Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

AMOXICILLIN 250 MG CAPSULE

Facility

$166.85

Service Code	NDC 781202001
Hospital Charge Code	450
Hospital Revenue Code	637
Min. Negotiated Rate	$61.73
Max. Negotiated Rate	$166.85
Rate for Payer: Aetna Commercial	$150.16
Rate for Payer: Aetna Medicare	$61.73
Rate for Payer: ASR ASR	$161.84
Rate for Payer: BCBS Complete	$66.74
Rate for Payer: BCBS Trust/PPO	$137.57
Rate for Payer: BCN Commercial	$137.57
Rate for Payer: Cash Price	$133.48
Rate for Payer: Cofinity Commercial	$156.84
Rate for Payer: Encore Health Key Benefits Commercial	$133.48
Rate for Payer: Healthscope Commercial	$161.84
Rate for Payer: Healthscope Whirlpool	$166.85
Rate for Payer: Mclaren Commercial	$150.16
Rate for Payer: MI Amish Medical Board Commercial	$133.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$141.82
Rate for Payer: Nomi Health Commercial	$136.82
Rate for Payer: Opus (Opus Packaging Group) HMA	$125.14
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$146.19
Rate for Payer: Priority Health Narrow Network	$116.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$146.83

AMOXICILLIN 250 MG CAPSULE

Facility

$775.50

Service Code	NDC 781202005
Hospital Charge Code	450
Hospital Revenue Code	637
Min. Negotiated Rate	$581.62
Max. Negotiated Rate	$775.50
Rate for Payer: Aetna Commercial	$697.95
Rate for Payer: ASR ASR	$752.24
Rate for Payer: BCBS Trust/PPO	$636.84
Rate for Payer: BCN Commercial	$636.84
Rate for Payer: Cash Price	$620.40
Rate for Payer: Cofinity Commercial	$728.97
Rate for Payer: Encore Health Key Benefits Commercial	$620.40
Rate for Payer: Healthscope Commercial	$752.24
Rate for Payer: Healthscope Whirlpool	$775.50
Rate for Payer: Mclaren Commercial	$697.95
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$659.17
Rate for Payer: Nomi Health Commercial	$635.91
Rate for Payer: Opus (Opus Packaging Group) HMA	$581.62
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$682.44

AMOXICILLIN 500 MG CAPSULE

Facility

$106.93

Service Code	NDC 93310953
Hospital Charge Code	451
Hospital Revenue Code	637
Min. Negotiated Rate	$39.56
Max. Negotiated Rate	$106.92
Rate for Payer: Aetna Commercial	$96.23
Rate for Payer: Aetna Medicare	$39.56
Rate for Payer: ASR ASR	$103.72
Rate for Payer: BCBS Complete	$42.77
Rate for Payer: BCBS Trust/PPO	$88.16
Rate for Payer: BCN Commercial	$88.16
Rate for Payer: Cash Price	$85.54
Rate for Payer: Cofinity Commercial	$100.51
Rate for Payer: Encore Health Key Benefits Commercial	$85.54
Rate for Payer: Healthscope Commercial	$103.72
Rate for Payer: Healthscope Whirlpool	$106.92
Rate for Payer: Mclaren Commercial	$96.23
Rate for Payer: MI Amish Medical Board Commercial	$85.54
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$90.89
Rate for Payer: Nomi Health Commercial	$87.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$80.19
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$93.69
Rate for Payer: Priority Health Narrow Network	$74.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$94.09

AMOXICILLIN 500 MG CAPSULE

Facility

$284.35

Service Code	NDC 781261301
Hospital Charge Code	451
Hospital Revenue Code	637
Min. Negotiated Rate	$213.26
Max. Negotiated Rate	$284.35
Rate for Payer: Aetna Commercial	$255.91
Rate for Payer: ASR ASR	$275.82
Rate for Payer: BCBS Trust/PPO	$233.51
Rate for Payer: BCN Commercial	$233.51
Rate for Payer: Cash Price	$227.48
Rate for Payer: Cofinity Commercial	$267.29
Rate for Payer: Encore Health Key Benefits Commercial	$227.48
Rate for Payer: Healthscope Commercial	$275.82
Rate for Payer: Healthscope Whirlpool	$284.35
Rate for Payer: Mclaren Commercial	$255.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$241.70
Rate for Payer: Nomi Health Commercial	$233.17
Rate for Payer: Opus (Opus Packaging Group) HMA	$213.26
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$250.23

AMOXICILLIN 500 MG CAPSULE

Facility

$284.35

Service Code	NDC 781261301
Hospital Charge Code	451
Hospital Revenue Code	637
Min. Negotiated Rate	$105.21
Max. Negotiated Rate	$284.35
Rate for Payer: Aetna Commercial	$255.91
Rate for Payer: Aetna Medicare	$105.21
Rate for Payer: ASR ASR	$275.82
Rate for Payer: BCBS Complete	$113.74
Rate for Payer: BCBS Trust/PPO	$234.45
Rate for Payer: BCN Commercial	$234.45
Rate for Payer: Cash Price	$227.48
Rate for Payer: Cofinity Commercial	$267.29
Rate for Payer: Encore Health Key Benefits Commercial	$227.48
Rate for Payer: Healthscope Commercial	$275.82
Rate for Payer: Healthscope Whirlpool	$284.35
Rate for Payer: Mclaren Commercial	$255.91
Rate for Payer: MI Amish Medical Board Commercial	$227.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$241.70
Rate for Payer: Nomi Health Commercial	$233.17
Rate for Payer: Opus (Opus Packaging Group) HMA	$213.26
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$249.15
Rate for Payer: Priority Health Narrow Network	$199.33
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$250.23

AMOXICILLIN 500 MG CAPSULE

Facility

$106.93

Service Code	NDC 93310953
Hospital Charge Code	451
Hospital Revenue Code	637
Min. Negotiated Rate	$80.19
Max. Negotiated Rate	$106.92
Rate for Payer: Aetna Commercial	$96.23
Rate for Payer: ASR ASR	$103.72
Rate for Payer: BCBS Trust/PPO	$87.81
Rate for Payer: BCN Commercial	$87.81
Rate for Payer: Cash Price	$85.54
Rate for Payer: Cofinity Commercial	$100.51
Rate for Payer: Encore Health Key Benefits Commercial	$85.54
Rate for Payer: Healthscope Commercial	$103.72
Rate for Payer: Healthscope Whirlpool	$106.92
Rate for Payer: Mclaren Commercial	$96.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$90.89
Rate for Payer: Nomi Health Commercial	$87.68
Rate for Payer: Opus (Opus Packaging Group) HMA	$80.19
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$94.09

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$62.70

Service Code	NDC 93227434
Hospital Charge Code	33227
Hospital Revenue Code	637
Min. Negotiated Rate	$47.02
Max. Negotiated Rate	$62.70
Rate for Payer: Aetna Commercial	$56.43
Rate for Payer: ASR ASR	$60.82
Rate for Payer: BCBS Trust/PPO	$51.49
Rate for Payer: BCN Commercial	$51.49
Rate for Payer: Cash Price	$50.16
Rate for Payer: Cofinity Commercial	$58.94
Rate for Payer: Encore Health Key Benefits Commercial	$50.16
Rate for Payer: Healthscope Commercial	$60.82
Rate for Payer: Healthscope Whirlpool	$62.70
Rate for Payer: Mclaren Commercial	$56.43
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.30
Rate for Payer: Nomi Health Commercial	$51.41
Rate for Payer: Opus (Opus Packaging Group) HMA	$47.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$55.18

AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$62.70

Service Code	NDC 93227434
Hospital Charge Code	33227
Hospital Revenue Code	637
Min. Negotiated Rate	$23.20
Max. Negotiated Rate	$62.70
Rate for Payer: Aetna Commercial	$56.43
Rate for Payer: Aetna Medicare	$23.20
Rate for Payer: ASR ASR	$60.82
Rate for Payer: BCBS Complete	$25.08
Rate for Payer: BCBS Trust/PPO	$51.70
Rate for Payer: BCN Commercial	$51.70
Rate for Payer: Cash Price	$50.16
Rate for Payer: Cofinity Commercial	$58.94
Rate for Payer: Encore Health Key Benefits Commercial	$50.16
Rate for Payer: Healthscope Commercial	$60.82
Rate for Payer: Healthscope Whirlpool	$62.70
Rate for Payer: Mclaren Commercial	$56.43
Rate for Payer: MI Amish Medical Board Commercial	$50.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.30
Rate for Payer: Nomi Health Commercial	$51.41
Rate for Payer: Opus (Opus Packaging Group) HMA	$47.02
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$54.94
Rate for Payer: Priority Health Narrow Network	$43.95
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$55.18

AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION

Facility

$311.96

Service Code	NDC 143985375
Hospital Charge Code	31177
Hospital Revenue Code	637
Min. Negotiated Rate	$115.43
Max. Negotiated Rate	$311.96
Rate for Payer: Aetna Commercial	$280.77
Rate for Payer: Aetna Medicare	$115.43
Rate for Payer: ASR ASR	$302.60
Rate for Payer: BCBS Complete	$124.79
Rate for Payer: BCBS Trust/PPO	$257.21
Rate for Payer: BCN Commercial	$257.21
Rate for Payer: Cash Price	$249.57
Rate for Payer: Cofinity Commercial	$293.25
Rate for Payer: Encore Health Key Benefits Commercial	$249.57
Rate for Payer: Healthscope Commercial	$302.60
Rate for Payer: Healthscope Whirlpool	$311.96
Rate for Payer: Mclaren Commercial	$280.77
Rate for Payer: MI Amish Medical Board Commercial	$249.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$265.17
Rate for Payer: Nomi Health Commercial	$255.81
Rate for Payer: Opus (Opus Packaging Group) HMA	$233.97
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$273.34
Rate for Payer: Priority Health Narrow Network	$218.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$274.53

AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION

Facility

$246.75

Service Code	NDC 65862053513
Hospital Charge Code	31177
Hospital Revenue Code	637
Min. Negotiated Rate	$91.30
Max. Negotiated Rate	$246.75
Rate for Payer: Aetna Commercial	$222.07
Rate for Payer: Aetna Medicare	$91.30
Rate for Payer: ASR ASR	$239.35
Rate for Payer: BCBS Complete	$98.70
Rate for Payer: BCBS Trust/PPO	$203.45
Rate for Payer: BCN Commercial	$203.45
Rate for Payer: Cash Price	$197.40
Rate for Payer: Cofinity Commercial	$231.94
Rate for Payer: Encore Health Key Benefits Commercial	$197.40
Rate for Payer: Healthscope Commercial	$239.35
Rate for Payer: Healthscope Whirlpool	$246.75
Rate for Payer: Mclaren Commercial	$222.07
Rate for Payer: MI Amish Medical Board Commercial	$197.40
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$209.74
Rate for Payer: Nomi Health Commercial	$202.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$185.06
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$216.20
Rate for Payer: Priority Health Narrow Network	$172.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$217.14

AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION

Facility

$246.75

Service Code	NDC 65862053513
Hospital Charge Code	31177
Hospital Revenue Code	637
Min. Negotiated Rate	$185.06
Max. Negotiated Rate	$246.75
Rate for Payer: Aetna Commercial	$222.07
Rate for Payer: ASR ASR	$239.35
Rate for Payer: BCBS Trust/PPO	$202.63
Rate for Payer: BCN Commercial	$202.63
Rate for Payer: Cash Price	$197.40
Rate for Payer: Cofinity Commercial	$231.94
Rate for Payer: Encore Health Key Benefits Commercial	$197.40
Rate for Payer: Healthscope Commercial	$239.35
Rate for Payer: Healthscope Whirlpool	$246.75
Rate for Payer: Mclaren Commercial	$222.07
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$209.74
Rate for Payer: Nomi Health Commercial	$202.34
Rate for Payer: Opus (Opus Packaging Group) HMA	$185.06
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$217.14

AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION

Facility

$149.81

Service Code	NDC 65862053575
Hospital Charge Code	31177
Hospital Revenue Code	637
Min. Negotiated Rate	$55.43
Max. Negotiated Rate	$149.81
Rate for Payer: Aetna Commercial	$134.83
Rate for Payer: Aetna Medicare	$55.43
Rate for Payer: ASR ASR	$145.32
Rate for Payer: BCBS Complete	$59.93
Rate for Payer: BCBS Trust/PPO	$123.52
Rate for Payer: BCN Commercial	$123.52
Rate for Payer: Cash Price	$119.85
Rate for Payer: Cofinity Commercial	$140.82
Rate for Payer: Encore Health Key Benefits Commercial	$119.85
Rate for Payer: Healthscope Commercial	$145.32
Rate for Payer: Healthscope Whirlpool	$149.81
Rate for Payer: Mclaren Commercial	$134.83
Rate for Payer: MI Amish Medical Board Commercial	$119.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$127.34
Rate for Payer: Nomi Health Commercial	$122.85
Rate for Payer: Opus (Opus Packaging Group) HMA	$112.36
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$131.27
Rate for Payer: Priority Health Narrow Network	$105.02
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$131.84

AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION

Facility

$311.96

Service Code	NDC 143985375
Hospital Charge Code	31177
Hospital Revenue Code	637
Min. Negotiated Rate	$233.97
Max. Negotiated Rate	$311.96
Rate for Payer: Aetna Commercial	$280.77
Rate for Payer: ASR ASR	$302.60
Rate for Payer: BCBS Trust/PPO	$256.18
Rate for Payer: BCN Commercial	$256.18
Rate for Payer: Cash Price	$249.57
Rate for Payer: Cofinity Commercial	$293.25
Rate for Payer: Encore Health Key Benefits Commercial	$249.57
Rate for Payer: Healthscope Commercial	$302.60
Rate for Payer: Healthscope Whirlpool	$311.96
Rate for Payer: Mclaren Commercial	$280.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$265.17
Rate for Payer: Nomi Health Commercial	$255.81
Rate for Payer: Opus (Opus Packaging Group) HMA	$233.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$274.53

AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION

Facility

$149.81

Service Code	NDC 65862053575
Hospital Charge Code	31177
Hospital Revenue Code	637
Min. Negotiated Rate	$112.36
Max. Negotiated Rate	$149.81
Rate for Payer: Aetna Commercial	$134.83
Rate for Payer: ASR ASR	$145.32
Rate for Payer: BCBS Trust/PPO	$123.03
Rate for Payer: BCN Commercial	$123.03
Rate for Payer: Cash Price	$119.85
Rate for Payer: Cofinity Commercial	$140.82
Rate for Payer: Encore Health Key Benefits Commercial	$119.85
Rate for Payer: Healthscope Commercial	$145.32
Rate for Payer: Healthscope Whirlpool	$149.81
Rate for Payer: Mclaren Commercial	$134.83
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$127.34
Rate for Payer: Nomi Health Commercial	$122.85
Rate for Payer: Opus (Opus Packaging Group) HMA	$112.36
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$131.84

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$101.28

Service Code	NDC 781185220
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$37.47
Max. Negotiated Rate	$101.28
Rate for Payer: Aetna Commercial	$91.15
Rate for Payer: Aetna Medicare	$37.47
Rate for Payer: ASR ASR	$98.24
Rate for Payer: BCBS Complete	$40.51
Rate for Payer: BCBS Trust/PPO	$83.51
Rate for Payer: BCN Commercial	$83.51
Rate for Payer: Cash Price	$81.02
Rate for Payer: Cofinity Commercial	$95.20
Rate for Payer: Encore Health Key Benefits Commercial	$81.02
Rate for Payer: Healthscope Commercial	$98.24
Rate for Payer: Healthscope Whirlpool	$101.28
Rate for Payer: Mclaren Commercial	$91.15
Rate for Payer: MI Amish Medical Board Commercial	$81.02
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.09
Rate for Payer: Nomi Health Commercial	$83.05
Rate for Payer: Opus (Opus Packaging Group) HMA	$75.96
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$88.74
Rate for Payer: Priority Health Narrow Network	$71.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$89.13

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$53.57

Service Code	NDC 42571016242
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$19.82
Max. Negotiated Rate	$53.57
Rate for Payer: Aetna Commercial	$48.21
Rate for Payer: Aetna Medicare	$19.82
Rate for Payer: ASR ASR	$51.96
Rate for Payer: BCBS Complete	$21.43
Rate for Payer: BCBS Trust/PPO	$44.17
Rate for Payer: BCN Commercial	$44.17
Rate for Payer: Cash Price	$42.85
Rate for Payer: Cofinity Commercial	$50.35
Rate for Payer: Encore Health Key Benefits Commercial	$42.85
Rate for Payer: Healthscope Commercial	$51.96
Rate for Payer: Healthscope Whirlpool	$53.57
Rate for Payer: Mclaren Commercial	$48.21
Rate for Payer: MI Amish Medical Board Commercial	$42.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.53
Rate for Payer: Nomi Health Commercial	$43.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$40.18
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$46.94
Rate for Payer: Priority Health Narrow Network	$37.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$47.14

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$63.27

Service Code	NDC 93227534
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$23.41
Max. Negotiated Rate	$63.27
Rate for Payer: Aetna Commercial	$56.94
Rate for Payer: Aetna Medicare	$23.41
Rate for Payer: ASR ASR	$61.37
Rate for Payer: BCBS Complete	$25.31
Rate for Payer: BCBS Trust/PPO	$52.17
Rate for Payer: BCN Commercial	$52.17
Rate for Payer: Cash Price	$50.62
Rate for Payer: Cofinity Commercial	$59.47
Rate for Payer: Encore Health Key Benefits Commercial	$50.62
Rate for Payer: Healthscope Commercial	$61.37
Rate for Payer: Healthscope Whirlpool	$63.27
Rate for Payer: Mclaren Commercial	$56.94
Rate for Payer: MI Amish Medical Board Commercial	$50.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.78
Rate for Payer: Nomi Health Commercial	$51.88
Rate for Payer: Opus (Opus Packaging Group) HMA	$47.45
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$55.44
Rate for Payer: Priority Health Narrow Network	$44.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$55.68

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$423.70

Service Code	NDC 65862050301
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$156.77
Max. Negotiated Rate	$423.70
Rate for Payer: Aetna Commercial	$381.33
Rate for Payer: Aetna Medicare	$156.77
Rate for Payer: ASR ASR	$410.99
Rate for Payer: BCBS Complete	$169.48
Rate for Payer: BCBS Trust/PPO	$349.34
Rate for Payer: BCN Commercial	$349.34
Rate for Payer: Cash Price	$338.96
Rate for Payer: Cofinity Commercial	$398.28
Rate for Payer: Encore Health Key Benefits Commercial	$338.96
Rate for Payer: Healthscope Commercial	$410.99
Rate for Payer: Healthscope Whirlpool	$423.70
Rate for Payer: Mclaren Commercial	$381.33
Rate for Payer: MI Amish Medical Board Commercial	$338.96
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$360.14
Rate for Payer: Nomi Health Commercial	$347.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$317.77
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$371.25
Rate for Payer: Priority Health Narrow Network	$297.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$372.86

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$423.70

Service Code	NDC 65862050301
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$317.77
Max. Negotiated Rate	$423.70
Rate for Payer: Aetna Commercial	$381.33
Rate for Payer: ASR ASR	$410.99
Rate for Payer: BCBS Trust/PPO	$347.94
Rate for Payer: BCN Commercial	$347.94
Rate for Payer: Cash Price	$338.96
Rate for Payer: Cofinity Commercial	$398.28
Rate for Payer: Encore Health Key Benefits Commercial	$338.96
Rate for Payer: Healthscope Commercial	$410.99
Rate for Payer: Healthscope Whirlpool	$423.70
Rate for Payer: Mclaren Commercial	$381.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$360.14
Rate for Payer: Nomi Health Commercial	$347.43
Rate for Payer: Opus (Opus Packaging Group) HMA	$317.77
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$372.86

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$63.27

Service Code	NDC 93227534
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$47.45
Max. Negotiated Rate	$63.27
Rate for Payer: Aetna Commercial	$56.94
Rate for Payer: ASR ASR	$61.37
Rate for Payer: BCBS Trust/PPO	$51.96
Rate for Payer: BCN Commercial	$51.96
Rate for Payer: Cash Price	$50.62
Rate for Payer: Cofinity Commercial	$59.47
Rate for Payer: Encore Health Key Benefits Commercial	$50.62
Rate for Payer: Healthscope Commercial	$61.37
Rate for Payer: Healthscope Whirlpool	$63.27
Rate for Payer: Mclaren Commercial	$56.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$53.78
Rate for Payer: Nomi Health Commercial	$51.88
Rate for Payer: Opus (Opus Packaging Group) HMA	$47.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$55.68

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$53.57

Service Code	NDC 42571016242
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$40.18
Max. Negotiated Rate	$53.57
Rate for Payer: Aetna Commercial	$48.21
Rate for Payer: ASR ASR	$51.96
Rate for Payer: BCBS Trust/PPO	$43.99
Rate for Payer: BCN Commercial	$43.99
Rate for Payer: Cash Price	$42.85
Rate for Payer: Cofinity Commercial	$50.35
Rate for Payer: Encore Health Key Benefits Commercial	$42.85
Rate for Payer: Healthscope Commercial	$51.96
Rate for Payer: Healthscope Whirlpool	$53.57
Rate for Payer: Mclaren Commercial	$48.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$45.53
Rate for Payer: Nomi Health Commercial	$43.93
Rate for Payer: Opus (Opus Packaging Group) HMA	$40.18
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$47.14

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$101.86

Service Code	NDC 66685100100
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$76.39
Max. Negotiated Rate	$101.86
Rate for Payer: Aetna Commercial	$91.67
Rate for Payer: ASR ASR	$98.80
Rate for Payer: BCBS Trust/PPO	$83.64
Rate for Payer: BCN Commercial	$83.64
Rate for Payer: Cash Price	$81.48
Rate for Payer: Cofinity Commercial	$95.74
Rate for Payer: Encore Health Key Benefits Commercial	$81.48
Rate for Payer: Healthscope Commercial	$98.80
Rate for Payer: Healthscope Whirlpool	$101.86
Rate for Payer: Mclaren Commercial	$91.67
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.58
Rate for Payer: Nomi Health Commercial	$83.52
Rate for Payer: Opus (Opus Packaging Group) HMA	$76.39
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$89.63

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$101.86

Service Code	NDC 66685100100
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$37.69
Max. Negotiated Rate	$101.86
Rate for Payer: Aetna Commercial	$91.67
Rate for Payer: Aetna Medicare	$37.69
Rate for Payer: ASR ASR	$98.80
Rate for Payer: BCBS Complete	$40.74
Rate for Payer: BCBS Trust/PPO	$83.98
Rate for Payer: BCN Commercial	$83.98
Rate for Payer: Cash Price	$81.48
Rate for Payer: Cofinity Commercial	$95.74
Rate for Payer: Encore Health Key Benefits Commercial	$81.48
Rate for Payer: Healthscope Commercial	$98.80
Rate for Payer: Healthscope Whirlpool	$101.86
Rate for Payer: Mclaren Commercial	$91.67
Rate for Payer: MI Amish Medical Board Commercial	$81.48
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.58
Rate for Payer: Nomi Health Commercial	$83.52
Rate for Payer: Opus (Opus Packaging Group) HMA	$76.39
Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network	$89.25
Rate for Payer: Priority Health Narrow Network	$71.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$89.63

AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET

Facility

$101.28

Service Code	NDC 781185220
Hospital Charge Code	33228
Hospital Revenue Code	637
Min. Negotiated Rate	$75.96
Max. Negotiated Rate	$101.28
Rate for Payer: Aetna Commercial	$91.15
Rate for Payer: ASR ASR	$98.24
Rate for Payer: BCBS Trust/PPO	$83.17
Rate for Payer: BCN Commercial	$83.17
Rate for Payer: Cash Price	$81.02
Rate for Payer: Cofinity Commercial	$95.20
Rate for Payer: Encore Health Key Benefits Commercial	$81.02
Rate for Payer: Healthscope Commercial	$98.24
Rate for Payer: Healthscope Whirlpool	$101.28
Rate for Payer: Mclaren Commercial	$91.15
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$86.09
Rate for Payer: Nomi Health Commercial	$83.05
Rate for Payer: Opus (Opus Packaging Group) HMA	$75.96
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$89.13

AMPICILLIN 1 GRAM SOLUTION FOR INJECTION

Facility

$14.96

Service Code	HCPCS J0290
Hospital Charge Code	469
Hospital Revenue Code	636
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$14.96
Rate for Payer: Aetna Commercial	$13.47
Rate for Payer: Aetna Commercial	$25.73
Rate for Payer: ASR ASR	$27.73
Rate for Payer: ASR ASR	$14.52
Rate for Payer: BCBS Trust/PPO	$23.48
Rate for Payer: BCBS Trust/PPO	$12.29
Rate for Payer: BCN Commercial	$23.48
Rate for Payer: BCN Commercial	$12.29
Rate for Payer: Cash Price	$22.87
Rate for Payer: Cash Price	$11.97
Rate for Payer: Cofinity Commercial	$14.07
Rate for Payer: Cofinity Commercial	$26.87
Rate for Payer: Encore Health Key Benefits Commercial	$22.87
Rate for Payer: Encore Health Key Benefits Commercial	$11.97
Rate for Payer: Healthscope Commercial	$14.52
Rate for Payer: Healthscope Commercial	$27.73
Rate for Payer: Healthscope Whirlpool	$28.59
Rate for Payer: Healthscope Whirlpool	$14.96
Rate for Payer: Mclaren Commercial	$25.73
Rate for Payer: Mclaren Commercial	$13.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$24.30
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.72
Rate for Payer: Nomi Health Commercial	$23.44
Rate for Payer: Nomi Health Commercial	$12.27
Rate for Payer: Opus (Opus Packaging Group) HMA	$11.22
Rate for Payer: Opus (Opus Packaging Group) HMA	$21.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.17
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$25.16

Know your out-of-pocket cost for care.

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