|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
OP
|
$346.55
|
|
|
Service Code
|
NDC 68084056111
|
| Hospital Charge Code |
27635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.31 |
| Max. Negotiated Rate |
$311.90 |
| Rate for Payer: Aetna Commercial |
$294.57
|
| Rate for Payer: Aetna Medicare |
$90.10
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$108.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$108.30
|
| Rate for Payer: BCBS Complete |
$138.62
|
| Rate for Payer: BCBS MAPPO |
$86.64
|
| Rate for Payer: BCBS Trust/PPO |
$284.90
|
| Rate for Payer: BCN Commercial |
$269.44
|
| Rate for Payer: BCN Medicare Advantage |
$86.64
|
| Rate for Payer: Cash Price |
$277.24
|
| Rate for Payer: Cofinity Commercial |
$298.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$277.24
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$86.64
|
| Rate for Payer: Healthscope Commercial |
$311.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$259.91
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$90.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$99.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$294.57
|
| Rate for Payer: Nomi Health Commercial |
$284.17
|
| Rate for Payer: PACE Senior Care Partners |
$82.31
|
| Rate for Payer: PACE SWMI |
$86.64
|
| Rate for Payer: PHP Commercial |
$294.57
|
| Rate for Payer: PHP Medicare Advantage |
$86.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$225.26
|
| Rate for Payer: Priority Health HMO/PPO |
$301.50
|
| Rate for Payer: Priority Health Medicare |
$87.50
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$232.19
|
| Rate for Payer: Railroad Medicare Medicare |
$86.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$304.96
|
| Rate for Payer: UHC Core |
$289.37
|
| Rate for Payer: UHC Dual Complete DSNP |
$86.64
|
| Rate for Payer: UHC Exchange |
$86.64
|
| Rate for Payer: UHC Medicare Advantage |
$86.64
|
| Rate for Payer: VA VA |
$86.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$259.91
|
|
|
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 |
$14.79 |
| Max. Negotiated Rate |
$20.48 |
| Rate for Payer: Aetna Commercial |
$19.34
|
| Rate for Payer: BCBS Trust/PPO |
$18.57
|
| Rate for Payer: BCN Commercial |
$17.58
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cofinity Commercial |
$19.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.20
|
| Rate for Payer: Healthscope Commercial |
$20.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.34
|
| Rate for Payer: Nomi Health Commercial |
$18.66
|
| Rate for Payer: PHP Commercial |
$19.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.79
|
| Rate for Payer: Priority Health HMO/PPO |
$19.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.02
|
| Rate for Payer: UHC Core |
$19.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.06
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$10.33
|
|
|
Service Code
|
NDC 23558007650
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.71 |
| Max. Negotiated Rate |
$9.30 |
| Rate for Payer: Aetna Commercial |
$8.78
|
| Rate for Payer: BCBS Trust/PPO |
$8.43
|
| Rate for Payer: BCN Commercial |
$7.98
|
| Rate for Payer: Cash Price |
$8.26
|
| Rate for Payer: Cofinity Commercial |
$8.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.26
|
| Rate for Payer: Healthscope Commercial |
$9.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.78
|
| Rate for Payer: Nomi Health Commercial |
$8.47
|
| Rate for Payer: PHP Commercial |
$8.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.71
|
| Rate for Payer: Priority Health HMO/PPO |
$8.99
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.09
|
| Rate for Payer: UHC Core |
$8.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.75
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$10.33
|
|
|
Service Code
|
NDC 23558007650
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.45 |
| Max. Negotiated Rate |
$9.30 |
| Rate for Payer: Aetna Commercial |
$8.78
|
| Rate for Payer: Aetna Medicare |
$2.69
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.23
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.23
|
| Rate for Payer: BCBS Complete |
$4.13
|
| Rate for Payer: BCBS MAPPO |
$2.58
|
| Rate for Payer: BCBS Trust/PPO |
$8.49
|
| Rate for Payer: BCN Commercial |
$8.03
|
| Rate for Payer: BCN Medicare Advantage |
$2.58
|
| Rate for Payer: Cash Price |
$8.26
|
| Rate for Payer: Cofinity Commercial |
$8.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.26
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2.58
|
| Rate for Payer: Healthscope Commercial |
$9.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.78
|
| Rate for Payer: Nomi Health Commercial |
$8.47
|
| Rate for Payer: PACE Senior Care Partners |
$2.45
|
| Rate for Payer: PACE SWMI |
$2.58
|
| Rate for Payer: PHP Commercial |
$8.78
|
| Rate for Payer: PHP Medicare Advantage |
$2.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.71
|
| Rate for Payer: Priority Health HMO/PPO |
$8.99
|
| Rate for Payer: Priority Health Medicare |
$2.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.92
|
| Rate for Payer: Railroad Medicare Medicare |
$2.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.09
|
| Rate for Payer: UHC Core |
$8.63
|
| Rate for Payer: UHC Dual Complete DSNP |
$2.58
|
| Rate for Payer: UHC Exchange |
$2.58
|
| Rate for Payer: UHC Medicare Advantage |
$2.58
|
| Rate for Payer: VA VA |
$2.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.75
|
|
|
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 |
$5.40 |
| Max. Negotiated Rate |
$20.48 |
| Rate for Payer: Aetna Commercial |
$19.34
|
| Rate for Payer: Aetna Medicare |
$5.92
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.11
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.11
|
| Rate for Payer: BCBS Complete |
$9.10
|
| Rate for Payer: BCBS MAPPO |
$5.69
|
| Rate for Payer: BCBS Trust/PPO |
$18.70
|
| Rate for Payer: BCN Commercial |
$17.69
|
| Rate for Payer: BCN Medicare Advantage |
$5.69
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cofinity Commercial |
$19.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.69
|
| Rate for Payer: Healthscope Commercial |
$20.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.06
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.34
|
| Rate for Payer: Nomi Health Commercial |
$18.66
|
| Rate for Payer: PACE Senior Care Partners |
$5.40
|
| Rate for Payer: PACE SWMI |
$5.69
|
| Rate for Payer: PHP Commercial |
$19.34
|
| Rate for Payer: PHP Medicare Advantage |
$5.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.79
|
| Rate for Payer: Priority Health HMO/PPO |
$19.79
|
| Rate for Payer: Priority Health Medicare |
$5.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.24
|
| Rate for Payer: Railroad Medicare Medicare |
$5.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$20.02
|
| Rate for Payer: UHC Core |
$19.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.69
|
| Rate for Payer: UHC Exchange |
$5.69
|
| Rate for Payer: UHC Medicare Advantage |
$5.69
|
| Rate for Payer: VA VA |
$5.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.06
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$22.37
|
|
|
Service Code
|
NDC 42037010478
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.54 |
| Max. Negotiated Rate |
$20.13 |
| Rate for Payer: Aetna Commercial |
$19.01
|
| Rate for Payer: BCBS Trust/PPO |
$18.26
|
| Rate for Payer: BCN Commercial |
$17.29
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cofinity Commercial |
$19.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.90
|
| Rate for Payer: Healthscope Commercial |
$20.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.01
|
| Rate for Payer: Nomi Health Commercial |
$18.34
|
| Rate for Payer: PHP Commercial |
$19.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.54
|
| Rate for Payer: Priority Health HMO/PPO |
$19.46
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.69
|
| Rate for Payer: UHC Core |
$18.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.78
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$9.79
|
|
|
Service Code
|
NDC 23558076501
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.36 |
| Max. Negotiated Rate |
$8.81 |
| Rate for Payer: Aetna Commercial |
$8.32
|
| Rate for Payer: BCBS Trust/PPO |
$7.99
|
| Rate for Payer: BCN Commercial |
$7.57
|
| Rate for Payer: Cash Price |
$7.83
|
| Rate for Payer: Cofinity Commercial |
$8.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.83
|
| Rate for Payer: Healthscope Commercial |
$8.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.32
|
| Rate for Payer: Nomi Health Commercial |
$8.03
|
| Rate for Payer: PHP Commercial |
$8.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.36
|
| Rate for Payer: Priority Health HMO/PPO |
$8.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.62
|
| Rate for Payer: UHC Core |
$8.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.34
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$22.37
|
|
|
Service Code
|
NDC 42037010478
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.31 |
| Max. Negotiated Rate |
$20.13 |
| Rate for Payer: Aetna Commercial |
$19.01
|
| Rate for Payer: Aetna Medicare |
$5.82
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.99
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.99
|
| Rate for Payer: BCBS Complete |
$8.95
|
| Rate for Payer: BCBS MAPPO |
$5.59
|
| Rate for Payer: BCBS Trust/PPO |
$18.39
|
| Rate for Payer: BCN Commercial |
$17.39
|
| Rate for Payer: BCN Medicare Advantage |
$5.59
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cofinity Commercial |
$19.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.59
|
| Rate for Payer: Healthscope Commercial |
$20.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.78
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.01
|
| Rate for Payer: Nomi Health Commercial |
$18.34
|
| Rate for Payer: PACE Senior Care Partners |
$5.31
|
| Rate for Payer: PACE SWMI |
$5.59
|
| Rate for Payer: PHP Commercial |
$19.01
|
| Rate for Payer: PHP Medicare Advantage |
$5.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.54
|
| Rate for Payer: Priority Health HMO/PPO |
$19.46
|
| Rate for Payer: Priority Health Medicare |
$5.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.99
|
| Rate for Payer: Railroad Medicare Medicare |
$5.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.69
|
| Rate for Payer: UHC Core |
$18.68
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.59
|
| Rate for Payer: UHC Exchange |
$5.59
|
| Rate for Payer: UHC Medicare Advantage |
$5.59
|
| Rate for Payer: VA VA |
$5.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.78
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$9.45
|
|
|
Service Code
|
NDC 00904662735
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.24 |
| Max. Negotiated Rate |
$8.50 |
| Rate for Payer: Aetna Commercial |
$8.03
|
| Rate for Payer: Aetna Medicare |
$2.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.95
|
| Rate for Payer: BCBS Complete |
$3.78
|
| Rate for Payer: BCBS MAPPO |
$2.36
|
| Rate for Payer: BCBS Trust/PPO |
$7.77
|
| Rate for Payer: BCN Commercial |
$7.35
|
| Rate for Payer: BCN Medicare Advantage |
$2.36
|
| Rate for Payer: Cash Price |
$7.56
|
| Rate for Payer: Cofinity Commercial |
$8.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.56
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2.36
|
| Rate for Payer: Healthscope Commercial |
$8.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.09
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.48
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.03
|
| Rate for Payer: Nomi Health Commercial |
$7.75
|
| Rate for Payer: PACE Senior Care Partners |
$2.24
|
| Rate for Payer: PACE SWMI |
$2.36
|
| Rate for Payer: PHP Commercial |
$8.03
|
| Rate for Payer: PHP Medicare Advantage |
$2.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.14
|
| Rate for Payer: Priority Health HMO/PPO |
$8.22
|
| Rate for Payer: Priority Health Medicare |
$2.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.33
|
| Rate for Payer: Railroad Medicare Medicare |
$2.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.32
|
| Rate for Payer: UHC Core |
$7.89
|
| Rate for Payer: UHC Dual Complete DSNP |
$2.36
|
| Rate for Payer: UHC Exchange |
$2.36
|
| Rate for Payer: UHC Medicare Advantage |
$2.36
|
| Rate for Payer: VA VA |
$2.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.09
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$9.45
|
|
|
Service Code
|
NDC 00904662735
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.14 |
| Max. Negotiated Rate |
$8.50 |
| Rate for Payer: Aetna Commercial |
$8.03
|
| Rate for Payer: BCBS Trust/PPO |
$7.71
|
| Rate for Payer: BCN Commercial |
$7.30
|
| Rate for Payer: Cash Price |
$7.56
|
| Rate for Payer: Cofinity Commercial |
$8.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.56
|
| Rate for Payer: Healthscope Commercial |
$8.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.03
|
| Rate for Payer: Nomi Health Commercial |
$7.75
|
| Rate for Payer: PHP Commercial |
$8.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.14
|
| Rate for Payer: Priority Health HMO/PPO |
$8.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.32
|
| Rate for Payer: UHC Core |
$7.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.09
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$9.79
|
|
|
Service Code
|
NDC 23558076501
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.33 |
| Max. Negotiated Rate |
$8.81 |
| Rate for Payer: Aetna Commercial |
$8.32
|
| Rate for Payer: Aetna Medicare |
$2.55
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3.06
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3.06
|
| Rate for Payer: BCBS Complete |
$3.92
|
| Rate for Payer: BCBS MAPPO |
$2.45
|
| Rate for Payer: BCBS Trust/PPO |
$8.05
|
| Rate for Payer: BCN Commercial |
$7.61
|
| Rate for Payer: BCN Medicare Advantage |
$2.45
|
| Rate for Payer: Cash Price |
$7.83
|
| Rate for Payer: Cofinity Commercial |
$8.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.83
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$2.45
|
| Rate for Payer: Healthscope Commercial |
$8.81
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.34
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$2.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.32
|
| Rate for Payer: Nomi Health Commercial |
$8.03
|
| Rate for Payer: PACE Senior Care Partners |
$2.33
|
| Rate for Payer: PACE SWMI |
$2.45
|
| Rate for Payer: PHP Commercial |
$8.32
|
| Rate for Payer: PHP Medicare Advantage |
$2.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.36
|
| Rate for Payer: Priority Health HMO/PPO |
$8.52
|
| Rate for Payer: Priority Health Medicare |
$2.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$6.56
|
| Rate for Payer: Railroad Medicare Medicare |
$2.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$8.62
|
| Rate for Payer: UHC Core |
$8.17
|
| Rate for Payer: UHC Dual Complete DSNP |
$2.45
|
| Rate for Payer: UHC Exchange |
$2.45
|
| Rate for Payer: UHC Medicare Advantage |
$2.45
|
| Rate for Payer: VA VA |
$2.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.34
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$230.85
|
|
|
Service Code
|
NDC 00378007801
|
| Hospital Charge Code |
9406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.83 |
| Max. Negotiated Rate |
$207.76 |
| Rate for Payer: Aetna Commercial |
$196.22
|
| Rate for Payer: Aetna Medicare |
$60.02
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$72.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$72.14
|
| Rate for Payer: BCBS Complete |
$92.34
|
| Rate for Payer: BCBS MAPPO |
$57.71
|
| Rate for Payer: BCBS Trust/PPO |
$189.78
|
| Rate for Payer: BCN Commercial |
$179.49
|
| Rate for Payer: BCN Medicare Advantage |
$57.71
|
| Rate for Payer: Cash Price |
$184.68
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.68
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$57.71
|
| Rate for Payer: Healthscope Commercial |
$207.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$60.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$66.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: Nomi Health Commercial |
$189.30
|
| Rate for Payer: PACE Senior Care Partners |
$54.83
|
| Rate for Payer: PACE SWMI |
$57.71
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: PHP Medicare Advantage |
$57.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.05
|
| Rate for Payer: Priority Health HMO/PPO |
$200.84
|
| Rate for Payer: Priority Health Medicare |
$58.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$154.67
|
| Rate for Payer: Railroad Medicare Medicare |
$57.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$203.15
|
| Rate for Payer: UHC Core |
$192.76
|
| Rate for Payer: UHC Dual Complete DSNP |
$57.71
|
| Rate for Payer: UHC Exchange |
$57.71
|
| Rate for Payer: UHC Medicare Advantage |
$57.71
|
| Rate for Payer: VA VA |
$57.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.14
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
9406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.78 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: BCBS Trust/PPO |
$159.22
|
| Rate for Payer: BCN Commercial |
$150.73
|
| Rate for Payer: Cash Price |
$156.04
|
| 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: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Nomi Health Commercial |
$159.94
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health HMO/PPO |
$169.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.64
|
| Rate for Payer: UHC Core |
$162.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$195.05
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
9406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.32 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna Medicare |
$50.71
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$60.95
|
| Rate for Payer: Amish Plain Church Group Commercial |
$60.95
|
| Rate for Payer: BCBS Complete |
$78.02
|
| Rate for Payer: BCBS MAPPO |
$48.76
|
| Rate for Payer: BCBS Trust/PPO |
$160.35
|
| Rate for Payer: BCN Commercial |
$151.65
|
| Rate for Payer: BCN Medicare Advantage |
$48.76
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$48.76
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$51.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Nomi Health Commercial |
$159.94
|
| Rate for Payer: PACE Senior Care Partners |
$46.32
|
| Rate for Payer: PACE SWMI |
$48.76
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: PHP Medicare Advantage |
$48.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health HMO/PPO |
$169.69
|
| Rate for Payer: Priority Health Medicare |
$49.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$130.68
|
| Rate for Payer: Railroad Medicare Medicare |
$48.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.64
|
| Rate for Payer: UHC Core |
$162.87
|
| Rate for Payer: UHC Dual Complete DSNP |
$48.76
|
| Rate for Payer: UHC Exchange |
$48.76
|
| Rate for Payer: UHC Medicare Advantage |
$48.76
|
| Rate for Payer: VA VA |
$48.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$230.85
|
|
|
Service Code
|
NDC 00378007801
|
| Hospital Charge Code |
9406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.05 |
| Max. Negotiated Rate |
$207.76 |
| Rate for Payer: Aetna Commercial |
$196.22
|
| Rate for Payer: BCBS Trust/PPO |
$188.44
|
| Rate for Payer: BCN Commercial |
$178.40
|
| Rate for Payer: Cash Price |
$184.68
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.68
|
| Rate for Payer: Healthscope Commercial |
$207.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: Nomi Health Commercial |
$189.30
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.05
|
| Rate for Payer: Priority Health HMO/PPO |
$200.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$154.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$203.15
|
| Rate for Payer: UHC Core |
$192.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.14
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$329.00
|
|
|
Service Code
|
NDC 00904623761
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$213.85 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: BCBS Trust/PPO |
$268.56
|
| Rate for Payer: BCN Commercial |
$254.25
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.65
|
| Rate for Payer: Nomi Health Commercial |
$269.78
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.85
|
| Rate for Payer: Priority Health HMO/PPO |
$286.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$220.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$289.52
|
| Rate for Payer: UHC Core |
$274.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.75
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$359.55
|
|
|
Service Code
|
NDC 00904725761
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$233.71 |
| Max. Negotiated Rate |
$323.60 |
| Rate for Payer: Aetna Commercial |
$305.62
|
| Rate for Payer: BCBS Trust/PPO |
$293.50
|
| Rate for Payer: BCN Commercial |
$277.86
|
| Rate for Payer: Cash Price |
$287.64
|
| Rate for Payer: Cofinity Commercial |
$309.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Healthscope Commercial |
$323.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.62
|
| Rate for Payer: Nomi Health Commercial |
$294.83
|
| Rate for Payer: PHP Commercial |
$305.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.71
|
| Rate for Payer: Priority Health HMO/PPO |
$312.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$240.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$316.40
|
| Rate for Payer: UHC Core |
$300.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$269.66
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$2.09
|
|
|
Service Code
|
NDC 60687066111
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna Commercial |
$1.78
|
| Rate for Payer: Aetna Medicare |
$0.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.65
|
| Rate for Payer: BCBS Complete |
$0.84
|
| Rate for Payer: BCBS MAPPO |
$0.52
|
| Rate for Payer: BCBS Trust/PPO |
$1.72
|
| Rate for Payer: BCN Commercial |
$1.62
|
| Rate for Payer: BCN Medicare Advantage |
$0.52
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cofinity Commercial |
$1.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.67
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.52
|
| Rate for Payer: Healthscope Commercial |
$1.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.78
|
| Rate for Payer: Nomi Health Commercial |
$1.71
|
| Rate for Payer: PACE Senior Care Partners |
$0.50
|
| Rate for Payer: PACE SWMI |
$0.52
|
| Rate for Payer: PHP Commercial |
$1.78
|
| Rate for Payer: PHP Medicare Advantage |
$0.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.36
|
| Rate for Payer: Priority Health HMO/PPO |
$1.82
|
| Rate for Payer: Priority Health Medicare |
$0.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.40
|
| Rate for Payer: Railroad Medicare Medicare |
$0.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.84
|
| Rate for Payer: UHC Core |
$1.75
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.52
|
| Rate for Payer: UHC Exchange |
$0.52
|
| Rate for Payer: UHC Medicare Advantage |
$0.52
|
| Rate for Payer: VA VA |
$0.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.57
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$208.05
|
|
|
Service Code
|
NDC 60687066101
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$135.23 |
| Max. Negotiated Rate |
$187.24 |
| Rate for Payer: Aetna Commercial |
$176.84
|
| Rate for Payer: BCBS Trust/PPO |
$169.83
|
| Rate for Payer: BCN Commercial |
$160.78
|
| Rate for Payer: Cash Price |
$166.44
|
| Rate for Payer: Cofinity Commercial |
$178.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.44
|
| Rate for Payer: Healthscope Commercial |
$187.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.84
|
| Rate for Payer: Nomi Health Commercial |
$170.60
|
| Rate for Payer: PHP Commercial |
$176.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.23
|
| Rate for Payer: Priority Health HMO/PPO |
$181.00
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$139.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$183.08
|
| Rate for Payer: UHC Core |
$173.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.04
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$329.00
|
|
|
Service Code
|
NDC 00904623761
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.14 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: Aetna Medicare |
$85.54
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$102.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$102.81
|
| Rate for Payer: BCBS Complete |
$131.60
|
| Rate for Payer: BCBS MAPPO |
$82.25
|
| Rate for Payer: BCBS Trust/PPO |
$270.47
|
| Rate for Payer: BCN Commercial |
$255.80
|
| Rate for Payer: BCN Medicare Advantage |
$82.25
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$82.25
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.75
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$86.36
|
| Rate for Payer: MI Amish Medical Board Commercial |
$94.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.65
|
| Rate for Payer: Nomi Health Commercial |
$269.78
|
| Rate for Payer: PACE Senior Care Partners |
$78.14
|
| Rate for Payer: PACE SWMI |
$82.25
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: PHP Medicare Advantage |
$82.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.85
|
| Rate for Payer: Priority Health HMO/PPO |
$286.23
|
| Rate for Payer: Priority Health Medicare |
$83.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$220.43
|
| Rate for Payer: Railroad Medicare Medicare |
$82.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$289.52
|
| Rate for Payer: UHC Core |
$274.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$82.25
|
| Rate for Payer: UHC Exchange |
$82.25
|
| Rate for Payer: UHC Medicare Advantage |
$82.25
|
| Rate for Payer: VA VA |
$82.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.75
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$359.55
|
|
|
Service Code
|
NDC 00904725761
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.39 |
| Max. Negotiated Rate |
$323.60 |
| Rate for Payer: Aetna Commercial |
$305.62
|
| Rate for Payer: Aetna Medicare |
$93.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$112.36
|
| Rate for Payer: Amish Plain Church Group Commercial |
$112.36
|
| Rate for Payer: BCBS Complete |
$143.82
|
| Rate for Payer: BCBS MAPPO |
$89.89
|
| Rate for Payer: BCBS Trust/PPO |
$295.59
|
| Rate for Payer: BCN Commercial |
$279.55
|
| Rate for Payer: BCN Medicare Advantage |
$89.89
|
| Rate for Payer: Cash Price |
$287.64
|
| Rate for Payer: Cofinity Commercial |
$309.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$89.89
|
| Rate for Payer: Healthscope Commercial |
$323.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$94.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$103.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.62
|
| Rate for Payer: Nomi Health Commercial |
$294.83
|
| Rate for Payer: PACE Senior Care Partners |
$85.39
|
| Rate for Payer: PACE SWMI |
$89.89
|
| Rate for Payer: PHP Commercial |
$305.62
|
| Rate for Payer: PHP Medicare Advantage |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.71
|
| Rate for Payer: Priority Health HMO/PPO |
$312.81
|
| Rate for Payer: Priority Health Medicare |
$90.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$240.90
|
| Rate for Payer: Railroad Medicare Medicare |
$89.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$316.40
|
| Rate for Payer: UHC Core |
$300.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$89.89
|
| Rate for Payer: UHC Exchange |
$89.89
|
| Rate for Payer: UHC Medicare Advantage |
$89.89
|
| Rate for Payer: VA VA |
$89.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$269.66
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$2.09
|
|
|
Service Code
|
NDC 60687066111
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$1.88 |
| Rate for Payer: Aetna Commercial |
$1.78
|
| Rate for Payer: BCBS Trust/PPO |
$1.71
|
| Rate for Payer: BCN Commercial |
$1.62
|
| Rate for Payer: Cash Price |
$1.67
|
| Rate for Payer: Cofinity Commercial |
$1.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.67
|
| Rate for Payer: Healthscope Commercial |
$1.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.78
|
| Rate for Payer: Nomi Health Commercial |
$1.71
|
| Rate for Payer: PHP Commercial |
$1.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.36
|
| Rate for Payer: Priority Health HMO/PPO |
$1.82
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.84
|
| Rate for Payer: UHC Core |
$1.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.57
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$208.05
|
|
|
Service Code
|
NDC 60687066101
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.41 |
| Max. Negotiated Rate |
$187.24 |
| Rate for Payer: Aetna Commercial |
$176.84
|
| Rate for Payer: Aetna Medicare |
$54.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$65.02
|
| Rate for Payer: Amish Plain Church Group Commercial |
$65.02
|
| Rate for Payer: BCBS Complete |
$83.22
|
| Rate for Payer: BCBS MAPPO |
$52.01
|
| Rate for Payer: BCBS Trust/PPO |
$171.04
|
| Rate for Payer: BCN Commercial |
$161.76
|
| Rate for Payer: BCN Medicare Advantage |
$52.01
|
| Rate for Payer: Cash Price |
$166.44
|
| Rate for Payer: Cofinity Commercial |
$178.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.44
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$52.01
|
| Rate for Payer: Healthscope Commercial |
$187.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$54.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$59.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$176.84
|
| Rate for Payer: Nomi Health Commercial |
$170.60
|
| Rate for Payer: PACE Senior Care Partners |
$49.41
|
| Rate for Payer: PACE SWMI |
$52.01
|
| Rate for Payer: PHP Commercial |
$176.84
|
| Rate for Payer: PHP Medicare Advantage |
$52.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.23
|
| Rate for Payer: Priority Health HMO/PPO |
$181.00
|
| Rate for Payer: Priority Health Medicare |
$52.53
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$139.39
|
| Rate for Payer: Railroad Medicare Medicare |
$52.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$183.08
|
| Rate for Payer: UHC Core |
$173.72
|
| Rate for Payer: UHC Dual Complete DSNP |
$52.01
|
| Rate for Payer: UHC Exchange |
$52.01
|
| Rate for Payer: UHC Medicare Advantage |
$52.01
|
| Rate for Payer: VA VA |
$52.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.04
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
OP
|
$200.45
|
|
|
Service Code
|
NDC 00904623861
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.61 |
| Max. Negotiated Rate |
$180.40 |
| Rate for Payer: Aetna Commercial |
$170.38
|
| Rate for Payer: Aetna Medicare |
$52.12
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62.64
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62.64
|
| Rate for Payer: BCBS Complete |
$80.18
|
| Rate for Payer: BCBS MAPPO |
$50.11
|
| Rate for Payer: BCBS Trust/PPO |
$164.79
|
| Rate for Payer: BCN Commercial |
$155.85
|
| Rate for Payer: BCN Medicare Advantage |
$50.11
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$50.11
|
| Rate for Payer: Healthscope Commercial |
$180.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.34
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$52.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: Nomi Health Commercial |
$164.37
|
| Rate for Payer: PACE Senior Care Partners |
$47.61
|
| Rate for Payer: PACE SWMI |
$50.11
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: PHP Medicare Advantage |
$50.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.29
|
| Rate for Payer: Priority Health HMO/PPO |
$174.39
|
| Rate for Payer: Priority Health Medicare |
$50.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$134.30
|
| Rate for Payer: Railroad Medicare Medicare |
$50.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.40
|
| Rate for Payer: UHC Core |
$167.38
|
| Rate for Payer: UHC Dual Complete DSNP |
$50.11
|
| Rate for Payer: UHC Exchange |
$50.11
|
| Rate for Payer: UHC Medicare Advantage |
$50.11
|
| Rate for Payer: VA VA |
$50.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.34
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
IP
|
$200.45
|
|
|
Service Code
|
NDC 00904623861
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.29 |
| Max. Negotiated Rate |
$180.40 |
| Rate for Payer: Aetna Commercial |
$170.38
|
| Rate for Payer: BCBS Trust/PPO |
$163.63
|
| Rate for Payer: BCN Commercial |
$154.91
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Healthscope Commercial |
$180.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: Nomi Health Commercial |
$164.37
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.29
|
| Rate for Payer: Priority Health HMO/PPO |
$174.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$134.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.40
|
| Rate for Payer: UHC Core |
$167.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.34
|
|
