Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

AMLODIPINE 10 MG TABLET

Facility

$338.40

Service Code	NDC 60687049601
Hospital Charge Code	9069
Hospital Revenue Code	637
Min. Negotiated Rate	$213.19
Max. Negotiated Rate	$304.56
Rate for Payer: Aetna Commercial	$287.64
Rate for Payer: Aetna New Business (MI Preferred)	$219.96
Rate for Payer: Cash Price	$270.72
Rate for Payer: Cofinity Commercial	$236.88
Rate for Payer: Cofinity Commercial	$291.02
Rate for Payer: Cofinity Medicare Advantage	$236.88
Rate for Payer: Encore Health Key Benefits Commercial	$270.72
Rate for Payer: Healthscope Commercial	$304.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$287.64
Rate for Payer: PHP Commercial	$287.64
Rate for Payer: Priority Health Cigna Priority Health	$219.96
Rate for Payer: Priority Health SBD	$213.19

AMLODIPINE 10 MG TABLET

Facility

$159.80

Service Code	NDC 00904637161
Hospital Charge Code	9069
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

AMLODIPINE 10 MG TABLET

Facility

$338.40

Service Code	NDC 60687049601
Hospital Charge Code	9069
Hospital Revenue Code	637
Min. Negotiated Rate	$135.36
Max. Negotiated Rate	$304.56
Rate for Payer: Aetna Commercial	$287.64
Rate for Payer: Aetna Medicare	$169.20
Rate for Payer: Aetna New Business (MI Preferred)	$219.96
Rate for Payer: BCBS Complete	$135.36
Rate for Payer: Cash Price	$270.72
Rate for Payer: Cofinity Commercial	$236.88
Rate for Payer: Cofinity Commercial	$291.02
Rate for Payer: Cofinity Medicare Advantage	$236.88
Rate for Payer: Encore Health Key Benefits Commercial	$270.72
Rate for Payer: Healthscope Commercial	$304.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$287.64
Rate for Payer: PHP Commercial	$287.64
Rate for Payer: Priority Health Cigna Priority Health	$219.96
Rate for Payer: Priority Health SBD	$213.19

AMLODIPINE 10 MG TABLET

Facility

$3.39

Service Code	NDC 60687049611
Hospital Charge Code	9069
Hospital Revenue Code	637
Min. Negotiated Rate	$1.36
Max. Negotiated Rate	$3.05
Rate for Payer: Aetna Commercial	$2.88
Rate for Payer: Aetna Medicare	$1.70
Rate for Payer: Aetna New Business (MI Preferred)	$2.20
Rate for Payer: BCBS Complete	$1.36
Rate for Payer: Cash Price	$2.71
Rate for Payer: Cofinity Commercial	$2.37
Rate for Payer: Cofinity Commercial	$2.92
Rate for Payer: Cofinity Medicare Advantage	$2.37
Rate for Payer: Encore Health Key Benefits Commercial	$2.71
Rate for Payer: Healthscope Commercial	$3.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.88
Rate for Payer: PHP Commercial	$2.88
Rate for Payer: Priority Health Cigna Priority Health	$2.20
Rate for Payer: Priority Health SBD	$2.14

AMLODIPINE 10 MG TABLET

Facility

$159.80

Service Code	NDC 00904637161
Hospital Charge Code	9069
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

AMLODIPINE 10 MG TABLET

Facility

$38.07

Service Code	NDC 69097012805
Hospital Charge Code	9069
Hospital Revenue Code	637
Min. Negotiated Rate	$23.98
Max. Negotiated Rate	$34.26
Rate for Payer: Aetna Commercial	$32.36
Rate for Payer: Aetna New Business (MI Preferred)	$24.75
Rate for Payer: Cash Price	$30.46
Rate for Payer: Cofinity Commercial	$26.65
Rate for Payer: Cofinity Commercial	$32.74
Rate for Payer: Cofinity Medicare Advantage	$26.65
Rate for Payer: Encore Health Key Benefits Commercial	$30.46
Rate for Payer: Healthscope Commercial	$34.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$32.36
Rate for Payer: PHP Commercial	$32.36
Rate for Payer: Priority Health Cigna Priority Health	$24.75
Rate for Payer: Priority Health SBD	$23.98

AMLODIPINE 2.5 MG TABLET

Facility

$197.40

Service Code	NDC 00904636961
Hospital Charge Code	9070
Hospital Revenue Code	637
Min. Negotiated Rate	$78.96
Max. Negotiated Rate	$177.66
Rate for Payer: Aetna Commercial	$167.79
Rate for Payer: Aetna Medicare	$98.70
Rate for Payer: Aetna New Business (MI Preferred)	$128.31
Rate for Payer: BCBS Complete	$78.96
Rate for Payer: Cash Price	$157.92
Rate for Payer: Cofinity Commercial	$138.18
Rate for Payer: Cofinity Commercial	$169.76
Rate for Payer: Cofinity Medicare Advantage	$138.18
Rate for Payer: Encore Health Key Benefits Commercial	$157.92
Rate for Payer: Healthscope Commercial	$177.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$167.79
Rate for Payer: PHP Commercial	$167.79
Rate for Payer: Priority Health Cigna Priority Health	$128.31
Rate for Payer: Priority Health SBD	$124.36

AMLODIPINE 2.5 MG TABLET

Facility

$197.40

Service Code	NDC 00904636961
Hospital Charge Code	9070
Hospital Revenue Code	637
Min. Negotiated Rate	$124.36
Max. Negotiated Rate	$177.66
Rate for Payer: Aetna Commercial	$167.79
Rate for Payer: Aetna New Business (MI Preferred)	$128.31
Rate for Payer: Cash Price	$157.92
Rate for Payer: Cofinity Commercial	$138.18
Rate for Payer: Cofinity Commercial	$169.76
Rate for Payer: Cofinity Medicare Advantage	$138.18
Rate for Payer: Encore Health Key Benefits Commercial	$157.92
Rate for Payer: Healthscope Commercial	$177.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$167.79
Rate for Payer: PHP Commercial	$167.79
Rate for Payer: Priority Health Cigna Priority Health	$128.31
Rate for Payer: Priority Health SBD	$124.36

AMLODIPINE 5 MG TABLET

Facility

$173.90

Service Code	NDC 00904637061
Hospital Charge Code	9071
Hospital Revenue Code	637
Min. Negotiated Rate	$109.56
Max. Negotiated Rate	$156.51
Rate for Payer: Aetna Commercial	$147.82
Rate for Payer: Aetna New Business (MI Preferred)	$113.04
Rate for Payer: Cash Price	$139.12
Rate for Payer: Cofinity Commercial	$121.73
Rate for Payer: Cofinity Commercial	$149.55
Rate for Payer: Cofinity Medicare Advantage	$121.73
Rate for Payer: Encore Health Key Benefits Commercial	$139.12
Rate for Payer: Healthscope Commercial	$156.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$147.82
Rate for Payer: PHP Commercial	$147.82
Rate for Payer: Priority Health Cigna Priority Health	$113.04
Rate for Payer: Priority Health SBD	$109.56

AMLODIPINE 5 MG TABLET

Facility

$1.84

Service Code	NDC 51079045101
Hospital Charge Code	9071
Hospital Revenue Code	637
Min. Negotiated Rate	$1.16
Max. Negotiated Rate	$1.66
Rate for Payer: Aetna Commercial	$1.56
Rate for Payer: Aetna New Business (MI Preferred)	$1.20
Rate for Payer: Cash Price	$1.47
Rate for Payer: Cofinity Commercial	$1.29
Rate for Payer: Cofinity Commercial	$1.58
Rate for Payer: Cofinity Medicare Advantage	$1.29
Rate for Payer: Encore Health Key Benefits Commercial	$1.47
Rate for Payer: Healthscope Commercial	$1.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.56
Rate for Payer: PHP Commercial	$1.56
Rate for Payer: Priority Health Cigna Priority Health	$1.20
Rate for Payer: Priority Health SBD	$1.16

AMLODIPINE 5 MG TABLET

Facility

$173.90

Service Code	NDC 00904637061
Hospital Charge Code	9071
Hospital Revenue Code	637
Min. Negotiated Rate	$69.56
Max. Negotiated Rate	$156.51
Rate for Payer: Aetna Commercial	$147.82
Rate for Payer: Aetna Medicare	$86.95
Rate for Payer: Aetna New Business (MI Preferred)	$113.04
Rate for Payer: BCBS Complete	$69.56
Rate for Payer: Cash Price	$139.12
Rate for Payer: Cofinity Commercial	$121.73
Rate for Payer: Cofinity Commercial	$149.55
Rate for Payer: Cofinity Medicare Advantage	$121.73
Rate for Payer: Encore Health Key Benefits Commercial	$139.12
Rate for Payer: Healthscope Commercial	$156.51
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$147.82
Rate for Payer: PHP Commercial	$147.82
Rate for Payer: Priority Health Cigna Priority Health	$113.04
Rate for Payer: Priority Health SBD	$109.56

AMLODIPINE 5 MG TABLET

Facility

$1.84

Service Code	NDC 51079045101
Hospital Charge Code	9071
Hospital Revenue Code	637
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.66
Rate for Payer: Aetna Commercial	$1.56
Rate for Payer: Aetna Medicare	$0.92
Rate for Payer: Aetna New Business (MI Preferred)	$1.20
Rate for Payer: BCBS Complete	$0.74
Rate for Payer: Cash Price	$1.47
Rate for Payer: Cofinity Commercial	$1.29
Rate for Payer: Cofinity Commercial	$1.58
Rate for Payer: Cofinity Medicare Advantage	$1.29
Rate for Payer: Encore Health Key Benefits Commercial	$1.47
Rate for Payer: Healthscope Commercial	$1.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$1.56
Rate for Payer: PHP Commercial	$1.56
Rate for Payer: Priority Health Cigna Priority Health	$1.20
Rate for Payer: Priority Health SBD	$1.16

AMMONIUM LACTATE 12 % LOTION

Facility

$26.22

Service Code	NDC 45802052555
Hospital Charge Code	10380
Hospital Revenue Code	637
Min. Negotiated Rate	$10.49
Max. Negotiated Rate	$23.60
Rate for Payer: Aetna Commercial	$22.29
Rate for Payer: Aetna Medicare	$13.11
Rate for Payer: Aetna New Business (MI Preferred)	$17.04
Rate for Payer: BCBS Complete	$10.49
Rate for Payer: Cash Price	$20.98
Rate for Payer: Cofinity Commercial	$18.35
Rate for Payer: Cofinity Commercial	$22.55
Rate for Payer: Cofinity Medicare Advantage	$18.35
Rate for Payer: Encore Health Key Benefits Commercial	$20.98
Rate for Payer: Healthscope Commercial	$23.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.29
Rate for Payer: PHP Commercial	$22.29
Rate for Payer: Priority Health Cigna Priority Health	$17.04
Rate for Payer: Priority Health SBD	$16.52

AMMONIUM LACTATE 12 % LOTION

Facility

$26.22

Service Code	NDC 45802052555
Hospital Charge Code	10380
Hospital Revenue Code	637
Min. Negotiated Rate	$16.52
Max. Negotiated Rate	$23.60
Rate for Payer: Aetna Commercial	$22.29
Rate for Payer: Aetna New Business (MI Preferred)	$17.04
Rate for Payer: Cash Price	$20.98
Rate for Payer: Cofinity Commercial	$18.35
Rate for Payer: Cofinity Commercial	$22.55
Rate for Payer: Cofinity Medicare Advantage	$18.35
Rate for Payer: Encore Health Key Benefits Commercial	$20.98
Rate for Payer: Healthscope Commercial	$23.60
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$22.29
Rate for Payer: PHP Commercial	$22.29
Rate for Payer: Priority Health Cigna Priority Health	$17.04
Rate for Payer: Priority Health SBD	$16.52

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION

Facility

$77.55

Service Code	NDC 00781604146
Hospital Charge Code	454
Hospital Revenue Code	637
Min. Negotiated Rate	$31.02
Max. Negotiated Rate	$69.80
Rate for Payer: Aetna Commercial	$65.92
Rate for Payer: Aetna Medicare	$38.78
Rate for Payer: Aetna New Business (MI Preferred)	$50.41
Rate for Payer: BCBS Complete	$31.02
Rate for Payer: Cash Price	$62.04
Rate for Payer: Cofinity Commercial	$54.28
Rate for Payer: Cofinity Commercial	$66.69
Rate for Payer: Cofinity Medicare Advantage	$54.28
Rate for Payer: Encore Health Key Benefits Commercial	$62.04
Rate for Payer: Healthscope Commercial	$69.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.92
Rate for Payer: PHP Commercial	$65.92
Rate for Payer: Priority Health Cigna Priority Health	$50.41
Rate for Payer: Priority Health SBD	$48.86

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION

Facility

$67.68

Service Code	NDC 00781604158
Hospital Charge Code	454
Hospital Revenue Code	637
Min. Negotiated Rate	$27.07
Max. Negotiated Rate	$60.91
Rate for Payer: Aetna Commercial	$57.53
Rate for Payer: Aetna Medicare	$33.84
Rate for Payer: Aetna New Business (MI Preferred)	$43.99
Rate for Payer: BCBS Complete	$27.07
Rate for Payer: Cash Price	$54.14
Rate for Payer: Cofinity Commercial	$47.38
Rate for Payer: Cofinity Commercial	$58.20
Rate for Payer: Cofinity Medicare Advantage	$47.38
Rate for Payer: Encore Health Key Benefits Commercial	$54.14
Rate for Payer: Healthscope Commercial	$60.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$57.53
Rate for Payer: PHP Commercial	$57.53
Rate for Payer: Priority Health Cigna Priority Health	$43.99
Rate for Payer: Priority Health SBD	$42.64

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION

Facility

$67.68

Service Code	NDC 00781604158
Hospital Charge Code	454
Hospital Revenue Code	637
Min. Negotiated Rate	$42.64
Max. Negotiated Rate	$60.91
Rate for Payer: Aetna Commercial	$57.53
Rate for Payer: Aetna New Business (MI Preferred)	$43.99
Rate for Payer: Cash Price	$54.14
Rate for Payer: Cofinity Commercial	$47.38
Rate for Payer: Cofinity Commercial	$58.20
Rate for Payer: Cofinity Medicare Advantage	$47.38
Rate for Payer: Encore Health Key Benefits Commercial	$54.14
Rate for Payer: Healthscope Commercial	$60.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$57.53
Rate for Payer: PHP Commercial	$57.53
Rate for Payer: Priority Health Cigna Priority Health	$43.99
Rate for Payer: Priority Health SBD	$42.64

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION

Facility

$82.25

Service Code	NDC 00093415573
Hospital Charge Code	454
Hospital Revenue Code	637
Min. Negotiated Rate	$32.90
Max. Negotiated Rate	$74.02
Rate for Payer: Aetna Commercial	$69.91
Rate for Payer: Aetna Medicare	$41.12
Rate for Payer: Aetna New Business (MI Preferred)	$53.46
Rate for Payer: BCBS Complete	$32.90
Rate for Payer: Cash Price	$65.80
Rate for Payer: Cofinity Commercial	$57.58
Rate for Payer: Cofinity Commercial	$70.74
Rate for Payer: Cofinity Medicare Advantage	$57.58
Rate for Payer: Encore Health Key Benefits Commercial	$65.80
Rate for Payer: Healthscope Commercial	$74.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.91
Rate for Payer: PHP Commercial	$69.91
Rate for Payer: Priority Health Cigna Priority Health	$53.46
Rate for Payer: Priority Health SBD	$51.82

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION

Facility

$82.25

Service Code	NDC 00093415573
Hospital Charge Code	454
Hospital Revenue Code	637
Min. Negotiated Rate	$51.82
Max. Negotiated Rate	$74.02
Rate for Payer: Aetna Commercial	$69.91
Rate for Payer: Aetna New Business (MI Preferred)	$53.46
Rate for Payer: Cash Price	$65.80
Rate for Payer: Cofinity Commercial	$57.58
Rate for Payer: Cofinity Commercial	$70.74
Rate for Payer: Cofinity Medicare Advantage	$57.58
Rate for Payer: Encore Health Key Benefits Commercial	$65.80
Rate for Payer: Healthscope Commercial	$74.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$69.91
Rate for Payer: PHP Commercial	$69.91
Rate for Payer: Priority Health Cigna Priority Health	$53.46
Rate for Payer: Priority Health SBD	$51.82

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION

Facility

$8.23

Service Code	NDC 09900001117
Hospital Charge Code	454
Hospital Revenue Code	637
Min. Negotiated Rate	$5.18
Max. Negotiated Rate	$7.41
Rate for Payer: Aetna Commercial	$7.00
Rate for Payer: Aetna New Business (MI Preferred)	$5.35
Rate for Payer: Cash Price	$6.58
Rate for Payer: Cofinity Commercial	$5.76
Rate for Payer: Cofinity Commercial	$7.08
Rate for Payer: Cofinity Medicare Advantage	$5.76
Rate for Payer: Encore Health Key Benefits Commercial	$6.58
Rate for Payer: Healthscope Commercial	$7.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.00
Rate for Payer: PHP Commercial	$7.00
Rate for Payer: Priority Health Cigna Priority Health	$5.35
Rate for Payer: Priority Health SBD	$5.18

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION

Facility

$8.23

Service Code	NDC 09900001117
Hospital Charge Code	454
Hospital Revenue Code	637
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$7.41
Rate for Payer: Aetna Commercial	$7.00
Rate for Payer: Aetna Medicare	$4.12
Rate for Payer: Aetna New Business (MI Preferred)	$5.35
Rate for Payer: BCBS Complete	$3.29
Rate for Payer: Cash Price	$6.58
Rate for Payer: Cofinity Commercial	$5.76
Rate for Payer: Cofinity Commercial	$7.08
Rate for Payer: Cofinity Medicare Advantage	$5.76
Rate for Payer: Encore Health Key Benefits Commercial	$6.58
Rate for Payer: Healthscope Commercial	$7.41
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.00
Rate for Payer: PHP Commercial	$7.00
Rate for Payer: Priority Health Cigna Priority Health	$5.35
Rate for Payer: Priority Health SBD	$5.18

AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION

Facility

$77.55

Service Code	NDC 00781604146
Hospital Charge Code	454
Hospital Revenue Code	637
Min. Negotiated Rate	$48.86
Max. Negotiated Rate	$69.80
Rate for Payer: Aetna Commercial	$65.92
Rate for Payer: Aetna New Business (MI Preferred)	$50.41
Rate for Payer: Cash Price	$62.04
Rate for Payer: Cofinity Commercial	$54.28
Rate for Payer: Cofinity Commercial	$66.69
Rate for Payer: Cofinity Medicare Advantage	$54.28
Rate for Payer: Encore Health Key Benefits Commercial	$62.04
Rate for Payer: Healthscope Commercial	$69.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$65.92
Rate for Payer: PHP Commercial	$65.92
Rate for Payer: Priority Health Cigna Priority Health	$50.41
Rate for Payer: Priority Health SBD	$48.86

AMOXICILLIN 250 MG CAPSULE

Facility

$197.40

Service Code	NDC 00781202001
Hospital Charge Code	450
Hospital Revenue Code	637
Min. Negotiated Rate	$124.36
Max. Negotiated Rate	$177.66
Rate for Payer: Aetna Commercial	$167.79
Rate for Payer: Aetna New Business (MI Preferred)	$128.31
Rate for Payer: Cash Price	$157.92
Rate for Payer: Cofinity Commercial	$138.18
Rate for Payer: Cofinity Commercial	$169.76
Rate for Payer: Cofinity Medicare Advantage	$138.18
Rate for Payer: Encore Health Key Benefits Commercial	$157.92
Rate for Payer: Healthscope Commercial	$177.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$167.79
Rate for Payer: PHP Commercial	$167.79
Rate for Payer: Priority Health Cigna Priority Health	$128.31
Rate for Payer: Priority Health SBD	$124.36

AMOXICILLIN 250 MG CAPSULE

Facility

$197.40

Service Code	NDC 00781202001
Hospital Charge Code	450
Hospital Revenue Code	637
Min. Negotiated Rate	$78.96
Max. Negotiated Rate	$177.66
Rate for Payer: Aetna Commercial	$167.79
Rate for Payer: Aetna Medicare	$98.70
Rate for Payer: Aetna New Business (MI Preferred)	$128.31
Rate for Payer: BCBS Complete	$78.96
Rate for Payer: Cash Price	$157.92
Rate for Payer: Cofinity Commercial	$138.18
Rate for Payer: Cofinity Commercial	$169.76
Rate for Payer: Cofinity Medicare Advantage	$138.18
Rate for Payer: Encore Health Key Benefits Commercial	$157.92
Rate for Payer: Healthscope Commercial	$177.66
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$167.79
Rate for Payer: PHP Commercial	$167.79
Rate for Payer: Priority Health Cigna Priority Health	$128.31
Rate for Payer: Priority Health SBD	$124.36

AMOXICILLIN 500 MG CAPSULE

Facility

$244.40

Service Code	NDC 00781261301
Hospital Charge Code	451
Hospital Revenue Code	637
Min. Negotiated Rate	$97.76
Max. Negotiated Rate	$219.96
Rate for Payer: Aetna Commercial	$207.74
Rate for Payer: Aetna Medicare	$122.20
Rate for Payer: Aetna New Business (MI Preferred)	$158.86
Rate for Payer: BCBS Complete	$97.76
Rate for Payer: Cash Price	$195.52
Rate for Payer: Cofinity Commercial	$171.08
Rate for Payer: Cofinity Commercial	$210.18
Rate for Payer: Cofinity Medicare Advantage	$171.08
Rate for Payer: Encore Health Key Benefits Commercial	$195.52
Rate for Payer: Healthscope Commercial	$219.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$207.74
Rate for Payer: PHP Commercial	$207.74
Rate for Payer: Priority Health Cigna Priority Health	$158.86
Rate for Payer: Priority Health SBD	$153.97

Know your out-of-pocket cost for care.

All Charges