|
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
|
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 Advantage |
$127.08
|
| Rate for Payer: Cofinity Commercial |
$156.12
|
| 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: MI Amish Medical Board Commercial |
$145.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$154.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$136.16
|
| Rate for Payer: PHP Commercial |
$154.31
|
| Rate for Payer: Priority Health SBD |
$114.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$118.00
|
| Rate for Payer: UHC Core |
$94.58
|
| Rate for Payer: UHC Exchange |
$71.35
|
| 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
|
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 Advantage |
$127.08
|
| Rate for Payer: Cofinity Commercial |
$156.12
|
| 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: Opus (Opus Packaging Group) HMA |
$136.16
|
| Rate for Payer: PHP Commercial |
$154.31
|
| 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
|
OP
|
$417.05
|
|
|
Service Code
|
NDC 43598020452
|
| Hospital Charge Code |
9080
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.31 |
| Max. Negotiated Rate |
$375.35 |
| Rate for Payer: Aetna American Axle |
$271.08
|
| Rate for Payer: Aetna Commercial |
$354.49
|
| Rate for Payer: Aetna Medicare |
$208.53
|
| 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 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: MI Amish Medical Board Commercial |
$333.64
|
| 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: UHC All Payor (Choice/PPO) |
$271.08
|
| Rate for Payer: UHC Core |
$217.28
|
| Rate for Payer: UHC Exchange |
$163.90
|
| 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
|
$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 Advantage |
$98.70
|
| 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: MI Amish Medical Board Commercial |
$112.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$105.75
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$91.65
|
| Rate for Payer: UHC Core |
$73.46
|
| Rate for Payer: UHC Exchange |
$55.41
|
| 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 57237003301
|
| 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 Advantage |
$98.70
|
| 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: MI Amish Medical Board Commercial |
$112.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$119.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$105.75
|
| Rate for Payer: PHP Commercial |
$119.85
|
| Rate for Payer: Priority Health SBD |
$88.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$91.65
|
| Rate for Payer: UHC Core |
$73.46
|
| Rate for Payer: UHC Exchange |
$55.41
|
| 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
|
$75.20
|
|
|
Service Code
|
NDC 65862007101
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.09 |
| Max. Negotiated Rate |
$67.68 |
| Rate for Payer: Aetna American Axle |
$48.88
|
| Rate for Payer: Aetna Commercial |
$63.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.88
|
| Rate for Payer: Cash Price |
$60.16
|
| Rate for Payer: Cofinity Advantage |
$52.64
|
| Rate for Payer: Cofinity Commercial |
$64.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.16
|
| Rate for Payer: Healthscope Commercial |
$67.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.40
|
| Rate for Payer: PHP Commercial |
$63.92
|
| Rate for Payer: Priority Health SBD |
$47.38
|
| Rate for Payer: UMR Bronson Commercial |
$33.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.40
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$171.55
|
|
|
Service Code
|
NDC 00093416173
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$75.48 |
| Max. Negotiated Rate |
$154.40 |
| Rate for Payer: Aetna American Axle |
$111.51
|
| Rate for Payer: Aetna Commercial |
$145.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$111.51
|
| Rate for Payer: Cash Price |
$137.24
|
| Rate for Payer: Cofinity Advantage |
$120.08
|
| Rate for Payer: Cofinity Commercial |
$147.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$137.24
|
| Rate for Payer: Healthscope Commercial |
$154.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$120.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$128.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$145.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$128.66
|
| Rate for Payer: PHP Commercial |
$145.82
|
| Rate for Payer: Priority Health SBD |
$108.08
|
| Rate for Payer: UMR Bronson Commercial |
$75.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$128.66
|
|
|
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 Advantage |
$98.70
|
| 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: Opus (Opus Packaging Group) HMA |
$105.75
|
| Rate for Payer: PHP Commercial |
$119.85
|
| 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
|
$143.35
|
|
|
Service Code
|
NDC 00143988701
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.04 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Aetna American Axle |
$93.18
|
| Rate for Payer: Aetna Commercial |
$121.85
|
| Rate for Payer: Aetna Medicare |
$71.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.18
|
| Rate for Payer: BCBS Complete |
$57.34
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Advantage |
$100.34
|
| Rate for Payer: Cofinity Commercial |
$123.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Healthscope Commercial |
$129.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$100.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$114.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$107.51
|
| Rate for Payer: PHP Commercial |
$121.85
|
| Rate for Payer: Priority Health SBD |
$90.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$93.18
|
| Rate for Payer: UHC Core |
$74.69
|
| Rate for Payer: UHC Exchange |
$56.34
|
| Rate for Payer: UMR Bronson Commercial |
$53.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.51
|
|
|
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 |
$51.99
|
| 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 Advantage |
$72.79
|
| Rate for Payer: Cofinity Commercial |
$89.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.19
|
| Rate for Payer: Healthscope Commercial |
$93.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$83.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.99
|
| Rate for Payer: PHP Commercial |
$88.39
|
| Rate for Payer: Priority Health SBD |
$65.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.59
|
| Rate for Payer: UHC Core |
$54.18
|
| Rate for Payer: UHC Exchange |
$40.87
|
| 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
|
$143.35
|
|
|
Service Code
|
NDC 00143988701
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.07 |
| Max. Negotiated Rate |
$129.01 |
| Rate for Payer: Aetna American Axle |
$93.18
|
| Rate for Payer: Aetna Commercial |
$121.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$93.18
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Advantage |
$100.34
|
| Rate for Payer: Cofinity Commercial |
$123.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Healthscope Commercial |
$129.01
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$100.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$107.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$121.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$107.51
|
| Rate for Payer: PHP Commercial |
$121.85
|
| Rate for Payer: Priority Health SBD |
$90.31
|
| Rate for Payer: UMR Bronson Commercial |
$63.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$107.51
|
|
|
AMOXICILLIN 400 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$171.55
|
|
|
Service Code
|
NDC 00093416173
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$63.47 |
| Max. Negotiated Rate |
$154.40 |
| Rate for Payer: Aetna American Axle |
$111.51
|
| Rate for Payer: Aetna Commercial |
$145.82
|
| Rate for Payer: Aetna Medicare |
$85.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$111.51
|
| Rate for Payer: BCBS Complete |
$68.62
|
| Rate for Payer: Cash Price |
$137.24
|
| Rate for Payer: Cofinity Advantage |
$120.08
|
| Rate for Payer: Cofinity Commercial |
$147.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$137.24
|
| Rate for Payer: Healthscope Commercial |
$154.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$120.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$128.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$137.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$145.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$128.66
|
| Rate for Payer: PHP Commercial |
$145.82
|
| Rate for Payer: Priority Health SBD |
$108.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$111.51
|
| Rate for Payer: UHC Core |
$89.38
|
| Rate for Payer: UHC Exchange |
$67.42
|
| Rate for Payer: UMR Bronson Commercial |
$63.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$128.66
|
|
|
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 Advantage |
$98.70
|
| 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: Opus (Opus Packaging Group) HMA |
$105.75
|
| Rate for Payer: PHP Commercial |
$119.85
|
| 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
|
$75.20
|
|
|
Service Code
|
NDC 65862007101
|
| Hospital Charge Code |
25246
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.82 |
| Max. Negotiated Rate |
$67.68 |
| Rate for Payer: Aetna American Axle |
$48.88
|
| Rate for Payer: Aetna Commercial |
$63.92
|
| Rate for Payer: Aetna Medicare |
$37.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.88
|
| Rate for Payer: BCBS Complete |
$30.08
|
| Rate for Payer: Cash Price |
$60.16
|
| Rate for Payer: Cofinity Advantage |
$52.64
|
| Rate for Payer: Cofinity Commercial |
$64.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$60.16
|
| Rate for Payer: Healthscope Commercial |
$67.68
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.64
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$60.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$63.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$56.40
|
| Rate for Payer: PHP Commercial |
$63.92
|
| Rate for Payer: Priority Health SBD |
$47.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$48.88
|
| Rate for Payer: UHC Core |
$39.18
|
| Rate for Payer: UHC Exchange |
$29.55
|
| Rate for Payer: UMR Bronson Commercial |
$27.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.40
|
|
|
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: 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 Advantage |
$72.79
|
| Rate for Payer: Cofinity Commercial |
$89.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.19
|
| Rate for Payer: Healthscope Commercial |
$93.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$77.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$77.99
|
| Rate for Payer: PHP Commercial |
$88.39
|
| 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-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$95.48
|
|
|
Service Code
|
NDC 00143998250
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$42.01 |
| Max. Negotiated Rate |
$85.93 |
| Rate for Payer: Aetna American Axle |
$62.06
|
| Rate for Payer: Aetna Commercial |
$81.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.06
|
| Rate for Payer: Cash Price |
$76.38
|
| Rate for Payer: Cofinity Advantage |
$66.84
|
| Rate for Payer: Cofinity Commercial |
$82.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.38
|
| Rate for Payer: Healthscope Commercial |
$85.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.61
|
| Rate for Payer: PHP Commercial |
$81.16
|
| Rate for Payer: Priority Health SBD |
$60.15
|
| Rate for Payer: UMR Bronson Commercial |
$42.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.61
|
|
|
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 Advantage |
$68.17
|
| Rate for Payer: Cofinity Commercial |
$83.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.90
|
| Rate for Payer: Healthscope Commercial |
$87.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$73.03
|
| Rate for Payer: PHP Commercial |
$82.77
|
| 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 |
$73.03
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$95.48
|
|
|
Service Code
|
NDC 00143998250
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.33 |
| Max. Negotiated Rate |
$85.93 |
| Rate for Payer: Aetna American Axle |
$62.06
|
| Rate for Payer: Aetna Commercial |
$81.16
|
| Rate for Payer: Aetna Medicare |
$47.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$62.06
|
| Rate for Payer: BCBS Complete |
$38.19
|
| Rate for Payer: Cash Price |
$76.38
|
| Rate for Payer: Cofinity Advantage |
$66.84
|
| Rate for Payer: Cofinity Commercial |
$82.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$76.38
|
| Rate for Payer: Healthscope Commercial |
$85.93
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$71.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$76.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$81.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$71.61
|
| Rate for Payer: PHP Commercial |
$81.16
|
| Rate for Payer: Priority Health SBD |
$60.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.06
|
| Rate for Payer: UHC Core |
$49.75
|
| Rate for Payer: UHC Exchange |
$37.52
|
| Rate for Payer: UMR Bronson Commercial |
$35.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$71.61
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$199.75
|
|
|
Service Code
|
NDC 65862053401
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.89 |
| Max. Negotiated Rate |
$179.78 |
| Rate for Payer: Aetna American Axle |
$129.84
|
| Rate for Payer: Aetna Commercial |
$169.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.84
|
| Rate for Payer: Cash Price |
$159.80
|
| Rate for Payer: Cofinity Advantage |
$139.82
|
| Rate for Payer: Cofinity Commercial |
$171.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.80
|
| Rate for Payer: Healthscope Commercial |
$179.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$139.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$149.81
|
| Rate for Payer: PHP Commercial |
$169.79
|
| Rate for Payer: Priority Health SBD |
$125.84
|
| Rate for Payer: UMR Bronson Commercial |
$87.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.81
|
|
|
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 Advantage |
$68.17
|
| Rate for Payer: Cofinity Commercial |
$83.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$77.90
|
| Rate for Payer: Healthscope Commercial |
$87.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.03
|
| Rate for Payer: MI Amish Medical Board Commercial |
$77.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$82.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$73.03
|
| Rate for Payer: PHP Commercial |
$82.77
|
| Rate for Payer: Priority Health SBD |
$61.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63.30
|
| Rate for Payer: UHC Core |
$50.73
|
| Rate for Payer: UHC Exchange |
$38.27
|
| Rate for Payer: UMR Bronson Commercial |
$36.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.03
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$121.62
|
|
|
Service Code
|
NDC 65862053475
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.51 |
| Max. Negotiated Rate |
$109.46 |
| Rate for Payer: Aetna American Axle |
$79.05
|
| Rate for Payer: Aetna Commercial |
$103.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.05
|
| Rate for Payer: Cash Price |
$97.30
|
| Rate for Payer: Cofinity Advantage |
$85.13
|
| Rate for Payer: Cofinity Commercial |
$104.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$97.30
|
| Rate for Payer: Healthscope Commercial |
$109.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$85.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$91.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$103.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$91.22
|
| Rate for Payer: PHP Commercial |
$103.38
|
| Rate for Payer: Priority Health SBD |
$76.62
|
| Rate for Payer: UMR Bronson Commercial |
$53.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$91.22
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$121.62
|
|
|
Service Code
|
NDC 65862053475
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.00 |
| Max. Negotiated Rate |
$109.46 |
| Rate for Payer: Aetna American Axle |
$79.05
|
| Rate for Payer: Aetna Commercial |
$103.38
|
| Rate for Payer: Aetna Medicare |
$60.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$79.05
|
| Rate for Payer: BCBS Complete |
$48.65
|
| Rate for Payer: Cash Price |
$97.30
|
| Rate for Payer: Cofinity Advantage |
$85.13
|
| Rate for Payer: Cofinity Commercial |
$104.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$97.30
|
| Rate for Payer: Healthscope Commercial |
$109.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$85.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$91.22
|
| Rate for Payer: MI Amish Medical Board Commercial |
$97.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$103.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$91.22
|
| Rate for Payer: PHP Commercial |
$103.38
|
| Rate for Payer: Priority Health SBD |
$76.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$79.05
|
| Rate for Payer: UHC Core |
$63.36
|
| Rate for Payer: UHC Exchange |
$47.80
|
| Rate for Payer: UMR Bronson Commercial |
$45.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$91.22
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$111.63
|
|
|
Service Code
|
NDC 65862053450
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.12 |
| Max. Negotiated Rate |
$100.47 |
| Rate for Payer: Aetna American Axle |
$72.56
|
| Rate for Payer: Aetna Commercial |
$94.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$72.56
|
| Rate for Payer: Cash Price |
$89.30
|
| Rate for Payer: Cofinity Advantage |
$78.14
|
| Rate for Payer: Cofinity Commercial |
$96.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$89.30
|
| Rate for Payer: Healthscope Commercial |
$100.47
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$78.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$83.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$94.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$83.72
|
| Rate for Payer: PHP Commercial |
$94.89
|
| Rate for Payer: Priority Health SBD |
$70.33
|
| Rate for Payer: UMR Bronson Commercial |
$49.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$83.72
|
|
|
AMOXICILLIN 400 MG-POTASSIUM CLAVULANATE 57 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$199.75
|
|
|
Service Code
|
NDC 65862053401
|
| Hospital Charge Code |
33230
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.91 |
| Max. Negotiated Rate |
$179.78 |
| Rate for Payer: Aetna American Axle |
$129.84
|
| Rate for Payer: Aetna Commercial |
$169.79
|
| Rate for Payer: Aetna Medicare |
$99.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$129.84
|
| Rate for Payer: BCBS Complete |
$79.90
|
| Rate for Payer: Cash Price |
$159.80
|
| Rate for Payer: Cofinity Advantage |
$139.82
|
| Rate for Payer: Cofinity Commercial |
$171.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$159.80
|
| Rate for Payer: Healthscope Commercial |
$179.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$139.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$149.81
|
| Rate for Payer: MI Amish Medical Board Commercial |
$159.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$169.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$149.81
|
| Rate for Payer: PHP Commercial |
$169.79
|
| Rate for Payer: Priority Health SBD |
$125.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$129.84
|
| Rate for Payer: UHC Core |
$104.07
|
| Rate for Payer: UHC Exchange |
$78.50
|
| Rate for Payer: UMR Bronson Commercial |
$73.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$149.81
|
|
