rate for Payer: Oxford Commercial	$1.09
Rate for Payer: Qualcare PPO/HMO/WC	$0.81
Rate for Payer: UnitedHealthcare Commercial	$1.09
Rate for Payer: UnitedHealthcare Community & State	$0.17
Rate for Payer: Wellpoint Medicaid Managed Care	$0.15

LEVOTHYROXINE TAB 25MCG

Facility

$4.00

Service Code	NDC 74434190
Hospital Charge Code	60628255
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
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	$1.04
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

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 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 50MCG

Facility

$8.04

Service Code	NDC 74455211
Hospital Charge Code	60628256
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$4.02
Rate for Payer: Aetna Commercial	$3.06
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	$2.09
Rate for Payer: Oxford Commercial	$1.61
Rate for Payer: Qualcare PPO/HMO/WC	$1.21
Rate for Payer: UnitedHealthcare Commercial	$1.61
Rate for Payer: UnitedHealthcare Community & State	$0.25
Rate for Payer: Wellpoint Medicaid Managed Care	$0.23

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	$0.23
Max. Negotiated Rate	$4.12
Rate for Payer: Aetna Commercial	$3.13
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	$2.14
Rate for Payer: Oxford Commercial	$1.65
Rate for Payer: Qualcare PPO/HMO/WC	$1.24
Rate for Payer: UnitedHealthcare Commercial	$1.65
Rate for Payer: UnitedHealthcare Community & State	$0.26
Rate for Payer: Wellpoint Medicaid Managed Care	$0.23

LEVOTHYROXINE TAB 88MCG

Facility

$4.00

Service Code	NDC 781518392
Hospital Charge Code	60628258
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 88MCG

Facility

$4.00

Service Code	NDC 781518392
Hospital Charge Code	60628258
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
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	$1.04
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

LEVOXINE/0.3MG/TAB

Facility

$7.30

Service Code	NDC 378182177
Hospital Charge Code	60633293
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$3.65
Rate for Payer: Aetna Commercial	$2.77
Rate for Payer: Aetna Medicare Advantage	$2.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.86
Rate for Payer: Cigna Commercial	$3.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.90
Rate for Payer: Oxford Commercial	$1.46
Rate for Payer: Qualcare PPO/HMO/WC	$1.09
Rate for Payer: UnitedHealthcare Commercial	$1.46
Rate for Payer: UnitedHealthcare Community & State	$0.23
Rate for Payer: Wellpoint Medicaid Managed Care	$0.21

LEVOXINE/0.3MG/TAB

Facility

$7.30

Service Code	NDC 378182177
Hospital Charge Code	60633293
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.09
Rate for Payer: Qualcare PPO/HMO/WC	$1.09

LEXIVA, 700MG, TAB

Facility

$134.47

Service Code	NDC 49702020718
Hospital Charge Code	60635465
Hospital Revenue Code	250
Min. Negotiated Rate	$20.17
Max. Negotiated Rate	$20.17
Rate for Payer: Qualcare PPO/HMO/WC	$20.17

LEXIVA, 700MG, TAB

Facility

$134.47

Service Code	NDC 49702020718
Hospital Charge Code	60635465
Hospital Revenue Code	250
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$67.23
Rate for Payer: Aetna Commercial	$51.10
Rate for Payer: Aetna Medicare Advantage	$40.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$34.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$34.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$34.29
Rate for Payer: Cigna Commercial	$67.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$34.96
Rate for Payer: Oxford Commercial	$26.89
Rate for Payer: Qualcare PPO/HMO/WC	$20.17
Rate for Payer: UnitedHealthcare Commercial	$26.89
Rate for Payer: UnitedHealthcare Community & State	$4.25
Rate for Payer: Wellpoint Medicaid Managed Care	$3.82

LG11 AUTOANTIBODY TEST

Facility

$2,575.00

Service Code	HCPCS 86255
Hospital Charge Code	3038555
Hospital Revenue Code	302
Min. Negotiated Rate	$386.25
Max. Negotiated Rate	$386.25
Rate for Payer: Qualcare PPO/HMO/WC	$386.25

LG11 AUTOANTIBODY TEST

Facility

$2,575.00

Service Code	HCPCS 86255
Hospital Charge Code	3038555
Hospital Revenue Code	302
Min. Negotiated Rate	$9.64
Max. Negotiated Rate	$1,287.50
Rate for Payer: Aetna Commercial	$32.78
Rate for Payer: Aetna Medicare Advantage	$39.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$43.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$43.71
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$12.05
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$12.87
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$43.71
Rate for Payer: Cigna Commercial	$1,287.50
Rate for Payer: Cigna Medicare Advantage	$12.05
Rate for Payer: Clover Medicare Advantage	$11.45
Rate for Payer: EmblemHealth Commercial	$36.15
Rate for Payer: Humana Medicare Advantage	$12.41
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$12.05
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$669.50
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$386.25
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$9.64
Rate for Payer: UnitedHealthcare Medicare Advantage	$12.05
Rate for Payer: Wellcare Medicare Advantage	$12.05
Rate for Payer: Wellpoint Medicaid Managed Care	$73.13

Know your out-of-pocket cost for care.

All Charges