|
AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$74.03
|
|
|
Service Code
|
NDC 00781603955
|
| Hospital Charge Code |
453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.12 |
| Max. Negotiated Rate |
$74.03 |
| Rate for Payer: Aetna Commercial |
$66.63
|
| Rate for Payer: ASR ASR |
$71.81
|
| Rate for Payer: ASR Commercial |
$71.81
|
| Rate for Payer: BCBS Trust/PPO |
$60.33
|
| 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 Commercial |
$62.93
|
| Rate for Payer: Nomi Health Commercial |
$60.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.12
|
| 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 00143988801
|
| Hospital Charge Code |
453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.13 |
| Max. Negotiated Rate |
$54.05 |
| Rate for Payer: Aetna Commercial |
$48.64
|
| Rate for Payer: ASR ASR |
$52.43
|
| Rate for Payer: ASR Commercial |
$52.43
|
| Rate for Payer: BCBS Trust/PPO |
$44.05
|
| 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 Commercial |
$45.94
|
| Rate for Payer: Nomi Health Commercial |
$44.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.56
|
|
|
AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$47.00
|
|
|
Service Code
|
NDC 00781603958
|
| Hospital Charge Code |
453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.55 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$42.30
|
| Rate for Payer: ASR ASR |
$45.59
|
| Rate for Payer: ASR Commercial |
$45.59
|
| Rate for Payer: BCBS Trust/PPO |
$38.30
|
| Rate for Payer: BCN Commercial |
$36.44
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Cofinity Commercial |
$44.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.60
|
| Rate for Payer: Healthscope Commercial |
$47.00
|
| Rate for Payer: Healthscope Whirlpool |
$45.59
|
| Rate for Payer: Mclaren Commercial |
$42.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.95
|
| Rate for Payer: Nomi Health Commercial |
$38.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.36
|
|
|
AMOXICILLIN 125 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$47.00
|
|
|
Service Code
|
NDC 00781603958
|
| Hospital Charge Code |
453
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.80 |
| Max. Negotiated Rate |
$47.00 |
| Rate for Payer: Aetna Commercial |
$42.30
|
| Rate for Payer: Aetna Medicare |
$23.50
|
| Rate for Payer: ASR ASR |
$45.59
|
| Rate for Payer: ASR Commercial |
$45.59
|
| Rate for Payer: BCBS Complete |
$18.80
|
| Rate for Payer: BCBS Trust/PPO |
$38.49
|
| Rate for Payer: BCN Commercial |
$36.44
|
| Rate for Payer: Cash Price |
$37.60
|
| Rate for Payer: Cofinity Commercial |
$44.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.60
|
| Rate for Payer: Healthscope Commercial |
$47.00
|
| Rate for Payer: Healthscope Whirlpool |
$45.59
|
| Rate for Payer: Mclaren Commercial |
$42.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$39.95
|
| Rate for Payer: Nomi Health Commercial |
$38.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$30.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$41.18
|
| Rate for Payer: Priority Health Narrow Network |
$32.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$41.36
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$1.29
|
|
|
Service Code
|
NDC 09900000421
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.52 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: Aetna Medicare |
$0.65
|
| Rate for Payer: ASR ASR |
$1.25
|
| Rate for Payer: ASR Commercial |
$1.25
|
| Rate for Payer: BCBS Complete |
$0.52
|
| Rate for Payer: BCBS Trust/PPO |
$1.06
|
| Rate for Payer: BCN Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cofinity Commercial |
$1.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.03
|
| Rate for Payer: Healthscope Commercial |
$1.29
|
| Rate for Payer: Healthscope Whirlpool |
$1.25
|
| Rate for Payer: Mclaren Commercial |
$1.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.10
|
| Rate for Payer: Nomi Health Commercial |
$1.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$1.13
|
| Rate for Payer: Priority Health Narrow Network |
$0.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.14
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$82.25
|
|
|
Service Code
|
NDC 00093415573
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.46 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$74.02
|
| Rate for Payer: ASR ASR |
$79.78
|
| Rate for Payer: ASR Commercial |
$79.78
|
| Rate for Payer: BCBS Trust/PPO |
$67.03
|
| 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 Commercial |
$69.91
|
| Rate for Payer: Nomi Health Commercial |
$67.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$72.38
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$1.29
|
|
|
Service Code
|
NDC 09900000421
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.84 |
| Max. Negotiated Rate |
$1.29 |
| Rate for Payer: Aetna Commercial |
$1.16
|
| Rate for Payer: ASR ASR |
$1.25
|
| Rate for Payer: ASR Commercial |
$1.25
|
| Rate for Payer: BCBS Trust/PPO |
$1.05
|
| Rate for Payer: BCN Commercial |
$1.00
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cofinity Commercial |
$1.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.03
|
| Rate for Payer: Healthscope Commercial |
$1.29
|
| Rate for Payer: Healthscope Whirlpool |
$1.25
|
| Rate for Payer: Mclaren Commercial |
$1.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1.10
|
| Rate for Payer: Nomi Health Commercial |
$1.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.14
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$67.68
|
|
|
Service Code
|
NDC 00781604158
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.99 |
| Max. Negotiated Rate |
$67.68 |
| Rate for Payer: Aetna Commercial |
$60.91
|
| Rate for Payer: ASR ASR |
$65.65
|
| Rate for Payer: ASR Commercial |
$65.65
|
| Rate for Payer: BCBS Trust/PPO |
$55.15
|
| 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 Commercial |
$57.53
|
| Rate for Payer: Nomi Health Commercial |
$55.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.56
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$77.55
|
|
|
Service Code
|
NDC 65862070701
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.02 |
| Max. Negotiated Rate |
$77.55 |
| Rate for Payer: Aetna Commercial |
$69.80
|
| Rate for Payer: Aetna Medicare |
$38.78
|
| Rate for Payer: ASR ASR |
$75.22
|
| Rate for Payer: ASR Commercial |
$75.22
|
| Rate for Payer: BCBS Complete |
$31.02
|
| Rate for Payer: BCBS Trust/PPO |
$63.51
|
| 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 Commercial |
$65.92
|
| Rate for Payer: Nomi Health Commercial |
$63.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$67.95
|
| Rate for Payer: Priority Health Narrow Network |
$54.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$68.24
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$67.68
|
|
|
Service Code
|
NDC 00781604158
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.07 |
| Max. Negotiated Rate |
$67.68 |
| Rate for Payer: Aetna Commercial |
$60.91
|
| Rate for Payer: Aetna Medicare |
$33.84
|
| Rate for Payer: ASR ASR |
$65.65
|
| Rate for Payer: ASR Commercial |
$65.65
|
| Rate for Payer: BCBS Complete |
$27.07
|
| Rate for Payer: BCBS Trust/PPO |
$55.42
|
| 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 Commercial |
$57.53
|
| Rate for Payer: Nomi Health Commercial |
$55.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$59.30
|
| Rate for Payer: Priority Health Narrow Network |
$47.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.56
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$77.55
|
|
|
Service Code
|
NDC 00781604146
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.02 |
| Max. Negotiated Rate |
$77.55 |
| Rate for Payer: Aetna Commercial |
$69.80
|
| Rate for Payer: Aetna Medicare |
$38.78
|
| Rate for Payer: ASR ASR |
$75.22
|
| Rate for Payer: ASR Commercial |
$75.22
|
| Rate for Payer: BCBS Complete |
$31.02
|
| Rate for Payer: BCBS Trust/PPO |
$63.51
|
| 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 Commercial |
$65.92
|
| Rate for Payer: Nomi Health Commercial |
$63.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$67.95
|
| Rate for Payer: Priority Health Narrow Network |
$54.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$68.24
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$82.25
|
|
|
Service Code
|
NDC 00093415573
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$32.90 |
| Max. Negotiated Rate |
$82.25 |
| Rate for Payer: Aetna Commercial |
$74.02
|
| Rate for Payer: Aetna Medicare |
$41.12
|
| Rate for Payer: ASR ASR |
$79.78
|
| Rate for Payer: ASR Commercial |
$79.78
|
| Rate for Payer: BCBS Complete |
$32.90
|
| Rate for Payer: BCBS Trust/PPO |
$67.35
|
| 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 Commercial |
$69.91
|
| Rate for Payer: Nomi Health Commercial |
$67.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$53.46
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$72.07
|
| Rate for Payer: Priority Health Narrow Network |
$57.66
|
| 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 65862070780
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.99 |
| Max. Negotiated Rate |
$67.68 |
| Rate for Payer: Aetna Commercial |
$60.91
|
| Rate for Payer: ASR ASR |
$65.65
|
| Rate for Payer: ASR Commercial |
$65.65
|
| Rate for Payer: BCBS Trust/PPO |
$55.15
|
| 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 Commercial |
$57.53
|
| Rate for Payer: Nomi Health Commercial |
$55.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.99
|
| 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 00781604146
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.41 |
| Max. Negotiated Rate |
$77.55 |
| Rate for Payer: Aetna Commercial |
$69.80
|
| Rate for Payer: ASR ASR |
$75.22
|
| Rate for Payer: ASR Commercial |
$75.22
|
| Rate for Payer: BCBS Trust/PPO |
$63.20
|
| 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 Commercial |
$65.92
|
| Rate for Payer: Nomi Health Commercial |
$63.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$68.24
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$77.55
|
|
|
Service Code
|
NDC 65862070701
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$50.41 |
| Max. Negotiated Rate |
$77.55 |
| Rate for Payer: Aetna Commercial |
$69.80
|
| Rate for Payer: ASR ASR |
$75.22
|
| Rate for Payer: ASR Commercial |
$75.22
|
| Rate for Payer: BCBS Trust/PPO |
$63.20
|
| 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 Commercial |
$65.92
|
| Rate for Payer: Nomi Health Commercial |
$63.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$50.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$68.24
|
|
|
AMOXICILLIN 250 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$67.68
|
|
|
Service Code
|
NDC 65862070780
|
| Hospital Charge Code |
454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$27.07 |
| Max. Negotiated Rate |
$67.68 |
| Rate for Payer: Aetna Commercial |
$60.91
|
| Rate for Payer: Aetna Medicare |
$33.84
|
| Rate for Payer: ASR ASR |
$65.65
|
| Rate for Payer: ASR Commercial |
$65.65
|
| Rate for Payer: BCBS Complete |
$27.07
|
| Rate for Payer: BCBS Trust/PPO |
$55.42
|
| 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 Commercial |
$57.53
|
| Rate for Payer: Nomi Health Commercial |
$55.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$43.99
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$59.30
|
| Rate for Payer: Priority Health Narrow Network |
$47.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$59.56
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$110.45
|
|
|
Service Code
|
NDC 65862001601
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.18 |
| Max. Negotiated Rate |
$110.45 |
| Rate for Payer: Aetna Commercial |
$99.40
|
| Rate for Payer: Aetna Medicare |
$55.22
|
| Rate for Payer: ASR ASR |
$107.14
|
| Rate for Payer: ASR Commercial |
$107.14
|
| Rate for Payer: BCBS Complete |
$44.18
|
| Rate for Payer: BCBS Trust/PPO |
$90.45
|
| 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 Commercial |
$93.88
|
| Rate for Payer: Nomi Health Commercial |
$90.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$96.78
|
| Rate for Payer: Priority Health Narrow Network |
$77.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$97.20
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$197.40
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.31 |
| Max. Negotiated Rate |
$197.40 |
| Rate for Payer: Aetna Commercial |
$177.66
|
| Rate for Payer: ASR ASR |
$191.48
|
| Rate for Payer: ASR Commercial |
$191.48
|
| Rate for Payer: BCBS Trust/PPO |
$160.86
|
| Rate for Payer: BCN Commercial |
$153.04
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$185.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$197.40
|
| Rate for Payer: Healthscope Whirlpool |
$191.48
|
| Rate for Payer: Mclaren Commercial |
$177.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: Nomi Health Commercial |
$161.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$173.71
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$110.45
|
|
|
Service Code
|
NDC 65862001601
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.79 |
| Max. Negotiated Rate |
$110.45 |
| Rate for Payer: Aetna Commercial |
$99.40
|
| Rate for Payer: ASR ASR |
$107.14
|
| Rate for Payer: ASR Commercial |
$107.14
|
| Rate for Payer: BCBS Trust/PPO |
$90.01
|
| 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 Commercial |
$93.88
|
| Rate for Payer: Nomi Health Commercial |
$90.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$97.20
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$197.40
|
|
|
Service Code
|
NDC 00781202001
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.96 |
| Max. Negotiated Rate |
$197.40 |
| Rate for Payer: Aetna Commercial |
$177.66
|
| Rate for Payer: Aetna Medicare |
$98.70
|
| Rate for Payer: ASR ASR |
$191.48
|
| Rate for Payer: ASR Commercial |
$191.48
|
| Rate for Payer: BCBS Complete |
$78.96
|
| Rate for Payer: BCBS Trust/PPO |
$161.65
|
| Rate for Payer: BCN Commercial |
$153.04
|
| Rate for Payer: Cash Price |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$185.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$157.92
|
| Rate for Payer: Healthscope Commercial |
$197.40
|
| Rate for Payer: Healthscope Whirlpool |
$191.48
|
| Rate for Payer: Mclaren Commercial |
$177.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$167.79
|
| Rate for Payer: Nomi Health Commercial |
$161.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.31
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$172.96
|
| Rate for Payer: Priority Health Narrow Network |
$138.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$173.71
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
IP
|
$775.50
|
|
|
Service Code
|
NDC 00781202005
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$504.08 |
| Max. Negotiated Rate |
$775.50 |
| Rate for Payer: Aetna Commercial |
$697.95
|
| Rate for Payer: ASR ASR |
$752.24
|
| Rate for Payer: ASR Commercial |
$752.24
|
| Rate for Payer: BCBS Trust/PPO |
$631.95
|
| Rate for Payer: BCN Commercial |
$601.25
|
| 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 |
$775.50
|
| Rate for Payer: Healthscope Whirlpool |
$752.24
|
| Rate for Payer: Mclaren Commercial |
$697.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$659.18
|
| Rate for Payer: Nomi Health Commercial |
$635.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$504.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$682.44
|
|
|
AMOXICILLIN 250 MG CAPSULE
|
Facility
|
OP
|
$775.50
|
|
|
Service Code
|
NDC 00781202005
|
| Hospital Charge Code |
450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$310.20 |
| Max. Negotiated Rate |
$775.50 |
| Rate for Payer: Aetna Commercial |
$697.95
|
| Rate for Payer: Aetna Medicare |
$387.75
|
| Rate for Payer: ASR ASR |
$752.24
|
| Rate for Payer: ASR Commercial |
$752.24
|
| Rate for Payer: BCBS Complete |
$310.20
|
| Rate for Payer: BCBS Trust/PPO |
$635.06
|
| Rate for Payer: BCN Commercial |
$601.25
|
| 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 |
$775.50
|
| Rate for Payer: Healthscope Whirlpool |
$752.24
|
| Rate for Payer: Mclaren Commercial |
$697.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$659.18
|
| Rate for Payer: Nomi Health Commercial |
$635.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$504.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$679.49
|
| Rate for Payer: Priority Health Narrow Network |
$543.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$682.44
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
OP
|
$244.40
|
|
|
Service Code
|
NDC 00781261301
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$97.76 |
| Max. Negotiated Rate |
$244.40 |
| Rate for Payer: Aetna Commercial |
$219.96
|
| Rate for Payer: Aetna Medicare |
$122.20
|
| Rate for Payer: ASR ASR |
$237.07
|
| Rate for Payer: ASR Commercial |
$237.07
|
| Rate for Payer: BCBS Complete |
$97.76
|
| Rate for Payer: BCBS Trust/PPO |
$200.14
|
| Rate for Payer: BCN Commercial |
$189.48
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Commercial |
$229.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$244.40
|
| Rate for Payer: Healthscope Whirlpool |
$237.07
|
| Rate for Payer: Mclaren Commercial |
$219.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.74
|
| Rate for Payer: Nomi Health Commercial |
$200.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$214.14
|
| Rate for Payer: Priority Health Narrow Network |
$171.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$215.07
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
IP
|
$105.75
|
|
|
Service Code
|
NDC 00093310953
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.74 |
| Max. Negotiated Rate |
$105.75 |
| Rate for Payer: Aetna Commercial |
$95.18
|
| Rate for Payer: ASR ASR |
$102.58
|
| Rate for Payer: ASR Commercial |
$102.58
|
| Rate for Payer: BCBS Trust/PPO |
$86.18
|
| Rate for Payer: BCN Commercial |
$81.99
|
| Rate for Payer: Cash Price |
$84.60
|
| Rate for Payer: Cofinity Commercial |
$99.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.60
|
| Rate for Payer: Healthscope Commercial |
$105.75
|
| Rate for Payer: Healthscope Whirlpool |
$102.58
|
| Rate for Payer: Mclaren Commercial |
$95.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.89
|
| Rate for Payer: Nomi Health Commercial |
$86.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$93.06
|
|
|
AMOXICILLIN 500 MG CAPSULE
|
Facility
|
IP
|
$244.40
|
|
|
Service Code
|
NDC 00781261301
|
| Hospital Charge Code |
451
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.86 |
| Max. Negotiated Rate |
$244.40 |
| Rate for Payer: Aetna Commercial |
$219.96
|
| Rate for Payer: ASR ASR |
$237.07
|
| Rate for Payer: ASR Commercial |
$237.07
|
| Rate for Payer: BCBS Trust/PPO |
$199.16
|
| Rate for Payer: BCN Commercial |
$189.48
|
| Rate for Payer: Cash Price |
$195.52
|
| Rate for Payer: Cofinity Commercial |
$229.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.52
|
| Rate for Payer: Healthscope Commercial |
$244.40
|
| Rate for Payer: Healthscope Whirlpool |
$237.07
|
| Rate for Payer: Mclaren Commercial |
$219.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.74
|
| Rate for Payer: Nomi Health Commercial |
$200.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$158.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$215.07
|
|
