St. Barnabas Hospital

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE SODIUM 150 MCG PO TABS

Facility

$0.24

Service Code	NDC 7230515030
Hospital Charge Code	7230515030
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: EmblemHealth Commercial	$0.12
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	$0.15

LEVOTHYROXINE SODIUM 150 MCG PO TABS

Facility

$0.24

Service Code	NDC 7230515030
Hospital Charge Code	7230515030
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.12
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.12

LEVOTHYROXINE SODIUM 150 MCG PO TABS

Facility

$0.68

Service Code	NDC 0378181577
Hospital Charge Code	0378181577
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 150 MCG PO TABS

Facility

$0.88

Service Code	NDC 6068753011
Hospital Charge Code	6068753011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.31
Max. Negotiated Rate	$0.70
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.48
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.44
Rate for Payer: Aetna Government	$0.44
Rate for Payer: Brighton Health Commercial	$0.66
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.70
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.60
Rate for Payer: EmblemHealth Commercial	$0.44
Rate for Payer: Group Health Inc Commercial	$0.44
Rate for Payer: Group Health Inc Medicare	$0.31
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.44
Rate for Payer: Hamaspik Choice Inc Medicare	$0.44
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.57

LEVOTHYROXINE SODIUM 150 MCG PO TABS

Facility

$0.71

Service Code	NDC 0527328846
Hospital Charge Code	0527328846
Hospital Revenue Code	250
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.39
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.35
Rate for Payer: Aetna Government	$0.35
Rate for Payer: Brighton Health Commercial	$0.53
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.56
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.48
Rate for Payer: EmblemHealth Commercial	$0.35
Rate for Payer: Group Health Inc Commercial	$0.35
Rate for Payer: Group Health Inc Medicare	$0.25
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35
Rate for Payer: Hamaspik Choice Inc Medicare	$0.35
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.46

LEVOTHYROXINE SODIUM 150 MCG PO TABS

Facility

$0.88

Service Code	NDC 6068753011
Hospital Charge Code	6068753011
Hospital Revenue Code	250
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.44
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.44

LEVOTHYROXINE SODIUM 200 MCG/5ML IV SOLN

Facility

$53.21

Service Code	NDC 6332389010
Hospital Charge Code	6332389010
Hospital Revenue Code	258
Min. Negotiated Rate	$18.62
Max. Negotiated Rate	$42.57
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$29.27
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$26.61
Rate for Payer: Aetna Government	$26.61
Rate for Payer: Brighton Health Commercial	$39.91
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$42.57
Rate for Payer: Cigna LocalPlus Benefit Plan	$36.18
Rate for Payer: EmblemHealth Commercial	$26.61
Rate for Payer: Group Health Inc Commercial	$26.61
Rate for Payer: Group Health Inc Medicare	$18.62
Rate for Payer: Hamaspik Choice Inc Medicaid	$26.61
Rate for Payer: Hamaspik Choice Inc Medicare	$26.61
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$34.59

LEVOTHYROXINE SODIUM 200 MCG/5ML IV SOLN

Facility

$53.21

Service Code	NDC 6332389010
Hospital Charge Code	6332389010
Hospital Revenue Code	258
Min. Negotiated Rate	$26.61
Max. Negotiated Rate	$26.61
Rate for Payer: Hamaspik Choice Inc Medicaid	$26.61

LEVOTHYROXINE SODIUM 200 MCG IV SOLR

Facility

$253.39

Service Code	NDC 4202320201
Hospital Charge Code	4202320201
Hospital Revenue Code	258
Min. Negotiated Rate	$88.69
Max. Negotiated Rate	$202.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$139.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$126.69
Rate for Payer: Aetna Government	$126.69
Rate for Payer: Brighton Health Commercial	$190.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$202.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$172.31
Rate for Payer: EmblemHealth Commercial	$126.69
Rate for Payer: Group Health Inc Commercial	$126.69
Rate for Payer: Group Health Inc Medicare	$88.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$126.69
Rate for Payer: Hamaspik Choice Inc Medicare	$126.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$164.70

LEVOTHYROXINE SODIUM 200 MCG IV SOLR

Facility

$253.39

Service Code	NDC 6332364710
Hospital Charge Code	6332364710
Hospital Revenue Code	258
Min. Negotiated Rate	$88.69
Max. Negotiated Rate	$202.71
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$139.36
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$126.69
Rate for Payer: Aetna Government	$126.69
Rate for Payer: Brighton Health Commercial	$190.04
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$202.71
Rate for Payer: Cigna LocalPlus Benefit Plan	$172.31
Rate for Payer: EmblemHealth Commercial	$126.69
Rate for Payer: Group Health Inc Commercial	$126.69
Rate for Payer: Group Health Inc Medicare	$88.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$126.69
Rate for Payer: Hamaspik Choice Inc Medicare	$126.69
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$164.70

LEVOTHYROXINE SODIUM 200 MCG IV SOLR

Facility

$253.39

Service Code	NDC 6332364710
Hospital Charge Code	6332364710
Hospital Revenue Code	258
Min. Negotiated Rate	$126.69
Max. Negotiated Rate	$126.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$126.69

LEVOTHYROXINE SODIUM 200 MCG IV SOLR

Facility

$228.42

Service Code	NDC 7086045210
Hospital Charge Code	7086045210
Hospital Revenue Code	258
Min. Negotiated Rate	$79.95
Max. Negotiated Rate	$182.74
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$125.63
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$114.21
Rate for Payer: Aetna Government	$114.21
Rate for Payer: Brighton Health Commercial	$171.31
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$182.74
Rate for Payer: Cigna LocalPlus Benefit Plan	$155.33
Rate for Payer: EmblemHealth Commercial	$114.21
Rate for Payer: Group Health Inc Commercial	$114.21
Rate for Payer: Group Health Inc Medicare	$79.95
Rate for Payer: Hamaspik Choice Inc Medicaid	$114.21
Rate for Payer: Hamaspik Choice Inc Medicare	$114.21
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$148.47

LEVOTHYROXINE SODIUM 200 MCG IV SOLR

Facility

$253.39

Service Code	NDC 4202320201
Hospital Charge Code	4202320201
Hospital Revenue Code	258
Min. Negotiated Rate	$126.69
Max. Negotiated Rate	$126.69
Rate for Payer: Hamaspik Choice Inc Medicaid	$126.69

LEVOTHYROXINE SODIUM 200 MCG IV SOLR

Facility

$228.42

Service Code	NDC 7086045210
Hospital Charge Code	7086045210
Hospital Revenue Code	258
Min. Negotiated Rate	$114.21
Max. Negotiated Rate	$114.21
Rate for Payer: Hamaspik Choice Inc Medicaid	$114.21

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.44

Service Code	NDC 0378180077
Hospital Charge Code	0378180077
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.22
Rate for Payer: Aetna Government	$0.22
Rate for Payer: Brighton Health Commercial	$0.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.30
Rate for Payer: EmblemHealth Commercial	$0.22
Rate for Payer: Group Health Inc Commercial	$0.22
Rate for Payer: Group Health Inc Medicare	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.22
Rate for Payer: Hamaspik Choice Inc Medicare	$0.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.28

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.18

Service Code	NDC 7230502530
Hospital Charge Code	7230502530
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.14
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.10
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.09
Rate for Payer: Aetna Government	$0.09
Rate for Payer: Brighton Health Commercial	$0.13
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.14
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.12
Rate for Payer: EmblemHealth Commercial	$0.09
Rate for Payer: Group Health Inc Commercial	$0.09
Rate for Payer: Group Health Inc Medicare	$0.06
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09
Rate for Payer: Hamaspik Choice Inc Medicare	$0.09
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.11

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.56

Service Code	NDC 6068745301
Hospital Charge Code	6068745301
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	$0.36

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.18

Service Code	NDC 7230502530
Hospital Charge Code	7230502530
Hospital Revenue Code	250
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.09
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.09

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.44

Service Code	NDC 6818096509
Hospital Charge Code	6818096509
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.35
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.24
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.22
Rate for Payer: Aetna Government	$0.22
Rate for Payer: Brighton Health Commercial	$0.33
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.35
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.30
Rate for Payer: EmblemHealth Commercial	$0.22
Rate for Payer: Group Health Inc Commercial	$0.22
Rate for Payer: Group Health Inc Medicare	$0.15
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.22
Rate for Payer: Hamaspik Choice Inc Medicare	$0.22
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.28

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.44

Service Code	NDC 0378180077
Hospital Charge Code	0378180077
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.22

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.55

Service Code	NDC 0904694961
Hospital Charge Code	0904694961
Hospital Revenue Code	250
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.44
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.30
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.27
Rate for Payer: Aetna Government	$0.27
Rate for Payer: Brighton Health Commercial	$0.41
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.44
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.37
Rate for Payer: EmblemHealth Commercial	$0.27
Rate for Payer: Group Health Inc Commercial	$0.27
Rate for Payer: Group Health Inc Medicare	$0.19
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27
Rate for Payer: Hamaspik Choice Inc Medicare	$0.27
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.36

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.55

Service Code	NDC 0904694961
Hospital Charge Code	0904694961
Hospital Revenue Code	250
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.27
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.27

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.44

Service Code	NDC 6818096509
Hospital Charge Code	6818096509
Hospital Revenue Code	250
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.22
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.22

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.46

Service Code	NDC 0527328046
Hospital Charge Code	0527328046
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.23
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23

LEVOTHYROXINE SODIUM 25 MCG PO TABS

Facility

$0.46

Service Code	NDC 0527328046
Hospital Charge Code	0527328046
Hospital Revenue Code	250
Min. Negotiated Rate	$0.16
Max. Negotiated Rate	$0.36
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.25
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.23
Rate for Payer: Aetna Government	$0.23
Rate for Payer: Brighton Health Commercial	$0.34
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.36
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.31
Rate for Payer: EmblemHealth Commercial	$0.23
Rate for Payer: Group Health Inc Commercial	$0.23
Rate for Payer: Group Health Inc Medicare	$0.16
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.23
Rate for Payer: Hamaspik Choice Inc Medicare	$0.23
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.30

Know your out-of-pocket cost for care.

All Charges