|
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 |
$184.04
|
| 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 |
$184.04
|
|
|
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
|
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
|
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 |
$184.04
|
| 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 |
$184.04
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$286.90
|
|
|
Service Code
|
NDC 59651002601
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$106.15 |
| Max. Negotiated Rate |
$258.21 |
| Rate for Payer: Aetna American Axle |
$186.48
|
| Rate for Payer: Aetna Commercial |
$243.86
|
| Rate for Payer: Aetna Medicare |
$143.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.48
|
| Rate for Payer: BCBS Complete |
$114.76
|
| Rate for Payer: Cash Price |
$229.52
|
| Rate for Payer: Cofinity Commercial |
$200.83
|
| Rate for Payer: Cofinity Commercial |
$246.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$200.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.52
|
| Rate for Payer: Healthscope Commercial |
$258.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$200.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.86
|
| Rate for Payer: PHP Commercial |
$243.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.48
|
| Rate for Payer: Priority Health SBD |
$180.75
|
| Rate for Payer: UMR Bronson Commercial |
$106.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.18
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$417.05
|
|
|
Service Code
|
NDC 43598020452
|
| 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: Cofinity Medicare Advantage |
$291.94
|
| 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 Commercial |
$354.49
|
| Rate for Payer: PHP Commercial |
$354.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.08
|
| 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
|
OP
|
$340.58
|
|
|
Service Code
|
NDC 43598020451
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.01 |
| Max. Negotiated Rate |
$306.52 |
| Rate for Payer: Aetna American Axle |
$221.38
|
| Rate for Payer: Aetna Commercial |
$289.49
|
| Rate for Payer: Aetna Medicare |
$170.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$221.38
|
| Rate for Payer: BCBS Complete |
$136.23
|
| Rate for Payer: Cash Price |
$272.46
|
| Rate for Payer: Cofinity Commercial |
$238.41
|
| Rate for Payer: Cofinity Commercial |
$292.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$238.41
|
| 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 Commercial |
$289.49
|
| Rate for Payer: PHP Commercial |
$289.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.38
|
| Rate for Payer: Priority Health SBD |
$214.57
|
| Rate for Payer: UMR Bronson Commercial |
$126.01
|
| 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
|
$181.54
|
|
|
Service Code
|
NDC 60432006575
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$79.88 |
| Max. Negotiated Rate |
$163.39 |
| Rate for Payer: Aetna American Axle |
$118.00
|
| Rate for Payer: Aetna Commercial |
$154.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.00
|
| Rate for Payer: Cash Price |
$145.23
|
| Rate for Payer: Cofinity Commercial |
$127.08
|
| Rate for Payer: Cofinity Commercial |
$156.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.23
|
| Rate for Payer: Healthscope Commercial |
$163.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$127.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$154.31
|
| Rate for Payer: PHP Commercial |
$154.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.00
|
| Rate for Payer: Priority Health SBD |
$114.37
|
| Rate for Payer: UMR Bronson Commercial |
$79.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.16
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$340.58
|
|
|
Service Code
|
NDC 43598020451
|
| 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: Cofinity Medicare Advantage |
$238.41
|
| 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 Commercial |
$289.49
|
| Rate for Payer: PHP Commercial |
$289.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$221.38
|
| 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
|
OP
|
$181.54
|
|
|
Service Code
|
NDC 60432006575
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.17 |
| Max. Negotiated Rate |
$163.39 |
| Rate for Payer: Aetna American Axle |
$118.00
|
| Rate for Payer: Aetna Commercial |
$154.31
|
| Rate for Payer: Aetna Medicare |
$90.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$118.00
|
| Rate for Payer: BCBS Complete |
$72.62
|
| Rate for Payer: Cash Price |
$145.23
|
| Rate for Payer: Cofinity Commercial |
$127.08
|
| Rate for Payer: Cofinity Commercial |
$156.12
|
| Rate for Payer: Cofinity Medicare Advantage |
$127.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$145.23
|
| Rate for Payer: Healthscope Commercial |
$163.39
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$127.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$136.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$154.31
|
| Rate for Payer: PHP Commercial |
$154.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$118.00
|
| Rate for Payer: Priority Health SBD |
$114.37
|
| Rate for Payer: UMR Bronson Commercial |
$67.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$136.16
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$195.05
|
|
|
Service Code
|
NDC 60432006500
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.17 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna Medicare |
$97.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: BCBS Complete |
$78.02
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$136.54
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$136.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UMR Bronson Commercial |
$72.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$286.90
|
|
|
Service Code
|
NDC 59651002601
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$126.24 |
| Max. Negotiated Rate |
$258.21 |
| Rate for Payer: Aetna American Axle |
$186.48
|
| Rate for Payer: Aetna Commercial |
$243.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$186.48
|
| Rate for Payer: Cash Price |
$229.52
|
| Rate for Payer: Cofinity Commercial |
$200.83
|
| Rate for Payer: Cofinity Commercial |
$246.73
|
| Rate for Payer: Cofinity Medicare Advantage |
$200.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$229.52
|
| Rate for Payer: Healthscope Commercial |
$258.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$200.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$215.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$243.86
|
| Rate for Payer: PHP Commercial |
$243.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$186.48
|
| Rate for Payer: Priority Health SBD |
$180.75
|
| Rate for Payer: UMR Bronson Commercial |
$126.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$215.18
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$195.05
|
|
|
Service Code
|
NDC 60432006500
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.82 |
| Max. Negotiated Rate |
$175.54 |
| Rate for Payer: Aetna American Axle |
$126.78
|
| Rate for Payer: Aetna Commercial |
$165.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$126.78
|
| Rate for Payer: Cash Price |
$156.04
|
| Rate for Payer: Cofinity Commercial |
$136.54
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$136.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.04
|
| Rate for Payer: Healthscope Commercial |
$175.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$136.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$126.78
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UMR Bronson Commercial |
$85.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
|
AMOXICILLIN 250 MG-POTASSIUM CLAVULANATE 62.5 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$417.05
|
|
|
Service Code
|
NDC 43598020452
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.31 |
| Max. Negotiated Rate |
$375.34 |
| Rate for Payer: Aetna American Axle |
$271.08
|
| Rate for Payer: Aetna Commercial |
$354.49
|
| Rate for Payer: Aetna Medicare |
$208.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$271.08
|
| Rate for Payer: BCBS Complete |
$166.82
|
| Rate for Payer: Cash Price |
$333.64
|
| Rate for Payer: Cofinity Commercial |
$291.94
|
| Rate for Payer: Cofinity Commercial |
$358.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$291.94
|
| 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 Commercial |
$354.49
|
| Rate for Payer: PHP Commercial |
$354.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.08
|
| Rate for Payer: Priority Health SBD |
$262.74
|
| Rate for Payer: UMR Bronson Commercial |
$154.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$312.79
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$103.99
|
|
|
Service Code
|
NDC 00143988775
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.48 |
| Max. Negotiated Rate |
$93.59 |
| Rate for Payer: Aetna American Axle |
$67.59
|
| Rate for Payer: Aetna Commercial |
$88.39
|
| Rate for Payer: Aetna Medicare |
$52.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.59
|
| Rate for Payer: BCBS Complete |
$41.60
|
| Rate for Payer: Cash Price |
$83.19
|
| Rate for Payer: Cofinity Commercial |
$72.79
|
| Rate for Payer: Cofinity Commercial |
$89.43
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.79
|
| 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 Commercial |
$88.39
|
| Rate for Payer: PHP Commercial |
$88.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.59
|
| Rate for Payer: Priority Health SBD |
$65.51
|
| Rate for Payer: UMR Bronson Commercial |
$38.48
|
| 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 00143988701
|
| 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: Cofinity Medicare Advantage |
$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 Commercial |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| 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 00093416173
|
| 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: Cofinity Medicare Advantage |
$36.19
|
| 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 Commercial |
$43.94
|
| Rate for Payer: PHP Commercial |
$43.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.60
|
| 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 00781615746
|
| 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: Cofinity Medicare Advantage |
$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 Commercial |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| 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
|
OP
|
$141.00
|
|
|
Service Code
|
NDC 57237003301
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.17 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$98.70
|
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna Medicare |
$70.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: BCBS Complete |
$56.40
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| 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 Commercial |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UMR Bronson Commercial |
$52.17
|
| 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 65862007101
|
| 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: Cofinity Medicare Advantage |
$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 Commercial |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| 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 57237003301
|
| 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: Cofinity Medicare Advantage |
$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 Commercial |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| 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
|
OP
|
$141.00
|
|
|
Service Code
|
NDC 00143988701
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.17 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna Medicare |
$70.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: BCBS Complete |
$56.40
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$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 Commercial |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UMR Bronson Commercial |
$52.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$103.99
|
|
|
Service Code
|
NDC 00143988775
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.76 |
| Max. Negotiated Rate |
$93.59 |
| Rate for Payer: PHP Commercial |
$88.39
|
| 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: Cofinity Medicare Advantage |
$72.79
|
| 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 Commercial |
$88.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.59
|
| 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
|
OP
|
$141.00
|
|
|
Service Code
|
NDC 00781615746
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.17 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna Medicare |
$70.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: BCBS Complete |
$56.40
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$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 Commercial |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UMR Bronson Commercial |
$52.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$141.00
|
|
|
Service Code
|
NDC 65862007101
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.17 |
| Max. Negotiated Rate |
$126.90 |
| Rate for Payer: Aetna American Axle |
$91.65
|
| Rate for Payer: Aetna Commercial |
$119.85
|
| Rate for Payer: Aetna Medicare |
$70.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$91.65
|
| Rate for Payer: BCBS Complete |
$56.40
|
| Rate for Payer: Cash Price |
$112.80
|
| Rate for Payer: Cofinity Commercial |
$121.26
|
| Rate for Payer: Cofinity Commercial |
$98.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$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 Commercial |
$119.85
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$91.65
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UMR Bronson Commercial |
$52.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$105.75
|
|
