Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

CARBAMAZEPINE ER 200 MG TABLET,EXTENDED RELEASE,12 HR

Facility

$11.57

Service Code	NDC 60687058311
Hospital Charge Code	27635
Hospital Revenue Code	637
Min. Negotiated Rate	$4.63
Max. Negotiated Rate	$11.57
Rate for Payer: Aetna Commercial	$10.41
Rate for Payer: Aetna Medicare	$5.79
Rate for Payer: ASR ASR	$11.22
Rate for Payer: ASR Commercial	$11.22
Rate for Payer: BCBS Complete	$4.63
Rate for Payer: BCBS Trust/PPO	$9.47
Rate for Payer: BCN Commercial	$8.97
Rate for Payer: Cash Price	$9.26
Rate for Payer: Cofinity Commercial	$10.88
Rate for Payer: Encore Health Key Benefits Commercial	$9.26
Rate for Payer: Healthscope Commercial	$11.57
Rate for Payer: Healthscope Whirlpool	$11.22
Rate for Payer: Mclaren Commercial	$10.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$9.83
Rate for Payer: Nomi Health Commercial	$9.49
Rate for Payer: Priority Health Cigna Priority Health	$7.52
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$10.14
Rate for Payer: Priority Health Narrow Network	$8.11
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.18

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$10.12

Service Code	NDC 70000049001
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$6.58
Max. Negotiated Rate	$10.12
Rate for Payer: Aetna Commercial	$9.11
Rate for Payer: ASR ASR	$9.82
Rate for Payer: ASR Commercial	$9.82
Rate for Payer: BCBS Trust/PPO	$8.25
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 Commercial	$8.60
Rate for Payer: Nomi Health Commercial	$8.30
Rate for Payer: Priority Health Cigna Priority Health	$6.58
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.91

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$9.45

Service Code	NDC 00904662735
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$3.78
Max. Negotiated Rate	$9.45
Rate for Payer: Aetna Commercial	$8.51
Rate for Payer: Aetna Medicare	$4.72
Rate for Payer: ASR ASR	$9.17
Rate for Payer: ASR Commercial	$9.17
Rate for Payer: BCBS Complete	$3.78
Rate for Payer: BCBS Trust/PPO	$7.74
Rate for Payer: BCN Commercial	$7.33
Rate for Payer: Cash Price	$7.56
Rate for Payer: Cofinity Commercial	$8.88
Rate for Payer: Encore Health Key Benefits Commercial	$7.56
Rate for Payer: Healthscope Commercial	$9.45
Rate for Payer: Healthscope Whirlpool	$9.17
Rate for Payer: Mclaren Commercial	$8.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.03
Rate for Payer: Nomi Health Commercial	$7.75
Rate for Payer: Priority Health Cigna Priority Health	$6.14
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8.28
Rate for Payer: Priority Health Narrow Network	$6.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.32

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$10.33

Service Code	NDC 23558076501
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$6.71
Max. Negotiated Rate	$10.33
Rate for Payer: Aetna Commercial	$9.30
Rate for Payer: ASR ASR	$10.02
Rate for Payer: ASR Commercial	$10.02
Rate for Payer: BCBS Trust/PPO	$8.42
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 Commercial	$8.78
Rate for Payer: Nomi Health Commercial	$8.47
Rate for Payer: Priority Health Cigna Priority Health	$6.71
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$9.09

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$22.75

Service Code	NDC 78112073623
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$9.10
Max. Negotiated Rate	$22.75
Rate for Payer: Aetna Commercial	$20.48
Rate for Payer: Aetna Medicare	$11.38
Rate for Payer: ASR ASR	$22.07
Rate for Payer: ASR Commercial	$22.07
Rate for Payer: BCBS Complete	$9.10
Rate for Payer: BCBS Trust/PPO	$18.63
Rate for Payer: BCN Commercial	$17.64
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cofinity Commercial	$21.39
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 Commercial	$19.34
Rate for Payer: Nomi Health Commercial	$18.66
Rate for Payer: Priority Health Cigna Priority Health	$14.79
Rate for Payer: 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

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$22.36

Service Code	NDC 42037010478
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$14.53
Max. Negotiated Rate	$22.36
Rate for Payer: Aetna Commercial	$20.12
Rate for Payer: ASR ASR	$21.69
Rate for Payer: ASR Commercial	$21.69
Rate for Payer: BCBS Trust/PPO	$18.22
Rate for Payer: BCN Commercial	$17.34
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	$22.36
Rate for Payer: Healthscope Whirlpool	$21.69
Rate for Payer: Mclaren Commercial	$20.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.01
Rate for Payer: Nomi Health Commercial	$18.34
Rate for Payer: Priority Health Cigna Priority Health	$14.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$19.68

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$10.12

Service Code	NDC 70000049001
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$4.05
Max. Negotiated Rate	$10.12
Rate for Payer: Aetna Commercial	$9.11
Rate for Payer: Aetna Medicare	$5.06
Rate for Payer: ASR ASR	$9.82
Rate for Payer: ASR Commercial	$9.82
Rate for Payer: BCBS Complete	$4.05
Rate for Payer: BCBS Trust/PPO	$8.29
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 Commercial	$8.60
Rate for Payer: Nomi Health Commercial	$8.30
Rate for Payer: Priority Health Cigna Priority Health	$6.58
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$8.87
Rate for Payer: Priority Health Narrow Network	$7.09
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.91

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$10.33

Service Code	NDC 23558076501
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$4.13
Max. Negotiated Rate	$10.33
Rate for Payer: Aetna Commercial	$9.30
Rate for Payer: Aetna Medicare	$5.17
Rate for Payer: ASR ASR	$10.02
Rate for Payer: ASR Commercial	$10.02
Rate for Payer: BCBS Complete	$4.13
Rate for Payer: BCBS Trust/PPO	$8.46
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 Commercial	$8.78
Rate for Payer: Nomi Health Commercial	$8.47
Rate for Payer: Priority Health Cigna Priority Health	$6.71
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$9.05
Rate for Payer: Priority Health Narrow Network	$7.24
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$9.09

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$9.45

Service Code	NDC 00904662735
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$6.14
Max. Negotiated Rate	$9.45
Rate for Payer: Aetna Commercial	$8.51
Rate for Payer: ASR ASR	$9.17
Rate for Payer: ASR Commercial	$9.17
Rate for Payer: BCBS Trust/PPO	$7.70
Rate for Payer: BCN Commercial	$7.33
Rate for Payer: Cash Price	$7.56
Rate for Payer: Cofinity Commercial	$8.88
Rate for Payer: Encore Health Key Benefits Commercial	$7.56
Rate for Payer: Healthscope Commercial	$9.45
Rate for Payer: Healthscope Whirlpool	$9.17
Rate for Payer: Mclaren Commercial	$8.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$8.03
Rate for Payer: Nomi Health Commercial	$7.75
Rate for Payer: Priority Health Cigna Priority Health	$6.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$8.32

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$22.36

Service Code	NDC 42037010478
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$8.94
Max. Negotiated Rate	$22.36
Rate for Payer: Aetna Commercial	$20.12
Rate for Payer: Aetna Medicare	$11.18
Rate for Payer: ASR ASR	$21.69
Rate for Payer: ASR Commercial	$21.69
Rate for Payer: BCBS Complete	$8.94
Rate for Payer: BCBS Trust/PPO	$18.31
Rate for Payer: BCN Commercial	$17.34
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	$22.36
Rate for Payer: Healthscope Whirlpool	$21.69
Rate for Payer: Mclaren Commercial	$20.12
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.01
Rate for Payer: Nomi Health Commercial	$18.34
Rate for Payer: Priority Health Cigna Priority Health	$14.53
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$19.59
Rate for Payer: Priority Health Narrow Network	$15.67
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$19.68

CARBAMIDE PEROXIDE 6.5 % EAR DROPS

Facility

$22.75

Service Code	NDC 78112073623
Hospital Charge Code	1359
Hospital Revenue Code	637
Min. Negotiated Rate	$14.79
Max. Negotiated Rate	$22.75
Rate for Payer: Aetna Commercial	$20.48
Rate for Payer: ASR ASR	$22.07
Rate for Payer: ASR Commercial	$22.07
Rate for Payer: BCBS Trust/PPO	$18.54
Rate for Payer: BCN Commercial	$17.64
Rate for Payer: Cash Price	$18.20
Rate for Payer: Cofinity Commercial	$21.39
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 Commercial	$19.34
Rate for Payer: Nomi Health Commercial	$18.66
Rate for Payer: Priority Health Cigna Priority Health	$14.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.02

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$190.35

Service Code	NDC 00228253910
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$123.73
Max. Negotiated Rate	$190.35
Rate for Payer: Aetna Commercial	$171.31
Rate for Payer: ASR ASR	$184.64
Rate for Payer: ASR Commercial	$184.64
Rate for Payer: BCBS Trust/PPO	$155.12
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	$171.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$161.80
Rate for Payer: Nomi Health Commercial	$156.09
Rate for Payer: Priority Health Cigna Priority Health	$123.73
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$167.51

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$202.35

Service Code	NDC 68084009301
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$131.53
Max. Negotiated Rate	$202.35
Rate for Payer: Aetna Commercial	$182.12
Rate for Payer: ASR ASR	$196.28
Rate for Payer: ASR Commercial	$196.28
Rate for Payer: BCBS Trust/PPO	$164.90
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 Commercial	$172.00
Rate for Payer: Nomi Health Commercial	$165.93
Rate for Payer: Priority Health Cigna Priority Health	$131.53
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$178.07

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$190.35

Service Code	NDC 00228253910
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$76.14
Max. Negotiated Rate	$190.35
Rate for Payer: Aetna Commercial	$171.31
Rate for Payer: Aetna Medicare	$95.17
Rate for Payer: ASR ASR	$184.64
Rate for Payer: ASR Commercial	$184.64
Rate for Payer: BCBS Complete	$76.14
Rate for Payer: BCBS Trust/PPO	$155.88
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	$171.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$161.80
Rate for Payer: Nomi Health Commercial	$156.09
Rate for Payer: Priority Health Cigna Priority Health	$123.73
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$166.78
Rate for Payer: Priority Health Narrow Network	$133.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$167.51

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$202.35

Service Code	NDC 68084009301
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$80.94
Max. Negotiated Rate	$202.35
Rate for Payer: Aetna Commercial	$182.12
Rate for Payer: Aetna Medicare	$101.17
Rate for Payer: ASR ASR	$196.28
Rate for Payer: ASR Commercial	$196.28
Rate for Payer: BCBS Complete	$80.94
Rate for Payer: BCBS Trust/PPO	$165.70
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 Commercial	$172.00
Rate for Payer: Nomi Health Commercial	$165.93
Rate for Payer: Priority Health Cigna Priority Health	$131.53
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$177.30
Rate for Payer: Priority Health Narrow Network	$141.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$178.07

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$359.55

Service Code	NDC 00904725761
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$233.71
Max. Negotiated Rate	$359.55
Rate for Payer: Aetna Commercial	$323.60
Rate for Payer: ASR ASR	$348.76
Rate for Payer: ASR Commercial	$348.76
Rate for Payer: BCBS Trust/PPO	$293.00
Rate for Payer: BCN Commercial	$278.76
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	$359.55
Rate for Payer: Healthscope Whirlpool	$348.76
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: Priority Health Cigna Priority Health	$233.71
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$316.40

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$329.00

Service Code	NDC 00904623761
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$131.60
Max. Negotiated Rate	$329.00
Rate for Payer: Aetna Commercial	$296.10
Rate for Payer: Aetna Medicare	$164.50
Rate for Payer: ASR ASR	$319.13
Rate for Payer: ASR Commercial	$319.13
Rate for Payer: BCBS Complete	$131.60
Rate for Payer: BCBS Trust/PPO	$269.42
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 Commercial	$279.65
Rate for Payer: Nomi Health Commercial	$269.78
Rate for Payer: Priority Health Cigna Priority Health	$213.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$288.27
Rate for Payer: Priority Health Narrow Network	$230.63
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$289.52

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$329.00

Service Code	NDC 00904623761
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$213.85
Max. Negotiated Rate	$329.00
Rate for Payer: Aetna Commercial	$296.10
Rate for Payer: ASR ASR	$319.13
Rate for Payer: ASR Commercial	$319.13
Rate for Payer: BCBS Trust/PPO	$268.10
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 Commercial	$279.65
Rate for Payer: Nomi Health Commercial	$269.78
Rate for Payer: Priority Health Cigna Priority Health	$213.85
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$289.52

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$359.55

Service Code	NDC 00904725761
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$143.82
Max. Negotiated Rate	$359.55
Rate for Payer: Aetna Commercial	$323.60
Rate for Payer: Aetna Medicare	$179.78
Rate for Payer: ASR ASR	$348.76
Rate for Payer: ASR Commercial	$348.76
Rate for Payer: BCBS Complete	$143.82
Rate for Payer: BCBS Trust/PPO	$294.44
Rate for Payer: BCN Commercial	$278.76
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	$359.55
Rate for Payer: Healthscope Whirlpool	$348.76
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: Priority Health Cigna Priority Health	$233.71
Rate for Payer: 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

$2.02

Service Code	NDC 68084009311
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$1.31
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna Commercial	$1.82
Rate for Payer: ASR ASR	$1.96
Rate for Payer: ASR Commercial	$1.96
Rate for Payer: BCBS Trust/PPO	$1.65
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 Commercial	$1.72
Rate for Payer: Nomi Health Commercial	$1.66
Rate for Payer: Priority Health Cigna Priority Health	$1.31
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1.78

CARBIDOPA 25 MG-LEVODOPA 100 MG TABLET

Facility

$2.02

Service Code	NDC 68084009311
Hospital Charge Code	9407
Hospital Revenue Code	637
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$2.02
Rate for Payer: Aetna Commercial	$1.82
Rate for Payer: Aetna Medicare	$1.01
Rate for Payer: ASR ASR	$1.96
Rate for Payer: ASR Commercial	$1.96
Rate for Payer: BCBS Complete	$0.81
Rate for Payer: BCBS Trust/PPO	$1.65
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 Commercial	$1.72
Rate for Payer: Nomi Health Commercial	$1.66
Rate for Payer: Priority Health Cigna Priority Health	$1.31
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1.77
Rate for Payer: Priority Health Narrow Network	$1.42
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1.78

CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET

Facility

$238.45

Service Code	NDC 68084009411
Hospital Charge Code	9408
Hospital Revenue Code	637
Min. Negotiated Rate	$95.38
Max. Negotiated Rate	$238.45
Rate for Payer: Aetna Commercial	$214.60
Rate for Payer: Aetna Medicare	$119.22
Rate for Payer: ASR ASR	$231.30
Rate for Payer: ASR Commercial	$231.30
Rate for Payer: BCBS Complete	$95.38
Rate for Payer: BCBS Trust/PPO	$195.27
Rate for Payer: BCN Commercial	$184.87
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	$238.45
Rate for Payer: Healthscope Whirlpool	$231.30
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: Priority Health Cigna Priority Health	$154.99
Rate for Payer: 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

$200.45

Service Code	NDC 00904623861
Hospital Charge Code	9408
Hospital Revenue Code	637
Min. Negotiated Rate	$130.29
Max. Negotiated Rate	$200.45
Rate for Payer: Aetna Commercial	$180.41
Rate for Payer: ASR ASR	$194.44
Rate for Payer: ASR Commercial	$194.44
Rate for Payer: BCBS Trust/PPO	$163.35
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	$180.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$170.38
Rate for Payer: Nomi Health Commercial	$164.37
Rate for Payer: Priority Health Cigna Priority Health	$130.29
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$176.40

CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET

Facility

$238.45

Service Code	NDC 68084009411
Hospital Charge Code	9408
Hospital Revenue Code	637
Min. Negotiated Rate	$154.99
Max. Negotiated Rate	$238.45
Rate for Payer: Aetna Commercial	$214.60
Rate for Payer: ASR ASR	$231.30
Rate for Payer: ASR Commercial	$231.30
Rate for Payer: BCBS Trust/PPO	$194.31
Rate for Payer: BCN Commercial	$184.87
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	$238.45
Rate for Payer: Healthscope Whirlpool	$231.30
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: Priority Health Cigna Priority Health	$154.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$209.84

CARBIDOPA 25 MG-LEVODOPA 250 MG TABLET

Facility

$200.45

Service Code	NDC 00904623861
Hospital Charge Code	9408
Hospital Revenue Code	637
Min. Negotiated Rate	$80.18
Max. Negotiated Rate	$200.45
Rate for Payer: Aetna Commercial	$180.41
Rate for Payer: Aetna Medicare	$100.22
Rate for Payer: ASR ASR	$194.44
Rate for Payer: ASR Commercial	$194.44
Rate for Payer: BCBS Complete	$80.18
Rate for Payer: BCBS Trust/PPO	$164.15
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	$180.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$170.38
Rate for Payer: Nomi Health Commercial	$164.37
Rate for Payer: Priority Health Cigna Priority Health	$130.29
Rate for Payer: 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

Know your out-of-pocket cost for care.

All Charges