|
LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$269.80
|
|
|
Service Code
|
NDC 00378145001
|
| Hospital Charge Code |
10455
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.83 |
| Max. Negotiated Rate |
$242.82 |
| Rate for Payer: Aetna American Axle |
$175.37
|
| Rate for Payer: Aetna Commercial |
$229.33
|
| Rate for Payer: Aetna Medicare |
$134.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.37
|
| Rate for Payer: BCBS Complete |
$107.92
|
| Rate for Payer: Cash Price |
$215.84
|
| Rate for Payer: Cofinity Commercial |
$188.86
|
| Rate for Payer: Cofinity Commercial |
$232.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$188.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.84
|
| Rate for Payer: Healthscope Commercial |
$242.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$188.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.33
|
| Rate for Payer: PHP Commercial |
$229.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.37
|
| Rate for Payer: Priority Health SBD |
$169.97
|
| Rate for Payer: UMR Bronson Commercial |
$99.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.35
|
|
|
LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$269.80
|
|
|
Service Code
|
NDC 00054002025
|
| Hospital Charge Code |
10455
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.83 |
| Max. Negotiated Rate |
$242.82 |
| Rate for Payer: Aetna American Axle |
$175.37
|
| Rate for Payer: Aetna Commercial |
$229.33
|
| Rate for Payer: Aetna Medicare |
$134.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$175.37
|
| Rate for Payer: BCBS Complete |
$107.92
|
| Rate for Payer: Cash Price |
$215.84
|
| Rate for Payer: Cofinity Commercial |
$188.86
|
| Rate for Payer: Cofinity Commercial |
$232.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$188.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$215.84
|
| Rate for Payer: Healthscope Commercial |
$242.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$188.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$202.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$229.33
|
| Rate for Payer: PHP Commercial |
$229.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$175.37
|
| Rate for Payer: Priority Health SBD |
$169.97
|
| Rate for Payer: UMR Bronson Commercial |
$99.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$202.35
|
|
|
LITHIUM CARBONATE ER 450 MG TABLET,EXTENDED RELEASE
|
Facility
|
OP
|
$255.84
|
|
|
Service Code
|
NDC 68084065501
|
| Hospital Charge Code |
10455
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$94.66 |
| Max. Negotiated Rate |
$230.26 |
| Rate for Payer: Aetna American Axle |
$166.30
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$179.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$191.88
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$94.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$191.88
|
|
|
LITHOLAPAXY: CRUSHING OR FRAGMENTATION OF CALCULUS BY ANY MEANS IN BLADDER AND REMOVAL OF FRAGMENTS; COMPLICATED OR LARGE (OVER 2.5 CM)
|
Facility
|
OP
|
$10,620.87
|
|
|
Service Code
|
CPT 52318
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$452.36 |
| Max. Negotiated Rate |
$10,620.87 |
| Rate for Payer: Aetna Medicare |
$3,514.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,224.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,224.04
|
| Rate for Payer: BCBS Complete |
$1,901.83
|
| Rate for Payer: BCBS MAPPO |
$3,379.23
|
| Rate for Payer: BCBS Trust/PPO |
$4,117.01
|
| Rate for Payer: BCN Commercial |
$4,117.01
|
| Rate for Payer: BCN Medicare Advantage |
$3,379.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,379.23
|
| Rate for Payer: Mclaren Medicaid |
$1,811.27
|
| Rate for Payer: Mclaren Medicare |
$3,379.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,548.19
|
| Rate for Payer: Meridian Medicaid |
$1,901.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,886.11
|
| Rate for Payer: Nomi Health Commercial |
$7,096.38
|
| Rate for Payer: PACE Medicare |
$3,210.27
|
| Rate for Payer: PACE SWMI |
$3,379.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,379.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,811.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,620.87
|
| Rate for Payer: Priority Health Medicare |
$3,379.23
|
| Rate for Payer: Priority Health Narrow Network |
$8,496.70
|
| Rate for Payer: Railroad Medicare Medicare |
$3,379.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$497.60
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,379.23
|
| Rate for Payer: UHC Exchange |
$452.36
|
| Rate for Payer: UHC Medicare Advantage |
$3,379.23
|
| Rate for Payer: UHCCP Medicaid |
$1,811.27
|
| Rate for Payer: VA VA |
$3,379.23
|
|
|
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
|
$10,620.87
|
|
|
Service Code
|
CPT 52317
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$330.77 |
| Max. Negotiated Rate |
$10,620.87 |
| Rate for Payer: Aetna Medicare |
$3,514.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,224.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,224.04
|
| Rate for Payer: BCBS Complete |
$1,901.83
|
| Rate for Payer: BCBS MAPPO |
$3,379.23
|
| Rate for Payer: BCBS Trust/PPO |
$3,340.49
|
| Rate for Payer: BCN Commercial |
$3,340.49
|
| Rate for Payer: BCN Medicare Advantage |
$3,379.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,379.23
|
| Rate for Payer: Mclaren Medicaid |
$1,811.27
|
| Rate for Payer: Mclaren Medicare |
$3,379.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,548.19
|
| Rate for Payer: Meridian Medicaid |
$1,901.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,886.11
|
| Rate for Payer: Nomi Health Commercial |
$7,096.38
|
| Rate for Payer: PACE Medicare |
$3,210.27
|
| Rate for Payer: PACE SWMI |
$3,379.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,379.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,811.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,620.87
|
| Rate for Payer: Priority Health Medicare |
$3,379.23
|
| Rate for Payer: Priority Health Narrow Network |
$8,496.70
|
| Rate for Payer: Railroad Medicare Medicare |
$3,379.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$363.85
|
| Rate for Payer: UHC Core |
$3,604.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,379.23
|
| Rate for Payer: UHC Exchange |
$330.77
|
| Rate for Payer: UHC Medicare Advantage |
$3,379.23
|
| Rate for Payer: UHCCP Medicaid |
$1,811.27
|
| Rate for Payer: VA VA |
$3,379.23
|
|
|
LITHOTRIPSY, EXTRACORPOREAL SHOCK WAVE
|
Facility
|
OP
|
$10,620.87
|
|
|
Service Code
|
CPT 50590
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$550.44 |
| Max. Negotiated Rate |
$10,620.87 |
| Rate for Payer: Aetna Medicare |
$3,514.40
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,224.04
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,224.04
|
| Rate for Payer: BCBS Complete |
$1,901.83
|
| Rate for Payer: BCBS MAPPO |
$3,379.23
|
| Rate for Payer: BCBS Trust/PPO |
$2,918.73
|
| Rate for Payer: BCN Commercial |
$2,918.73
|
| Rate for Payer: BCN Medicare Advantage |
$3,379.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,379.23
|
| Rate for Payer: Mclaren Medicaid |
$1,811.27
|
| Rate for Payer: Mclaren Medicare |
$3,379.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,548.19
|
| Rate for Payer: Meridian Medicaid |
$1,901.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,886.11
|
| Rate for Payer: Nomi Health Commercial |
$7,096.38
|
| Rate for Payer: PACE Medicare |
$3,210.27
|
| Rate for Payer: PACE SWMI |
$3,379.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,379.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,811.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10,620.87
|
| Rate for Payer: Priority Health Medicare |
$3,379.23
|
| Rate for Payer: Priority Health Narrow Network |
$8,496.70
|
| Rate for Payer: Railroad Medicare Medicare |
$3,379.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$605.48
|
| Rate for Payer: UHC Core |
$8,596.00
|
| Rate for Payer: UHC Dual Complete DSNP |
$3,379.23
|
| Rate for Payer: UHC Exchange |
$550.44
|
| Rate for Payer: UHC Medicare Advantage |
$3,379.23
|
| Rate for Payer: UHCCP Medicaid |
$1,811.27
|
| Rate for Payer: VA VA |
$3,379.23
|
|
|
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
|
|
|
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
|
|
|
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
|
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
|
|
|
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
|
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
|
|
|
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
|
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 |
$11.48
|
| 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 |
$11.48
|
| Rate for Payer: PHP Commercial |
$11.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health SBD |
$8.50
|
| 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 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 |
$11.48
|
| 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 |
$11.48
|
| Rate for Payer: PHP Commercial |
$11.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health SBD |
$8.50
|
| 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 |
$11.48
|
| 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 |
$11.48
|
| Rate for Payer: PHP Commercial |
$11.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health SBD |
$8.50
|
| 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
|
$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
|
$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
|
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
|
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
|
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
|
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 |
$11.48
|
| 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 |
$11.48
|
| Rate for Payer: PHP Commercial |
$11.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.78
|
| Rate for Payer: Priority Health SBD |
$8.50
|
| Rate for Payer: UMR Bronson Commercial |
$5.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$10.12
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$2.47
|
|
|
Service Code
|
NDC 60687022911
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.09 |
| Max. Negotiated Rate |
$2.22 |
| Rate for Payer: Aetna American Axle |
$1.61
|
| Rate for Payer: Aetna Commercial |
$2.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.61
|
| Rate for Payer: Cash Price |
$1.98
|
| Rate for Payer: Cofinity Commercial |
$1.73
|
| Rate for Payer: Cofinity Commercial |
$2.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.98
|
| Rate for Payer: Healthscope Commercial |
$2.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.10
|
| Rate for Payer: PHP Commercial |
$2.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.61
|
| Rate for Payer: Priority Health SBD |
$1.56
|
| Rate for Payer: UMR Bronson Commercial |
$1.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.85
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$246.24
|
|
|
Service Code
|
NDC 60687022901
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.35 |
| Max. Negotiated Rate |
$221.62 |
| Rate for Payer: Aetna American Axle |
$160.06
|
| Rate for Payer: Aetna Commercial |
$209.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.06
|
| Rate for Payer: Cash Price |
$196.99
|
| Rate for Payer: Cofinity Commercial |
$172.37
|
| Rate for Payer: Cofinity Commercial |
$211.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$172.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.99
|
| Rate for Payer: Healthscope Commercial |
$221.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$184.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.30
|
| Rate for Payer: PHP Commercial |
$209.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$160.06
|
| Rate for Payer: Priority Health SBD |
$155.13
|
| Rate for Payer: UMR Bronson Commercial |
$108.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$184.68
|
|
|
LOPERAMIDE 2 MG CAPSULE
|
Facility
|
IP
|
$330.72
|
|
|
Service Code
|
NDC 51079069020
|
| Hospital Charge Code |
4560
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$145.52 |
| Max. Negotiated Rate |
$297.65 |
| Rate for Payer: Aetna American Axle |
$214.97
|
| Rate for Payer: Aetna Commercial |
$281.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$214.97
|
| Rate for Payer: Cash Price |
$264.58
|
| Rate for Payer: Cofinity Commercial |
$231.50
|
| Rate for Payer: Cofinity Commercial |
$284.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$231.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$264.58
|
| Rate for Payer: Healthscope Commercial |
$297.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$231.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$248.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$281.11
|
| Rate for Payer: PHP Commercial |
$281.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$214.97
|
| Rate for Payer: Priority Health SBD |
$208.35
|
| Rate for Payer: UMR Bronson Commercial |
$145.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$248.04
|
|
