|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 65862001601
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.87 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: BCBS Trust/PPO |
$91.22
|
| Rate for Payer: BCN Commercial |
$91.22
|
| 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 |
$99.41
|
| 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: Opus (Opus Packaging Group) HMA |
$82.84
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$96.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$76.87
|
| 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 |
$19.47 |
| Max. Negotiated Rate |
$99.41 |
| 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 |
$20.44
|
| Rate for Payer: BCBS MAPPO |
$27.61
|
| Rate for Payer: BCBS Trust/PPO |
$90.80
|
| Rate for Payer: BCN Commercial |
$90.80
|
| 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 |
$99.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Mclaren Medicaid |
$19.47
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$28.99
|
| Rate for Payer: Meridian Medicaid |
$20.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.75
|
| Rate for Payer: Molina Medicare/Medicaid |
$30.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: Nomi Health Commercial |
$90.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.84
|
| 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 Choice Medicaid |
$19.47
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$96.09
|
| Rate for Payer: Priority Health Medicare |
$27.89
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$76.87
|
| 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 Exchange |
$27.61
|
| Rate for Payer: UHC Medicaid |
$19.47
|
| Rate for Payer: UHC Medicare Advantage |
$27.61
|
| Rate for Payer: UHCCP Medicaid |
$19.47
|
| Rate for Payer: VA VA |
$27.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 57237003001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.87 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: BCBS Trust/PPO |
$91.22
|
| Rate for Payer: BCN Commercial |
$91.22
|
| 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 |
$99.41
|
| 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: Opus (Opus Packaging Group) HMA |
$82.84
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$96.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$76.87
|
| 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
|
$166.85
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.42 |
| Max. Negotiated Rate |
$150.16 |
| Rate for Payer: Aetna Commercial |
$141.82
|
| Rate for Payer: Aetna Medicare |
$43.38
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$52.14
|
| Rate for Payer: Amish Plain Church Group Commercial |
$52.14
|
| Rate for Payer: BCBS Complete |
$30.88
|
| Rate for Payer: BCBS MAPPO |
$41.71
|
| Rate for Payer: BCBS Trust/PPO |
$137.17
|
| Rate for Payer: BCN Commercial |
$137.17
|
| Rate for Payer: BCN Medicare Advantage |
$41.71
|
| Rate for Payer: Cash Price |
$133.48
|
| Rate for Payer: Cofinity Commercial |
$143.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.48
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$41.71
|
| Rate for Payer: Healthscope Commercial |
$150.16
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$125.14
|
| Rate for Payer: Mclaren Medicaid |
$29.42
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$43.80
|
| Rate for Payer: Meridian Medicaid |
$30.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.97
|
| Rate for Payer: Molina Medicare/Medicaid |
$45.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.82
|
| Rate for Payer: Nomi Health Commercial |
$136.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$125.14
|
| Rate for Payer: PACE Senior Care Partners |
$39.63
|
| Rate for Payer: PACE SWMI |
$41.71
|
| Rate for Payer: PHP Commercial |
$141.82
|
| Rate for Payer: PHP Medicare Advantage |
$41.71
|
| Rate for Payer: Priority Health Choice Medicaid |
$29.42
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$145.16
|
| Rate for Payer: Priority Health Medicare |
$42.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$116.13
|
| Rate for Payer: Railroad Medicare Medicare |
$41.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$146.83
|
| Rate for Payer: UHC Core |
$139.32
|
| Rate for Payer: UHC Exchange |
$41.71
|
| Rate for Payer: UHC Medicaid |
$29.42
|
| Rate for Payer: UHC Medicare Advantage |
$41.71
|
| Rate for Payer: UHCCP Medicaid |
$29.42
|
| Rate for Payer: VA VA |
$41.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$125.14
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$619.88
|
|
|
Service Code
|
NDC 59651002655
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$431.44 |
| Max. Negotiated Rate |
$557.89 |
| Rate for Payer: Aetna Commercial |
$526.90
|
| Rate for Payer: BCBS Trust/PPO |
$511.96
|
| Rate for Payer: BCN Commercial |
$511.96
|
| Rate for Payer: Cash Price |
$495.90
|
| Rate for Payer: Cofinity Commercial |
$533.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$495.90
|
| Rate for Payer: Healthscope Commercial |
$557.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$464.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$526.90
|
| Rate for Payer: Nomi Health Commercial |
$508.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$464.91
|
| Rate for Payer: PHP Commercial |
$526.90
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$539.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$431.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$545.49
|
| Rate for Payer: UHC Core |
$517.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$464.91
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$619.88
|
|
|
Service Code
|
NDC 59651002655
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.28 |
| Max. Negotiated Rate |
$557.89 |
| Rate for Payer: Aetna Commercial |
$526.90
|
| Rate for Payer: Aetna Medicare |
$161.17
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$193.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$193.71
|
| Rate for Payer: BCBS Complete |
$114.74
|
| Rate for Payer: BCBS MAPPO |
$154.97
|
| Rate for Payer: BCBS Trust/PPO |
$509.60
|
| Rate for Payer: BCN Commercial |
$509.60
|
| Rate for Payer: BCN Medicare Advantage |
$154.97
|
| Rate for Payer: Cash Price |
$495.90
|
| Rate for Payer: Cofinity Commercial |
$533.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$495.90
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$154.97
|
| Rate for Payer: Healthscope Commercial |
$557.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$464.91
|
| Rate for Payer: Mclaren Medicaid |
$109.28
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$162.72
|
| Rate for Payer: Meridian Medicaid |
$114.74
|
| Rate for Payer: MI Amish Medical Board Commercial |
$178.22
|
| Rate for Payer: Molina Medicare/Medicaid |
$170.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$526.90
|
| Rate for Payer: Nomi Health Commercial |
$508.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$464.91
|
| Rate for Payer: PACE Senior Care Partners |
$147.22
|
| Rate for Payer: PACE SWMI |
$154.97
|
| Rate for Payer: PHP Commercial |
$526.90
|
| Rate for Payer: PHP Medicare Advantage |
$154.97
|
| Rate for Payer: Priority Health Choice Medicaid |
$109.28
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$539.30
|
| Rate for Payer: Priority Health Medicare |
$156.52
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$431.44
|
| Rate for Payer: Railroad Medicare Medicare |
$154.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$545.49
|
| Rate for Payer: UHC Core |
$517.60
|
| Rate for Payer: UHC Exchange |
$154.97
|
| Rate for Payer: UHC Medicaid |
$109.28
|
| Rate for Payer: UHC Medicare Advantage |
$154.97
|
| Rate for Payer: UHCCP Medicaid |
$109.28
|
| Rate for Payer: VA VA |
$154.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$464.91
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$111.63
|
|
|
Service Code
|
NDC 65862053450
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.69 |
| Max. Negotiated Rate |
$100.47 |
| Rate for Payer: Aetna Commercial |
$94.89
|
| Rate for Payer: BCBS Trust/PPO |
$92.20
|
| Rate for Payer: BCN Commercial |
$92.20
|
| Rate for Payer: Cash Price |
$89.30
|
| Rate for Payer: Cofinity Commercial |
$96.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.30
|
| Rate for Payer: Healthscope Commercial |
$100.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.89
|
| Rate for Payer: Nomi Health Commercial |
$91.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$83.72
|
| Rate for Payer: PHP Commercial |
$94.89
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$97.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$77.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.23
|
| Rate for Payer: UHC Core |
$93.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.72
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$111.63
|
|
|
Service Code
|
NDC 65862053450
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.68 |
| Max. Negotiated Rate |
$100.47 |
| Rate for Payer: Aetna Commercial |
$94.89
|
| Rate for Payer: Aetna Medicare |
$29.02
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$34.88
|
| Rate for Payer: Amish Plain Church Group Commercial |
$34.88
|
| Rate for Payer: BCBS Complete |
$20.66
|
| Rate for Payer: BCBS MAPPO |
$27.91
|
| Rate for Payer: BCBS Trust/PPO |
$91.77
|
| Rate for Payer: BCN Commercial |
$91.77
|
| Rate for Payer: BCN Medicare Advantage |
$27.91
|
| Rate for Payer: Cash Price |
$89.30
|
| Rate for Payer: Cofinity Commercial |
$96.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.30
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$27.91
|
| Rate for Payer: Healthscope Commercial |
$100.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.72
|
| Rate for Payer: Mclaren Medicaid |
$19.68
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$29.30
|
| Rate for Payer: Meridian Medicaid |
$20.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$32.09
|
| Rate for Payer: Molina Medicare/Medicaid |
$30.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.89
|
| Rate for Payer: Nomi Health Commercial |
$91.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$83.72
|
| Rate for Payer: PACE Senior Care Partners |
$26.51
|
| Rate for Payer: PACE SWMI |
$27.91
|
| Rate for Payer: PHP Commercial |
$94.89
|
| Rate for Payer: PHP Medicare Advantage |
$27.91
|
| Rate for Payer: Priority Health Choice Medicaid |
$19.68
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$97.12
|
| Rate for Payer: Priority Health Medicare |
$28.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$77.69
|
| Rate for Payer: Railroad Medicare Medicare |
$27.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$98.23
|
| Rate for Payer: UHC Core |
$93.21
|
| Rate for Payer: UHC Exchange |
$27.91
|
| Rate for Payer: UHC Medicaid |
$19.68
|
| Rate for Payer: UHC Medicare Advantage |
$27.91
|
| Rate for Payer: UHCCP Medicaid |
$19.68
|
| Rate for Payer: VA VA |
$27.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.72
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$62.70
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.64 |
| Max. Negotiated Rate |
$56.43 |
| Rate for Payer: Aetna Commercial |
$53.30
|
| Rate for Payer: BCBS Trust/PPO |
$51.78
|
| Rate for Payer: BCN Commercial |
$51.78
|
| Rate for Payer: Cash Price |
$50.16
|
| Rate for Payer: Cofinity Commercial |
$53.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.16
|
| Rate for Payer: Healthscope Commercial |
$56.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.30
|
| Rate for Payer: Nomi Health Commercial |
$51.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.02
|
| Rate for Payer: PHP Commercial |
$53.30
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$54.55
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$43.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.18
|
| Rate for Payer: UHC Core |
$52.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.02
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$62.70
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.05 |
| Max. Negotiated Rate |
$56.43 |
| Rate for Payer: Aetna Commercial |
$53.30
|
| Rate for Payer: Aetna Medicare |
$16.30
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$19.59
|
| Rate for Payer: Amish Plain Church Group Commercial |
$19.59
|
| Rate for Payer: BCBS Complete |
$11.61
|
| Rate for Payer: BCBS MAPPO |
$15.68
|
| Rate for Payer: BCBS Trust/PPO |
$51.55
|
| Rate for Payer: BCN Commercial |
$51.55
|
| Rate for Payer: BCN Medicare Advantage |
$15.68
|
| Rate for Payer: Cash Price |
$50.16
|
| Rate for Payer: Cofinity Commercial |
$53.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.16
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$15.68
|
| Rate for Payer: Healthscope Commercial |
$56.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.02
|
| Rate for Payer: Mclaren Medicaid |
$11.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.46
|
| Rate for Payer: Meridian Medicaid |
$11.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.03
|
| Rate for Payer: Molina Medicare/Medicaid |
$17.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.30
|
| Rate for Payer: Nomi Health Commercial |
$51.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.02
|
| Rate for Payer: PACE Senior Care Partners |
$14.89
|
| Rate for Payer: PACE SWMI |
$15.68
|
| Rate for Payer: PHP Commercial |
$53.30
|
| Rate for Payer: PHP Medicare Advantage |
$15.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$11.05
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$54.55
|
| Rate for Payer: Priority Health Medicare |
$15.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$43.64
|
| Rate for Payer: Railroad Medicare Medicare |
$15.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.18
|
| Rate for Payer: UHC Core |
$52.35
|
| Rate for Payer: UHC Exchange |
$15.68
|
| Rate for Payer: UHC Medicaid |
$11.05
|
| Rate for Payer: UHC Medicare Advantage |
$15.68
|
| Rate for Payer: UHCCP Medicaid |
$11.05
|
| Rate for Payer: VA VA |
$15.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.02
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$311.97
|
|
|
Service Code
|
NDC 00143985375
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.00 |
| Max. Negotiated Rate |
$280.77 |
| Rate for Payer: Aetna Commercial |
$265.17
|
| Rate for Payer: Aetna Medicare |
$81.11
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$97.49
|
| Rate for Payer: Amish Plain Church Group Commercial |
$97.49
|
| Rate for Payer: BCBS Complete |
$57.75
|
| Rate for Payer: BCBS MAPPO |
$77.99
|
| Rate for Payer: BCBS Trust/PPO |
$256.47
|
| Rate for Payer: BCN Commercial |
$256.47
|
| Rate for Payer: BCN Medicare Advantage |
$77.99
|
| Rate for Payer: Cash Price |
$249.58
|
| Rate for Payer: Cofinity Commercial |
$268.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$77.99
|
| Rate for Payer: Healthscope Commercial |
$280.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$233.98
|
| Rate for Payer: Mclaren Medicaid |
$55.00
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$81.89
|
| Rate for Payer: Meridian Medicaid |
$57.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$89.69
|
| Rate for Payer: Molina Medicare/Medicaid |
$85.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.17
|
| Rate for Payer: Nomi Health Commercial |
$255.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$233.98
|
| Rate for Payer: PACE Senior Care Partners |
$74.09
|
| Rate for Payer: PACE SWMI |
$77.99
|
| Rate for Payer: PHP Commercial |
$265.17
|
| Rate for Payer: PHP Medicare Advantage |
$77.99
|
| Rate for Payer: Priority Health Choice Medicaid |
$55.00
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$271.41
|
| Rate for Payer: Priority Health Medicare |
$78.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$217.13
|
| Rate for Payer: Railroad Medicare Medicare |
$77.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$274.53
|
| Rate for Payer: UHC Core |
$260.49
|
| Rate for Payer: UHC Exchange |
$77.99
|
| Rate for Payer: UHC Medicaid |
$55.00
|
| Rate for Payer: UHC Medicare Advantage |
$77.99
|
| Rate for Payer: UHCCP Medicaid |
$55.00
|
| Rate for Payer: VA VA |
$77.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$233.98
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$149.82
|
|
|
Service Code
|
NDC 65862053575
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.41 |
| Max. Negotiated Rate |
$134.84 |
| Rate for Payer: Aetna Commercial |
$127.35
|
| Rate for Payer: Aetna Medicare |
$38.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$46.82
|
| Rate for Payer: Amish Plain Church Group Commercial |
$46.82
|
| Rate for Payer: BCBS Complete |
$27.73
|
| Rate for Payer: BCBS MAPPO |
$37.45
|
| Rate for Payer: BCBS Trust/PPO |
$123.17
|
| Rate for Payer: BCN Commercial |
$123.17
|
| Rate for Payer: BCN Medicare Advantage |
$37.45
|
| Rate for Payer: Cash Price |
$119.86
|
| Rate for Payer: Cofinity Commercial |
$128.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.86
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$37.45
|
| Rate for Payer: Healthscope Commercial |
$134.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.36
|
| Rate for Payer: Mclaren Medicaid |
$26.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$39.33
|
| Rate for Payer: Meridian Medicaid |
$27.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$43.07
|
| Rate for Payer: Molina Medicare/Medicaid |
$41.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.35
|
| Rate for Payer: Nomi Health Commercial |
$122.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$112.36
|
| Rate for Payer: PACE Senior Care Partners |
$35.58
|
| Rate for Payer: PACE SWMI |
$37.45
|
| Rate for Payer: PHP Commercial |
$127.35
|
| Rate for Payer: PHP Medicare Advantage |
$37.45
|
| Rate for Payer: Priority Health Choice Medicaid |
$26.41
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$130.34
|
| Rate for Payer: Priority Health Medicare |
$37.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$104.27
|
| Rate for Payer: Railroad Medicare Medicare |
$37.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$131.84
|
| Rate for Payer: UHC Core |
$125.10
|
| Rate for Payer: UHC Exchange |
$37.45
|
| Rate for Payer: UHC Medicaid |
$26.41
|
| Rate for Payer: UHC Medicare Advantage |
$37.45
|
| Rate for Payer: UHCCP Medicaid |
$26.41
|
| Rate for Payer: VA VA |
$37.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.36
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$311.97
|
|
|
Service Code
|
NDC 00143985375
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$217.13 |
| Max. Negotiated Rate |
$280.77 |
| Rate for Payer: Aetna Commercial |
$265.17
|
| Rate for Payer: BCBS Trust/PPO |
$257.66
|
| Rate for Payer: BCN Commercial |
$257.66
|
| Rate for Payer: Cash Price |
$249.58
|
| Rate for Payer: Cofinity Commercial |
$268.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.58
|
| Rate for Payer: Healthscope Commercial |
$280.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$233.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.17
|
| Rate for Payer: Nomi Health Commercial |
$255.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$233.98
|
| Rate for Payer: PHP Commercial |
$265.17
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$271.41
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$217.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$274.53
|
| Rate for Payer: UHC Core |
$260.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$233.98
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$149.82
|
|
|
Service Code
|
NDC 65862053575
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.27 |
| Max. Negotiated Rate |
$134.84 |
| Rate for Payer: Aetna Commercial |
$127.35
|
| Rate for Payer: BCBS Trust/PPO |
$123.74
|
| Rate for Payer: BCN Commercial |
$123.74
|
| Rate for Payer: Cash Price |
$119.86
|
| Rate for Payer: Cofinity Commercial |
$128.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$119.86
|
| Rate for Payer: Healthscope Commercial |
$134.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$112.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$127.35
|
| Rate for Payer: Nomi Health Commercial |
$122.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$112.36
|
| Rate for Payer: PHP Commercial |
$127.35
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$130.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$104.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$131.84
|
| Rate for Payer: UHC Core |
$125.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$112.36
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$6.31
|
|
|
Service Code
|
NDC 60687080311
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.11 |
| Max. Negotiated Rate |
$5.68 |
| Rate for Payer: Aetna Commercial |
$5.36
|
| Rate for Payer: Aetna Medicare |
$1.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.97
|
| Rate for Payer: BCBS Complete |
$1.17
|
| Rate for Payer: BCBS MAPPO |
$1.58
|
| Rate for Payer: BCBS Trust/PPO |
$5.19
|
| Rate for Payer: BCN Commercial |
$5.19
|
| Rate for Payer: BCN Medicare Advantage |
$1.58
|
| Rate for Payer: Cash Price |
$5.05
|
| Rate for Payer: Cofinity Commercial |
$5.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.05
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.58
|
| Rate for Payer: Healthscope Commercial |
$5.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.73
|
| Rate for Payer: Mclaren Medicaid |
$1.11
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.66
|
| Rate for Payer: Meridian Medicaid |
$1.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.81
|
| Rate for Payer: Molina Medicare/Medicaid |
$1.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.36
|
| Rate for Payer: Nomi Health Commercial |
$5.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.73
|
| Rate for Payer: PACE Senior Care Partners |
$1.50
|
| Rate for Payer: PACE SWMI |
$1.58
|
| Rate for Payer: PHP Commercial |
$5.36
|
| Rate for Payer: PHP Medicare Advantage |
$1.58
|
| Rate for Payer: Priority Health Choice Medicaid |
$1.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$5.49
|
| Rate for Payer: Priority Health Medicare |
$1.59
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.39
|
| Rate for Payer: Railroad Medicare Medicare |
$1.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.55
|
| Rate for Payer: UHC Core |
$5.27
|
| Rate for Payer: UHC Exchange |
$1.58
|
| Rate for Payer: UHC Medicaid |
$1.11
|
| Rate for Payer: UHC Medicare Advantage |
$1.58
|
| Rate for Payer: UHCCP Medicaid |
$1.11
|
| Rate for Payer: VA VA |
$1.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.73
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$423.70
|
|
|
Service Code
|
NDC 65862050301
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.70 |
| Max. Negotiated Rate |
$381.33 |
| Rate for Payer: Aetna Commercial |
$360.14
|
| Rate for Payer: Aetna Medicare |
$110.16
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$132.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$132.41
|
| Rate for Payer: BCBS Complete |
$78.43
|
| Rate for Payer: BCBS MAPPO |
$105.92
|
| Rate for Payer: BCBS Trust/PPO |
$348.32
|
| Rate for Payer: BCN Commercial |
$348.32
|
| Rate for Payer: BCN Medicare Advantage |
$105.92
|
| Rate for Payer: Cash Price |
$338.96
|
| Rate for Payer: Cofinity Commercial |
$364.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$105.92
|
| Rate for Payer: Healthscope Commercial |
$381.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.77
|
| Rate for Payer: Mclaren Medicaid |
$74.70
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$111.22
|
| Rate for Payer: Meridian Medicaid |
$78.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$121.81
|
| Rate for Payer: Molina Medicare/Medicaid |
$116.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.14
|
| Rate for Payer: Nomi Health Commercial |
$347.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$317.77
|
| Rate for Payer: PACE Senior Care Partners |
$100.63
|
| Rate for Payer: PACE SWMI |
$105.92
|
| Rate for Payer: PHP Commercial |
$360.14
|
| Rate for Payer: PHP Medicare Advantage |
$105.92
|
| Rate for Payer: Priority Health Choice Medicaid |
$74.70
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$368.62
|
| Rate for Payer: Priority Health Medicare |
$106.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$294.90
|
| Rate for Payer: Railroad Medicare Medicare |
$105.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$372.86
|
| Rate for Payer: UHC Core |
$353.79
|
| Rate for Payer: UHC Exchange |
$105.92
|
| Rate for Payer: UHC Medicaid |
$74.70
|
| Rate for Payer: UHC Medicare Advantage |
$105.92
|
| Rate for Payer: UHCCP Medicaid |
$74.70
|
| Rate for Payer: VA VA |
$105.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.77
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$630.72
|
|
|
Service Code
|
NDC 60687080301
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$438.98 |
| Max. Negotiated Rate |
$567.65 |
| Rate for Payer: Aetna Commercial |
$536.11
|
| Rate for Payer: BCBS Trust/PPO |
$520.91
|
| Rate for Payer: BCN Commercial |
$520.91
|
| Rate for Payer: Cash Price |
$504.58
|
| Rate for Payer: Cofinity Commercial |
$542.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$504.58
|
| Rate for Payer: Healthscope Commercial |
$567.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$473.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.11
|
| Rate for Payer: Nomi Health Commercial |
$517.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$473.04
|
| Rate for Payer: PHP Commercial |
$536.11
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$548.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$438.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$555.03
|
| Rate for Payer: UHC Core |
$526.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$473.04
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$630.72
|
|
|
Service Code
|
NDC 60687080301
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.20 |
| Max. Negotiated Rate |
$567.65 |
| Rate for Payer: Aetna Commercial |
$536.11
|
| Rate for Payer: Aetna Medicare |
$163.99
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$197.10
|
| Rate for Payer: Amish Plain Church Group Commercial |
$197.10
|
| Rate for Payer: BCBS Complete |
$116.75
|
| Rate for Payer: BCBS MAPPO |
$157.68
|
| Rate for Payer: BCBS Trust/PPO |
$518.51
|
| Rate for Payer: BCN Commercial |
$518.51
|
| Rate for Payer: BCN Medicare Advantage |
$157.68
|
| Rate for Payer: Cash Price |
$504.58
|
| Rate for Payer: Cofinity Commercial |
$542.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$504.58
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$157.68
|
| Rate for Payer: Healthscope Commercial |
$567.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$473.04
|
| Rate for Payer: Mclaren Medicaid |
$111.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$165.56
|
| Rate for Payer: Meridian Medicaid |
$116.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$181.33
|
| Rate for Payer: Molina Medicare/Medicaid |
$173.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$536.11
|
| Rate for Payer: Nomi Health Commercial |
$517.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$473.04
|
| Rate for Payer: PACE Senior Care Partners |
$149.80
|
| Rate for Payer: PACE SWMI |
$157.68
|
| Rate for Payer: PHP Commercial |
$536.11
|
| Rate for Payer: PHP Medicare Advantage |
$157.68
|
| Rate for Payer: Priority Health Choice Medicaid |
$111.20
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$548.73
|
| Rate for Payer: Priority Health Medicare |
$159.26
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$438.98
|
| Rate for Payer: Railroad Medicare Medicare |
$157.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$555.03
|
| Rate for Payer: UHC Core |
$526.65
|
| Rate for Payer: UHC Exchange |
$157.68
|
| Rate for Payer: UHC Medicaid |
$111.20
|
| Rate for Payer: UHC Medicare Advantage |
$157.68
|
| Rate for Payer: UHCCP Medicaid |
$111.20
|
| Rate for Payer: VA VA |
$157.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$473.04
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$101.86
|
|
|
Service Code
|
NDC 66685100100
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.96 |
| Max. Negotiated Rate |
$91.67 |
| Rate for Payer: Aetna Commercial |
$86.58
|
| Rate for Payer: Aetna Medicare |
$26.48
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31.83
|
| Rate for Payer: BCBS Complete |
$18.85
|
| Rate for Payer: BCBS MAPPO |
$25.46
|
| Rate for Payer: BCBS Trust/PPO |
$83.74
|
| Rate for Payer: BCN Commercial |
$83.74
|
| Rate for Payer: BCN Medicare Advantage |
$25.46
|
| Rate for Payer: Cash Price |
$81.49
|
| Rate for Payer: Cofinity Commercial |
$87.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.49
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25.46
|
| Rate for Payer: Healthscope Commercial |
$91.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$76.39
|
| Rate for Payer: Mclaren Medicaid |
$17.96
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$26.74
|
| Rate for Payer: Meridian Medicaid |
$18.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29.28
|
| Rate for Payer: Molina Medicare/Medicaid |
$28.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.58
|
| Rate for Payer: Nomi Health Commercial |
$83.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$76.39
|
| Rate for Payer: PACE Senior Care Partners |
$24.19
|
| Rate for Payer: PACE SWMI |
$25.46
|
| Rate for Payer: PHP Commercial |
$86.58
|
| Rate for Payer: PHP Medicare Advantage |
$25.46
|
| Rate for Payer: Priority Health Choice Medicaid |
$17.96
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$88.62
|
| Rate for Payer: Priority Health Medicare |
$25.72
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$70.89
|
| Rate for Payer: Railroad Medicare Medicare |
$25.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$89.64
|
| Rate for Payer: UHC Core |
$85.05
|
| Rate for Payer: UHC Exchange |
$25.46
|
| Rate for Payer: UHC Medicaid |
$17.96
|
| Rate for Payer: UHC Medicare Advantage |
$25.46
|
| Rate for Payer: UHCCP Medicaid |
$17.96
|
| Rate for Payer: VA VA |
$25.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$76.39
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$63.27
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.04 |
| Max. Negotiated Rate |
$56.94 |
| Rate for Payer: Aetna Commercial |
$53.78
|
| Rate for Payer: BCBS Trust/PPO |
$52.25
|
| Rate for Payer: BCN Commercial |
$52.25
|
| 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: Healthscope Commercial |
$56.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.78
|
| Rate for Payer: Nomi Health Commercial |
$51.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.45
|
| Rate for Payer: PHP Commercial |
$53.78
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$55.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$44.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.68
|
| Rate for Payer: UHC Core |
$52.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.45
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$101.28
|
|
|
Service Code
|
NDC 00781185220
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.86 |
| Max. Negotiated Rate |
$91.15 |
| Rate for Payer: Aetna Commercial |
$86.09
|
| Rate for Payer: Aetna Medicare |
$26.33
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31.65
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31.65
|
| Rate for Payer: BCBS Complete |
$18.75
|
| Rate for Payer: BCBS MAPPO |
$25.32
|
| Rate for Payer: BCBS Trust/PPO |
$83.26
|
| Rate for Payer: BCN Commercial |
$83.26
|
| Rate for Payer: BCN Medicare Advantage |
$25.32
|
| Rate for Payer: Cash Price |
$81.02
|
| Rate for Payer: Cofinity Commercial |
$87.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.02
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25.32
|
| Rate for Payer: Healthscope Commercial |
$91.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.96
|
| Rate for Payer: Mclaren Medicaid |
$17.86
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$26.59
|
| Rate for Payer: Meridian Medicaid |
$18.75
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29.12
|
| Rate for Payer: Molina Medicare/Medicaid |
$27.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.09
|
| Rate for Payer: Nomi Health Commercial |
$83.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.96
|
| Rate for Payer: PACE Senior Care Partners |
$24.05
|
| Rate for Payer: PACE SWMI |
$25.32
|
| Rate for Payer: PHP Commercial |
$86.09
|
| Rate for Payer: PHP Medicare Advantage |
$25.32
|
| Rate for Payer: Priority Health Choice Medicaid |
$17.86
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$88.11
|
| Rate for Payer: Priority Health Medicare |
$25.57
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$70.49
|
| Rate for Payer: Railroad Medicare Medicare |
$25.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$89.13
|
| Rate for Payer: UHC Core |
$84.57
|
| Rate for Payer: UHC Exchange |
$25.32
|
| Rate for Payer: UHC Medicaid |
$17.86
|
| Rate for Payer: UHC Medicare Advantage |
$25.32
|
| Rate for Payer: UHCCP Medicaid |
$17.86
|
| Rate for Payer: VA VA |
$25.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.96
|
|
|
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 |
$11.15 |
| 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 |
$11.71
|
| Rate for Payer: BCBS MAPPO |
$15.82
|
| Rate for Payer: BCBS Trust/PPO |
$52.01
|
| Rate for Payer: BCN Commercial |
$52.01
|
| 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: Mclaren Medicaid |
$11.15
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$16.61
|
| Rate for Payer: Meridian Medicaid |
$11.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.19
|
| Rate for Payer: Molina Medicare/Medicaid |
$17.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.78
|
| Rate for Payer: Nomi Health Commercial |
$51.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.45
|
| 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 Choice Medicaid |
$11.15
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$55.04
|
| Rate for Payer: Priority Health Medicare |
$15.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$44.04
|
| 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 Exchange |
$15.82
|
| Rate for Payer: UHC Medicaid |
$11.15
|
| Rate for Payer: UHC Medicare Advantage |
$15.82
|
| Rate for Payer: UHCCP Medicaid |
$11.15
|
| Rate for Payer: VA VA |
$15.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.45
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$423.70
|
|
|
Service Code
|
NDC 65862050301
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$294.90 |
| Max. Negotiated Rate |
$381.33 |
| Rate for Payer: Aetna Commercial |
$360.14
|
| Rate for Payer: BCBS Trust/PPO |
$349.93
|
| Rate for Payer: BCN Commercial |
$349.93
|
| Rate for Payer: Cash Price |
$338.96
|
| Rate for Payer: Cofinity Commercial |
$364.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.96
|
| Rate for Payer: Healthscope Commercial |
$381.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.14
|
| Rate for Payer: Nomi Health Commercial |
$347.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$317.77
|
| Rate for Payer: PHP Commercial |
$360.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$368.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$294.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$372.86
|
| Rate for Payer: UHC Core |
$353.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.77
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$101.28
|
|
|
Service Code
|
NDC 00781185220
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.49 |
| Max. Negotiated Rate |
$91.15 |
| Rate for Payer: Aetna Commercial |
$86.09
|
| Rate for Payer: BCBS Trust/PPO |
$83.65
|
| Rate for Payer: BCN Commercial |
$83.65
|
| Rate for Payer: Cash Price |
$81.02
|
| Rate for Payer: Cofinity Commercial |
$87.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.02
|
| Rate for Payer: Healthscope Commercial |
$91.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$75.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.09
|
| Rate for Payer: Nomi Health Commercial |
$83.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$75.96
|
| Rate for Payer: PHP Commercial |
$86.09
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$88.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$70.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$89.13
|
| Rate for Payer: UHC Core |
$84.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$75.96
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$101.86
|
|
|
Service Code
|
NDC 66685100100
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.89 |
| Max. Negotiated Rate |
$91.67 |
| Rate for Payer: Aetna Commercial |
$86.58
|
| Rate for Payer: BCBS Trust/PPO |
$84.13
|
| Rate for Payer: BCN Commercial |
$84.13
|
| Rate for Payer: Cash Price |
$81.49
|
| Rate for Payer: Cofinity Commercial |
$87.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.49
|
| Rate for Payer: Healthscope Commercial |
$91.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$76.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.58
|
| Rate for Payer: Nomi Health Commercial |
$83.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$76.39
|
| Rate for Payer: PHP Commercial |
$86.58
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO |
$88.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$70.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$89.64
|
| Rate for Payer: UHC Core |
$85.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$76.39
|
|
