|
LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$372.40
|
|
|
Service Code
|
NDC 51079014220
|
| Hospital Charge Code |
10455
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.79 |
| Max. Negotiated Rate |
$335.16 |
| Rate for Payer: Aetna American Axle |
$242.06
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$260.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.30
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$137.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.30
|
|
|
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM)
|
Facility
|
OP
|
$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 Exchange |
$6,428.39
|
| Rate for Payer: UHC Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,802.95
|
| 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
|
OP
|
$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 Exchange |
$6,428.39
|
| Rate for Payer: UHC Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,802.95
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE
|
Facility
|
OP
|
$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 Exchange |
$6,428.39
|
| Rate for Payer: UHC Medicare Advantage |
$3,363.71
|
| Rate for Payer: UHCCP Medicaid |
$1,802.95
|
| Rate for Payer: VA VA |
$3,363.71
|
|
|
LOMUSTINE 10 MG CAPSULE
|
Facility
|
OP
|
$2,029.05
|
|
|
Service Code
|
NDC 58181304005
|
| Hospital Charge Code |
10459
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$750.75 |
| Max. Negotiated Rate |
$1,826.14 |
| Rate for Payer: Aetna American Axle |
$1,318.88
|
| Rate for Payer: Aetna Commercial |
$1,724.69
|
| Rate for Payer: Aetna Medicare |
$1,014.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,318.88
|
| Rate for Payer: BCBS Complete |
$811.62
|
| Rate for Payer: Cash Price |
$1,623.24
|
| Rate for Payer: Cofinity Commercial |
$1,420.34
|
| Rate for Payer: Cofinity Commercial |
$1,744.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,420.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,623.24
|
| Rate for Payer: Healthscope Commercial |
$1,826.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,420.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,521.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,724.69
|
| Rate for Payer: PHP Commercial |
$1,724.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,318.88
|
| Rate for Payer: Priority Health SBD |
$1,278.30
|
| Rate for Payer: UMR Bronson Commercial |
$750.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,521.79
|
|
|
LOMUSTINE 10 MG CAPSULE
|
Facility
|
IP
|
$2,029.05
|
|
|
Service Code
|
NDC 58181304005
|
| Hospital Charge Code |
10459
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$892.78 |
| Max. Negotiated Rate |
$1,826.14 |
| Rate for Payer: Aetna American Axle |
$1,318.88
|
| Rate for Payer: Aetna Commercial |
$1,724.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,318.88
|
| Rate for Payer: Cash Price |
$1,623.24
|
| Rate for Payer: Cofinity Commercial |
$1,420.34
|
| Rate for Payer: Cofinity Commercial |
$1,744.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$1,420.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,623.24
|
| Rate for Payer: Healthscope Commercial |
$1,826.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,420.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,521.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,724.69
|
| Rate for Payer: PHP Commercial |
$1,724.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,318.88
|
| Rate for Payer: Priority Health SBD |
$1,278.30
|
| Rate for Payer: UMR Bronson Commercial |
$892.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,521.79
|
|
|
LONG CHAIN TRIGLYCERIDES 7.5 GRAM-67.5 KCAL/15 ML ORAL EMULSION
|
Facility
|
OP
|
$17.09
|
|
|
Service Code
|
NDC 41679008702
|
| Hospital Charge Code |
173669
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.32 |
| Max. Negotiated Rate |
$15.38 |
| Rate for Payer: Aetna American Axle |
$11.11
|
| Rate for Payer: Aetna Commercial |
$14.53
|
| Rate for Payer: Aetna Medicare |
$8.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.11
|
| Rate for Payer: BCBS Complete |
$6.84
|
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Cofinity Commercial |
$11.96
|
| Rate for Payer: Cofinity Commercial |
$14.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.67
|
| Rate for Payer: Healthscope Commercial |
$15.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.53
|
| Rate for Payer: PHP Commercial |
$14.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.11
|
| Rate for Payer: Priority Health SBD |
$10.77
|
| Rate for Payer: UMR Bronson Commercial |
$6.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.82
|
|
|
LONG CHAIN TRIGLYCERIDES 7.5 GRAM-67.5 KCAL/15 ML ORAL EMULSION
|
Facility
|
IP
|
$17.09
|
|
|
Service Code
|
NDC 41679008743
|
| Hospital Charge Code |
173669
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$15.38 |
| Rate for Payer: Aetna American Axle |
$11.11
|
| Rate for Payer: Aetna Commercial |
$14.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.11
|
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Cofinity Commercial |
$11.96
|
| Rate for Payer: Cofinity Commercial |
$14.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.67
|
| Rate for Payer: Healthscope Commercial |
$15.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.53
|
| Rate for Payer: PHP Commercial |
$14.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.11
|
| Rate for Payer: Priority Health SBD |
$10.77
|
| Rate for Payer: UMR Bronson Commercial |
$7.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.82
|
|
|
LONG CHAIN TRIGLYCERIDES 7.5 GRAM-67.5 KCAL/15 ML ORAL EMULSION
|
Facility
|
OP
|
$17.09
|
|
|
Service Code
|
NDC 41679008743
|
| Hospital Charge Code |
173669
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.32 |
| Max. Negotiated Rate |
$15.38 |
| Rate for Payer: Aetna American Axle |
$11.11
|
| Rate for Payer: Aetna Commercial |
$14.53
|
| Rate for Payer: Aetna Medicare |
$8.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.11
|
| Rate for Payer: BCBS Complete |
$6.84
|
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Cofinity Commercial |
$11.96
|
| Rate for Payer: Cofinity Commercial |
$14.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.67
|
| Rate for Payer: Healthscope Commercial |
$15.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.53
|
| Rate for Payer: PHP Commercial |
$14.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.11
|
| Rate for Payer: Priority Health SBD |
$10.77
|
| Rate for Payer: UMR Bronson Commercial |
$6.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.82
|
|
|
LONG CHAIN TRIGLYCERIDES 7.5 GRAM-67.5 KCAL/15 ML ORAL EMULSION
|
Facility
|
IP
|
$17.09
|
|
|
Service Code
|
NDC 41679008702
|
| Hospital Charge Code |
173669
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.52 |
| Max. Negotiated Rate |
$15.38 |
| Rate for Payer: Aetna American Axle |
$11.11
|
| Rate for Payer: Aetna Commercial |
$14.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.11
|
| Rate for Payer: Cash Price |
$13.67
|
| Rate for Payer: Cofinity Commercial |
$11.96
|
| Rate for Payer: Cofinity Commercial |
$14.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.67
|
| Rate for Payer: Healthscope Commercial |
$15.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.53
|
| Rate for Payer: PHP Commercial |
$14.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.11
|
| Rate for Payer: Priority Health SBD |
$10.77
|
| Rate for Payer: UMR Bronson Commercial |
$7.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.82
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
IP
|
$22.26
|
|
|
Service Code
|
NDC 00450013444
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.79 |
| Max. Negotiated Rate |
$20.03 |
| Rate for Payer: Aetna American Axle |
$14.47
|
| Rate for Payer: Aetna Commercial |
$18.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.47
|
| Rate for Payer: Cash Price |
$17.81
|
| Rate for Payer: Cofinity Commercial |
$15.58
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.81
|
| Rate for Payer: Healthscope Commercial |
$20.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.92
|
| Rate for Payer: PHP Commercial |
$18.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.47
|
| Rate for Payer: Priority Health SBD |
$14.02
|
| Rate for Payer: UMR Bronson Commercial |
$9.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.70
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
IP
|
$16.20
|
|
|
Service Code
|
NDC 00904683620
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.13 |
| Max. Negotiated Rate |
$14.58 |
| Rate for Payer: Aetna American Axle |
$10.53
|
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.53
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cofinity Commercial |
$11.34
|
| Rate for Payer: Cofinity Commercial |
$13.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.96
|
| Rate for Payer: Healthscope Commercial |
$14.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.77
|
| Rate for Payer: PHP Commercial |
$13.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.53
|
| Rate for Payer: Priority Health SBD |
$10.21
|
| Rate for Payer: UMR Bronson Commercial |
$7.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.15
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
OP
|
$16.20
|
|
|
Service Code
|
NDC 00904683620
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.99 |
| Max. Negotiated Rate |
$14.58 |
| Rate for Payer: Aetna American Axle |
$10.53
|
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: Aetna Medicare |
$8.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.53
|
| Rate for Payer: BCBS Complete |
$6.48
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cofinity Commercial |
$11.34
|
| Rate for Payer: Cofinity Commercial |
$13.93
|
| Rate for Payer: Cofinity Medicare Advantage |
$11.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.96
|
| Rate for Payer: Healthscope Commercial |
$14.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.77
|
| Rate for Payer: PHP Commercial |
$13.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.53
|
| Rate for Payer: Priority Health SBD |
$10.21
|
| Rate for Payer: UMR Bronson Commercial |
$5.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.15
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
OP
|
$21.84
|
|
|
Service Code
|
NDC 00450013404
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$19.66 |
| Rate for Payer: Aetna American Axle |
$14.20
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$15.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.38
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$8.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.38
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
IP
|
$21.84
|
|
|
Service Code
|
NDC 00450013404
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$19.66 |
| Rate for Payer: Aetna American Axle |
$14.20
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$15.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.38
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$9.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.38
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
OP
|
$22.26
|
|
|
Service Code
|
NDC 00450013444
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$20.03 |
| Rate for Payer: Aetna American Axle |
$14.47
|
| Rate for Payer: Aetna Commercial |
$18.92
|
| Rate for Payer: Aetna Medicare |
$11.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.47
|
| Rate for Payer: BCBS Complete |
$8.90
|
| Rate for Payer: Cash Price |
$17.81
|
| Rate for Payer: Cofinity Commercial |
$15.58
|
| Rate for Payer: Cofinity Commercial |
$19.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.81
|
| Rate for Payer: Healthscope Commercial |
$20.03
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.92
|
| Rate for Payer: PHP Commercial |
$18.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.47
|
| Rate for Payer: Priority Health SBD |
$14.02
|
| Rate for Payer: UMR Bronson Commercial |
$8.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.70
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
OP
|
$13.50
|
|
|
Service Code
|
NDC 96295013558
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$12.15 |
| Rate for Payer: Aetna American Axle |
$8.78
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Medicare |
$6.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.78
|
| Rate for Payer: BCBS Complete |
$5.40
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Cofinity Commercial |
$9.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.80
|
| Rate for Payer: Healthscope Commercial |
$12.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health SBD |
$8.51
|
| Rate for Payer: UMR Bronson Commercial |
$5.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.12
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
IP
|
$13.50
|
|
|
Service Code
|
NDC 96295013558
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$12.15 |
| Rate for Payer: Aetna American Axle |
$8.78
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.78
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Cofinity Commercial |
$9.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.80
|
| Rate for Payer: Healthscope Commercial |
$12.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health SBD |
$8.51
|
| Rate for Payer: UMR Bronson Commercial |
$5.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.12
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
IP
|
$13.50
|
|
|
Service Code
|
NDC 70000041801
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.94 |
| Max. Negotiated Rate |
$12.15 |
| Rate for Payer: Aetna American Axle |
$8.78
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.78
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Cofinity Commercial |
$9.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.80
|
| Rate for Payer: Healthscope Commercial |
$12.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health SBD |
$8.51
|
| Rate for Payer: UMR Bronson Commercial |
$5.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.12
|
|
|
LOPERAMIDE 1 MG/7.5 ML ORAL LIQUID
|
Facility
|
OP
|
$13.50
|
|
|
Service Code
|
NDC 70000041801
|
| Hospital Charge Code |
42219
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.00 |
| Max. Negotiated Rate |
$12.15 |
| Rate for Payer: Aetna American Axle |
$8.78
|
| Rate for Payer: Aetna Commercial |
$11.47
|
| Rate for Payer: Aetna Medicare |
$6.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.78
|
| Rate for Payer: BCBS Complete |
$5.40
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cofinity Commercial |
$11.61
|
| Rate for Payer: Cofinity Commercial |
$9.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.80
|
| Rate for Payer: Healthscope Commercial |
$12.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$9.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$10.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.47
|
| Rate for Payer: PHP Commercial |
$11.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health SBD |
$8.51
|
| Rate for Payer: UMR Bronson Commercial |
$5.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.12
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
OP
|
$331.55
|
|
|
Service Code
|
NDC 00093031101
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.67 |
| Max. Negotiated Rate |
$298.39 |
| Rate for Payer: Aetna American Axle |
$215.51
|
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: Aetna Medicare |
$165.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.51
|
| Rate for Payer: BCBS Complete |
$132.62
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$232.09
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$232.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.24
|
| Rate for Payer: Healthscope Commercial |
$298.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.51
|
| Rate for Payer: Priority Health SBD |
$208.88
|
| Rate for Payer: UMR Bronson Commercial |
$122.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.66
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
OP
|
$3.31
|
|
|
Service Code
|
NDC 51079069001
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.22 |
| Max. Negotiated Rate |
$2.98 |
| Rate for Payer: Aetna American Axle |
$2.15
|
| Rate for Payer: Aetna Commercial |
$2.81
|
| Rate for Payer: Aetna Medicare |
$1.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.15
|
| Rate for Payer: BCBS Complete |
$1.32
|
| Rate for Payer: Cash Price |
$2.65
|
| Rate for Payer: Cofinity Commercial |
$2.32
|
| Rate for Payer: Cofinity Commercial |
$2.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.65
|
| Rate for Payer: Healthscope Commercial |
$2.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.81
|
| Rate for Payer: PHP Commercial |
$2.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.15
|
| Rate for Payer: Priority Health SBD |
$2.09
|
| Rate for Payer: UMR Bronson Commercial |
$1.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.48
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$331.55
|
|
|
Service Code
|
NDC 00093031101
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.88 |
| Max. Negotiated Rate |
$298.39 |
| Rate for Payer: Aetna American Axle |
$215.51
|
| Rate for Payer: Aetna Commercial |
$281.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$215.51
|
| Rate for Payer: Cash Price |
$265.24
|
| Rate for Payer: Cofinity Commercial |
$232.09
|
| Rate for Payer: Cofinity Commercial |
$285.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$232.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$265.24
|
| Rate for Payer: Healthscope Commercial |
$298.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$232.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.82
|
| Rate for Payer: PHP Commercial |
$281.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.51
|
| Rate for Payer: Priority Health SBD |
$208.88
|
| Rate for Payer: UMR Bronson Commercial |
$145.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.66
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$247.95
|
|
|
Service Code
|
NDC 69452027120
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.10 |
| Max. Negotiated Rate |
$223.16 |
| Rate for Payer: Aetna American Axle |
$161.17
|
| Rate for Payer: Aetna Commercial |
$210.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.17
|
| Rate for Payer: Cash Price |
$198.36
|
| Rate for Payer: Cofinity Commercial |
$173.56
|
| Rate for Payer: Cofinity Commercial |
$213.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$173.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$198.36
|
| Rate for Payer: Healthscope Commercial |
$223.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.76
|
| Rate for Payer: PHP Commercial |
$210.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.17
|
| Rate for Payer: Priority Health SBD |
$156.21
|
| Rate for Payer: UMR Bronson Commercial |
$109.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.96
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
OP
|
$247.95
|
|
|
Service Code
|
NDC 69452027120
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.74 |
| Max. Negotiated Rate |
$223.16 |
| Rate for Payer: Aetna American Axle |
$161.17
|
| Rate for Payer: Aetna Commercial |
$210.76
|
| Rate for Payer: Aetna Medicare |
$123.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$161.17
|
| Rate for Payer: BCBS Complete |
$99.18
|
| Rate for Payer: Cash Price |
$198.36
|
| Rate for Payer: Cofinity Commercial |
$173.56
|
| Rate for Payer: Cofinity Commercial |
$213.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$173.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$198.36
|
| Rate for Payer: Healthscope Commercial |
$223.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$173.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$210.76
|
| Rate for Payer: PHP Commercial |
$210.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$161.17
|
| Rate for Payer: Priority Health SBD |
$156.21
|
| Rate for Payer: UMR Bronson Commercial |
$91.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.96
|
|
