Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

levothyroxine 200 mcg (0.2 mg) Tab [HMC]

Facility

OP

$7.42

Service Code	NDC 72305020030
Hospital Charge Code	3800454
Hospital Revenue Code	250
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$7.05
Rate for Payer: Aetna Commercial	$6.68
Rate for Payer: Humana Medicare Advantage	$3.12
Rate for Payer: UnitedHealthcare Commercial	$7.05
Rate for Payer: UnitedHealthcare Medicaid	$2.97
Rate for Payer: WPPA Medicare Advantage	$4.45

levothyroxine 200 mcg (0.2 mg) Tab [HMC]

Facility

OP

$7.42

Service Code	NDC 68180097501
Hospital Charge Code	3800454
Hospital Revenue Code	250
Min. Negotiated Rate	$2.97
Max. Negotiated Rate	$7.05
Rate for Payer: Aetna Commercial	$6.68
Rate for Payer: Humana Medicare Advantage	$3.12
Rate for Payer: UnitedHealthcare Commercial	$7.05
Rate for Payer: UnitedHealthcare Medicaid	$2.97
Rate for Payer: WPPA Medicare Advantage	$4.45

levothyroxine 200 mcg (0.2 mg) Tab [HMC]

Facility

OP

$8.60

Service Code	NDC 60687055201
Hospital Charge Code	3800454
Hospital Revenue Code	250
Min. Negotiated Rate	$3.44
Max. Negotiated Rate	$8.17
Rate for Payer: Aetna Commercial	$7.74
Rate for Payer: Humana Medicare Advantage	$3.61
Rate for Payer: UnitedHealthcare Commercial	$8.17
Rate for Payer: UnitedHealthcare Medicaid	$3.44
Rate for Payer: WPPA Medicare Advantage	$5.16

levothyroxine 200 mcg (0.2 mg) Tab [HMC]

Facility

IP

$7.42

Service Code	NDC 72305020030
Hospital Charge Code	3800454
Hospital Revenue Code	250
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.68
Rate for Payer: UnitedHealthcare Commercial	$7.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 200 mcg (0.2 mg) Tab [HMC]

Facility

IP

$7.42

Service Code	NDC 68180097501
Hospital Charge Code	3800454
Hospital Revenue Code	250
Min. Negotiated Rate	$6.68
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.68
Rate for Payer: UnitedHealthcare Commercial	$7.05
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 50 mcg (0.05 mg) Tab [HMC]

Facility

IP

$10.68

Service Code	NDC 00074455211
Hospital Charge Code	3801004
Hospital Revenue Code	250
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 50 mcg (0.05 mg) Tab [HMC]

Facility

OP

$6.69

Service Code	NDC 00904695061
Hospital Charge Code	3801004
Hospital Revenue Code	250
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$6.36
Rate for Payer: Aetna Commercial	$6.02
Rate for Payer: Humana Medicare Advantage	$2.81
Rate for Payer: UnitedHealthcare Commercial	$6.36
Rate for Payer: UnitedHealthcare Medicaid	$2.68
Rate for Payer: WPPA Medicare Advantage	$4.01

levothyroxine 50 mcg (0.05 mg) Tab [HMC]

Facility

OP

$10.68

Service Code	NDC 00074455211
Hospital Charge Code	3801004
Hospital Revenue Code	250
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$10.15
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: Humana Medicare Advantage	$4.49
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: WPPA Medicare Advantage	$6.41

levothyroxine 50 mcg (0.05 mg) Tab [HMC]

Facility

IP

$6.69

Service Code	NDC 00904695061
Hospital Charge Code	3801004
Hospital Revenue Code	250
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.02
Rate for Payer: UnitedHealthcare Commercial	$6.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 50 mcg (0.05) Tab [HMC]

Facility

OP

$6.69

Service Code	NDC 60687046401
Hospital Charge Code	3801004
Hospital Revenue Code	250
Min. Negotiated Rate	$2.68
Max. Negotiated Rate	$6.36
Rate for Payer: Aetna Commercial	$6.02
Rate for Payer: Humana Medicare Advantage	$2.81
Rate for Payer: UnitedHealthcare Commercial	$6.36
Rate for Payer: UnitedHealthcare Medicaid	$2.68
Rate for Payer: WPPA Medicare Advantage	$4.01

levothyroxine 50 mcg (0.05) Tab [HMC]

Facility

IP

$6.69

Service Code	NDC 60687046401
Hospital Charge Code	3801004
Hospital Revenue Code	250
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.02
Rate for Payer: UnitedHealthcare Commercial	$6.36
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 50 mcg Tab [HMC]

Facility

IP

$6.49

Service Code	NDC 68180096609
Hospital Charge Code	3801004
Hospital Revenue Code	250
Min. Negotiated Rate	$5.84
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.84
Rate for Payer: UnitedHealthcare Commercial	$6.17
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 50 mcg Tab [HMC]

Facility

OP

$6.49

Service Code	NDC 68180096609
Hospital Charge Code	3801004
Hospital Revenue Code	250
Min. Negotiated Rate	$2.60
Max. Negotiated Rate	$6.17
Rate for Payer: Aetna Commercial	$5.84
Rate for Payer: Humana Medicare Advantage	$2.73
Rate for Payer: UnitedHealthcare Commercial	$6.17
Rate for Payer: UnitedHealthcare Medicaid	$2.60
Rate for Payer: WPPA Medicare Advantage	$3.89

levothyroxine 75 mcg (0.075 mg) Tab

Facility

OP

$6.64

Service Code	NDC 68180096701
Hospital Charge Code	3809198
Hospital Revenue Code	250
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$6.31
Rate for Payer: Aetna Commercial	$5.98
Rate for Payer: Humana Medicare Advantage	$2.79
Rate for Payer: UnitedHealthcare Commercial	$6.31
Rate for Payer: UnitedHealthcare Medicaid	$2.66
Rate for Payer: WPPA Medicare Advantage	$3.98

levothyroxine 75 mcg (0.075 mg) Tab

Facility

IP

$6.64

Service Code	NDC 68180096701
Hospital Charge Code	3809198
Hospital Revenue Code	250
Min. Negotiated Rate	$5.98
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$5.98
Rate for Payer: UnitedHealthcare Commercial	$6.31
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 75 mcg (0.075 mg) Tab [HMC]

Facility

OP

$10.68

Service Code	NDC 00074518211
Hospital Charge Code	3809198
Hospital Revenue Code	250
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$10.15
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: Humana Medicare Advantage	$4.49
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: WPPA Medicare Advantage	$6.41

levothyroxine 75 mcg (0.075 mg) Tab [HMC]

Facility

IP

$10.68

Service Code	NDC 00074518211
Hospital Charge Code	3809198
Hospital Revenue Code	250
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 75 mcg (0.075 mg) Tab [HMC]

Facility

OP

$7.06

Service Code	NDC 00904695161
Hospital Charge Code	3809198
Hospital Revenue Code	250
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$6.71
Rate for Payer: Aetna Commercial	$6.35
Rate for Payer: Humana Medicare Advantage	$2.97
Rate for Payer: UnitedHealthcare Commercial	$6.71
Rate for Payer: UnitedHealthcare Medicaid	$2.82
Rate for Payer: WPPA Medicare Advantage	$4.24

levothyroxine 75 mcg (0.075 mg) Tab [HMC]

Facility

IP

$7.06

Service Code	NDC 00904695161
Hospital Charge Code	3809198
Hospital Revenue Code	250
Min. Negotiated Rate	$6.35
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.35
Rate for Payer: UnitedHealthcare Commercial	$6.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 88 mcg (0.088 mg) Tab [HMC]

Facility

OP

$7.10

Service Code	NDC 00904695261
Hospital Charge Code	3808801
Hospital Revenue Code	250
Min. Negotiated Rate	$2.84
Max. Negotiated Rate	$6.75
Rate for Payer: Aetna Commercial	$6.39
Rate for Payer: Humana Medicare Advantage	$2.98
Rate for Payer: UnitedHealthcare Commercial	$6.75
Rate for Payer: UnitedHealthcare Medicaid	$2.84
Rate for Payer: WPPA Medicare Advantage	$4.26

levothyroxine 88 mcg (0.088 mg) Tab [HMC]

Facility

OP

$10.68

Service Code	NDC 00074659490
Hospital Charge Code	3808801
Hospital Revenue Code	250
Min. Negotiated Rate	$4.27
Max. Negotiated Rate	$10.15
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: Humana Medicare Advantage	$4.49
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: UnitedHealthcare Medicaid	$4.27
Rate for Payer: WPPA Medicare Advantage	$6.41

levothyroxine 88 mcg (0.088 mg) Tab [HMC]

Facility

IP

$10.68

Service Code	NDC 00074659490
Hospital Charge Code	3808801
Hospital Revenue Code	250
Min. Negotiated Rate	$9.61
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$9.61
Rate for Payer: UnitedHealthcare Commercial	$10.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

levothyroxine 88 mcg (0.088 mg) Tab [HMC]

Facility

IP

$7.10

Service Code	NDC 00904695261
Hospital Charge Code	3808801
Hospital Revenue Code	250
Min. Negotiated Rate	$6.39
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$6.39
Rate for Payer: UnitedHealthcare Commercial	$6.75
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LH QST

Facility

IP

$114.00

Service Code	HCPCS 83002
Hospital Charge Code	3551468
Hospital Revenue Code	300
Min. Negotiated Rate	$102.60
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: UnitedHealthcare Commercial	$108.30
Rate for Payer: WPPA Medicare Advantage	$1,200.00

LH QST

Facility

OP

$114.00

Service Code	HCPCS 83002
Hospital Charge Code	3551468
Hospital Revenue Code	300
Min. Negotiated Rate	$18.52
Max. Negotiated Rate	$108.30
Rate for Payer: Aetna Commercial	$102.60
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$69.56
Rate for Payer: Humana Medicare Advantage	$47.88
Rate for Payer: UnitedHealthcare Commercial	$108.30
Rate for Payer: UnitedHealthcare Medicaid	$18.52
Rate for Payer: WPPA Medicare Advantage	$68.40

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