|
CAPTOPRIL 25 MG TABLET
|
Facility
IP
|
$5.95
|
|
|
Service Code
|
NDC 51079-864-01
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.16 |
| Max. Negotiated Rate |
$5.95 |
| Rate for Payer: Aetna Commercial |
$5.36
|
| Rate for Payer: ASR ASR |
$5.77
|
| Rate for Payer: BCBS Trust/PPO |
$4.61
|
| Rate for Payer: BCN Commercial |
$4.61
|
| Rate for Payer: Cash Price |
$4.76
|
| Rate for Payer: Cofinity Commercial |
$5.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.76
|
| Rate for Payer: Healthscope Commercial |
$5.95
|
| Rate for Payer: Healthscope Whirlpool |
$5.77
|
| Rate for Payer: Mclaren Commercial |
$5.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.24
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
IP
|
$595.20
|
|
|
Service Code
|
NDC 51079-864-20
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$416.64 |
| Max. Negotiated Rate |
$595.20 |
| Rate for Payer: Aetna Commercial |
$535.68
|
| Rate for Payer: ASR ASR |
$577.34
|
| Rate for Payer: BCBS Trust/PPO |
$461.46
|
| Rate for Payer: BCN Commercial |
$461.46
|
| Rate for Payer: Cash Price |
$476.16
|
| Rate for Payer: Cofinity Commercial |
$559.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$476.16
|
| Rate for Payer: Healthscope Commercial |
$595.20
|
| Rate for Payer: Healthscope Whirlpool |
$577.34
|
| Rate for Payer: Mclaren Commercial |
$535.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$505.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$416.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$523.78
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
IP
|
$6.50
|
|
|
Service Code
|
NDC 60687-315-11
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.55 |
| Max. Negotiated Rate |
$6.50 |
| Rate for Payer: Aetna Commercial |
$5.85
|
| Rate for Payer: ASR ASR |
$6.30
|
| Rate for Payer: BCBS Trust/PPO |
$5.04
|
| Rate for Payer: BCN Commercial |
$5.04
|
| Rate for Payer: Cash Price |
$5.20
|
| Rate for Payer: Cofinity Commercial |
$6.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.20
|
| Rate for Payer: Healthscope Commercial |
$6.50
|
| Rate for Payer: Healthscope Whirlpool |
$6.30
|
| Rate for Payer: Mclaren Commercial |
$5.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.72
|
|
|
CAPTOPRIL 25 MG TABLET
|
Facility
IP
|
$194.98
|
|
|
Service Code
|
NDC 60687-315-21
|
| Hospital Charge Code |
9402
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.49 |
| Max. Negotiated Rate |
$194.98 |
| Rate for Payer: Aetna Commercial |
$175.48
|
| Rate for Payer: ASR ASR |
$189.13
|
| Rate for Payer: BCBS Trust/PPO |
$151.17
|
| Rate for Payer: BCN Commercial |
$151.17
|
| Rate for Payer: Cash Price |
$155.98
|
| Rate for Payer: Cofinity Commercial |
$183.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.98
|
| Rate for Payer: Healthscope Commercial |
$194.98
|
| Rate for Payer: Healthscope Whirlpool |
$189.13
|
| Rate for Payer: Mclaren Commercial |
$175.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$171.58
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
IP
|
$312.55
|
|
|
Service Code
|
NDC 0904-3854-61
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$218.78 |
| Max. Negotiated Rate |
$312.55 |
| Rate for Payer: Aetna Commercial |
$281.30
|
| Rate for Payer: ASR ASR |
$303.17
|
| Rate for Payer: BCBS Trust/PPO |
$242.32
|
| Rate for Payer: BCN Commercial |
$242.32
|
| Rate for Payer: Cash Price |
$250.04
|
| Rate for Payer: Cofinity Commercial |
$293.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.04
|
| Rate for Payer: Healthscope Commercial |
$312.55
|
| Rate for Payer: Healthscope Whirlpool |
$303.17
|
| Rate for Payer: Mclaren Commercial |
$281.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$265.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$218.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$275.04
|
|
|
CARBAMAZEPINE 100 MG CHEWABLE TABLET
|
Facility
IP
|
$3.13
|
|
|
Service Code
|
NDC 51079-870-01
|
| Hospital Charge Code |
1355
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.19 |
| Max. Negotiated Rate |
$3.13 |
| Rate for Payer: Aetna Commercial |
$2.82
|
| Rate for Payer: ASR ASR |
$3.04
|
| Rate for Payer: BCBS Trust/PPO |
$2.43
|
| Rate for Payer: BCN Commercial |
$2.43
|
| Rate for Payer: Cash Price |
$2.51
|
| Rate for Payer: Cofinity Commercial |
$2.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.50
|
| Rate for Payer: Healthscope Commercial |
$3.13
|
| Rate for Payer: Healthscope Whirlpool |
$3.04
|
| Rate for Payer: Mclaren Commercial |
$2.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.75
|
|
|
CARBAMAZEPINE 200 MG TABLET
|
Facility
IP
|
$326.65
|
|
|
Service Code
|
NDC 75834-221-01
|
| Hospital Charge Code |
1357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$228.66 |
| Max. Negotiated Rate |
$326.65 |
| Rate for Payer: Aetna Commercial |
$293.98
|
| Rate for Payer: ASR ASR |
$316.85
|
| Rate for Payer: BCBS Trust/PPO |
$253.25
|
| Rate for Payer: BCN Commercial |
$253.25
|
| Rate for Payer: Cash Price |
$261.32
|
| Rate for Payer: Cofinity Commercial |
$307.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$261.32
|
| Rate for Payer: Healthscope Commercial |
$326.65
|
| Rate for Payer: Healthscope Whirlpool |
$316.85
|
| Rate for Payer: Mclaren Commercial |
$293.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$277.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$228.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$287.45
|
|
|
CARBAMAZEPINE 200 MG TABLET
|
Facility
IP
|
$3.74
|
|
|
Service Code
|
NDC 51079-385-01
|
| Hospital Charge Code |
1357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.62 |
| Max. Negotiated Rate |
$3.74 |
| Rate for Payer: Aetna Commercial |
$3.37
|
| Rate for Payer: ASR ASR |
$3.63
|
| Rate for Payer: BCBS Trust/PPO |
$2.90
|
| Rate for Payer: BCN Commercial |
$2.90
|
| Rate for Payer: Cash Price |
$2.99
|
| Rate for Payer: Cofinity Commercial |
$3.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.99
|
| Rate for Payer: Healthscope Commercial |
$3.74
|
| Rate for Payer: Healthscope Whirlpool |
$3.63
|
| Rate for Payer: Mclaren Commercial |
$3.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.29
|
|
|
CARBAMAZEPINE 200 MG TABLET
|
Facility
IP
|
$244.32
|
|
|
Service Code
|
NDC 0904-6172-61
|
| Hospital Charge Code |
1357
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$171.02 |
| Max. Negotiated Rate |
$244.32 |
| Rate for Payer: Aetna Commercial |
$219.89
|
| Rate for Payer: ASR ASR |
$236.99
|
| Rate for Payer: BCBS Trust/PPO |
$189.42
|
| Rate for Payer: BCN Commercial |
$189.42
|
| Rate for Payer: Cash Price |
$195.46
|
| Rate for Payer: Cofinity Commercial |
$229.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.46
|
| Rate for Payer: Healthscope Commercial |
$244.32
|
| Rate for Payer: Healthscope Whirlpool |
$236.99
|
| Rate for Payer: Mclaren Commercial |
$219.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$207.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$215.00
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
IP
|
$10.65
|
|
|
Service Code
|
NDC 60687-583-11
|
| Hospital Charge Code |
27635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.46 |
| Max. Negotiated Rate |
$10.65 |
| Rate for Payer: Aetna Commercial |
$9.58
|
| Rate for Payer: ASR ASR |
$10.33
|
| Rate for Payer: BCBS Trust/PPO |
$8.26
|
| Rate for Payer: BCN Commercial |
$8.26
|
| Rate for Payer: Cash Price |
$8.52
|
| Rate for Payer: Cofinity Commercial |
$10.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.52
|
| Rate for Payer: Healthscope Commercial |
$10.65
|
| Rate for Payer: Healthscope Whirlpool |
$10.33
|
| Rate for Payer: Mclaren Commercial |
$9.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.37
|
|
|
CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR
|
Facility
IP
|
$319.46
|
|
|
Service Code
|
NDC 60687-583-21
|
| Hospital Charge Code |
27635
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$223.62 |
| Max. Negotiated Rate |
$319.46 |
| Rate for Payer: Aetna Commercial |
$287.51
|
| Rate for Payer: ASR ASR |
$309.88
|
| Rate for Payer: BCBS Trust/PPO |
$247.68
|
| Rate for Payer: BCN Commercial |
$247.68
|
| Rate for Payer: Cash Price |
$255.57
|
| Rate for Payer: Cofinity Commercial |
$300.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.57
|
| Rate for Payer: Healthscope Commercial |
$319.46
|
| Rate for Payer: Healthscope Whirlpool |
$309.88
|
| Rate for Payer: Mclaren Commercial |
$287.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$271.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$223.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$281.12
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
IP
|
$10.33
|
|
|
Service Code
|
NDC 23558-76501
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.23 |
| Max. Negotiated Rate |
$10.33 |
| Rate for Payer: Aetna Commercial |
$9.30
|
| Rate for Payer: ASR ASR |
$10.02
|
| Rate for Payer: BCBS Trust/PPO |
$8.01
|
| Rate for Payer: BCN Commercial |
$8.01
|
| Rate for Payer: Cash Price |
$8.26
|
| Rate for Payer: Cofinity Commercial |
$9.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.26
|
| Rate for Payer: Healthscope Commercial |
$10.33
|
| Rate for Payer: Healthscope Whirlpool |
$10.02
|
| Rate for Payer: Mclaren Commercial |
$9.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.09
|
|
|
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 |
$6.49 |
| Max. Negotiated Rate |
$9.27 |
| Rate for Payer: Aetna Commercial |
$8.34
|
| Rate for Payer: ASR ASR |
$8.99
|
| Rate for Payer: BCBS Trust/PPO |
$7.19
|
| Rate for Payer: BCN Commercial |
$7.19
|
| Rate for Payer: Cash Price |
$7.42
|
| Rate for Payer: Cofinity Commercial |
$8.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.42
|
| Rate for Payer: Healthscope Commercial |
$9.27
|
| Rate for Payer: Healthscope Whirlpool |
$8.99
|
| Rate for Payer: Mclaren Commercial |
$8.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.16
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
IP
|
$10.12
|
|
|
Service Code
|
NDC 70000-0490-1
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.08 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Aetna Commercial |
$9.11
|
| Rate for Payer: ASR ASR |
$9.82
|
| Rate for Payer: BCBS Trust/PPO |
$7.85
|
| Rate for Payer: BCN Commercial |
$7.85
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cofinity Commercial |
$9.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.10
|
| Rate for Payer: Healthscope Commercial |
$10.12
|
| Rate for Payer: Healthscope Whirlpool |
$9.82
|
| Rate for Payer: Mclaren Commercial |
$9.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.91
|
|
|
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 |
$15.92 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Aetna Commercial |
$20.48
|
| Rate for Payer: ASR ASR |
$22.07
|
| Rate for Payer: BCBS Trust/PPO |
$17.64
|
| Rate for Payer: BCN Commercial |
$17.64
|
| Rate for Payer: Cash Price |
$18.20
|
| Rate for Payer: Cofinity Commercial |
$21.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.20
|
| Rate for Payer: Healthscope Commercial |
$22.75
|
| Rate for Payer: Healthscope Whirlpool |
$22.07
|
| Rate for Payer: Mclaren Commercial |
$20.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.02
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
IP
|
$25.58
|
|
|
Service Code
|
NDC 4203710478
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.91 |
| Max. Negotiated Rate |
$25.58 |
| Rate for Payer: Aetna Commercial |
$23.02
|
| Rate for Payer: ASR ASR |
$24.81
|
| Rate for Payer: BCBS Trust/PPO |
$19.83
|
| Rate for Payer: BCN Commercial |
$19.83
|
| Rate for Payer: Cash Price |
$20.47
|
| Rate for Payer: Cofinity Commercial |
$24.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.46
|
| Rate for Payer: Healthscope Commercial |
$25.58
|
| Rate for Payer: Healthscope Whirlpool |
$24.81
|
| Rate for Payer: Mclaren Commercial |
$23.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.51
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
IP
|
$190.35
|
|
|
Service Code
|
NDC 0228-2539-10
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.24 |
| Max. Negotiated Rate |
$190.35 |
| Rate for Payer: Aetna Commercial |
$171.32
|
| Rate for Payer: ASR ASR |
$184.64
|
| Rate for Payer: BCBS Trust/PPO |
$147.58
|
| Rate for Payer: BCN Commercial |
$147.58
|
| Rate for Payer: Cash Price |
$152.28
|
| Rate for Payer: Cofinity Commercial |
$178.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$152.28
|
| Rate for Payer: Healthscope Commercial |
$190.35
|
| Rate for Payer: Healthscope Whirlpool |
$184.64
|
| Rate for Payer: Mclaren Commercial |
$171.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$161.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$133.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$167.51
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
IP
|
$2.02
|
|
|
Service Code
|
NDC 68084-093-11
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.41 |
| Max. Negotiated Rate |
$2.02 |
| Rate for Payer: Aetna Commercial |
$1.82
|
| Rate for Payer: ASR ASR |
$1.96
|
| Rate for Payer: BCBS Trust/PPO |
$1.57
|
| Rate for Payer: BCN Commercial |
$1.57
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cofinity Commercial |
$1.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.62
|
| Rate for Payer: Healthscope Commercial |
$2.02
|
| Rate for Payer: Healthscope Whirlpool |
$1.96
|
| Rate for Payer: Mclaren Commercial |
$1.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.78
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
IP
|
$350.15
|
|
|
Service Code
|
NDC 0904-7257-61
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.10 |
| Max. Negotiated Rate |
$350.15 |
| Rate for Payer: Aetna Commercial |
$315.14
|
| Rate for Payer: ASR ASR |
$339.65
|
| Rate for Payer: BCBS Trust/PPO |
$271.47
|
| Rate for Payer: BCN Commercial |
$271.47
|
| Rate for Payer: Cash Price |
$280.12
|
| Rate for Payer: Cofinity Commercial |
$329.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.12
|
| Rate for Payer: Healthscope Commercial |
$350.15
|
| Rate for Payer: Healthscope Whirlpool |
$339.65
|
| Rate for Payer: Mclaren Commercial |
$315.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$297.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$245.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$308.13
|
|
|
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 |
$367.92 |
| Max. Negotiated Rate |
$525.60 |
| Rate for Payer: Aetna Commercial |
$473.04
|
| Rate for Payer: ASR ASR |
$509.83
|
| Rate for Payer: BCBS Trust/PPO |
$407.50
|
| Rate for Payer: BCN Commercial |
$407.50
|
| Rate for Payer: Cash Price |
$420.48
|
| Rate for Payer: Cofinity Commercial |
$494.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$420.48
|
| Rate for Payer: Healthscope Commercial |
$525.60
|
| Rate for Payer: Healthscope Whirlpool |
$509.83
|
| Rate for Payer: Mclaren Commercial |
$473.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$446.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$367.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$462.53
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
IP
|
$329.00
|
|
|
Service Code
|
NDC 0904-6237-61
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$230.30 |
| Max. Negotiated Rate |
$329.00 |
| Rate for Payer: Aetna Commercial |
$296.10
|
| Rate for Payer: ASR ASR |
$319.13
|
| Rate for Payer: BCBS Trust/PPO |
$255.07
|
| Rate for Payer: BCN Commercial |
$255.07
|
| Rate for Payer: Cash Price |
$263.20
|
| Rate for Payer: Cofinity Commercial |
$309.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$263.20
|
| Rate for Payer: Healthscope Commercial |
$329.00
|
| Rate for Payer: Healthscope Whirlpool |
$319.13
|
| Rate for Payer: Mclaren Commercial |
$296.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$279.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$289.52
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
IP
|
$202.35
|
|
|
Service Code
|
NDC 68084-093-01
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$141.64 |
| Max. Negotiated Rate |
$202.35 |
| Rate for Payer: Aetna Commercial |
$182.12
|
| Rate for Payer: ASR ASR |
$196.28
|
| Rate for Payer: BCBS Trust/PPO |
$156.88
|
| Rate for Payer: BCN Commercial |
$156.88
|
| Rate for Payer: Cash Price |
$161.88
|
| Rate for Payer: Cofinity Commercial |
$190.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.88
|
| Rate for Payer: Healthscope Commercial |
$202.35
|
| Rate for Payer: Healthscope Whirlpool |
$196.28
|
| Rate for Payer: Mclaren Commercial |
$182.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$172.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$178.07
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
IP
|
$224.20
|
|
|
Service Code
|
NDC 68084-094-01
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.94 |
| Max. Negotiated Rate |
$224.20 |
| Rate for Payer: Aetna Commercial |
$201.78
|
| Rate for Payer: ASR ASR |
$217.47
|
| Rate for Payer: BCBS Trust/PPO |
$173.82
|
| Rate for Payer: BCN Commercial |
$173.82
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$210.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$224.20
|
| Rate for Payer: Healthscope Whirlpool |
$217.47
|
| Rate for Payer: Mclaren Commercial |
$201.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$197.30
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
IP
|
$224.20
|
|
|
Service Code
|
NDC 68084-094-11
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.94 |
| Max. Negotiated Rate |
$224.20 |
| Rate for Payer: Aetna Commercial |
$201.78
|
| Rate for Payer: ASR ASR |
$217.47
|
| Rate for Payer: BCBS Trust/PPO |
$173.82
|
| Rate for Payer: BCN Commercial |
$173.82
|
| Rate for Payer: Cash Price |
$179.36
|
| Rate for Payer: Cofinity Commercial |
$210.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$179.36
|
| Rate for Payer: Healthscope Commercial |
$224.20
|
| Rate for Payer: Healthscope Whirlpool |
$217.47
|
| Rate for Payer: Mclaren Commercial |
$201.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$190.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$197.30
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
IP
|
$200.45
|
|
|
Service Code
|
NDC 0904-6238-61
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$140.32 |
| Max. Negotiated Rate |
$200.45 |
| Rate for Payer: Aetna Commercial |
$180.40
|
| Rate for Payer: ASR ASR |
$194.44
|
| Rate for Payer: BCBS Trust/PPO |
$155.41
|
| Rate for Payer: BCN Commercial |
$155.41
|
| Rate for Payer: Cash Price |
$160.36
|
| Rate for Payer: Cofinity Commercial |
$188.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.36
|
| Rate for Payer: Healthscope Commercial |
$200.45
|
| Rate for Payer: Healthscope Whirlpool |
$194.44
|
| Rate for Payer: Mclaren Commercial |
$180.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$170.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$140.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$176.40
|
|
