St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 112 MCG TAB

Facility

$0.35

Hospital Charge Code	41643967
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.18
Rate for Payer: Aetna Government	$0.18
Rate for Payer: Brighton Health Commercial	$0.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.24
Rate for Payer: Group Health Inc Commercial	$0.18
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.23

LEVOTHYROXINE 112 MCG TAB

Facility

$0.35

Hospital Charge Code	41653967
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.28
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.19
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.18
Rate for Payer: Aetna Government	$0.18
Rate for Payer: Brighton Health Commercial	$0.26
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.28
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.24
Rate for Payer: Group Health Inc Commercial	$0.18
Rate for Payer: Group Health Inc Medicare	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.23

LEVOTHYROXINE 125 MCG TAB

Facility

$0.36

Hospital Charge Code	41653878
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.18
Rate for Payer: Aetna Government	$0.18
Rate for Payer: Brighton Health Commercial	$0.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.29
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.24
Rate for Payer: Group Health Inc Commercial	$0.18
Rate for Payer: Group Health Inc Medicare	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.23

LEVOTHYROXINE 125 MCG TAB

Facility

$0.36

Hospital Charge Code	41643878
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.29
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.18
Rate for Payer: Aetna Government	$0.18
Rate for Payer: Brighton Health Commercial	$0.27
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.29
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.24
Rate for Payer: Group Health Inc Commercial	$0.18
Rate for Payer: Group Health Inc Medicare	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.18
Rate for Payer: Hamaspik Choice Inc Medicare	$0.18
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.23

LEVOTHYROXINE 150 MCG TAB

Facility

$0.37

Hospital Charge Code	41653968
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.19
Rate for Payer: Aetna Government	$0.19
Rate for Payer: Brighton Health Commercial	$0.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.25
Rate for Payer: Group Health Inc Commercial	$0.19
Rate for Payer: Group Health Inc Medicare	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.19
Rate for Payer: Hamaspik Choice Inc Medicare	$0.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.24

LEVOTHYROXINE 150 MCG TAB

Facility

$0.37

Hospital Charge Code	41643968
Hospital Revenue Code	250
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.30
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.19
Rate for Payer: Aetna Government	$0.19
Rate for Payer: Brighton Health Commercial	$0.28
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.30
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.25
Rate for Payer: Group Health Inc Commercial	$0.19
Rate for Payer: Group Health Inc Medicare	$0.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.19
Rate for Payer: Hamaspik Choice Inc Medicare	$0.19
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.24

LEVOTHYROXINE 200 MCG INJ

Facility

$104.00

Hospital Charge Code	41653531
Hospital Revenue Code	250
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$83.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$57.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$52.00
Rate for Payer: Aetna Government	$52.00
Rate for Payer: Brighton Health Commercial	$78.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$83.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$70.72
Rate for Payer: Group Health Inc Commercial	$52.00
Rate for Payer: Group Health Inc Medicare	$36.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$52.00
Rate for Payer: Hamaspik Choice Inc Medicare	$52.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$67.60

LEVOTHYROXINE 200 MCG INJ

Facility

$104.00

Hospital Charge Code	41643531
Hospital Revenue Code	250
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$83.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$57.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$52.00
Rate for Payer: Aetna Government	$52.00
Rate for Payer: Brighton Health Commercial	$78.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$83.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$70.72
Rate for Payer: Group Health Inc Commercial	$52.00
Rate for Payer: Group Health Inc Medicare	$36.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$52.00
Rate for Payer: Hamaspik Choice Inc Medicare	$52.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$67.60

LEVOTHYROXINE 200 MCG TAB

Facility

$1.00

Hospital Charge Code	41643969
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

LEVOTHYROXINE 200 MCG TAB

Facility

$1.00

Hospital Charge Code	41653969
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

LEVOTHYROXINE 20 MCG/ML INJ NEONATAL

Facility

$104.00

Hospital Charge Code	41645611
Hospital Revenue Code	250
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$83.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$57.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$52.00
Rate for Payer: Aetna Government	$52.00
Rate for Payer: Brighton Health Commercial	$78.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$83.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$70.72
Rate for Payer: Group Health Inc Commercial	$52.00
Rate for Payer: Group Health Inc Medicare	$36.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$52.00
Rate for Payer: Hamaspik Choice Inc Medicare	$52.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$67.60

LEVOTHYROXINE 20 MCG/ML INJ NEONATAL

Facility

$104.00

Hospital Charge Code	41655611
Hospital Revenue Code	250
Min. Negotiated Rate	$36.40
Max. Negotiated Rate	$83.20
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$57.20
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$52.00
Rate for Payer: Aetna Government	$52.00
Rate for Payer: Brighton Health Commercial	$78.00
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$83.20
Rate for Payer: Cigna LocalPlus Benefit Plan	$70.72
Rate for Payer: Group Health Inc Commercial	$52.00
Rate for Payer: Group Health Inc Medicare	$36.40
Rate for Payer: Hamaspik Choice Inc Medicaid	$52.00
Rate for Payer: Hamaspik Choice Inc Medicare	$52.00
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$67.60

LEVOTHYROXINE 25 MCG TAB

Facility

$1.00

Hospital Charge Code	41642678
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

LEVOTHYROXINE 25 MCG TAB

Facility

$1.00

Hospital Charge Code	41652678
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.80
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.55
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.50
Rate for Payer: Aetna Government	$0.50
Rate for Payer: Brighton Health Commercial	$0.75
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.80
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.68
Rate for Payer: Group Health Inc Commercial	$0.50
Rate for Payer: Group Health Inc Medicare	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.50
Rate for Payer: Hamaspik Choice Inc Medicare	$0.50
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.65

LEVOTHYROXINE 500 MCG VIAL

Facility

$114.78

Hospital Charge Code	41646095
Hospital Revenue Code	250
Min. Negotiated Rate	$40.17
Max. Negotiated Rate	$91.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$63.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$57.39
Rate for Payer: Aetna Government	$57.39
Rate for Payer: Brighton Health Commercial	$86.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$91.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$78.05
Rate for Payer: Group Health Inc Commercial	$57.39
Rate for Payer: Group Health Inc Medicare	$40.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$57.39
Rate for Payer: Hamaspik Choice Inc Medicare	$57.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$74.61

LEVOTHYROXINE 500 MCG VIAL

Facility

$114.78

Hospital Charge Code	41656095
Hospital Revenue Code	250
Min. Negotiated Rate	$40.17
Max. Negotiated Rate	$91.82
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$63.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$57.39
Rate for Payer: Aetna Government	$57.39
Rate for Payer: Brighton Health Commercial	$86.08
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$91.82
Rate for Payer: Cigna LocalPlus Benefit Plan	$78.05
Rate for Payer: Group Health Inc Commercial	$57.39
Rate for Payer: Group Health Inc Medicare	$40.17
Rate for Payer: Hamaspik Choice Inc Medicaid	$57.39
Rate for Payer: Hamaspik Choice Inc Medicare	$57.39
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$74.61

LEVOTHYROXINE 50 MCG TAB

Facility

$0.27

Hospital Charge Code	41643963
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.14
Rate for Payer: Aetna Government	$0.14
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: Group Health Inc Commercial	$0.14
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.14
Rate for Payer: Hamaspik Choice Inc Medicare	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.18

LEVOTHYROXINE 50 MCG TAB

Facility

$0.27

Hospital Charge Code	41653963
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.22
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.15
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.14
Rate for Payer: Aetna Government	$0.14
Rate for Payer: Brighton Health Commercial	$0.20
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.22
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.18
Rate for Payer: Group Health Inc Commercial	$0.14
Rate for Payer: Group Health Inc Medicare	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.14
Rate for Payer: Hamaspik Choice Inc Medicare	$0.14
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.18

LEVOTHYROXINE 5 MCG/ML SOLN NEONATAL

Facility

$0.24

Hospital Charge Code	41653962
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.16
Rate for Payer: Group Health Inc Commercial	$0.12
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.12
Rate for Payer: Hamaspik Choice Inc Medicare	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

LEVOTHYROXINE 5 MCG/ML SOLN NEONATAL

Facility

$0.24

Hospital Charge Code	41643962
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.19
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.13
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.12
Rate for Payer: Aetna Government	$0.12
Rate for Payer: Brighton Health Commercial	$0.18
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.19
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.16
Rate for Payer: Group Health Inc Commercial	$0.12
Rate for Payer: Group Health Inc Medicare	$0.08
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.12
Rate for Payer: Hamaspik Choice Inc Medicare	$0.12
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.16

LEVOTHYROXINE 75 MCG TAB

Facility

$0.30

Hospital Charge Code	41653964
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

LEVOTHYROXINE 75 MCG TAB

Facility

$0.30

Hospital Charge Code	41643964
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

LEVOTHYROXINE 88 MCG TAB

Facility

$0.30

Hospital Charge Code	41643965
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

LEVOTHYROXINE 88 MCG TAB

Facility

$0.30

Hospital Charge Code	41653965
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.24
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.17
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.15
Rate for Payer: Aetna Government	$0.15
Rate for Payer: Brighton Health Commercial	$0.23
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.24
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.20
Rate for Payer: Group Health Inc Commercial	$0.15
Rate for Payer: Group Health Inc Medicare	$0.11
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.15
Rate for Payer: Hamaspik Choice Inc Medicare	$0.15
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.20

LEVOTHYROXINE SODIUM 100 MCG/5ML IV SOLN [167874]

Facility

$17.98

Service Code	NDC 63323088512
Hospital Charge Code	63323088512
Hospital Revenue Code	278
Min. Negotiated Rate	$8.99
Max. Negotiated Rate	$8.99
Rate for Payer: Hamaspik Choice Inc Medicaid	$8.99
Rate for Payer: Hamaspik Choice Inc Medicare	$8.99

Know your out-of-pocket cost for care.

All Charges