Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

AMOXICILLIN 500 MG CAPSULE

Facility

$244.40

Service Code	NDC 00781261301
Hospital Charge Code	451
Hospital Revenue Code	637
Min. Negotiated Rate	$153.97
Max. Negotiated Rate	$219.96
Rate for Payer: Aetna Commercial	$207.74
Rate for Payer: Aetna New Business (MI Preferred)	$158.86
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

AMOXICILLIN 500 MG CAPSULE

Facility

$105.75

Service Code	NDC 00093310953
Hospital Charge Code	451
Hospital Revenue Code	637
Min. Negotiated Rate	$42.30
Max. Negotiated Rate	$95.18
Rate for Payer: Aetna Commercial	$89.89
Rate for Payer: Aetna Medicare	$52.88
Rate for Payer: Aetna New Business (MI Preferred)	$68.74
Rate for Payer: BCBS Complete	$42.30
Rate for Payer: Cash Price	$84.60
Rate for Payer: Cofinity Commercial	$74.02
Rate for Payer: Cofinity Commercial	$90.94
Rate for Payer: Cofinity Medicare Advantage	$74.02
Rate for Payer: Encore Health Key Benefits Commercial	$84.60
Rate for Payer: Healthscope Commercial	$95.18
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$89.89
Rate for Payer: PHP Commercial	$89.89
Rate for Payer: Priority Health Cigna Priority Health	$68.74
Rate for Payer: Priority Health SBD	$66.62

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

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$53.96

Service Code	NDC 00093227434
Hospital Charge Code	33227
Hospital Revenue Code	637
Min. Negotiated Rate	$33.99
Max. Negotiated Rate	$48.56
Rate for Payer: Aetna Commercial	$45.87
Rate for Payer: Aetna New Business (MI Preferred)	$35.07
Rate for Payer: Cash Price	$43.17
Rate for Payer: Cofinity Commercial	$37.77
Rate for Payer: Cofinity Commercial	$46.41
Rate for Payer: Cofinity Medicare Advantage	$37.77
Rate for Payer: Encore Health Key Benefits Commercial	$43.17
Rate for Payer: Healthscope Commercial	$48.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.87
Rate for Payer: PHP Commercial	$45.87
Rate for Payer: Priority Health Cigna Priority Health	$35.07
Rate for Payer: Priority Health SBD	$33.99

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$53.96

Service Code	NDC 00093227434
Hospital Charge Code	33227
Hospital Revenue Code	637
Min. Negotiated Rate	$21.58
Max. Negotiated Rate	$48.56
Rate for Payer: Aetna Commercial	$45.87
Rate for Payer: Aetna Medicare	$26.98
Rate for Payer: Aetna New Business (MI Preferred)	$35.07
Rate for Payer: BCBS Complete	$21.58
Rate for Payer: Cash Price	$43.17
Rate for Payer: Cofinity Commercial	$37.77
Rate for Payer: Cofinity Commercial	$46.41
Rate for Payer: Cofinity Medicare Advantage	$37.77
Rate for Payer: Encore Health Key Benefits Commercial	$43.17
Rate for Payer: Healthscope Commercial	$48.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.87
Rate for Payer: PHP Commercial	$45.87
Rate for Payer: Priority Health Cigna Priority Health	$35.07
Rate for Payer: Priority Health SBD	$33.99

AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION

Facility

$200.93

Service Code	NDC 65862053575
Hospital Charge Code	31177
Hospital Revenue Code	637
Min. Negotiated Rate	$80.37
Max. Negotiated Rate	$180.84
Rate for Payer: Aetna Commercial	$170.79
Rate for Payer: Aetna Medicare	$100.46
Rate for Payer: Aetna New Business (MI Preferred)	$130.60
Rate for Payer: BCBS Complete	$80.37
Rate for Payer: Cash Price	$160.74
Rate for Payer: Cofinity Commercial	$140.65
Rate for Payer: Cofinity Commercial	$172.80
Rate for Payer: Cofinity Medicare Advantage	$140.65
Rate for Payer: Encore Health Key Benefits Commercial	$160.74
Rate for Payer: Healthscope Commercial	$180.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$170.79
Rate for Payer: PHP Commercial	$170.79
Rate for Payer: Priority Health Cigna Priority Health	$130.60
Rate for Payer: Priority Health SBD	$126.59

AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION

Facility

$200.93

Service Code	NDC 65862053575
Hospital Charge Code	31177
Hospital Revenue Code	637
Min. Negotiated Rate	$126.59
Max. Negotiated Rate	$180.84
Rate for Payer: Aetna Commercial	$170.79
Rate for Payer: Aetna New Business (MI Preferred)	$130.60
Rate for Payer: Cash Price	$160.74
Rate for Payer: Cofinity Commercial	$140.65
Rate for Payer: Cofinity Commercial	$172.80
Rate for Payer: Cofinity Medicare Advantage	$140.65
Rate for Payer: Encore Health Key Benefits Commercial	$160.74
Rate for Payer: Healthscope Commercial	$180.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$170.79
Rate for Payer: PHP Commercial	$170.79
Rate for Payer: Priority Health Cigna Priority Health	$130.60
Rate for Payer: Priority Health SBD	$126.59

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$63.27

Service Code	NDC 00093227534
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$25.31
Max. Negotiated Rate	$56.94
Rate for Payer: Aetna Commercial	$53.78
Rate for Payer: Aetna Medicare	$31.64
Rate for Payer: Aetna New Business (MI Preferred)	$41.13
Rate for Payer: BCBS Complete	$25.31
Rate for Payer: Cash Price	$50.62
Rate for Payer: Cofinity Commercial	$44.29
Rate for Payer: Cofinity Commercial	$54.41
Rate for Payer: Cofinity Medicare Advantage	$44.29
Rate for Payer: Encore Health Key Benefits Commercial	$50.62
Rate for Payer: Healthscope Commercial	$56.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.78
Rate for Payer: PHP Commercial	$53.78
Rate for Payer: Priority Health Cigna Priority Health	$41.13
Rate for Payer: Priority Health SBD	$39.86

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$101.86

Service Code	NDC 66685100100
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$64.17
Max. Negotiated Rate	$91.67
Rate for Payer: Aetna Commercial	$86.58
Rate for Payer: Aetna New Business (MI Preferred)	$66.21
Rate for Payer: Cash Price	$81.49
Rate for Payer: Cofinity Commercial	$71.30
Rate for Payer: Cofinity Commercial	$87.60
Rate for Payer: Cofinity Medicare Advantage	$71.30
Rate for Payer: Encore Health Key Benefits Commercial	$81.49
Rate for Payer: Healthscope Commercial	$91.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.58
Rate for Payer: PHP Commercial	$86.58
Rate for Payer: Priority Health Cigna Priority Health	$66.21
Rate for Payer: Priority Health SBD	$64.17

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$101.86

Service Code	NDC 66685100100
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$40.74
Max. Negotiated Rate	$91.67
Rate for Payer: Aetna Commercial	$86.58
Rate for Payer: Aetna Medicare	$50.93
Rate for Payer: Aetna New Business (MI Preferred)	$66.21
Rate for Payer: BCBS Complete	$40.74
Rate for Payer: Cash Price	$81.49
Rate for Payer: Cofinity Commercial	$71.30
Rate for Payer: Cofinity Commercial	$87.60
Rate for Payer: Cofinity Medicare Advantage	$71.30
Rate for Payer: Encore Health Key Benefits Commercial	$81.49
Rate for Payer: Healthscope Commercial	$91.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.58
Rate for Payer: PHP Commercial	$86.58
Rate for Payer: Priority Health Cigna Priority Health	$66.21
Rate for Payer: Priority Health SBD	$64.17

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$64.03

Service Code	NDC 65862050320
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$25.61
Max. Negotiated Rate	$57.63
Rate for Payer: Aetna Commercial	$54.43
Rate for Payer: Aetna Medicare	$32.02
Rate for Payer: Aetna New Business (MI Preferred)	$41.62
Rate for Payer: BCBS Complete	$25.61
Rate for Payer: Cash Price	$51.22
Rate for Payer: Cofinity Commercial	$44.82
Rate for Payer: Cofinity Commercial	$55.07
Rate for Payer: Cofinity Medicare Advantage	$44.82
Rate for Payer: Encore Health Key Benefits Commercial	$51.22
Rate for Payer: Healthscope Commercial	$57.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.43
Rate for Payer: PHP Commercial	$54.43
Rate for Payer: Priority Health Cigna Priority Health	$41.62
Rate for Payer: Priority Health SBD	$40.34

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$509.28

Service Code	NDC 66685100101
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$203.71
Max. Negotiated Rate	$458.35
Rate for Payer: Aetna Commercial	$432.89
Rate for Payer: Aetna Medicare	$254.64
Rate for Payer: Aetna New Business (MI Preferred)	$331.03
Rate for Payer: BCBS Complete	$203.71
Rate for Payer: Cash Price	$407.42
Rate for Payer: Cofinity Commercial	$356.50
Rate for Payer: Cofinity Commercial	$437.98
Rate for Payer: Cofinity Medicare Advantage	$356.50
Rate for Payer: Encore Health Key Benefits Commercial	$407.42
Rate for Payer: Healthscope Commercial	$458.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$432.89
Rate for Payer: PHP Commercial	$432.89
Rate for Payer: Priority Health Cigna Priority Health	$331.03
Rate for Payer: Priority Health SBD	$320.85

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$63.27

Service Code	NDC 00093227534
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$39.86
Max. Negotiated Rate	$56.94
Rate for Payer: Aetna Commercial	$53.78
Rate for Payer: Aetna New Business (MI Preferred)	$41.13
Rate for Payer: Cash Price	$50.62
Rate for Payer: Cofinity Commercial	$44.29
Rate for Payer: Cofinity Commercial	$54.41
Rate for Payer: Cofinity Medicare Advantage	$44.29
Rate for Payer: Encore Health Key Benefits Commercial	$50.62
Rate for Payer: Healthscope Commercial	$56.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.78
Rate for Payer: PHP Commercial	$53.78
Rate for Payer: Priority Health Cigna Priority Health	$41.13
Rate for Payer: Priority Health SBD	$39.86

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$509.28

Service Code	NDC 66685100101
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$320.85
Max. Negotiated Rate	$458.35
Rate for Payer: Aetna Commercial	$432.89
Rate for Payer: Aetna New Business (MI Preferred)	$331.03
Rate for Payer: Cash Price	$407.42
Rate for Payer: Cofinity Commercial	$356.50
Rate for Payer: Cofinity Commercial	$437.98
Rate for Payer: Cofinity Medicare Advantage	$356.50
Rate for Payer: Encore Health Key Benefits Commercial	$407.42
Rate for Payer: Healthscope Commercial	$458.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$432.89
Rate for Payer: PHP Commercial	$432.89
Rate for Payer: Priority Health Cigna Priority Health	$331.03
Rate for Payer: Priority Health SBD	$320.85

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$64.03

Service Code	NDC 65862050320
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$40.34
Max. Negotiated Rate	$57.63
Rate for Payer: Aetna Commercial	$54.43
Rate for Payer: Aetna New Business (MI Preferred)	$41.62
Rate for Payer: Cash Price	$51.22
Rate for Payer: Cofinity Commercial	$44.82
Rate for Payer: Cofinity Commercial	$55.07
Rate for Payer: Cofinity Medicare Advantage	$44.82
Rate for Payer: Encore Health Key Benefits Commercial	$51.22
Rate for Payer: Healthscope Commercial	$57.63
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$54.43
Rate for Payer: PHP Commercial	$54.43
Rate for Payer: Priority Health Cigna Priority Health	$41.62
Rate for Payer: Priority Health SBD	$40.34

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$54.72

Service Code	NDC 42571016242
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$21.89
Max. Negotiated Rate	$49.25
Rate for Payer: Aetna Commercial	$46.51
Rate for Payer: Aetna Medicare	$27.36
Rate for Payer: Aetna New Business (MI Preferred)	$35.57
Rate for Payer: BCBS Complete	$21.89
Rate for Payer: Cash Price	$43.78
Rate for Payer: Cofinity Commercial	$38.30
Rate for Payer: Cofinity Commercial	$47.06
Rate for Payer: Cofinity Medicare Advantage	$38.30
Rate for Payer: Encore Health Key Benefits Commercial	$43.78
Rate for Payer: Healthscope Commercial	$49.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$46.51
Rate for Payer: PHP Commercial	$46.51
Rate for Payer: Priority Health Cigna Priority Health	$35.57
Rate for Payer: Priority Health SBD	$34.47

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$54.72

Service Code	NDC 42571016242
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$34.47
Max. Negotiated Rate	$49.25
Rate for Payer: Aetna Commercial	$46.51
Rate for Payer: Aetna New Business (MI Preferred)	$35.57
Rate for Payer: Cash Price	$43.78
Rate for Payer: Cofinity Commercial	$38.30
Rate for Payer: Cofinity Commercial	$47.06
Rate for Payer: Cofinity Medicare Advantage	$38.30
Rate for Payer: Encore Health Key Benefits Commercial	$43.78
Rate for Payer: Healthscope Commercial	$49.25
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$46.51
Rate for Payer: PHP Commercial	$46.51
Rate for Payer: Priority Health Cigna Priority Health	$35.57
Rate for Payer: Priority Health SBD	$34.47

AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION

Facility

$341.20

Service Code	HCPCS J0289
Hospital Charge Code	21900
Hospital Revenue Code	636
Min. Negotiated Rate	$214.96
Max. Negotiated Rate	$307.08
Rate for Payer: Aetna Commercial	$290.02
Rate for Payer: Aetna New Business (MI Preferred)	$221.78
Rate for Payer: Cash Price	$272.96
Rate for Payer: Cofinity Commercial	$238.84
Rate for Payer: Cofinity Commercial	$293.43
Rate for Payer: Cofinity Medicare Advantage	$238.84
Rate for Payer: Encore Health Key Benefits Commercial	$272.96
Rate for Payer: Healthscope Commercial	$307.08
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$290.02
Rate for Payer: PHP Commercial	$290.02
Rate for Payer: Priority Health Cigna Priority Health	$221.78
Rate for Payer: Priority Health SBD	$214.96

AMPHOTERICIN B LIPOSOME 50 MG INTRAVENOUS SUSPENSION

Facility

$341.20

Service Code	HCPCS J0289
Hospital Charge Code	21900
Hospital Revenue Code	636
Min. Negotiated Rate	$12.85
Max. Negotiated Rate	$307.08
Rate for Payer: Aetna Commercial	$290.02
Rate for Payer: Aetna Medicare	$24.94
Rate for Payer: Aetna New Business (MI Preferred)	$221.78
Rate for Payer: Allen County Amish Medical Aid Commercial	$29.98
Rate for Payer: Amish Plain Church Group Commercial	$29.98
Rate for Payer: BCBS Complete	$13.50
Rate for Payer: BCBS MAPPO	$23.98
Rate for Payer: BCBS Trust/PPO	$65.87
Rate for Payer: BCN Commercial	$65.87
Rate for Payer: BCN Medicare Advantage	$23.98
Rate for Payer: Cash Price	$272.96
Rate for Payer: Cash Price	$272.96
Rate for Payer: Cofinity Commercial	$293.43
Rate for Payer: Cofinity Commercial	$238.84
Rate for Payer: Cofinity Medicare Advantage	$238.84
Rate for Payer: Encore Health Key Benefits Commercial	$272.96
Rate for Payer: Health Alliance Plan Medicare Advantage	$23.98
Rate for Payer: Healthscope Commercial	$307.08
Rate for Payer: Mclaren Medicaid	$12.85
Rate for Payer: Mclaren Medicare	$23.98
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$25.18
Rate for Payer: Meridian Medicaid	$13.50
Rate for Payer: MI Amish Medical Board Commercial	$27.58
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$290.02
Rate for Payer: Nomi Health Commercial	$71.94
Rate for Payer: PACE Medicare	$22.78
Rate for Payer: PACE SWMI	$23.98
Rate for Payer: PHP Commercial	$290.02
Rate for Payer: PHP Medicare Advantage	$23.98
Rate for Payer: Priority Health Choice Medicaid	$12.85
Rate for Payer: Priority Health Cigna Priority Health	$221.78
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$67.13
Rate for Payer: Priority Health Medicare	$23.98
Rate for Payer: Priority Health Narrow Network	$53.70
Rate for Payer: Priority Health SBD	$214.96
Rate for Payer: Railroad Medicare Medicare	$23.98
Rate for Payer: UHC All Payor (Choice/PPO)	$67.50
Rate for Payer: UHC Dual Complete DSNP	$23.98
Rate for Payer: UHC Medicare Advantage	$23.98
Rate for Payer: UHCCP Medicaid	$13.50
Rate for Payer: VA VA	$23.98

AMPICILLIN 125 MG SOLUTION FOR INJECTION

Facility

$18.88

Service Code	HCPCS J0290
Hospital Charge Code	471
Hospital Revenue Code	636
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$16.99
Rate for Payer: Aetna Commercial	$16.05
Rate for Payer: Aetna Medicare	$9.44
Rate for Payer: Aetna New Business (MI Preferred)	$12.27
Rate for Payer: BCBS Complete	$7.55
Rate for Payer: BCBS Trust/PPO	$2.19
Rate for Payer: BCN Commercial	$2.19
Rate for Payer: Cash Price	$15.10
Rate for Payer: Cash Price	$15.10
Rate for Payer: Cofinity Commercial	$13.22
Rate for Payer: Cofinity Commercial	$16.24
Rate for Payer: Cofinity Medicare Advantage	$13.22
Rate for Payer: Encore Health Key Benefits Commercial	$15.10
Rate for Payer: Healthscope Commercial	$16.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.05
Rate for Payer: PHP Commercial	$16.05
Rate for Payer: Priority Health Cigna Priority Health	$12.27
Rate for Payer: Priority Health SBD	$11.89

AMPICILLIN 125 MG SOLUTION FOR INJECTION

Facility

$18.88

Service Code	HCPCS J0290
Hospital Charge Code	471
Hospital Revenue Code	636
Min. Negotiated Rate	$11.89
Max. Negotiated Rate	$16.99
Rate for Payer: Aetna Commercial	$16.05
Rate for Payer: Aetna New Business (MI Preferred)	$12.27
Rate for Payer: Cash Price	$15.10
Rate for Payer: Cofinity Commercial	$13.22
Rate for Payer: Cofinity Commercial	$16.24
Rate for Payer: Cofinity Medicare Advantage	$13.22
Rate for Payer: Encore Health Key Benefits Commercial	$15.10
Rate for Payer: Healthscope Commercial	$16.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.05
Rate for Payer: PHP Commercial	$16.05
Rate for Payer: Priority Health Cigna Priority Health	$12.27
Rate for Payer: Priority Health SBD	$11.89

AMPICILLIN 1 GRAM CUSTOM SOLUTION FOR INJECTION (CHARGE IN INCREMENTS)

Facility

$23.55

Service Code	HCPCS J0290
Hospital Charge Code	180568
Hospital Revenue Code	636
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$21.20
Rate for Payer: Aetna Commercial	$20.02
Rate for Payer: Aetna Medicare	$11.78
Rate for Payer: Aetna New Business (MI Preferred)	$15.31
Rate for Payer: BCBS Complete	$9.42
Rate for Payer: BCBS Trust/PPO	$2.19
Rate for Payer: BCN Commercial	$2.19
Rate for Payer: Cash Price	$18.84
Rate for Payer: Cash Price	$18.84
Rate for Payer: Cofinity Commercial	$16.48
Rate for Payer: Cofinity Commercial	$20.25
Rate for Payer: Cofinity Medicare Advantage	$16.48
Rate for Payer: Encore Health Key Benefits Commercial	$18.84
Rate for Payer: Healthscope Commercial	$21.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.02
Rate for Payer: PHP Commercial	$20.02
Rate for Payer: Priority Health Cigna Priority Health	$15.31
Rate for Payer: Priority Health SBD	$14.84

AMPICILLIN 1 GRAM CUSTOM SOLUTION FOR INJECTION (CHARGE IN INCREMENTS)

Facility

$23.55

Service Code	HCPCS J0290
Hospital Charge Code	180568
Hospital Revenue Code	636
Min. Negotiated Rate	$14.84
Max. Negotiated Rate	$21.20
Rate for Payer: Aetna Commercial	$20.02
Rate for Payer: Aetna New Business (MI Preferred)	$15.31
Rate for Payer: Cash Price	$18.84
Rate for Payer: Cofinity Commercial	$16.48
Rate for Payer: Cofinity Commercial	$20.25
Rate for Payer: Cofinity Medicare Advantage	$16.48
Rate for Payer: Encore Health Key Benefits Commercial	$18.84
Rate for Payer: Healthscope Commercial	$21.20
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$20.02
Rate for Payer: PHP Commercial	$20.02
Rate for Payer: Priority Health Cigna Priority Health	$15.31
Rate for Payer: Priority Health SBD	$14.84

AMPICILLIN 1 GRAM SOLUTION FOR INJECTION

Facility

$18.88

Service Code	HCPCS J0290
Hospital Charge Code	469
Hospital Revenue Code	636
Min. Negotiated Rate	$11.89
Max. Negotiated Rate	$16.99
Rate for Payer: Aetna Commercial	$16.05
Rate for Payer: Aetna Commercial	$17.48
Rate for Payer: Aetna Commercial	$19.03
Rate for Payer: Aetna New Business (MI Preferred)	$13.37
Rate for Payer: Aetna New Business (MI Preferred)	$12.27
Rate for Payer: Aetna New Business (MI Preferred)	$14.55
Rate for Payer: Cash Price	$15.10
Rate for Payer: Cash Price	$16.46
Rate for Payer: Cash Price	$17.91
Rate for Payer: Cofinity Commercial	$15.67
Rate for Payer: Cofinity Commercial	$13.22
Rate for Payer: Cofinity Commercial	$16.24
Rate for Payer: Cofinity Commercial	$19.26
Rate for Payer: Cofinity Commercial	$14.40
Rate for Payer: Cofinity Commercial	$17.69
Rate for Payer: Cofinity Medicare Advantage	$14.40
Rate for Payer: Cofinity Medicare Advantage	$15.67
Rate for Payer: Cofinity Medicare Advantage	$13.22
Rate for Payer: Encore Health Key Benefits Commercial	$16.46
Rate for Payer: Encore Health Key Benefits Commercial	$15.10
Rate for Payer: Encore Health Key Benefits Commercial	$17.91
Rate for Payer: Healthscope Commercial	$18.51
Rate for Payer: Healthscope Commercial	$20.15
Rate for Payer: Healthscope Commercial	$16.99
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.03
Rate for Payer: PHP Commercial	$19.03
Rate for Payer: PHP Commercial	$16.05
Rate for Payer: PHP Commercial	$17.48
Rate for Payer: Priority Health Cigna Priority Health	$12.27
Rate for Payer: Priority Health Cigna Priority Health	$14.55
Rate for Payer: Priority Health Cigna Priority Health	$13.37
Rate for Payer: Priority Health SBD	$14.11
Rate for Payer: Priority Health SBD	$11.89
Rate for Payer: Priority Health SBD	$12.96

AMPICILLIN 1 GRAM SOLUTION FOR INJECTION

Facility

$22.39

Service Code	HCPCS J0290
Hospital Charge Code	469
Hospital Revenue Code	636
Min. Negotiated Rate	$2.19
Max. Negotiated Rate	$20.15
Rate for Payer: Aetna Commercial	$19.03
Rate for Payer: Aetna Commercial	$16.05
Rate for Payer: Aetna Commercial	$17.48
Rate for Payer: Aetna Medicare	$9.44
Rate for Payer: Aetna Medicare	$10.28
Rate for Payer: Aetna Medicare	$11.20
Rate for Payer: Aetna New Business (MI Preferred)	$13.37
Rate for Payer: Aetna New Business (MI Preferred)	$12.27
Rate for Payer: Aetna New Business (MI Preferred)	$14.55
Rate for Payer: BCBS Complete	$8.23
Rate for Payer: BCBS Complete	$7.55
Rate for Payer: BCBS Complete	$8.96
Rate for Payer: BCBS Trust/PPO	$2.19
Rate for Payer: BCBS Trust/PPO	$2.19
Rate for Payer: BCBS Trust/PPO	$2.19
Rate for Payer: BCN Commercial	$2.19
Rate for Payer: BCN Commercial	$2.19
Rate for Payer: BCN Commercial	$2.19
Rate for Payer: Cash Price	$16.46
Rate for Payer: Cash Price	$15.10
Rate for Payer: Cash Price	$17.91
Rate for Payer: Cash Price	$16.46
Rate for Payer: Cash Price	$15.10
Rate for Payer: Cash Price	$17.91
Rate for Payer: Cofinity Commercial	$14.40
Rate for Payer: Cofinity Commercial	$13.22
Rate for Payer: Cofinity Commercial	$16.24
Rate for Payer: Cofinity Commercial	$17.69
Rate for Payer: Cofinity Commercial	$15.67
Rate for Payer: Cofinity Commercial	$19.26
Rate for Payer: Cofinity Medicare Advantage	$15.67
Rate for Payer: Cofinity Medicare Advantage	$14.40
Rate for Payer: Cofinity Medicare Advantage	$13.22
Rate for Payer: Encore Health Key Benefits Commercial	$15.10
Rate for Payer: Encore Health Key Benefits Commercial	$16.46
Rate for Payer: Encore Health Key Benefits Commercial	$17.91
Rate for Payer: Healthscope Commercial	$18.51
Rate for Payer: Healthscope Commercial	$16.99
Rate for Payer: Healthscope Commercial	$20.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$17.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.03
Rate for Payer: PHP Commercial	$17.48
Rate for Payer: PHP Commercial	$19.03
Rate for Payer: PHP Commercial	$16.05
Rate for Payer: Priority Health Cigna Priority Health	$13.37
Rate for Payer: Priority Health Cigna Priority Health	$14.55
Rate for Payer: Priority Health Cigna Priority Health	$12.27
Rate for Payer: Priority Health SBD	$11.89
Rate for Payer: Priority Health SBD	$14.11
Rate for Payer: Priority Health SBD	$12.96

Know your out-of-pocket cost for care.

All Charges