|
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
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$94.00
|
|
|
Service Code
|
NDC 65862053450
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.36 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna American Axle |
$61.10
|
| Rate for Payer: Aetna Commercial |
$79.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.10
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$80.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.20
|
| Rate for Payer: Healthscope Commercial |
$84.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.90
|
| Rate for Payer: PHP Commercial |
$79.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.10
|
| Rate for Payer: Priority Health SBD |
$59.22
|
| Rate for Payer: UMR Bronson Commercial |
$41.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.50
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$94.00
|
|
|
Service Code
|
NDC 65862053450
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.78 |
| Max. Negotiated Rate |
$84.60 |
| Rate for Payer: Aetna American Axle |
$61.10
|
| Rate for Payer: Aetna Commercial |
$79.90
|
| Rate for Payer: Aetna Medicare |
$47.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.10
|
| Rate for Payer: BCBS Complete |
$37.60
|
| Rate for Payer: Cash Price |
$75.20
|
| Rate for Payer: Cofinity Commercial |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$80.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$65.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.20
|
| Rate for Payer: Healthscope Commercial |
$84.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$65.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$79.90
|
| Rate for Payer: PHP Commercial |
$79.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.10
|
| Rate for Payer: Priority Health SBD |
$59.22
|
| Rate for Payer: UMR Bronson Commercial |
$34.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.50
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$97.38
|
|
|
Service Code
|
NDC 66685101200
|
| 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: Cofinity Medicare Advantage |
$68.17
|
| 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 Commercial |
$82.77
|
| Rate for Payer: PHP Commercial |
$82.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.30
|
| 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
|
$99.75
|
|
|
Service Code
|
NDC 00143998250
|
| 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: Cofinity Medicare Advantage |
$69.82
|
| 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 Commercial |
$84.79
|
| Rate for Payer: PHP Commercial |
$84.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.84
|
| 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
|
OP
|
$119.85
|
|
|
Service Code
|
NDC 65862053475
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.34 |
| Max. Negotiated Rate |
$107.86 |
| Rate for Payer: Aetna American Axle |
$77.90
|
| Rate for Payer: Aetna Commercial |
$101.87
|
| Rate for Payer: Aetna Medicare |
$59.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.90
|
| Rate for Payer: BCBS Complete |
$47.94
|
| Rate for Payer: Cash Price |
$95.88
|
| Rate for Payer: Cofinity Commercial |
$103.07
|
| Rate for Payer: Cofinity Commercial |
$83.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.88
|
| Rate for Payer: Healthscope Commercial |
$107.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.87
|
| Rate for Payer: PHP Commercial |
$101.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.90
|
| Rate for Payer: Priority Health SBD |
$75.51
|
| Rate for Payer: UMR Bronson Commercial |
$44.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.89
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$99.75
|
|
|
Service Code
|
NDC 00143998250
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.91 |
| Max. Negotiated Rate |
$89.78 |
| Rate for Payer: Aetna American Axle |
$64.84
|
| Rate for Payer: Aetna Commercial |
$84.79
|
| Rate for Payer: Aetna Medicare |
$49.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$64.84
|
| Rate for Payer: BCBS Complete |
$39.90
|
| Rate for Payer: Cash Price |
$79.80
|
| Rate for Payer: Cofinity Commercial |
$69.82
|
| Rate for Payer: Cofinity Commercial |
$85.78
|
| Rate for Payer: Cofinity Medicare Advantage |
$69.82
|
| 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 Commercial |
$84.79
|
| Rate for Payer: PHP Commercial |
$84.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$64.84
|
| Rate for Payer: Priority Health SBD |
$62.84
|
| Rate for Payer: UMR Bronson Commercial |
$36.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$74.81
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$97.38
|
|
|
Service Code
|
NDC 66685101200
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.03 |
| Max. Negotiated Rate |
$87.64 |
| Rate for Payer: Aetna American Axle |
$63.30
|
| Rate for Payer: Aetna Commercial |
$82.77
|
| Rate for Payer: Aetna Medicare |
$48.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.30
|
| Rate for Payer: BCBS Complete |
$38.95
|
| Rate for Payer: Cash Price |
$77.90
|
| Rate for Payer: Cofinity Commercial |
$68.17
|
| Rate for Payer: Cofinity Commercial |
$83.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$68.17
|
| 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 Commercial |
$82.77
|
| Rate for Payer: PHP Commercial |
$82.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.30
|
| Rate for Payer: Priority Health SBD |
$61.35
|
| Rate for Payer: UMR Bronson Commercial |
$36.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.04
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$162.15
|
|
|
Service Code
|
NDC 65862053401
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.35 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna American Axle |
$105.40
|
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.40
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$145.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.40
|
| Rate for Payer: Priority Health SBD |
$102.15
|
| Rate for Payer: UMR Bronson Commercial |
$71.35
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.61
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$119.85
|
|
|
Service Code
|
NDC 65862053475
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$52.73 |
| Max. Negotiated Rate |
$107.86 |
| Rate for Payer: Aetna American Axle |
$77.90
|
| Rate for Payer: Aetna Commercial |
$101.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$77.90
|
| Rate for Payer: Cash Price |
$95.88
|
| Rate for Payer: Cofinity Commercial |
$103.07
|
| Rate for Payer: Cofinity Commercial |
$83.90
|
| Rate for Payer: Cofinity Medicare Advantage |
$83.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$95.88
|
| Rate for Payer: Healthscope Commercial |
$107.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$83.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$89.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$101.87
|
| Rate for Payer: PHP Commercial |
$101.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.90
|
| Rate for Payer: Priority Health SBD |
$75.51
|
| Rate for Payer: UMR Bronson Commercial |
$52.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$89.89
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$162.15
|
|
|
Service Code
|
NDC 65862053401
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$60.00 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna American Axle |
$105.40
|
| Rate for Payer: Aetna Commercial |
$137.83
|
| Rate for Payer: Aetna Medicare |
$81.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$105.40
|
| Rate for Payer: BCBS Complete |
$64.86
|
| Rate for Payer: Cash Price |
$129.72
|
| Rate for Payer: Cofinity Commercial |
$113.50
|
| Rate for Payer: Cofinity Commercial |
$139.45
|
| Rate for Payer: Cofinity Medicare Advantage |
$113.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$129.72
|
| Rate for Payer: Healthscope Commercial |
$145.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$113.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$121.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$137.83
|
| Rate for Payer: PHP Commercial |
$137.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.40
|
| Rate for Payer: Priority Health SBD |
$102.15
|
| Rate for Payer: UMR Bronson Commercial |
$60.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$121.61
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 00093310953
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.53 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$46.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
IP
|
$244.40
|
|
|
Service Code
|
NDC 00781261301
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$107.54 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna American Axle |
$158.86
|
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.86
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Commercial |
$171.08
|
| Rate for Payer: Cofinity Commercial |
$210.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$219.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.74
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.86
|
| Rate for Payer: Priority Health SBD |
$153.97
|
| Rate for Payer: UMR Bronson Commercial |
$107.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.30
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
OP
|
$105.75
|
|
|
Service Code
|
NDC 00093310953
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.13 |
| Max. Negotiated Rate |
$95.18 |
| Rate for Payer: Aetna American Axle |
$68.74
|
| Rate for Payer: Aetna Commercial |
$89.89
|
| Rate for Payer: Aetna Medicare |
$52.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.74
|
| Rate for Payer: BCBS Complete |
$42.30
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$74.02
|
| Rate for Payer: Cofinity Commercial |
$90.94
|
| Rate for Payer: Cofinity Medicare Advantage |
$74.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$95.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: PHP Commercial |
$89.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| Rate for Payer: Priority Health SBD |
$66.62
|
| Rate for Payer: UMR Bronson Commercial |
$39.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.31
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
OP
|
$202.10
|
|
|
Service Code
|
NDC 57237003101
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$74.78 |
| Max. Negotiated Rate |
$181.89 |
| Rate for Payer: Aetna American Axle |
$131.36
|
| Rate for Payer: Aetna Commercial |
$171.78
|
| Rate for Payer: Aetna Medicare |
$101.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$131.36
|
| Rate for Payer: BCBS Complete |
$80.84
|
| Rate for Payer: Cash Price |
$161.68
|
| Rate for Payer: Cofinity Commercial |
$141.47
|
| Rate for Payer: Cofinity Commercial |
$173.81
|
| Rate for Payer: Cofinity Medicare Advantage |
$141.47
|
| 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 Commercial |
$171.78
|
| Rate for Payer: PHP Commercial |
$171.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.36
|
| Rate for Payer: Priority Health SBD |
$127.32
|
| Rate for Payer: UMR Bronson Commercial |
$74.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$151.58
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
OP
|
$244.40
|
|
|
Service Code
|
NDC 00781261301
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.43 |
| Max. Negotiated Rate |
$219.96 |
| Rate for Payer: Aetna American Axle |
$158.86
|
| Rate for Payer: Aetna Commercial |
$207.74
|
| Rate for Payer: Aetna Medicare |
$122.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.86
|
| Rate for Payer: BCBS Complete |
$97.76
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Commercial |
$171.08
|
| Rate for Payer: Cofinity Commercial |
$210.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$171.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$219.96
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$171.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$183.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.74
|
| Rate for Payer: PHP Commercial |
$207.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.86
|
| Rate for Payer: Priority Health SBD |
$153.97
|
| Rate for Payer: UMR Bronson Commercial |
$90.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$183.30
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
IP
|
$202.10
|
|
|
Service Code
|
NDC 57237003101
|
| 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: Cofinity Medicare Advantage |
$141.47
|
| 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 Commercial |
$171.78
|
| Rate for Payer: PHP Commercial |
$171.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$131.36
|
| 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
|
$53.96
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.74 |
| Max. Negotiated Rate |
$48.56 |
| Rate for Payer: Aetna American Axle |
$35.07
|
| Rate for Payer: Aetna Commercial |
$45.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.07
|
| Rate for Payer: Cash Price |
$43.17
|
| Rate for Payer: Cofinity Commercial |
$37.77
|
| Rate for Payer: Cofinity Commercial |
$46.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.17
|
| Rate for Payer: Healthscope Commercial |
$48.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.87
|
| Rate for Payer: PHP Commercial |
$45.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.07
|
| Rate for Payer: Priority Health SBD |
$33.99
|
| Rate for Payer: UMR Bronson Commercial |
$23.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.47
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$451.25
|
|
|
Service Code
|
NDC 42571016101
|
| 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: Cofinity Medicare Advantage |
$315.88
|
| 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 Commercial |
$383.56
|
| Rate for Payer: PHP Commercial |
$383.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.31
|
| 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 66685100202
|
| 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: Cofinity Medicare Advantage |
$298.03
|
| 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 Commercial |
$361.90
|
| Rate for Payer: PHP Commercial |
$361.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.74
|
| 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 65862050220
|
| 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: Cofinity Medicare Advantage |
$54.40
|
| 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 Commercial |
$66.05
|
| Rate for Payer: PHP Commercial |
$66.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.51
|
| 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 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$77.71
|
|
|
Service Code
|
NDC 65862050220
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.75 |
| Max. Negotiated Rate |
$69.94 |
| Rate for Payer: Aetna American Axle |
$50.51
|
| Rate for Payer: Aetna Commercial |
$66.05
|
| Rate for Payer: Aetna Medicare |
$38.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$50.51
|
| Rate for Payer: BCBS Complete |
$31.08
|
| Rate for Payer: Cash Price |
$62.17
|
| Rate for Payer: Cofinity Commercial |
$54.40
|
| Rate for Payer: Cofinity Commercial |
$66.83
|
| Rate for Payer: Cofinity Medicare Advantage |
$54.40
|
| 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 Commercial |
$66.05
|
| Rate for Payer: PHP Commercial |
$66.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.51
|
| Rate for Payer: Priority Health SBD |
$48.96
|
| Rate for Payer: UMR Bronson Commercial |
$28.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$58.28
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$451.25
|
|
|
Service Code
|
NDC 42571016101
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.96 |
| Max. Negotiated Rate |
$406.12 |
| Rate for Payer: Aetna American Axle |
$293.31
|
| Rate for Payer: Aetna Commercial |
$383.56
|
| Rate for Payer: Aetna Medicare |
$225.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$293.31
|
| Rate for Payer: BCBS Complete |
$180.50
|
| Rate for Payer: Cash Price |
$361.00
|
| Rate for Payer: Cofinity Commercial |
$315.88
|
| Rate for Payer: Cofinity Commercial |
$388.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$315.88
|
| 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 Commercial |
$383.56
|
| Rate for Payer: PHP Commercial |
$383.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$293.31
|
| Rate for Payer: Priority Health SBD |
$284.29
|
| Rate for Payer: UMR Bronson Commercial |
$166.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$338.44
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$425.76
|
|
|
Service Code
|
NDC 66685100202
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.53 |
| Max. Negotiated Rate |
$383.18 |
| Rate for Payer: Aetna American Axle |
$276.74
|
| Rate for Payer: Aetna Commercial |
$361.90
|
| Rate for Payer: Aetna Medicare |
$212.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$276.74
|
| Rate for Payer: BCBS Complete |
$170.30
|
| Rate for Payer: Cash Price |
$340.61
|
| Rate for Payer: Cofinity Commercial |
$298.03
|
| Rate for Payer: Cofinity Commercial |
$366.15
|
| Rate for Payer: Cofinity Medicare Advantage |
$298.03
|
| 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 Commercial |
$361.90
|
| Rate for Payer: PHP Commercial |
$361.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.74
|
| Rate for Payer: Priority Health SBD |
$268.23
|
| Rate for Payer: UMR Bronson Commercial |
$157.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$319.32
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$53.96
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.97 |
| Max. Negotiated Rate |
$48.56 |
| Rate for Payer: Aetna American Axle |
$35.07
|
| Rate for Payer: Aetna Commercial |
$45.87
|
| Rate for Payer: Aetna Medicare |
$26.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.07
|
| Rate for Payer: BCBS Complete |
$21.58
|
| Rate for Payer: Cash Price |
$43.17
|
| Rate for Payer: Cofinity Commercial |
$37.77
|
| Rate for Payer: Cofinity Commercial |
$46.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$37.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.17
|
| Rate for Payer: Healthscope Commercial |
$48.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$37.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$40.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.87
|
| Rate for Payer: PHP Commercial |
$45.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.07
|
| Rate for Payer: Priority Health SBD |
$33.99
|
| Rate for Payer: UMR Bronson Commercial |
$19.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$40.47
|
|
