|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$56.40
|
|
|
Service Code
|
NDC 00143988980
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.87 |
| Max. Negotiated Rate |
$50.76 |
| Rate for Payer: Aetna American Axle |
$36.66
|
| Rate for Payer: Aetna Commercial |
$47.94
|
| Rate for Payer: Aetna Medicare |
$28.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$36.66
|
| Rate for Payer: BCBS Complete |
$22.56
|
| Rate for Payer: Cash Price |
$45.12
|
| Rate for Payer: Cofinity Commercial |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$48.50
|
| Rate for Payer: Cofinity Medicare Advantage |
$39.48
|
| 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 Commercial |
$47.94
|
| Rate for Payer: PHP Commercial |
$47.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.66
|
| Rate for Payer: Priority Health SBD |
$35.53
|
| Rate for Payer: UMR Bronson Commercial |
$20.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.30
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$79.90
|
|
|
Service Code
|
NDC 43598020952
|
| 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: Cofinity Medicare Advantage |
$55.93
|
| 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 Commercial |
$67.92
|
| Rate for Payer: PHP Commercial |
$67.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.94
|
| 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
|
$71.44
|
|
|
Service Code
|
NDC 00093415579
|
| 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: Cofinity Medicare Advantage |
$50.01
|
| 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 Commercial |
$60.72
|
| Rate for Payer: PHP Commercial |
$60.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.44
|
| 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
|
OP
|
$77.55
|
|
|
Service Code
|
NDC 00781604146
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.69 |
| Max. Negotiated Rate |
$69.80 |
| Rate for Payer: Aetna American Axle |
$50.41
|
| Rate for Payer: Aetna Commercial |
$65.92
|
| Rate for Payer: Aetna Medicare |
$38.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.41
|
| Rate for Payer: BCBS Complete |
$31.02
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.28
|
| 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 Commercial |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UMR Bronson Commercial |
$28.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.16
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$82.25
|
|
|
Service Code
|
NDC 00093415573
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.43 |
| Max. Negotiated Rate |
$74.03 |
| Rate for Payer: Aetna American Axle |
$53.46
|
| Rate for Payer: Aetna Commercial |
$69.91
|
| Rate for Payer: Aetna Medicare |
$41.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.46
|
| Rate for Payer: BCBS Complete |
$32.90
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$57.58
|
| Rate for Payer: Cofinity Commercial |
$70.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$74.03
|
| 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 Commercial |
$69.91
|
| Rate for Payer: PHP Commercial |
$69.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.46
|
| Rate for Payer: Priority Health SBD |
$51.82
|
| Rate for Payer: UMR Bronson Commercial |
$30.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.69
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$67.68
|
|
|
Service Code
|
NDC 00781604158
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$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: Cofinity Medicare Advantage |
$47.38
|
| 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 Commercial |
$57.53
|
| Rate for Payer: PHP Commercial |
$57.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.99
|
| 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
|
$109.28
|
|
|
Service Code
|
NDC 65862070755
|
| 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: Cofinity Medicare Advantage |
$76.50
|
| 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 Commercial |
$92.89
|
| Rate for Payer: PHP Commercial |
$92.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.03
|
| 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
|
$82.25
|
|
|
Service Code
|
NDC 00093415573
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.19 |
| Max. Negotiated Rate |
$74.03 |
| 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 |
$70.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$57.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$74.03
|
| 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 Commercial |
$69.91
|
| Rate for Payer: PHP Commercial |
$69.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.46
|
| 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
|
$98.70
|
|
|
Service Code
|
NDC 00143988915
|
| 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 |
$83.89
|
| 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: Cofinity Medicare Advantage |
$69.09
|
| 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 |
$74.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.89
|
| Rate for Payer: PHP Commercial |
$83.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.16
|
| 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 |
$74.03
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 00781604146
|
| 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: Cofinity Medicare Advantage |
$54.28
|
| 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 Commercial |
$65.92
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| 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
|
$63.45
|
|
|
Service Code
|
NDC 00143988901
|
| 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 |
$44.41
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.41
|
| 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 |
$44.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.24
|
| 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
|
OP
|
$79.90
|
|
|
Service Code
|
NDC 43598020952
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.56 |
| Max. Negotiated Rate |
$71.91 |
| Rate for Payer: Aetna American Axle |
$51.94
|
| Rate for Payer: Aetna Commercial |
$67.92
|
| Rate for Payer: Aetna Medicare |
$39.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.94
|
| Rate for Payer: BCBS Complete |
$31.96
|
| Rate for Payer: Cash Price |
$63.92
|
| Rate for Payer: Cofinity Commercial |
$55.93
|
| Rate for Payer: Cofinity Commercial |
$68.71
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.93
|
| 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 Commercial |
$67.92
|
| Rate for Payer: PHP Commercial |
$67.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.94
|
| Rate for Payer: Priority Health SBD |
$50.34
|
| Rate for Payer: UMR Bronson Commercial |
$29.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.92
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$67.68
|
|
|
Service Code
|
NDC 00781604158
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.04 |
| Max. Negotiated Rate |
$60.91 |
| Rate for Payer: Aetna American Axle |
$43.99
|
| Rate for Payer: Aetna Commercial |
$57.53
|
| Rate for Payer: Aetna Medicare |
$33.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$43.99
|
| Rate for Payer: BCBS Complete |
$27.07
|
| Rate for Payer: Cash Price |
$54.14
|
| Rate for Payer: Cofinity Commercial |
$47.38
|
| Rate for Payer: Cofinity Commercial |
$58.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$47.38
|
| 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 Commercial |
$57.53
|
| Rate for Payer: PHP Commercial |
$57.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.99
|
| Rate for Payer: Priority Health SBD |
$42.64
|
| Rate for Payer: UMR Bronson Commercial |
$25.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$50.76
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$109.28
|
|
|
Service Code
|
NDC 65862070755
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.43 |
| Max. Negotiated Rate |
$98.35 |
| Rate for Payer: Aetna American Axle |
$71.03
|
| Rate for Payer: Aetna Commercial |
$92.89
|
| Rate for Payer: Aetna Medicare |
$54.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.03
|
| Rate for Payer: BCBS Complete |
$43.71
|
| Rate for Payer: Cash Price |
$87.42
|
| Rate for Payer: Cofinity Commercial |
$76.50
|
| Rate for Payer: Cofinity Commercial |
$93.98
|
| Rate for Payer: Cofinity Medicare Advantage |
$76.50
|
| 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 Commercial |
$92.89
|
| Rate for Payer: PHP Commercial |
$92.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.03
|
| Rate for Payer: Priority Health SBD |
$68.85
|
| Rate for Payer: UMR Bronson Commercial |
$40.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$81.96
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$63.45
|
|
|
Service Code
|
NDC 00143988901
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.48 |
| Max. Negotiated Rate |
$57.10 |
| Rate for Payer: Aetna American Axle |
$41.24
|
| Rate for Payer: Aetna Commercial |
$53.93
|
| Rate for Payer: Aetna Medicare |
$31.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$41.24
|
| Rate for Payer: BCBS Complete |
$25.38
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cofinity Commercial |
$44.41
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$44.41
|
| 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 |
$44.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.24
|
| Rate for Payer: Priority Health SBD |
$39.97
|
| Rate for Payer: UMR Bronson Commercial |
$23.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.59
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$56.40
|
|
|
Service Code
|
NDC 00143988980
|
| 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: Cofinity Medicare Advantage |
$39.48
|
| 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 Commercial |
$47.94
|
| Rate for Payer: PHP Commercial |
$47.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.66
|
| 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/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$98.70
|
|
|
Service Code
|
NDC 00143988915
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.52 |
| Max. Negotiated Rate |
$88.83 |
| Rate for Payer: Aetna American Axle |
$64.16
|
| Rate for Payer: Aetna Commercial |
$83.89
|
| Rate for Payer: Aetna Medicare |
$49.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.16
|
| Rate for Payer: BCBS Complete |
$39.48
|
| Rate for Payer: Cash Price |
$78.96
|
| Rate for Payer: Cofinity Commercial |
$69.09
|
| Rate for Payer: Cofinity Commercial |
$84.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$69.09
|
| 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 |
$74.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.89
|
| Rate for Payer: PHP Commercial |
$83.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.16
|
| Rate for Payer: Priority Health SBD |
$62.18
|
| Rate for Payer: UMR Bronson Commercial |
$36.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.03
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$197.40
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.04 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna American Axle |
$128.31
|
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna Medicare |
$98.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: BCBS Complete |
$78.96
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| Rate for Payer: UMR Bronson Commercial |
$73.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$197.40
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.86 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna American Axle |
$128.31
|
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$138.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| Rate for Payer: UMR Bronson Commercial |
$86.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 65862001601
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.60 |
| Max. Negotiated Rate |
$99.41 |
| 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 |
$77.31
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| 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
|
OP
|
$110.45
|
|
|
Service Code
|
NDC 65862001601
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.87 |
| Max. Negotiated Rate |
$99.41 |
| Rate for Payer: Aetna American Axle |
$71.79
|
| Rate for Payer: Aetna Commercial |
$93.88
|
| Rate for Payer: Aetna Medicare |
$55.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$71.79
|
| Rate for Payer: BCBS Complete |
$44.18
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$77.31
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$77.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$99.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$77.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$82.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UMR Bronson Commercial |
$40.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$245.38
|
|
|
Service Code
|
NDC 00781187431
|
| Hospital Charge Code |
22992
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.79 |
| Max. Negotiated Rate |
$220.84 |
| Rate for Payer: Aetna American Axle |
$159.50
|
| Rate for Payer: Aetna Commercial |
$208.57
|
| Rate for Payer: Aetna Medicare |
$122.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.50
|
| Rate for Payer: BCBS Complete |
$98.15
|
| Rate for Payer: Cash Price |
$196.30
|
| Rate for Payer: Cofinity Commercial |
$171.77
|
| Rate for Payer: Cofinity Commercial |
$211.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.30
|
| Rate for Payer: Healthscope Commercial |
$220.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$184.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.57
|
| Rate for Payer: PHP Commercial |
$208.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.50
|
| Rate for Payer: Priority Health SBD |
$154.59
|
| Rate for Payer: UMR Bronson Commercial |
$90.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$184.03
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$440.79
|
|
|
Service Code
|
NDC 65862050130
|
| Hospital Charge Code |
22992
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.09 |
| Max. Negotiated Rate |
$396.71 |
| Rate for Payer: Aetna American Axle |
$286.51
|
| Rate for Payer: Aetna Commercial |
$374.67
|
| Rate for Payer: Aetna Medicare |
$220.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$286.51
|
| Rate for Payer: BCBS Complete |
$176.32
|
| Rate for Payer: Cash Price |
$352.63
|
| Rate for Payer: Cofinity Commercial |
$308.55
|
| Rate for Payer: Cofinity Commercial |
$379.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$308.55
|
| 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 Commercial |
$374.67
|
| Rate for Payer: PHP Commercial |
$374.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.51
|
| Rate for Payer: Priority Health SBD |
$277.70
|
| Rate for Payer: UMR Bronson Commercial |
$163.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$330.59
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$440.79
|
|
|
Service Code
|
NDC 65862050130
|
| 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: Cofinity Medicare Advantage |
$308.55
|
| 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 Commercial |
$374.67
|
| Rate for Payer: PHP Commercial |
$374.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$286.51
|
| 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 125 MG TABLET
|
Facility
|
IP
|
$245.38
|
|
|
Service Code
|
NDC 00781187431
|
| Hospital Charge Code |
22992
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.97 |
| Max. Negotiated Rate |
$220.84 |
| Rate for Payer: Aetna American Axle |
$159.50
|
| Rate for Payer: Aetna Commercial |
$208.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.50
|
| Rate for Payer: Cash Price |
$196.30
|
| Rate for Payer: Cofinity Commercial |
$171.77
|
| Rate for Payer: Cofinity Commercial |
$211.03
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.30
|
| Rate for Payer: Healthscope Commercial |
$220.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$184.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.57
|
| Rate for Payer: PHP Commercial |
$208.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.50
|
| Rate for Payer: Priority Health SBD |
$154.59
|
| Rate for Payer: UMR Bronson Commercial |
$107.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$184.03
|
|
