|
AMLODIPINE 10 MG TABLET
|
Facility
IP
|
$157.45
|
|
|
Service Code
|
NDC 0904-6371-61
|
| Hospital Charge Code |
9069
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.03 |
| Max. Negotiated Rate |
$141.70 |
| Rate for Payer: Aetna Commercial |
$133.83
|
| Rate for Payer: BCBS Trust/PPO |
$121.68
|
| Rate for Payer: BCN Commercial |
$121.68
|
| Rate for Payer: Cash Price |
$125.96
|
| Rate for Payer: Cofinity Commercial |
$135.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$125.96
|
| Rate for Payer: Healthscope Commercial |
$141.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$118.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$133.83
|
| Rate for Payer: PHP Commercial |
$133.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$110.22
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$136.98
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$96.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$138.56
|
| Rate for Payer: UHC Core |
$131.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$118.09
|
|
|
AMLODIPINE 2.5 MG TABLET
|
Facility
IP
|
$195.05
|
|
|
Service Code
|
NDC 0904-6369-61
|
| Hospital Charge Code |
9070
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$118.96 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: BCBS Trust/PPO |
$150.73
|
| Rate for Payer: BCN Commercial |
$150.73
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$169.69
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$118.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$171.64
|
| Rate for Payer: UHC Core |
$162.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$164.50
|
|
|
Service Code
|
NDC 0904-6370-61
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.33 |
| Max. Negotiated Rate |
$148.05 |
| Rate for Payer: Aetna Commercial |
$139.82
|
| Rate for Payer: BCBS Trust/PPO |
$127.13
|
| Rate for Payer: BCN Commercial |
$127.13
|
| Rate for Payer: Cash Price |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$141.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.60
|
| Rate for Payer: Healthscope Commercial |
$148.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$123.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.82
|
| Rate for Payer: PHP Commercial |
$139.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.15
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$143.12
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$100.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$144.76
|
| Rate for Payer: UHC Core |
$137.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$123.38
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$1.27
|
|
|
Service Code
|
NDC 50268-084-11
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.77 |
| Max. Negotiated Rate |
$1.14 |
| Rate for Payer: Aetna Commercial |
$1.08
|
| Rate for Payer: BCBS Trust/PPO |
$0.98
|
| Rate for Payer: BCN Commercial |
$0.98
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cofinity Commercial |
$1.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.02
|
| Rate for Payer: Healthscope Commercial |
$1.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.08
|
| Rate for Payer: PHP Commercial |
$1.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.89
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$0.77
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1.12
|
| Rate for Payer: UHC Core |
$1.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.95
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$63.45
|
|
|
Service Code
|
NDC 50268-084-15
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.70 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: BCBS Trust/PPO |
$49.03
|
| Rate for Payer: BCN Commercial |
$49.03
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$44.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$55.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$38.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$55.84
|
| Rate for Payer: UHC Core |
$52.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
IP
|
$16.20
|
|
|
Service Code
|
NDC 904598426
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.88 |
| Max. Negotiated Rate |
$14.58 |
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: BCBS Trust/PPO |
$12.52
|
| Rate for Payer: BCN Commercial |
$12.52
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cofinity Commercial |
$13.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.96
|
| Rate for Payer: Healthscope Commercial |
$14.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.77
|
| Rate for Payer: PHP Commercial |
$13.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.26
|
| Rate for Payer: UHC Core |
$13.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.15
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$67.68
|
|
|
Service Code
|
NDC 0781-6041-58
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.28 |
| Max. Negotiated Rate |
$60.91 |
| Rate for Payer: Aetna Commercial |
$57.53
|
| Rate for Payer: BCBS Trust/PPO |
$52.30
|
| 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 Multiplan/Beech St/PHCS |
$57.53
|
| Rate for Payer: PHP Commercial |
$57.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$58.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$41.28
|
| 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
IP
|
$77.55
|
|
|
Service Code
|
NDC 0781-6041-46
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.30 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: BCBS Trust/PPO |
$59.93
|
| Rate for Payer: BCN Commercial |
$59.93
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$67.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$47.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.24
|
| Rate for Payer: UHC Core |
$64.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$2.59
|
|
|
Service Code
|
NDC 9900-0004-21
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$2.33 |
| Rate for Payer: Aetna Commercial |
$2.20
|
| Rate for Payer: BCBS Trust/PPO |
$2.00
|
| 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 Multiplan/Beech St/PHCS |
$2.20
|
| Rate for Payer: PHP Commercial |
$2.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.81
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.58
|
| 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
IP
|
$88.13
|
|
|
Service Code
|
NDC 0781-6041-55
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.75 |
| Max. Negotiated Rate |
$79.32 |
| Rate for Payer: Aetna Commercial |
$74.91
|
| Rate for Payer: BCBS Trust/PPO |
$68.11
|
| Rate for Payer: BCN Commercial |
$68.11
|
| 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: Healthscope Commercial |
$79.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.91
|
| Rate for Payer: PHP Commercial |
$74.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$76.67
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$53.75
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$77.55
|
| Rate for Payer: UHC Core |
$73.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.10
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$71.44
|
|
|
Service Code
|
NDC 0093-4155-79
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.57 |
| Max. Negotiated Rate |
$64.30 |
| Rate for Payer: Aetna Commercial |
$60.72
|
| Rate for Payer: BCBS Trust/PPO |
$55.21
|
| 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 Multiplan/Beech St/PHCS |
$60.72
|
| Rate for Payer: PHP Commercial |
$60.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$62.15
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$43.57
|
| 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 65862-707-80
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.28 |
| Max. Negotiated Rate |
$60.91 |
| Rate for Payer: Aetna Commercial |
$57.53
|
| Rate for Payer: BCBS Trust/PPO |
$52.30
|
| 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 Multiplan/Beech St/PHCS |
$57.53
|
| Rate for Payer: PHP Commercial |
$57.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.38
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$58.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$41.28
|
| 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
IP
|
$56.40
|
|
|
Service Code
|
NDC 0143-9889-80
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.40 |
| Max. Negotiated Rate |
$50.76 |
| Rate for Payer: Aetna Commercial |
$47.94
|
| Rate for Payer: BCBS Trust/PPO |
$43.59
|
| Rate for Payer: BCN Commercial |
$43.59
|
| 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: Healthscope Commercial |
$50.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$47.94
|
| Rate for Payer: PHP Commercial |
$47.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$39.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$49.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$34.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.63
|
| Rate for Payer: UHC Core |
$47.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.30
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
IP
|
$110.45
|
|
|
Service Code
|
NDC 65862-016-01
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.36 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: BCBS Trust/PPO |
$85.36
|
| 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 Multiplan/Beech St/PHCS |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$96.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.36
|
| 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
IP
|
$159.80
|
|
|
Service Code
|
NDC 0781-2020-01
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.46 |
| Max. Negotiated Rate |
$143.82 |
| Rate for Payer: Aetna Commercial |
$135.83
|
| Rate for Payer: BCBS Trust/PPO |
$123.49
|
| Rate for Payer: BCN Commercial |
$123.49
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$137.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Healthscope Commercial |
$143.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$119.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.83
|
| Rate for Payer: PHP Commercial |
$135.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$139.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$97.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$140.62
|
| Rate for Payer: UHC Core |
$133.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.85
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
IP
|
$110.45
|
|
|
Service Code
|
NDC 57237-030-01
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.36 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: BCBS Trust/PPO |
$85.36
|
| 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 Multiplan/Beech St/PHCS |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$96.09
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.36
|
| 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-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$609.90
|
|
|
Service Code
|
NDC 59651-026-55
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$371.98 |
| Max. Negotiated Rate |
$548.91 |
| Rate for Payer: Aetna Commercial |
$518.42
|
| Rate for Payer: BCBS Trust/PPO |
$471.33
|
| Rate for Payer: BCN Commercial |
$471.33
|
| Rate for Payer: Cash Price |
$487.92
|
| Rate for Payer: Cofinity Commercial |
$524.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$487.92
|
| Rate for Payer: Healthscope Commercial |
$548.91
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$457.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$518.42
|
| Rate for Payer: PHP Commercial |
$518.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$426.93
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$530.61
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$371.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$536.71
|
| Rate for Payer: UHC Core |
$509.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$457.42
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$91.65
|
|
|
Service Code
|
NDC 65862-534-50
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$55.90 |
| Max. Negotiated Rate |
$82.48 |
| Rate for Payer: Aetna Commercial |
$77.90
|
| Rate for Payer: BCBS Trust/PPO |
$70.83
|
| Rate for Payer: BCN Commercial |
$70.83
|
| Rate for Payer: Cash Price |
$73.32
|
| Rate for Payer: Cofinity Commercial |
$78.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$73.32
|
| Rate for Payer: Healthscope Commercial |
$82.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$77.90
|
| Rate for Payer: PHP Commercial |
$77.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$79.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$55.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$80.65
|
| Rate for Payer: UHC Core |
$76.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.74
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$52.82
|
|
|
Service Code
|
NDC 0093-2274-34
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.21 |
| Max. Negotiated Rate |
$47.54 |
| Rate for Payer: Aetna Commercial |
$44.90
|
| Rate for Payer: BCBS Trust/PPO |
$40.82
|
| Rate for Payer: BCN Commercial |
$40.82
|
| Rate for Payer: Cash Price |
$42.26
|
| Rate for Payer: Cofinity Commercial |
$45.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.26
|
| Rate for Payer: Healthscope Commercial |
$47.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.90
|
| Rate for Payer: PHP Commercial |
$44.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.97
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$45.95
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$32.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.48
|
| Rate for Payer: UHC Core |
$44.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.62
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$195.64
|
|
|
Service Code
|
NDC 65862-535-75
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.32 |
| Max. Negotiated Rate |
$176.08 |
| Rate for Payer: Aetna Commercial |
$166.29
|
| Rate for Payer: BCBS Trust/PPO |
$151.19
|
| Rate for Payer: BCN Commercial |
$151.19
|
| Rate for Payer: Cash Price |
$156.51
|
| Rate for Payer: Cofinity Commercial |
$168.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.51
|
| Rate for Payer: Healthscope Commercial |
$176.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$166.29
|
| Rate for Payer: PHP Commercial |
$166.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$170.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$119.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$172.16
|
| Rate for Payer: UHC Core |
$163.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.73
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$308.44
|
|
|
Service Code
|
NDC 0143-9853-75
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.12 |
| Max. Negotiated Rate |
$277.60 |
| Rate for Payer: Aetna Commercial |
$262.17
|
| Rate for Payer: BCBS Trust/PPO |
$238.36
|
| 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 Multiplan/Beech St/PHCS |
$262.17
|
| Rate for Payer: PHP Commercial |
$262.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.91
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$268.34
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$188.12
|
| 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
IP
|
$423.70
|
|
|
Service Code
|
NDC 65862-503-01
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$258.41 |
| Max. Negotiated Rate |
$381.33 |
| Rate for Payer: Aetna Commercial |
$360.14
|
| Rate for Payer: BCBS Trust/PPO |
$327.44
|
| Rate for Payer: BCN Commercial |
$327.44
|
| 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 |
$317.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$360.14
|
| Rate for Payer: PHP Commercial |
$360.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$368.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$258.41
|
| 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 |
$317.78
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$101.28
|
|
|
Service Code
|
NDC 66685-1001-0
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.77 |
| Max. Negotiated Rate |
$91.15 |
| Rate for Payer: Aetna Commercial |
$86.09
|
| Rate for Payer: BCBS Trust/PPO |
$78.27
|
| Rate for Payer: BCN Commercial |
$78.27
|
| 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 Multiplan/Beech St/PHCS |
$86.09
|
| Rate for Payer: PHP Commercial |
$86.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$88.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$61.77
|
| 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
|
$101.28
|
|
|
Service Code
|
NDC 0781-1852-20
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.77 |
| Max. Negotiated Rate |
$91.15 |
| Rate for Payer: Aetna Commercial |
$86.09
|
| Rate for Payer: BCBS Trust/PPO |
$78.27
|
| Rate for Payer: BCN Commercial |
$78.27
|
| 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 Multiplan/Beech St/PHCS |
$86.09
|
| Rate for Payer: PHP Commercial |
$86.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$88.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$61.77
|
| 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
|
$62.13
|
|
|
Service Code
|
NDC 0093-2275-34
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.89 |
| Max. Negotiated Rate |
$55.92 |
| Rate for Payer: Aetna Commercial |
$52.81
|
| Rate for Payer: BCBS Trust/PPO |
$48.01
|
| Rate for Payer: BCN Commercial |
$48.01
|
| Rate for Payer: Cash Price |
$49.70
|
| Rate for Payer: Cofinity Commercial |
$53.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.70
|
| Rate for Payer: Healthscope Commercial |
$55.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$46.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.81
|
| Rate for Payer: PHP Commercial |
$52.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$54.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$37.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$54.67
|
| Rate for Payer: UHC Core |
$51.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$46.60
|
|
