|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$10.33
|
|
|
Service Code
|
NDC 23558076501
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.75 |
| 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 |
$8.48
|
| Rate for Payer: BCN Commercial |
$8.48
|
| 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 |
$10.02
|
| Rate for Payer: Healthscope Whirlpool |
$10.33
|
| Rate for Payer: Mclaren Commercial |
$9.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.78
|
| Rate for Payer: Nomi Health Commercial |
$8.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$9.09
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
IP
|
$10.13
|
|
|
Service Code
|
NDC 70000049001
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.59 |
| 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 |
$8.31
|
| Rate for Payer: BCN Commercial |
$8.31
|
| Rate for Payer: Cash Price |
$8.10
|
| Rate for Payer: Cofinity Commercial |
$9.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.10
|
| Rate for Payer: Healthscope Commercial |
$9.82
|
| Rate for Payer: Healthscope Whirlpool |
$10.12
|
| Rate for Payer: Mclaren Commercial |
$9.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.61
|
| Rate for Payer: Nomi Health Commercial |
$8.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.91
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$22.37
|
|
|
Service Code
|
NDC 42037010478
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.28 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Aetna Commercial |
$20.13
|
| Rate for Payer: Aetna Medicare |
$8.28
|
| Rate for Payer: ASR ASR |
$21.69
|
| Rate for Payer: BCBS Complete |
$8.95
|
| Rate for Payer: BCBS Trust/PPO |
$18.44
|
| Rate for Payer: BCN Commercial |
$18.44
|
| Rate for Payer: Cash Price |
$17.89
|
| Rate for Payer: Cofinity Commercial |
$21.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.89
|
| Rate for Payer: Healthscope Commercial |
$21.69
|
| Rate for Payer: Healthscope Whirlpool |
$22.36
|
| Rate for Payer: Mclaren Commercial |
$20.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.01
|
| Rate for Payer: Nomi Health Commercial |
$18.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.77
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$19.60
|
| Rate for Payer: Priority Health Narrow Network |
$15.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.68
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$9.99
|
|
|
Service Code
|
NDC 904747835
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.70 |
| Max. Negotiated Rate |
$9.99 |
| Rate for Payer: Aetna Commercial |
$8.99
|
| Rate for Payer: Aetna Medicare |
$3.70
|
| Rate for Payer: ASR ASR |
$9.69
|
| Rate for Payer: BCBS Complete |
$4.00
|
| Rate for Payer: BCBS Trust/PPO |
$8.24
|
| Rate for Payer: BCN Commercial |
$8.24
|
| Rate for Payer: Cash Price |
$7.99
|
| Rate for Payer: Cofinity Commercial |
$9.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.99
|
| Rate for Payer: Healthscope Commercial |
$9.69
|
| Rate for Payer: Healthscope Whirlpool |
$9.99
|
| Rate for Payer: Mclaren Commercial |
$8.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.49
|
| Rate for Payer: Nomi Health Commercial |
$8.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.49
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$8.75
|
| Rate for Payer: Priority Health Narrow Network |
$7.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$8.79
|
|
|
CARBAMIDE PEROXIDE 6.5 % EAR DROPS
|
Facility
|
OP
|
$22.75
|
|
|
Service Code
|
NDC 78112073623
|
| Hospital Charge Code |
1359
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.42 |
| Max. Negotiated Rate |
$22.75 |
| Rate for Payer: Aetna Commercial |
$20.47
|
| Rate for Payer: Aetna Medicare |
$8.42
|
| Rate for Payer: ASR ASR |
$22.07
|
| Rate for Payer: BCBS Complete |
$9.10
|
| Rate for Payer: BCBS Trust/PPO |
$18.76
|
| Rate for Payer: BCN Commercial |
$18.76
|
| 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 |
$22.07
|
| Rate for Payer: Healthscope Whirlpool |
$22.75
|
| Rate for Payer: Mclaren Commercial |
$20.47
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.34
|
| Rate for Payer: Nomi Health Commercial |
$18.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.06
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$19.93
|
| Rate for Payer: Priority Health Narrow Network |
$15.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.02
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$425.35
|
|
|
Service Code
|
NDC 904750161
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.38 |
| Max. Negotiated Rate |
$425.35 |
| Rate for Payer: Aetna Commercial |
$382.81
|
| Rate for Payer: Aetna Medicare |
$157.38
|
| Rate for Payer: ASR ASR |
$412.59
|
| Rate for Payer: BCBS Complete |
$170.14
|
| Rate for Payer: BCBS Trust/PPO |
$350.70
|
| Rate for Payer: BCN Commercial |
$350.70
|
| Rate for Payer: Cash Price |
$340.28
|
| Rate for Payer: Cofinity Commercial |
$399.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.28
|
| Rate for Payer: Healthscope Commercial |
$412.59
|
| Rate for Payer: Healthscope Whirlpool |
$425.35
|
| Rate for Payer: Mclaren Commercial |
$382.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$340.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.55
|
| Rate for Payer: Nomi Health Commercial |
$348.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$372.69
|
| Rate for Payer: Priority Health Narrow Network |
$298.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$374.31
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$425.35
|
|
|
Service Code
|
NDC 904750161
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$319.01 |
| Max. Negotiated Rate |
$425.35 |
| Rate for Payer: Aetna Commercial |
$382.81
|
| Rate for Payer: ASR ASR |
$412.59
|
| Rate for Payer: BCBS Trust/PPO |
$349.30
|
| Rate for Payer: BCN Commercial |
$349.30
|
| Rate for Payer: Cash Price |
$340.28
|
| Rate for Payer: Cofinity Commercial |
$399.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.28
|
| Rate for Payer: Healthscope Commercial |
$412.59
|
| Rate for Payer: Healthscope Whirlpool |
$425.35
|
| Rate for Payer: Mclaren Commercial |
$382.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$361.55
|
| Rate for Payer: Nomi Health Commercial |
$348.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$319.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$374.31
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
OP
|
$359.55
|
|
|
Service Code
|
NDC 904725761
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.03 |
| Max. Negotiated Rate |
$359.55 |
| Rate for Payer: Aetna Commercial |
$323.60
|
| Rate for Payer: Aetna Medicare |
$133.03
|
| Rate for Payer: ASR ASR |
$348.76
|
| Rate for Payer: BCBS Complete |
$143.82
|
| Rate for Payer: BCBS Trust/PPO |
$296.45
|
| Rate for Payer: BCN Commercial |
$296.45
|
| Rate for Payer: Cash Price |
$287.64
|
| Rate for Payer: Cofinity Commercial |
$337.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Healthscope Commercial |
$348.76
|
| Rate for Payer: Healthscope Whirlpool |
$359.55
|
| Rate for Payer: Mclaren Commercial |
$323.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$287.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.62
|
| Rate for Payer: Nomi Health Commercial |
$294.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$269.66
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$315.04
|
| Rate for Payer: Priority Health Narrow Network |
$252.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$316.40
|
|
|
CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET
|
Facility
|
IP
|
$359.55
|
|
|
Service Code
|
NDC 904725761
|
| Hospital Charge Code |
9407
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$269.66 |
| Max. Negotiated Rate |
$359.55 |
| Rate for Payer: Aetna Commercial |
$323.60
|
| Rate for Payer: ASR ASR |
$348.76
|
| Rate for Payer: BCBS Trust/PPO |
$295.26
|
| Rate for Payer: BCN Commercial |
$295.26
|
| Rate for Payer: Cash Price |
$287.64
|
| Rate for Payer: Cofinity Commercial |
$337.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.64
|
| Rate for Payer: Healthscope Commercial |
$348.76
|
| Rate for Payer: Healthscope Whirlpool |
$359.55
|
| Rate for Payer: Mclaren Commercial |
$323.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$305.62
|
| Rate for Payer: Nomi Health Commercial |
$294.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$269.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$316.40
|
|
|
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 |
$178.84 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Aetna Commercial |
$214.60
|
| Rate for Payer: ASR ASR |
$231.30
|
| Rate for Payer: BCBS Trust/PPO |
$195.82
|
| Rate for Payer: BCN Commercial |
$195.82
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$224.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$231.30
|
| Rate for Payer: Healthscope Whirlpool |
$238.45
|
| Rate for Payer: Mclaren Commercial |
$214.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Nomi Health Commercial |
$195.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$209.84
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
IP
|
$354.35
|
|
|
Service Code
|
NDC 60687083601
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$265.76 |
| Max. Negotiated Rate |
$354.35 |
| Rate for Payer: Aetna Commercial |
$318.92
|
| Rate for Payer: ASR ASR |
$343.72
|
| Rate for Payer: BCBS Trust/PPO |
$290.99
|
| Rate for Payer: BCN Commercial |
$290.99
|
| Rate for Payer: Cash Price |
$283.48
|
| Rate for Payer: Cofinity Commercial |
$333.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.48
|
| Rate for Payer: Healthscope Commercial |
$343.72
|
| Rate for Payer: Healthscope Whirlpool |
$354.35
|
| Rate for Payer: Mclaren Commercial |
$318.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.20
|
| Rate for Payer: Nomi Health Commercial |
$290.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$265.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$311.83
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
OP
|
$200.45
|
|
|
Service Code
|
NDC 904623861
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.17 |
| Max. Negotiated Rate |
$200.45 |
| Rate for Payer: Aetna Commercial |
$180.41
|
| Rate for Payer: Aetna Medicare |
$74.17
|
| Rate for Payer: ASR ASR |
$194.44
|
| Rate for Payer: BCBS Complete |
$80.18
|
| Rate for Payer: BCBS Trust/PPO |
$165.27
|
| Rate for Payer: BCN Commercial |
$165.27
|
| 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 |
$194.44
|
| Rate for Payer: Healthscope Whirlpool |
$200.45
|
| Rate for Payer: Mclaren Commercial |
$180.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$160.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: Nomi Health Commercial |
$164.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$150.34
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$175.63
|
| Rate for Payer: Priority Health Narrow Network |
$140.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$176.40
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
IP
|
$200.45
|
|
|
Service Code
|
NDC 904623861
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$150.34 |
| Max. Negotiated Rate |
$200.45 |
| Rate for Payer: Aetna Commercial |
$180.41
|
| Rate for Payer: ASR ASR |
$194.44
|
| Rate for Payer: BCBS Trust/PPO |
$164.61
|
| Rate for Payer: BCN Commercial |
$164.61
|
| 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 |
$194.44
|
| Rate for Payer: Healthscope Whirlpool |
$200.45
|
| Rate for Payer: Mclaren Commercial |
$180.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.38
|
| Rate for Payer: Nomi Health Commercial |
$164.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$150.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$176.40
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
IP
|
$3.54
|
|
|
Service Code
|
NDC 60687083611
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.66 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Aetna Commercial |
$3.19
|
| Rate for Payer: ASR ASR |
$3.44
|
| Rate for Payer: BCBS Trust/PPO |
$2.91
|
| Rate for Payer: BCN Commercial |
$2.91
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cofinity Commercial |
$3.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.84
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Healthscope Whirlpool |
$3.54
|
| Rate for Payer: Mclaren Commercial |
$3.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.01
|
| Rate for Payer: Nomi Health Commercial |
$2.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.12
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
OP
|
$3.54
|
|
|
Service Code
|
NDC 60687083611
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.31 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Aetna Commercial |
$3.19
|
| Rate for Payer: Aetna Medicare |
$1.31
|
| Rate for Payer: ASR ASR |
$3.44
|
| Rate for Payer: BCBS Complete |
$1.42
|
| Rate for Payer: BCBS Trust/PPO |
$2.92
|
| Rate for Payer: BCN Commercial |
$2.92
|
| Rate for Payer: Cash Price |
$2.84
|
| Rate for Payer: Cofinity Commercial |
$3.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.84
|
| Rate for Payer: Healthscope Commercial |
$3.44
|
| Rate for Payer: Healthscope Whirlpool |
$3.54
|
| Rate for Payer: Mclaren Commercial |
$3.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.01
|
| Rate for Payer: Nomi Health Commercial |
$2.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.66
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.11
|
| Rate for Payer: Priority Health Narrow Network |
$2.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.12
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
OP
|
$354.35
|
|
|
Service Code
|
NDC 60687083601
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.11 |
| Max. Negotiated Rate |
$354.35 |
| Rate for Payer: Aetna Commercial |
$318.92
|
| Rate for Payer: Aetna Medicare |
$131.11
|
| Rate for Payer: ASR ASR |
$343.72
|
| Rate for Payer: BCBS Complete |
$141.74
|
| Rate for Payer: BCBS Trust/PPO |
$292.16
|
| Rate for Payer: BCN Commercial |
$292.16
|
| Rate for Payer: Cash Price |
$283.48
|
| Rate for Payer: Cofinity Commercial |
$333.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$283.48
|
| Rate for Payer: Healthscope Commercial |
$343.72
|
| Rate for Payer: Healthscope Whirlpool |
$354.35
|
| Rate for Payer: Mclaren Commercial |
$318.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$283.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$301.20
|
| Rate for Payer: Nomi Health Commercial |
$290.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$265.76
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$310.48
|
| Rate for Payer: Priority Health Narrow Network |
$248.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$311.83
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
IP
|
$238.45
|
|
|
Service Code
|
NDC 68084009401
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.84 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Aetna Commercial |
$214.60
|
| Rate for Payer: ASR ASR |
$231.30
|
| Rate for Payer: BCBS Trust/PPO |
$195.82
|
| Rate for Payer: BCN Commercial |
$195.82
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$224.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$231.30
|
| Rate for Payer: Healthscope Whirlpool |
$238.45
|
| Rate for Payer: Mclaren Commercial |
$214.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Nomi Health Commercial |
$195.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$209.84
|
|
|
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 |
$238.45 |
| Rate for Payer: Aetna Commercial |
$214.60
|
| Rate for Payer: Aetna Medicare |
$88.23
|
| Rate for Payer: ASR ASR |
$231.30
|
| Rate for Payer: BCBS Complete |
$95.38
|
| Rate for Payer: BCBS Trust/PPO |
$196.60
|
| Rate for Payer: BCN Commercial |
$196.60
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$224.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$231.30
|
| Rate for Payer: Healthscope Whirlpool |
$238.45
|
| Rate for Payer: Mclaren Commercial |
$214.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Nomi Health Commercial |
$195.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$208.93
|
| Rate for Payer: Priority Health Narrow Network |
$167.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$209.84
|
|
|
CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET
|
Facility
|
OP
|
$238.45
|
|
|
Service Code
|
NDC 68084009401
|
| Hospital Charge Code |
9408
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.23 |
| Max. Negotiated Rate |
$238.45 |
| Rate for Payer: Aetna Commercial |
$214.60
|
| Rate for Payer: Aetna Medicare |
$88.23
|
| Rate for Payer: ASR ASR |
$231.30
|
| Rate for Payer: BCBS Complete |
$95.38
|
| Rate for Payer: BCBS Trust/PPO |
$196.60
|
| Rate for Payer: BCN Commercial |
$196.60
|
| Rate for Payer: Cash Price |
$190.76
|
| Rate for Payer: Cofinity Commercial |
$224.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.76
|
| Rate for Payer: Healthscope Commercial |
$231.30
|
| Rate for Payer: Healthscope Whirlpool |
$238.45
|
| Rate for Payer: Mclaren Commercial |
$214.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$190.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$202.68
|
| Rate for Payer: Nomi Health Commercial |
$195.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$178.84
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$208.93
|
| Rate for Payer: Priority Health Narrow Network |
$167.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$209.84
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$3.28
|
|
|
Service Code
|
NDC 68084028111
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.21 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Aetna Commercial |
$2.95
|
| Rate for Payer: Aetna Medicare |
$1.21
|
| Rate for Payer: ASR ASR |
$3.18
|
| Rate for Payer: BCBS Complete |
$1.31
|
| Rate for Payer: BCBS Trust/PPO |
$2.70
|
| Rate for Payer: BCN Commercial |
$2.70
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.62
|
| Rate for Payer: Healthscope Commercial |
$3.18
|
| Rate for Payer: Healthscope Whirlpool |
$3.28
|
| Rate for Payer: Mclaren Commercial |
$2.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.79
|
| Rate for Payer: Nomi Health Commercial |
$2.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.46
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.87
|
| Rate for Payer: Priority Health Narrow Network |
$2.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.89
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$3.18
|
|
|
Service Code
|
NDC 51079097801
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.18 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Aetna Commercial |
$2.86
|
| Rate for Payer: Aetna Medicare |
$1.18
|
| Rate for Payer: ASR ASR |
$3.09
|
| Rate for Payer: BCBS Complete |
$1.27
|
| Rate for Payer: BCBS Trust/PPO |
$2.62
|
| Rate for Payer: BCN Commercial |
$2.62
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cofinity Commercial |
$2.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.55
|
| Rate for Payer: Healthscope Commercial |
$3.09
|
| Rate for Payer: Healthscope Whirlpool |
$3.18
|
| Rate for Payer: Mclaren Commercial |
$2.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.71
|
| Rate for Payer: Nomi Health Commercial |
$2.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.39
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$2.79
|
| Rate for Payer: Priority Health Narrow Network |
$2.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.80
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$318.25
|
|
|
Service Code
|
NDC 51079097820
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.75 |
| Max. Negotiated Rate |
$318.25 |
| Rate for Payer: Aetna Commercial |
$286.43
|
| Rate for Payer: Aetna Medicare |
$117.75
|
| Rate for Payer: ASR ASR |
$308.70
|
| Rate for Payer: BCBS Complete |
$127.30
|
| Rate for Payer: BCBS Trust/PPO |
$262.40
|
| Rate for Payer: BCN Commercial |
$262.40
|
| Rate for Payer: Cash Price |
$254.60
|
| Rate for Payer: Cofinity Commercial |
$299.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.60
|
| Rate for Payer: Healthscope Commercial |
$308.70
|
| Rate for Payer: Healthscope Whirlpool |
$318.25
|
| Rate for Payer: Mclaren Commercial |
$286.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$254.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.51
|
| Rate for Payer: Nomi Health Commercial |
$260.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$238.69
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$278.85
|
| Rate for Payer: Priority Health Narrow Network |
$223.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$280.06
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$3.18
|
|
|
Service Code
|
NDC 51079097801
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.39 |
| Max. Negotiated Rate |
$3.18 |
| Rate for Payer: Aetna Commercial |
$2.86
|
| Rate for Payer: ASR ASR |
$3.09
|
| Rate for Payer: BCBS Trust/PPO |
$2.61
|
| Rate for Payer: BCN Commercial |
$2.61
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cofinity Commercial |
$2.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.55
|
| Rate for Payer: Healthscope Commercial |
$3.09
|
| Rate for Payer: Healthscope Whirlpool |
$3.18
|
| Rate for Payer: Mclaren Commercial |
$2.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.71
|
| Rate for Payer: Nomi Health Commercial |
$2.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.80
|
|
|
CARBIDOPA ER 25 MG-LEVODOPA 100 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$318.25
|
|
|
Service Code
|
NDC 51079097820
|
| Hospital Charge Code |
12329
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$238.69 |
| Max. Negotiated Rate |
$318.25 |
| Rate for Payer: Aetna Commercial |
$286.43
|
| Rate for Payer: ASR ASR |
$308.70
|
| Rate for Payer: BCBS Trust/PPO |
$261.35
|
| Rate for Payer: BCN Commercial |
$261.35
|
| Rate for Payer: Cash Price |
$254.60
|
| Rate for Payer: Cofinity Commercial |
$299.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.60
|
| Rate for Payer: Healthscope Commercial |
$308.70
|
| Rate for Payer: Healthscope Whirlpool |
$318.25
|
| Rate for Payer: Mclaren Commercial |
$286.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.51
|
| Rate for Payer: Nomi Health Commercial |
$260.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$238.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$280.06
|
|
|
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 |
$2.46 |
| Max. Negotiated Rate |
$3.28 |
| Rate for Payer: Aetna Commercial |
$2.95
|
| Rate for Payer: ASR ASR |
$3.18
|
| Rate for Payer: BCBS Trust/PPO |
$2.69
|
| Rate for Payer: BCN Commercial |
$2.69
|
| Rate for Payer: Cash Price |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.62
|
| Rate for Payer: Healthscope Commercial |
$3.18
|
| Rate for Payer: Healthscope Whirlpool |
$3.28
|
| Rate for Payer: Mclaren Commercial |
$2.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.79
|
| Rate for Payer: Nomi Health Commercial |
$2.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.89
|
|
