|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$71.44
|
|
|
Service Code
|
NDC 00093415579
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.44 |
| Max. Negotiated Rate |
$64.30 |
| Rate for Payer: Aetna Commercial |
$60.72
|
| Rate for Payer: BCBS Trust/PPO |
$58.32
|
| Rate for Payer: BCN Commercial |
$55.21
|
| Rate for Payer: Cash Price |
$57.15
|
| Rate for Payer: Cofinity Commercial |
$61.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.15
|
| Rate for Payer: Healthscope Commercial |
$64.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.72
|
| Rate for Payer: Nomi Health Commercial |
$58.58
|
| Rate for Payer: PHP Commercial |
$60.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.44
|
| Rate for Payer: Priority Health HMO/PPO |
$62.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.87
|
| Rate for Payer: UHC Core |
$59.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.58
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$67.68
|
|
|
Service Code
|
NDC 65862070780
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.99 |
| Max. Negotiated Rate |
$60.91 |
| Rate for Payer: Aetna Commercial |
$57.53
|
| Rate for Payer: BCBS Trust/PPO |
$55.25
|
| Rate for Payer: BCN Commercial |
$52.30
|
| Rate for Payer: Cash Price |
$54.14
|
| Rate for Payer: Cofinity Commercial |
$58.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.14
|
| Rate for Payer: Healthscope Commercial |
$60.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.53
|
| Rate for Payer: Nomi Health Commercial |
$55.50
|
| Rate for Payer: PHP Commercial |
$57.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.99
|
| Rate for Payer: Priority Health HMO/PPO |
$58.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.56
|
| Rate for Payer: UHC Core |
$56.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.76
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$2.59
|
|
|
Service Code
|
NDC 09900000421
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna Commercial |
$2.20
|
| Rate for Payer: Aetna Medicare |
$0.67
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$0.81
|
| Rate for Payer: Amish Plain Church Group Commercial |
$0.81
|
| Rate for Payer: BCBS Complete |
$1.04
|
| Rate for Payer: BCBS MAPPO |
$0.65
|
| Rate for Payer: BCBS Trust/PPO |
$2.13
|
| Rate for Payer: BCN Commercial |
$2.01
|
| Rate for Payer: BCN Medicare Advantage |
$0.65
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: Cofinity Commercial |
$2.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.07
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$0.65
|
| Rate for Payer: Healthscope Commercial |
$2.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.94
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$0.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$0.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.20
|
| Rate for Payer: Nomi Health Commercial |
$2.12
|
| Rate for Payer: PACE Senior Care Partners |
$0.62
|
| Rate for Payer: PACE SWMI |
$0.65
|
| Rate for Payer: PHP Commercial |
$2.20
|
| Rate for Payer: PHP Medicare Advantage |
$0.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.68
|
| Rate for Payer: Priority Health HMO/PPO |
$2.25
|
| Rate for Payer: Priority Health Medicare |
$0.65
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.74
|
| Rate for Payer: Railroad Medicare Medicare |
$0.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.28
|
| Rate for Payer: UHC Core |
$2.16
|
| Rate for Payer: UHC Dual Complete DSNP |
$0.65
|
| Rate for Payer: UHC Exchange |
$0.65
|
| Rate for Payer: UHC Medicare Advantage |
$0.65
|
| Rate for Payer: VA VA |
$0.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.94
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$67.68
|
|
|
Service Code
|
NDC 65862070780
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.07 |
| Max. Negotiated Rate |
$60.91 |
| Rate for Payer: Aetna Commercial |
$57.53
|
| Rate for Payer: Aetna Medicare |
$17.60
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$21.15
|
| Rate for Payer: Amish Plain Church Group Commercial |
$21.15
|
| Rate for Payer: BCBS Complete |
$27.07
|
| Rate for Payer: BCBS MAPPO |
$16.92
|
| Rate for Payer: BCBS Trust/PPO |
$55.64
|
| Rate for Payer: BCN Commercial |
$52.62
|
| Rate for Payer: BCN Medicare Advantage |
$16.92
|
| Rate for Payer: Cash Price |
$54.14
|
| Rate for Payer: Cofinity Commercial |
$58.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.14
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$16.92
|
| Rate for Payer: Healthscope Commercial |
$60.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.76
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$17.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.53
|
| Rate for Payer: Nomi Health Commercial |
$55.50
|
| Rate for Payer: PACE Senior Care Partners |
$16.07
|
| Rate for Payer: PACE SWMI |
$16.92
|
| Rate for Payer: PHP Commercial |
$57.53
|
| Rate for Payer: PHP Medicare Advantage |
$16.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.99
|
| Rate for Payer: Priority Health HMO/PPO |
$58.88
|
| Rate for Payer: Priority Health Medicare |
$17.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.35
|
| Rate for Payer: Railroad Medicare Medicare |
$16.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.56
|
| Rate for Payer: UHC Core |
$56.51
|
| Rate for Payer: UHC Dual Complete DSNP |
$16.92
|
| Rate for Payer: UHC Exchange |
$16.92
|
| Rate for Payer: UHC Medicare Advantage |
$16.92
|
| Rate for Payer: VA VA |
$16.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.76
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$67.68
|
|
|
Service Code
|
NDC 00781604158
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.99 |
| Max. Negotiated Rate |
$60.91 |
| Rate for Payer: Aetna Commercial |
$57.53
|
| Rate for Payer: BCBS Trust/PPO |
$55.25
|
| Rate for Payer: BCN Commercial |
$52.30
|
| Rate for Payer: Cash Price |
$54.14
|
| Rate for Payer: Cofinity Commercial |
$58.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.14
|
| Rate for Payer: Healthscope Commercial |
$60.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$57.53
|
| Rate for Payer: Nomi Health Commercial |
$55.50
|
| Rate for Payer: PHP Commercial |
$57.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.99
|
| Rate for Payer: Priority Health HMO/PPO |
$58.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$45.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$59.56
|
| Rate for Payer: UHC Core |
$56.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.76
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$56.40
|
|
|
Service Code
|
NDC 00143988980
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.40 |
| Max. Negotiated Rate |
$50.76 |
| Rate for Payer: Aetna Commercial |
$47.94
|
| Rate for Payer: Aetna Medicare |
$14.66
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$17.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$17.62
|
| Rate for Payer: BCBS Complete |
$22.56
|
| Rate for Payer: BCBS MAPPO |
$14.10
|
| Rate for Payer: BCBS Trust/PPO |
$46.37
|
| Rate for Payer: BCN Commercial |
$43.85
|
| Rate for Payer: BCN Medicare Advantage |
$14.10
|
| Rate for Payer: Cash Price |
$45.12
|
| Rate for Payer: Cofinity Commercial |
$48.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.12
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$14.10
|
| Rate for Payer: Healthscope Commercial |
$50.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.94
|
| Rate for Payer: Nomi Health Commercial |
$46.25
|
| Rate for Payer: PACE Senior Care Partners |
$13.40
|
| Rate for Payer: PACE SWMI |
$14.10
|
| Rate for Payer: PHP Commercial |
$47.94
|
| Rate for Payer: PHP Medicare Advantage |
$14.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.66
|
| Rate for Payer: Priority Health HMO/PPO |
$49.07
|
| Rate for Payer: Priority Health Medicare |
$14.24
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$37.79
|
| Rate for Payer: Railroad Medicare Medicare |
$14.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.63
|
| Rate for Payer: UHC Core |
$47.09
|
| Rate for Payer: UHC Dual Complete DSNP |
$14.10
|
| Rate for Payer: UHC Exchange |
$14.10
|
| Rate for Payer: UHC Medicare Advantage |
$14.10
|
| Rate for Payer: VA VA |
$14.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.30
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$2.59
|
|
|
Service Code
|
NDC 09900000421
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna Commercial |
$2.20
|
| Rate for Payer: BCBS Trust/PPO |
$2.11
|
| Rate for Payer: BCN Commercial |
$2.00
|
| Rate for Payer: Cash Price |
$2.07
|
| Rate for Payer: Cofinity Commercial |
$2.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.07
|
| Rate for Payer: Healthscope Commercial |
$2.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.20
|
| Rate for Payer: Nomi Health Commercial |
$2.12
|
| Rate for Payer: PHP Commercial |
$2.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.68
|
| Rate for Payer: Priority Health HMO/PPO |
$2.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.28
|
| Rate for Payer: UHC Core |
$2.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.94
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$88.13
|
|
|
Service Code
|
NDC 00781604155
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.93 |
| Max. Negotiated Rate |
$79.32 |
| Rate for Payer: Aetna Commercial |
$74.91
|
| Rate for Payer: Aetna Medicare |
$22.91
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$27.54
|
| Rate for Payer: Amish Plain Church Group Commercial |
$27.54
|
| Rate for Payer: BCBS Complete |
$35.25
|
| Rate for Payer: BCBS MAPPO |
$22.03
|
| Rate for Payer: BCBS Trust/PPO |
$72.45
|
| Rate for Payer: BCN Commercial |
$68.52
|
| Rate for Payer: BCN Medicare Advantage |
$22.03
|
| Rate for Payer: Cash Price |
$70.50
|
| Rate for Payer: Cofinity Commercial |
$75.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.50
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$22.03
|
| Rate for Payer: Healthscope Commercial |
$79.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.10
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$23.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$74.91
|
| Rate for Payer: Nomi Health Commercial |
$72.27
|
| Rate for Payer: PACE Senior Care Partners |
$20.93
|
| Rate for Payer: PACE SWMI |
$22.03
|
| Rate for Payer: PHP Commercial |
$74.91
|
| Rate for Payer: PHP Medicare Advantage |
$22.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.28
|
| Rate for Payer: Priority Health HMO/PPO |
$76.67
|
| Rate for Payer: Priority Health Medicare |
$22.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$59.05
|
| Rate for Payer: Railroad Medicare Medicare |
$22.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.55
|
| Rate for Payer: UHC Core |
$73.59
|
| Rate for Payer: UHC Dual Complete DSNP |
$22.03
|
| Rate for Payer: UHC Exchange |
$22.03
|
| Rate for Payer: UHC Medicare Advantage |
$22.03
|
| Rate for Payer: VA VA |
$22.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.10
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 65862001601
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.79 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: BCBS Trust/PPO |
$90.16
|
| Rate for Payer: BCN Commercial |
$85.36
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: Nomi Health Commercial |
$90.57
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health HMO/PPO |
$96.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$74.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.20
|
| Rate for Payer: UHC Core |
$92.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$110.45
|
|
|
Service Code
|
NDC 57237003001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.23 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna Medicare |
$28.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$34.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$34.52
|
| Rate for Payer: BCBS Complete |
$44.18
|
| Rate for Payer: BCBS MAPPO |
$27.61
|
| Rate for Payer: BCBS Trust/PPO |
$90.80
|
| Rate for Payer: BCN Commercial |
$85.87
|
| Rate for Payer: BCN Medicare Advantage |
$27.61
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27.61
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: Nomi Health Commercial |
$90.57
|
| Rate for Payer: PACE Senior Care Partners |
$26.23
|
| Rate for Payer: PACE SWMI |
$27.61
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: PHP Medicare Advantage |
$27.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health HMO/PPO |
$96.09
|
| Rate for Payer: Priority Health Medicare |
$27.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$74.00
|
| Rate for Payer: Railroad Medicare Medicare |
$27.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.20
|
| Rate for Payer: UHC Core |
$92.23
|
| Rate for Payer: UHC Dual Complete DSNP |
$27.61
|
| Rate for Payer: UHC Exchange |
$27.61
|
| Rate for Payer: UHC Medicare Advantage |
$27.61
|
| Rate for Payer: VA VA |
$27.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$197.40
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.88 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna Medicare |
$51.32
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$61.69
|
| Rate for Payer: Amish Plain Church Group Commercial |
$61.69
|
| Rate for Payer: BCBS Complete |
$78.96
|
| Rate for Payer: BCBS MAPPO |
$49.35
|
| Rate for Payer: BCBS Trust/PPO |
$162.28
|
| Rate for Payer: BCN Commercial |
$153.48
|
| Rate for Payer: BCN Medicare Advantage |
$49.35
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$49.35
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$51.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$56.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: Nomi Health Commercial |
$161.87
|
| Rate for Payer: PACE Senior Care Partners |
$46.88
|
| Rate for Payer: PACE SWMI |
$49.35
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: PHP Medicare Advantage |
$49.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health HMO/PPO |
$171.74
|
| Rate for Payer: Priority Health Medicare |
$49.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$132.26
|
| Rate for Payer: Railroad Medicare Medicare |
$49.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$173.71
|
| Rate for Payer: UHC Core |
$164.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$49.35
|
| Rate for Payer: UHC Exchange |
$49.35
|
| Rate for Payer: UHC Medicare Advantage |
$49.35
|
| Rate for Payer: VA VA |
$49.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$197.40
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.31 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: BCBS Trust/PPO |
$161.14
|
| Rate for Payer: BCN Commercial |
$152.55
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: Nomi Health Commercial |
$161.87
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health HMO/PPO |
$171.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$132.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$173.71
|
| Rate for Payer: UHC Core |
$164.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 57237003001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.79 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: BCBS Trust/PPO |
$90.16
|
| Rate for Payer: BCN Commercial |
$85.36
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: Nomi Health Commercial |
$90.57
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health HMO/PPO |
$96.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$74.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.20
|
| Rate for Payer: UHC Core |
$92.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$110.45
|
|
|
Service Code
|
NDC 65862001601
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.23 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna Medicare |
$28.72
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$34.52
|
| Rate for Payer: Amish Plain Church Group Commercial |
$34.52
|
| Rate for Payer: BCBS Complete |
$44.18
|
| Rate for Payer: BCBS MAPPO |
$27.61
|
| Rate for Payer: BCBS Trust/PPO |
$90.80
|
| Rate for Payer: BCN Commercial |
$85.87
|
| Rate for Payer: BCN Medicare Advantage |
$27.61
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27.61
|
| Rate for Payer: Healthscope Commercial |
$99.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: Nomi Health Commercial |
$90.57
|
| Rate for Payer: PACE Senior Care Partners |
$26.23
|
| Rate for Payer: PACE SWMI |
$27.61
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: PHP Medicare Advantage |
$27.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health HMO/PPO |
$96.09
|
| Rate for Payer: Priority Health Medicare |
$27.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$74.00
|
| Rate for Payer: Railroad Medicare Medicare |
$27.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$97.20
|
| Rate for Payer: UHC Core |
$92.23
|
| Rate for Payer: UHC Dual Complete DSNP |
$27.61
|
| Rate for Payer: UHC Exchange |
$27.61
|
| Rate for Payer: UHC Medicare Advantage |
$27.61
|
| Rate for Payer: VA VA |
$27.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$618.45
|
|
|
Service Code
|
NDC 59651002655
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$401.99 |
| Max. Negotiated Rate |
$556.60 |
| Rate for Payer: Aetna Commercial |
$525.68
|
| Rate for Payer: BCBS Trust/PPO |
$504.84
|
| Rate for Payer: BCN Commercial |
$477.94
|
| Rate for Payer: Cash Price |
$494.76
|
| Rate for Payer: Cofinity Commercial |
$531.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$494.76
|
| Rate for Payer: Healthscope Commercial |
$556.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$463.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$525.68
|
| Rate for Payer: Nomi Health Commercial |
$507.13
|
| Rate for Payer: PHP Commercial |
$525.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$401.99
|
| Rate for Payer: Priority Health HMO/PPO |
$538.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$414.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$544.24
|
| Rate for Payer: UHC Core |
$516.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$463.84
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$618.45
|
|
|
Service Code
|
NDC 59651002655
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$146.88 |
| Max. Negotiated Rate |
$556.60 |
| Rate for Payer: Aetna Commercial |
$525.68
|
| Rate for Payer: Aetna Medicare |
$160.80
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$193.27
|
| Rate for Payer: Amish Plain Church Group Commercial |
$193.27
|
| Rate for Payer: BCBS Complete |
$247.38
|
| Rate for Payer: BCBS MAPPO |
$154.61
|
| Rate for Payer: BCBS Trust/PPO |
$508.43
|
| Rate for Payer: BCN Commercial |
$480.84
|
| Rate for Payer: BCN Medicare Advantage |
$154.61
|
| Rate for Payer: Cash Price |
$494.76
|
| Rate for Payer: Cofinity Commercial |
$531.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$494.76
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$154.61
|
| Rate for Payer: Healthscope Commercial |
$556.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$463.84
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$162.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$177.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$525.68
|
| Rate for Payer: Nomi Health Commercial |
$507.13
|
| Rate for Payer: PACE Senior Care Partners |
$146.88
|
| Rate for Payer: PACE SWMI |
$154.61
|
| Rate for Payer: PHP Commercial |
$525.68
|
| Rate for Payer: PHP Medicare Advantage |
$154.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$401.99
|
| Rate for Payer: Priority Health HMO/PPO |
$538.05
|
| Rate for Payer: Priority Health Medicare |
$156.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$414.36
|
| Rate for Payer: Railroad Medicare Medicare |
$154.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$544.24
|
| Rate for Payer: UHC Core |
$516.41
|
| Rate for Payer: UHC Dual Complete DSNP |
$154.61
|
| Rate for Payer: UHC Exchange |
$154.61
|
| Rate for Payer: UHC Medicare Advantage |
$154.61
|
| Rate for Payer: VA VA |
$154.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$463.84
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
NDC 65862053450
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.32 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna Commercial |
$79.90
|
| Rate for Payer: Aetna Medicare |
$24.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$29.38
|
| Rate for Payer: Amish Plain Church Group Commercial |
$29.38
|
| Rate for Payer: BCBS Complete |
$37.60
|
| Rate for Payer: BCBS MAPPO |
$23.50
|
| Rate for Payer: BCBS Trust/PPO |
$77.28
|
| Rate for Payer: BCN Commercial |
$73.08
|
| Rate for Payer: BCN Medicare Advantage |
$23.50
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$80.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.20
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$23.50
|
| Rate for Payer: Healthscope Commercial |
$84.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$24.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.90
|
| Rate for Payer: Nomi Health Commercial |
$77.08
|
| Rate for Payer: PACE Senior Care Partners |
$22.32
|
| Rate for Payer: PACE SWMI |
$23.50
|
| Rate for Payer: PHP Commercial |
$79.90
|
| Rate for Payer: PHP Medicare Advantage |
$23.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.10
|
| Rate for Payer: Priority Health HMO/PPO |
$81.78
|
| Rate for Payer: Priority Health Medicare |
$23.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$62.98
|
| Rate for Payer: Railroad Medicare Medicare |
$23.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$82.72
|
| Rate for Payer: UHC Core |
$78.49
|
| Rate for Payer: UHC Dual Complete DSNP |
$23.50
|
| Rate for Payer: UHC Exchange |
$23.50
|
| Rate for Payer: UHC Medicare Advantage |
$23.50
|
| Rate for Payer: VA VA |
$23.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.50
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
NDC 65862053450
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.10 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna Commercial |
$79.90
|
| Rate for Payer: BCBS Trust/PPO |
$76.73
|
| Rate for Payer: BCN Commercial |
$72.64
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$80.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.20
|
| Rate for Payer: Healthscope Commercial |
$84.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.90
|
| Rate for Payer: Nomi Health Commercial |
$77.08
|
| Rate for Payer: PHP Commercial |
$79.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.10
|
| Rate for Payer: Priority Health HMO/PPO |
$81.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$62.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$82.72
|
| Rate for Payer: UHC Core |
$78.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.50
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$53.96
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.07 |
| Max. Negotiated Rate |
$48.56 |
| Rate for Payer: Aetna Commercial |
$45.87
|
| Rate for Payer: BCBS Trust/PPO |
$44.05
|
| Rate for Payer: BCN Commercial |
$41.70
|
| Rate for Payer: Cash Price |
$43.17
|
| Rate for Payer: Cofinity Commercial |
$46.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.17
|
| Rate for Payer: Healthscope Commercial |
$48.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.87
|
| Rate for Payer: Nomi Health Commercial |
$44.25
|
| Rate for Payer: PHP Commercial |
$45.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.07
|
| Rate for Payer: Priority Health HMO/PPO |
$46.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$36.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$47.48
|
| Rate for Payer: UHC Core |
$45.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.47
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$53.96
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.82 |
| Max. Negotiated Rate |
$48.56 |
| Rate for Payer: Aetna Commercial |
$45.87
|
| Rate for Payer: Aetna Medicare |
$14.03
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$16.86
|
| Rate for Payer: Amish Plain Church Group Commercial |
$16.86
|
| Rate for Payer: BCBS Complete |
$21.58
|
| Rate for Payer: BCBS MAPPO |
$13.49
|
| Rate for Payer: BCBS Trust/PPO |
$44.36
|
| Rate for Payer: BCN Commercial |
$41.95
|
| Rate for Payer: BCN Medicare Advantage |
$13.49
|
| Rate for Payer: Cash Price |
$43.17
|
| Rate for Payer: Cofinity Commercial |
$46.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.17
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$13.49
|
| Rate for Payer: Healthscope Commercial |
$48.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$14.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.87
|
| Rate for Payer: Nomi Health Commercial |
$44.25
|
| Rate for Payer: PACE Senior Care Partners |
$12.82
|
| Rate for Payer: PACE SWMI |
$13.49
|
| Rate for Payer: PHP Commercial |
$45.87
|
| Rate for Payer: PHP Medicare Advantage |
$13.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.07
|
| Rate for Payer: Priority Health HMO/PPO |
$46.95
|
| Rate for Payer: Priority Health Medicare |
$13.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$36.15
|
| Rate for Payer: Railroad Medicare Medicare |
$13.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$47.48
|
| Rate for Payer: UHC Core |
$45.06
|
| Rate for Payer: UHC Dual Complete DSNP |
$13.49
|
| Rate for Payer: UHC Exchange |
$13.49
|
| Rate for Payer: UHC Medicare Advantage |
$13.49
|
| Rate for Payer: VA VA |
$13.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.47
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$200.93
|
|
|
Service Code
|
NDC 65862053575
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.60 |
| Max. Negotiated Rate |
$180.84 |
| Rate for Payer: Aetna Commercial |
$170.79
|
| Rate for Payer: BCBS Trust/PPO |
$164.02
|
| Rate for Payer: BCN Commercial |
$155.28
|
| Rate for Payer: Cash Price |
$160.74
|
| Rate for Payer: Cofinity Commercial |
$172.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.74
|
| Rate for Payer: Healthscope Commercial |
$180.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.79
|
| Rate for Payer: Nomi Health Commercial |
$164.76
|
| Rate for Payer: PHP Commercial |
$170.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.60
|
| Rate for Payer: Priority Health HMO/PPO |
$174.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$134.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.82
|
| Rate for Payer: UHC Core |
$167.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.70
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$308.44
|
|
|
Service Code
|
NDC 00143985375
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.25 |
| Max. Negotiated Rate |
$277.60 |
| Rate for Payer: Aetna Commercial |
$262.17
|
| Rate for Payer: Aetna Medicare |
$80.19
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$96.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$96.39
|
| Rate for Payer: BCBS Complete |
$123.38
|
| Rate for Payer: BCBS MAPPO |
$77.11
|
| Rate for Payer: BCBS Trust/PPO |
$253.57
|
| Rate for Payer: BCN Commercial |
$239.81
|
| Rate for Payer: BCN Medicare Advantage |
$77.11
|
| Rate for Payer: Cash Price |
$246.75
|
| Rate for Payer: Cofinity Commercial |
$265.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$77.11
|
| Rate for Payer: Healthscope Commercial |
$277.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$80.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$88.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$262.17
|
| Rate for Payer: Nomi Health Commercial |
$252.92
|
| Rate for Payer: PACE Senior Care Partners |
$73.25
|
| Rate for Payer: PACE SWMI |
$77.11
|
| Rate for Payer: PHP Commercial |
$262.17
|
| Rate for Payer: PHP Medicare Advantage |
$77.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.49
|
| Rate for Payer: Priority Health HMO/PPO |
$268.34
|
| Rate for Payer: Priority Health Medicare |
$77.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$206.65
|
| Rate for Payer: Railroad Medicare Medicare |
$77.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$271.43
|
| Rate for Payer: UHC Core |
$257.55
|
| Rate for Payer: UHC Dual Complete DSNP |
$77.11
|
| Rate for Payer: UHC Exchange |
$77.11
|
| Rate for Payer: UHC Medicare Advantage |
$77.11
|
| Rate for Payer: VA VA |
$77.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.33
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$200.93
|
|
|
Service Code
|
NDC 65862053575
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.72 |
| Max. Negotiated Rate |
$180.84 |
| Rate for Payer: Aetna Commercial |
$170.79
|
| Rate for Payer: Aetna Medicare |
$52.24
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$62.79
|
| Rate for Payer: Amish Plain Church Group Commercial |
$62.79
|
| Rate for Payer: BCBS Complete |
$80.37
|
| Rate for Payer: BCBS MAPPO |
$50.23
|
| Rate for Payer: BCBS Trust/PPO |
$165.18
|
| Rate for Payer: BCN Commercial |
$156.22
|
| Rate for Payer: BCN Medicare Advantage |
$50.23
|
| Rate for Payer: Cash Price |
$160.74
|
| Rate for Payer: Cofinity Commercial |
$172.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.74
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$50.23
|
| Rate for Payer: Healthscope Commercial |
$180.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$150.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$52.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.79
|
| Rate for Payer: Nomi Health Commercial |
$164.76
|
| Rate for Payer: PACE Senior Care Partners |
$47.72
|
| Rate for Payer: PACE SWMI |
$50.23
|
| Rate for Payer: PHP Commercial |
$170.79
|
| Rate for Payer: PHP Medicare Advantage |
$50.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.60
|
| Rate for Payer: Priority Health HMO/PPO |
$174.81
|
| Rate for Payer: Priority Health Medicare |
$50.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$134.62
|
| Rate for Payer: Railroad Medicare Medicare |
$50.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$176.82
|
| Rate for Payer: UHC Core |
$167.78
|
| Rate for Payer: UHC Dual Complete DSNP |
$50.23
|
| Rate for Payer: UHC Exchange |
$50.23
|
| Rate for Payer: UHC Medicare Advantage |
$50.23
|
| Rate for Payer: VA VA |
$50.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$150.70
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$308.44
|
|
|
Service Code
|
NDC 00143985375
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.49 |
| Max. Negotiated Rate |
$277.60 |
| Rate for Payer: Aetna Commercial |
$262.17
|
| Rate for Payer: BCBS Trust/PPO |
$251.78
|
| Rate for Payer: BCN Commercial |
$238.36
|
| Rate for Payer: Cash Price |
$246.75
|
| Rate for Payer: Cofinity Commercial |
$265.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.75
|
| Rate for Payer: Healthscope Commercial |
$277.60
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$231.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$262.17
|
| Rate for Payer: Nomi Health Commercial |
$252.92
|
| Rate for Payer: PHP Commercial |
$262.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.49
|
| Rate for Payer: Priority Health HMO/PPO |
$268.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$206.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$271.43
|
| Rate for Payer: UHC Core |
$257.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.33
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$63.27
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.03 |
| Max. Negotiated Rate |
$56.94 |
| Rate for Payer: Aetna Commercial |
$53.78
|
| Rate for Payer: Aetna Medicare |
$16.45
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.77
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.77
|
| Rate for Payer: BCBS Complete |
$25.31
|
| Rate for Payer: BCBS MAPPO |
$15.82
|
| Rate for Payer: BCBS Trust/PPO |
$52.01
|
| Rate for Payer: BCN Commercial |
$49.19
|
| Rate for Payer: BCN Medicare Advantage |
$15.82
|
| Rate for Payer: Cash Price |
$50.62
|
| Rate for Payer: Cofinity Commercial |
$54.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.62
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.82
|
| Rate for Payer: Healthscope Commercial |
$56.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.78
|
| Rate for Payer: Nomi Health Commercial |
$51.88
|
| Rate for Payer: PACE Senior Care Partners |
$15.03
|
| Rate for Payer: PACE SWMI |
$15.82
|
| Rate for Payer: PHP Commercial |
$53.78
|
| Rate for Payer: PHP Medicare Advantage |
$15.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.13
|
| Rate for Payer: Priority Health HMO/PPO |
$55.04
|
| Rate for Payer: Priority Health Medicare |
$15.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.39
|
| Rate for Payer: Railroad Medicare Medicare |
$15.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.68
|
| Rate for Payer: UHC Core |
$52.83
|
| Rate for Payer: UHC Dual Complete DSNP |
$15.82
|
| Rate for Payer: UHC Exchange |
$15.82
|
| Rate for Payer: UHC Medicare Advantage |
$15.82
|
| Rate for Payer: VA VA |
$15.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.45
|
|
