|
CARBAMAZEPINE 200 MG TABLET
|
Facility
|
OP
|
$247.68
|
|
|
Service Code
|
NDC 00904617261
|
| Hospital Charge Code |
1357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.34 |
| Max. Negotiated Rate |
$222.91 |
| Rate for Payer: Aetna Commercial |
$210.53
|
| Rate for Payer: Aetna Medicare |
$123.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.99
|
| Rate for Payer: BCBS Complete |
$99.07
|
| Rate for Payer: Cash Price |
$198.14
|
| Rate for Payer: Cofinity Advantage |
$173.38
|
| Rate for Payer: Cofinity Commercial |
$213.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$198.14
|
| Rate for Payer: Healthscope Commercial |
$222.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$198.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$185.76
|
| Rate for Payer: PHP Commercial |
$210.53
|
| Rate for Payer: Priority Health SBD |
$156.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$160.99
|
| Rate for Payer: UHC Core |
$129.04
|
| Rate for Payer: UHC Exchange |
$97.34
|
|
|
CARBAMAZEPINE 200 MG TABLET
|
Facility
|
OP
|
$361.00
|
|
|
Service Code
|
NDC 51672400501
|
| Hospital Charge Code |
1357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.87 |
| Max. Negotiated Rate |
$324.90 |
| Rate for Payer: Aetna Commercial |
$306.85
|
| Rate for Payer: Aetna Medicare |
$180.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$234.65
|
| Rate for Payer: BCBS Complete |
$144.40
|
| Rate for Payer: Cash Price |
$288.80
|
| Rate for Payer: Cofinity Advantage |
$252.70
|
| Rate for Payer: Cofinity Commercial |
$310.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$288.80
|
| Rate for Payer: Healthscope Commercial |
$324.90
|
| Rate for Payer: MI Amish Medical Board Commercial |
$288.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$306.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$270.75
|
| Rate for Payer: PHP Commercial |
$306.85
|
| Rate for Payer: Priority Health SBD |
$227.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$234.65
|
| Rate for Payer: UHC Core |
$188.08
|
| Rate for Payer: UHC Exchange |
$141.87
|
|
|
CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
OP
|
$878.40
|
|
|
Service Code
|
NDC 66993040732
|
| Hospital Charge Code |
37567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$345.21 |
| Max. Negotiated Rate |
$790.56 |
| Rate for Payer: Aetna Commercial |
$746.64
|
| Rate for Payer: Aetna Medicare |
$439.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$570.96
|
| Rate for Payer: BCBS Complete |
$351.36
|
| Rate for Payer: Cash Price |
$702.72
|
| Rate for Payer: Cofinity Advantage |
$614.88
|
| Rate for Payer: Cofinity Commercial |
$755.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$702.72
|
| Rate for Payer: Healthscope Commercial |
$790.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$702.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$746.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$658.80
|
| Rate for Payer: PHP Commercial |
$746.64
|
| Rate for Payer: Priority Health SBD |
$553.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$570.96
|
| Rate for Payer: UHC Core |
$457.65
|
| Rate for Payer: UHC Exchange |
$345.21
|
|
|
CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$878.40
|
|
|
Service Code
|
NDC 66993040732
|
| Hospital Charge Code |
37567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$553.39 |
| Max. Negotiated Rate |
$790.56 |
| Rate for Payer: Aetna Commercial |
$746.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$570.96
|
| Rate for Payer: Cash Price |
$702.72
|
| Rate for Payer: Cofinity Advantage |
$614.88
|
| Rate for Payer: Cofinity Commercial |
$755.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$702.72
|
| Rate for Payer: Healthscope Commercial |
$790.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$746.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$658.80
|
| Rate for Payer: PHP Commercial |
$746.64
|
| Rate for Payer: Priority Health SBD |
$553.39
|
|
|
CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
OP
|
$11.80
|
|
|
Service Code
|
NDC 50268017011
|
| Hospital Charge Code |
37567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.64 |
| Max. Negotiated Rate |
$10.62 |
| Rate for Payer: Aetna Commercial |
$10.03
|
| Rate for Payer: Aetna Medicare |
$5.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.67
|
| Rate for Payer: BCBS Complete |
$4.72
|
| Rate for Payer: Cash Price |
$9.44
|
| Rate for Payer: Cofinity Advantage |
$8.26
|
| Rate for Payer: Cofinity Commercial |
$10.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.44
|
| Rate for Payer: Healthscope Commercial |
$10.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.85
|
| Rate for Payer: PHP Commercial |
$10.03
|
| Rate for Payer: Priority Health SBD |
$7.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$7.67
|
| Rate for Payer: UHC Core |
$6.15
|
| Rate for Payer: UHC Exchange |
$4.64
|
|
|
CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$11.80
|
|
|
Service Code
|
NDC 50268017011
|
| Hospital Charge Code |
37567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.43 |
| Max. Negotiated Rate |
$10.62 |
| Rate for Payer: Aetna Commercial |
$10.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.67
|
| Rate for Payer: Cash Price |
$9.44
|
| Rate for Payer: Cofinity Advantage |
$8.26
|
| Rate for Payer: Cofinity Commercial |
$10.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.44
|
| Rate for Payer: Healthscope Commercial |
$10.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.03
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.85
|
| Rate for Payer: PHP Commercial |
$10.03
|
| Rate for Payer: Priority Health SBD |
$7.43
|
|
|
CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$353.87
|
|
|
Service Code
|
NDC 50268017013
|
| Hospital Charge Code |
37567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$222.94 |
| Max. Negotiated Rate |
$318.48 |
| Rate for Payer: Aetna Commercial |
$300.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.02
|
| Rate for Payer: Cash Price |
$283.10
|
| Rate for Payer: Cofinity Advantage |
$247.71
|
| Rate for Payer: Cofinity Commercial |
$304.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.10
|
| Rate for Payer: Healthscope Commercial |
$318.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$300.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$265.40
|
| Rate for Payer: PHP Commercial |
$300.79
|
| Rate for Payer: Priority Health SBD |
$222.94
|
|
|
CARBAMAZEPINE ER 100 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
OP
|
$353.87
|
|
|
Service Code
|
NDC 50268017013
|
| Hospital Charge Code |
37567
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$139.07 |
| Max. Negotiated Rate |
$318.48 |
| Rate for Payer: Aetna Commercial |
$300.79
|
| Rate for Payer: Aetna Medicare |
$176.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$230.02
|
| Rate for Payer: BCBS Complete |
$141.55
|
| Rate for Payer: Cash Price |
$283.10
|
| Rate for Payer: Cofinity Advantage |
$247.71
|
| Rate for Payer: Cofinity Commercial |
$304.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.10
|
| Rate for Payer: Healthscope Commercial |
$318.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$283.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$300.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$265.40
|
| Rate for Payer: PHP Commercial |
$300.79
|
| Rate for Payer: Priority Health SBD |
$222.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$230.02
|
| Rate for Payer: UHC Core |
$184.37
|
| Rate for Payer: UHC Exchange |
$139.07
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$9.99
|
|
|
Service Code
|
NDC 00904747835
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.93 |
| Max. Negotiated Rate |
$8.99 |
| Rate for Payer: Aetna Commercial |
$8.49
|
| Rate for Payer: Aetna Medicare |
$5.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.49
|
| Rate for Payer: BCBS Complete |
$4.00
|
| Rate for Payer: Cash Price |
$7.99
|
| Rate for Payer: Cofinity Advantage |
$6.99
|
| Rate for Payer: Cofinity Commercial |
$8.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.99
|
| Rate for Payer: Healthscope Commercial |
$8.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.49
|
| Rate for Payer: PHP Commercial |
$8.49
|
| Rate for Payer: Priority Health SBD |
$6.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.49
|
| Rate for Payer: UHC Core |
$5.20
|
| Rate for Payer: UHC Exchange |
$3.93
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$8.73
|
|
|
Service Code
|
NDC 70000049002
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.43 |
| Max. Negotiated Rate |
$7.86 |
| Rate for Payer: Aetna Commercial |
$7.42
|
| Rate for Payer: Aetna Medicare |
$4.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.67
|
| Rate for Payer: BCBS Complete |
$3.49
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Cofinity Advantage |
$6.11
|
| Rate for Payer: Cofinity Commercial |
$7.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.98
|
| Rate for Payer: Healthscope Commercial |
$7.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.55
|
| Rate for Payer: PHP Commercial |
$7.42
|
| Rate for Payer: Priority Health SBD |
$5.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.67
|
| Rate for Payer: UHC Core |
$4.55
|
| Rate for Payer: UHC Exchange |
$3.43
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$9.99
|
|
|
Service Code
|
NDC 00904747835
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$8.99 |
| Rate for Payer: Aetna Commercial |
$8.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.49
|
| Rate for Payer: Cash Price |
$7.99
|
| Rate for Payer: Cofinity Advantage |
$6.99
|
| Rate for Payer: Cofinity Commercial |
$8.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.99
|
| Rate for Payer: Healthscope Commercial |
$8.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.49
|
| Rate for Payer: PHP Commercial |
$8.49
|
| Rate for Payer: Priority Health SBD |
$6.29
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$22.75
|
|
|
Service Code
|
NDC 78112073623
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.94 |
| 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 Advantage |
$15.93
|
| Rate for Payer: Cofinity Commercial |
$19.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.20
|
| Rate for Payer: Healthscope Commercial |
$20.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.06
|
| Rate for Payer: PHP Commercial |
$19.34
|
| Rate for Payer: Priority Health SBD |
$14.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.79
|
| Rate for Payer: UHC Core |
$11.85
|
| Rate for Payer: UHC Exchange |
$8.94
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$10.74
|
|
|
Service Code
|
NDC 00904662735
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.22 |
| Max. Negotiated Rate |
$9.67 |
| Rate for Payer: Aetna Commercial |
$9.13
|
| Rate for Payer: Aetna Medicare |
$5.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.98
|
| Rate for Payer: BCBS Complete |
$4.30
|
| Rate for Payer: Cash Price |
$8.59
|
| Rate for Payer: Cofinity Advantage |
$7.52
|
| Rate for Payer: Cofinity Commercial |
$9.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.59
|
| Rate for Payer: Healthscope Commercial |
$9.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.05
|
| Rate for Payer: PHP Commercial |
$9.13
|
| Rate for Payer: Priority Health SBD |
$6.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.98
|
| Rate for Payer: UHC Core |
$5.60
|
| Rate for Payer: UHC Exchange |
$4.22
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$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 Advantage |
$15.93
|
| Rate for Payer: Cofinity Commercial |
$19.57
|
| 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: Opus (Opus Packaging Group) HMA |
$17.06
|
| Rate for Payer: PHP Commercial |
$19.34
|
| Rate for Payer: Priority Health SBD |
$14.33
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$26.13
|
|
|
Service Code
|
NDC 78112073621
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.27 |
| 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 Advantage |
$18.29
|
| Rate for Payer: Cofinity Commercial |
$22.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.90
|
| Rate for Payer: Healthscope Commercial |
$23.52
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.21
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.60
|
| Rate for Payer: PHP Commercial |
$22.21
|
| Rate for Payer: Priority Health SBD |
$16.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.98
|
| Rate for Payer: UHC Core |
$13.61
|
| Rate for Payer: UHC Exchange |
$10.27
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$10.74
|
|
|
Service Code
|
NDC 00904662735
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.77 |
| Max. Negotiated Rate |
$9.67 |
| Rate for Payer: Aetna Commercial |
$9.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.98
|
| Rate for Payer: Cash Price |
$8.59
|
| Rate for Payer: Cofinity Advantage |
$7.52
|
| Rate for Payer: Cofinity Commercial |
$9.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.59
|
| Rate for Payer: Healthscope Commercial |
$9.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$9.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.05
|
| Rate for Payer: PHP Commercial |
$9.13
|
| Rate for Payer: Priority Health SBD |
$6.77
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$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 Advantage |
$18.29
|
| Rate for Payer: Cofinity Commercial |
$22.47
|
| 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: Opus (Opus Packaging Group) HMA |
$19.60
|
| Rate for Payer: PHP Commercial |
$22.21
|
| Rate for Payer: Priority Health SBD |
$16.46
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$8.73
|
|
|
Service Code
|
NDC 70000049002
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.50 |
| Max. Negotiated Rate |
$7.86 |
| Rate for Payer: Aetna Commercial |
$7.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.67
|
| Rate for Payer: Cash Price |
$6.98
|
| Rate for Payer: Cofinity Advantage |
$6.11
|
| Rate for Payer: Cofinity Commercial |
$7.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.98
|
| Rate for Payer: Healthscope Commercial |
$7.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.55
|
| Rate for Payer: PHP Commercial |
$7.42
|
| Rate for Payer: Priority Health SBD |
$5.50
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$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 Advantage |
$136.53
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| 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: Opus (Opus Packaging Group) HMA |
$146.29
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health SBD |
$122.88
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$195.05
|
|
|
Service Code
|
NDC 69367033801
|
| Hospital Charge Code |
9406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.65 |
| 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 Advantage |
$136.53
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$156.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.29
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.78
|
| Rate for Payer: UHC Core |
$101.62
|
| Rate for Payer: UHC Exchange |
$76.65
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$194.75
|
|
|
Service Code
|
NDC 60687066101
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.54 |
| Max. Negotiated Rate |
$175.28 |
| Rate for Payer: Aetna Commercial |
$165.54
|
| Rate for Payer: Aetna Medicare |
$97.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.59
|
| Rate for Payer: BCBS Complete |
$77.90
|
| Rate for Payer: Cash Price |
$155.80
|
| Rate for Payer: Cofinity Advantage |
$136.32
|
| Rate for Payer: Cofinity Commercial |
$167.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.80
|
| Rate for Payer: Healthscope Commercial |
$175.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$155.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.06
|
| Rate for Payer: PHP Commercial |
$165.54
|
| Rate for Payer: Priority Health SBD |
$122.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.59
|
| Rate for Payer: UHC Core |
$101.46
|
| Rate for Payer: UHC Exchange |
$76.54
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$194.75
|
|
|
Service Code
|
NDC 60687066101
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.69 |
| Max. Negotiated Rate |
$175.28 |
| Rate for Payer: Aetna Commercial |
$165.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.59
|
| Rate for Payer: Cash Price |
$155.80
|
| Rate for Payer: Cofinity Advantage |
$136.32
|
| Rate for Payer: Cofinity Commercial |
$167.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.80
|
| Rate for Payer: Healthscope Commercial |
$175.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.06
|
| Rate for Payer: PHP Commercial |
$165.54
|
| Rate for Payer: Priority Health SBD |
$122.69
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$198.55
|
|
|
Service Code
|
NDC 63739010810
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.03 |
| 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 Advantage |
$138.99
|
| Rate for Payer: Cofinity Commercial |
$170.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.84
|
| Rate for Payer: Healthscope Commercial |
$178.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$158.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$168.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.91
|
| Rate for Payer: PHP Commercial |
$168.77
|
| Rate for Payer: Priority Health SBD |
$125.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$129.06
|
| Rate for Payer: UHC Core |
$103.44
|
| Rate for Payer: UHC Exchange |
$78.03
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$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 Advantage |
$138.99
|
| Rate for Payer: Cofinity Commercial |
$170.75
|
| 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: Opus (Opus Packaging Group) HMA |
$148.91
|
| Rate for Payer: PHP Commercial |
$168.77
|
| Rate for Payer: Priority Health SBD |
$125.09
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$1.95
|
|
|
Service Code
|
NDC 60687066111
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.23 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Aetna Commercial |
$1.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.27
|
| Rate for Payer: Cash Price |
$1.56
|
| Rate for Payer: Cofinity Advantage |
$1.36
|
| Rate for Payer: Cofinity Commercial |
$1.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.56
|
| Rate for Payer: Healthscope Commercial |
$1.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.46
|
| Rate for Payer: PHP Commercial |
$1.66
|
| Rate for Payer: Priority Health SBD |
$1.23
|
|
