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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE SODIUM 75 MCG PO TABS

Facility

IP

$1.89

Service Code	NDC 0074518211
Hospital Charge Code	0074518211
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 75 MCG PO TABS

Facility

IP

$1.89

Service Code	NDC 0074518290
Hospital Charge Code	0074518290
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 75 MCG PO TABS

Facility

OP

$0.55

Service Code	NDC 0378180577
Hospital Charge Code	0378180577
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 6923818321
Hospital Charge Code	6923818321
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

$0.69

Service Code	NDC 0904695161
Hospital Charge Code	0904695161
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 75 MCG PO TABS

Facility

OP

$1.12

Service Code	NDC 6079385201
Hospital Charge Code	6079385201
Hospital Revenue Code	250
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.89
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.61
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.56
Rate for Payer: Aetna Government	$0.56
Rate for Payer: Brighton Health Commercial	$0.84
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.89
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.76
Rate for Payer: EmblemHealth Commercial	$0.56
Rate for Payer: Group Health Inc Commercial	$0.56
Rate for Payer: Group Health Inc Medicare	$0.39
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.56
Rate for Payer: Hamaspik Choice Inc Medicare	$0.56
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.73

LEVOTHYROXINE SODIUM 75 MCG PO TABS

Facility

OP

$1.89

Service Code	NDC 0074518290
Hospital Charge Code	0074518290
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 75 MCG PO TABS

Facility

OP

$0.69

Service Code	NDC 0904695161
Hospital Charge Code	0904695161
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.55
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.38
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	$0.55
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.47
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	$0.45

LEVOTHYROXINE SODIUM 75 MCG PO TABS

Facility

IP

$1.12

Service Code	NDC 6079385201
Hospital Charge Code	6079385201
Hospital Revenue Code	250
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.56
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.56

LEVOTHYROXINE SODIUM 75 MCG PO TABS

Facility

OP

$0.20

Service Code	NDC 7230507530
Hospital Charge Code	7230507530
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.13
Rate for Payer: EmblemHealth Commercial	$0.10
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

LEVOTHYROXINE SODIUM 88 MCG PO TABS

Facility

IP

$0.20

Service Code	NDC 7230508830
Hospital Charge Code	7230508830
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 88 MCG PO TABS

Facility

IP

$0.70

Service Code	NDC 0904695261
Hospital Charge Code	0904695261
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35

LEVOTHYROXINE SODIUM 88 MCG PO TABS

Facility

OP

$0.56

Service Code	NDC 6818096809
Hospital Charge Code	6818096809
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 88 MCG PO TABS

Facility

OP

$0.70

Service Code	NDC 0904695261
Hospital Charge Code	0904695261
Hospital Revenue Code	250
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.56
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.38
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.35
Rate for Payer: Aetna Government	$0.35
Rate for Payer: Brighton Health Commercial	$0.52
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	$0.24
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	$0.45

LEVOTHYROXINE SODIUM 88 MCG PO TABS

Facility

OP

$0.70

Service Code	NDC 6068748601
Hospital Charge Code	6068748601
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 88 MCG PO TABS

Facility

IP

$0.70

Service Code	NDC 6068748601
Hospital Charge Code	6068748601
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.35
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.35

LEVOTHYROXINE SODIUM 88 MCG PO TABS

Facility

OP

$0.20

Service Code	NDC 7230508830
Hospital Charge Code	7230508830
Hospital Revenue Code	250
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.16
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$0.11
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$0.10
Rate for Payer: Aetna Government	$0.10
Rate for Payer: Brighton Health Commercial	$0.15
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$0.16
Rate for Payer: Cigna LocalPlus Benefit Plan	$0.13
Rate for Payer: EmblemHealth Commercial	$0.10
Rate for Payer: Group Health Inc Commercial	$0.10
Rate for Payer: Group Health Inc Medicare	$0.07
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.10
Rate for Payer: Hamaspik Choice Inc Medicare	$0.10
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$0.13

LEVOTHYROXINE SODIUM 88 MCG PO TABS

Facility

IP

$0.56

Service Code	NDC 6818096809
Hospital Charge Code	6818096809
Hospital Revenue Code	250
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.28
Rate for Payer: Hamaspik Choice Inc Medicaid	$0.28

LIDOCAINE 5 % EX OINT

Facility

OP

$8.94

Service Code	NDC 7075211303
Hospital Charge Code	7075211303
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$7.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.47
Rate for Payer: Aetna Government	$4.47
Rate for Payer: Brighton Health Commercial	$6.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.08
Rate for Payer: EmblemHealth Commercial	$4.47
Rate for Payer: Group Health Inc Commercial	$4.47
Rate for Payer: Group Health Inc Medicare	$3.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.47
Rate for Payer: Hamaspik Choice Inc Medicare	$4.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.81

LIDOCAINE 5 % EX OINT

Facility

IP

$8.94

Service Code	NDC 7075211303
Hospital Charge Code	7075211303
Hospital Revenue Code	250
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$4.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.47

LIDOCAINE 5 % EX OINT

Facility

OP

$8.94

Service Code	NDC 6846241820
Hospital Charge Code	6846241820
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$7.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.47
Rate for Payer: Aetna Government	$4.47
Rate for Payer: Brighton Health Commercial	$6.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.08
Rate for Payer: EmblemHealth Commercial	$4.47
Rate for Payer: Group Health Inc Commercial	$4.47
Rate for Payer: Group Health Inc Medicare	$3.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.47
Rate for Payer: Hamaspik Choice Inc Medicare	$4.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.81

LIDOCAINE 5 % EX OINT

Facility

OP

$8.94

Service Code	NDC 5167230209
Hospital Charge Code	5167230209
Hospital Revenue Code	250
Min. Negotiated Rate	$3.13
Max. Negotiated Rate	$7.15
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$4.91
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$4.47
Rate for Payer: Aetna Government	$4.47
Rate for Payer: Brighton Health Commercial	$6.70
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$7.15
Rate for Payer: Cigna LocalPlus Benefit Plan	$6.08
Rate for Payer: EmblemHealth Commercial	$4.47
Rate for Payer: Group Health Inc Commercial	$4.47
Rate for Payer: Group Health Inc Medicare	$3.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.47
Rate for Payer: Hamaspik Choice Inc Medicare	$4.47
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$5.81

LIDOCAINE 5 % EX OINT

Facility

IP

$8.94

Service Code	NDC 6846241820
Hospital Charge Code	6846241820
Hospital Revenue Code	250
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$4.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.47

LIDOCAINE 5 % EX OINT

Facility

IP

$8.94

Service Code	NDC 5167230209
Hospital Charge Code	5167230209
Hospital Revenue Code	250
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$4.47
Rate for Payer: Hamaspik Choice Inc Medicaid	$4.47

LIDOCAINE 5 % EX PTCH

Facility

OP

$31.81

Service Code	NDC 6348168706
Hospital Charge Code	6348168706
Hospital Revenue Code	250
Min. Negotiated Rate	$11.13
Max. Negotiated Rate	$25.45
Rate for Payer: 1199SEIU National Benefit Fund Commercial	$17.49
Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper	$15.90
Rate for Payer: Aetna Government	$15.90
Rate for Payer: Brighton Health Commercial	$23.86
Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access	$25.45
Rate for Payer: Cigna LocalPlus Benefit Plan	$21.63
Rate for Payer: EmblemHealth Commercial	$15.90
Rate for Payer: Group Health Inc Commercial	$15.90
Rate for Payer: Group Health Inc Medicare	$11.13
Rate for Payer: Hamaspik Choice Inc Medicaid	$15.90
Rate for Payer: Hamaspik Choice Inc Medicare	$15.90
Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual	$20.68

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