|
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 500 MG CAPSULE
|
Facility
|
IP
|
$106.93
|
|
|
Service Code
|
NDC 00093310953
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.05 |
| Max. Negotiated Rate |
$96.24 |
| Rate for Payer: Aetna American Axle |
$69.50
|
| Rate for Payer: Aetna Commercial |
$90.89
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.50
|
| Rate for Payer: Cash Price |
$85.54
|
| Rate for Payer: Cofinity Advantage |
$74.85
|
| Rate for Payer: Cofinity Commercial |
$91.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.54
|
| Rate for Payer: Healthscope Commercial |
$96.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80.20
|
| Rate for Payer: PHP Commercial |
$90.89
|
| Rate for Payer: Priority Health SBD |
$67.37
|
| Rate for Payer: UMR Bronson Commercial |
$47.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.20
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
OP
|
$106.93
|
|
|
Service Code
|
NDC 00093310953
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.56 |
| Max. Negotiated Rate |
$96.24 |
| Rate for Payer: Aetna American Axle |
$69.50
|
| Rate for Payer: Aetna Commercial |
$90.89
|
| Rate for Payer: Aetna Medicare |
$53.47
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.50
|
| Rate for Payer: BCBS Complete |
$42.77
|
| Rate for Payer: Cash Price |
$85.54
|
| Rate for Payer: Cofinity Advantage |
$74.85
|
| Rate for Payer: Cofinity Commercial |
$91.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.54
|
| Rate for Payer: Healthscope Commercial |
$96.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$74.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$80.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$85.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.89
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$80.20
|
| Rate for Payer: PHP Commercial |
$90.89
|
| Rate for Payer: Priority Health SBD |
$67.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$69.50
|
| Rate for Payer: UHC Core |
$55.71
|
| Rate for Payer: UHC Exchange |
$42.02
|
| Rate for Payer: UMR Bronson Commercial |
$39.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$80.20
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
IP
|
$284.35
|
|
|
Service Code
|
NDC 00781261301
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.11 |
| Max. Negotiated Rate |
$255.91 |
| Rate for Payer: Aetna American Axle |
$184.83
|
| Rate for Payer: Aetna Commercial |
$241.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.83
|
| Rate for Payer: Cash Price |
$227.48
|
| Rate for Payer: Cofinity Advantage |
$199.04
|
| Rate for Payer: Cofinity Commercial |
$244.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.48
|
| Rate for Payer: Healthscope Commercial |
$255.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$213.26
|
| Rate for Payer: PHP Commercial |
$241.70
|
| Rate for Payer: Priority Health SBD |
$179.14
|
| Rate for Payer: UMR Bronson Commercial |
$125.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.26
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
OP
|
$197.40
|
|
|
Service Code
|
NDC 57237003101
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.04 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna American Axle |
$128.31
|
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna Medicare |
$98.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: BCBS Complete |
$78.96
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Advantage |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$157.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.05
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$128.31
|
| Rate for Payer: UHC Core |
$102.85
|
| Rate for Payer: UHC Exchange |
$77.58
|
| Rate for Payer: UMR Bronson Commercial |
$73.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
IP
|
$197.40
|
|
|
Service Code
|
NDC 57237003101
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.86 |
| Max. Negotiated Rate |
$177.66 |
| Rate for Payer: Aetna American Axle |
$128.31
|
| Rate for Payer: Aetna Commercial |
$167.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$128.31
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Advantage |
$138.18
|
| Rate for Payer: Cofinity Commercial |
$169.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$177.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$138.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$148.05
|
| Rate for Payer: PHP Commercial |
$167.79
|
| Rate for Payer: Priority Health SBD |
$124.36
|
| Rate for Payer: UMR Bronson Commercial |
$86.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.05
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
OP
|
$284.35
|
|
|
Service Code
|
NDC 00781261301
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.21 |
| Max. Negotiated Rate |
$255.91 |
| Rate for Payer: Aetna American Axle |
$184.83
|
| Rate for Payer: Aetna Commercial |
$241.70
|
| Rate for Payer: Aetna Medicare |
$142.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$184.83
|
| Rate for Payer: BCBS Complete |
$113.74
|
| Rate for Payer: Cash Price |
$227.48
|
| Rate for Payer: Cofinity Advantage |
$199.04
|
| Rate for Payer: Cofinity Commercial |
$244.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$227.48
|
| Rate for Payer: Healthscope Commercial |
$255.91
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$199.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$213.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$227.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$241.70
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$213.26
|
| Rate for Payer: PHP Commercial |
$241.70
|
| Rate for Payer: Priority Health SBD |
$179.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$184.83
|
| Rate for Payer: UHC Core |
$148.15
|
| Rate for Payer: UHC Exchange |
$111.75
|
| Rate for Payer: UMR Bronson Commercial |
$105.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$213.26
|
|
|
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 |
$38.85
|
| 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 Advantage |
$54.40
|
| Rate for Payer: Cofinity Commercial |
$66.83
|
| 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: MI Amish Medical Board Commercial |
$62.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$58.28
|
| Rate for Payer: PHP Commercial |
$66.05
|
| Rate for Payer: Priority Health SBD |
$48.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$50.51
|
| Rate for Payer: UHC Core |
$40.49
|
| Rate for Payer: UHC Exchange |
$30.54
|
| 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
|
$62.70
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.20 |
| Max. Negotiated Rate |
$56.43 |
| Rate for Payer: Aetna American Axle |
$40.76
|
| Rate for Payer: Aetna Commercial |
$53.30
|
| Rate for Payer: Aetna Medicare |
$31.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.76
|
| Rate for Payer: BCBS Complete |
$25.08
|
| Rate for Payer: Cash Price |
$50.16
|
| Rate for Payer: Cofinity Advantage |
$43.89
|
| Rate for Payer: Cofinity Commercial |
$53.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.16
|
| Rate for Payer: Healthscope Commercial |
$56.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$43.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$50.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.02
|
| Rate for Payer: PHP Commercial |
$53.30
|
| Rate for Payer: Priority Health SBD |
$39.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$40.76
|
| Rate for Payer: UHC Core |
$32.67
|
| Rate for Payer: UHC Exchange |
$24.64
|
| Rate for Payer: UMR Bronson Commercial |
$23.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.02
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$62.70
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.59 |
| Max. Negotiated Rate |
$56.43 |
| Rate for Payer: Aetna American Axle |
$40.76
|
| Rate for Payer: Aetna Commercial |
$53.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$40.76
|
| Rate for Payer: Cash Price |
$50.16
|
| Rate for Payer: Cofinity Advantage |
$43.89
|
| Rate for Payer: Cofinity Commercial |
$53.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$50.16
|
| Rate for Payer: Healthscope Commercial |
$56.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$43.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$47.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$53.30
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$47.02
|
| Rate for Payer: PHP Commercial |
$53.30
|
| Rate for Payer: Priority Health SBD |
$39.50
|
| Rate for Payer: UMR Bronson Commercial |
$27.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$47.02
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$441.75
|
|
|
Service Code
|
NDC 42571016101
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.37 |
| Max. Negotiated Rate |
$397.57 |
| Rate for Payer: Aetna American Axle |
$287.14
|
| Rate for Payer: Aetna Commercial |
$375.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.14
|
| Rate for Payer: Cash Price |
$353.40
|
| Rate for Payer: Cofinity Advantage |
$309.23
|
| Rate for Payer: Cofinity Commercial |
$379.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.40
|
| Rate for Payer: Healthscope Commercial |
$397.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$309.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$331.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$331.31
|
| Rate for Payer: PHP Commercial |
$375.49
|
| Rate for Payer: Priority Health SBD |
$278.30
|
| Rate for Payer: UMR Bronson Commercial |
$194.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.31
|
|
|
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 Advantage |
$54.40
|
| Rate for Payer: Cofinity Commercial |
$66.83
|
| 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: Opus (Opus Packaging Group) HMA |
$58.28
|
| Rate for Payer: PHP Commercial |
$66.05
|
| 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
|
$441.75
|
|
|
Service Code
|
NDC 42571016101
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.45 |
| Max. Negotiated Rate |
$397.57 |
| Rate for Payer: Aetna American Axle |
$287.14
|
| Rate for Payer: Aetna Commercial |
$375.49
|
| Rate for Payer: Aetna Medicare |
$220.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$287.14
|
| Rate for Payer: BCBS Complete |
$176.70
|
| Rate for Payer: Cash Price |
$353.40
|
| Rate for Payer: Cofinity Advantage |
$309.23
|
| Rate for Payer: Cofinity Commercial |
$379.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$353.40
|
| Rate for Payer: Healthscope Commercial |
$397.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$309.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$331.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$353.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$375.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$331.31
|
| Rate for Payer: PHP Commercial |
$375.49
|
| Rate for Payer: Priority Health SBD |
$278.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$287.14
|
| Rate for Payer: UHC Core |
$230.15
|
| Rate for Payer: UHC Exchange |
$173.61
|
| Rate for Payer: UMR Bronson Commercial |
$163.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$331.31
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$311.97
|
|
|
Service Code
|
NDC 00143985375
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.27 |
| Max. Negotiated Rate |
$280.77 |
| Rate for Payer: Aetna American Axle |
$202.78
|
| Rate for Payer: Aetna Commercial |
$265.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.78
|
| Rate for Payer: Cash Price |
$249.58
|
| Rate for Payer: Cofinity Advantage |
$218.38
|
| Rate for Payer: Cofinity Commercial |
$268.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.58
|
| Rate for Payer: Healthscope Commercial |
$280.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$218.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$233.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$233.98
|
| Rate for Payer: PHP Commercial |
$265.17
|
| Rate for Payer: Priority Health SBD |
$196.54
|
| Rate for Payer: UMR Bronson Commercial |
$137.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$233.98
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$311.97
|
|
|
Service Code
|
NDC 00143985375
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.43 |
| Max. Negotiated Rate |
$280.77 |
| Rate for Payer: Aetna American Axle |
$202.78
|
| Rate for Payer: Aetna Commercial |
$265.17
|
| Rate for Payer: Aetna Medicare |
$155.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$202.78
|
| Rate for Payer: BCBS Complete |
$124.79
|
| Rate for Payer: Cash Price |
$249.58
|
| Rate for Payer: Cofinity Advantage |
$218.38
|
| Rate for Payer: Cofinity Commercial |
$268.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$249.58
|
| Rate for Payer: Healthscope Commercial |
$280.77
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$218.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$233.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$249.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$265.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$233.98
|
| Rate for Payer: PHP Commercial |
$265.17
|
| Rate for Payer: Priority Health SBD |
$196.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$202.78
|
| Rate for Payer: UHC Core |
$162.54
|
| Rate for Payer: UHC Exchange |
$122.60
|
| Rate for Payer: UMR Bronson Commercial |
$115.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$233.98
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$246.75
|
|
|
Service Code
|
NDC 65862053513
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.57 |
| Max. Negotiated Rate |
$222.07 |
| Rate for Payer: Aetna American Axle |
$160.39
|
| Rate for Payer: Aetna Commercial |
$209.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.39
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cofinity Advantage |
$172.72
|
| Rate for Payer: Cofinity Commercial |
$212.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.40
|
| Rate for Payer: Healthscope Commercial |
$222.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$185.06
|
| Rate for Payer: PHP Commercial |
$209.74
|
| Rate for Payer: Priority Health SBD |
$155.45
|
| Rate for Payer: UMR Bronson Commercial |
$108.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.06
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$246.75
|
|
|
Service Code
|
NDC 65862053513
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.30 |
| Max. Negotiated Rate |
$222.07 |
| Rate for Payer: Aetna American Axle |
$160.39
|
| Rate for Payer: Aetna Commercial |
$209.74
|
| Rate for Payer: Aetna Medicare |
$123.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$160.39
|
| Rate for Payer: BCBS Complete |
$98.70
|
| Rate for Payer: Cash Price |
$197.40
|
| Rate for Payer: Cofinity Advantage |
$172.72
|
| Rate for Payer: Cofinity Commercial |
$212.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$197.40
|
| Rate for Payer: Healthscope Commercial |
$222.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$172.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$185.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$197.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$209.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$185.06
|
| Rate for Payer: PHP Commercial |
$209.74
|
| Rate for Payer: Priority Health SBD |
$155.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$160.39
|
| Rate for Payer: UHC Core |
$128.56
|
| Rate for Payer: UHC Exchange |
$96.97
|
| Rate for Payer: UMR Bronson Commercial |
$91.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$185.06
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$266.14
|
|
|
Service Code
|
NDC 00781613957
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$98.47 |
| Max. Negotiated Rate |
$239.53 |
| Rate for Payer: Aetna American Axle |
$172.99
|
| Rate for Payer: Aetna Commercial |
$226.22
|
| Rate for Payer: Aetna Medicare |
$133.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.99
|
| Rate for Payer: BCBS Complete |
$106.46
|
| Rate for Payer: Cash Price |
$212.91
|
| Rate for Payer: Cofinity Advantage |
$186.30
|
| Rate for Payer: Cofinity Commercial |
$228.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.91
|
| Rate for Payer: Healthscope Commercial |
$239.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$212.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$199.60
|
| Rate for Payer: PHP Commercial |
$226.22
|
| Rate for Payer: Priority Health SBD |
$167.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$172.99
|
| Rate for Payer: UHC Core |
$138.66
|
| Rate for Payer: UHC Exchange |
$104.59
|
| Rate for Payer: UMR Bronson Commercial |
$98.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.60
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$266.14
|
|
|
Service Code
|
NDC 00781613957
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.10 |
| Max. Negotiated Rate |
$239.53 |
| Rate for Payer: Aetna American Axle |
$172.99
|
| Rate for Payer: Aetna Commercial |
$226.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$172.99
|
| Rate for Payer: Cash Price |
$212.91
|
| Rate for Payer: Cofinity Advantage |
$186.30
|
| Rate for Payer: Cofinity Commercial |
$228.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$212.91
|
| Rate for Payer: Healthscope Commercial |
$239.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$186.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$199.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$226.22
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$199.60
|
| Rate for Payer: PHP Commercial |
$226.22
|
| Rate for Payer: Priority Health SBD |
$167.67
|
| Rate for Payer: UMR Bronson Commercial |
$117.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$199.60
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$506.40
|
|
|
Service Code
|
NDC 00781185201
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$187.37 |
| Max. Negotiated Rate |
$455.76 |
| Rate for Payer: Aetna American Axle |
$329.16
|
| Rate for Payer: Aetna Commercial |
$430.44
|
| Rate for Payer: Aetna Medicare |
$253.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$329.16
|
| Rate for Payer: BCBS Complete |
$202.56
|
| Rate for Payer: Cash Price |
$405.12
|
| Rate for Payer: Cofinity Advantage |
$354.48
|
| Rate for Payer: Cofinity Commercial |
$435.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$405.12
|
| Rate for Payer: Healthscope Commercial |
$455.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$354.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$379.80
|
| Rate for Payer: MI Amish Medical Board Commercial |
$405.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$430.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$379.80
|
| Rate for Payer: PHP Commercial |
$430.44
|
| Rate for Payer: Priority Health SBD |
$319.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$329.16
|
| Rate for Payer: UHC Core |
$263.83
|
| Rate for Payer: UHC Exchange |
$199.02
|
| Rate for Payer: UMR Bronson Commercial |
$187.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$379.80
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$267.84
|
|
|
Service Code
|
NDC 42571016201
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.10 |
| Max. Negotiated Rate |
$241.06 |
| Rate for Payer: Aetna American Axle |
$174.10
|
| Rate for Payer: Aetna Commercial |
$227.66
|
| Rate for Payer: Aetna Medicare |
$133.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.10
|
| Rate for Payer: BCBS Complete |
$107.14
|
| Rate for Payer: Cash Price |
$214.27
|
| Rate for Payer: Cofinity Advantage |
$187.49
|
| Rate for Payer: Cofinity Commercial |
$230.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.27
|
| Rate for Payer: Healthscope Commercial |
$241.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$187.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$214.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$227.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$200.88
|
| Rate for Payer: PHP Commercial |
$227.66
|
| Rate for Payer: Priority Health SBD |
$168.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$174.10
|
| Rate for Payer: UHC Core |
$139.54
|
| Rate for Payer: UHC Exchange |
$105.26
|
| Rate for Payer: UMR Bronson Commercial |
$99.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.88
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$423.70
|
|
|
Service Code
|
NDC 65862050301
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.77 |
| Max. Negotiated Rate |
$381.33 |
| Rate for Payer: Aetna American Axle |
$275.40
|
| Rate for Payer: Aetna Commercial |
$360.14
|
| Rate for Payer: Aetna Medicare |
$211.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.40
|
| Rate for Payer: BCBS Complete |
$169.48
|
| Rate for Payer: Cash Price |
$338.96
|
| Rate for Payer: Cofinity Advantage |
$296.59
|
| Rate for Payer: Cofinity Commercial |
$364.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.96
|
| Rate for Payer: Healthscope Commercial |
$381.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$338.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$317.77
|
| Rate for Payer: PHP Commercial |
$360.14
|
| Rate for Payer: Priority Health SBD |
$266.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$275.40
|
| Rate for Payer: UHC Core |
$220.75
|
| Rate for Payer: UHC Exchange |
$166.51
|
| Rate for Payer: UMR Bronson Commercial |
$156.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.77
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$423.70
|
|
|
Service Code
|
NDC 65862050301
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.43 |
| Max. Negotiated Rate |
$381.33 |
| Rate for Payer: Aetna American Axle |
$275.40
|
| Rate for Payer: Aetna Commercial |
$360.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$275.40
|
| Rate for Payer: Cash Price |
$338.96
|
| Rate for Payer: Cofinity Advantage |
$296.59
|
| Rate for Payer: Cofinity Commercial |
$364.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.96
|
| Rate for Payer: Healthscope Commercial |
$381.33
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$360.14
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$317.77
|
| Rate for Payer: PHP Commercial |
$360.14
|
| Rate for Payer: Priority Health SBD |
$266.93
|
| Rate for Payer: UMR Bronson Commercial |
$186.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.77
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$267.84
|
|
|
Service Code
|
NDC 42571016201
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$117.85 |
| Max. Negotiated Rate |
$241.06 |
| Rate for Payer: Aetna American Axle |
$174.10
|
| Rate for Payer: Aetna Commercial |
$227.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$174.10
|
| Rate for Payer: Cash Price |
$214.27
|
| Rate for Payer: Cofinity Advantage |
$187.49
|
| Rate for Payer: Cofinity Commercial |
$230.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$214.27
|
| Rate for Payer: Healthscope Commercial |
$241.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$187.49
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$200.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$227.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$200.88
|
| Rate for Payer: PHP Commercial |
$227.66
|
| Rate for Payer: Priority Health SBD |
$168.74
|
| Rate for Payer: UMR Bronson Commercial |
$117.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$200.88
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$506.40
|
|
|
Service Code
|
NDC 00781185201
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$222.82 |
| Max. Negotiated Rate |
$455.76 |
| Rate for Payer: Aetna American Axle |
$329.16
|
| Rate for Payer: Aetna Commercial |
$430.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$329.16
|
| Rate for Payer: Cash Price |
$405.12
|
| Rate for Payer: Cofinity Advantage |
$354.48
|
| Rate for Payer: Cofinity Commercial |
$435.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$405.12
|
| Rate for Payer: Healthscope Commercial |
$455.76
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$354.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$379.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$430.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$379.80
|
| Rate for Payer: PHP Commercial |
$430.44
|
| Rate for Payer: Priority Health SBD |
$319.03
|
| Rate for Payer: UMR Bronson Commercial |
$222.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$379.80
|
|
