|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
OP
|
$89.46
|
|
|
Service Code
|
NDC 50268006815
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.10 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Aetna American Axle |
$58.15
|
| Rate for Payer: Aetna Commercial |
$76.04
|
| Rate for Payer: Aetna Medicare |
$44.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.15
|
| Rate for Payer: BCBS Complete |
$35.78
|
| Rate for Payer: Cash Price |
$71.57
|
| Rate for Payer: Cofinity Commercial |
$62.62
|
| Rate for Payer: Cofinity Commercial |
$76.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.57
|
| Rate for Payer: Healthscope Commercial |
$80.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.04
|
| Rate for Payer: PHP Commercial |
$76.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.15
|
| Rate for Payer: Priority Health SBD |
$56.36
|
| Rate for Payer: UMR Bronson Commercial |
$33.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.10
|
|
|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
IP
|
$89.46
|
|
|
Service Code
|
NDC 50268006815
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.36 |
| Max. Negotiated Rate |
$80.51 |
| Rate for Payer: Aetna American Axle |
$58.15
|
| Rate for Payer: Aetna Commercial |
$76.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$58.15
|
| Rate for Payer: Cash Price |
$71.57
|
| Rate for Payer: Cofinity Commercial |
$62.62
|
| Rate for Payer: Cofinity Commercial |
$76.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$62.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.57
|
| Rate for Payer: Healthscope Commercial |
$80.51
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$62.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$67.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.04
|
| Rate for Payer: PHP Commercial |
$76.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.15
|
| Rate for Payer: Priority Health SBD |
$56.36
|
| Rate for Payer: UMR Bronson Commercial |
$39.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$67.10
|
|
|
ARTIFICIAL TEARS EYE DROPS WRAPPER
|
Facility
|
OP
|
$55.98
|
|
|
Service Code
|
NDC 00536138635
|
| Hospital Charge Code |
301578
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.71 |
| Max. Negotiated Rate |
$50.38 |
| Rate for Payer: Aetna American Axle |
$36.39
|
| Rate for Payer: Aetna Commercial |
$47.58
|
| Rate for Payer: Aetna Medicare |
$27.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.39
|
| Rate for Payer: BCBS Complete |
$22.39
|
| Rate for Payer: Cash Price |
$44.78
|
| Rate for Payer: Cofinity Commercial |
$39.19
|
| Rate for Payer: Cofinity Commercial |
$48.14
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.78
|
| Rate for Payer: Healthscope Commercial |
$50.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.58
|
| Rate for Payer: PHP Commercial |
$47.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.39
|
| Rate for Payer: Priority Health SBD |
$35.27
|
| Rate for Payer: UMR Bronson Commercial |
$20.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.98
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL
|
Facility
|
IP
|
$43.51
|
|
|
Service Code
|
NDC 00065047401
|
| Hospital Charge Code |
21058
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.14 |
| Max. Negotiated Rate |
$39.16 |
| Rate for Payer: Aetna American Axle |
$28.28
|
| Rate for Payer: Aetna Commercial |
$36.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.28
|
| Rate for Payer: Cash Price |
$34.81
|
| Rate for Payer: Cofinity Commercial |
$30.46
|
| Rate for Payer: Cofinity Commercial |
$37.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.81
|
| Rate for Payer: Healthscope Commercial |
$39.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.98
|
| Rate for Payer: PHP Commercial |
$36.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.28
|
| Rate for Payer: Priority Health SBD |
$27.41
|
| Rate for Payer: UMR Bronson Commercial |
$19.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.63
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL
|
Facility
|
OP
|
$31.75
|
|
|
Service Code
|
NDC 00065806401
|
| Hospital Charge Code |
21058
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.75 |
| Max. Negotiated Rate |
$28.58 |
| Rate for Payer: Aetna American Axle |
$20.64
|
| Rate for Payer: Aetna Commercial |
$26.99
|
| Rate for Payer: Aetna Medicare |
$15.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.64
|
| Rate for Payer: BCBS Complete |
$12.70
|
| Rate for Payer: Cash Price |
$25.40
|
| Rate for Payer: Cofinity Commercial |
$22.22
|
| Rate for Payer: Cofinity Commercial |
$27.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.40
|
| Rate for Payer: Healthscope Commercial |
$28.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.99
|
| Rate for Payer: PHP Commercial |
$26.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.64
|
| Rate for Payer: Priority Health SBD |
$20.00
|
| Rate for Payer: UMR Bronson Commercial |
$11.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.81
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL
|
Facility
|
IP
|
$31.75
|
|
|
Service Code
|
NDC 00065806401
|
| Hospital Charge Code |
21058
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.97 |
| Max. Negotiated Rate |
$28.58 |
| Rate for Payer: Cofinity Commercial |
$22.22
|
| Rate for Payer: Cofinity Commercial |
$27.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.22
|
| Rate for Payer: Aetna American Axle |
$20.64
|
| Rate for Payer: Aetna Commercial |
$26.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.64
|
| Rate for Payer: Cash Price |
$25.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.40
|
| Rate for Payer: Healthscope Commercial |
$28.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.22
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$26.99
|
| Rate for Payer: PHP Commercial |
$26.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.64
|
| Rate for Payer: Priority Health SBD |
$20.00
|
| Rate for Payer: UMR Bronson Commercial |
$13.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.81
|
|
|
ARTIFICIAL TEARS (HYPROMELLOSE) 0.3 % EYE GEL
|
Facility
|
OP
|
$43.51
|
|
|
Service Code
|
NDC 00065047401
|
| Hospital Charge Code |
21058
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$39.16 |
| Rate for Payer: Aetna American Axle |
$28.28
|
| Rate for Payer: Aetna Commercial |
$36.98
|
| Rate for Payer: Aetna Medicare |
$21.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$28.28
|
| Rate for Payer: BCBS Complete |
$17.40
|
| Rate for Payer: Cash Price |
$34.81
|
| Rate for Payer: Cofinity Commercial |
$30.46
|
| Rate for Payer: Cofinity Commercial |
$37.42
|
| Rate for Payer: Cofinity Medicare Advantage |
$30.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$34.81
|
| Rate for Payer: Healthscope Commercial |
$39.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$30.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$32.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$36.98
|
| Rate for Payer: PHP Commercial |
$36.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.28
|
| Rate for Payer: Priority Health SBD |
$27.41
|
| Rate for Payer: UMR Bronson Commercial |
$16.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$32.63
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET
|
Facility
|
IP
|
$105.05
|
|
|
Service Code
|
NDC 50268086015
|
| Hospital Charge Code |
663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.22 |
| Max. Negotiated Rate |
$94.54 |
| Rate for Payer: Aetna American Axle |
$68.28
|
| Rate for Payer: Aetna Commercial |
$89.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.28
|
| Rate for Payer: Cash Price |
$84.04
|
| Rate for Payer: Cofinity Commercial |
$73.54
|
| Rate for Payer: Cofinity Commercial |
$90.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$73.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.04
|
| Rate for Payer: Healthscope Commercial |
$94.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$73.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$78.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.29
|
| Rate for Payer: PHP Commercial |
$89.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.28
|
| Rate for Payer: Priority Health SBD |
$66.18
|
| Rate for Payer: UMR Bronson Commercial |
$46.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.79
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET
|
Facility
|
OP
|
$2.11
|
|
|
Service Code
|
NDC 50268086011
|
| Hospital Charge Code |
663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna American Axle |
$1.37
|
| Rate for Payer: Aetna Commercial |
$1.79
|
| Rate for Payer: Aetna Medicare |
$1.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.37
|
| Rate for Payer: BCBS Complete |
$0.84
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Cofinity Commercial |
$1.48
|
| Rate for Payer: Cofinity Commercial |
$1.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.69
|
| Rate for Payer: Healthscope Commercial |
$1.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.79
|
| Rate for Payer: PHP Commercial |
$1.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.37
|
| Rate for Payer: Priority Health SBD |
$1.33
|
| Rate for Payer: UMR Bronson Commercial |
$0.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.58
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET
|
Facility
|
OP
|
$105.05
|
|
|
Service Code
|
NDC 50268086015
|
| Hospital Charge Code |
663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.87 |
| Max. Negotiated Rate |
$94.54 |
| Rate for Payer: Aetna American Axle |
$68.28
|
| Rate for Payer: Aetna Commercial |
$89.29
|
| Rate for Payer: Aetna Medicare |
$52.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.28
|
| Rate for Payer: BCBS Complete |
$42.02
|
| Rate for Payer: Cash Price |
$84.04
|
| Rate for Payer: Cofinity Commercial |
$73.54
|
| Rate for Payer: Cofinity Commercial |
$90.34
|
| Rate for Payer: Cofinity Medicare Advantage |
$73.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.04
|
| Rate for Payer: Healthscope Commercial |
$94.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$73.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$78.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.29
|
| Rate for Payer: PHP Commercial |
$89.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.28
|
| Rate for Payer: Priority Health SBD |
$66.18
|
| Rate for Payer: UMR Bronson Commercial |
$38.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.79
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET
|
Facility
|
IP
|
$132.30
|
|
|
Service Code
|
NDC 96295012843
|
| Hospital Charge Code |
663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.21 |
| Max. Negotiated Rate |
$119.07 |
| Rate for Payer: Aetna American Axle |
$86.00
|
| Rate for Payer: Aetna Commercial |
$112.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.00
|
| Rate for Payer: Cash Price |
$105.84
|
| Rate for Payer: Cofinity Commercial |
$113.78
|
| Rate for Payer: Cofinity Commercial |
$92.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.84
|
| Rate for Payer: Healthscope Commercial |
$119.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.46
|
| Rate for Payer: PHP Commercial |
$112.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.00
|
| Rate for Payer: Priority Health SBD |
$83.35
|
| Rate for Payer: UMR Bronson Commercial |
$58.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.22
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET
|
Facility
|
OP
|
$94.50
|
|
|
Service Code
|
NDC 20555000100
|
| Hospital Charge Code |
663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.96 |
| Max. Negotiated Rate |
$85.05 |
| Rate for Payer: Aetna American Axle |
$61.42
|
| Rate for Payer: Aetna Commercial |
$80.32
|
| Rate for Payer: Aetna Medicare |
$47.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.42
|
| Rate for Payer: BCBS Complete |
$37.80
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cofinity Commercial |
$66.15
|
| Rate for Payer: Cofinity Commercial |
$81.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.60
|
| Rate for Payer: Healthscope Commercial |
$85.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.32
|
| Rate for Payer: PHP Commercial |
$80.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.42
|
| Rate for Payer: Priority Health SBD |
$59.54
|
| Rate for Payer: UMR Bronson Commercial |
$34.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.88
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET
|
Facility
|
IP
|
$94.50
|
|
|
Service Code
|
NDC 20555000100
|
| Hospital Charge Code |
663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.58 |
| Max. Negotiated Rate |
$85.05 |
| Rate for Payer: Aetna American Axle |
$61.42
|
| Rate for Payer: Aetna Commercial |
$80.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.42
|
| Rate for Payer: Cash Price |
$75.60
|
| Rate for Payer: Cofinity Commercial |
$66.15
|
| Rate for Payer: Cofinity Commercial |
$81.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$66.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.60
|
| Rate for Payer: Healthscope Commercial |
$85.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$80.32
|
| Rate for Payer: PHP Commercial |
$80.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.42
|
| Rate for Payer: Priority Health SBD |
$59.54
|
| Rate for Payer: UMR Bronson Commercial |
$41.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.88
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET
|
Facility
|
OP
|
$132.30
|
|
|
Service Code
|
NDC 96295012843
|
| Hospital Charge Code |
663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.95 |
| Max. Negotiated Rate |
$119.07 |
| Rate for Payer: Aetna American Axle |
$86.00
|
| Rate for Payer: Aetna Commercial |
$112.46
|
| Rate for Payer: Aetna Medicare |
$66.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.00
|
| Rate for Payer: BCBS Complete |
$52.92
|
| Rate for Payer: Cash Price |
$105.84
|
| Rate for Payer: Cofinity Commercial |
$113.78
|
| Rate for Payer: Cofinity Commercial |
$92.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$105.84
|
| Rate for Payer: Healthscope Commercial |
$119.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.46
|
| Rate for Payer: PHP Commercial |
$112.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.00
|
| Rate for Payer: Priority Health SBD |
$83.35
|
| Rate for Payer: UMR Bronson Commercial |
$48.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.22
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET
|
Facility
|
OP
|
$138.60
|
|
|
Service Code
|
NDC 57896083101
|
| Hospital Charge Code |
663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.28 |
| Max. Negotiated Rate |
$124.74 |
| Rate for Payer: Aetna American Axle |
$90.09
|
| Rate for Payer: Aetna Commercial |
$117.81
|
| Rate for Payer: Aetna Medicare |
$69.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.09
|
| Rate for Payer: BCBS Complete |
$55.44
|
| Rate for Payer: Cash Price |
$110.88
|
| Rate for Payer: Cofinity Commercial |
$119.20
|
| Rate for Payer: Cofinity Commercial |
$97.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.88
|
| Rate for Payer: Healthscope Commercial |
$124.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.81
|
| Rate for Payer: PHP Commercial |
$117.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.09
|
| Rate for Payer: Priority Health SBD |
$87.32
|
| Rate for Payer: UMR Bronson Commercial |
$51.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.95
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET
|
Facility
|
IP
|
$138.60
|
|
|
Service Code
|
NDC 57896083101
|
| Hospital Charge Code |
663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.98 |
| Max. Negotiated Rate |
$124.74 |
| Rate for Payer: Aetna American Axle |
$90.09
|
| Rate for Payer: Aetna Commercial |
$117.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.09
|
| Rate for Payer: Cash Price |
$110.88
|
| Rate for Payer: Cofinity Commercial |
$119.20
|
| Rate for Payer: Cofinity Commercial |
$97.02
|
| Rate for Payer: Cofinity Medicare Advantage |
$97.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$110.88
|
| Rate for Payer: Healthscope Commercial |
$124.74
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$103.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$117.81
|
| Rate for Payer: PHP Commercial |
$117.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$90.09
|
| Rate for Payer: Priority Health SBD |
$87.32
|
| Rate for Payer: UMR Bronson Commercial |
$60.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$103.95
|
|
|
ASCORBIC ACID (VITAMIN C) 250 MG TABLET
|
Facility
|
IP
|
$2.11
|
|
|
Service Code
|
NDC 50268086011
|
| Hospital Charge Code |
663
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$1.90 |
| Rate for Payer: Aetna American Axle |
$1.37
|
| Rate for Payer: Aetna Commercial |
$1.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.37
|
| Rate for Payer: Cash Price |
$1.69
|
| Rate for Payer: Cofinity Commercial |
$1.48
|
| Rate for Payer: Cofinity Commercial |
$1.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$1.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.69
|
| Rate for Payer: Healthscope Commercial |
$1.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.79
|
| Rate for Payer: PHP Commercial |
$1.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.37
|
| Rate for Payer: Priority Health SBD |
$1.33
|
| Rate for Payer: UMR Bronson Commercial |
$0.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.58
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$292.17
|
|
|
Service Code
|
NDC 71414011501
|
| Hospital Charge Code |
654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$128.55 |
| Max. Negotiated Rate |
$262.95 |
| Rate for Payer: Aetna American Axle |
$189.91
|
| Rate for Payer: Aetna Commercial |
$248.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.91
|
| Rate for Payer: Cash Price |
$233.74
|
| Rate for Payer: Cofinity Commercial |
$204.52
|
| Rate for Payer: Cofinity Commercial |
$251.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$204.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.74
|
| Rate for Payer: Healthscope Commercial |
$262.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$219.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.34
|
| Rate for Payer: PHP Commercial |
$248.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.91
|
| Rate for Payer: Priority Health SBD |
$184.07
|
| Rate for Payer: UMR Bronson Commercial |
$128.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$219.13
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$292.17
|
|
|
Service Code
|
NDC 71414011501
|
| Hospital Charge Code |
654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$108.10 |
| Max. Negotiated Rate |
$262.95 |
| Rate for Payer: Aetna American Axle |
$189.91
|
| Rate for Payer: Aetna Commercial |
$248.34
|
| Rate for Payer: Aetna Medicare |
$146.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.91
|
| Rate for Payer: BCBS Complete |
$116.87
|
| Rate for Payer: Cash Price |
$233.74
|
| Rate for Payer: Cofinity Commercial |
$204.52
|
| Rate for Payer: Cofinity Commercial |
$251.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$204.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.74
|
| Rate for Payer: Healthscope Commercial |
$262.95
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$204.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$219.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$248.34
|
| Rate for Payer: PHP Commercial |
$248.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.91
|
| Rate for Payer: Priority Health SBD |
$184.07
|
| Rate for Payer: UMR Bronson Commercial |
$108.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$219.13
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$291.28
|
|
|
Service Code
|
NDC 67457011850
|
| Hospital Charge Code |
654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$128.16 |
| Max. Negotiated Rate |
$262.15 |
| Rate for Payer: Aetna American Axle |
$189.33
|
| Rate for Payer: Aetna Commercial |
$247.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.33
|
| Rate for Payer: Cash Price |
$233.02
|
| Rate for Payer: Cofinity Commercial |
$203.90
|
| Rate for Payer: Cofinity Commercial |
$250.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.02
|
| Rate for Payer: Healthscope Commercial |
$262.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.59
|
| Rate for Payer: PHP Commercial |
$247.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.33
|
| Rate for Payer: Priority Health SBD |
$183.51
|
| Rate for Payer: UMR Bronson Commercial |
$128.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.46
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INJECTION SOLUTION
|
Facility
|
OP
|
$291.28
|
|
|
Service Code
|
NDC 67457011850
|
| Hospital Charge Code |
654
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$107.77 |
| Max. Negotiated Rate |
$262.15 |
| Rate for Payer: Aetna American Axle |
$189.33
|
| Rate for Payer: Aetna Commercial |
$247.59
|
| Rate for Payer: Aetna Medicare |
$145.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$189.33
|
| Rate for Payer: BCBS Complete |
$116.51
|
| Rate for Payer: Cash Price |
$233.02
|
| Rate for Payer: Cofinity Commercial |
$203.90
|
| Rate for Payer: Cofinity Commercial |
$250.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$203.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$233.02
|
| Rate for Payer: Healthscope Commercial |
$262.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$203.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$218.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.59
|
| Rate for Payer: PHP Commercial |
$247.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$189.33
|
| Rate for Payer: Priority Health SBD |
$183.51
|
| Rate for Payer: UMR Bronson Commercial |
$107.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$218.46
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,119.85
|
|
|
Service Code
|
NDC 67157010151
|
| Hospital Charge Code |
186102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$414.34 |
| Max. Negotiated Rate |
$1,007.86 |
| Rate for Payer: Aetna American Axle |
$727.90
|
| Rate for Payer: Aetna Commercial |
$951.87
|
| Rate for Payer: Aetna Medicare |
$559.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$727.90
|
| Rate for Payer: BCBS Complete |
$447.94
|
| Rate for Payer: Cash Price |
$895.88
|
| Rate for Payer: Cofinity Commercial |
$783.90
|
| Rate for Payer: Cofinity Commercial |
$963.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$783.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$895.88
|
| Rate for Payer: Healthscope Commercial |
$1,007.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$783.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$839.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$951.87
|
| Rate for Payer: PHP Commercial |
$951.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$727.90
|
| Rate for Payer: Priority Health SBD |
$705.51
|
| Rate for Payer: UMR Bronson Commercial |
$414.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$839.89
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG/ML INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$1,119.85
|
|
|
Service Code
|
NDC 67157010150
|
| Hospital Charge Code |
186102
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$414.34 |
| Max. Negotiated Rate |
$1,007.86 |
| Rate for Payer: Aetna American Axle |
$727.90
|
| Rate for Payer: Aetna Commercial |
$951.87
|
| Rate for Payer: Aetna Medicare |
$559.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$727.90
|
| Rate for Payer: BCBS Complete |
$447.94
|
| Rate for Payer: Cash Price |
$895.88
|
| Rate for Payer: Cofinity Commercial |
$783.90
|
| Rate for Payer: Cofinity Commercial |
$963.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$783.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$895.88
|
| Rate for Payer: Healthscope Commercial |
$1,007.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$783.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$839.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$951.87
|
| Rate for Payer: PHP Commercial |
$951.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$727.90
|
| Rate for Payer: Priority Health SBD |
$705.51
|
| Rate for Payer: UMR Bronson Commercial |
$414.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$839.89
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
OP
|
$70.50
|
|
|
Service Code
|
NDC 00904052361
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.08 |
| Max. Negotiated Rate |
$63.45 |
| Rate for Payer: Aetna American Axle |
$45.82
|
| Rate for Payer: Aetna Commercial |
$59.92
|
| Rate for Payer: Aetna Medicare |
$35.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.82
|
| Rate for Payer: BCBS Complete |
$28.20
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$49.35
|
| Rate for Payer: Cofinity Commercial |
$60.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$63.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.92
|
| Rate for Payer: PHP Commercial |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.82
|
| Rate for Payer: Priority Health SBD |
$44.42
|
| Rate for Payer: UMR Bronson Commercial |
$26.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.88
|
|
|
ASCORBIC ACID (VITAMIN C) 500 MG TABLET
|
Facility
|
IP
|
$72.85
|
|
|
Service Code
|
NDC 00904052360
|
| Hospital Charge Code |
664
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.05 |
| Max. Negotiated Rate |
$65.56 |
| Rate for Payer: Aetna American Axle |
$47.35
|
| Rate for Payer: Aetna Commercial |
$61.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$47.35
|
| Rate for Payer: Cash Price |
$58.28
|
| Rate for Payer: Cofinity Commercial |
$51.00
|
| Rate for Payer: Cofinity Commercial |
$62.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$51.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$58.28
|
| Rate for Payer: Healthscope Commercial |
$65.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$51.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$54.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$61.92
|
| Rate for Payer: PHP Commercial |
$61.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.35
|
| Rate for Payer: Priority Health SBD |
$45.90
|
| Rate for Payer: UMR Bronson Commercial |
$32.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$54.64
|
|
