|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$1.84
|
|
|
Service Code
|
NDC 51079-451-01
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.81 |
| Max. Negotiated Rate |
$1.66 |
| Rate for Payer: Aetna American Axle |
$1.20
|
| Rate for Payer: Aetna Commercial |
$1.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1.20
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cofinity Commercial |
$1.29
|
| Rate for Payer: Cofinity Commercial |
$1.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.47
|
| Rate for Payer: Healthscope Commercial |
$1.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.56
|
| Rate for Payer: PHP Commercial |
$1.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.29
|
| Rate for Payer: Priority Health SBD |
$1.16
|
| Rate for Payer: UMR Bronson Commercial |
$0.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.38
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$183.30
|
|
|
Service Code
|
NDC 51079-451-20
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.65 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna American Axle |
$119.14
|
| Rate for Payer: Aetna Commercial |
$155.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.14
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Commercial |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$164.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$128.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$155.80
|
| Rate for Payer: PHP Commercial |
$155.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health SBD |
$115.48
|
| Rate for Payer: UMR Bronson Commercial |
$80.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.48
|
|
|
AMLODIPINE BENZOATE 1 MG/ML ORAL SUSPENSION
|
Facility
IP
|
$1,714.95
|
|
|
Service Code
|
NDC 52652-5001-1
|
| Hospital Charge Code |
190812
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$754.58 |
| Max. Negotiated Rate |
$1,543.46 |
| Rate for Payer: Aetna American Axle |
$1,114.72
|
| Rate for Payer: Aetna Commercial |
$1,457.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,114.72
|
| Rate for Payer: Cash Price |
$1,371.96
|
| Rate for Payer: Cofinity Commercial |
$1,200.46
|
| Rate for Payer: Cofinity Commercial |
$1,474.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,371.96
|
| Rate for Payer: Healthscope Commercial |
$1,543.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,200.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,286.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1,457.71
|
| Rate for Payer: PHP Commercial |
$1,457.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,200.46
|
| Rate for Payer: Priority Health SBD |
$1,080.42
|
| Rate for Payer: UMR Bronson Commercial |
$754.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,286.21
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
IP
|
$16.20
|
|
|
Service Code
|
NDC 904598426
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.13 |
| Max. Negotiated Rate |
$14.58 |
| Rate for Payer: Aetna American Axle |
$10.53
|
| Rate for Payer: Aetna Commercial |
$13.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.53
|
| Rate for Payer: Cash Price |
$12.96
|
| Rate for Payer: Cofinity Commercial |
$11.34
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$11.34
|
| 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 SBD |
$10.21
|
| Rate for Payer: UMR Bronson Commercial |
$7.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.15
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
IP
|
$65.37
|
|
|
Service Code
|
NDC 45802-419-54
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.76 |
| Max. Negotiated Rate |
$58.83 |
| Rate for Payer: Aetna American Axle |
$42.49
|
| Rate for Payer: Aetna Commercial |
$55.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.49
|
| Rate for Payer: Cash Price |
$52.30
|
| Rate for Payer: Cofinity Commercial |
$56.22
|
| Rate for Payer: Cofinity Commercial |
$45.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$52.30
|
| Rate for Payer: Healthscope Commercial |
$58.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$49.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$55.56
|
| Rate for Payer: PHP Commercial |
$55.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.76
|
| Rate for Payer: Priority Health SBD |
$41.18
|
| Rate for Payer: UMR Bronson Commercial |
$28.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$49.03
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
IP
|
$22.84
|
|
|
Service Code
|
NDC 63044-484-09
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.05 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna American Axle |
$14.85
|
| Rate for Payer: Aetna Commercial |
$19.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.85
|
| Rate for Payer: Cash Price |
$18.27
|
| Rate for Payer: Cofinity Commercial |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$19.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.27
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.41
|
| Rate for Payer: PHP Commercial |
$19.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.99
|
| Rate for Payer: Priority Health SBD |
$14.39
|
| Rate for Payer: UMR Bronson Commercial |
$10.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.13
|
|
|
AMMONIUM LACTATE 12 % LOTION
|
Facility
IP
|
$26.22
|
|
|
Service Code
|
NDC 4580252555
|
| Hospital Charge Code |
10380
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.54 |
| Max. Negotiated Rate |
$23.60 |
| Rate for Payer: Aetna American Axle |
$17.04
|
| Rate for Payer: Aetna Commercial |
$22.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.04
|
| Rate for Payer: Cash Price |
$20.98
|
| Rate for Payer: Cofinity Commercial |
$18.35
|
| Rate for Payer: Cofinity Commercial |
$22.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.98
|
| Rate for Payer: Healthscope Commercial |
$23.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.29
|
| Rate for Payer: PHP Commercial |
$22.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.35
|
| Rate for Payer: Priority Health SBD |
$16.52
|
| Rate for Payer: UMR Bronson Commercial |
$11.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.66
|
|
|
AMOBARBITAL 500 MG SOLUTION FOR INJECTION
|
Facility
IP
|
$2,522.44
|
|
|
Service Code
|
HCPCS J0300
|
| Hospital Charge Code |
9075
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1,109.87 |
| Max. Negotiated Rate |
$2,270.20 |
| Rate for Payer: Aetna American Axle |
$1,639.59
|
| Rate for Payer: Aetna Commercial |
$2,144.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,639.59
|
| Rate for Payer: Cash Price |
$2,017.95
|
| Rate for Payer: Cofinity Commercial |
$1,765.71
|
| Rate for Payer: Cofinity Commercial |
$2,169.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,017.95
|
| Rate for Payer: Healthscope Commercial |
$2,270.20
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$1,765.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1,891.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2,144.07
|
| Rate for Payer: PHP Commercial |
$2,144.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1,765.71
|
| Rate for Payer: Priority Health SBD |
$1,589.14
|
| Rate for Payer: UMR Bronson Commercial |
$1,109.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1,891.83
|
|
|
AMOXICILLIN 200 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$67.20
|
|
|
Service Code
|
NDC 65862-070-01
|
| Hospital Charge Code |
25245
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.57 |
| Max. Negotiated Rate |
$60.48 |
| Rate for Payer: Aetna American Axle |
$43.68
|
| Rate for Payer: Aetna Commercial |
$57.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.68
|
| Rate for Payer: Cash Price |
$53.76
|
| Rate for Payer: Cofinity Commercial |
$47.04
|
| Rate for Payer: Cofinity Commercial |
$57.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$53.76
|
| Rate for Payer: Healthscope Commercial |
$60.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$50.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.12
|
| Rate for Payer: PHP Commercial |
$57.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.04
|
| Rate for Payer: Priority Health SBD |
$42.34
|
| Rate for Payer: UMR Bronson Commercial |
$29.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.40
|
|
|
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 |
$31.43 |
| Max. Negotiated Rate |
$64.30 |
| Rate for Payer: Aetna American Axle |
$46.44
|
| Rate for Payer: Aetna Commercial |
$60.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.44
|
| Rate for Payer: Cash Price |
$57.15
|
| Rate for Payer: Cofinity Commercial |
$50.01
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$50.01
|
| 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 SBD |
$45.01
|
| Rate for Payer: UMR Bronson Commercial |
$31.43
|
| 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 0781-6041-58
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.78 |
| Max. Negotiated Rate |
$60.91 |
| Rate for Payer: Aetna American Axle |
$43.99
|
| Rate for Payer: Aetna Commercial |
$57.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.99
|
| Rate for Payer: Cash Price |
$54.14
|
| Rate for Payer: Cofinity Commercial |
$47.38
|
| Rate for Payer: Cofinity Commercial |
$58.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.14
|
| Rate for Payer: Healthscope Commercial |
$60.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$47.38
|
| 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 SBD |
$42.64
|
| Rate for Payer: UMR Bronson Commercial |
$29.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.76
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$98.70
|
|
|
Service Code
|
NDC 0143-9889-15
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.43 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.96
|
| Rate for Payer: Healthscope Commercial |
$88.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$83.90
|
| Rate for Payer: PHP Commercial |
$83.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.09
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UMR Bronson Commercial |
$43.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.02
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$82.25
|
|
|
Service Code
|
NDC 0093-4155-73
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.19 |
| Max. Negotiated Rate |
$74.02 |
| Rate for Payer: Aetna American Axle |
$53.46
|
| Rate for Payer: Aetna Commercial |
$69.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.46
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$57.58
|
| Rate for Payer: Cofinity Commercial |
$70.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$74.02
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$57.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.91
|
| Rate for Payer: PHP Commercial |
$69.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.58
|
| Rate for Payer: Priority Health SBD |
$51.82
|
| Rate for Payer: UMR Bronson Commercial |
$36.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.69
|
|
|
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 |
$34.12 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| 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 SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$34.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$109.28
|
|
|
Service Code
|
NDC 65862-707-55
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.08 |
| Max. Negotiated Rate |
$98.35 |
| Rate for Payer: Aetna American Axle |
$71.03
|
| Rate for Payer: Aetna Commercial |
$92.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.03
|
| Rate for Payer: Cash Price |
$87.42
|
| Rate for Payer: Cofinity Commercial |
$76.50
|
| Rate for Payer: Cofinity Commercial |
$93.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.42
|
| Rate for Payer: Healthscope Commercial |
$98.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$92.89
|
| Rate for Payer: PHP Commercial |
$92.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.50
|
| Rate for Payer: Priority Health SBD |
$68.85
|
| Rate for Payer: UMR Bronson Commercial |
$48.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.96
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$63.45
|
|
|
Service Code
|
NDC 0143-9889-01
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.92 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna American Axle |
$41.24
|
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.24
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$44.42
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$44.42
|
| 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 SBD |
$39.97
|
| Rate for Payer: UMR Bronson Commercial |
$27.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$79.90
|
|
|
Service Code
|
NDC 43598-209-52
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.16 |
| Max. Negotiated Rate |
$71.91 |
| Rate for Payer: Aetna American Axle |
$51.94
|
| Rate for Payer: Aetna Commercial |
$67.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.94
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$55.93
|
| Rate for Payer: Cofinity Commercial |
$68.71
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$63.92
|
| Rate for Payer: Healthscope Commercial |
$71.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$67.92
|
| Rate for Payer: PHP Commercial |
$67.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$55.93
|
| Rate for Payer: Priority Health SBD |
$50.34
|
| Rate for Payer: UMR Bronson Commercial |
$35.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.92
|
|
|
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 |
$24.82 |
| Max. Negotiated Rate |
$50.76 |
| Rate for Payer: Aetna American Axle |
$36.66
|
| Rate for Payer: Aetna Commercial |
$47.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.66
|
| Rate for Payer: Cash Price |
$45.12
|
| Rate for Payer: Cofinity Commercial |
$39.48
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$39.48
|
| 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 SBD |
$35.53
|
| Rate for Payer: UMR Bronson Commercial |
$24.82
|
| 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 |
$48.60 |
| Max. Negotiated Rate |
$99.40 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$77.32
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$77.32
|
| 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 SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$48.60
|
| 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 |
$70.31 |
| Max. Negotiated Rate |
$143.82 |
| Rate for Payer: Aetna American Axle |
$103.87
|
| Rate for Payer: Aetna Commercial |
$135.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$103.87
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$111.86
|
| Rate for Payer: Cofinity Commercial |
$137.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Healthscope Commercial |
$143.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$111.86
|
| 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 SBD |
$100.67
|
| Rate for Payer: UMR Bronson Commercial |
$70.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$119.85
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$208.52
|
|
|
Service Code
|
NDC 0781-1874-31
|
| Hospital Charge Code |
22992
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.75 |
| Max. Negotiated Rate |
$187.67 |
| Rate for Payer: Aetna American Axle |
$135.54
|
| Rate for Payer: Aetna Commercial |
$177.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$135.54
|
| Rate for Payer: Cash Price |
$166.82
|
| Rate for Payer: Cofinity Commercial |
$145.96
|
| Rate for Payer: Cofinity Commercial |
$179.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$166.82
|
| Rate for Payer: Healthscope Commercial |
$187.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$145.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$156.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$177.24
|
| Rate for Payer: PHP Commercial |
$177.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$145.96
|
| Rate for Payer: Priority Health SBD |
$131.37
|
| Rate for Payer: UMR Bronson Commercial |
$91.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$156.39
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$440.79
|
|
|
Service Code
|
NDC 65862-501-30
|
| Hospital Charge Code |
22992
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$193.95 |
| Max. Negotiated Rate |
$396.71 |
| Rate for Payer: Aetna American Axle |
$286.51
|
| Rate for Payer: Aetna Commercial |
$374.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.51
|
| Rate for Payer: Cash Price |
$352.63
|
| Rate for Payer: Cofinity Commercial |
$308.55
|
| Rate for Payer: Cofinity Commercial |
$379.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$352.63
|
| Rate for Payer: Healthscope Commercial |
$396.71
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$308.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$330.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$374.67
|
| Rate for Payer: PHP Commercial |
$374.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$308.55
|
| Rate for Payer: Priority Health SBD |
$277.70
|
| Rate for Payer: UMR Bronson Commercial |
$193.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.59
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$340.58
|
|
|
Service Code
|
NDC 43598-204-51
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$149.86 |
| Max. Negotiated Rate |
$306.52 |
| Rate for Payer: Aetna American Axle |
$221.38
|
| Rate for Payer: Aetna Commercial |
$289.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.38
|
| Rate for Payer: Cash Price |
$272.46
|
| Rate for Payer: Cofinity Commercial |
$238.41
|
| Rate for Payer: Cofinity Commercial |
$292.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$272.46
|
| Rate for Payer: Healthscope Commercial |
$306.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$238.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$255.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$289.49
|
| Rate for Payer: PHP Commercial |
$289.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$238.41
|
| Rate for Payer: Priority Health SBD |
$214.57
|
| Rate for Payer: UMR Bronson Commercial |
$149.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$255.44
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$417.05
|
|
|
Service Code
|
NDC 43598-204-52
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$183.50 |
| Max. Negotiated Rate |
$375.34 |
| Rate for Payer: Aetna American Axle |
$271.08
|
| Rate for Payer: Aetna Commercial |
$354.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.08
|
| Rate for Payer: Cash Price |
$333.64
|
| Rate for Payer: Cofinity Commercial |
$291.94
|
| Rate for Payer: Cofinity Commercial |
$358.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$333.64
|
| Rate for Payer: Healthscope Commercial |
$375.34
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$291.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$312.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$354.49
|
| Rate for Payer: PHP Commercial |
$354.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$291.94
|
| Rate for Payer: Priority Health SBD |
$262.74
|
| Rate for Payer: UMR Bronson Commercial |
$183.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$312.79
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$280.25
|
|
|
Service Code
|
NDC 59651-026-01
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.31 |
| Max. Negotiated Rate |
$252.22 |
| Rate for Payer: Aetna American Axle |
$182.16
|
| Rate for Payer: Aetna Commercial |
$238.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$182.16
|
| Rate for Payer: Cash Price |
$224.20
|
| Rate for Payer: Cofinity Commercial |
$196.18
|
| Rate for Payer: Cofinity Commercial |
$241.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$224.20
|
| Rate for Payer: Healthscope Commercial |
$252.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$196.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$210.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$238.21
|
| Rate for Payer: PHP Commercial |
$238.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$196.18
|
| Rate for Payer: Priority Health SBD |
$176.56
|
| Rate for Payer: UMR Bronson Commercial |
$123.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$210.19
|
|
