|
CARBAMAZEPINE ER 100 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$398.05
|
|
|
Service Code
|
NDC 51672-4123-1
|
| Hospital Charge Code |
27634
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$175.14 |
| Max. Negotiated Rate |
$358.24 |
| Rate for Payer: Aetna American Axle |
$258.73
|
| Rate for Payer: Aetna Commercial |
$338.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$258.73
|
| Rate for Payer: Cash Price |
$318.44
|
| Rate for Payer: Cofinity Commercial |
$278.64
|
| Rate for Payer: Cofinity Commercial |
$342.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$318.44
|
| Rate for Payer: Healthscope Commercial |
$358.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$278.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$298.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$338.34
|
| Rate for Payer: PHP Commercial |
$338.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$278.64
|
| Rate for Payer: Priority Health SBD |
$250.77
|
| Rate for Payer: UMR Bronson Commercial |
$175.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$298.54
|
|
|
CARBAMAZEPINE ER 200 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$656.07
|
|
|
Service Code
|
NDC 60505-2806-7
|
| Hospital Charge Code |
27632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$288.67 |
| Max. Negotiated Rate |
$590.46 |
| Rate for Payer: Aetna American Axle |
$426.45
|
| Rate for Payer: Aetna Commercial |
$557.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$426.45
|
| Rate for Payer: Cash Price |
$524.86
|
| Rate for Payer: Cofinity Commercial |
$459.25
|
| Rate for Payer: Cofinity Commercial |
$564.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$524.86
|
| Rate for Payer: Healthscope Commercial |
$590.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$459.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$492.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$557.66
|
| Rate for Payer: PHP Commercial |
$557.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$459.25
|
| Rate for Payer: Priority Health SBD |
$413.32
|
| Rate for Payer: UMR Bronson Commercial |
$288.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$492.05
|
|
|
CARBAMAZEPINE ER 200 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$256.08
|
|
|
Service Code
|
NDC 0904-6885-04
|
| Hospital Charge Code |
27632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.68 |
| Max. Negotiated Rate |
$230.47 |
| Rate for Payer: Aetna American Axle |
$166.45
|
| Rate for Payer: Aetna Commercial |
$217.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$166.45
|
| Rate for Payer: Cash Price |
$204.86
|
| Rate for Payer: Cofinity Commercial |
$179.26
|
| Rate for Payer: Cofinity Commercial |
$220.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.86
|
| Rate for Payer: Healthscope Commercial |
$230.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$179.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$192.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.67
|
| Rate for Payer: PHP Commercial |
$217.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.26
|
| Rate for Payer: Priority Health SBD |
$161.33
|
| Rate for Payer: UMR Bronson Commercial |
$112.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$192.06
|
|
|
CARBAMAZEPINE ER 200 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$949.83
|
|
|
Service Code
|
NDC 54092-172-12
|
| Hospital Charge Code |
27632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$417.93 |
| Max. Negotiated Rate |
$854.85 |
| Rate for Payer: Aetna American Axle |
$617.39
|
| Rate for Payer: Aetna Commercial |
$807.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$617.39
|
| Rate for Payer: Cash Price |
$759.86
|
| Rate for Payer: Cofinity Commercial |
$664.88
|
| Rate for Payer: Cofinity Commercial |
$816.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$759.86
|
| Rate for Payer: Healthscope Commercial |
$854.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$664.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$712.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$807.36
|
| Rate for Payer: PHP Commercial |
$807.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$664.88
|
| Rate for Payer: Priority Health SBD |
$598.39
|
| Rate for Payer: UMR Bronson Commercial |
$417.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$712.37
|
|
|
CARBAMAZEPINE ER 200 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$895.68
|
|
|
Service Code
|
NDC 66993-408-32
|
| Hospital Charge Code |
27632
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$394.10 |
| Max. Negotiated Rate |
$806.11 |
| Rate for Payer: Aetna American Axle |
$582.19
|
| Rate for Payer: Aetna Commercial |
$761.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$582.19
|
| Rate for Payer: Cash Price |
$716.54
|
| Rate for Payer: Cofinity Commercial |
$626.98
|
| Rate for Payer: Cofinity Commercial |
$770.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$716.54
|
| Rate for Payer: Healthscope Commercial |
$806.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$626.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$671.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$761.33
|
| Rate for Payer: PHP Commercial |
$761.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$626.98
|
| Rate for Payer: Priority Health SBD |
$564.28
|
| Rate for Payer: UMR Bronson Commercial |
$394.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$671.76
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$758.40
|
|
|
Service Code
|
NDC 0781-5987-01
|
| Hospital Charge Code |
27635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$333.70 |
| Max. Negotiated Rate |
$682.56 |
| Rate for Payer: Aetna American Axle |
$492.96
|
| Rate for Payer: Aetna Commercial |
$644.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$492.96
|
| Rate for Payer: Cash Price |
$606.72
|
| Rate for Payer: Cofinity Commercial |
$530.88
|
| Rate for Payer: Cofinity Commercial |
$652.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$606.72
|
| Rate for Payer: Healthscope Commercial |
$682.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$530.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$568.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$644.64
|
| Rate for Payer: PHP Commercial |
$644.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$530.88
|
| Rate for Payer: Priority Health SBD |
$477.79
|
| Rate for Payer: UMR Bronson Commercial |
$333.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$568.80
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$401.76
|
|
|
Service Code
|
NDC 51672-4124-1
|
| Hospital Charge Code |
27635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$176.77 |
| Max. Negotiated Rate |
$361.58 |
| Rate for Payer: Aetna American Axle |
$261.14
|
| Rate for Payer: Aetna Commercial |
$341.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$261.14
|
| Rate for Payer: Cash Price |
$321.41
|
| Rate for Payer: Cofinity Commercial |
$281.23
|
| Rate for Payer: Cofinity Commercial |
$345.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$321.41
|
| Rate for Payer: Healthscope Commercial |
$361.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$281.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$301.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$341.50
|
| Rate for Payer: PHP Commercial |
$341.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$281.23
|
| Rate for Payer: Priority Health SBD |
$253.11
|
| Rate for Payer: UMR Bronson Commercial |
$176.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$301.32
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$357.12
|
|
|
Service Code
|
NDC 16571-681-01
|
| Hospital Charge Code |
27635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.13 |
| Max. Negotiated Rate |
$321.41 |
| Rate for Payer: Aetna American Axle |
$232.13
|
| Rate for Payer: Aetna Commercial |
$303.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$232.13
|
| Rate for Payer: Cash Price |
$285.70
|
| Rate for Payer: Cofinity Commercial |
$249.98
|
| Rate for Payer: Cofinity Commercial |
$307.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$285.70
|
| Rate for Payer: Healthscope Commercial |
$321.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$249.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$267.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$303.55
|
| Rate for Payer: PHP Commercial |
$303.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$249.98
|
| Rate for Payer: Priority Health SBD |
$224.99
|
| Rate for Payer: UMR Bronson Commercial |
$157.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$267.84
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
|
IP
|
$344.85
|
|
|
Service Code
|
NDC 50742-258-01
|
| Hospital Charge Code |
27635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.73 |
| Max. Negotiated Rate |
$310.36 |
| Rate for Payer: Aetna American Axle |
$224.15
|
| Rate for Payer: Aetna Commercial |
$293.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$224.15
|
| Rate for Payer: Cash Price |
$275.88
|
| Rate for Payer: Cofinity Commercial |
$241.40
|
| Rate for Payer: Cofinity Commercial |
$296.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$275.88
|
| Rate for Payer: Healthscope Commercial |
$310.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$241.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$258.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$293.12
|
| Rate for Payer: PHP Commercial |
$293.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$241.40
|
| Rate for Payer: Priority Health SBD |
$217.26
|
| Rate for Payer: UMR Bronson Commercial |
$151.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$258.64
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$818.50
|
|
|
Service Code
|
NDC 29033-004-12
|
| Hospital Charge Code |
27633
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$360.14 |
| Max. Negotiated Rate |
$736.65 |
| Rate for Payer: Aetna American Axle |
$532.02
|
| Rate for Payer: Aetna Commercial |
$695.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$532.02
|
| Rate for Payer: Cash Price |
$654.80
|
| Rate for Payer: Cofinity Commercial |
$572.95
|
| Rate for Payer: Cofinity Commercial |
$703.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$654.80
|
| Rate for Payer: Healthscope Commercial |
$736.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$572.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$613.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$695.72
|
| Rate for Payer: PHP Commercial |
$695.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$572.95
|
| Rate for Payer: Priority Health SBD |
$515.66
|
| Rate for Payer: UMR Bronson Commercial |
$360.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$613.88
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$895.68
|
|
|
Service Code
|
NDC 66993-409-32
|
| Hospital Charge Code |
27633
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$394.10 |
| Max. Negotiated Rate |
$806.11 |
| Rate for Payer: Aetna American Axle |
$582.19
|
| Rate for Payer: Aetna Commercial |
$761.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$582.19
|
| Rate for Payer: Cash Price |
$716.54
|
| Rate for Payer: Cofinity Commercial |
$626.98
|
| Rate for Payer: Cofinity Commercial |
$770.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$716.54
|
| Rate for Payer: Healthscope Commercial |
$806.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$626.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$671.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$761.33
|
| Rate for Payer: PHP Commercial |
$761.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$626.98
|
| Rate for Payer: Priority Health SBD |
$564.28
|
| Rate for Payer: UMR Bronson Commercial |
$394.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$671.76
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$656.07
|
|
|
Service Code
|
NDC 60505-2807-7
|
| Hospital Charge Code |
27633
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$288.67 |
| Max. Negotiated Rate |
$590.46 |
| Rate for Payer: Aetna American Axle |
$426.45
|
| Rate for Payer: Aetna Commercial |
$557.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$426.45
|
| Rate for Payer: Cash Price |
$524.86
|
| Rate for Payer: Cofinity Commercial |
$459.25
|
| Rate for Payer: Cofinity Commercial |
$564.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$524.86
|
| Rate for Payer: Healthscope Commercial |
$590.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$459.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$492.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$557.66
|
| Rate for Payer: PHP Commercial |
$557.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$459.25
|
| Rate for Payer: Priority Health SBD |
$413.32
|
| Rate for Payer: UMR Bronson Commercial |
$288.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$492.05
|
|
|
CARBAMAZEPINE ER 300 MG CAPSULE,EXTENDED RELEASE MPHASE12HR
|
Facility
|
IP
|
$949.83
|
|
|
Service Code
|
NDC 54092-173-12
|
| Hospital Charge Code |
27633
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$417.93 |
| Max. Negotiated Rate |
$854.85 |
| Rate for Payer: Aetna American Axle |
$617.39
|
| Rate for Payer: Aetna Commercial |
$807.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$617.39
|
| Rate for Payer: Cash Price |
$759.86
|
| Rate for Payer: Cofinity Commercial |
$664.88
|
| Rate for Payer: Cofinity Commercial |
$816.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$759.86
|
| Rate for Payer: Healthscope Commercial |
$854.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$664.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$712.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$807.36
|
| Rate for Payer: PHP Commercial |
$807.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$664.88
|
| Rate for Payer: Priority Health SBD |
$598.39
|
| Rate for Payer: UMR Bronson Commercial |
$417.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$712.37
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$25.47
|
|
|
Service Code
|
NDC 4203710479
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.21 |
| Max. Negotiated Rate |
$22.92 |
| Rate for Payer: Aetna American Axle |
$16.56
|
| Rate for Payer: Aetna Commercial |
$21.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.56
|
| Rate for Payer: Cash Price |
$20.38
|
| Rate for Payer: Cofinity Commercial |
$17.83
|
| Rate for Payer: Cofinity Commercial |
$21.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.38
|
| Rate for Payer: Healthscope Commercial |
$22.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.65
|
| Rate for Payer: PHP Commercial |
$21.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.83
|
| Rate for Payer: Priority Health SBD |
$16.05
|
| Rate for Payer: UMR Bronson Commercial |
$11.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.10
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$22.75
|
|
|
Service Code
|
NDC 7811273623
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.01 |
| Max. Negotiated Rate |
$20.48 |
| Rate for Payer: Aetna American Axle |
$14.79
|
| Rate for Payer: Aetna Commercial |
$19.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.79
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cofinity Commercial |
$15.92
|
| Rate for Payer: Cofinity Commercial |
$19.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.20
|
| Rate for Payer: Healthscope Commercial |
$20.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.34
|
| Rate for Payer: PHP Commercial |
$19.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.92
|
| Rate for Payer: Priority Health SBD |
$14.33
|
| Rate for Payer: UMR Bronson Commercial |
$10.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.06
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$25.59
|
|
|
Service Code
|
NDC 4203710478
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$23.03 |
| Rate for Payer: Aetna American Axle |
$16.63
|
| Rate for Payer: Aetna Commercial |
$21.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.63
|
| Rate for Payer: Cash Price |
$20.47
|
| Rate for Payer: Cofinity Commercial |
$17.91
|
| Rate for Payer: Cofinity Commercial |
$22.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.47
|
| Rate for Payer: Healthscope Commercial |
$23.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.75
|
| Rate for Payer: PHP Commercial |
$21.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.91
|
| Rate for Payer: Priority Health SBD |
$16.12
|
| Rate for Payer: UMR Bronson Commercial |
$11.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.19
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$9.27
|
|
|
Service Code
|
NDC 0904-6627-35
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.08 |
| Max. Negotiated Rate |
$8.34 |
| Rate for Payer: Aetna American Axle |
$6.03
|
| Rate for Payer: Aetna Commercial |
$7.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.03
|
| Rate for Payer: Cash Price |
$7.42
|
| Rate for Payer: Cofinity Commercial |
$6.49
|
| Rate for Payer: Cofinity Commercial |
$7.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.42
|
| Rate for Payer: Healthscope Commercial |
$8.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.88
|
| Rate for Payer: PHP Commercial |
$7.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.49
|
| Rate for Payer: Priority Health SBD |
$5.84
|
| Rate for Payer: UMR Bronson Commercial |
$4.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.95
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$26.13
|
|
|
Service Code
|
NDC 7811273621
|
| 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: 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 Multiplan/Beech St/PHCS |
$22.21
|
| Rate for Payer: PHP Commercial |
$22.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.29
|
| 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
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 50228-457-01
|
| 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 |
$136.54
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.54
|
| 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 0378-0078-01
|
| 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: 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 Multiplan/Beech St/PHCS |
$196.22
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.60
|
| 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 62756-517-88
|
| 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: 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 Multiplan/Beech St/PHCS |
$196.22
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.60
|
| 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 12.5 MG-LEVODOPA 50 MG-ENTACAPONE 200 MG TABLET
|
Facility
|
IP
|
$2,638.47
|
|
|
Service Code
|
NDC 0078-0407-05
|
| Hospital Charge Code |
36135
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,160.93 |
| Max. Negotiated Rate |
$2,374.62 |
| Rate for Payer: Aetna American Axle |
$1,715.01
|
| Rate for Payer: Aetna Commercial |
$2,242.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,715.01
|
| Rate for Payer: Cash Price |
$2,110.78
|
| Rate for Payer: Cofinity Commercial |
$1,846.93
|
| Rate for Payer: Cofinity Commercial |
$2,269.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,110.78
|
| Rate for Payer: Healthscope Commercial |
$2,374.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,846.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,978.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,242.70
|
| Rate for Payer: PHP Commercial |
$2,242.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,846.93
|
| Rate for Payer: Priority Health SBD |
$1,662.24
|
| Rate for Payer: UMR Bronson Commercial |
$1,160.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,978.85
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG-ENTACAPONE 200 MG TABLET
|
Facility
|
IP
|
$2,631.07
|
|
|
Service Code
|
NDC 52427-816-01
|
| 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: 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 Multiplan/Beech St/PHCS |
$2,236.41
|
| Rate for Payer: PHP Commercial |
$2,236.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,841.75
|
| 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
|
IP
|
$262.20
|
|
|
Service Code
|
NDC 62756-518-88
|
| 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: 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 Multiplan/Beech St/PHCS |
$222.87
|
| Rate for Payer: PHP Commercial |
$222.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.54
|
| 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
|
$525.60
|
|
|
Service Code
|
NDC 0006-3916-68
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$231.26 |
| Max. Negotiated Rate |
$473.04 |
| Rate for Payer: Aetna American Axle |
$341.64
|
| Rate for Payer: Aetna Commercial |
$446.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$341.64
|
| Rate for Payer: Cash Price |
$420.48
|
| Rate for Payer: Cofinity Commercial |
$367.92
|
| Rate for Payer: Cofinity Commercial |
$452.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$420.48
|
| Rate for Payer: Healthscope Commercial |
$473.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$367.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$394.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$446.76
|
| Rate for Payer: PHP Commercial |
$446.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$367.92
|
| Rate for Payer: Priority Health SBD |
$331.13
|
| Rate for Payer: UMR Bronson Commercial |
$231.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$394.20
|
|
