|
LISINOPRIL 10 MG TABLET
|
Facility
|
IP
|
$232.65
|
|
|
Service Code
|
NDC 60687-325-01
|
| Hospital Charge Code |
10449
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.37 |
| Max. Negotiated Rate |
$209.38 |
| Rate for Payer: Aetna American Axle |
$151.22
|
| Rate for Payer: Aetna Commercial |
$197.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$151.22
|
| Rate for Payer: Cash Price |
$186.12
|
| Rate for Payer: Cofinity Commercial |
$162.86
|
| Rate for Payer: Cofinity Commercial |
$200.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$186.12
|
| Rate for Payer: Healthscope Commercial |
$209.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$162.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$174.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$197.75
|
| Rate for Payer: PHP Commercial |
$197.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.86
|
| Rate for Payer: Priority Health SBD |
$146.57
|
| Rate for Payer: UMR Bronson Commercial |
$102.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$174.49
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
IP
|
$2.64
|
|
|
Service Code
|
NDC 60687-333-11
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.16 |
| Max. Negotiated Rate |
$2.38 |
| Rate for Payer: Aetna American Axle |
$1.72
|
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.72
|
| Rate for Payer: Cash Price |
$2.11
|
| Rate for Payer: Cofinity Commercial |
$1.85
|
| Rate for Payer: Cofinity Commercial |
$2.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.11
|
| Rate for Payer: Healthscope Commercial |
$2.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.24
|
| Rate for Payer: PHP Commercial |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.85
|
| Rate for Payer: Priority Health SBD |
$1.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.98
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
IP
|
$159.80
|
|
|
Service Code
|
NDC 63739-350-10
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.31 |
| Max. Negotiated Rate |
$143.82 |
| Rate for Payer: Aetna American Axle |
$103.87
|
| Rate for Payer: Aetna Commercial |
$135.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.87
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$111.86
|
| Rate for Payer: Cofinity Commercial |
$137.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Healthscope Commercial |
$143.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$111.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$119.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.83
|
| Rate for Payer: PHP Commercial |
$135.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.86
|
| Rate for Payer: Priority Health SBD |
$100.67
|
| Rate for Payer: UMR Bronson Commercial |
$70.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.85
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
IP
|
$263.20
|
|
|
Service Code
|
NDC 60687-333-01
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.81 |
| Max. Negotiated Rate |
$236.88 |
| Rate for Payer: Aetna American Axle |
$171.08
|
| Rate for Payer: Aetna Commercial |
$223.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$171.08
|
| Rate for Payer: Cash Price |
$210.56
|
| Rate for Payer: Cofinity Commercial |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$226.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.56
|
| Rate for Payer: Healthscope Commercial |
$236.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$184.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$197.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$223.72
|
| Rate for Payer: PHP Commercial |
$223.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$184.24
|
| Rate for Payer: Priority Health SBD |
$165.82
|
| Rate for Payer: UMR Bronson Commercial |
$115.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$197.40
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
IP
|
$178.60
|
|
|
Service Code
|
NDC 43547-354-10
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.58 |
| Max. Negotiated Rate |
$160.74 |
| Rate for Payer: Aetna American Axle |
$116.09
|
| Rate for Payer: Aetna Commercial |
$151.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$116.09
|
| Rate for Payer: Cash Price |
$142.88
|
| Rate for Payer: Cofinity Commercial |
$125.02
|
| Rate for Payer: Cofinity Commercial |
$153.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$142.88
|
| Rate for Payer: Healthscope Commercial |
$160.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$125.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$133.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$151.81
|
| Rate for Payer: PHP Commercial |
$151.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$125.02
|
| Rate for Payer: Priority Health SBD |
$112.52
|
| Rate for Payer: UMR Bronson Commercial |
$78.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$133.95
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
IP
|
$58.75
|
|
|
Service Code
|
NDC 68180-981-01
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.85 |
| Max. Negotiated Rate |
$52.88 |
| Rate for Payer: Aetna American Axle |
$38.19
|
| Rate for Payer: Aetna Commercial |
$49.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.19
|
| Rate for Payer: Cash Price |
$47.00
|
| Rate for Payer: Cofinity Commercial |
$41.12
|
| Rate for Payer: Cofinity Commercial |
$50.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.00
|
| Rate for Payer: Healthscope Commercial |
$52.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$41.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$44.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$49.94
|
| Rate for Payer: PHP Commercial |
$49.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.12
|
| Rate for Payer: Priority Health SBD |
$37.01
|
| Rate for Payer: UMR Bronson Commercial |
$25.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$44.06
|
|
|
LISINOPRIL 20 MG TABLET
|
Facility
|
IP
|
$148.05
|
|
|
Service Code
|
NDC 0591-0408-01
|
| Hospital Charge Code |
4526
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.14 |
| Max. Negotiated Rate |
$133.24 |
| Rate for Payer: Aetna American Axle |
$96.23
|
| Rate for Payer: Aetna Commercial |
$125.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$96.23
|
| Rate for Payer: Cash Price |
$118.44
|
| Rate for Payer: Cofinity Commercial |
$103.64
|
| Rate for Payer: Cofinity Commercial |
$127.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.44
|
| Rate for Payer: Healthscope Commercial |
$133.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$103.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.84
|
| Rate for Payer: PHP Commercial |
$125.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.64
|
| Rate for Payer: Priority Health SBD |
$93.27
|
| Rate for Payer: UMR Bronson Commercial |
$65.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.04
|
|
|
LISINOPRIL 2.5 MG TABLET
|
Facility
|
IP
|
$30.55
|
|
|
Service Code
|
NDC 68180-512-01
|
| Hospital Charge Code |
13089
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.44 |
| Max. Negotiated Rate |
$27.50 |
| Rate for Payer: Aetna American Axle |
$19.86
|
| Rate for Payer: Aetna Commercial |
$25.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.86
|
| Rate for Payer: Cash Price |
$24.44
|
| Rate for Payer: Cofinity Commercial |
$21.38
|
| Rate for Payer: Cofinity Commercial |
$26.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.44
|
| Rate for Payer: Healthscope Commercial |
$27.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.97
|
| Rate for Payer: PHP Commercial |
$25.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.38
|
| Rate for Payer: Priority Health SBD |
$19.25
|
| Rate for Payer: UMR Bronson Commercial |
$13.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.91
|
|
|
LISINOPRIL 40 MG TABLET
|
Facility
|
IP
|
$3.93
|
|
|
Service Code
|
NDC 68084-199-11
|
| Hospital Charge Code |
10450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.73 |
| Max. Negotiated Rate |
$3.54 |
| Rate for Payer: Aetna American Axle |
$2.55
|
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.55
|
| Rate for Payer: Cash Price |
$3.14
|
| Rate for Payer: Cofinity Commercial |
$2.75
|
| Rate for Payer: Cofinity Commercial |
$3.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.14
|
| Rate for Payer: Healthscope Commercial |
$3.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.34
|
| Rate for Payer: PHP Commercial |
$3.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.48
|
| Rate for Payer: UMR Bronson Commercial |
$1.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.95
|
|
|
LISINOPRIL 40 MG TABLET
|
Facility
|
IP
|
$392.45
|
|
|
Service Code
|
NDC 68084-199-01
|
| Hospital Charge Code |
10450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.68 |
| Max. Negotiated Rate |
$353.20 |
| Rate for Payer: Aetna American Axle |
$255.09
|
| Rate for Payer: Aetna Commercial |
$333.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$255.09
|
| Rate for Payer: Cash Price |
$313.96
|
| Rate for Payer: Cofinity Commercial |
$274.72
|
| Rate for Payer: Cofinity Commercial |
$337.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$313.96
|
| Rate for Payer: Healthscope Commercial |
$353.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$274.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$294.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$333.58
|
| Rate for Payer: PHP Commercial |
$333.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$274.72
|
| Rate for Payer: Priority Health SBD |
$247.24
|
| Rate for Payer: UMR Bronson Commercial |
$172.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$294.34
|
|
|
LISINOPRIL 40 MG TABLET
|
Facility
|
IP
|
$108.10
|
|
|
Service Code
|
NDC 68180-979-01
|
| Hospital Charge Code |
10450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.56 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna American Axle |
$70.26
|
| Rate for Payer: Aetna Commercial |
$91.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$70.26
|
| Rate for Payer: Cash Price |
$86.48
|
| Rate for Payer: Cofinity Commercial |
$75.67
|
| Rate for Payer: Cofinity Commercial |
$92.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.48
|
| Rate for Payer: Healthscope Commercial |
$97.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$75.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$91.88
|
| Rate for Payer: PHP Commercial |
$91.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$75.67
|
| Rate for Payer: Priority Health SBD |
$68.10
|
| Rate for Payer: UMR Bronson Commercial |
$47.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.08
|
|
|
LISINOPRIL 40 MG TABLET
|
Facility
|
IP
|
$75.20
|
|
|
Service Code
|
NDC 68180-517-01
|
| Hospital Charge Code |
10450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.09 |
| Max. Negotiated Rate |
$67.68 |
| Rate for Payer: Aetna American Axle |
$48.88
|
| Rate for Payer: Aetna Commercial |
$63.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.88
|
| Rate for Payer: Cash Price |
$60.16
|
| Rate for Payer: Cofinity Commercial |
$52.64
|
| Rate for Payer: Cofinity Commercial |
$64.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.16
|
| Rate for Payer: Healthscope Commercial |
$67.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.92
|
| Rate for Payer: PHP Commercial |
$63.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.64
|
| Rate for Payer: Priority Health SBD |
$47.38
|
| Rate for Payer: UMR Bronson Commercial |
$33.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.40
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
IP
|
$37.60
|
|
|
Service Code
|
NDC 68180-513-01
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.54 |
| Max. Negotiated Rate |
$33.84 |
| Rate for Payer: Aetna American Axle |
$24.44
|
| Rate for Payer: Aetna Commercial |
$31.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.44
|
| Rate for Payer: Cash Price |
$30.08
|
| Rate for Payer: Cofinity Commercial |
$26.32
|
| Rate for Payer: Cofinity Commercial |
$32.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.08
|
| Rate for Payer: Healthscope Commercial |
$33.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.96
|
| Rate for Payer: PHP Commercial |
$31.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.32
|
| Rate for Payer: Priority Health SBD |
$23.69
|
| Rate for Payer: UMR Bronson Commercial |
$16.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.20
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
IP
|
$2.73
|
|
|
Service Code
|
NDC 68084-196-11
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$2.46 |
| Rate for Payer: Aetna American Axle |
$1.77
|
| Rate for Payer: Aetna Commercial |
$2.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.77
|
| Rate for Payer: Cash Price |
$2.18
|
| Rate for Payer: Cofinity Commercial |
$1.91
|
| Rate for Payer: Cofinity Commercial |
$2.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.18
|
| Rate for Payer: Healthscope Commercial |
$2.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.32
|
| Rate for Payer: PHP Commercial |
$2.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.91
|
| Rate for Payer: Priority Health SBD |
$1.72
|
| Rate for Payer: UMR Bronson Commercial |
$1.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.05
|
|
|
LISINOPRIL 5 MG TABLET
|
Facility
|
IP
|
$272.60
|
|
|
Service Code
|
NDC 68084-196-01
|
| Hospital Charge Code |
10451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.94 |
| Max. Negotiated Rate |
$245.34 |
| Rate for Payer: Aetna American Axle |
$177.19
|
| Rate for Payer: Aetna Commercial |
$231.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.19
|
| Rate for Payer: Cash Price |
$218.08
|
| Rate for Payer: Cofinity Commercial |
$190.82
|
| Rate for Payer: Cofinity Commercial |
$234.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.08
|
| Rate for Payer: Healthscope Commercial |
$245.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$190.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$204.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$231.71
|
| Rate for Payer: PHP Commercial |
$231.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$190.82
|
| Rate for Payer: Priority Health SBD |
$171.74
|
| Rate for Payer: UMR Bronson Commercial |
$119.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$204.45
|
|
|
LITHIUM CARBONATE 150 MG CAPSULE
|
Facility
|
IP
|
$244.40
|
|
|
Service Code
|
NDC 68462-220-01
|
| Hospital Charge Code |
4528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.54 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna American Axle |
$158.86
|
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.86
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Commercial |
$171.08
|
| Rate for Payer: Cofinity Commercial |
$210.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$219.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$207.74
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$171.08
|
| Rate for Payer: Priority Health SBD |
$153.97
|
| Rate for Payer: UMR Bronson Commercial |
$107.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.30
|
|
|
LITHIUM CARBONATE 150 MG CAPSULE
|
Facility
|
IP
|
$192.70
|
|
|
Service Code
|
NDC 0054-2526-25
|
| Hospital Charge Code |
4528
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.79 |
| Max. Negotiated Rate |
$173.43 |
| Rate for Payer: Aetna American Axle |
$125.26
|
| Rate for Payer: Aetna Commercial |
$163.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.26
|
| Rate for Payer: Cash Price |
$154.16
|
| Rate for Payer: Cofinity Commercial |
$134.89
|
| Rate for Payer: Cofinity Commercial |
$165.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$154.16
|
| Rate for Payer: Healthscope Commercial |
$173.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$134.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$144.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$163.80
|
| Rate for Payer: PHP Commercial |
$163.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$134.89
|
| Rate for Payer: Priority Health SBD |
$121.40
|
| Rate for Payer: UMR Bronson Commercial |
$84.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$144.52
|
|
|
LITHIUM CARBONATE 300 MG CAPSULE
|
Facility
|
IP
|
$25.94
|
|
|
Service Code
|
NDC 0054-8527-25
|
| Hospital Charge Code |
4529
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.41 |
| Max. Negotiated Rate |
$23.35 |
| Rate for Payer: Aetna American Axle |
$16.86
|
| 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: Encore Health Key Benefits Commercial |
$20.75
|
| Rate for Payer: Healthscope Commercial |
$23.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.05
|
| Rate for Payer: PHP Commercial |
$22.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.16
|
| Rate for Payer: Priority Health SBD |
$16.34
|
| Rate for Payer: UMR Bronson Commercial |
$11.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.46
|
|
|
LITHIUM CARBONATE 300 MG CAPSULE
|
Facility
|
IP
|
$141.00
|
|
|
Service Code
|
NDC 31722-545-01
|
| Hospital Charge Code |
4529
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.04 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$126.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.70
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UMR Bronson Commercial |
$62.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
LITHIUM CARBONATE 300 MG CAPSULE
|
Facility
|
IP
|
$193.80
|
|
|
Service Code
|
NDC 0054-2527-25
|
| Hospital Charge Code |
4529
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.27 |
| Max. Negotiated Rate |
$174.42 |
| Rate for Payer: Aetna American Axle |
$125.97
|
| Rate for Payer: Aetna Commercial |
$164.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$125.97
|
| Rate for Payer: Cash Price |
$155.04
|
| Rate for Payer: Cofinity Commercial |
$135.66
|
| Rate for Payer: Cofinity Commercial |
$166.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$155.04
|
| Rate for Payer: Healthscope Commercial |
$174.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$135.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$145.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$164.73
|
| Rate for Payer: PHP Commercial |
$164.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$135.66
|
| Rate for Payer: Priority Health SBD |
$122.09
|
| Rate for Payer: UMR Bronson Commercial |
$85.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$145.35
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$287.85
|
|
|
Service Code
|
NDC 68084-640-01
|
| Hospital Charge Code |
10454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.65 |
| Max. Negotiated Rate |
$259.06 |
| Rate for Payer: Aetna American Axle |
$187.10
|
| Rate for Payer: Aetna Commercial |
$244.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$187.10
|
| Rate for Payer: Cash Price |
$230.28
|
| Rate for Payer: Cofinity Commercial |
$201.50
|
| Rate for Payer: Cofinity Commercial |
$247.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$230.28
|
| Rate for Payer: Healthscope Commercial |
$259.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$201.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$244.67
|
| Rate for Payer: PHP Commercial |
$244.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$201.50
|
| Rate for Payer: Priority Health SBD |
$181.35
|
| Rate for Payer: UMR Bronson Commercial |
$126.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.89
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$3.11
|
|
|
Service Code
|
NDC 51079-180-01
|
| Hospital Charge Code |
10454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$2.80 |
| Rate for Payer: Aetna American Axle |
$2.02
|
| 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: Encore Health Key Benefits Commercial |
$2.49
|
| Rate for Payer: Healthscope Commercial |
$2.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.64
|
| Rate for Payer: PHP Commercial |
$2.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.18
|
| Rate for Payer: Priority Health SBD |
$1.96
|
| Rate for Payer: UMR Bronson Commercial |
$1.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.33
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$270.25
|
|
|
Service Code
|
NDC 0378-1300-01
|
| Hospital Charge Code |
10454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.91 |
| Max. Negotiated Rate |
$243.22 |
| Rate for Payer: Aetna American Axle |
$175.66
|
| Rate for Payer: Aetna Commercial |
$229.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.66
|
| Rate for Payer: Cash Price |
$216.20
|
| Rate for Payer: Cofinity Commercial |
$189.18
|
| Rate for Payer: Cofinity Commercial |
$232.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$216.20
|
| Rate for Payer: Healthscope Commercial |
$243.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$189.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$229.71
|
| Rate for Payer: PHP Commercial |
$229.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.18
|
| Rate for Payer: Priority Health SBD |
$170.26
|
| Rate for Payer: UMR Bronson Commercial |
$118.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.69
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$294.50
|
|
|
Service Code
|
NDC 0054-0021-25
|
| Hospital Charge Code |
10454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$129.58 |
| Max. Negotiated Rate |
$265.05 |
| Rate for Payer: Aetna American Axle |
$191.42
|
| Rate for Payer: Aetna Commercial |
$250.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$191.42
|
| Rate for Payer: Cash Price |
$235.60
|
| Rate for Payer: Cofinity Commercial |
$206.15
|
| Rate for Payer: Cofinity Commercial |
$253.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.60
|
| Rate for Payer: Healthscope Commercial |
$265.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$206.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$220.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$250.32
|
| Rate for Payer: PHP Commercial |
$250.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$206.15
|
| Rate for Payer: Priority Health SBD |
$185.54
|
| Rate for Payer: UMR Bronson Commercial |
$129.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$220.88
|
|
|
LITHIUM CARBONATE ER 300 MG TABLET,EXTENDED RELEASE
|
Facility
|
IP
|
$310.65
|
|
|
Service Code
|
NDC 51079-180-20
|
| Hospital Charge Code |
10454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.69 |
| Max. Negotiated Rate |
$279.58 |
| Rate for Payer: Aetna American Axle |
$201.92
|
| 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: Encore Health Key Benefits Commercial |
$248.52
|
| Rate for Payer: Healthscope Commercial |
$279.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$217.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$232.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$264.05
|
| Rate for Payer: PHP Commercial |
$264.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$217.46
|
| Rate for Payer: Priority Health SBD |
$195.71
|
| Rate for Payer: UMR Bronson Commercial |
$136.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$232.99
|
|
