Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE SODIUM 100 MCG PO TABS

Facility

IP

$0.56

Service Code	NDC 6818096901
Hospital Charge Code	6818096901
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.28

LEVOTHYROXINE SODIUM 100 MCG PO TABS

Facility

OP

$1.89

Service Code	NDC 0074662490
Hospital Charge Code	0074662490
Hospital Revenue Code	250
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$1.51
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.95
Rate for Payer: Aetna Government	$0.95
Rate for Payer: Brighton Health Commercial	$1.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.51
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.29
Rate for Payer: EmblemHealth Commercial	$0.95
Rate for Payer: Group Health Inc Commercial	$0.95
Rate for Payer: Group Health Inc Medicare	$0.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.95
Rate for Payer: Hamaspik Choice Inc Medicare	$0.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.23

LEVOTHYROXINE SODIUM 100 MCG PO TABS

Facility

IP

$1.89

Service Code	NDC 0074662490
Hospital Charge Code	0074662490
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.95

LEVOTHYROXINE SODIUM 100 MCG PO TABS

Facility

OP

$0.56

Service Code	NDC 6818096901
Hospital Charge Code	6818096901
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.31
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.28
Rate for Payer: Aetna Government	$0.28
Rate for Payer: Brighton Health Commercial	$0.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.38
Rate for Payer: EmblemHealth Commercial	$0.28
Rate for Payer: Group Health Inc Commercial	$0.28
Rate for Payer: Group Health Inc Medicare	$0.20
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.28
Rate for Payer: Hamaspik Choice Inc Medicare	$0.28
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.37

LEVOTHYROXINE SODIUM 100 MCG PO TABS

Facility

OP

$0.61

Service Code	NDC 5107944220
Hospital Charge Code	5107944220
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.49
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.34
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.31
Rate for Payer: Aetna Government	$0.31
Rate for Payer: Brighton Health Commercial	$0.46
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.49
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.42
Rate for Payer: EmblemHealth Commercial	$0.31
Rate for Payer: Group Health Inc Commercial	$0.31
Rate for Payer: Group Health Inc Medicare	$0.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.31
Rate for Payer: Hamaspik Choice Inc Medicare	$0.31
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.40

LEVOTHYROXINE SODIUM 112 MCG PO TABS

Facility

OP

$0.68

Service Code	NDC 0527328546
Hospital Charge Code	0527328546
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.54
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.37
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.34
Rate for Payer: Aetna Government	$0.34
Rate for Payer: Brighton Health Commercial	$0.51
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.54
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.46
Rate for Payer: EmblemHealth Commercial	$0.34
Rate for Payer: Group Health Inc Commercial	$0.34
Rate for Payer: Group Health Inc Medicare	$0.24
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.34
Rate for Payer: Hamaspik Choice Inc Medicare	$0.34
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.44

LEVOTHYROXINE SODIUM 112 MCG PO TABS

Facility

IP

$0.68

Service Code	NDC 0527328546
Hospital Charge Code	0527328546
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.34

LEVOTHYROXINE SODIUM 112 MCG PO TABS

Facility

OP

$0.65

Service Code	NDC 6818097009
Hospital Charge Code	6818097009
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.33
Rate for Payer: Aetna Government	$0.33
Rate for Payer: Brighton Health Commercial	$0.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.44
Rate for Payer: EmblemHealth Commercial	$0.33
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

LEVOTHYROXINE SODIUM 112 MCG PO TABS

Facility

IP

$0.65

Service Code	NDC 6818097009
Hospital Charge Code	6818097009
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33

LEVOTHYROXINE SODIUM 112 MCG PO TABS

Facility

IP

$1.89

Service Code	NDC 0074929690
Hospital Charge Code	0074929690
Hospital Revenue Code	250
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$0.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.95

LEVOTHYROXINE SODIUM 112 MCG PO TABS

Facility

IP

$0.65

Service Code	NDC 0378181177
Hospital Charge Code	0378181177
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33

LEVOTHYROXINE SODIUM 112 MCG PO TABS

Facility

OP

$0.65

Service Code	NDC 0378181177
Hospital Charge Code	0378181177
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.52
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.33
Rate for Payer: Aetna Government	$0.33
Rate for Payer: Brighton Health Commercial	$0.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.52
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.44
Rate for Payer: EmblemHealth Commercial	$0.33
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.42

LEVOTHYROXINE SODIUM 112 MCG PO TABS

Facility

OP

$1.89

Service Code	NDC 0074929690
Hospital Charge Code	0074929690
Hospital Revenue Code	250
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$1.51
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$1.04
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.95
Rate for Payer: Aetna Government	$0.95
Rate for Payer: Brighton Health Commercial	$1.42
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$1.51
Rate for Payer: Cigna LocalPlus Benefit Plan	$1.29
Rate for Payer: EmblemHealth Commercial	$0.95
Rate for Payer: Group Health Inc Commercial	$0.95
Rate for Payer: Group Health Inc Medicare	$0.66
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.95
Rate for Payer: Hamaspik Choice Inc Medicare	$0.95
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$1.23

LEVOTHYROXINE SODIUM 112 MCG PO TABS

Facility

IP

$0.81

Service Code	NDC 0904695461
Hospital Charge Code	0904695461
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41

LEVOTHYROXINE SODIUM 112 MCG PO TABS

Facility

OP

$0.81

Service Code	NDC 0904695461
Hospital Charge Code	0904695461
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.65
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.41
Rate for Payer: Aetna Government	$0.41
Rate for Payer: Brighton Health Commercial	$0.61
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.65
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.55
Rate for Payer: EmblemHealth Commercial	$0.41
Rate for Payer: Group Health Inc Commercial	$0.41
Rate for Payer: Group Health Inc Medicare	$0.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41
Rate for Payer: Hamaspik Choice Inc Medicare	$0.41
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.53

LEVOTHYROXINE SODIUM 125 MCG PO TABS

Facility

OP

$0.83

Service Code	NDC 0904695561
Hospital Charge Code	0904695561
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.66
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.45
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.41
Rate for Payer: Aetna Government	$0.41
Rate for Payer: Brighton Health Commercial	$0.62
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.66
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.56
Rate for Payer: EmblemHealth Commercial	$0.41
Rate for Payer: Group Health Inc Commercial	$0.41
Rate for Payer: Group Health Inc Medicare	$0.29
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41
Rate for Payer: Hamaspik Choice Inc Medicare	$0.41
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.54

LEVOTHYROXINE SODIUM 125 MCG PO TABS

Facility

IP

$0.83

Service Code	NDC 0904695561
Hospital Charge Code	0904695561
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.41
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.41

LEVOTHYROXINE SODIUM 125 MCG PO TABS

Facility

IP

$0.66

Service Code	NDC 6818097109
Hospital Charge Code	6818097109
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33

LEVOTHYROXINE SODIUM 125 MCG PO TABS

Facility

OP

$0.66

Service Code	NDC 6818097109
Hospital Charge Code	6818097109
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.33
Rate for Payer: Aetna Government	$0.33
Rate for Payer: Brighton Health Commercial	$0.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.45
Rate for Payer: EmblemHealth Commercial	$0.33
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.43

LEVOTHYROXINE SODIUM 125 MCG PO TABS

Facility

OP

$0.66

Service Code	NDC 0378181377
Hospital Charge Code	0378181377
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.53
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.33
Rate for Payer: Aetna Government	$0.33
Rate for Payer: Brighton Health Commercial	$0.49
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.53
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.45
Rate for Payer: EmblemHealth Commercial	$0.33
Rate for Payer: Group Health Inc Commercial	$0.33
Rate for Payer: Group Health Inc Medicare	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33
Rate for Payer: Hamaspik Choice Inc Medicare	$0.33
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.43

LEVOTHYROXINE SODIUM 125 MCG PO TABS

Facility

IP

$0.66

Service Code	NDC 0378181377
Hospital Charge Code	0378181377
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.33
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.33

LEVOTHYROXINE SODIUM 150 MCG PO TABS

Facility

IP

$0.85

Service Code	NDC 0904695661
Hospital Charge Code	0904695661
Hospital Revenue Code	250
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.42
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.42

LEVOTHYROXINE SODIUM 150 MCG PO TABS

Facility

IP

$0.68

Service Code	NDC 0378181577
Hospital Charge Code	0378181577
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.34
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.34

LEVOTHYROXINE SODIUM 150 MCG PO TABS

Facility

OP

$0.85

Service Code	NDC 0904695661
Hospital Charge Code	0904695661
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.68
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.47
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.42
Rate for Payer: Aetna Government	$0.42
Rate for Payer: Brighton Health Commercial	$0.64
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.68
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.58
Rate for Payer: EmblemHealth Commercial	$0.42
Rate for Payer: Group Health Inc Commercial	$0.42
Rate for Payer: Group Health Inc Medicare	$0.30
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.42
Rate for Payer: Hamaspik Choice Inc Medicare	$0.42
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.55

LEVOTHYROXINE SODIUM 150 MCG PO TABS

Facility

IP

$0.71

Service Code	NDC 0527328846
Hospital Charge Code	0527328846
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35

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