|
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 |
$251.69
|
| Rate for Payer: Cofinity Commercial |
$309.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$251.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Healthscope Commercial |
$323.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$251.69
|
| 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
|
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
|
$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
|
$329.00
|
|
|
Service Code
|
NDC 00904623761
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.73 |
| Max. Negotiated Rate |
$296.10 |
| Rate for Payer: Aetna American Axle |
$213.85
|
| Rate for Payer: Aetna Commercial |
$279.65
|
| Rate for Payer: Aetna Medicare |
$164.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$213.85
|
| Rate for Payer: BCBS Complete |
$131.60
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$230.30
|
| Rate for Payer: Cofinity Commercial |
$282.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$230.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$296.10
|
| Rate for Payer: 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 |
$121.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.75
|
|
|
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
|
$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 |
$101.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.53
|
| Rate for Payer: BCBS Complete |
$80.94
|
| Rate for Payer: Cash Price |
$161.88
|
| Rate for Payer: Cofinity Commercial |
$141.65
|
| Rate for Payer: Cofinity Commercial |
$174.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$141.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.88
|
| Rate for Payer: Healthscope Commercial |
$182.12
|
| Rate for Payer: 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 |
$74.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.76
|
|
|
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
|
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
|
$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 |
$155.81
|
| Rate for Payer: Aetna Commercial |
$203.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$155.81
|
| 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 |
$105.47
|
| 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 |
$1.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.32
|
| Rate for Payer: BCBS Complete |
$0.81
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cofinity Commercial |
$1.42
|
| Rate for Payer: Cofinity Commercial |
$1.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.62
|
| Rate for Payer: Healthscope Commercial |
$1.83
|
| Rate for Payer: 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
|
$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 |
$143.59
|
| Rate for Payer: Aetna Commercial |
$187.76
|
| Rate for Payer: Aetna Medicare |
$110.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.59
|
| 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 |
$143.59
|
| 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
|
|
|
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 |
$171.31 |
| Rate for Payer: Aetna American Axle |
$123.73
|
| Rate for Payer: Aetna Commercial |
$161.80
|
| Rate for Payer: Aetna Medicare |
$95.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$123.73
|
| Rate for Payer: BCBS Complete |
$76.14
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$133.25
|
| Rate for Payer: Cofinity Commercial |
$163.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$133.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$171.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$133.25
|
| 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
|
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 250 MG TABLET
|
Facility
|
OP
|
$200.45
|
|
|
Service Code
|
NDC 00904623861
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.17 |
| Max. Negotiated Rate |
$180.41 |
| Rate for Payer: Aetna American Axle |
$130.29
|
| Rate for Payer: Aetna Commercial |
$170.38
|
| Rate for Payer: Aetna Medicare |
$100.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.29
|
| Rate for Payer: BCBS Complete |
$80.18
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$140.31
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Healthscope Commercial |
$180.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.29
|
| Rate for Payer: Priority Health SBD |
$126.28
|
| Rate for Payer: UMR Bronson Commercial |
$74.17
|
| 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 |
$88.20 |
| Max. Negotiated Rate |
$180.41 |
| Rate for Payer: Aetna American Axle |
$130.29
|
| Rate for Payer: Aetna Commercial |
$170.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$130.29
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$140.31
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| Rate for Payer: Cofinity Medicare Advantage |
$140.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Healthscope Commercial |
$180.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$140.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.29
|
| Rate for Payer: Priority Health SBD |
$126.28
|
| Rate for Payer: UMR Bronson Commercial |
$88.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.34
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 68084009411
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.92 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna American Axle |
$154.99
|
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$166.91
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$166.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.99
|
| Rate for Payer: Priority Health SBD |
$150.22
|
| Rate for Payer: UMR Bronson Commercial |
$104.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
OP
|
$238.45
|
|
|
Service Code
|
NDC 68084009411
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.23 |
| Max. Negotiated Rate |
$214.60 |
| Rate for Payer: Aetna American Axle |
$154.99
|
| Rate for Payer: Aetna Commercial |
$202.68
|
| Rate for Payer: Aetna Medicare |
$119.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.99
|
| Rate for Payer: BCBS Complete |
$95.38
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$166.91
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$166.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$214.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$154.99
|
| Rate for Payer: Priority Health SBD |
$150.22
|
| Rate for Payer: UMR Bronson Commercial |
$88.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
CARBIDOPA 4.63 MG-LEVODOPA 20 MG/ML SUSPENSION IN J-TUBE PUMP
|
Facility
|
OP
|
$807.71
|
|
|
Service Code
|
HCPCS J7340
|
| Hospital Charge Code |
174006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$130.57 |
| Max. Negotiated Rate |
$726.94 |
| Rate for Payer: Aetna American Axle |
$525.01
|
| Rate for Payer: Aetna Commercial |
$686.55
|
| Rate for Payer: Aetna Medicare |
$253.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$525.01
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$304.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$304.51
|
| Rate for Payer: BCBS Complete |
$137.10
|
| Rate for Payer: BCBS MAPPO |
$243.61
|
| Rate for Payer: BCN Medicare Advantage |
$243.61
|
| Rate for Payer: Cash Price |
$646.17
|
| Rate for Payer: Cash Price |
$646.17
|
| Rate for Payer: Cofinity Commercial |
$565.40
|
| Rate for Payer: Cofinity Commercial |
$694.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$565.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$646.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$243.61
|
| Rate for Payer: Healthscope Commercial |
$726.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$565.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$605.78
|
| Rate for Payer: Mclaren Medicaid |
$130.57
|
| Rate for Payer: Mclaren Medicare |
$243.61
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$255.79
|
| Rate for Payer: Meridian Medicaid |
$137.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$280.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$686.55
|
| Rate for Payer: PACE Medicare |
$231.43
|
| Rate for Payer: PACE SWMI |
$243.61
|
| Rate for Payer: PHP Commercial |
$686.55
|
| Rate for Payer: PHP Medicare Advantage |
$243.61
|
| Rate for Payer: Priority Health Choice Medicaid |
$130.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$525.01
|
| Rate for Payer: Priority Health Medicare |
$243.61
|
| Rate for Payer: Priority Health SBD |
$508.86
|
| Rate for Payer: Railroad Medicare Medicare |
$243.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$685.74
|
| Rate for Payer: UHC Dual Complete DSNP |
$243.61
|
| Rate for Payer: UHC Exchange |
$465.56
|
| Rate for Payer: UHC Medicare Advantage |
$243.61
|
| Rate for Payer: UHCCP Medicaid |
$130.57
|
| Rate for Payer: UMR Bronson Commercial |
$298.85
|
| Rate for Payer: VA VA |
$243.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$605.78
|
|
|
CARBIDOPA 4.63 MG-LEVODOPA 20 MG/ML SUSPENSION IN J-TUBE PUMP
|
Facility
|
IP
|
$807.71
|
|
|
Service Code
|
HCPCS J7340
|
| Hospital Charge Code |
174006
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$355.39 |
| Max. Negotiated Rate |
$726.94 |
| Rate for Payer: Aetna American Axle |
$525.01
|
| Rate for Payer: Aetna Commercial |
$686.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$525.01
|
| Rate for Payer: Cash Price |
$646.17
|
| Rate for Payer: Cofinity Commercial |
$565.40
|
| Rate for Payer: Cofinity Commercial |
$694.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$565.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$646.17
|
| Rate for Payer: Healthscope Commercial |
$726.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$565.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$605.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$686.55
|
| Rate for Payer: PHP Commercial |
$686.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$525.01
|
| Rate for Payer: Priority Health SBD |
$508.86
|
| Rate for Payer: UMR Bronson Commercial |
$355.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$605.78
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$2.73
|
|
|
Service Code
|
NDC 51079097801
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Aetna American Axle |
$1.77
|
| Rate for Payer: Aetna Commercial |
$2.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.77
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$1.91
|
| Rate for Payer: Cofinity Commercial |
$2.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.32
|
| Rate for Payer: PHP Commercial |
$2.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.77
|
| Rate for Payer: Priority Health SBD |
$1.72
|
| Rate for Payer: UMR Bronson Commercial |
$1.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.05
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$331.55
|
|
|
Service Code
|
NDC 62756046188
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.67 |
| Max. Negotiated Rate |
$298.39 |
| Rate for Payer: Aetna American Axle |
$215.51
|
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: Aetna Medicare |
$165.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.51
|
| Rate for Payer: BCBS Complete |
$132.62
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$232.09
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$232.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.24
|
| Rate for Payer: Healthscope Commercial |
$298.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.51
|
| Rate for Payer: Priority Health SBD |
$208.88
|
| Rate for Payer: UMR Bronson Commercial |
$122.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.66
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$3.28
|
|
|
Service Code
|
NDC 68084028111
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.44 |
| Max. Negotiated Rate |
$2.95 |
| Rate for Payer: Aetna American Axle |
$2.13
|
| Rate for Payer: Aetna Commercial |
$2.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.13
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$2.30
|
| Rate for Payer: Cofinity Commercial |
$2.82
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.62
|
| Rate for Payer: Healthscope Commercial |
$2.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.79
|
| Rate for Payer: PHP Commercial |
$2.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.13
|
| Rate for Payer: Priority Health SBD |
$2.07
|
| Rate for Payer: UMR Bronson Commercial |
$1.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.46
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$272.65
|
|
|
Service Code
|
NDC 51079097820
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.97 |
| Max. Negotiated Rate |
$245.38 |
| Rate for Payer: Aetna American Axle |
$177.22
|
| Rate for Payer: Aetna Commercial |
$231.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.22
|
| Rate for Payer: Cash Price |
$218.12
|
| Rate for Payer: Cofinity Commercial |
$190.85
|
| Rate for Payer: Cofinity Commercial |
$234.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$190.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.12
|
| Rate for Payer: Healthscope Commercial |
$245.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$231.75
|
| Rate for Payer: PHP Commercial |
$231.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.22
|
| Rate for Payer: Priority Health SBD |
$171.77
|
| Rate for Payer: UMR Bronson Commercial |
$119.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.49
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$2.73
|
|
|
Service Code
|
NDC 51079097801
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Aetna American Axle |
$1.77
|
| Rate for Payer: Aetna Commercial |
$2.32
|
| Rate for Payer: Aetna Medicare |
$1.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.77
|
| Rate for Payer: BCBS Complete |
$1.09
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$1.91
|
| Rate for Payer: Cofinity Commercial |
$2.35
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.32
|
| Rate for Payer: PHP Commercial |
$2.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.77
|
| Rate for Payer: Priority Health SBD |
$1.72
|
| Rate for Payer: UMR Bronson Commercial |
$1.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.05
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$331.55
|
|
|
Service Code
|
NDC 62756046188
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.88 |
| Max. Negotiated Rate |
$298.39 |
| Rate for Payer: Aetna American Axle |
$215.51
|
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.51
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$232.09
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$232.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.24
|
| Rate for Payer: Healthscope Commercial |
$298.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.51
|
| Rate for Payer: Priority Health SBD |
$208.88
|
| Rate for Payer: UMR Bronson Commercial |
$145.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.66
|
|
