|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$28.72
|
|
|
Service Code
|
NDC 42037010479
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$25.85 |
| Rate for Payer: Aetna American Axle |
$18.67
|
| Rate for Payer: Aetna Commercial |
$24.41
|
| Rate for Payer: Aetna Medicare |
$14.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.67
|
| Rate for Payer: BCBS Complete |
$11.49
|
| Rate for Payer: Cash Price |
$22.98
|
| Rate for Payer: Cofinity Commercial |
$20.10
|
| Rate for Payer: Cofinity Commercial |
$24.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.98
|
| Rate for Payer: Healthscope Commercial |
$25.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.41
|
| Rate for Payer: PHP Commercial |
$24.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.67
|
| Rate for Payer: Priority Health SBD |
$18.09
|
| Rate for Payer: UMR Bronson Commercial |
$10.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.54
|
|
|
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 |
$4.16 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: Aetna American Axle |
$6.14
|
| Rate for Payer: Aetna Commercial |
$8.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.14
|
| Rate for Payer: Cash Price |
$7.56
|
| Rate for Payer: Cofinity Commercial |
$6.62
|
| Rate for Payer: Cofinity Commercial |
$8.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.56
|
| Rate for Payer: Healthscope Commercial |
$8.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.03
|
| Rate for Payer: PHP Commercial |
$8.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.14
|
| Rate for Payer: Priority Health SBD |
$5.95
|
| Rate for Payer: UMR Bronson Commercial |
$4.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.09
|
|
|
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 |
$8.42 |
| Max. Negotiated Rate |
$20.48 |
| Rate for Payer: Aetna American Axle |
$14.79
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$15.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.06
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$8.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.06
|
|
|
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 |
$11.50 |
| Max. Negotiated Rate |
$23.52 |
| Rate for Payer: Aetna American Axle |
$16.98
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$18.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.60
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$11.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.60
|
|
|
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 |
$9.67 |
| Max. Negotiated Rate |
$23.52 |
| Rate for Payer: Aetna American Axle |
$16.98
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$18.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.60
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$9.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.60
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$28.72
|
|
|
Service Code
|
NDC 42037010479
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.64 |
| Max. Negotiated Rate |
$25.85 |
| Rate for Payer: Aetna American Axle |
$18.67
|
| Rate for Payer: Aetna Commercial |
$24.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.67
|
| Rate for Payer: Cash Price |
$22.98
|
| Rate for Payer: Cofinity Commercial |
$20.10
|
| Rate for Payer: Cofinity Commercial |
$24.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.98
|
| Rate for Payer: Healthscope Commercial |
$25.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.41
|
| Rate for Payer: PHP Commercial |
$24.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.67
|
| Rate for Payer: Priority Health SBD |
$18.09
|
| Rate for Payer: UMR Bronson Commercial |
$12.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.54
|
|
|
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 |
$3.50 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: Aetna American Axle |
$6.14
|
| Rate for Payer: Aetna Commercial |
$8.03
|
| Rate for Payer: Aetna Medicare |
$4.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.14
|
| Rate for Payer: BCBS Complete |
$3.78
|
| Rate for Payer: Cash Price |
$7.56
|
| Rate for Payer: Cofinity Commercial |
$6.62
|
| Rate for Payer: Cofinity Commercial |
$8.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$6.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.56
|
| Rate for Payer: Healthscope Commercial |
$8.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.03
|
| Rate for Payer: PHP Commercial |
$8.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.14
|
| Rate for Payer: Priority Health SBD |
$5.95
|
| Rate for Payer: UMR Bronson Commercial |
$3.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.09
|
|
|
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 |
$9.84 |
| Max. Negotiated Rate |
$20.13 |
| Rate for Payer: Aetna American Axle |
$14.54
|
| Rate for Payer: Aetna Commercial |
$19.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.54
|
| Rate for Payer: Cash Price |
$17.90
|
| Rate for Payer: Cofinity Commercial |
$15.66
|
| Rate for Payer: Cofinity Commercial |
$19.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.90
|
| Rate for Payer: Healthscope Commercial |
$20.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.01
|
| Rate for Payer: PHP Commercial |
$19.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.54
|
| Rate for Payer: Priority Health SBD |
$14.09
|
| Rate for Payer: UMR Bronson Commercial |
$9.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.78
|
|
|
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 |
$72.17 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$136.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$72.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
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 |
$85.82 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$136.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$85.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$230.85
|
|
|
Service Code
|
NDC 62756051788
|
| Hospital Charge Code |
9406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.41 |
| Max. Negotiated Rate |
$207.76 |
| Rate for Payer: Aetna American Axle |
$150.05
|
| Rate for Payer: Aetna Commercial |
$196.22
|
| Rate for Payer: Aetna Medicare |
$115.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.05
|
| Rate for Payer: BCBS Complete |
$92.34
|
| Rate for Payer: Cash Price |
$184.68
|
| Rate for Payer: Cofinity Commercial |
$161.59
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.68
|
| Rate for Payer: Healthscope Commercial |
$207.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.05
|
| Rate for Payer: Priority Health SBD |
$145.44
|
| Rate for Payer: UMR Bronson Commercial |
$85.41
|
| 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 |
$85.82 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$136.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$85.82
|
| 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 62756051788
|
| Hospital Charge Code |
9406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.57 |
| Max. Negotiated Rate |
$207.76 |
| Rate for Payer: Aetna American Axle |
$150.05
|
| Rate for Payer: Aetna Commercial |
$196.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.05
|
| Rate for Payer: Cash Price |
$184.68
|
| Rate for Payer: Cofinity Commercial |
$161.59
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.68
|
| Rate for Payer: Healthscope Commercial |
$207.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.05
|
| Rate for Payer: Priority Health SBD |
$145.44
|
| Rate for Payer: UMR Bronson Commercial |
$101.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.14
|
|
|
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 |
$72.17 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$136.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$72.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
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 |
$85.41 |
| Max. Negotiated Rate |
$207.76 |
| Rate for Payer: Aetna American Axle |
$150.05
|
| Rate for Payer: Aetna Commercial |
$196.22
|
| Rate for Payer: Aetna Medicare |
$115.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.05
|
| Rate for Payer: BCBS Complete |
$92.34
|
| Rate for Payer: Cash Price |
$184.68
|
| Rate for Payer: Cofinity Commercial |
$161.59
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.68
|
| Rate for Payer: Healthscope Commercial |
$207.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.05
|
| Rate for Payer: Priority Health SBD |
$145.44
|
| Rate for Payer: UMR Bronson Commercial |
$85.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.14
|
|
|
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 |
$101.57 |
| Max. Negotiated Rate |
$207.76 |
| Rate for Payer: Aetna American Axle |
$150.05
|
| Rate for Payer: Aetna Commercial |
$196.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$150.05
|
| Rate for Payer: Cash Price |
$184.68
|
| Rate for Payer: Cofinity Commercial |
$161.59
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.68
|
| Rate for Payer: Healthscope Commercial |
$207.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$150.05
|
| Rate for Payer: Priority Health SBD |
$145.44
|
| Rate for Payer: UMR Bronson Commercial |
$101.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$173.14
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG-ENTACAPONE 200 MG TABLET
|
Facility
|
OP
|
$2,631.07
|
|
|
Service Code
|
NDC 52427081601
|
| Hospital Charge Code |
36136
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$973.50 |
| Max. Negotiated Rate |
$2,367.96 |
| Rate for Payer: Aetna American Axle |
$1,710.20
|
| Rate for Payer: Aetna Commercial |
$2,236.41
|
| Rate for Payer: Aetna Medicare |
$1,315.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,710.20
|
| Rate for Payer: BCBS Complete |
$1,052.43
|
| Rate for Payer: Cash Price |
$2,104.86
|
| Rate for Payer: Cofinity Commercial |
$1,841.75
|
| Rate for Payer: Cofinity Commercial |
$2,262.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,841.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,104.86
|
| Rate for Payer: Healthscope Commercial |
$2,367.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,841.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,973.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,236.41
|
| Rate for Payer: PHP Commercial |
$2,236.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,710.20
|
| Rate for Payer: Priority Health SBD |
$1,657.57
|
| Rate for Payer: UMR Bronson Commercial |
$973.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,973.30
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG-ENTACAPONE 200 MG TABLET
|
Facility
|
IP
|
$2,631.07
|
|
|
Service Code
|
NDC 52427081601
|
| Hospital Charge Code |
36136
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,157.67 |
| Max. Negotiated Rate |
$2,367.96 |
| Rate for Payer: Aetna American Axle |
$1,710.20
|
| Rate for Payer: Aetna Commercial |
$2,236.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,710.20
|
| Rate for Payer: Cash Price |
$2,104.86
|
| Rate for Payer: Cofinity Commercial |
$1,841.75
|
| Rate for Payer: Cofinity Commercial |
$2,262.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,841.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,104.86
|
| Rate for Payer: Healthscope Commercial |
$2,367.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,841.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,973.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,236.41
|
| Rate for Payer: PHP Commercial |
$2,236.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,710.20
|
| Rate for Payer: Priority Health SBD |
$1,657.57
|
| Rate for Payer: UMR Bronson Commercial |
$1,157.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,973.30
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$239.70
|
|
|
Service Code
|
NDC 00093970201
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.69 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Aetna American Axle |
$155.81
|
| Rate for Payer: Aetna Commercial |
$203.75
|
| Rate for Payer: Aetna Medicare |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.81
|
| Rate for Payer: BCBS Complete |
$95.88
|
| Rate for Payer: Cash Price |
$191.76
|
| Rate for Payer: Cofinity Commercial |
$167.79
|
| Rate for Payer: Cofinity Commercial |
$206.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$167.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$191.76
|
| Rate for Payer: Healthscope Commercial |
$215.73
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$167.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$179.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$203.75
|
| Rate for Payer: PHP Commercial |
$203.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.81
|
| Rate for Payer: Priority Health SBD |
$151.01
|
| Rate for Payer: UMR Bronson Commercial |
$88.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.78
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$2.03
|
|
|
Service Code
|
NDC 68084009311
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.89 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Aetna American Axle |
$1.32
|
| Rate for Payer: Aetna Commercial |
$1.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.32
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$1.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.52
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$0.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.52
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$1,244.50
|
|
|
Service Code
|
NDC 62756051813
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$460.46 |
| Max. Negotiated Rate |
$1,120.05 |
| Rate for Payer: Aetna American Axle |
$808.92
|
| Rate for Payer: Aetna Commercial |
$1,057.83
|
| Rate for Payer: Aetna Medicare |
$622.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$808.92
|
| Rate for Payer: BCBS Complete |
$497.80
|
| Rate for Payer: Cash Price |
$995.60
|
| Rate for Payer: Cofinity Commercial |
$1,070.27
|
| Rate for Payer: Cofinity Commercial |
$871.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$871.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$995.60
|
| Rate for Payer: Healthscope Commercial |
$1,120.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$871.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$933.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,057.83
|
| Rate for Payer: PHP Commercial |
$1,057.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$808.92
|
| Rate for Payer: Priority Health SBD |
$784.03
|
| Rate for Payer: UMR Bronson Commercial |
$460.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$933.38
|
|
|
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 |
$87.36 |
| Max. Negotiated Rate |
$178.69 |
| Rate for Payer: Aetna American Axle |
$129.06
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$138.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.91
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$87.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.91
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$262.20
|
|
|
Service Code
|
NDC 62756051888
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.37 |
| Max. Negotiated Rate |
$235.98 |
| Rate for Payer: Aetna American Axle |
$170.43
|
| Rate for Payer: Aetna Commercial |
$222.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.43
|
| Rate for Payer: Cash Price |
$209.76
|
| Rate for Payer: Cofinity Commercial |
$183.54
|
| Rate for Payer: Cofinity Commercial |
$225.49
|
| Rate for Payer: Cofinity Medicare Advantage |
$183.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$209.76
|
| Rate for Payer: Healthscope Commercial |
$235.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$183.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.87
|
| Rate for Payer: PHP Commercial |
$222.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$170.43
|
| Rate for Payer: Priority Health SBD |
$165.19
|
| Rate for Payer: UMR Bronson Commercial |
$115.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.65
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$202.35
|
|
|
Service Code
|
NDC 68084009301
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.03 |
| Max. Negotiated Rate |
$182.12 |
| Rate for Payer: Aetna American Axle |
$131.53
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$141.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$151.76
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$89.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.76
|
|
|
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 |
$73.46 |
| Max. Negotiated Rate |
$178.69 |
| Rate for Payer: Aetna American Axle |
$129.06
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$138.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.91
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$73.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.91
|
|
