Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

CHLORTHALIDONE 25 MG TABLET

Facility

$8.69

Service Code	NDC 51079005801
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$7.82
Rate for Payer: Aetna Commercial	$7.39
Rate for Payer: Aetna Medicare	$4.34
Rate for Payer: Aetna New Business (MI Preferred)	$5.65
Rate for Payer: BCBS Complete	$3.48
Rate for Payer: Cash Price	$6.95
Rate for Payer: Cofinity Commercial	$6.08
Rate for Payer: Cofinity Commercial	$7.47
Rate for Payer: Cofinity Medicare Advantage	$6.08
Rate for Payer: Encore Health Key Benefits Commercial	$6.95
Rate for Payer: Healthscope Commercial	$7.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.39
Rate for Payer: PHP Commercial	$7.39
Rate for Payer: Priority Health Cigna Priority Health	$5.65
Rate for Payer: Priority Health SBD	$5.47

CHLORTHALIDONE 25 MG TABLET

Facility

$7.56

Service Code	NDC 60687031795
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$6.80
Rate for Payer: Aetna Commercial	$6.43
Rate for Payer: Aetna New Business (MI Preferred)	$4.91
Rate for Payer: Cash Price	$6.05
Rate for Payer: Cofinity Commercial	$5.29
Rate for Payer: Cofinity Commercial	$6.50
Rate for Payer: Cofinity Medicare Advantage	$5.29
Rate for Payer: Encore Health Key Benefits Commercial	$6.05
Rate for Payer: Healthscope Commercial	$6.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.43
Rate for Payer: PHP Commercial	$6.43
Rate for Payer: Priority Health Cigna Priority Health	$4.91
Rate for Payer: Priority Health SBD	$4.76

CHLORTHALIDONE 25 MG TABLET

Facility

$206.07

Service Code	NDC 00904690004
Hospital Charge Code	1661
Hospital Revenue Code	637
Min. Negotiated Rate	$82.43
Max. Negotiated Rate	$185.46
Rate for Payer: Aetna Commercial	$175.16
Rate for Payer: Aetna Medicare	$103.03
Rate for Payer: Aetna New Business (MI Preferred)	$133.95
Rate for Payer: BCBS Complete	$82.43
Rate for Payer: Cash Price	$164.86
Rate for Payer: Cofinity Commercial	$144.25
Rate for Payer: Cofinity Commercial	$177.22
Rate for Payer: Cofinity Medicare Advantage	$144.25
Rate for Payer: Encore Health Key Benefits Commercial	$164.86
Rate for Payer: Healthscope Commercial	$185.46
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$175.16
Rate for Payer: PHP Commercial	$175.16
Rate for Payer: Priority Health Cigna Priority Health	$133.95
Rate for Payer: Priority Health SBD	$129.82

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$3.32

Service Code	NDC 77333094825
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$2.09
Max. Negotiated Rate	$2.99
Rate for Payer: Aetna Commercial	$2.82
Rate for Payer: Aetna New Business (MI Preferred)	$2.16
Rate for Payer: Cash Price	$2.66
Rate for Payer: Cofinity Commercial	$2.32
Rate for Payer: Cofinity Commercial	$2.86
Rate for Payer: Cofinity Medicare Advantage	$2.32
Rate for Payer: Encore Health Key Benefits Commercial	$2.66
Rate for Payer: Healthscope Commercial	$2.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.82
Rate for Payer: PHP Commercial	$2.82
Rate for Payer: Priority Health Cigna Priority Health	$2.16
Rate for Payer: Priority Health SBD	$2.09

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$331.35

Service Code	NDC 77333094810
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$208.75
Max. Negotiated Rate	$298.21
Rate for Payer: Aetna Commercial	$281.65
Rate for Payer: Aetna New Business (MI Preferred)	$215.38
Rate for Payer: Cash Price	$265.08
Rate for Payer: Cofinity Commercial	$231.94
Rate for Payer: Cofinity Commercial	$284.96
Rate for Payer: Cofinity Medicare Advantage	$231.94
Rate for Payer: Encore Health Key Benefits Commercial	$265.08
Rate for Payer: Healthscope Commercial	$298.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$281.65
Rate for Payer: PHP Commercial	$281.65
Rate for Payer: Priority Health Cigna Priority Health	$215.38
Rate for Payer: Priority Health SBD	$208.75

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$2.03

Service Code	NDC 50268086311
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.83
Rate for Payer: Aetna Commercial	$1.73
Rate for Payer: Aetna New Business (MI Preferred)	$1.32
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cofinity Commercial	$1.42
Rate for Payer: Cofinity Commercial	$1.75
Rate for Payer: Cofinity Medicare Advantage	$1.42
Rate for Payer: Encore Health Key Benefits Commercial	$1.62
Rate for Payer: Healthscope Commercial	$1.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.73
Rate for Payer: PHP Commercial	$1.73
Rate for Payer: Priority Health Cigna Priority Health	$1.32
Rate for Payer: Priority Health SBD	$1.28

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$331.35

Service Code	NDC 77333094810
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$132.54
Max. Negotiated Rate	$298.21
Rate for Payer: Aetna Commercial	$281.65
Rate for Payer: Aetna Medicare	$165.68
Rate for Payer: Aetna New Business (MI Preferred)	$215.38
Rate for Payer: BCBS Complete	$132.54
Rate for Payer: Cash Price	$265.08
Rate for Payer: Cofinity Commercial	$231.94
Rate for Payer: Cofinity Commercial	$284.96
Rate for Payer: Cofinity Medicare Advantage	$231.94
Rate for Payer: Encore Health Key Benefits Commercial	$265.08
Rate for Payer: Healthscope Commercial	$298.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$281.65
Rate for Payer: PHP Commercial	$281.65
Rate for Payer: Priority Health Cigna Priority Health	$215.38
Rate for Payer: Priority Health SBD	$208.75

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$30.55

Service Code	NDC 00904582360
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$12.22
Max. Negotiated Rate	$27.50
Rate for Payer: Aetna Commercial	$25.97
Rate for Payer: Aetna Medicare	$15.28
Rate for Payer: Aetna New Business (MI Preferred)	$19.86
Rate for Payer: BCBS Complete	$12.22
Rate for Payer: Cash Price	$24.44
Rate for Payer: Cofinity Commercial	$21.39
Rate for Payer: Cofinity Commercial	$26.27
Rate for Payer: Cofinity Medicare Advantage	$21.39
Rate for Payer: Encore Health Key Benefits Commercial	$24.44
Rate for Payer: Healthscope Commercial	$27.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$25.97
Rate for Payer: PHP Commercial	$25.97
Rate for Payer: Priority Health Cigna Priority Health	$19.86
Rate for Payer: Priority Health SBD	$19.25

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$39.95

Service Code	NDC 96295012845
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$25.17
Max. Negotiated Rate	$35.95
Rate for Payer: Aetna Commercial	$33.96
Rate for Payer: Aetna New Business (MI Preferred)	$25.97
Rate for Payer: Cash Price	$31.96
Rate for Payer: Cofinity Commercial	$27.96
Rate for Payer: Cofinity Commercial	$34.36
Rate for Payer: Cofinity Medicare Advantage	$27.96
Rate for Payer: Encore Health Key Benefits Commercial	$31.96
Rate for Payer: Healthscope Commercial	$35.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.96
Rate for Payer: PHP Commercial	$33.96
Rate for Payer: Priority Health Cigna Priority Health	$25.97
Rate for Payer: Priority Health SBD	$25.17

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$101.18

Service Code	NDC 50268086315
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$63.74
Max. Negotiated Rate	$91.06
Rate for Payer: Aetna Commercial	$86.00
Rate for Payer: Aetna New Business (MI Preferred)	$65.77
Rate for Payer: Cash Price	$80.94
Rate for Payer: Cofinity Commercial	$70.83
Rate for Payer: Cofinity Commercial	$87.01
Rate for Payer: Cofinity Medicare Advantage	$70.83
Rate for Payer: Encore Health Key Benefits Commercial	$80.94
Rate for Payer: Healthscope Commercial	$91.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.00
Rate for Payer: PHP Commercial	$86.00
Rate for Payer: Priority Health Cigna Priority Health	$65.77
Rate for Payer: Priority Health SBD	$63.74

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$30.55

Service Code	NDC 00904582360
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$19.25
Max. Negotiated Rate	$27.50
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	$21.39
Rate for Payer: Cofinity Commercial	$26.27
Rate for Payer: Cofinity Medicare Advantage	$21.39
Rate for Payer: Encore Health Key Benefits Commercial	$24.44
Rate for Payer: Healthscope Commercial	$27.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$25.97
Rate for Payer: PHP Commercial	$25.97
Rate for Payer: Priority Health Cigna Priority Health	$19.86
Rate for Payer: Priority Health SBD	$19.25

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$101.18

Service Code	NDC 50268086315
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$40.47
Max. Negotiated Rate	$91.06
Rate for Payer: Aetna Commercial	$86.00
Rate for Payer: Aetna Medicare	$50.59
Rate for Payer: Aetna New Business (MI Preferred)	$65.77
Rate for Payer: BCBS Complete	$40.47
Rate for Payer: Cash Price	$80.94
Rate for Payer: Cofinity Commercial	$70.83
Rate for Payer: Cofinity Commercial	$87.01
Rate for Payer: Cofinity Medicare Advantage	$70.83
Rate for Payer: Encore Health Key Benefits Commercial	$80.94
Rate for Payer: Healthscope Commercial	$91.06
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.00
Rate for Payer: PHP Commercial	$86.00
Rate for Payer: Priority Health Cigna Priority Health	$65.77
Rate for Payer: Priority Health SBD	$63.74

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$3.32

Service Code	NDC 77333094825
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$1.33
Max. Negotiated Rate	$2.99
Rate for Payer: Aetna Commercial	$2.82
Rate for Payer: Aetna Medicare	$1.66
Rate for Payer: Aetna New Business (MI Preferred)	$2.16
Rate for Payer: BCBS Complete	$1.33
Rate for Payer: Cash Price	$2.66
Rate for Payer: Cofinity Commercial	$2.32
Rate for Payer: Cofinity Commercial	$2.86
Rate for Payer: Cofinity Medicare Advantage	$2.32
Rate for Payer: Encore Health Key Benefits Commercial	$2.66
Rate for Payer: Healthscope Commercial	$2.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.82
Rate for Payer: PHP Commercial	$2.82
Rate for Payer: Priority Health Cigna Priority Health	$2.16
Rate for Payer: Priority Health SBD	$2.09

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$39.95

Service Code	NDC 96295012845
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$15.98
Max. Negotiated Rate	$35.95
Rate for Payer: Aetna Commercial	$33.96
Rate for Payer: Aetna Medicare	$19.98
Rate for Payer: Aetna New Business (MI Preferred)	$25.97
Rate for Payer: BCBS Complete	$15.98
Rate for Payer: Cash Price	$31.96
Rate for Payer: Cofinity Commercial	$27.96
Rate for Payer: Cofinity Commercial	$34.36
Rate for Payer: Cofinity Medicare Advantage	$27.96
Rate for Payer: Encore Health Key Benefits Commercial	$31.96
Rate for Payer: Healthscope Commercial	$35.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$33.96
Rate for Payer: PHP Commercial	$33.96
Rate for Payer: Priority Health Cigna Priority Health	$25.97
Rate for Payer: Priority Health SBD	$25.17

CHOLECALCIFEROL (VITAMIN D3) 10 MCG (400 UNIT) TABLET

Facility

$2.03

Service Code	NDC 50268086311
Hospital Charge Code	109842
Hospital Revenue Code	637
Min. Negotiated Rate	$0.81
Max. Negotiated Rate	$1.83
Rate for Payer: Aetna Commercial	$1.73
Rate for Payer: Aetna Medicare	$1.01
Rate for Payer: Aetna New Business (MI Preferred)	$1.32
Rate for Payer: BCBS Complete	$0.81
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cofinity Commercial	$1.42
Rate for Payer: Cofinity Commercial	$1.75
Rate for Payer: Cofinity Medicare Advantage	$1.42
Rate for Payer: Encore Health Key Benefits Commercial	$1.62
Rate for Payer: Healthscope Commercial	$1.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.73
Rate for Payer: PHP Commercial	$1.73
Rate for Payer: Priority Health Cigna Priority Health	$1.32
Rate for Payer: Priority Health SBD	$1.28

CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE

Facility

$61.10

Service Code	NDC 80681013100
Hospital Charge Code	15636
Hospital Revenue Code	637
Min. Negotiated Rate	$38.49
Max. Negotiated Rate	$54.99
Rate for Payer: Aetna Commercial	$51.94
Rate for Payer: Aetna New Business (MI Preferred)	$39.72
Rate for Payer: Cash Price	$48.88
Rate for Payer: Cofinity Commercial	$42.77
Rate for Payer: Cofinity Commercial	$52.55
Rate for Payer: Cofinity Medicare Advantage	$42.77
Rate for Payer: Encore Health Key Benefits Commercial	$48.88
Rate for Payer: Healthscope Commercial	$54.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$51.94
Rate for Payer: PHP Commercial	$51.94
Rate for Payer: Priority Health Cigna Priority Health	$39.72
Rate for Payer: Priority Health SBD	$38.49

CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE

Facility

$2.77

Service Code	NDC 50268086811
Hospital Charge Code	15636
Hospital Revenue Code	637
Min. Negotiated Rate	$1.75
Max. Negotiated Rate	$2.49
Rate for Payer: Aetna Commercial	$2.35
Rate for Payer: Aetna New Business (MI Preferred)	$1.80
Rate for Payer: Cash Price	$2.22
Rate for Payer: Cofinity Commercial	$1.94
Rate for Payer: Cofinity Commercial	$2.38
Rate for Payer: Cofinity Medicare Advantage	$1.94
Rate for Payer: Encore Health Key Benefits Commercial	$2.22
Rate for Payer: Healthscope Commercial	$2.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.35
Rate for Payer: PHP Commercial	$2.35
Rate for Payer: Priority Health Cigna Priority Health	$1.80
Rate for Payer: Priority Health SBD	$1.75

CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE

Facility

$61.10

Service Code	NDC 80681013100
Hospital Charge Code	15636
Hospital Revenue Code	637
Min. Negotiated Rate	$24.44
Max. Negotiated Rate	$54.99
Rate for Payer: Aetna Commercial	$51.94
Rate for Payer: Aetna Medicare	$30.55
Rate for Payer: Aetna New Business (MI Preferred)	$39.72
Rate for Payer: BCBS Complete	$24.44
Rate for Payer: Cash Price	$48.88
Rate for Payer: Cofinity Commercial	$42.77
Rate for Payer: Cofinity Commercial	$52.55
Rate for Payer: Cofinity Medicare Advantage	$42.77
Rate for Payer: Encore Health Key Benefits Commercial	$48.88
Rate for Payer: Healthscope Commercial	$54.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$51.94
Rate for Payer: PHP Commercial	$51.94
Rate for Payer: Priority Health Cigna Priority Health	$39.72
Rate for Payer: Priority Health SBD	$38.49

CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE

Facility

$138.23

Service Code	NDC 50268086815
Hospital Charge Code	15636
Hospital Revenue Code	637
Min. Negotiated Rate	$87.08
Max. Negotiated Rate	$124.41
Rate for Payer: Aetna Commercial	$117.50
Rate for Payer: Aetna New Business (MI Preferred)	$89.85
Rate for Payer: Cash Price	$110.58
Rate for Payer: Cofinity Commercial	$118.88
Rate for Payer: Cofinity Commercial	$96.76
Rate for Payer: Cofinity Medicare Advantage	$96.76
Rate for Payer: Encore Health Key Benefits Commercial	$110.58
Rate for Payer: Healthscope Commercial	$124.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$117.50
Rate for Payer: PHP Commercial	$117.50
Rate for Payer: Priority Health Cigna Priority Health	$89.85
Rate for Payer: Priority Health SBD	$87.08

CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE

Facility

$108.10

Service Code	NDC 00510509460
Hospital Charge Code	15636
Hospital Revenue Code	637
Min. Negotiated Rate	$43.24
Max. Negotiated Rate	$97.29
Rate for Payer: Aetna Commercial	$91.89
Rate for Payer: Aetna Medicare	$54.05
Rate for Payer: Aetna New Business (MI Preferred)	$70.27
Rate for Payer: BCBS Complete	$43.24
Rate for Payer: Cash Price	$86.48
Rate for Payer: Cofinity Commercial	$75.67
Rate for Payer: Cofinity Commercial	$92.97
Rate for Payer: Cofinity Medicare Advantage	$75.67
Rate for Payer: Encore Health Key Benefits Commercial	$86.48
Rate for Payer: Healthscope Commercial	$97.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$91.89
Rate for Payer: PHP Commercial	$91.89
Rate for Payer: Priority Health Cigna Priority Health	$70.27
Rate for Payer: Priority Health SBD	$68.10

CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE

Facility

$159.80

Service Code	NDC 79854009098
Hospital Charge Code	15636
Hospital Revenue Code	637
Min. Negotiated Rate	$100.67
Max. Negotiated Rate	$143.82
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: Cofinity Medicare Advantage	$111.86
Rate for Payer: Encore Health Key Benefits Commercial	$127.84
Rate for Payer: Healthscope Commercial	$143.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.83
Rate for Payer: PHP Commercial	$135.83
Rate for Payer: Priority Health Cigna Priority Health	$103.87
Rate for Payer: Priority Health SBD	$100.67

CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE

Facility

$2.77

Service Code	NDC 50268086811
Hospital Charge Code	15636
Hospital Revenue Code	637
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$2.49
Rate for Payer: Aetna Commercial	$2.35
Rate for Payer: Aetna Medicare	$1.39
Rate for Payer: Aetna New Business (MI Preferred)	$1.80
Rate for Payer: BCBS Complete	$1.11
Rate for Payer: Cash Price	$2.22
Rate for Payer: Cofinity Commercial	$1.94
Rate for Payer: Cofinity Commercial	$2.38
Rate for Payer: Cofinity Medicare Advantage	$1.94
Rate for Payer: Encore Health Key Benefits Commercial	$2.22
Rate for Payer: Healthscope Commercial	$2.49
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.35
Rate for Payer: PHP Commercial	$2.35
Rate for Payer: Priority Health Cigna Priority Health	$1.80
Rate for Payer: Priority Health SBD	$1.75

CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE

Facility

$108.10

Service Code	NDC 00510509460
Hospital Charge Code	15636
Hospital Revenue Code	637
Min. Negotiated Rate	$68.10
Max. Negotiated Rate	$97.29
Rate for Payer: Aetna Commercial	$91.89
Rate for Payer: Aetna New Business (MI Preferred)	$70.27
Rate for Payer: Cash Price	$86.48
Rate for Payer: Cofinity Commercial	$75.67
Rate for Payer: Cofinity Commercial	$92.97
Rate for Payer: Cofinity Medicare Advantage	$75.67
Rate for Payer: Encore Health Key Benefits Commercial	$86.48
Rate for Payer: Healthscope Commercial	$97.29
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$91.89
Rate for Payer: PHP Commercial	$91.89
Rate for Payer: Priority Health Cigna Priority Health	$70.27
Rate for Payer: Priority Health SBD	$68.10

CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE

Facility

$159.80

Service Code	NDC 79854009098
Hospital Charge Code	15636
Hospital Revenue Code	637
Min. Negotiated Rate	$63.92
Max. Negotiated Rate	$143.82
Rate for Payer: Aetna Commercial	$135.83
Rate for Payer: Aetna Medicare	$79.90
Rate for Payer: Aetna New Business (MI Preferred)	$103.87
Rate for Payer: BCBS Complete	$63.92
Rate for Payer: Cash Price	$127.84
Rate for Payer: Cofinity Commercial	$111.86
Rate for Payer: Cofinity Commercial	$137.43
Rate for Payer: Cofinity Medicare Advantage	$111.86
Rate for Payer: Encore Health Key Benefits Commercial	$127.84
Rate for Payer: Healthscope Commercial	$143.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$135.83
Rate for Payer: PHP Commercial	$135.83
Rate for Payer: Priority Health Cigna Priority Health	$103.87
Rate for Payer: Priority Health SBD	$100.67

CHOLECALCIFEROL (VITAMIN D3) 125 MCG (5,000 UNIT) CAPSULE

Facility

$138.23

Service Code	NDC 50268086815
Hospital Charge Code	15636
Hospital Revenue Code	637
Min. Negotiated Rate	$55.29
Max. Negotiated Rate	$124.41
Rate for Payer: Aetna Commercial	$117.50
Rate for Payer: Aetna Medicare	$69.11
Rate for Payer: Aetna New Business (MI Preferred)	$89.85
Rate for Payer: BCBS Complete	$55.29
Rate for Payer: Cash Price	$110.58
Rate for Payer: Cofinity Commercial	$118.88
Rate for Payer: Cofinity Commercial	$96.76
Rate for Payer: Cofinity Medicare Advantage	$96.76
Rate for Payer: Encore Health Key Benefits Commercial	$110.58
Rate for Payer: Healthscope Commercial	$124.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$117.50
Rate for Payer: PHP Commercial	$117.50
Rate for Payer: Priority Health Cigna Priority Health	$89.85
Rate for Payer: Priority Health SBD	$87.08

Know your out-of-pocket cost for care.

All Charges