|
LEVOTHYROXINE SODIUM 25 MCG PO TABS
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 6068745301
|
| Hospital Charge Code |
6068745301
|
|
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 500 MCG IV SOLR
|
Facility
|
OP
|
$633.49
|
|
|
Service Code
|
NDC 6332364810
|
| Hospital Charge Code |
6332364810
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$221.72 |
| Max. Negotiated Rate |
$506.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$348.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$316.75
|
| Rate for Payer: Aetna Government |
$316.75
|
| Rate for Payer: Brighton Health Commercial |
$475.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$506.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$430.77
|
| Rate for Payer: EmblemHealth Commercial |
$316.75
|
| Rate for Payer: Group Health Inc Commercial |
$316.75
|
| Rate for Payer: Group Health Inc Medicare |
$221.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$316.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$316.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$411.77
|
|
|
LEVOTHYROXINE SODIUM 500 MCG IV SOLR
|
Facility
|
OP
|
$633.49
|
|
|
Service Code
|
NDC 4202320301
|
| Hospital Charge Code |
4202320301
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$221.72 |
| Max. Negotiated Rate |
$506.79 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$348.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$316.75
|
| Rate for Payer: Aetna Government |
$316.75
|
| Rate for Payer: Brighton Health Commercial |
$475.12
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$506.79
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$430.77
|
| Rate for Payer: EmblemHealth Commercial |
$316.75
|
| Rate for Payer: Group Health Inc Commercial |
$316.75
|
| Rate for Payer: Group Health Inc Medicare |
$221.72
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$316.75
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$316.75
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$411.77
|
|
|
LEVOTHYROXINE SODIUM 500 MCG IV SOLR
|
Facility
|
IP
|
$633.49
|
|
|
Service Code
|
NDC 4202320301
|
| Hospital Charge Code |
4202320301
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$316.75 |
| Max. Negotiated Rate |
$316.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$316.75
|
|
|
LEVOTHYROXINE SODIUM 500 MCG IV SOLR
|
Facility
|
IP
|
$633.49
|
|
|
Service Code
|
NDC 6332364810
|
| Hospital Charge Code |
6332364810
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$316.75 |
| Max. Negotiated Rate |
$316.75 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$316.75
|
|
|
LEVOTHYROXINE SODIUM 500 MCG IV SOLR
|
Facility
|
IP
|
$570.78
|
|
|
Service Code
|
NDC 7086045310
|
| Hospital Charge Code |
7086045310
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$285.39 |
| Max. Negotiated Rate |
$285.39 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$285.39
|
|
|
LEVOTHYROXINE SODIUM 500 MCG IV SOLR
|
Facility
|
OP
|
$570.78
|
|
|
Service Code
|
NDC 7086045310
|
| Hospital Charge Code |
7086045310
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$199.77 |
| Max. Negotiated Rate |
$456.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$313.93
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$285.39
|
| Rate for Payer: Aetna Government |
$285.39
|
| Rate for Payer: Brighton Health Commercial |
$428.08
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$456.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$388.13
|
| Rate for Payer: EmblemHealth Commercial |
$285.39
|
| Rate for Payer: Group Health Inc Commercial |
$285.39
|
| Rate for Payer: Group Health Inc Medicare |
$199.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$285.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$285.39
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$371.01
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS
|
Facility
|
OP
|
$0.52
|
|
|
Service Code
|
NDC 0527328146
|
| Hospital Charge Code |
0527328146
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.41 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.28
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.26
|
| Rate for Payer: Aetna Government |
$0.26
|
| Rate for Payer: Brighton Health Commercial |
$0.39
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.41
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.35
|
| Rate for Payer: EmblemHealth Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Commercial |
$0.26
|
| Rate for Payer: Group Health Inc Medicare |
$0.18
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.26
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.34
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 6818096601
|
| Hospital Charge Code |
6818096601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
NDC 0074455290
|
| Hospital Charge Code |
0074455290
|
|
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 50 MCG PO TABS
|
Facility
|
IP
|
$0.19
|
|
|
Service Code
|
NDC 7230505030
|
| Hospital Charge Code |
7230505030
|
|
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 50 MCG PO TABS
|
Facility
|
IP
|
$1.89
|
|
|
Service Code
|
NDC 0074455211
|
| Hospital Charge Code |
0074455211
|
|
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 50 MCG PO TABS
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 0074455211
|
| Hospital Charge Code |
0074455211
|
|
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 50 MCG PO TABS
|
Facility
|
IP
|
$0.52
|
|
|
Service Code
|
NDC 0527328146
|
| Hospital Charge Code |
0527328146
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.26 |
| Max. Negotiated Rate |
$0.26 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.26
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 0074455290
|
| Hospital Charge Code |
0074455290
|
|
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 50 MCG PO TABS
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 6818096601
|
| Hospital Charge Code |
6818096601
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.25
|
| Rate for Payer: Aetna Government |
$0.25
|
| Rate for Payer: Brighton Health Commercial |
$0.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.34
|
| Rate for Payer: EmblemHealth Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Medicare |
$0.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.32
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS
|
Facility
|
OP
|
$0.19
|
|
|
Service Code
|
NDC 7230505030
|
| Hospital Charge Code |
7230505030
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.15 |
| 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 |
$0.14
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.15
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.13
|
| Rate for Payer: EmblemHealth Commercial |
$0.09
|
| Rate for Payer: Group Health Inc Commercial |
$0.09
|
| Rate for Payer: Group Health Inc Medicare |
$0.07
|
| 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 |
$0.12
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS
|
Facility
|
OP
|
$0.50
|
|
|
Service Code
|
NDC 6818096609
|
| Hospital Charge Code |
6818096609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.17 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.25
|
| Rate for Payer: Aetna Government |
$0.25
|
| Rate for Payer: Brighton Health Commercial |
$0.37
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.40
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.34
|
| Rate for Payer: EmblemHealth Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Commercial |
$0.25
|
| Rate for Payer: Group Health Inc Medicare |
$0.17
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.25
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.32
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS
|
Facility
|
IP
|
$0.50
|
|
|
Service Code
|
NDC 6818096609
|
| Hospital Charge Code |
6818096609
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.25
|
|
|
LEVOTHYROXINE SODIUM 50 MCG PO TABS
|
Facility
|
IP
|
$0.56
|
|
|
Service Code
|
NDC 0904695061
|
| Hospital Charge Code |
0904695061
|
|
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 50 MCG PO TABS
|
Facility
|
OP
|
$0.56
|
|
|
Service Code
|
NDC 0904695061
|
| Hospital Charge Code |
0904695061
|
|
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 75 MCG PO TABS
|
Facility
|
OP
|
$0.55
|
|
|
Service Code
|
NDC 6923818321
|
| Hospital Charge Code |
6923818321
|
|
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 75 MCG PO TABS
|
Facility
|
IP
|
$0.55
|
|
|
Service Code
|
NDC 0378180577
|
| Hospital Charge Code |
0378180577
|
|
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 75 MCG PO TABS
|
Facility
|
IP
|
$0.20
|
|
|
Service Code
|
NDC 7230507530
|
| Hospital Charge Code |
7230507530
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.10
|
|
|
LEVOTHYROXINE SODIUM 75 MCG PO TABS
|
Facility
|
OP
|
$1.89
|
|
|
Service Code
|
NDC 0074518211
|
| Hospital Charge Code |
0074518211
|
|
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
|
|
