|
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 CAPSULE
|
Facility
IP
|
$110.45
|
|
|
Service Code
|
NDC 65862-016-01
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$77.32 |
| Max. Negotiated Rate |
$110.45 |
| Rate for Payer: Aetna Commercial |
$99.40
|
| Rate for Payer: ASR ASR |
$107.14
|
| Rate for Payer: BCBS Trust/PPO |
$85.63
|
| Rate for Payer: BCN Commercial |
$85.63
|
| Rate for Payer: Cash Price |
$88.36
|
| Rate for Payer: Cofinity Commercial |
$103.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$88.36
|
| Rate for Payer: Healthscope Commercial |
$110.45
|
| Rate for Payer: Healthscope Whirlpool |
$107.14
|
| Rate for Payer: Mclaren Commercial |
$99.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$93.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$77.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$97.20
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
IP
|
$159.80
|
|
|
Service Code
|
NDC 0781-2020-01
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$111.86 |
| Max. Negotiated Rate |
$159.80 |
| Rate for Payer: Aetna Commercial |
$143.82
|
| Rate for Payer: ASR ASR |
$155.01
|
| Rate for Payer: BCBS Trust/PPO |
$123.89
|
| Rate for Payer: BCN Commercial |
$123.89
|
| Rate for Payer: Cash Price |
$127.84
|
| Rate for Payer: Cofinity Commercial |
$150.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$127.84
|
| Rate for Payer: Healthscope Commercial |
$159.80
|
| Rate for Payer: Healthscope Whirlpool |
$155.01
|
| Rate for Payer: Mclaren Commercial |
$143.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$135.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$111.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$140.62
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
IP
|
$622.75
|
|
|
Service Code
|
NDC 0781-2020-05
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$435.92 |
| Max. Negotiated Rate |
$622.75 |
| Rate for Payer: Aetna Commercial |
$560.48
|
| Rate for Payer: ASR ASR |
$604.07
|
| Rate for Payer: BCBS Trust/PPO |
$482.82
|
| Rate for Payer: BCN Commercial |
$482.82
|
| Rate for Payer: Cash Price |
$498.20
|
| Rate for Payer: Cofinity Commercial |
$585.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$498.20
|
| Rate for Payer: Healthscope Commercial |
$622.75
|
| Rate for Payer: Healthscope Whirlpool |
$604.07
|
| Rate for Payer: Mclaren Commercial |
$560.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$529.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$435.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$548.02
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
IP
|
$142.18
|
|
|
Service Code
|
NDC 0093-3109-53
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.53 |
| Max. Negotiated Rate |
$142.18 |
| Rate for Payer: Aetna Commercial |
$127.96
|
| Rate for Payer: ASR ASR |
$137.91
|
| Rate for Payer: BCBS Trust/PPO |
$110.23
|
| Rate for Payer: BCN Commercial |
$110.23
|
| Rate for Payer: Cash Price |
$113.74
|
| Rate for Payer: Cofinity Commercial |
$133.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.74
|
| Rate for Payer: Healthscope Commercial |
$142.18
|
| Rate for Payer: Healthscope Whirlpool |
$137.91
|
| Rate for Payer: Mclaren Commercial |
$127.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$120.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$99.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$125.12
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
IP
|
$227.95
|
|
|
Service Code
|
NDC 0781-2613-01
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$159.56 |
| Max. Negotiated Rate |
$227.95 |
| Rate for Payer: Aetna Commercial |
$205.16
|
| Rate for Payer: ASR ASR |
$221.11
|
| Rate for Payer: BCBS Trust/PPO |
$176.73
|
| Rate for Payer: BCN Commercial |
$176.73
|
| Rate for Payer: Cash Price |
$182.36
|
| Rate for Payer: Cofinity Commercial |
$214.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$182.36
|
| Rate for Payer: Healthscope Commercial |
$227.95
|
| Rate for Payer: Healthscope Whirlpool |
$221.11
|
| Rate for Payer: Mclaren Commercial |
$205.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$193.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$159.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$200.60
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$425.76
|
|
|
Service Code
|
NDC 66685-1002-2
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$298.03 |
| Max. Negotiated Rate |
$425.76 |
| Rate for Payer: Aetna Commercial |
$383.18
|
| Rate for Payer: ASR ASR |
$412.99
|
| Rate for Payer: BCBS Trust/PPO |
$330.09
|
| Rate for Payer: BCN Commercial |
$330.09
|
| Rate for Payer: Cash Price |
$340.61
|
| Rate for Payer: Cofinity Commercial |
$400.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$340.61
|
| Rate for Payer: Healthscope Commercial |
$425.76
|
| Rate for Payer: Healthscope Whirlpool |
$412.99
|
| Rate for Payer: Mclaren Commercial |
$383.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$361.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$298.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$374.67
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$52.82
|
|
|
Service Code
|
NDC 0093-2274-34
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.97 |
| Max. Negotiated Rate |
$52.82 |
| Rate for Payer: Aetna Commercial |
$47.54
|
| Rate for Payer: ASR ASR |
$51.24
|
| Rate for Payer: BCBS Trust/PPO |
$40.95
|
| Rate for Payer: BCN Commercial |
$40.95
|
| Rate for Payer: Cash Price |
$42.26
|
| Rate for Payer: Cofinity Commercial |
$49.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$42.26
|
| Rate for Payer: Healthscope Commercial |
$52.82
|
| Rate for Payer: Healthscope Whirlpool |
$51.24
|
| Rate for Payer: Mclaren Commercial |
$47.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.90
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$46.48
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$308.44
|
|
|
Service Code
|
NDC 0143-9853-75
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$215.91 |
| Max. Negotiated Rate |
$308.44 |
| Rate for Payer: Aetna Commercial |
$277.60
|
| Rate for Payer: ASR ASR |
$299.19
|
| Rate for Payer: BCBS Trust/PPO |
$239.13
|
| Rate for Payer: BCN Commercial |
$239.13
|
| Rate for Payer: Cash Price |
$246.75
|
| Rate for Payer: Cofinity Commercial |
$289.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$246.75
|
| Rate for Payer: Healthscope Commercial |
$308.44
|
| Rate for Payer: Healthscope Whirlpool |
$299.19
|
| Rate for Payer: Mclaren Commercial |
$277.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$262.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$215.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$271.43
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$195.64
|
|
|
Service Code
|
NDC 65862-535-75
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$136.95 |
| Max. Negotiated Rate |
$195.64 |
| Rate for Payer: Aetna Commercial |
$176.08
|
| Rate for Payer: ASR ASR |
$189.77
|
| Rate for Payer: BCBS Trust/PPO |
$151.68
|
| Rate for Payer: BCN Commercial |
$151.68
|
| Rate for Payer: Cash Price |
$156.51
|
| Rate for Payer: Cofinity Commercial |
$183.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$156.51
|
| Rate for Payer: Healthscope Commercial |
$195.64
|
| Rate for Payer: Healthscope Whirlpool |
$189.77
|
| Rate for Payer: Mclaren Commercial |
$176.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$166.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$136.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$172.16
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
IP
|
$237.94
|
|
|
Service Code
|
NDC 65862-535-13
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$166.56 |
| Max. Negotiated Rate |
$237.94 |
| Rate for Payer: Aetna Commercial |
$214.15
|
| Rate for Payer: ASR ASR |
$230.80
|
| Rate for Payer: BCBS Trust/PPO |
$184.47
|
| Rate for Payer: BCN Commercial |
$184.47
|
| Rate for Payer: Cash Price |
$190.35
|
| Rate for Payer: Cofinity Commercial |
$223.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$190.35
|
| Rate for Payer: Healthscope Commercial |
$237.94
|
| Rate for Payer: Healthscope Whirlpool |
$230.80
|
| Rate for Payer: Mclaren Commercial |
$214.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$202.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$166.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$209.39
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$54.72
|
|
|
Service Code
|
NDC 42571-162-42
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.30 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$49.25
|
| Rate for Payer: ASR ASR |
$53.08
|
| Rate for Payer: BCBS Trust/PPO |
$42.42
|
| Rate for Payer: BCN Commercial |
$42.42
|
| Rate for Payer: Cash Price |
$43.78
|
| Rate for Payer: Cofinity Commercial |
$51.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.78
|
| Rate for Payer: Healthscope Commercial |
$54.72
|
| Rate for Payer: Healthscope Whirlpool |
$53.08
|
| Rate for Payer: Mclaren Commercial |
$49.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$46.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$38.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$48.15
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$101.28
|
|
|
Service Code
|
NDC 0781-1852-20
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.90 |
| 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 |
$78.52
|
| Rate for Payer: BCN Commercial |
$78.52
|
| 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 |
$101.28
|
| Rate for Payer: Healthscope Whirlpool |
$98.24
|
| Rate for Payer: Mclaren Commercial |
$91.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$86.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$89.13
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$423.70
|
|
|
Service Code
|
NDC 65862-503-01
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$296.59 |
| 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 |
$328.49
|
| Rate for Payer: BCN Commercial |
$328.49
|
| 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 |
$423.70
|
| Rate for Payer: Healthscope Whirlpool |
$410.99
|
| Rate for Payer: Mclaren Commercial |
$381.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$360.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$372.86
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$62.13
|
|
|
Service Code
|
NDC 0093-2275-34
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.49 |
| Max. Negotiated Rate |
$62.13 |
| Rate for Payer: Aetna Commercial |
$55.92
|
| Rate for Payer: ASR ASR |
$60.27
|
| Rate for Payer: BCBS Trust/PPO |
$48.17
|
| Rate for Payer: BCN Commercial |
$48.17
|
| Rate for Payer: Cash Price |
$49.70
|
| Rate for Payer: Cofinity Commercial |
$58.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$49.70
|
| Rate for Payer: Healthscope Commercial |
$62.13
|
| Rate for Payer: Healthscope Whirlpool |
$60.27
|
| Rate for Payer: Mclaren Commercial |
$55.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$52.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$54.67
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$101.28
|
|
|
Service Code
|
NDC 66685-1001-0
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$70.90 |
| 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 |
$78.52
|
| Rate for Payer: BCN Commercial |
$78.52
|
| 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 |
$101.28
|
| Rate for Payer: Healthscope Whirlpool |
$98.24
|
| Rate for Payer: Mclaren Commercial |
$91.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$86.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$70.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$89.13
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
IP
|
$509.28
|
|
|
Service Code
|
NDC 66685-1001-1
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$356.50 |
| Max. Negotiated Rate |
$509.28 |
| Rate for Payer: Aetna Commercial |
$458.35
|
| Rate for Payer: ASR ASR |
$494.00
|
| Rate for Payer: BCBS Trust/PPO |
$394.84
|
| Rate for Payer: BCN Commercial |
$394.84
|
| Rate for Payer: Cash Price |
$407.42
|
| Rate for Payer: Cofinity Commercial |
$478.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$407.42
|
| Rate for Payer: Healthscope Commercial |
$509.28
|
| Rate for Payer: Healthscope Whirlpool |
$494.00
|
| Rate for Payer: Mclaren Commercial |
$458.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$432.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$356.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$448.17
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION
|
Facility
IP
|
$20.56
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.39 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna Commercial |
$18.50
|
| Rate for Payer: Aetna Commercial |
$24.03
|
| Rate for Payer: ASR ASR |
$25.90
|
| Rate for Payer: ASR ASR |
$19.94
|
| Rate for Payer: BCBS Trust/PPO |
$20.70
|
| Rate for Payer: BCBS Trust/PPO |
$15.94
|
| Rate for Payer: BCN Commercial |
$20.70
|
| Rate for Payer: BCN Commercial |
$15.94
|
| Rate for Payer: Cash Price |
$21.36
|
| Rate for Payer: Cash Price |
$16.45
|
| Rate for Payer: Cofinity Commercial |
$25.10
|
| Rate for Payer: Cofinity Commercial |
$19.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.45
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Healthscope Commercial |
$26.70
|
| Rate for Payer: Healthscope Whirlpool |
$19.94
|
| Rate for Payer: Healthscope Whirlpool |
$25.90
|
| Rate for Payer: Mclaren Commercial |
$24.03
|
| Rate for Payer: Mclaren Commercial |
$18.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.50
|
|
|
AMPICILLIN 2 GRAM SOLUTION FOR INJECTION
|
Facility
IP
|
$18.14
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
472
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.70 |
| Max. Negotiated Rate |
$18.14 |
| Rate for Payer: Aetna Commercial |
$16.33
|
| Rate for Payer: Aetna Commercial |
$15.99
|
| Rate for Payer: ASR ASR |
$17.24
|
| Rate for Payer: ASR ASR |
$17.60
|
| Rate for Payer: BCBS Trust/PPO |
$14.06
|
| Rate for Payer: BCBS Trust/PPO |
$13.78
|
| Rate for Payer: BCN Commercial |
$14.06
|
| Rate for Payer: BCN Commercial |
$13.78
|
| Rate for Payer: Cash Price |
$14.22
|
| Rate for Payer: Cash Price |
$14.51
|
| Rate for Payer: Cofinity Commercial |
$17.05
|
| Rate for Payer: Cofinity Commercial |
$16.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.51
|
| Rate for Payer: Healthscope Commercial |
$18.14
|
| Rate for Payer: Healthscope Commercial |
$17.77
|
| Rate for Payer: Healthscope Whirlpool |
$17.24
|
| Rate for Payer: Healthscope Whirlpool |
$17.60
|
| Rate for Payer: Mclaren Commercial |
$15.99
|
| Rate for Payer: Mclaren Commercial |
$16.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$15.96
|
|
|
AMPICILLIN 500 MG IM
|
Facility
IP
|
$20.16
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
155218
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.11 |
| Max. Negotiated Rate |
$20.16 |
| Rate for Payer: Aetna Commercial |
$18.14
|
| Rate for Payer: ASR ASR |
$19.56
|
| Rate for Payer: BCBS Trust/PPO |
$15.63
|
| Rate for Payer: BCN Commercial |
$15.63
|
| Rate for Payer: Cash Price |
$16.12
|
| Rate for Payer: Cofinity Commercial |
$18.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.13
|
| Rate for Payer: Healthscope Commercial |
$20.16
|
| Rate for Payer: Healthscope Whirlpool |
$19.56
|
| Rate for Payer: Mclaren Commercial |
$18.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.74
|
|
|
AMPICILLIN 500 MG SOLUTION FOR INJECTION
|
Facility
IP
|
$20.16
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
474
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.11 |
| Max. Negotiated Rate |
$20.16 |
| Rate for Payer: Aetna Commercial |
$18.14
|
| Rate for Payer: ASR ASR |
$19.56
|
| Rate for Payer: BCBS Trust/PPO |
$15.63
|
| Rate for Payer: BCN Commercial |
$15.63
|
| Rate for Payer: Cash Price |
$16.12
|
| Rate for Payer: Cofinity Commercial |
$18.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.13
|
| Rate for Payer: Healthscope Commercial |
$20.16
|
| Rate for Payer: Healthscope Whirlpool |
$19.56
|
| Rate for Payer: Mclaren Commercial |
$18.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.74
|
|
|
AMPICILLIN-SULBACTAM 1.5 GRAM SOLUTION FOR INJECTION
|
Facility
IP
|
$29.06
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
32470
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$20.34 |
| Max. Negotiated Rate |
$29.06 |
| Rate for Payer: ASR ASR |
$28.19
|
| Rate for Payer: Aetna Commercial |
$26.15
|
| Rate for Payer: Aetna Commercial |
$17.24
|
| Rate for Payer: Aetna Commercial |
$18.25
|
| Rate for Payer: Aetna Commercial |
$24.93
|
| Rate for Payer: Aetna Commercial |
$25.86
|
| Rate for Payer: ASR ASR |
$19.67
|
| Rate for Payer: ASR ASR |
$27.87
|
| Rate for Payer: ASR ASR |
$26.87
|
| Rate for Payer: ASR ASR |
$18.59
|
| Rate for Payer: BCBS Trust/PPO |
$21.48
|
| Rate for Payer: BCBS Trust/PPO |
$22.53
|
| Rate for Payer: BCBS Trust/PPO |
$15.72
|
| Rate for Payer: BCBS Trust/PPO |
$22.27
|
| Rate for Payer: BCBS Trust/PPO |
$14.85
|
| Rate for Payer: BCN Commercial |
$14.85
|
| Rate for Payer: BCN Commercial |
$21.48
|
| Rate for Payer: BCN Commercial |
$22.27
|
| Rate for Payer: BCN Commercial |
$22.53
|
| Rate for Payer: BCN Commercial |
$15.72
|
| Rate for Payer: Cash Price |
$22.98
|
| Rate for Payer: Cash Price |
$16.22
|
| Rate for Payer: Cash Price |
$22.16
|
| Rate for Payer: Cash Price |
$15.32
|
| Rate for Payer: Cash Price |
$23.25
|
| Rate for Payer: Cofinity Commercial |
$27.01
|
| Rate for Payer: Cofinity Commercial |
$18.01
|
| Rate for Payer: Cofinity Commercial |
$19.06
|
| Rate for Payer: Cofinity Commercial |
$26.04
|
| Rate for Payer: Cofinity Commercial |
$27.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.98
|
| Rate for Payer: Healthscope Commercial |
$29.06
|
| Rate for Payer: Healthscope Commercial |
$27.70
|
| Rate for Payer: Healthscope Commercial |
$19.16
|
| Rate for Payer: Healthscope Commercial |
$20.28
|
| Rate for Payer: Healthscope Commercial |
$28.73
|
| Rate for Payer: Healthscope Whirlpool |
$19.67
|
| Rate for Payer: Healthscope Whirlpool |
$18.59
|
| Rate for Payer: Healthscope Whirlpool |
$26.87
|
| Rate for Payer: Healthscope Whirlpool |
$28.19
|
| Rate for Payer: Healthscope Whirlpool |
$27.87
|
| Rate for Payer: Mclaren Commercial |
$25.86
|
| Rate for Payer: Mclaren Commercial |
$18.25
|
| Rate for Payer: Mclaren Commercial |
$26.15
|
| Rate for Payer: Mclaren Commercial |
$24.93
|
| Rate for Payer: Mclaren Commercial |
$17.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$25.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$25.57
|
|
|
AMPICILLIN-SULBACTAM 3 GRAM SOLUTION FOR INJECTION
|
Facility
IP
|
$36.66
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
32471
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$25.66 |
| Max. Negotiated Rate |
$36.66 |
| Rate for Payer: Aetna Commercial |
$32.99
|
| Rate for Payer: Aetna Commercial |
$36.87
|
| Rate for Payer: Aetna Commercial |
$32.78
|
| Rate for Payer: Aetna Commercial |
$23.02
|
| Rate for Payer: Aetna Commercial |
$30.22
|
| Rate for Payer: Aetna Commercial |
$22.91
|
| Rate for Payer: ASR ASR |
$32.57
|
| Rate for Payer: ASR ASR |
$24.70
|
| Rate for Payer: ASR ASR |
$35.56
|
| Rate for Payer: ASR ASR |
$35.33
|
| Rate for Payer: ASR ASR |
$24.81
|
| Rate for Payer: ASR ASR |
$39.74
|
| Rate for Payer: BCBS Trust/PPO |
$28.42
|
| Rate for Payer: BCBS Trust/PPO |
$31.76
|
| Rate for Payer: BCBS Trust/PPO |
$19.74
|
| Rate for Payer: BCBS Trust/PPO |
$19.83
|
| Rate for Payer: BCBS Trust/PPO |
$28.24
|
| Rate for Payer: BCBS Trust/PPO |
$26.03
|
| Rate for Payer: BCN Commercial |
$28.42
|
| Rate for Payer: BCN Commercial |
$19.74
|
| Rate for Payer: BCN Commercial |
$19.83
|
| Rate for Payer: BCN Commercial |
$26.03
|
| Rate for Payer: BCN Commercial |
$28.24
|
| Rate for Payer: BCN Commercial |
$31.76
|
| Rate for Payer: Cash Price |
$20.46
|
| Rate for Payer: Cash Price |
$29.33
|
| Rate for Payer: Cash Price |
$32.78
|
| Rate for Payer: Cash Price |
$26.86
|
| Rate for Payer: Cash Price |
$29.14
|
| Rate for Payer: Cash Price |
$20.37
|
| Rate for Payer: Cofinity Commercial |
$34.23
|
| Rate for Payer: Cofinity Commercial |
$34.46
|
| Rate for Payer: Cofinity Commercial |
$31.57
|
| Rate for Payer: Cofinity Commercial |
$23.93
|
| Rate for Payer: Cofinity Commercial |
$24.05
|
| Rate for Payer: Cofinity Commercial |
$38.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$32.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.46
|
| Rate for Payer: Healthscope Commercial |
$36.66
|
| Rate for Payer: Healthscope Commercial |
$33.58
|
| Rate for Payer: Healthscope Commercial |
$25.58
|
| Rate for Payer: Healthscope Commercial |
$36.42
|
| Rate for Payer: Healthscope Commercial |
$25.46
|
| Rate for Payer: Healthscope Commercial |
$40.97
|
| Rate for Payer: Healthscope Whirlpool |
$35.33
|
| Rate for Payer: Healthscope Whirlpool |
$24.81
|
| Rate for Payer: Healthscope Whirlpool |
$32.57
|
| Rate for Payer: Healthscope Whirlpool |
$35.56
|
| Rate for Payer: Healthscope Whirlpool |
$24.70
|
| Rate for Payer: Healthscope Whirlpool |
$39.74
|
| Rate for Payer: Mclaren Commercial |
$36.87
|
| Rate for Payer: Mclaren Commercial |
$22.91
|
| Rate for Payer: Mclaren Commercial |
$32.78
|
| Rate for Payer: Mclaren Commercial |
$32.99
|
| Rate for Payer: Mclaren Commercial |
$23.02
|
| Rate for Payer: Mclaren Commercial |
$30.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$34.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$22.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$36.05
|
|
|
AMPICILLIN-SULBACTAM IM INJECTION
|
Facility
IP
|
$27.70
|
|
|
Service Code
|
HCPCS J0295
|
| Hospital Charge Code |
181600
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$19.39 |
| Max. Negotiated Rate |
$27.70 |
| Rate for Payer: Aetna Commercial |
$24.93
|
| Rate for Payer: ASR ASR |
$26.87
|
| Rate for Payer: BCBS Trust/PPO |
$21.48
|
| Rate for Payer: BCN Commercial |
$21.48
|
| Rate for Payer: Cash Price |
$22.16
|
| Rate for Payer: Cofinity Commercial |
$26.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.16
|
| Rate for Payer: Healthscope Commercial |
$27.70
|
| Rate for Payer: Healthscope Whirlpool |
$26.87
|
| Rate for Payer: Mclaren Commercial |
$24.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.38
|
|
|
AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC
|
Facility
IP
|
$36,070.13
|
|
|
Service Code
|
MS-DRG 240
|
| Min. Negotiated Rate |
$24,191.51 |
| Max. Negotiated Rate |
$36,070.13 |
| Rate for Payer: Aetna Medicare |
$25,464.75
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$31,830.94
|
| Rate for Payer: Amish Plain Church Group Commercial |
$31,830.94
|
| Rate for Payer: BCBS MAPPO |
$25,464.75
|
| Rate for Payer: BCN Medicare Advantage |
$25,464.75
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$25,464.75
|
| Rate for Payer: Humana Choice PPO Medicare |
$25,464.75
|
| Rate for Payer: Mclaren Medicare |
$25,464.75
|
| Rate for Payer: Meridian Wellcare - Medicare Advantage |
$26,737.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$29,284.46
|
| Rate for Payer: PACE Medicare |
$24,191.51
|
| Rate for Payer: PACE SWMI |
$25,464.75
|
| Rate for Payer: PHP Commercial |
$28,011.22
|
| Rate for Payer: PHP Medicare Advantage |
$25,464.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$36,070.13
|
| Rate for Payer: Priority Health Medicare |
$25,464.75
|
| Rate for Payer: Priority Health Narrow Network |
$28,856.10
|
| Rate for Payer: Railroad Medicare Medicare |
$25,464.75
|
| Rate for Payer: UHC Medicare Advantage |
$26,228.69
|
| Rate for Payer: VA VA |
$25,464.75
|
|
