|
VITAMIN A 2,400 MCG CAPSULE
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
NDC 54629011001
|
| Hospital Charge Code |
8641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.89
|
| Rate for Payer: Aetna Medicare |
$49.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: BCBS Complete |
$39.48
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Advantage |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$78.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$74.03
|
| Rate for Payer: PHP Commercial |
$83.89
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$64.16
|
| Rate for Payer: UHC Core |
$51.42
|
| Rate for Payer: UHC Exchange |
$38.79
|
| Rate for Payer: UMR Bronson Commercial |
$36.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.03
|
|
|
VITAMIN A 2,400 MCG CAPSULE
|
Facility
|
IP
|
$98.70
|
|
|
Service Code
|
NDC 54629011001
|
| Hospital Charge Code |
8641
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.43 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Advantage |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$74.03
|
| Rate for Payer: PHP Commercial |
$83.89
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UMR Bronson Commercial |
$43.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.03
|
|
|
VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE
|
Facility
|
IP
|
$152.00
|
|
|
Service Code
|
NDC 00904208560
|
| Hospital Charge Code |
8639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.88 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Aetna American Axle |
$98.80
|
| Rate for Payer: Aetna Commercial |
$129.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.80
|
| Rate for Payer: Cash Price |
$121.60
|
| Rate for Payer: Cofinity Advantage |
$106.40
|
| Rate for Payer: Cofinity Commercial |
$130.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.60
|
| Rate for Payer: Healthscope Commercial |
$136.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$106.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$129.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$114.00
|
| Rate for Payer: PHP Commercial |
$129.20
|
| Rate for Payer: Priority Health SBD |
$95.76
|
| Rate for Payer: UMR Bronson Commercial |
$66.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.00
|
|
|
VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
NDC 07610043310
|
| Hospital Charge Code |
8639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.16 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna American Axle |
$106.60
|
| Rate for Payer: Aetna Commercial |
$139.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.60
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cofinity Advantage |
$114.80
|
| Rate for Payer: Cofinity Commercial |
$141.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.20
|
| Rate for Payer: Healthscope Commercial |
$147.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$114.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$123.00
|
| Rate for Payer: PHP Commercial |
$139.40
|
| Rate for Payer: Priority Health SBD |
$103.32
|
| Rate for Payer: UMR Bronson Commercial |
$72.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.00
|
|
|
VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
NDC 07610043310
|
| Hospital Charge Code |
8639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.68 |
| Max. Negotiated Rate |
$147.60 |
| Rate for Payer: Aetna American Axle |
$106.60
|
| Rate for Payer: Aetna Commercial |
$139.40
|
| Rate for Payer: Aetna Medicare |
$82.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$106.60
|
| Rate for Payer: BCBS Complete |
$65.60
|
| Rate for Payer: Cash Price |
$131.20
|
| Rate for Payer: Cofinity Advantage |
$114.80
|
| Rate for Payer: Cofinity Commercial |
$141.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.20
|
| Rate for Payer: Healthscope Commercial |
$147.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$114.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$131.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$139.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$123.00
|
| Rate for Payer: PHP Commercial |
$139.40
|
| Rate for Payer: Priority Health SBD |
$103.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$106.60
|
| Rate for Payer: UHC Core |
$85.44
|
| Rate for Payer: UHC Exchange |
$64.45
|
| Rate for Payer: UMR Bronson Commercial |
$60.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.00
|
|
|
VITAMIN A 3,000 MCG (10,000 UNIT) CAPSULE
|
Facility
|
OP
|
$152.00
|
|
|
Service Code
|
NDC 00904208560
|
| Hospital Charge Code |
8639
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.24 |
| Max. Negotiated Rate |
$136.80 |
| Rate for Payer: Aetna American Axle |
$98.80
|
| Rate for Payer: Aetna Commercial |
$129.20
|
| Rate for Payer: Aetna Medicare |
$76.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$98.80
|
| Rate for Payer: BCBS Complete |
$60.80
|
| Rate for Payer: Cash Price |
$121.60
|
| Rate for Payer: Cofinity Advantage |
$106.40
|
| Rate for Payer: Cofinity Commercial |
$130.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$121.60
|
| Rate for Payer: Healthscope Commercial |
$136.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$106.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$114.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$121.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$129.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$114.00
|
| Rate for Payer: PHP Commercial |
$129.20
|
| Rate for Payer: Priority Health SBD |
$95.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.80
|
| Rate for Payer: UHC Core |
$79.19
|
| Rate for Payer: UHC Exchange |
$59.74
|
| Rate for Payer: UMR Bronson Commercial |
$56.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$114.00
|
|
|
VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET
|
Facility
|
IP
|
$119.85
|
|
|
Service Code
|
NDC 60258016001
|
| Hospital Charge Code |
29833
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.73 |
| Max. Negotiated Rate |
$107.86 |
| Rate for Payer: Aetna American Axle |
$77.90
|
| Rate for Payer: Aetna Commercial |
$101.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.90
|
| Rate for Payer: Cash Price |
$95.88
|
| Rate for Payer: Cofinity Advantage |
$83.89
|
| Rate for Payer: Cofinity Commercial |
$103.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.88
|
| Rate for Payer: Healthscope Commercial |
$107.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.89
|
| Rate for Payer: PHP Commercial |
$101.87
|
| Rate for Payer: Priority Health SBD |
$75.51
|
| Rate for Payer: UMR Bronson Commercial |
$52.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.89
|
|
|
VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET
|
Facility
|
OP
|
$108.10
|
|
|
Service Code
|
NDC 00536141501
|
| Hospital Charge Code |
29833
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.00 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna American Axle |
$70.27
|
| 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 Advantage |
$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: MI Amish Medical Board Commercial |
$86.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$81.08
|
| Rate for Payer: PHP Commercial |
$91.89
|
| Rate for Payer: Priority Health SBD |
$68.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$70.27
|
| Rate for Payer: UHC Core |
$56.32
|
| Rate for Payer: UHC Exchange |
$42.48
|
| Rate for Payer: UMR Bronson Commercial |
$40.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.08
|
|
|
VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET
|
Facility
|
IP
|
$103.40
|
|
|
Service Code
|
NDC 00536730001
|
| Hospital Charge Code |
29833
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.50 |
| Max. Negotiated Rate |
$93.06 |
| Rate for Payer: Aetna American Axle |
$67.21
|
| Rate for Payer: Aetna Commercial |
$87.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.21
|
| Rate for Payer: Cash Price |
$82.72
|
| Rate for Payer: Cofinity Advantage |
$72.38
|
| Rate for Payer: Cofinity Commercial |
$88.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.72
|
| Rate for Payer: Healthscope Commercial |
$93.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.55
|
| Rate for Payer: PHP Commercial |
$87.89
|
| Rate for Payer: Priority Health SBD |
$65.14
|
| Rate for Payer: UMR Bronson Commercial |
$45.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.55
|
|
|
VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET
|
Facility
|
OP
|
$103.40
|
|
|
Service Code
|
NDC 00536730001
|
| Hospital Charge Code |
29833
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.26 |
| Max. Negotiated Rate |
$93.06 |
| Rate for Payer: Aetna American Axle |
$67.21
|
| Rate for Payer: Aetna Commercial |
$87.89
|
| Rate for Payer: Aetna Medicare |
$51.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.21
|
| Rate for Payer: BCBS Complete |
$41.36
|
| Rate for Payer: Cash Price |
$82.72
|
| Rate for Payer: Cofinity Advantage |
$72.38
|
| Rate for Payer: Cofinity Commercial |
$88.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.72
|
| Rate for Payer: Healthscope Commercial |
$93.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$82.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$87.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.55
|
| Rate for Payer: PHP Commercial |
$87.89
|
| Rate for Payer: Priority Health SBD |
$65.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.21
|
| Rate for Payer: UHC Core |
$53.87
|
| Rate for Payer: UHC Exchange |
$40.64
|
| Rate for Payer: UMR Bronson Commercial |
$38.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.55
|
|
|
VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET
|
Facility
|
OP
|
$119.85
|
|
|
Service Code
|
NDC 60258016001
|
| Hospital Charge Code |
29833
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$107.86 |
| Rate for Payer: Aetna American Axle |
$77.90
|
| Rate for Payer: Aetna Commercial |
$101.87
|
| Rate for Payer: Aetna Medicare |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.90
|
| Rate for Payer: BCBS Complete |
$47.94
|
| Rate for Payer: Cash Price |
$95.88
|
| Rate for Payer: Cofinity Advantage |
$83.89
|
| Rate for Payer: Cofinity Commercial |
$103.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.88
|
| Rate for Payer: Healthscope Commercial |
$107.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$95.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$89.89
|
| Rate for Payer: PHP Commercial |
$101.87
|
| Rate for Payer: Priority Health SBD |
$75.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.90
|
| Rate for Payer: UHC Core |
$62.44
|
| Rate for Payer: UHC Exchange |
$47.10
|
| Rate for Payer: UMR Bronson Commercial |
$44.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.89
|
|
|
VITAMIN B COMPLEX-VITAMIN C-FOLIC ACID 0.8 MG TABLET
|
Facility
|
IP
|
$108.10
|
|
|
Service Code
|
NDC 00536141501
|
| Hospital Charge Code |
29833
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.56 |
| Max. Negotiated Rate |
$97.29 |
| Rate for Payer: Aetna American Axle |
$70.27
|
| 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 Advantage |
$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 Commercial |
$91.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$81.08
|
| Rate for Payer: PHP Commercial |
$91.89
|
| 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
|
|
|
VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE
|
Facility
|
OP
|
$203.50
|
|
|
Service Code
|
NDC 77333095110
|
| Hospital Charge Code |
118622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.30 |
| Max. Negotiated Rate |
$183.15 |
| Rate for Payer: Aetna American Axle |
$132.28
|
| Rate for Payer: Aetna Commercial |
$172.97
|
| Rate for Payer: Aetna Medicare |
$101.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.28
|
| Rate for Payer: BCBS Complete |
$81.40
|
| Rate for Payer: Cash Price |
$162.80
|
| Rate for Payer: Cofinity Advantage |
$142.45
|
| Rate for Payer: Cofinity Commercial |
$175.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$162.80
|
| Rate for Payer: Healthscope Commercial |
$183.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$152.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$162.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$172.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$152.62
|
| Rate for Payer: PHP Commercial |
$172.97
|
| Rate for Payer: Priority Health SBD |
$128.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$132.28
|
| Rate for Payer: UHC Core |
$106.02
|
| Rate for Payer: UHC Exchange |
$79.98
|
| Rate for Payer: UMR Bronson Commercial |
$75.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$152.62
|
|
|
VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE
|
Facility
|
IP
|
$176.00
|
|
|
Service Code
|
NDC 09629513796
|
| Hospital Charge Code |
118622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.44 |
| Max. Negotiated Rate |
$158.40 |
| Rate for Payer: Aetna American Axle |
$114.40
|
| Rate for Payer: Aetna Commercial |
$149.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.40
|
| Rate for Payer: Cash Price |
$140.80
|
| Rate for Payer: Cofinity Advantage |
$123.20
|
| Rate for Payer: Cofinity Commercial |
$151.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.80
|
| Rate for Payer: Healthscope Commercial |
$158.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$132.00
|
| Rate for Payer: PHP Commercial |
$149.60
|
| Rate for Payer: Priority Health SBD |
$110.88
|
| Rate for Payer: UMR Bronson Commercial |
$77.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.00
|
|
|
VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE
|
Facility
|
IP
|
$203.50
|
|
|
Service Code
|
NDC 77333095110
|
| Hospital Charge Code |
118622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.54 |
| Max. Negotiated Rate |
$183.15 |
| Rate for Payer: Aetna American Axle |
$132.28
|
| Rate for Payer: Aetna Commercial |
$172.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.28
|
| Rate for Payer: Cash Price |
$162.80
|
| Rate for Payer: Cofinity Advantage |
$142.45
|
| Rate for Payer: Cofinity Commercial |
$175.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$162.80
|
| Rate for Payer: Healthscope Commercial |
$183.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$152.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$172.97
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$152.62
|
| Rate for Payer: PHP Commercial |
$172.97
|
| Rate for Payer: Priority Health SBD |
$128.21
|
| Rate for Payer: UMR Bronson Commercial |
$89.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$152.62
|
|
|
VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE
|
Facility
|
OP
|
$176.00
|
|
|
Service Code
|
NDC 09629513796
|
| Hospital Charge Code |
118622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.12 |
| Max. Negotiated Rate |
$158.40 |
| Rate for Payer: Aetna American Axle |
$114.40
|
| Rate for Payer: Aetna Commercial |
$149.60
|
| Rate for Payer: Aetna Medicare |
$88.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$114.40
|
| Rate for Payer: BCBS Complete |
$70.40
|
| Rate for Payer: Cash Price |
$140.80
|
| Rate for Payer: Cofinity Advantage |
$123.20
|
| Rate for Payer: Cofinity Commercial |
$151.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$140.80
|
| Rate for Payer: Healthscope Commercial |
$158.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$123.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$132.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$140.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$149.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$132.00
|
| Rate for Payer: PHP Commercial |
$149.60
|
| Rate for Payer: Priority Health SBD |
$110.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$114.40
|
| Rate for Payer: UHC Core |
$91.70
|
| Rate for Payer: UHC Exchange |
$69.17
|
| Rate for Payer: UMR Bronson Commercial |
$65.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$132.00
|
|
|
VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE
|
Facility
|
IP
|
$2.04
|
|
|
Service Code
|
NDC 77333095125
|
| Hospital Charge Code |
118622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna American Axle |
$1.33
|
| Rate for Payer: Aetna Commercial |
$1.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.33
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Cofinity Advantage |
$1.43
|
| Rate for Payer: Cofinity Commercial |
$1.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.63
|
| Rate for Payer: Healthscope Commercial |
$1.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.53
|
| Rate for Payer: PHP Commercial |
$1.73
|
| Rate for Payer: Priority Health SBD |
$1.29
|
| Rate for Payer: UMR Bronson Commercial |
$0.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.53
|
|
|
VITAMIN E (DL, ACETATE) 180 MG (400 UNIT) CAPSULE
|
Facility
|
OP
|
$2.04
|
|
|
Service Code
|
NDC 77333095125
|
| Hospital Charge Code |
118622
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna American Axle |
$1.33
|
| Rate for Payer: Aetna Commercial |
$1.73
|
| Rate for Payer: Aetna Medicare |
$1.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.33
|
| Rate for Payer: BCBS Complete |
$0.82
|
| Rate for Payer: Cash Price |
$1.63
|
| Rate for Payer: Cofinity Advantage |
$1.43
|
| Rate for Payer: Cofinity Commercial |
$1.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.63
|
| Rate for Payer: Healthscope Commercial |
$1.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.73
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1.53
|
| Rate for Payer: PHP Commercial |
$1.73
|
| Rate for Payer: Priority Health SBD |
$1.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.33
|
| Rate for Payer: UHC Core |
$1.06
|
| Rate for Payer: UHC Exchange |
$0.80
|
| Rate for Payer: UMR Bronson Commercial |
$0.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.53
|
|
|
VITAMIN E (DL, ACETATE) 22.5 MG (50 UNIT)/ML ORAL DROPS
|
Facility
|
IP
|
$103.68
|
|
|
Service Code
|
NDC 71321080230
|
| Hospital Charge Code |
116319
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.62 |
| Max. Negotiated Rate |
$93.31 |
| Rate for Payer: Aetna American Axle |
$67.39
|
| Rate for Payer: Aetna Commercial |
$88.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.39
|
| Rate for Payer: Cash Price |
$82.94
|
| Rate for Payer: Cofinity Advantage |
$72.58
|
| Rate for Payer: Cofinity Commercial |
$89.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.94
|
| Rate for Payer: Healthscope Commercial |
$93.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.76
|
| Rate for Payer: PHP Commercial |
$88.13
|
| Rate for Payer: Priority Health SBD |
$65.32
|
| Rate for Payer: UMR Bronson Commercial |
$45.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.76
|
|
|
VITAMIN E (DL, ACETATE) 22.5 MG (50 UNIT)/ML ORAL DROPS
|
Facility
|
OP
|
$103.68
|
|
|
Service Code
|
NDC 71321080230
|
| Hospital Charge Code |
116319
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.36 |
| Max. Negotiated Rate |
$93.31 |
| Rate for Payer: Aetna American Axle |
$67.39
|
| Rate for Payer: Aetna Commercial |
$88.13
|
| Rate for Payer: Aetna Medicare |
$51.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.39
|
| Rate for Payer: BCBS Complete |
$41.47
|
| Rate for Payer: Cash Price |
$82.94
|
| Rate for Payer: Cofinity Advantage |
$72.58
|
| Rate for Payer: Cofinity Commercial |
$89.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$82.94
|
| Rate for Payer: Healthscope Commercial |
$93.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$82.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.76
|
| Rate for Payer: PHP Commercial |
$88.13
|
| Rate for Payer: Priority Health SBD |
$65.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.39
|
| Rate for Payer: UHC Core |
$54.02
|
| Rate for Payer: UHC Exchange |
$40.75
|
| Rate for Payer: UMR Bronson Commercial |
$38.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.76
|
|
|
VITAMIN E (DL, ACETATE) 450 MG (1,000 UNIT) CAPSULE
|
Facility
|
IP
|
$80.37
|
|
|
Service Code
|
NDC 00904027746
|
| Hospital Charge Code |
152874
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.36 |
| Max. Negotiated Rate |
$72.33 |
| Rate for Payer: Aetna American Axle |
$52.24
|
| Rate for Payer: Aetna Commercial |
$68.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.24
|
| Rate for Payer: Cash Price |
$64.30
|
| Rate for Payer: Cofinity Advantage |
$56.26
|
| Rate for Payer: Cofinity Commercial |
$69.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.30
|
| Rate for Payer: Healthscope Commercial |
$72.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$60.28
|
| Rate for Payer: PHP Commercial |
$68.31
|
| Rate for Payer: Priority Health SBD |
$50.63
|
| Rate for Payer: UMR Bronson Commercial |
$35.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.28
|
|
|
VITAMIN E (DL, ACETATE) 450 MG (1,000 UNIT) CAPSULE
|
Facility
|
OP
|
$80.37
|
|
|
Service Code
|
NDC 00904027746
|
| Hospital Charge Code |
152874
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.74 |
| Max. Negotiated Rate |
$72.33 |
| Rate for Payer: Aetna American Axle |
$52.24
|
| Rate for Payer: Aetna Commercial |
$68.31
|
| Rate for Payer: Aetna Medicare |
$40.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.24
|
| Rate for Payer: BCBS Complete |
$32.15
|
| Rate for Payer: Cash Price |
$64.30
|
| Rate for Payer: Cofinity Advantage |
$56.26
|
| Rate for Payer: Cofinity Commercial |
$69.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.30
|
| Rate for Payer: Healthscope Commercial |
$72.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$60.28
|
| Rate for Payer: MI Amish Medical Board Commercial |
$64.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$68.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$60.28
|
| Rate for Payer: PHP Commercial |
$68.31
|
| Rate for Payer: Priority Health SBD |
$50.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$52.24
|
| Rate for Payer: UHC Core |
$41.87
|
| Rate for Payer: UHC Exchange |
$31.59
|
| Rate for Payer: UMR Bronson Commercial |
$29.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$60.28
|
|
|
VITAMIN E (DL, ACETATE) 45 MG (100 UNIT) CAPSULE
|
Facility
|
IP
|
$39.95
|
|
|
Service Code
|
NDC 80681013400
|
| Hospital Charge Code |
115972
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.58 |
| Max. Negotiated Rate |
$35.95 |
| Rate for Payer: Aetna American Axle |
$25.97
|
| 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 Advantage |
$27.96
|
| Rate for Payer: Cofinity Commercial |
$34.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.96
|
| Rate for Payer: Healthscope Commercial |
$35.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.96
|
| Rate for Payer: PHP Commercial |
$33.96
|
| Rate for Payer: Priority Health SBD |
$25.17
|
| Rate for Payer: UMR Bronson Commercial |
$17.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.96
|
|
|
VITAMIN E (DL, ACETATE) 45 MG (100 UNIT) CAPSULE
|
Facility
|
OP
|
$39.95
|
|
|
Service Code
|
NDC 80681013400
|
| Hospital Charge Code |
115972
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$35.95 |
| Rate for Payer: Aetna American Axle |
$25.97
|
| 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 Advantage |
$27.96
|
| Rate for Payer: Cofinity Commercial |
$34.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.96
|
| Rate for Payer: Healthscope Commercial |
$35.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.96
|
| Rate for Payer: PHP Commercial |
$33.96
|
| Rate for Payer: Priority Health SBD |
$25.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.97
|
| Rate for Payer: UHC Core |
$20.81
|
| Rate for Payer: UHC Exchange |
$15.70
|
| Rate for Payer: UMR Bronson Commercial |
$14.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.96
|
|
|
VITAMINS A AND D-WHITE PETROLATUM-LANOLIN TOPICAL OINTMENT
|
Facility
|
OP
|
$16.79
|
|
|
Service Code
|
NDC 65197040101
|
| Hospital Charge Code |
118725
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.21 |
| Max. Negotiated Rate |
$15.11 |
| Rate for Payer: Aetna American Axle |
$10.91
|
| Rate for Payer: Aetna Commercial |
$14.27
|
| Rate for Payer: Aetna Medicare |
$8.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.91
|
| Rate for Payer: BCBS Complete |
$6.72
|
| Rate for Payer: Cash Price |
$13.43
|
| Rate for Payer: Cofinity Advantage |
$11.75
|
| Rate for Payer: Cofinity Commercial |
$14.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.43
|
| Rate for Payer: Healthscope Commercial |
$15.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.59
|
| Rate for Payer: PHP Commercial |
$14.27
|
| Rate for Payer: Priority Health SBD |
$10.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.91
|
| Rate for Payer: UHC Core |
$8.75
|
| Rate for Payer: UHC Exchange |
$6.60
|
| Rate for Payer: UMR Bronson Commercial |
$6.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.59
|
|
