|
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 |
$161.60
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.60
|
| 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 |
$161.60
|
| 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
|
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 |
$161.60
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.60
|
| 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 |
$161.60
|
| 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
|
$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 |
$161.60
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.60
|
| 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 |
$161.60
|
| 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
|
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 |
$161.60
|
| Rate for Payer: Cofinity Commercial |
$198.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.60
|
| 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 |
$161.60
|
| 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 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
|
$202.35
|
|
|
Service Code
|
NDC 68084009301
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.87 |
| Max. Negotiated Rate |
$182.12 |
| Rate for Payer: Aetna American Axle |
$131.53
|
| Rate for Payer: Aetna Commercial |
$172.00
|
| Rate for Payer: Aetna Medicare |
$101.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.53
|
| Rate for Payer: BCBS Complete |
$80.94
|
| Rate for Payer: Cash Price |
$161.88
|
| Rate for Payer: Cofinity Commercial |
$141.64
|
| Rate for Payer: Cofinity Commercial |
$174.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$141.64
|
| 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 |
$141.64
|
| 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 |
$74.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.76
|
|
|
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 |
$1,057.82
|
| 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 |
$1,057.82
|
| Rate for Payer: PHP Commercial |
$1,057.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$808.92
|
| Rate for Payer: Priority Health SBD |
$784.04
|
| 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
|
$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
|
IP
|
$359.55
|
|
|
Service Code
|
NDC 00904725761
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.20 |
| Max. Negotiated Rate |
$323.60 |
| Rate for Payer: Aetna American Axle |
$233.71
|
| Rate for Payer: Aetna Commercial |
$305.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$233.71
|
| Rate for Payer: Cash Price |
$287.64
|
| Rate for Payer: Cofinity Commercial |
$251.68
|
| Rate for Payer: Cofinity Commercial |
$309.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$251.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Healthscope Commercial |
$323.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$251.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.62
|
| Rate for Payer: PHP Commercial |
$305.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.71
|
| Rate for Payer: Priority Health SBD |
$226.52
|
| Rate for Payer: UMR Bronson Commercial |
$158.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$269.66
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$220.90
|
|
|
Service Code
|
NDC 69367033901
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.20 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Aetna American Axle |
$143.58
|
| Rate for Payer: Aetna Commercial |
$187.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.58
|
| Rate for Payer: Cash Price |
$176.72
|
| Rate for Payer: Cofinity Commercial |
$154.63
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$154.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.72
|
| Rate for Payer: Healthscope Commercial |
$198.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$154.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$165.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.76
|
| Rate for Payer: PHP Commercial |
$187.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$143.58
|
| Rate for Payer: Priority Health SBD |
$139.17
|
| Rate for Payer: UMR Bronson Commercial |
$97.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$165.68
|
|
|
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 |
$141.64
|
| Rate for Payer: Cofinity Commercial |
$174.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$141.64
|
| 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 |
$141.64
|
| 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
|
IP
|
$190.35
|
|
|
Service Code
|
NDC 00228253910
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.75 |
| Max. Negotiated Rate |
$171.32 |
| Rate for Payer: Aetna American Axle |
$123.73
|
| Rate for Payer: Aetna Commercial |
$161.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.73
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$133.24
|
| Rate for Payer: Cofinity Commercial |
$163.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$133.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$171.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.80
|
| Rate for Payer: PHP Commercial |
$161.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.73
|
| Rate for Payer: Priority Health SBD |
$119.92
|
| Rate for Payer: UMR Bronson Commercial |
$83.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.76
|
|
|
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 |
$133.03 |
| Max. Negotiated Rate |
$323.60 |
| Rate for Payer: Aetna American Axle |
$233.71
|
| Rate for Payer: Aetna Commercial |
$305.62
|
| Rate for Payer: Aetna Medicare |
$179.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$233.71
|
| Rate for Payer: BCBS Complete |
$143.82
|
| Rate for Payer: Cash Price |
$287.64
|
| Rate for Payer: Cofinity Commercial |
$251.68
|
| Rate for Payer: Cofinity Commercial |
$309.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$251.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Healthscope Commercial |
$323.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$251.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.62
|
| Rate for Payer: PHP Commercial |
$305.62
|
| Rate for Payer: Priority Health Cigna Priority Health |
$233.71
|
| Rate for Payer: Priority Health SBD |
$226.52
|
| Rate for Payer: UMR Bronson Commercial |
$133.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$269.66
|
|
|
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 |
$155.80
|
| Rate for Payer: Aetna Commercial |
$203.74
|
| Rate for Payer: Aetna Medicare |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.80
|
| 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 |
$203.74
|
| Rate for Payer: PHP Commercial |
$203.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.80
|
| 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
|
OP
|
$2.03
|
|
|
Service Code
|
NDC 68084009311
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Aetna American Axle |
$1.32
|
| Rate for Payer: Aetna Commercial |
$1.73
|
| Rate for Payer: Aetna Medicare |
$1.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.32
|
| Rate for Payer: BCBS Complete |
$0.81
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cofinity Commercial |
$1.42
|
| Rate for Payer: Cofinity Commercial |
$1.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.62
|
| Rate for Payer: Healthscope Commercial |
$1.83
|
| Rate for Payer: 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 |
$0.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.52
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$262.20
|
|
|
Service Code
|
NDC 62756051888
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.01 |
| Max. Negotiated Rate |
$235.98 |
| Rate for Payer: Aetna American Axle |
$170.43
|
| Rate for Payer: Aetna Commercial |
$222.87
|
| Rate for Payer: Aetna Medicare |
$131.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.43
|
| Rate for Payer: BCBS Complete |
$104.88
|
| 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 |
$97.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.65
|
|
|
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 |
$178.70 |
| 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 |
$138.98
|
| Rate for Payer: Cofinity Commercial |
$170.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.84
|
| Rate for Payer: Healthscope Commercial |
$178.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.98
|
| 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
|
OP
|
$198.55
|
|
|
Service Code
|
NDC 63739010810
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.46 |
| Max. Negotiated Rate |
$178.70 |
| 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 |
$138.98
|
| Rate for Payer: Cofinity Commercial |
$170.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$158.84
|
| Rate for Payer: Healthscope Commercial |
$178.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.98
|
| 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
|
|
|
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 |
$144.76 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna American Axle |
$213.85
|
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.85
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$230.30
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$230.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$230.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$279.65
|
| Rate for Payer: PHP Commercial |
$279.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$213.85
|
| Rate for Payer: Priority Health SBD |
$207.27
|
| Rate for Payer: UMR Bronson Commercial |
$144.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.75
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$1,244.50
|
|
|
Service Code
|
NDC 62756051813
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$547.58 |
| Max. Negotiated Rate |
$1,120.05 |
| Rate for Payer: Aetna American Axle |
$808.92
|
| Rate for Payer: Aetna Commercial |
$1,057.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$808.92
|
| 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 |
$1,057.82
|
| Rate for Payer: PHP Commercial |
$1,057.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$808.92
|
| Rate for Payer: Priority Health SBD |
$784.04
|
| Rate for Payer: UMR Bronson Commercial |
$547.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$933.38
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$239.70
|
|
|
Service Code
|
NDC 00093970201
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.47 |
| Max. Negotiated Rate |
$215.73 |
| Rate for Payer: Aetna American Axle |
$155.80
|
| Rate for Payer: Aetna Commercial |
$203.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.80
|
| 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 |
$203.74
|
| Rate for Payer: PHP Commercial |
$203.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$155.80
|
| Rate for Payer: Priority Health SBD |
$151.01
|
| Rate for Payer: UMR Bronson Commercial |
$105.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$179.78
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$190.35
|
|
|
Service Code
|
NDC 00228253910
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.43 |
| Max. Negotiated Rate |
$171.32 |
| Rate for Payer: Aetna American Axle |
$123.73
|
| Rate for Payer: Aetna Commercial |
$161.80
|
| Rate for Payer: Aetna Medicare |
$95.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.73
|
| Rate for Payer: BCBS Complete |
$76.14
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$133.24
|
| Rate for Payer: Cofinity Commercial |
$163.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$133.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$171.32
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$142.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$161.80
|
| Rate for Payer: PHP Commercial |
$161.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$123.73
|
| Rate for Payer: Priority Health SBD |
$119.92
|
| Rate for Payer: UMR Bronson Commercial |
$70.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$142.76
|
|
|
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
|
OP
|
$220.90
|
|
|
Service Code
|
NDC 69367033901
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.73 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Aetna American Axle |
$143.58
|
| Rate for Payer: Aetna Commercial |
$187.76
|
| Rate for Payer: Aetna Medicare |
$110.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.58
|
| Rate for Payer: BCBS Complete |
$88.36
|
| Rate for Payer: Cash Price |
$176.72
|
| Rate for Payer: Cofinity Commercial |
$154.63
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| Rate for Payer: Cofinity Medicare Advantage |
$154.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$176.72
|
| Rate for Payer: Healthscope Commercial |
$198.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$154.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$165.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.76
|
| Rate for Payer: PHP Commercial |
$187.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$143.58
|
| Rate for Payer: Priority Health SBD |
$139.17
|
| Rate for Payer: UMR Bronson Commercial |
$81.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$165.68
|
|
