|
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 Advantage |
$44.41
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: MI Amish Medical Board Commercial |
$50.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.59
|
| Rate for Payer: PHP Commercial |
$53.93
|
| Rate for Payer: Priority Health SBD |
$39.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$41.24
|
| Rate for Payer: UHC Core |
$33.06
|
| Rate for Payer: UHC Exchange |
$24.94
|
| 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
|
OP
|
$69.56
|
|
|
Service Code
|
NDC 00781604158
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.74 |
| Max. Negotiated Rate |
$62.60 |
| Rate for Payer: Aetna American Axle |
$45.21
|
| Rate for Payer: Aetna Commercial |
$59.13
|
| Rate for Payer: Aetna Medicare |
$34.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.21
|
| Rate for Payer: BCBS Complete |
$27.82
|
| Rate for Payer: Cash Price |
$55.65
|
| Rate for Payer: Cofinity Advantage |
$48.69
|
| Rate for Payer: Cofinity Commercial |
$59.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.65
|
| Rate for Payer: Healthscope Commercial |
$62.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$55.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.17
|
| Rate for Payer: PHP Commercial |
$59.13
|
| Rate for Payer: Priority Health SBD |
$43.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$45.21
|
| Rate for Payer: UHC Core |
$36.24
|
| Rate for Payer: UHC Exchange |
$27.34
|
| Rate for Payer: UMR Bronson Commercial |
$25.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.17
|
|
|
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 Advantage |
$57.58
|
| Rate for Payer: Cofinity Commercial |
$70.73
|
| 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: Opus (Opus Packaging Group) HMA |
$61.69
|
| Rate for Payer: PHP Commercial |
$69.91
|
| 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
|
$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 Advantage |
$44.41
|
| Rate for Payer: Cofinity Commercial |
$54.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.76
|
| Rate for Payer: Healthscope Commercial |
$57.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$44.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.59
|
| Rate for Payer: PHP Commercial |
$53.93
|
| 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
|
$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 Advantage |
$57.58
|
| Rate for Payer: Cofinity Commercial |
$70.73
|
| 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: MI Amish Medical Board Commercial |
$65.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.69
|
| Rate for Payer: PHP Commercial |
$69.91
|
| Rate for Payer: Priority Health SBD |
$51.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$53.46
|
| Rate for Payer: UHC Core |
$42.85
|
| Rate for Payer: UHC Exchange |
$32.32
|
| 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
|
OP
|
$71.44
|
|
|
Service Code
|
NDC 00093415579
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.43 |
| Max. Negotiated Rate |
$64.30 |
| Rate for Payer: Aetna American Axle |
$46.44
|
| Rate for Payer: Aetna Commercial |
$60.72
|
| Rate for Payer: Aetna Medicare |
$35.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.44
|
| Rate for Payer: BCBS Complete |
$28.58
|
| Rate for Payer: Cash Price |
$57.15
|
| Rate for Payer: Cofinity Advantage |
$50.01
|
| Rate for Payer: Cofinity Commercial |
$61.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.15
|
| Rate for Payer: Healthscope Commercial |
$64.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$57.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.58
|
| Rate for Payer: PHP Commercial |
$60.72
|
| Rate for Payer: Priority Health SBD |
$45.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.44
|
| Rate for Payer: UHC Core |
$37.22
|
| Rate for Payer: UHC Exchange |
$28.08
|
| Rate for Payer: UMR Bronson Commercial |
$26.43
|
| 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 Advantage |
$54.28
|
| Rate for Payer: Cofinity Commercial |
$66.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$69.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$54.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$58.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$62.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$58.16
|
| Rate for Payer: PHP Commercial |
$65.92
|
| Rate for Payer: Priority Health SBD |
$48.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.41
|
| Rate for Payer: UHC Core |
$40.40
|
| Rate for Payer: UHC Exchange |
$30.48
|
| 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
|
IP
|
$69.56
|
|
|
Service Code
|
NDC 00781604158
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.61 |
| Max. Negotiated Rate |
$62.60 |
| Rate for Payer: Aetna American Axle |
$45.21
|
| Rate for Payer: Aetna Commercial |
$59.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.21
|
| Rate for Payer: Cash Price |
$55.65
|
| Rate for Payer: Cofinity Advantage |
$48.69
|
| Rate for Payer: Cofinity Commercial |
$59.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.65
|
| Rate for Payer: Healthscope Commercial |
$62.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$48.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$52.17
|
| Rate for Payer: PHP Commercial |
$59.13
|
| Rate for Payer: Priority Health SBD |
$43.82
|
| Rate for Payer: UMR Bronson Commercial |
$30.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.17
|
|
|
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 Advantage |
$76.50
|
| Rate for Payer: Cofinity Commercial |
$93.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.42
|
| Rate for Payer: Healthscope Commercial |
$98.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$87.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$92.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$81.96
|
| Rate for Payer: PHP Commercial |
$92.89
|
| Rate for Payer: Priority Health SBD |
$68.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.03
|
| Rate for Payer: UHC Core |
$56.93
|
| Rate for Payer: UHC Exchange |
$42.95
|
| 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
|
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 Advantage |
$76.50
|
| Rate for Payer: Cofinity Commercial |
$93.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$87.42
|
| Rate for Payer: Healthscope Commercial |
$98.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$76.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$81.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$92.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$81.96
|
| Rate for Payer: PHP Commercial |
$92.89
|
| 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
|
OP
|
$102.23
|
|
|
Service Code
|
NDC 00143988915
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.83 |
| Max. Negotiated Rate |
$92.01 |
| Rate for Payer: Aetna American Axle |
$66.45
|
| Rate for Payer: Aetna Commercial |
$86.90
|
| Rate for Payer: Aetna Medicare |
$51.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.45
|
| Rate for Payer: BCBS Complete |
$40.89
|
| Rate for Payer: Cash Price |
$81.78
|
| Rate for Payer: Cofinity Advantage |
$71.56
|
| Rate for Payer: Cofinity Commercial |
$87.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.78
|
| Rate for Payer: Healthscope Commercial |
$92.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$71.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$76.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$81.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$76.67
|
| Rate for Payer: PHP Commercial |
$86.90
|
| Rate for Payer: Priority Health SBD |
$64.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$66.45
|
| Rate for Payer: UHC Core |
$53.26
|
| Rate for Payer: UHC Exchange |
$40.18
|
| Rate for Payer: UMR Bronson Commercial |
$37.83
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$76.67
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$102.23
|
|
|
Service Code
|
NDC 00143988915
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$92.01 |
| Rate for Payer: Aetna American Axle |
$66.45
|
| Rate for Payer: Aetna Commercial |
$86.90
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$66.45
|
| Rate for Payer: Cash Price |
$81.78
|
| Rate for Payer: Cofinity Advantage |
$71.56
|
| Rate for Payer: Cofinity Commercial |
$87.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.78
|
| Rate for Payer: Healthscope Commercial |
$92.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$71.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$76.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$76.67
|
| Rate for Payer: PHP Commercial |
$86.90
|
| Rate for Payer: Priority Health SBD |
$64.40
|
| Rate for Payer: UMR Bronson Commercial |
$44.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$76.67
|
|
|
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 Advantage |
$50.01
|
| Rate for Payer: Cofinity Commercial |
$61.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.15
|
| Rate for Payer: Healthscope Commercial |
$64.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$50.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$53.58
|
| Rate for Payer: PHP Commercial |
$60.72
|
| Rate for Payer: Priority Health SBD |
$45.01
|
| Rate for Payer: UMR Bronson Commercial |
$31.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.58
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$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 Advantage |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$48.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.12
|
| Rate for Payer: Healthscope Commercial |
$50.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.30
|
| Rate for Payer: PHP Commercial |
$47.94
|
| 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
|
$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 Advantage |
$39.48
|
| Rate for Payer: Cofinity Commercial |
$48.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.12
|
| Rate for Payer: Healthscope Commercial |
$50.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$39.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$42.30
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$47.94
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.30
|
| Rate for Payer: PHP Commercial |
$47.94
|
| Rate for Payer: Priority Health SBD |
$35.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$36.66
|
| Rate for Payer: UHC Core |
$29.38
|
| Rate for Payer: UHC Exchange |
$22.17
|
| Rate for Payer: UMR Bronson Commercial |
$20.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$42.30
|
|
|
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 Advantage |
$77.31
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| 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: Opus (Opus Packaging Group) HMA |
$82.84
|
| Rate for Payer: PHP Commercial |
$93.88
|
| 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 Advantage |
$77.31
|
| Rate for Payer: Cofinity Commercial |
$94.99
|
| 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: MI Amish Medical Board Commercial |
$88.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$93.88
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$82.84
|
| Rate for Payer: PHP Commercial |
$93.88
|
| Rate for Payer: Priority Health SBD |
$69.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$71.79
|
| Rate for Payer: UHC Core |
$57.54
|
| Rate for Payer: UHC Exchange |
$43.41
|
| Rate for Payer: UMR Bronson Commercial |
$40.87
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$82.84
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$166.85
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.41 |
| Max. Negotiated Rate |
$150.16 |
| Rate for Payer: Aetna American Axle |
$108.45
|
| Rate for Payer: Aetna Commercial |
$141.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.45
|
| Rate for Payer: Cash Price |
$133.48
|
| Rate for Payer: Cofinity Advantage |
$116.80
|
| Rate for Payer: Cofinity Commercial |
$143.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.48
|
| Rate for Payer: Healthscope Commercial |
$150.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$116.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$125.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$125.14
|
| Rate for Payer: PHP Commercial |
$141.82
|
| Rate for Payer: Priority Health SBD |
$105.12
|
| Rate for Payer: UMR Bronson Commercial |
$73.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$125.14
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$166.85
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.73 |
| Max. Negotiated Rate |
$150.16 |
| Rate for Payer: Aetna American Axle |
$108.45
|
| Rate for Payer: Aetna Commercial |
$141.82
|
| Rate for Payer: Aetna Medicare |
$83.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$108.45
|
| Rate for Payer: BCBS Complete |
$66.74
|
| Rate for Payer: Cash Price |
$133.48
|
| Rate for Payer: Cofinity Advantage |
$116.80
|
| Rate for Payer: Cofinity Commercial |
$143.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$133.48
|
| Rate for Payer: Healthscope Commercial |
$150.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$116.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$125.14
|
| Rate for Payer: MI Amish Medical Board Commercial |
$133.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$141.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$125.14
|
| Rate for Payer: PHP Commercial |
$141.82
|
| Rate for Payer: Priority Health SBD |
$105.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$108.45
|
| Rate for Payer: UHC Core |
$86.93
|
| Rate for Payer: UHC Exchange |
$65.57
|
| Rate for Payer: UMR Bronson Commercial |
$61.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$125.14
|
|
|
AMOXICILLIN 250 MG CHEWABLE TABLET
|
Facility
|
IP
|
$304.00
|
|
|
Service Code
|
NDC 00093226801
|
| Hospital Charge Code |
452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$133.76 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna American Axle |
$197.60
|
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.60
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Cofinity Advantage |
$212.80
|
| Rate for Payer: Cofinity Commercial |
$261.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.20
|
| Rate for Payer: Healthscope Commercial |
$273.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$212.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$258.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$228.00
|
| Rate for Payer: PHP Commercial |
$258.40
|
| Rate for Payer: Priority Health SBD |
$191.52
|
| Rate for Payer: UMR Bronson Commercial |
$133.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.00
|
|
|
AMOXICILLIN 250 MG CHEWABLE TABLET
|
Facility
|
OP
|
$304.00
|
|
|
Service Code
|
NDC 00093226801
|
| Hospital Charge Code |
452
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$112.48 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna American Axle |
$197.60
|
| Rate for Payer: Aetna Commercial |
$258.40
|
| Rate for Payer: Aetna Medicare |
$152.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$197.60
|
| Rate for Payer: BCBS Complete |
$121.60
|
| Rate for Payer: Cash Price |
$243.20
|
| Rate for Payer: Cofinity Advantage |
$212.80
|
| Rate for Payer: Cofinity Commercial |
$261.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$243.20
|
| Rate for Payer: Healthscope Commercial |
$273.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$212.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$228.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$243.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$258.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$228.00
|
| Rate for Payer: PHP Commercial |
$258.40
|
| Rate for Payer: Priority Health SBD |
$191.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$197.60
|
| Rate for Payer: UHC Core |
$158.38
|
| Rate for Payer: UHC Exchange |
$119.47
|
| Rate for Payer: UMR Bronson Commercial |
$112.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$228.00
|
|
|
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 Advantage |
$136.53
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| 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 |
$136.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.29
|
| Rate for Payer: PHP Commercial |
$165.79
|
| 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
|
$323.95
|
|
|
Service Code
|
NDC 59651002601
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.86 |
| Max. Negotiated Rate |
$291.56 |
| Rate for Payer: Aetna American Axle |
$210.57
|
| Rate for Payer: Aetna Commercial |
$275.36
|
| Rate for Payer: Aetna Medicare |
$161.97
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$210.57
|
| Rate for Payer: BCBS Complete |
$129.58
|
| Rate for Payer: Cash Price |
$259.16
|
| Rate for Payer: Cofinity Advantage |
$226.76
|
| Rate for Payer: Cofinity Commercial |
$278.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$259.16
|
| Rate for Payer: Healthscope Commercial |
$291.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$226.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$242.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$259.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$275.36
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$242.96
|
| Rate for Payer: PHP Commercial |
$275.36
|
| Rate for Payer: Priority Health SBD |
$204.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$210.57
|
| Rate for Payer: UHC Core |
$168.78
|
| Rate for Payer: UHC Exchange |
$127.31
|
| Rate for Payer: UMR Bronson Commercial |
$119.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$242.96
|
|
|
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 |
$375.35 |
| 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 Advantage |
$291.94
|
| Rate for Payer: Cofinity Commercial |
$358.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$333.64
|
| Rate for Payer: Healthscope Commercial |
$375.35
|
| 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: Opus (Opus Packaging Group) HMA |
$312.79
|
| Rate for Payer: PHP Commercial |
$354.49
|
| 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
|
$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 |
$97.53
|
| 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 Advantage |
$136.53
|
| Rate for Payer: Cofinity Commercial |
$167.74
|
| 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 |
$136.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$146.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$156.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$165.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$146.29
|
| Rate for Payer: PHP Commercial |
$165.79
|
| Rate for Payer: Priority Health SBD |
$122.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$126.78
|
| Rate for Payer: UHC Core |
$101.62
|
| Rate for Payer: UHC Exchange |
$76.65
|
| Rate for Payer: UMR Bronson Commercial |
$72.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$146.29
|
|
