|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$133.95
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
9406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.94 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna American Axle |
$87.07
|
| Rate for Payer: Aetna Commercial |
$113.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.07
|
| Rate for Payer: Cash Price |
$107.16
|
| Rate for Payer: Cofinity Advantage |
$93.77
|
| Rate for Payer: Cofinity Commercial |
$115.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.16
|
| Rate for Payer: Healthscope Commercial |
$120.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.46
|
| Rate for Payer: PHP Commercial |
$113.86
|
| Rate for Payer: Priority Health SBD |
$84.39
|
| Rate for Payer: UMR Bronson Commercial |
$58.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.46
|
|
|
CARBIDOPA 10 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$133.95
|
|
|
Service Code
|
NDC 50228045701
|
| Hospital Charge Code |
9406
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.56 |
| Max. Negotiated Rate |
$120.56 |
| Rate for Payer: Aetna American Axle |
$87.07
|
| Rate for Payer: Aetna Commercial |
$113.86
|
| Rate for Payer: Aetna Medicare |
$66.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$87.07
|
| Rate for Payer: BCBS Complete |
$53.58
|
| Rate for Payer: Cash Price |
$107.16
|
| Rate for Payer: Cofinity Advantage |
$93.77
|
| Rate for Payer: Cofinity Commercial |
$115.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$107.16
|
| Rate for Payer: Healthscope Commercial |
$120.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$100.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$107.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$100.46
|
| Rate for Payer: PHP Commercial |
$113.86
|
| Rate for Payer: Priority Health SBD |
$84.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$87.07
|
| Rate for Payer: UHC Core |
$69.79
|
| Rate for Payer: UHC Exchange |
$52.64
|
| Rate for Payer: UMR Bronson Commercial |
$49.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$100.46
|
|
|
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 Advantage |
$161.59
|
| 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 |
$161.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$173.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$184.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$196.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$173.14
|
| Rate for Payer: PHP Commercial |
$196.22
|
| Rate for Payer: Priority Health SBD |
$145.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$150.05
|
| Rate for Payer: UHC Core |
$120.27
|
| Rate for Payer: UHC Exchange |
$90.72
|
| 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 TABLET
|
Facility
|
OP
|
$198.55
|
|
|
Service Code
|
NDC 63739010810
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.46 |
| Max. Negotiated Rate |
$178.69 |
| Rate for Payer: Aetna American Axle |
$129.06
|
| Rate for Payer: Aetna Commercial |
$168.77
|
| Rate for Payer: Aetna Medicare |
$99.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.06
|
| Rate for Payer: BCBS Complete |
$79.42
|
| Rate for Payer: Cash Price |
$158.84
|
| Rate for Payer: Cofinity Advantage |
$138.99
|
| Rate for Payer: Cofinity Commercial |
$170.75
|
| 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: MI Amish Medical Board Commercial |
$158.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$168.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.91
|
| Rate for Payer: PHP Commercial |
$168.77
|
| Rate for Payer: Priority Health SBD |
$125.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$129.06
|
| Rate for Payer: UHC Core |
$103.44
|
| Rate for Payer: UHC Exchange |
$78.03
|
| 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
|
$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 Advantage |
$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 Commercial |
$222.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$196.65
|
| Rate for Payer: PHP Commercial |
$222.87
|
| 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
|
$2,162.00
|
|
|
Service Code
|
NDC 69367033910
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$951.28 |
| Max. Negotiated Rate |
$1,945.80 |
| Rate for Payer: Aetna American Axle |
$1,405.30
|
| Rate for Payer: Aetna Commercial |
$1,837.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,405.30
|
| Rate for Payer: Cash Price |
$1,729.60
|
| Rate for Payer: Cofinity Advantage |
$1,513.40
|
| Rate for Payer: Cofinity Commercial |
$1,859.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,729.60
|
| Rate for Payer: Healthscope Commercial |
$1,945.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,513.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,621.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,837.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,621.50
|
| Rate for Payer: PHP Commercial |
$1,837.70
|
| Rate for Payer: Priority Health SBD |
$1,362.06
|
| Rate for Payer: UMR Bronson Commercial |
$951.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,621.50
|
|
|
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 Advantage |
$154.63
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| 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: MI Amish Medical Board Commercial |
$176.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$165.68
|
| Rate for Payer: PHP Commercial |
$187.76
|
| Rate for Payer: Priority Health SBD |
$139.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$143.59
|
| Rate for Payer: UHC Core |
$115.09
|
| Rate for Payer: UHC Exchange |
$86.81
|
| 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
|
$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 Advantage |
$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: MI Amish Medical Board Commercial |
$209.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$222.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$196.65
|
| Rate for Payer: PHP Commercial |
$222.87
|
| Rate for Payer: Priority Health SBD |
$165.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$170.43
|
| Rate for Payer: UHC Core |
$136.61
|
| Rate for Payer: UHC Exchange |
$103.04
|
| 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 |
$178.69 |
| 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 Advantage |
$138.99
|
| Rate for Payer: Cofinity Commercial |
$170.75
|
| 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: Opus (Opus Packaging Group) HMA |
$148.91
|
| Rate for Payer: PHP Commercial |
$168.77
|
| 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
|
$2,162.00
|
|
|
Service Code
|
NDC 69367033910
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$799.94 |
| Max. Negotiated Rate |
$1,945.80 |
| Rate for Payer: Aetna American Axle |
$1,405.30
|
| Rate for Payer: Aetna Commercial |
$1,837.70
|
| Rate for Payer: Aetna Medicare |
$1,081.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,405.30
|
| Rate for Payer: BCBS Complete |
$864.80
|
| Rate for Payer: Cash Price |
$1,729.60
|
| Rate for Payer: Cofinity Advantage |
$1,513.40
|
| Rate for Payer: Cofinity Commercial |
$1,859.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,729.60
|
| Rate for Payer: Healthscope Commercial |
$1,945.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,513.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,621.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,729.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,837.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,621.50
|
| Rate for Payer: PHP Commercial |
$1,837.70
|
| Rate for Payer: Priority Health SBD |
$1,362.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,405.30
|
| Rate for Payer: UHC Core |
$1,126.40
|
| Rate for Payer: UHC Exchange |
$849.67
|
| Rate for Payer: UMR Bronson Commercial |
$799.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,621.50
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$220.90
|
|
|
Service Code
|
NDC 52817039110
|
| 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 Advantage |
$154.63
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| 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: MI Amish Medical Board Commercial |
$176.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$187.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$165.68
|
| Rate for Payer: PHP Commercial |
$187.76
|
| Rate for Payer: Priority Health SBD |
$139.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$143.59
|
| Rate for Payer: UHC Core |
$115.09
|
| Rate for Payer: UHC Exchange |
$86.81
|
| 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
|
$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 Advantage |
$251.69
|
| Rate for Payer: Cofinity Commercial |
$309.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Healthscope Commercial |
$323.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$251.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$287.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$269.66
|
| Rate for Payer: PHP Commercial |
$305.62
|
| Rate for Payer: Priority Health SBD |
$226.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$233.71
|
| Rate for Payer: UHC Core |
$187.33
|
| Rate for Payer: UHC Exchange |
$141.30
|
| 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
|
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 Advantage |
$251.69
|
| Rate for Payer: Cofinity Commercial |
$309.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Healthscope Commercial |
$323.60
|
| Rate for Payer: 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: Opus (Opus Packaging Group) HMA |
$269.66
|
| Rate for Payer: PHP Commercial |
$305.62
|
| 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
|
$242.05
|
|
|
Service Code
|
NDC 00093970201
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.50 |
| Max. Negotiated Rate |
$217.84 |
| Rate for Payer: Aetna American Axle |
$157.33
|
| Rate for Payer: Aetna Commercial |
$205.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.33
|
| Rate for Payer: Cash Price |
$193.64
|
| Rate for Payer: Cofinity Advantage |
$169.44
|
| Rate for Payer: Cofinity Commercial |
$208.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.64
|
| Rate for Payer: Healthscope Commercial |
$217.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$169.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.54
|
| Rate for Payer: PHP Commercial |
$205.74
|
| Rate for Payer: Priority Health SBD |
$152.49
|
| Rate for Payer: UMR Bronson Commercial |
$106.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.54
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$242.05
|
|
|
Service Code
|
NDC 00093970201
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.56 |
| Max. Negotiated Rate |
$217.84 |
| Rate for Payer: Aetna American Axle |
$157.33
|
| Rate for Payer: Aetna Commercial |
$205.74
|
| Rate for Payer: Aetna Medicare |
$121.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$157.33
|
| Rate for Payer: BCBS Complete |
$96.82
|
| Rate for Payer: Cash Price |
$193.64
|
| Rate for Payer: Cofinity Advantage |
$169.44
|
| Rate for Payer: Cofinity Commercial |
$208.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.64
|
| Rate for Payer: Healthscope Commercial |
$217.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$169.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$193.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$205.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$181.54
|
| Rate for Payer: PHP Commercial |
$205.74
|
| Rate for Payer: Priority Health SBD |
$152.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$157.33
|
| Rate for Payer: UHC Core |
$126.11
|
| Rate for Payer: UHC Exchange |
$95.13
|
| Rate for Payer: UMR Bronson Commercial |
$89.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.54
|
|
|
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 |
$143.59
|
| Rate for Payer: Aetna Commercial |
$187.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.59
|
| Rate for Payer: Cash Price |
$176.72
|
| Rate for Payer: Cofinity Advantage |
$154.63
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| 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: Opus (Opus Packaging Group) HMA |
$165.68
|
| Rate for Payer: PHP Commercial |
$187.76
|
| 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
|
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 Advantage |
$871.15
|
| Rate for Payer: Cofinity Commercial |
$1,070.27
|
| 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: MI Amish Medical Board Commercial |
$995.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,057.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$933.38
|
| Rate for Payer: PHP Commercial |
$1,057.83
|
| Rate for Payer: Priority Health SBD |
$784.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$808.92
|
| Rate for Payer: UHC Core |
$648.38
|
| Rate for Payer: UHC Exchange |
$489.09
|
| 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
|
$220.90
|
|
|
Service Code
|
NDC 52817039110
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.20 |
| Max. Negotiated Rate |
$198.81 |
| Rate for Payer: Aetna American Axle |
$143.59
|
| Rate for Payer: Aetna Commercial |
$187.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$143.59
|
| Rate for Payer: Cash Price |
$176.72
|
| Rate for Payer: Cofinity Advantage |
$154.63
|
| Rate for Payer: Cofinity Commercial |
$189.97
|
| 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: Opus (Opus Packaging Group) HMA |
$165.68
|
| Rate for Payer: PHP Commercial |
$187.76
|
| 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
|
$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 |
$1,057.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$808.92
|
| Rate for Payer: Cash Price |
$995.60
|
| Rate for Payer: Cofinity Advantage |
$871.15
|
| Rate for Payer: Cofinity Commercial |
$1,070.27
|
| 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: Opus (Opus Packaging Group) HMA |
$933.38
|
| Rate for Payer: PHP Commercial |
$1,057.83
|
| Rate for Payer: Priority Health SBD |
$784.03
|
| Rate for Payer: UMR Bronson Commercial |
$547.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$933.38
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
IP
|
$322.05
|
|
|
Service Code
|
NDC 00904754961
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.70 |
| Max. Negotiated Rate |
$289.85 |
| Rate for Payer: Aetna American Axle |
$209.33
|
| Rate for Payer: Aetna Commercial |
$273.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$209.33
|
| Rate for Payer: Cash Price |
$257.64
|
| Rate for Payer: Cofinity Advantage |
$225.44
|
| Rate for Payer: Cofinity Commercial |
$276.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$257.64
|
| Rate for Payer: Healthscope Commercial |
$289.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$225.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$241.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$273.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$241.54
|
| Rate for Payer: PHP Commercial |
$273.74
|
| Rate for Payer: Priority Health SBD |
$202.89
|
| Rate for Payer: UMR Bronson Commercial |
$141.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$241.54
|
|
|
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 Advantage |
$140.31
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| 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: MI Amish Medical Board Commercial |
$160.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$150.34
|
| Rate for Payer: PHP Commercial |
$170.38
|
| Rate for Payer: Priority Health SBD |
$126.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.29
|
| Rate for Payer: UHC Core |
$104.43
|
| Rate for Payer: UHC Exchange |
$78.78
|
| 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
|
$253.80
|
|
|
Service Code
|
NDC 69367034001
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.67 |
| Max. Negotiated Rate |
$228.42 |
| Rate for Payer: Aetna American Axle |
$164.97
|
| Rate for Payer: Aetna Commercial |
$215.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$164.97
|
| Rate for Payer: Cash Price |
$203.04
|
| Rate for Payer: Cofinity Advantage |
$177.66
|
| Rate for Payer: Cofinity Commercial |
$218.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$203.04
|
| Rate for Payer: Healthscope Commercial |
$228.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$177.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$190.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$215.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$190.35
|
| Rate for Payer: PHP Commercial |
$215.73
|
| Rate for Payer: Priority Health SBD |
$159.89
|
| Rate for Payer: UMR Bronson Commercial |
$111.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$190.35
|
|
|
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 Advantage |
$166.91
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| 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: MI Amish Medical Board Commercial |
$190.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: PHP Commercial |
$202.68
|
| Rate for Payer: Priority Health SBD |
$150.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$154.99
|
| Rate for Payer: UHC Core |
$124.23
|
| Rate for Payer: UHC Exchange |
$93.71
|
| Rate for Payer: UMR Bronson Commercial |
$88.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.84
|
|
|
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 Advantage |
$166.91
|
| Rate for Payer: Cofinity Commercial |
$205.07
|
| 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: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: PHP Commercial |
$202.68
|
| 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
|
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 Advantage |
$140.31
|
| Rate for Payer: Cofinity Commercial |
$172.39
|
| 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: Opus (Opus Packaging Group) HMA |
$150.34
|
| Rate for Payer: PHP Commercial |
$170.38
|
| 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
|
|
