Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$22.75

Service Code	NDC 78112073623
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$20.48
Rate for Payer: Aetna Commercial	$19.34
Rate for Payer: Aetna Medicare	$11.38
Rate for Payer: Aetna New Business (MI Preferred)	$14.79
Rate for Payer: BCBS Complete	$9.10
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cofinity Commercial	$15.93
Rate for Payer: Cofinity Commercial	$19.57
Rate for Payer: Cofinity Medicare Advantage	$15.93
Rate for Payer: Encore Health Key Benefits Commercial	$18.20
Rate for Payer: Healthscope Commercial	$20.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.34
Rate for Payer: PHP Commercial	$19.34
Rate for Payer: Priority Health Cigna Priority Health	$14.79
Rate for Payer: Priority Health SBD	$14.33

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$26.13

Service Code	NDC 78112073621
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$16.46
Max. Negotiated Rate	$23.52
Rate for Payer: Aetna Commercial	$22.21
Rate for Payer: Aetna New Business (MI Preferred)	$16.98
Rate for Payer: Cash Price	$20.90
Rate for Payer: Cofinity Commercial	$18.29
Rate for Payer: Cofinity Commercial	$22.47
Rate for Payer: Cofinity Medicare Advantage	$18.29
Rate for Payer: Encore Health Key Benefits Commercial	$20.90
Rate for Payer: Healthscope Commercial	$23.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.21
Rate for Payer: PHP Commercial	$22.21
Rate for Payer: Priority Health Cigna Priority Health	$16.98
Rate for Payer: Priority Health SBD	$16.46

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$22.75

Service Code	NDC 78112073623
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$14.33
Max. Negotiated Rate	$20.48
Rate for Payer: Aetna Commercial	$19.34
Rate for Payer: Aetna New Business (MI Preferred)	$14.79
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cofinity Commercial	$15.93
Rate for Payer: Cofinity Commercial	$19.57
Rate for Payer: Cofinity Medicare Advantage	$15.93
Rate for Payer: Encore Health Key Benefits Commercial	$18.20
Rate for Payer: Healthscope Commercial	$20.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.34
Rate for Payer: PHP Commercial	$19.34
Rate for Payer: Priority Health Cigna Priority Health	$14.79
Rate for Payer: Priority Health SBD	$14.33

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$12.63

Service Code	NDC 70000049002
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$5.05
Max. Negotiated Rate	$11.37
Rate for Payer: Aetna Commercial	$10.74
Rate for Payer: Aetna Medicare	$6.32
Rate for Payer: Aetna New Business (MI Preferred)	$8.21
Rate for Payer: BCBS Complete	$5.05
Rate for Payer: Cash Price	$10.10
Rate for Payer: Cofinity Commercial	$10.86
Rate for Payer: Cofinity Commercial	$8.84
Rate for Payer: Cofinity Medicare Advantage	$8.84
Rate for Payer: Encore Health Key Benefits Commercial	$10.10
Rate for Payer: Healthscope Commercial	$11.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.74
Rate for Payer: PHP Commercial	$10.74
Rate for Payer: Priority Health Cigna Priority Health	$8.21
Rate for Payer: Priority Health SBD	$7.96

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$26.13

Service Code	NDC 78112073621
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$10.45
Max. Negotiated Rate	$23.52
Rate for Payer: Aetna Commercial	$22.21
Rate for Payer: Aetna Medicare	$13.06
Rate for Payer: Aetna New Business (MI Preferred)	$16.98
Rate for Payer: BCBS Complete	$10.45
Rate for Payer: Cash Price	$20.90
Rate for Payer: Cofinity Commercial	$18.29
Rate for Payer: Cofinity Commercial	$22.47
Rate for Payer: Cofinity Medicare Advantage	$18.29
Rate for Payer: Encore Health Key Benefits Commercial	$20.90
Rate for Payer: Healthscope Commercial	$23.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.21
Rate for Payer: PHP Commercial	$22.21
Rate for Payer: Priority Health Cigna Priority Health	$16.98
Rate for Payer: Priority Health SBD	$16.46

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$12.63

Service Code	NDC 70000049002
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$7.96
Max. Negotiated Rate	$11.37
Rate for Payer: Aetna Commercial	$10.74
Rate for Payer: Aetna New Business (MI Preferred)	$8.21
Rate for Payer: Cash Price	$10.10
Rate for Payer: Cofinity Commercial	$10.86
Rate for Payer: Cofinity Commercial	$8.84
Rate for Payer: Cofinity Medicare Advantage	$8.84
Rate for Payer: Encore Health Key Benefits Commercial	$10.10
Rate for Payer: Healthscope Commercial	$11.37
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$10.74
Rate for Payer: PHP Commercial	$10.74
Rate for Payer: Priority Health Cigna Priority Health	$8.21
Rate for Payer: Priority Health SBD	$7.96

CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET

Facility

$195.05

Service Code	NDC 69367033801
Hospital Charge Code	9406
Hospital Revenue Code	637
Min. Negotiated Rate	$122.88
Max. Negotiated Rate	$175.54
Rate for Payer: Aetna Commercial	$165.79
Rate for Payer: Aetna New Business (MI Preferred)	$126.78
Rate for Payer: Cash Price	$156.04
Rate for Payer: Cofinity Commercial	$136.53
Rate for Payer: Cofinity Commercial	$167.74
Rate for Payer: Cofinity Medicare Advantage	$136.53
Rate for Payer: Encore Health Key Benefits Commercial	$156.04
Rate for Payer: Healthscope Commercial	$175.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$165.79
Rate for Payer: PHP Commercial	$165.79
Rate for Payer: Priority Health Cigna Priority Health	$126.78
Rate for Payer: Priority Health SBD	$122.88

CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET

Facility

$195.05

Service Code	NDC 69367033801
Hospital Charge Code	9406
Hospital Revenue Code	637
Min. Negotiated Rate	$78.02
Max. Negotiated Rate	$175.54
Rate for Payer: Aetna Commercial	$165.79
Rate for Payer: Aetna Medicare	$97.53
Rate for Payer: Aetna New Business (MI Preferred)	$126.78
Rate for Payer: BCBS Complete	$78.02
Rate for Payer: Cash Price	$156.04
Rate for Payer: Cofinity Commercial	$136.53
Rate for Payer: Cofinity Commercial	$167.74
Rate for Payer: Cofinity Medicare Advantage	$136.53
Rate for Payer: Encore Health Key Benefits Commercial	$156.04
Rate for Payer: Healthscope Commercial	$175.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$165.79
Rate for Payer: PHP Commercial	$165.79
Rate for Payer: Priority Health Cigna Priority Health	$126.78
Rate for Payer: Priority Health SBD	$122.88

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$260.30

Service Code	NDC 51862007901
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$104.12
Max. Negotiated Rate	$234.27
Rate for Payer: Aetna Commercial	$221.25
Rate for Payer: Aetna Medicare	$130.15
Rate for Payer: Aetna New Business (MI Preferred)	$169.19
Rate for Payer: BCBS Complete	$104.12
Rate for Payer: Cash Price	$208.24
Rate for Payer: Cofinity Commercial	$182.21
Rate for Payer: Cofinity Commercial	$223.86
Rate for Payer: Cofinity Medicare Advantage	$182.21
Rate for Payer: Encore Health Key Benefits Commercial	$208.24
Rate for Payer: Healthscope Commercial	$234.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$221.25
Rate for Payer: PHP Commercial	$221.25
Rate for Payer: Priority Health Cigna Priority Health	$169.19
Rate for Payer: Priority Health SBD	$163.99

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$329.00

Service Code	NDC 00904623761
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$207.27
Max. Negotiated Rate	$296.10
Rate for Payer: Aetna Commercial	$279.65
Rate for Payer: Aetna New Business (MI Preferred)	$213.85
Rate for Payer: Cash Price	$263.20
Rate for Payer: Cofinity Commercial	$230.30
Rate for Payer: Cofinity Commercial	$282.94
Rate for Payer: Cofinity Medicare Advantage	$230.30
Rate for Payer: Encore Health Key Benefits Commercial	$263.20
Rate for Payer: Healthscope Commercial	$296.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$279.65
Rate for Payer: PHP Commercial	$279.65
Rate for Payer: Priority Health Cigna Priority Health	$213.85
Rate for Payer: Priority Health SBD	$207.27

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$260.30

Service Code	NDC 51862007901
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$163.99
Max. Negotiated Rate	$234.27
Rate for Payer: Aetna Commercial	$221.25
Rate for Payer: Aetna New Business (MI Preferred)	$169.19
Rate for Payer: Cash Price	$208.24
Rate for Payer: Cofinity Commercial	$182.21
Rate for Payer: Cofinity Commercial	$223.86
Rate for Payer: Cofinity Medicare Advantage	$182.21
Rate for Payer: Encore Health Key Benefits Commercial	$208.24
Rate for Payer: Healthscope Commercial	$234.27
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$221.25
Rate for Payer: PHP Commercial	$221.25
Rate for Payer: Priority Health Cigna Priority Health	$169.19
Rate for Payer: Priority Health SBD	$163.99

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$202.35

Service Code	NDC 68084009301
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$127.48
Max. Negotiated Rate	$182.12
Rate for Payer: Aetna Commercial	$172.00
Rate for Payer: Aetna New Business (MI Preferred)	$131.53
Rate for Payer: Cash Price	$161.88
Rate for Payer: Cofinity Commercial	$141.65
Rate for Payer: Cofinity Commercial	$174.02
Rate for Payer: Cofinity Medicare Advantage	$141.65
Rate for Payer: Encore Health Key Benefits Commercial	$161.88
Rate for Payer: Healthscope Commercial	$182.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$172.00
Rate for Payer: PHP Commercial	$172.00
Rate for Payer: Priority Health Cigna Priority Health	$131.53
Rate for Payer: Priority Health SBD	$127.48

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$190.35

Service Code	NDC 00228253910
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$76.14
Max. Negotiated Rate	$171.31
Rate for Payer: Aetna Commercial	$161.80
Rate for Payer: Aetna Medicare	$95.17
Rate for Payer: Aetna New Business (MI Preferred)	$123.73
Rate for Payer: BCBS Complete	$76.14
Rate for Payer: Cash Price	$152.28
Rate for Payer: Cofinity Commercial	$133.25
Rate for Payer: Cofinity Commercial	$163.70
Rate for Payer: Cofinity Medicare Advantage	$133.25
Rate for Payer: Encore Health Key Benefits Commercial	$152.28
Rate for Payer: Healthscope Commercial	$171.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$161.80
Rate for Payer: PHP Commercial	$161.80
Rate for Payer: Priority Health Cigna Priority Health	$123.73
Rate for Payer: Priority Health SBD	$119.92

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$359.55

Service Code	NDC 00904725761
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$226.52
Max. Negotiated Rate	$323.60
Rate for Payer: Aetna Commercial	$305.62
Rate for Payer: Aetna New Business (MI Preferred)	$233.71
Rate for Payer: Cash Price	$287.64
Rate for Payer: Cofinity Commercial	$251.69
Rate for Payer: Cofinity Commercial	$309.21
Rate for Payer: Cofinity Medicare Advantage	$251.69
Rate for Payer: Encore Health Key Benefits Commercial	$287.64
Rate for Payer: Healthscope Commercial	$323.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$305.62
Rate for Payer: PHP Commercial	$305.62
Rate for Payer: Priority Health Cigna Priority Health	$233.71
Rate for Payer: Priority Health SBD	$226.52

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$329.00

Service Code	NDC 00904623761
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$296.10
Rate for Payer: Aetna Commercial	$279.65
Rate for Payer: Aetna Medicare	$164.50
Rate for Payer: Aetna New Business (MI Preferred)	$213.85
Rate for Payer: BCBS Complete	$131.60
Rate for Payer: Cash Price	$263.20
Rate for Payer: Cofinity Commercial	$230.30
Rate for Payer: Cofinity Commercial	$282.94
Rate for Payer: Cofinity Medicare Advantage	$230.30
Rate for Payer: Encore Health Key Benefits Commercial	$263.20
Rate for Payer: Healthscope Commercial	$296.10
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$279.65
Rate for Payer: PHP Commercial	$279.65
Rate for Payer: Priority Health Cigna Priority Health	$213.85
Rate for Payer: Priority Health SBD	$207.27

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$208.05

Service Code	NDC 60687066101
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$83.22
Max. Negotiated Rate	$187.25
Rate for Payer: Aetna Commercial	$176.84
Rate for Payer: Aetna Medicare	$104.03
Rate for Payer: Aetna New Business (MI Preferred)	$135.23
Rate for Payer: BCBS Complete	$83.22
Rate for Payer: Cash Price	$166.44
Rate for Payer: Cofinity Commercial	$145.63
Rate for Payer: Cofinity Commercial	$178.92
Rate for Payer: Cofinity Medicare Advantage	$145.63
Rate for Payer: Encore Health Key Benefits Commercial	$166.44
Rate for Payer: Healthscope Commercial	$187.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$176.84
Rate for Payer: PHP Commercial	$176.84
Rate for Payer: Priority Health Cigna Priority Health	$135.23
Rate for Payer: Priority Health SBD	$131.07

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$2.09

Service Code	NDC 60687066111
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna Commercial	$1.78
Rate for Payer: Aetna New Business (MI Preferred)	$1.36
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cofinity Commercial	$1.46
Rate for Payer: Cofinity Commercial	$1.80
Rate for Payer: Cofinity Medicare Advantage	$1.46
Rate for Payer: Encore Health Key Benefits Commercial	$1.67
Rate for Payer: Healthscope Commercial	$1.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.78
Rate for Payer: PHP Commercial	$1.78
Rate for Payer: Priority Health Cigna Priority Health	$1.36
Rate for Payer: Priority Health SBD	$1.32

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$198.55

Service Code	NDC 63739010810
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$79.42
Max. Negotiated Rate	$178.69
Rate for Payer: Aetna Commercial	$168.77
Rate for Payer: Aetna Medicare	$99.28
Rate for Payer: Aetna New Business (MI Preferred)	$129.06
Rate for Payer: BCBS Complete	$79.42
Rate for Payer: Cash Price	$158.84
Rate for Payer: Cofinity Commercial	$138.99
Rate for Payer: Cofinity Commercial	$170.75
Rate for Payer: Cofinity Medicare Advantage	$138.99
Rate for Payer: Encore Health Key Benefits Commercial	$158.84
Rate for Payer: Healthscope Commercial	$178.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$168.77
Rate for Payer: PHP Commercial	$168.77
Rate for Payer: Priority Health Cigna Priority Health	$129.06
Rate for Payer: Priority Health SBD	$125.09

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$359.55

Service Code	NDC 00904725761
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$143.82
Max. Negotiated Rate	$323.60
Rate for Payer: Aetna Commercial	$305.62
Rate for Payer: Aetna Medicare	$179.78
Rate for Payer: Aetna New Business (MI Preferred)	$233.71
Rate for Payer: BCBS Complete	$143.82
Rate for Payer: Cash Price	$287.64
Rate for Payer: Cofinity Commercial	$251.69
Rate for Payer: Cofinity Commercial	$309.21
Rate for Payer: Cofinity Medicare Advantage	$251.69
Rate for Payer: Encore Health Key Benefits Commercial	$287.64
Rate for Payer: Healthscope Commercial	$323.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$305.62
Rate for Payer: PHP Commercial	$305.62
Rate for Payer: Priority Health Cigna Priority Health	$233.71
Rate for Payer: Priority Health SBD	$226.52

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$198.55

Service Code	NDC 63739010810
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$125.09
Max. Negotiated Rate	$178.69
Rate for Payer: Aetna Commercial	$168.77
Rate for Payer: Aetna New Business (MI Preferred)	$129.06
Rate for Payer: Cash Price	$158.84
Rate for Payer: Cofinity Commercial	$138.99
Rate for Payer: Cofinity Commercial	$170.75
Rate for Payer: Cofinity Medicare Advantage	$138.99
Rate for Payer: Encore Health Key Benefits Commercial	$158.84
Rate for Payer: Healthscope Commercial	$178.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$168.77
Rate for Payer: PHP Commercial	$168.77
Rate for Payer: Priority Health Cigna Priority Health	$129.06
Rate for Payer: Priority Health SBD	$125.09

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$202.35

Service Code	NDC 68084009301
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$80.94
Max. Negotiated Rate	$182.12
Rate for Payer: Aetna Commercial	$172.00
Rate for Payer: Aetna Medicare	$101.17
Rate for Payer: Aetna New Business (MI Preferred)	$131.53
Rate for Payer: BCBS Complete	$80.94
Rate for Payer: Cash Price	$161.88
Rate for Payer: Cofinity Commercial	$141.65
Rate for Payer: Cofinity Commercial	$174.02
Rate for Payer: Cofinity Medicare Advantage	$141.65
Rate for Payer: Encore Health Key Benefits Commercial	$161.88
Rate for Payer: Healthscope Commercial	$182.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$172.00
Rate for Payer: PHP Commercial	$172.00
Rate for Payer: Priority Health Cigna Priority Health	$131.53
Rate for Payer: Priority Health SBD	$127.48

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$190.35

Service Code	NDC 00228253910
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$119.92
Max. Negotiated Rate	$171.31
Rate for Payer: Aetna Commercial	$161.80
Rate for Payer: Aetna New Business (MI Preferred)	$123.73
Rate for Payer: Cash Price	$152.28
Rate for Payer: Cofinity Commercial	$133.25
Rate for Payer: Cofinity Commercial	$163.70
Rate for Payer: Cofinity Medicare Advantage	$133.25
Rate for Payer: Encore Health Key Benefits Commercial	$152.28
Rate for Payer: Healthscope Commercial	$171.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$161.80
Rate for Payer: PHP Commercial	$161.80
Rate for Payer: Priority Health Cigna Priority Health	$123.73
Rate for Payer: Priority Health SBD	$119.92

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$2.03

Service Code	NDC 68084009311
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.83
Rate for Payer: Aetna Commercial	$1.73
Rate for Payer: Aetna Medicare	$1.01
Rate for Payer: Aetna New Business (MI Preferred)	$1.32
Rate for Payer: BCBS Complete	$0.81
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cofinity Commercial	$1.42
Rate for Payer: Cofinity Commercial	$1.75
Rate for Payer: Cofinity Medicare Advantage	$1.42
Rate for Payer: Encore Health Key Benefits Commercial	$1.62
Rate for Payer: Healthscope Commercial	$1.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.73
Rate for Payer: PHP Commercial	$1.73
Rate for Payer: Priority Health Cigna Priority Health	$1.32
Rate for Payer: Priority Health SBD	$1.28

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$208.05

Service Code	NDC 60687066101
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$131.07
Max. Negotiated Rate	$187.25
Rate for Payer: Aetna Commercial	$176.84
Rate for Payer: Aetna New Business (MI Preferred)	$135.23
Rate for Payer: Cash Price	$166.44
Rate for Payer: Cofinity Commercial	$145.63
Rate for Payer: Cofinity Commercial	$178.92
Rate for Payer: Cofinity Medicare Advantage	$145.63
Rate for Payer: Encore Health Key Benefits Commercial	$166.44
Rate for Payer: Healthscope Commercial	$187.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$176.84
Rate for Payer: PHP Commercial	$176.84
Rate for Payer: Priority Health Cigna Priority Health	$135.23
Rate for Payer: Priority Health SBD	$131.07

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$2.09

Service Code	NDC 60687066111
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.88
Rate for Payer: Aetna Commercial	$1.78
Rate for Payer: Aetna Medicare	$1.04
Rate for Payer: Aetna New Business (MI Preferred)	$1.36
Rate for Payer: BCBS Complete	$0.84
Rate for Payer: Cash Price	$1.67
Rate for Payer: Cofinity Commercial	$1.46
Rate for Payer: Cofinity Commercial	$1.80
Rate for Payer: Cofinity Medicare Advantage	$1.46
Rate for Payer: Encore Health Key Benefits Commercial	$1.67
Rate for Payer: Healthscope Commercial	$1.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.78
Rate for Payer: PHP Commercial	$1.78
Rate for Payer: Priority Health Cigna Priority Health	$1.36
Rate for Payer: Priority Health SBD	$1.32

Know your out-of-pocket cost for care.

All Charges