Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LITHIUM CARBONATE 150 MG CAPSULE

Facility

$326.65

Service Code	NDC 00054852625
Hospital Charge Code	4528
Hospital Revenue Code	637
Min. Negotiated Rate	$205.79
Max. Negotiated Rate	$293.99
Rate for Payer: Aetna Commercial	$277.65
Rate for Payer: Aetna New Business (MI Preferred)	$212.32
Rate for Payer: Cash Price	$261.32
Rate for Payer: Cofinity Commercial	$228.66
Rate for Payer: Cofinity Commercial	$280.92
Rate for Payer: Cofinity Medicare Advantage	$228.66
Rate for Payer: Encore Health Key Benefits Commercial	$261.32
Rate for Payer: Healthscope Commercial	$293.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$277.65
Rate for Payer: PHP Commercial	$277.65
Rate for Payer: Priority Health Cigna Priority Health	$212.32
Rate for Payer: Priority Health SBD	$205.79

LITHIUM CARBONATE 150 MG CAPSULE

Facility

$326.65

Service Code	NDC 00054852625
Hospital Charge Code	4528
Hospital Revenue Code	637
Min. Negotiated Rate	$130.66
Max. Negotiated Rate	$293.99
Rate for Payer: Aetna Commercial	$277.65
Rate for Payer: Aetna Medicare	$163.32
Rate for Payer: Aetna New Business (MI Preferred)	$212.32
Rate for Payer: BCBS Complete	$130.66
Rate for Payer: Cash Price	$261.32
Rate for Payer: Cofinity Commercial	$228.66
Rate for Payer: Cofinity Commercial	$280.92
Rate for Payer: Cofinity Medicare Advantage	$228.66
Rate for Payer: Encore Health Key Benefits Commercial	$261.32
Rate for Payer: Healthscope Commercial	$293.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$277.65
Rate for Payer: PHP Commercial	$277.65
Rate for Payer: Priority Health Cigna Priority Health	$212.32
Rate for Payer: Priority Health SBD	$205.79

LITHIUM CARBONATE 300 MG CAPSULE

Facility

$25.94

Service Code	NDC 00054852725
Hospital Charge Code	4529
Hospital Revenue Code	637
Min. Negotiated Rate	$16.34
Max. Negotiated Rate	$23.35
Rate for Payer: Aetna Commercial	$22.05
Rate for Payer: Aetna New Business (MI Preferred)	$16.86
Rate for Payer: Cash Price	$20.75
Rate for Payer: Cofinity Commercial	$18.16
Rate for Payer: Cofinity Commercial	$22.31
Rate for Payer: Cofinity Medicare Advantage	$18.16
Rate for Payer: Encore Health Key Benefits Commercial	$20.75
Rate for Payer: Healthscope Commercial	$23.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.05
Rate for Payer: PHP Commercial	$22.05
Rate for Payer: Priority Health Cigna Priority Health	$16.86
Rate for Payer: Priority Health SBD	$16.34

LITHIUM CARBONATE 300 MG CAPSULE

Facility

$25.94

Service Code	NDC 00054852725
Hospital Charge Code	4529
Hospital Revenue Code	637
Min. Negotiated Rate	$10.38
Max. Negotiated Rate	$23.35
Rate for Payer: Aetna Commercial	$22.05
Rate for Payer: Aetna Medicare	$12.97
Rate for Payer: Aetna New Business (MI Preferred)	$16.86
Rate for Payer: BCBS Complete	$10.38
Rate for Payer: Cash Price	$20.75
Rate for Payer: Cofinity Commercial	$18.16
Rate for Payer: Cofinity Commercial	$22.31
Rate for Payer: Cofinity Medicare Advantage	$18.16
Rate for Payer: Encore Health Key Benefits Commercial	$20.75
Rate for Payer: Healthscope Commercial	$23.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.05
Rate for Payer: PHP Commercial	$22.05
Rate for Payer: Priority Health Cigna Priority Health	$16.86
Rate for Payer: Priority Health SBD	$16.34

LITHIUM CARBONATE 600 MG CAPSULE

Facility

$232.75

Service Code	NDC 00054253125
Hospital Charge Code	4530
Hospital Revenue Code	637
Min. Negotiated Rate	$146.63
Max. Negotiated Rate	$209.47
Rate for Payer: Aetna Commercial	$197.84
Rate for Payer: Aetna New Business (MI Preferred)	$151.29
Rate for Payer: Cash Price	$186.20
Rate for Payer: Cofinity Commercial	$162.93
Rate for Payer: Cofinity Commercial	$200.16
Rate for Payer: Cofinity Medicare Advantage	$162.93
Rate for Payer: Encore Health Key Benefits Commercial	$186.20
Rate for Payer: Healthscope Commercial	$209.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$197.84
Rate for Payer: PHP Commercial	$197.84
Rate for Payer: Priority Health Cigna Priority Health	$151.29
Rate for Payer: Priority Health SBD	$146.63

LITHIUM CARBONATE 600 MG CAPSULE

Facility

$232.75

Service Code	NDC 00054253125
Hospital Charge Code	4530
Hospital Revenue Code	637
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$209.47
Rate for Payer: Aetna Commercial	$197.84
Rate for Payer: Aetna Medicare	$116.38
Rate for Payer: Aetna New Business (MI Preferred)	$151.29
Rate for Payer: BCBS Complete	$93.10
Rate for Payer: Cash Price	$186.20
Rate for Payer: Cofinity Commercial	$162.93
Rate for Payer: Cofinity Commercial	$200.16
Rate for Payer: Cofinity Medicare Advantage	$162.93
Rate for Payer: Encore Health Key Benefits Commercial	$186.20
Rate for Payer: Healthscope Commercial	$209.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$197.84
Rate for Payer: PHP Commercial	$197.84
Rate for Payer: Priority Health Cigna Priority Health	$151.29
Rate for Payer: Priority Health SBD	$146.63

LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE

Facility

$310.65

Service Code	NDC 51079018020
Hospital Charge Code	10454
Hospital Revenue Code	637
Min. Negotiated Rate	$195.71
Max. Negotiated Rate	$279.58
Rate for Payer: Aetna Commercial	$264.05
Rate for Payer: Aetna New Business (MI Preferred)	$201.92
Rate for Payer: Cash Price	$248.52
Rate for Payer: Cofinity Commercial	$217.46
Rate for Payer: Cofinity Commercial	$267.16
Rate for Payer: Cofinity Medicare Advantage	$217.46
Rate for Payer: Encore Health Key Benefits Commercial	$248.52
Rate for Payer: Healthscope Commercial	$279.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$264.05
Rate for Payer: PHP Commercial	$264.05
Rate for Payer: Priority Health Cigna Priority Health	$201.92
Rate for Payer: Priority Health SBD	$195.71

LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE

Facility

$3.11

Service Code	NDC 51079018001
Hospital Charge Code	10454
Hospital Revenue Code	637
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$2.80
Rate for Payer: Aetna Commercial	$2.64
Rate for Payer: Aetna Medicare	$1.55
Rate for Payer: Aetna New Business (MI Preferred)	$2.02
Rate for Payer: BCBS Complete	$1.24
Rate for Payer: Cash Price	$2.49
Rate for Payer: Cofinity Commercial	$2.18
Rate for Payer: Cofinity Commercial	$2.67
Rate for Payer: Cofinity Medicare Advantage	$2.18
Rate for Payer: Encore Health Key Benefits Commercial	$2.49
Rate for Payer: Healthscope Commercial	$2.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.64
Rate for Payer: PHP Commercial	$2.64
Rate for Payer: Priority Health Cigna Priority Health	$2.02
Rate for Payer: Priority Health SBD	$1.96

LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE

Facility

$3.11

Service Code	NDC 51079018001
Hospital Charge Code	10454
Hospital Revenue Code	637
Min. Negotiated Rate	$1.96
Max. Negotiated Rate	$2.80
Rate for Payer: Aetna Commercial	$2.64
Rate for Payer: Aetna New Business (MI Preferred)	$2.02
Rate for Payer: Cash Price	$2.49
Rate for Payer: Cofinity Commercial	$2.18
Rate for Payer: Cofinity Commercial	$2.67
Rate for Payer: Cofinity Medicare Advantage	$2.18
Rate for Payer: Encore Health Key Benefits Commercial	$2.49
Rate for Payer: Healthscope Commercial	$2.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.64
Rate for Payer: PHP Commercial	$2.64
Rate for Payer: Priority Health Cigna Priority Health	$2.02
Rate for Payer: Priority Health SBD	$1.96

LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE

Facility

$310.65

Service Code	NDC 51079018020
Hospital Charge Code	10454
Hospital Revenue Code	637
Min. Negotiated Rate	$124.26
Max. Negotiated Rate	$279.58
Rate for Payer: Aetna Commercial	$264.05
Rate for Payer: Aetna Medicare	$155.32
Rate for Payer: Aetna New Business (MI Preferred)	$201.92
Rate for Payer: BCBS Complete	$124.26
Rate for Payer: Cash Price	$248.52
Rate for Payer: Cofinity Commercial	$217.46
Rate for Payer: Cofinity Commercial	$267.16
Rate for Payer: Cofinity Medicare Advantage	$217.46
Rate for Payer: Encore Health Key Benefits Commercial	$248.52
Rate for Payer: Healthscope Commercial	$279.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$264.05
Rate for Payer: PHP Commercial	$264.05
Rate for Payer: Priority Health Cigna Priority Health	$201.92
Rate for Payer: Priority Health SBD	$195.71

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE

Facility

$2.56

Service Code	NDC 68084065511
Hospital Charge Code	10455
Hospital Revenue Code	637
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$2.30
Rate for Payer: Aetna Commercial	$2.18
Rate for Payer: Aetna Medicare	$1.28
Rate for Payer: Aetna New Business (MI Preferred)	$1.66
Rate for Payer: BCBS Complete	$1.02
Rate for Payer: Cash Price	$2.05
Rate for Payer: Cofinity Commercial	$1.79
Rate for Payer: Cofinity Commercial	$2.20
Rate for Payer: Cofinity Medicare Advantage	$1.79
Rate for Payer: Encore Health Key Benefits Commercial	$2.05
Rate for Payer: Healthscope Commercial	$2.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.18
Rate for Payer: PHP Commercial	$2.18
Rate for Payer: Priority Health Cigna Priority Health	$1.66
Rate for Payer: Priority Health SBD	$1.61

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE

Facility

$3.73

Service Code	NDC 51079014201
Hospital Charge Code	10455
Hospital Revenue Code	637
Min. Negotiated Rate	$2.35
Max. Negotiated Rate	$3.36
Rate for Payer: Aetna Commercial	$3.17
Rate for Payer: Aetna New Business (MI Preferred)	$2.42
Rate for Payer: Cash Price	$2.98
Rate for Payer: Cofinity Commercial	$2.61
Rate for Payer: Cofinity Commercial	$3.21
Rate for Payer: Cofinity Medicare Advantage	$2.61
Rate for Payer: Encore Health Key Benefits Commercial	$2.98
Rate for Payer: Healthscope Commercial	$3.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.17
Rate for Payer: PHP Commercial	$3.17
Rate for Payer: Priority Health Cigna Priority Health	$2.42
Rate for Payer: Priority Health SBD	$2.35

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE

Facility

$3.73

Service Code	NDC 51079014201
Hospital Charge Code	10455
Hospital Revenue Code	637
Min. Negotiated Rate	$1.49
Max. Negotiated Rate	$3.36
Rate for Payer: Aetna Commercial	$3.17
Rate for Payer: Aetna Medicare	$1.86
Rate for Payer: Aetna New Business (MI Preferred)	$2.42
Rate for Payer: BCBS Complete	$1.49
Rate for Payer: Cash Price	$2.98
Rate for Payer: Cofinity Commercial	$2.61
Rate for Payer: Cofinity Commercial	$3.21
Rate for Payer: Cofinity Medicare Advantage	$2.61
Rate for Payer: Encore Health Key Benefits Commercial	$2.98
Rate for Payer: Healthscope Commercial	$3.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.17
Rate for Payer: PHP Commercial	$3.17
Rate for Payer: Priority Health Cigna Priority Health	$2.42
Rate for Payer: Priority Health SBD	$2.35

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE

Facility

$372.40

Service Code	NDC 51079014220
Hospital Charge Code	10455
Hospital Revenue Code	637
Min. Negotiated Rate	$234.61
Max. Negotiated Rate	$335.16
Rate for Payer: Aetna Commercial	$316.54
Rate for Payer: Aetna New Business (MI Preferred)	$242.06
Rate for Payer: Cash Price	$297.92
Rate for Payer: Cofinity Commercial	$260.68
Rate for Payer: Cofinity Commercial	$320.26
Rate for Payer: Cofinity Medicare Advantage	$260.68
Rate for Payer: Encore Health Key Benefits Commercial	$297.92
Rate for Payer: Healthscope Commercial	$335.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$316.54
Rate for Payer: PHP Commercial	$316.54
Rate for Payer: Priority Health Cigna Priority Health	$242.06
Rate for Payer: Priority Health SBD	$234.61

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE

Facility

$372.40

Service Code	NDC 51079014220
Hospital Charge Code	10455
Hospital Revenue Code	637
Min. Negotiated Rate	$148.96
Max. Negotiated Rate	$335.16
Rate for Payer: Aetna Commercial	$316.54
Rate for Payer: Aetna Medicare	$186.20
Rate for Payer: Aetna New Business (MI Preferred)	$242.06
Rate for Payer: BCBS Complete	$148.96
Rate for Payer: Cash Price	$297.92
Rate for Payer: Cofinity Commercial	$260.68
Rate for Payer: Cofinity Commercial	$320.26
Rate for Payer: Cofinity Medicare Advantage	$260.68
Rate for Payer: Encore Health Key Benefits Commercial	$297.92
Rate for Payer: Healthscope Commercial	$335.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$316.54
Rate for Payer: PHP Commercial	$316.54
Rate for Payer: Priority Health Cigna Priority Health	$242.06
Rate for Payer: Priority Health SBD	$234.61

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE

Facility

$255.84

Service Code	NDC 68084065501
Hospital Charge Code	10455
Hospital Revenue Code	637
Min. Negotiated Rate	$161.18
Max. Negotiated Rate	$230.26
Rate for Payer: Aetna Commercial	$217.46
Rate for Payer: Aetna New Business (MI Preferred)	$166.30
Rate for Payer: Cash Price	$204.67
Rate for Payer: Cofinity Commercial	$179.09
Rate for Payer: Cofinity Commercial	$220.02
Rate for Payer: Cofinity Medicare Advantage	$179.09
Rate for Payer: Encore Health Key Benefits Commercial	$204.67
Rate for Payer: Healthscope Commercial	$230.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$217.46
Rate for Payer: PHP Commercial	$217.46
Rate for Payer: Priority Health Cigna Priority Health	$166.30
Rate for Payer: Priority Health SBD	$161.18

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE

Facility

$245.10

Service Code	NDC 68462022401
Hospital Charge Code	10455
Hospital Revenue Code	637
Min. Negotiated Rate	$154.41
Max. Negotiated Rate	$220.59
Rate for Payer: Aetna Commercial	$208.34
Rate for Payer: Aetna New Business (MI Preferred)	$159.31
Rate for Payer: Cash Price	$196.08
Rate for Payer: Cofinity Commercial	$171.57
Rate for Payer: Cofinity Commercial	$210.79
Rate for Payer: Cofinity Medicare Advantage	$171.57
Rate for Payer: Encore Health Key Benefits Commercial	$196.08
Rate for Payer: Healthscope Commercial	$220.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$208.34
Rate for Payer: PHP Commercial	$208.34
Rate for Payer: Priority Health Cigna Priority Health	$159.31
Rate for Payer: Priority Health SBD	$154.41

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE

Facility

$245.10

Service Code	NDC 68462022401
Hospital Charge Code	10455
Hospital Revenue Code	637
Min. Negotiated Rate	$98.04
Max. Negotiated Rate	$220.59
Rate for Payer: Aetna Commercial	$208.34
Rate for Payer: Aetna Medicare	$122.55
Rate for Payer: Aetna New Business (MI Preferred)	$159.31
Rate for Payer: BCBS Complete	$98.04
Rate for Payer: Cash Price	$196.08
Rate for Payer: Cofinity Commercial	$171.57
Rate for Payer: Cofinity Commercial	$210.79
Rate for Payer: Cofinity Medicare Advantage	$171.57
Rate for Payer: Encore Health Key Benefits Commercial	$196.08
Rate for Payer: Healthscope Commercial	$220.59
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$208.34
Rate for Payer: PHP Commercial	$208.34
Rate for Payer: Priority Health Cigna Priority Health	$159.31
Rate for Payer: Priority Health SBD	$154.41

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE

Facility

$255.84

Service Code	NDC 68084065501
Hospital Charge Code	10455
Hospital Revenue Code	637
Min. Negotiated Rate	$102.34
Max. Negotiated Rate	$230.26
Rate for Payer: Aetna Commercial	$217.46
Rate for Payer: Aetna Medicare	$127.92
Rate for Payer: Aetna New Business (MI Preferred)	$166.30
Rate for Payer: BCBS Complete	$102.34
Rate for Payer: Cash Price	$204.67
Rate for Payer: Cofinity Commercial	$179.09
Rate for Payer: Cofinity Commercial	$220.02
Rate for Payer: Cofinity Medicare Advantage	$179.09
Rate for Payer: Encore Health Key Benefits Commercial	$204.67
Rate for Payer: Healthscope Commercial	$230.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$217.46
Rate for Payer: PHP Commercial	$217.46
Rate for Payer: Priority Health Cigna Priority Health	$166.30
Rate for Payer: Priority Health SBD	$161.18

LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE

Facility

$2.56

Service Code	NDC 68084065511
Hospital Charge Code	10455
Hospital Revenue Code	637
Min. Negotiated Rate	$1.61
Max. Negotiated Rate	$2.30
Rate for Payer: Aetna Commercial	$2.18
Rate for Payer: Aetna New Business (MI Preferred)	$1.66
Rate for Payer: Cash Price	$2.05
Rate for Payer: Cofinity Commercial	$1.79
Rate for Payer: Cofinity Commercial	$2.20
Rate for Payer: Cofinity Medicare Advantage	$1.79
Rate for Payer: Encore Health Key Benefits Commercial	$2.05
Rate for Payer: Healthscope Commercial	$2.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.18
Rate for Payer: PHP Commercial	$2.18
Rate for Payer: Priority Health Cigna Priority Health	$1.66
Rate for Payer: Priority Health SBD	$1.61

LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM)

Facility

$9,468.51

Service Code	CPT 52318
Hospital Revenue Code	360
Min. Negotiated Rate	$1,802.95
Max. Negotiated Rate	$9,468.51
Rate for Payer: Aetna Medicare	$3,498.26
Rate for Payer: Allen County Amish Medical Aid Commercial	$4,204.64
Rate for Payer: Amish Plain Church Group Commercial	$4,204.64
Rate for Payer: BCBS Complete	$1,893.10
Rate for Payer: BCBS MAPPO	$3,363.71
Rate for Payer: BCN Medicare Advantage	$3,363.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,363.71
Rate for Payer: Mclaren Medicaid	$1,802.95
Rate for Payer: Mclaren Medicare	$3,363.71
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,531.90
Rate for Payer: Meridian Medicaid	$1,893.10
Rate for Payer: MI Amish Medical Board Commercial	$3,868.27
Rate for Payer: PACE Medicare	$3,195.52
Rate for Payer: PACE SWMI	$3,363.71
Rate for Payer: PHP Medicare Advantage	$3,363.71
Rate for Payer: Priority Health Choice Medicaid	$1,802.95
Rate for Payer: Priority Health Medicare	$3,363.71
Rate for Payer: Railroad Medicare Medicare	$3,363.71
Rate for Payer: UHC All Payor (Choice/PPO)	$9,468.51
Rate for Payer: UHC Dual Complete DSNP	$3,363.71
Rate for Payer: UHC Medicare Advantage	$3,363.71
Rate for Payer: UHCCP Medicaid	$1,893.77
Rate for Payer: VA VA	$3,363.71

LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; SIMPLE OR SMALL (LESS THAN 2.5 CM)

Facility

$9,468.51

Service Code	CPT 52317
Hospital Revenue Code	360
Min. Negotiated Rate	$1,802.95
Max. Negotiated Rate	$9,468.51
Rate for Payer: Aetna Medicare	$3,498.26
Rate for Payer: Allen County Amish Medical Aid Commercial	$4,204.64
Rate for Payer: Amish Plain Church Group Commercial	$4,204.64
Rate for Payer: BCBS Complete	$1,893.10
Rate for Payer: BCBS MAPPO	$3,363.71
Rate for Payer: BCN Medicare Advantage	$3,363.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,363.71
Rate for Payer: Mclaren Medicaid	$1,802.95
Rate for Payer: Mclaren Medicare	$3,363.71
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,531.90
Rate for Payer: Meridian Medicaid	$1,893.10
Rate for Payer: MI Amish Medical Board Commercial	$3,868.27
Rate for Payer: PACE Medicare	$3,195.52
Rate for Payer: PACE SWMI	$3,363.71
Rate for Payer: PHP Medicare Advantage	$3,363.71
Rate for Payer: Priority Health Choice Medicaid	$1,802.95
Rate for Payer: Priority Health Medicare	$3,363.71
Rate for Payer: Railroad Medicare Medicare	$3,363.71
Rate for Payer: UHC All Payor (Choice/PPO)	$9,468.51
Rate for Payer: UHC Dual Complete DSNP	$3,363.71
Rate for Payer: UHC Medicare Advantage	$3,363.71
Rate for Payer: UHCCP Medicaid	$1,893.77
Rate for Payer: VA VA	$3,363.71

LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE

Facility

$9,468.51

Service Code	CPT 50590
Hospital Revenue Code	360
Min. Negotiated Rate	$1,802.95
Max. Negotiated Rate	$9,468.51
Rate for Payer: Aetna Medicare	$3,498.26
Rate for Payer: Allen County Amish Medical Aid Commercial	$4,204.64
Rate for Payer: Amish Plain Church Group Commercial	$4,204.64
Rate for Payer: BCBS Complete	$1,893.10
Rate for Payer: BCBS MAPPO	$3,363.71
Rate for Payer: BCN Medicare Advantage	$3,363.71
Rate for Payer: Health Alliance Plan Medicare Advantage	$3,363.71
Rate for Payer: Mclaren Medicaid	$1,802.95
Rate for Payer: Mclaren Medicare	$3,363.71
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$3,531.90
Rate for Payer: Meridian Medicaid	$1,893.10
Rate for Payer: MI Amish Medical Board Commercial	$3,868.27
Rate for Payer: PACE Medicare	$3,195.52
Rate for Payer: PACE SWMI	$3,363.71
Rate for Payer: PHP Medicare Advantage	$3,363.71
Rate for Payer: Priority Health Choice Medicaid	$1,802.95
Rate for Payer: Priority Health Medicare	$3,363.71
Rate for Payer: Railroad Medicare Medicare	$3,363.71
Rate for Payer: UHC All Payor (Choice/PPO)	$9,468.51
Rate for Payer: UHC Dual Complete DSNP	$3,363.71
Rate for Payer: UHC Medicare Advantage	$3,363.71
Rate for Payer: UHCCP Medicaid	$1,893.77
Rate for Payer: VA VA	$3,363.71

LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID

Facility

$21.84

Service Code	NDC 00450013404
Hospital Charge Code	42219
Hospital Revenue Code	637
Min. Negotiated Rate	$8.74
Max. Negotiated Rate	$19.66
Rate for Payer: Aetna Commercial	$18.56
Rate for Payer: Aetna Medicare	$10.92
Rate for Payer: Aetna New Business (MI Preferred)	$14.20
Rate for Payer: BCBS Complete	$8.74
Rate for Payer: Cash Price	$17.47
Rate for Payer: Cofinity Commercial	$15.29
Rate for Payer: Cofinity Commercial	$18.78
Rate for Payer: Cofinity Medicare Advantage	$15.29
Rate for Payer: Encore Health Key Benefits Commercial	$17.47
Rate for Payer: Healthscope Commercial	$19.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.56
Rate for Payer: PHP Commercial	$18.56
Rate for Payer: Priority Health Cigna Priority Health	$14.20
Rate for Payer: Priority Health SBD	$13.76

LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID

Facility

$21.84

Service Code	NDC 00450013404
Hospital Charge Code	42219
Hospital Revenue Code	637
Min. Negotiated Rate	$13.76
Max. Negotiated Rate	$19.66
Rate for Payer: Aetna Commercial	$18.56
Rate for Payer: Aetna New Business (MI Preferred)	$14.20
Rate for Payer: Cash Price	$17.47
Rate for Payer: Cofinity Commercial	$15.29
Rate for Payer: Cofinity Commercial	$18.78
Rate for Payer: Cofinity Medicare Advantage	$15.29
Rate for Payer: Encore Health Key Benefits Commercial	$17.47
Rate for Payer: Healthscope Commercial	$19.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.56
Rate for Payer: PHP Commercial	$18.56
Rate for Payer: Priority Health Cigna Priority Health	$14.20
Rate for Payer: Priority Health SBD	$13.76

Know your out-of-pocket cost for care.

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