|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$236.16
|
|
|
Service Code
|
NDC 60432-065-75
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$103.91 |
| Max. Negotiated Rate |
$212.54 |
| Rate for Payer: Aetna American Axle |
$153.50
|
| Rate for Payer: Aetna Commercial |
$200.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$153.50
|
| Rate for Payer: Cash Price |
$188.93
|
| Rate for Payer: Cofinity Commercial |
$165.31
|
| Rate for Payer: Cofinity Commercial |
$203.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$188.93
|
| Rate for Payer: Healthscope Commercial |
$212.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$165.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$177.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$200.74
|
| Rate for Payer: PHP Commercial |
$200.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$165.31
|
| Rate for Payer: Priority Health SBD |
$148.78
|
| Rate for Payer: UMR Bronson Commercial |
$103.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$177.12
|
|
|
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 400 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$103.99
|
|
|
Service Code
|
NDC 0143-9887-75
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.76 |
| Max. Negotiated Rate |
$93.59 |
| Rate for Payer: Aetna American Axle |
$67.59
|
| Rate for Payer: Aetna Commercial |
$88.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.59
|
| Rate for Payer: Cash Price |
$83.19
|
| Rate for Payer: Cofinity Commercial |
$72.79
|
| Rate for Payer: Cofinity Commercial |
$89.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.19
|
| Rate for Payer: Healthscope Commercial |
$93.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$88.39
|
| Rate for Payer: PHP Commercial |
$88.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.79
|
| Rate for Payer: Priority Health SBD |
$65.51
|
| Rate for Payer: UMR Bronson Commercial |
$45.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$77.99
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$141.00
|
|
|
Service Code
|
NDC 0143-9887-01
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.04 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$126.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.70
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UMR Bronson Commercial |
$62.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$141.00
|
|
|
Service Code
|
NDC 0781-6157-46
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.04 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$126.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.70
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UMR Bronson Commercial |
$62.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$51.70
|
|
|
Service Code
|
NDC 0093-4161-73
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.75 |
| Max. Negotiated Rate |
$46.53 |
| Rate for Payer: Aetna American Axle |
$33.60
|
| Rate for Payer: Aetna Commercial |
$43.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$33.60
|
| Rate for Payer: Cash Price |
$41.36
|
| Rate for Payer: Cofinity Commercial |
$36.19
|
| Rate for Payer: Cofinity Commercial |
$44.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.36
|
| Rate for Payer: Healthscope Commercial |
$46.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$36.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$38.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$43.94
|
| Rate for Payer: PHP Commercial |
$43.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.19
|
| Rate for Payer: Priority Health SBD |
$32.57
|
| Rate for Payer: UMR Bronson Commercial |
$22.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$38.78
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$141.00
|
|
|
Service Code
|
NDC 57237-033-01
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.04 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$126.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.70
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UMR Bronson Commercial |
$62.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$141.00
|
|
|
Service Code
|
NDC 65862-071-01
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.04 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$112.80
|
| Rate for Payer: Healthscope Commercial |
$126.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$98.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$105.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$98.70
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UMR Bronson Commercial |
$62.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$116.33
|
|
|
Service Code
|
NDC 65862-534-75
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.19 |
| Max. Negotiated Rate |
$104.70 |
| Rate for Payer: Aetna American Axle |
$75.61
|
| Rate for Payer: Aetna Commercial |
$98.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$75.61
|
| Rate for Payer: Cash Price |
$93.06
|
| Rate for Payer: Cofinity Commercial |
$100.04
|
| Rate for Payer: Cofinity Commercial |
$81.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.06
|
| Rate for Payer: Healthscope Commercial |
$104.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$81.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$98.88
|
| Rate for Payer: PHP Commercial |
$98.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.43
|
| Rate for Payer: Priority Health SBD |
$73.29
|
| Rate for Payer: UMR Bronson Commercial |
$51.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.25
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$97.38
|
|
|
Service Code
|
NDC 66685-1012-0
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.85 |
| Max. Negotiated Rate |
$87.64 |
| Rate for Payer: Aetna American Axle |
$63.30
|
| Rate for Payer: Aetna Commercial |
$82.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.30
|
| Rate for Payer: Cash Price |
$77.90
|
| Rate for Payer: Cofinity Commercial |
$68.17
|
| Rate for Payer: Cofinity Commercial |
$83.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.90
|
| Rate for Payer: Healthscope Commercial |
$87.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$82.77
|
| Rate for Payer: PHP Commercial |
$82.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.17
|
| Rate for Payer: Priority Health SBD |
$61.35
|
| Rate for Payer: UMR Bronson Commercial |
$42.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.04
|
|
|
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 |
$40.33 |
| Max. Negotiated Rate |
$82.48 |
| Rate for Payer: Aetna American Axle |
$59.57
|
| Rate for Payer: Aetna Commercial |
$77.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.57
|
| Rate for Payer: Cash Price |
$73.32
|
| Rate for Payer: Cofinity Commercial |
$64.16
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$64.16
|
| 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 SBD |
$57.74
|
| Rate for Payer: UMR Bronson Commercial |
$40.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.74
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$99.75
|
|
|
Service Code
|
NDC 0143-9982-50
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.89 |
| Max. Negotiated Rate |
$89.78 |
| Rate for Payer: Aetna American Axle |
$64.84
|
| Rate for Payer: Aetna Commercial |
$84.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.84
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cofinity Commercial |
$69.82
|
| Rate for Payer: Cofinity Commercial |
$85.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$79.80
|
| Rate for Payer: Healthscope Commercial |
$89.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$69.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$74.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$84.79
|
| Rate for Payer: PHP Commercial |
$84.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.82
|
| Rate for Payer: Priority Health SBD |
$62.84
|
| Rate for Payer: UMR Bronson Commercial |
$43.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.81
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$159.80
|
|
|
Service Code
|
NDC 65862-534-01
|
| Hospital Charge Code |
33230
|
|
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 500 MG CAPSULE
|
Facility
IP
|
$227.95
|
|
|
Service Code
|
NDC 0781-2613-01
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.30 |
| Max. Negotiated Rate |
$205.16 |
| Rate for Payer: Aetna American Axle |
$148.17
|
| Rate for Payer: Aetna Commercial |
$193.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$148.17
|
| Rate for Payer: Cash Price |
$182.36
|
| Rate for Payer: Cofinity Commercial |
$159.56
|
| Rate for Payer: Cofinity Commercial |
$196.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.36
|
| Rate for Payer: Healthscope Commercial |
$205.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$159.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$170.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.76
|
| Rate for Payer: PHP Commercial |
$193.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.56
|
| Rate for Payer: Priority Health SBD |
$143.61
|
| Rate for Payer: UMR Bronson Commercial |
$100.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$170.96
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
IP
|
$142.18
|
|
|
Service Code
|
NDC 0093-3109-53
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.56 |
| Max. Negotiated Rate |
$127.96 |
| Rate for Payer: Aetna American Axle |
$92.42
|
| Rate for Payer: Aetna Commercial |
$120.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.42
|
| Rate for Payer: Cash Price |
$113.74
|
| Rate for Payer: Cofinity Commercial |
$122.27
|
| Rate for Payer: Cofinity Commercial |
$99.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.74
|
| Rate for Payer: Healthscope Commercial |
$127.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$120.85
|
| Rate for Payer: PHP Commercial |
$120.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.53
|
| Rate for Payer: Priority Health SBD |
$89.57
|
| Rate for Payer: UMR Bronson Commercial |
$62.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.64
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
IP
|
$202.10
|
|
|
Service Code
|
NDC 57237-031-01
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.92 |
| Max. Negotiated Rate |
$181.89 |
| Rate for Payer: Aetna American Axle |
$131.36
|
| Rate for Payer: Aetna Commercial |
$171.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.36
|
| Rate for Payer: Cash Price |
$161.68
|
| Rate for Payer: Cofinity Commercial |
$141.47
|
| Rate for Payer: Cofinity Commercial |
$173.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$161.68
|
| Rate for Payer: Healthscope Commercial |
$181.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$141.47
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$151.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$171.78
|
| Rate for Payer: PHP Commercial |
$171.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$141.47
|
| Rate for Payer: Priority Health SBD |
$127.32
|
| Rate for Payer: UMR Bronson Commercial |
$88.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.58
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$451.25
|
|
|
Service Code
|
NDC 42571-161-01
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.55 |
| Max. Negotiated Rate |
$406.12 |
| Rate for Payer: Aetna American Axle |
$293.31
|
| Rate for Payer: Aetna Commercial |
$383.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.31
|
| Rate for Payer: Cash Price |
$361.00
|
| Rate for Payer: Cofinity Commercial |
$315.88
|
| Rate for Payer: Cofinity Commercial |
$388.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$361.00
|
| Rate for Payer: Healthscope Commercial |
$406.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$315.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$338.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$383.56
|
| Rate for Payer: PHP Commercial |
$383.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$315.88
|
| Rate for Payer: Priority Health SBD |
$284.29
|
| Rate for Payer: UMR Bronson Commercial |
$198.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$338.44
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$425.76
|
|
|
Service Code
|
NDC 66685-1002-2
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.33 |
| Max. Negotiated Rate |
$383.18 |
| Rate for Payer: Aetna American Axle |
$276.74
|
| Rate for Payer: Aetna Commercial |
$361.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.74
|
| Rate for Payer: Cash Price |
$340.61
|
| Rate for Payer: Cofinity Commercial |
$298.03
|
| Rate for Payer: Cofinity Commercial |
$366.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.61
|
| Rate for Payer: Healthscope Commercial |
$383.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$298.03
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$319.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$361.90
|
| Rate for Payer: PHP Commercial |
$361.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.03
|
| Rate for Payer: Priority Health SBD |
$268.23
|
| Rate for Payer: UMR Bronson Commercial |
$187.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.32
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$77.71
|
|
|
Service Code
|
NDC 65862-502-20
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.19 |
| Max. Negotiated Rate |
$69.94 |
| Rate for Payer: Aetna American Axle |
$50.51
|
| Rate for Payer: Aetna Commercial |
$66.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.51
|
| Rate for Payer: Cash Price |
$62.17
|
| Rate for Payer: Cofinity Commercial |
$54.40
|
| Rate for Payer: Cofinity Commercial |
$66.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.17
|
| Rate for Payer: Healthscope Commercial |
$69.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$66.05
|
| Rate for Payer: PHP Commercial |
$66.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.40
|
| Rate for Payer: Priority Health SBD |
$48.96
|
| Rate for Payer: UMR Bronson Commercial |
$34.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.28
|
|
|
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 |
$135.71 |
| Max. Negotiated Rate |
$277.60 |
| Rate for Payer: Aetna American Axle |
$200.49
|
| Rate for Payer: Aetna Commercial |
$262.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$200.49
|
| Rate for Payer: Cash Price |
$246.75
|
| Rate for Payer: Cofinity Commercial |
$215.91
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$215.91
|
| 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 SBD |
$194.32
|
| Rate for Payer: UMR Bronson Commercial |
$135.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$231.33
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$203.07
|
|
|
Service Code
|
NDC 0781-6139-57
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$89.35 |
| Max. Negotiated Rate |
$182.76 |
| Rate for Payer: Aetna American Axle |
$132.00
|
| Rate for Payer: Aetna Commercial |
$172.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.00
|
| Rate for Payer: Cash Price |
$162.46
|
| Rate for Payer: Cofinity Commercial |
$142.15
|
| Rate for Payer: Cofinity Commercial |
$174.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$162.46
|
| Rate for Payer: Healthscope Commercial |
$182.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$152.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$172.61
|
| Rate for Payer: PHP Commercial |
$172.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.15
|
| Rate for Payer: Priority Health SBD |
$127.93
|
| Rate for Payer: UMR Bronson Commercial |
$89.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$152.30
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$237.94
|
|
|
Service Code
|
NDC 65862-535-13
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$104.69 |
| Max. Negotiated Rate |
$214.15 |
| Rate for Payer: Aetna American Axle |
$154.66
|
| Rate for Payer: Aetna Commercial |
$202.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$154.66
|
| Rate for Payer: Cash Price |
$190.35
|
| Rate for Payer: Cofinity Commercial |
$166.56
|
| Rate for Payer: Cofinity Commercial |
$204.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.35
|
| Rate for Payer: Healthscope Commercial |
$214.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$166.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$178.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.25
|
| Rate for Payer: PHP Commercial |
$202.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.56
|
| Rate for Payer: Priority Health SBD |
$149.90
|
| Rate for Payer: UMR Bronson Commercial |
$104.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$178.46
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$273.60
|
|
|
Service Code
|
NDC 42571-162-01
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$120.38 |
| Max. Negotiated Rate |
$246.24 |
| Rate for Payer: Aetna American Axle |
$177.84
|
| Rate for Payer: Aetna Commercial |
$232.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$177.84
|
| Rate for Payer: Cash Price |
$218.88
|
| Rate for Payer: Cofinity Commercial |
$191.52
|
| Rate for Payer: Cofinity Commercial |
$235.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.88
|
| Rate for Payer: Healthscope Commercial |
$246.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$191.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$205.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$232.56
|
| Rate for Payer: PHP Commercial |
$232.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$191.52
|
| Rate for Payer: Priority Health SBD |
$172.37
|
| Rate for Payer: UMR Bronson Commercial |
$120.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$205.20
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$509.28
|
|
|
Service Code
|
NDC 66685-1001-1
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$224.08 |
| Max. Negotiated Rate |
$458.35 |
| Rate for Payer: Aetna American Axle |
$331.03
|
| Rate for Payer: Aetna Commercial |
$432.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$331.03
|
| Rate for Payer: Cash Price |
$407.42
|
| Rate for Payer: Cofinity Commercial |
$356.50
|
| Rate for Payer: Cofinity Commercial |
$437.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$407.42
|
| Rate for Payer: Healthscope Commercial |
$458.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$356.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$381.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$432.89
|
| Rate for Payer: PHP Commercial |
$432.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$356.50
|
| Rate for Payer: Priority Health SBD |
$320.85
|
| Rate for Payer: UMR Bronson Commercial |
$224.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$381.96
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$506.40
|
|
|
Service Code
|
NDC 0781-1852-01
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$222.82 |
| Max. Negotiated Rate |
$455.76 |
| Rate for Payer: Aetna American Axle |
$329.16
|
| Rate for Payer: Aetna Commercial |
$430.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$329.16
|
| Rate for Payer: Cash Price |
$405.12
|
| Rate for Payer: Cofinity Commercial |
$354.48
|
| Rate for Payer: Cofinity Commercial |
$435.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$405.12
|
| Rate for Payer: Healthscope Commercial |
$455.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$354.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$379.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$430.44
|
| Rate for Payer: PHP Commercial |
$430.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$354.48
|
| Rate for Payer: Priority Health SBD |
$319.03
|
| Rate for Payer: UMR Bronson Commercial |
$222.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$379.80
|
|
