|
AMIODARONE 150 MG/100 ML (1.5 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
IP
|
$60.52
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152869
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$42.36 |
| Max. Negotiated Rate |
$60.52 |
| Rate for Payer: Aetna Commercial |
$54.47
|
| Rate for Payer: ASR ASR |
$58.70
|
| Rate for Payer: BCBS Trust/PPO |
$46.92
|
| Rate for Payer: BCN Commercial |
$46.92
|
| Rate for Payer: Cash Price |
$48.42
|
| Rate for Payer: Cofinity Commercial |
$56.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$48.42
|
| Rate for Payer: Healthscope Commercial |
$60.52
|
| Rate for Payer: Healthscope Whirlpool |
$58.70
|
| Rate for Payer: Mclaren Commercial |
$54.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$51.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$42.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$53.26
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$327.75
|
|
|
Service Code
|
NDC 68084-371-11
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$229.42 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Aetna Commercial |
$294.98
|
| Rate for Payer: ASR ASR |
$317.92
|
| Rate for Payer: BCBS Trust/PPO |
$254.10
|
| Rate for Payer: BCN Commercial |
$254.10
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cofinity Commercial |
$308.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.20
|
| Rate for Payer: Healthscope Commercial |
$327.75
|
| Rate for Payer: Healthscope Whirlpool |
$317.92
|
| Rate for Payer: Mclaren Commercial |
$294.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$278.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$288.42
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$2.00
|
|
|
Service Code
|
NDC 0245-0147-89
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.40 |
| Max. Negotiated Rate |
$2.00 |
| Rate for Payer: Aetna Commercial |
$1.80
|
| Rate for Payer: ASR ASR |
$1.94
|
| Rate for Payer: BCBS Trust/PPO |
$1.55
|
| Rate for Payer: BCN Commercial |
$1.55
|
| Rate for Payer: Cash Price |
$1.60
|
| Rate for Payer: Cofinity Commercial |
$1.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.60
|
| Rate for Payer: Healthscope Commercial |
$2.00
|
| Rate for Payer: Healthscope Whirlpool |
$1.94
|
| Rate for Payer: Mclaren Commercial |
$1.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.76
|
|
|
AMIODARONE 200 MG TABLET
|
Facility
IP
|
$327.75
|
|
|
Service Code
|
NDC 68084-371-01
|
| Hospital Charge Code |
9066
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$229.42 |
| Max. Negotiated Rate |
$327.75 |
| Rate for Payer: Aetna Commercial |
$294.98
|
| Rate for Payer: ASR ASR |
$317.92
|
| Rate for Payer: BCBS Trust/PPO |
$254.10
|
| Rate for Payer: BCN Commercial |
$254.10
|
| Rate for Payer: Cash Price |
$262.20
|
| Rate for Payer: Cofinity Commercial |
$308.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.20
|
| Rate for Payer: Healthscope Commercial |
$327.75
|
| Rate for Payer: Healthscope Whirlpool |
$317.92
|
| Rate for Payer: Mclaren Commercial |
$294.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$278.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$229.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$288.42
|
|
|
AMIODARONE 360 MG/200 ML (1.8 MG/ML) IN DEXTROSE, ISO-OSMOTIC IV
|
Facility
IP
|
$73.87
|
|
|
Service Code
|
HCPCS J0283
|
| Hospital Charge Code |
152870
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$51.71 |
| Max. Negotiated Rate |
$73.87 |
| Rate for Payer: Aetna Commercial |
$66.48
|
| Rate for Payer: ASR ASR |
$71.65
|
| Rate for Payer: BCBS Trust/PPO |
$57.27
|
| Rate for Payer: BCN Commercial |
$57.27
|
| Rate for Payer: Cash Price |
$59.10
|
| Rate for Payer: Cofinity Commercial |
$69.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.10
|
| Rate for Payer: Healthscope Commercial |
$73.87
|
| Rate for Payer: Healthscope Whirlpool |
$71.65
|
| Rate for Payer: Mclaren Commercial |
$66.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.01
|
|
|
AMIODARONE 50 MG/ML INTRAVENOUS SOLUTION
|
Facility
IP
|
$26.37
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
9065
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.46 |
| Max. Negotiated Rate |
$26.37 |
| Rate for Payer: Aetna Commercial |
$23.73
|
| Rate for Payer: Aetna Commercial |
$11.86
|
| Rate for Payer: Aetna Commercial |
$21.10
|
| Rate for Payer: ASR ASR |
$25.58
|
| Rate for Payer: ASR ASR |
$22.75
|
| Rate for Payer: ASR ASR |
$12.78
|
| Rate for Payer: BCBS Trust/PPO |
$20.44
|
| Rate for Payer: BCBS Trust/PPO |
$10.22
|
| Rate for Payer: BCBS Trust/PPO |
$18.18
|
| Rate for Payer: BCN Commercial |
$10.22
|
| Rate for Payer: BCN Commercial |
$20.44
|
| Rate for Payer: BCN Commercial |
$18.18
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Cash Price |
$10.54
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cofinity Commercial |
$22.04
|
| Rate for Payer: Cofinity Commercial |
$12.39
|
| Rate for Payer: Cofinity Commercial |
$24.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Healthscope Commercial |
$13.18
|
| Rate for Payer: Healthscope Commercial |
$26.37
|
| Rate for Payer: Healthscope Commercial |
$23.45
|
| Rate for Payer: Healthscope Whirlpool |
$22.75
|
| Rate for Payer: Healthscope Whirlpool |
$12.78
|
| Rate for Payer: Healthscope Whirlpool |
$25.58
|
| Rate for Payer: Mclaren Commercial |
$11.86
|
| Rate for Payer: Mclaren Commercial |
$21.10
|
| Rate for Payer: Mclaren Commercial |
$23.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$11.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.21
|
|
|
AMIODARONE 50 MG/ML IV (CODE)
|
Facility
IP
|
$26.37
|
|
|
Service Code
|
HCPCS J0282
|
| Hospital Charge Code |
163703
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$18.46 |
| Max. Negotiated Rate |
$26.37 |
| Rate for Payer: Aetna Commercial |
$23.73
|
| Rate for Payer: Aetna Commercial |
$21.10
|
| Rate for Payer: ASR ASR |
$25.58
|
| Rate for Payer: ASR ASR |
$22.75
|
| Rate for Payer: BCBS Trust/PPO |
$18.18
|
| Rate for Payer: BCBS Trust/PPO |
$20.44
|
| Rate for Payer: BCN Commercial |
$20.44
|
| Rate for Payer: BCN Commercial |
$18.18
|
| Rate for Payer: Cash Price |
$21.10
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Cofinity Commercial |
$24.79
|
| Rate for Payer: Cofinity Commercial |
$22.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.76
|
| Rate for Payer: Healthscope Commercial |
$23.45
|
| Rate for Payer: Healthscope Commercial |
$26.37
|
| Rate for Payer: Healthscope Whirlpool |
$22.75
|
| Rate for Payer: Healthscope Whirlpool |
$25.58
|
| Rate for Payer: Mclaren Commercial |
$23.73
|
| Rate for Payer: Mclaren Commercial |
$21.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.21
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$3.46
|
|
|
Service Code
|
NDC 50268-037-11
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$3.46 |
| Rate for Payer: Aetna Commercial |
$3.11
|
| Rate for Payer: ASR ASR |
$3.36
|
| Rate for Payer: BCBS Trust/PPO |
$2.68
|
| Rate for Payer: BCN Commercial |
$2.68
|
| Rate for Payer: Cash Price |
$2.77
|
| Rate for Payer: Cofinity Commercial |
$3.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.77
|
| Rate for Payer: Healthscope Commercial |
$3.46
|
| Rate for Payer: Healthscope Whirlpool |
$3.36
|
| Rate for Payer: Mclaren Commercial |
$3.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.04
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$2.19
|
|
|
Service Code
|
NDC 51079-131-01
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.53 |
| Max. Negotiated Rate |
$2.19 |
| Rate for Payer: Aetna Commercial |
$1.97
|
| Rate for Payer: ASR ASR |
$2.12
|
| Rate for Payer: BCBS Trust/PPO |
$1.70
|
| Rate for Payer: BCN Commercial |
$1.70
|
| Rate for Payer: Cash Price |
$1.75
|
| Rate for Payer: Cofinity Commercial |
$2.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.75
|
| Rate for Payer: Healthscope Commercial |
$2.19
|
| Rate for Payer: Healthscope Whirlpool |
$2.12
|
| Rate for Payer: Mclaren Commercial |
$1.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.93
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$143.35
|
|
|
Service Code
|
NDC 16729-171-01
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.34 |
| Max. Negotiated Rate |
$143.35 |
| Rate for Payer: Aetna Commercial |
$129.02
|
| Rate for Payer: ASR ASR |
$139.05
|
| Rate for Payer: BCBS Trust/PPO |
$111.14
|
| Rate for Payer: BCN Commercial |
$111.14
|
| Rate for Payer: Cash Price |
$114.68
|
| Rate for Payer: Cofinity Commercial |
$134.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$114.68
|
| Rate for Payer: Healthscope Commercial |
$143.35
|
| Rate for Payer: Healthscope Whirlpool |
$139.05
|
| Rate for Payer: Mclaren Commercial |
$129.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$121.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$100.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$126.15
|
|
|
AMITRIPTYLINE 10 MG TABLET
|
Facility
IP
|
$172.90
|
|
|
Service Code
|
NDC 50268-037-15
|
| Hospital Charge Code |
432
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.03 |
| Max. Negotiated Rate |
$172.90 |
| Rate for Payer: Aetna Commercial |
$155.61
|
| Rate for Payer: ASR ASR |
$167.71
|
| Rate for Payer: BCBS Trust/PPO |
$134.05
|
| Rate for Payer: BCN Commercial |
$134.05
|
| Rate for Payer: Cash Price |
$138.32
|
| Rate for Payer: Cofinity Commercial |
$162.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$138.32
|
| Rate for Payer: Healthscope Commercial |
$172.90
|
| Rate for Payer: Healthscope Whirlpool |
$167.71
|
| Rate for Payer: Mclaren Commercial |
$155.61
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$146.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$121.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$152.15
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$240.35
|
|
|
Service Code
|
NDC 0904-0201-61
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$168.24 |
| Max. Negotiated Rate |
$240.35 |
| Rate for Payer: Aetna Commercial |
$216.32
|
| Rate for Payer: ASR ASR |
$233.14
|
| Rate for Payer: BCBS Trust/PPO |
$186.34
|
| Rate for Payer: BCN Commercial |
$186.34
|
| Rate for Payer: Cash Price |
$192.28
|
| Rate for Payer: Cofinity Commercial |
$225.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.28
|
| Rate for Payer: Healthscope Commercial |
$240.35
|
| Rate for Payer: Healthscope Whirlpool |
$233.14
|
| Rate for Payer: Mclaren Commercial |
$216.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$204.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$168.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$211.51
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$2.82
|
|
|
Service Code
|
NDC 60687-433-11
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.97 |
| Max. Negotiated Rate |
$2.82 |
| Rate for Payer: Aetna Commercial |
$2.54
|
| Rate for Payer: ASR ASR |
$2.74
|
| Rate for Payer: BCBS Trust/PPO |
$2.19
|
| Rate for Payer: BCN Commercial |
$2.19
|
| Rate for Payer: Cash Price |
$2.26
|
| Rate for Payer: Cofinity Commercial |
$2.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.26
|
| Rate for Payer: Healthscope Commercial |
$2.82
|
| Rate for Payer: Healthscope Whirlpool |
$2.74
|
| Rate for Payer: Mclaren Commercial |
$2.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.48
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$282.15
|
|
|
Service Code
|
NDC 60687-433-01
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$197.50 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Aetna Commercial |
$253.94
|
| Rate for Payer: ASR ASR |
$273.69
|
| Rate for Payer: BCBS Trust/PPO |
$218.75
|
| Rate for Payer: BCN Commercial |
$218.75
|
| Rate for Payer: Cash Price |
$225.72
|
| Rate for Payer: Cofinity Commercial |
$265.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$225.72
|
| Rate for Payer: Healthscope Commercial |
$282.15
|
| Rate for Payer: Healthscope Whirlpool |
$273.69
|
| Rate for Payer: Mclaren Commercial |
$253.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$239.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$197.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$248.29
|
|
|
AMITRIPTYLINE 25 MG TABLET
|
Facility
IP
|
$225.15
|
|
|
Service Code
|
NDC 0904-7184-61
|
| Hospital Charge Code |
435
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$157.60 |
| Max. Negotiated Rate |
$225.15 |
| Rate for Payer: Aetna Commercial |
$202.64
|
| Rate for Payer: ASR ASR |
$218.40
|
| Rate for Payer: BCBS Trust/PPO |
$174.56
|
| Rate for Payer: BCN Commercial |
$174.56
|
| Rate for Payer: Cash Price |
$180.12
|
| Rate for Payer: Cofinity Commercial |
$211.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.12
|
| Rate for Payer: Healthscope Commercial |
$225.15
|
| Rate for Payer: Healthscope Whirlpool |
$218.40
|
| Rate for Payer: Mclaren Commercial |
$202.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$191.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$157.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$198.13
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$164.50
|
|
|
Service Code
|
NDC 0904-6370-61
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.15 |
| Max. Negotiated Rate |
$164.50 |
| Rate for Payer: Aetna Commercial |
$148.05
|
| Rate for Payer: ASR ASR |
$159.56
|
| Rate for Payer: BCBS Trust/PPO |
$127.54
|
| Rate for Payer: BCN Commercial |
$127.54
|
| Rate for Payer: Cash Price |
$131.60
|
| Rate for Payer: Cofinity Commercial |
$154.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$131.60
|
| Rate for Payer: Healthscope Commercial |
$164.50
|
| Rate for Payer: Healthscope Whirlpool |
$159.56
|
| Rate for Payer: Mclaren Commercial |
$148.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$139.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$144.76
|
|
|
AMLODIPINE 5 MG TABLET
|
Facility
IP
|
$1.83
|
|
|
Service Code
|
NDC 51079-451-01
|
| Hospital Charge Code |
9071
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.28 |
| Max. Negotiated Rate |
$1.83 |
| Rate for Payer: Aetna Commercial |
$1.65
|
| Rate for Payer: ASR ASR |
$1.78
|
| Rate for Payer: BCBS Trust/PPO |
$1.42
|
| Rate for Payer: BCN Commercial |
$1.42
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cofinity Commercial |
$1.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.46
|
| Rate for Payer: Healthscope Commercial |
$1.83
|
| Rate for Payer: Healthscope Whirlpool |
$1.78
|
| Rate for Payer: Mclaren Commercial |
$1.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.61
|
|
|
AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$70.50
|
|
|
Service Code
|
NDC 0143-9888-15
|
| Hospital Charge Code |
453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.35 |
| Max. Negotiated Rate |
$70.50 |
| Rate for Payer: Aetna Commercial |
$63.45
|
| Rate for Payer: ASR ASR |
$68.38
|
| Rate for Payer: BCBS Trust/PPO |
$54.66
|
| Rate for Payer: BCN Commercial |
$54.66
|
| Rate for Payer: Cash Price |
$56.40
|
| Rate for Payer: Cofinity Commercial |
$66.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.40
|
| Rate for Payer: Healthscope Commercial |
$70.50
|
| Rate for Payer: Healthscope Whirlpool |
$68.38
|
| Rate for Payer: Mclaren Commercial |
$63.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.04
|
|
|
AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$74.03
|
|
|
Service Code
|
NDC 0781-6039-55
|
| Hospital Charge Code |
453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$51.82 |
| Max. Negotiated Rate |
$74.03 |
| Rate for Payer: Aetna Commercial |
$66.63
|
| Rate for Payer: ASR ASR |
$71.81
|
| Rate for Payer: BCBS Trust/PPO |
$57.40
|
| Rate for Payer: BCN Commercial |
$57.40
|
| Rate for Payer: Cash Price |
$59.22
|
| Rate for Payer: Cofinity Commercial |
$69.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.22
|
| Rate for Payer: Healthscope Commercial |
$74.03
|
| Rate for Payer: Healthscope Whirlpool |
$71.81
|
| Rate for Payer: Mclaren Commercial |
$66.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$62.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$65.15
|
|
|
AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$54.05
|
|
|
Service Code
|
NDC 0143-9888-01
|
| Hospital Charge Code |
453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.84 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna Commercial |
$48.64
|
| Rate for Payer: ASR ASR |
$52.43
|
| Rate for Payer: BCBS Trust/PPO |
$41.90
|
| Rate for Payer: BCN Commercial |
$41.90
|
| Rate for Payer: Cash Price |
$43.24
|
| Rate for Payer: Cofinity Commercial |
$50.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.24
|
| Rate for Payer: Healthscope Commercial |
$54.05
|
| Rate for Payer: Healthscope Whirlpool |
$52.43
|
| Rate for Payer: Mclaren Commercial |
$48.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$45.94
|
| Rate for Payer: Priority Health Cigna Priority Health |
$37.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.56
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$82.25
|
|
|
Service Code
|
NDC 0093-4155-73
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.58 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$74.02
|
| Rate for Payer: ASR ASR |
$79.78
|
| Rate for Payer: BCBS Trust/PPO |
$63.77
|
| Rate for Payer: BCN Commercial |
$63.77
|
| Rate for Payer: Cash Price |
$65.80
|
| Rate for Payer: Cofinity Commercial |
$77.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.80
|
| Rate for Payer: Healthscope Commercial |
$82.25
|
| Rate for Payer: Healthscope Whirlpool |
$79.78
|
| Rate for Payer: Mclaren Commercial |
$74.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$69.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$57.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.38
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$67.68
|
|
|
Service Code
|
NDC 65862-707-80
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.38 |
| Max. Negotiated Rate |
$67.68 |
| Rate for Payer: Aetna Commercial |
$60.91
|
| Rate for Payer: ASR ASR |
$65.65
|
| Rate for Payer: BCBS Trust/PPO |
$52.47
|
| Rate for Payer: BCN Commercial |
$52.47
|
| Rate for Payer: Cash Price |
$54.14
|
| Rate for Payer: Cofinity Commercial |
$63.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.14
|
| Rate for Payer: Healthscope Commercial |
$67.68
|
| Rate for Payer: Healthscope Whirlpool |
$65.65
|
| Rate for Payer: Mclaren Commercial |
$60.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.56
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$77.55
|
|
|
Service Code
|
NDC 0781-6041-46
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.28 |
| Max. Negotiated Rate |
$77.55 |
| Rate for Payer: Aetna Commercial |
$69.80
|
| Rate for Payer: ASR ASR |
$75.22
|
| Rate for Payer: BCBS Trust/PPO |
$60.12
|
| Rate for Payer: BCN Commercial |
$60.12
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$72.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$77.55
|
| Rate for Payer: Healthscope Whirlpool |
$75.22
|
| Rate for Payer: Mclaren Commercial |
$69.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$68.24
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$67.68
|
|
|
Service Code
|
NDC 0781-6041-58
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$47.38 |
| Max. Negotiated Rate |
$67.68 |
| Rate for Payer: Aetna Commercial |
$60.91
|
| Rate for Payer: ASR ASR |
$65.65
|
| Rate for Payer: BCBS Trust/PPO |
$52.47
|
| Rate for Payer: BCN Commercial |
$52.47
|
| Rate for Payer: Cash Price |
$54.14
|
| Rate for Payer: Cofinity Commercial |
$63.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.14
|
| Rate for Payer: Healthscope Commercial |
$67.68
|
| Rate for Payer: Healthscope Whirlpool |
$65.65
|
| Rate for Payer: Mclaren Commercial |
$60.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$57.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.56
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$77.55
|
|
|
Service Code
|
NDC 65862-707-01
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.28 |
| Max. Negotiated Rate |
$77.55 |
| Rate for Payer: Aetna Commercial |
$69.80
|
| Rate for Payer: ASR ASR |
$75.22
|
| Rate for Payer: BCBS Trust/PPO |
$60.12
|
| Rate for Payer: BCN Commercial |
$60.12
|
| Rate for Payer: Cash Price |
$62.04
|
| Rate for Payer: Cofinity Commercial |
$72.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.04
|
| Rate for Payer: Healthscope Commercial |
$77.55
|
| Rate for Payer: Healthscope Whirlpool |
$75.22
|
| Rate for Payer: Mclaren Commercial |
$69.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$65.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$54.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$68.24
|
|
