|
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-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$53.96
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.58 |
| Max. Negotiated Rate |
$53.96 |
| Rate for Payer: Aetna Commercial |
$48.56
|
| Rate for Payer: Aetna Medicare |
$26.98
|
| Rate for Payer: ASR ASR |
$52.34
|
| Rate for Payer: ASR Commercial |
$52.34
|
| Rate for Payer: BCBS Complete |
$21.58
|
| Rate for Payer: BCBS Trust/PPO |
$44.19
|
| Rate for Payer: BCN Commercial |
$41.84
|
| Rate for Payer: Cash Price |
$43.17
|
| Rate for Payer: Cofinity Commercial |
$50.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.17
|
| Rate for Payer: Healthscope Commercial |
$53.96
|
| Rate for Payer: Healthscope Whirlpool |
$52.34
|
| Rate for Payer: Mclaren Commercial |
$48.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.87
|
| Rate for Payer: Nomi Health Commercial |
$44.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$47.28
|
| Rate for Payer: Priority Health Narrow Network |
$37.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.48
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$425.76
|
|
|
Service Code
|
NDC 66685100202
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$170.30 |
| Max. Negotiated Rate |
$425.76 |
| Rate for Payer: Aetna Commercial |
$383.18
|
| Rate for Payer: Aetna Medicare |
$212.88
|
| Rate for Payer: ASR ASR |
$412.99
|
| Rate for Payer: ASR Commercial |
$412.99
|
| Rate for Payer: BCBS Complete |
$170.30
|
| Rate for Payer: BCBS Trust/PPO |
$348.65
|
| 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 Commercial |
$361.90
|
| Rate for Payer: Nomi Health Commercial |
$349.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$373.05
|
| Rate for Payer: Priority Health Narrow Network |
$298.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$374.67
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$425.76
|
|
|
Service Code
|
NDC 66685100202
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$276.74 |
| Max. Negotiated Rate |
$425.76 |
| Rate for Payer: Aetna Commercial |
$383.18
|
| Rate for Payer: ASR ASR |
$412.99
|
| Rate for Payer: ASR Commercial |
$412.99
|
| Rate for Payer: BCBS Trust/PPO |
$346.95
|
| 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 Commercial |
$361.90
|
| Rate for Payer: Nomi Health Commercial |
$349.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$276.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$374.67
|
|
|
AMOXICILLIN 500 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$53.96
|
|
|
Service Code
|
NDC 00093227434
|
| Hospital Charge Code |
33227
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.07 |
| Max. Negotiated Rate |
$53.96 |
| Rate for Payer: Aetna Commercial |
$48.56
|
| Rate for Payer: ASR ASR |
$52.34
|
| Rate for Payer: ASR Commercial |
$52.34
|
| Rate for Payer: BCBS Trust/PPO |
$43.97
|
| Rate for Payer: BCN Commercial |
$41.84
|
| Rate for Payer: Cash Price |
$43.17
|
| Rate for Payer: Cofinity Commercial |
$50.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.17
|
| Rate for Payer: Healthscope Commercial |
$53.96
|
| Rate for Payer: Healthscope Whirlpool |
$52.34
|
| Rate for Payer: Mclaren Commercial |
$48.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$45.87
|
| Rate for Payer: Nomi Health Commercial |
$44.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$47.48
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$240.88
|
|
|
Service Code
|
NDC 65862053513
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$156.57 |
| Max. Negotiated Rate |
$240.88 |
| Rate for Payer: Aetna Commercial |
$216.79
|
| Rate for Payer: ASR ASR |
$233.65
|
| Rate for Payer: ASR Commercial |
$233.65
|
| Rate for Payer: BCBS Trust/PPO |
$196.29
|
| Rate for Payer: BCN Commercial |
$186.75
|
| Rate for Payer: Cash Price |
$192.70
|
| Rate for Payer: Cofinity Commercial |
$226.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.70
|
| Rate for Payer: Healthscope Commercial |
$240.88
|
| Rate for Payer: Healthscope Whirlpool |
$233.65
|
| Rate for Payer: Mclaren Commercial |
$216.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.75
|
| Rate for Payer: Nomi Health Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$211.97
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$200.93
|
|
|
Service Code
|
NDC 65862053575
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.37 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$180.84
|
| Rate for Payer: Aetna Medicare |
$100.46
|
| Rate for Payer: ASR ASR |
$194.90
|
| Rate for Payer: ASR Commercial |
$194.90
|
| Rate for Payer: BCBS Complete |
$80.37
|
| Rate for Payer: BCBS Trust/PPO |
$164.54
|
| Rate for Payer: BCN Commercial |
$155.78
|
| Rate for Payer: Cash Price |
$160.74
|
| Rate for Payer: Cofinity Commercial |
$188.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.74
|
| Rate for Payer: Healthscope Commercial |
$200.93
|
| Rate for Payer: Healthscope Whirlpool |
$194.90
|
| Rate for Payer: Mclaren Commercial |
$180.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.79
|
| Rate for Payer: Nomi Health Commercial |
$164.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.60
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$176.05
|
| Rate for Payer: Priority Health Narrow Network |
$140.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$176.82
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$308.44
|
|
|
Service Code
|
NDC 00143985375
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.49 |
| Max. Negotiated Rate |
$308.44 |
| Rate for Payer: Aetna Commercial |
$277.60
|
| Rate for Payer: ASR ASR |
$299.19
|
| Rate for Payer: ASR Commercial |
$299.19
|
| Rate for Payer: BCBS Trust/PPO |
$251.35
|
| 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 Commercial |
$262.17
|
| Rate for Payer: Nomi Health Commercial |
$252.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.49
|
| 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
|
$200.93
|
|
|
Service Code
|
NDC 65862053575
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$130.60 |
| Max. Negotiated Rate |
$200.93 |
| Rate for Payer: Aetna Commercial |
$180.84
|
| Rate for Payer: ASR ASR |
$194.90
|
| Rate for Payer: ASR Commercial |
$194.90
|
| Rate for Payer: BCBS Trust/PPO |
$163.74
|
| Rate for Payer: BCN Commercial |
$155.78
|
| Rate for Payer: Cash Price |
$160.74
|
| Rate for Payer: Cofinity Commercial |
$188.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$160.74
|
| Rate for Payer: Healthscope Commercial |
$200.93
|
| Rate for Payer: Healthscope Whirlpool |
$194.90
|
| Rate for Payer: Mclaren Commercial |
$180.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$170.79
|
| Rate for Payer: Nomi Health Commercial |
$164.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$130.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$176.82
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$240.88
|
|
|
Service Code
|
NDC 65862053513
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.35 |
| Max. Negotiated Rate |
$240.88 |
| Rate for Payer: Aetna Commercial |
$216.79
|
| Rate for Payer: Aetna Medicare |
$120.44
|
| Rate for Payer: ASR ASR |
$233.65
|
| Rate for Payer: ASR Commercial |
$233.65
|
| Rate for Payer: BCBS Complete |
$96.35
|
| Rate for Payer: BCBS Trust/PPO |
$197.26
|
| Rate for Payer: BCN Commercial |
$186.75
|
| Rate for Payer: Cash Price |
$192.70
|
| Rate for Payer: Cofinity Commercial |
$226.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$192.70
|
| Rate for Payer: Healthscope Commercial |
$240.88
|
| Rate for Payer: Healthscope Whirlpool |
$233.65
|
| Rate for Payer: Mclaren Commercial |
$216.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$204.75
|
| Rate for Payer: Nomi Health Commercial |
$197.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$156.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$211.06
|
| Rate for Payer: Priority Health Narrow Network |
$168.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$211.97
|
|
|
AMOXICILLIN 600 MG-POTASSIUM CLAVULANATE 42.9 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$308.44
|
|
|
Service Code
|
NDC 00143985375
|
| Hospital Charge Code |
31177
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$123.38 |
| Max. Negotiated Rate |
$308.44 |
| Rate for Payer: Aetna Commercial |
$277.60
|
| Rate for Payer: Aetna Medicare |
$154.22
|
| Rate for Payer: ASR ASR |
$299.19
|
| Rate for Payer: ASR Commercial |
$299.19
|
| Rate for Payer: BCBS Complete |
$123.38
|
| Rate for Payer: BCBS Trust/PPO |
$252.58
|
| 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 Commercial |
$262.17
|
| Rate for Payer: Nomi Health Commercial |
$252.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$200.49
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$270.26
|
| Rate for Payer: Priority Health Narrow Network |
$216.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$271.43
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$509.28
|
|
|
Service Code
|
NDC 66685100101
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$331.03 |
| Max. Negotiated Rate |
$509.28 |
| Rate for Payer: Aetna Commercial |
$458.35
|
| Rate for Payer: ASR ASR |
$494.00
|
| Rate for Payer: ASR Commercial |
$494.00
|
| Rate for Payer: BCBS Trust/PPO |
$415.01
|
| 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 Commercial |
$432.89
|
| Rate for Payer: Nomi Health Commercial |
$417.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$331.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$448.17
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$423.70
|
|
|
Service Code
|
NDC 65862050301
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$275.40 |
| Max. Negotiated Rate |
$423.70 |
| Rate for Payer: Aetna Commercial |
$381.33
|
| Rate for Payer: ASR ASR |
$410.99
|
| Rate for Payer: ASR Commercial |
$410.99
|
| Rate for Payer: BCBS Trust/PPO |
$345.27
|
| 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 Commercial |
$360.14
|
| Rate for Payer: Nomi Health Commercial |
$347.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$275.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$372.86
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$509.28
|
|
|
Service Code
|
NDC 66685100101
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.71 |
| Max. Negotiated Rate |
$509.28 |
| Rate for Payer: Aetna Commercial |
$458.35
|
| Rate for Payer: Aetna Medicare |
$254.64
|
| Rate for Payer: ASR ASR |
$494.00
|
| Rate for Payer: ASR Commercial |
$494.00
|
| Rate for Payer: BCBS Complete |
$203.71
|
| Rate for Payer: BCBS Trust/PPO |
$417.05
|
| 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 Commercial |
$432.89
|
| Rate for Payer: Nomi Health Commercial |
$417.61
|
| Rate for Payer: Priority Health Cigna Priority Health |
$331.03
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$446.23
|
| Rate for Payer: Priority Health Narrow Network |
$357.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$448.17
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$101.86
|
|
|
Service Code
|
NDC 66685100100
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.21 |
| Max. Negotiated Rate |
$101.86 |
| Rate for Payer: Aetna Commercial |
$91.67
|
| Rate for Payer: ASR ASR |
$98.80
|
| Rate for Payer: ASR Commercial |
$98.80
|
| Rate for Payer: BCBS Trust/PPO |
$83.01
|
| Rate for Payer: BCN Commercial |
$78.97
|
| Rate for Payer: Cash Price |
$81.48
|
| Rate for Payer: Cofinity Commercial |
$95.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.49
|
| Rate for Payer: Healthscope Commercial |
$101.86
|
| Rate for Payer: Healthscope Whirlpool |
$98.80
|
| Rate for Payer: Mclaren Commercial |
$91.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.58
|
| Rate for Payer: Nomi Health Commercial |
$83.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$89.64
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
IP
|
$63.27
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.13 |
| Max. Negotiated Rate |
$63.27 |
| Rate for Payer: Aetna Commercial |
$56.94
|
| Rate for Payer: ASR ASR |
$61.37
|
| Rate for Payer: ASR Commercial |
$61.37
|
| Rate for Payer: BCBS Trust/PPO |
$51.56
|
| Rate for Payer: BCN Commercial |
$49.05
|
| 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 |
$63.27
|
| Rate for Payer: Healthscope Whirlpool |
$61.37
|
| 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: Priority Health Cigna Priority Health |
$41.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$55.68
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$54.72
|
|
|
Service Code
|
NDC 42571016242
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.89 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$49.25
|
| Rate for Payer: Aetna Medicare |
$27.36
|
| Rate for Payer: ASR ASR |
$53.08
|
| Rate for Payer: ASR Commercial |
$53.08
|
| Rate for Payer: BCBS Complete |
$21.89
|
| Rate for Payer: BCBS Trust/PPO |
$44.81
|
| 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 Commercial |
$46.51
|
| Rate for Payer: Nomi Health Commercial |
$44.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.57
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$47.95
|
| Rate for Payer: Priority Health Narrow Network |
$38.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$48.15
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$101.28
|
|
|
Service Code
|
NDC 00781185220
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.51 |
| Max. Negotiated Rate |
$101.28 |
| Rate for Payer: Aetna Commercial |
$91.15
|
| Rate for Payer: Aetna Medicare |
$50.64
|
| Rate for Payer: ASR ASR |
$98.24
|
| Rate for Payer: ASR Commercial |
$98.24
|
| Rate for Payer: BCBS Complete |
$40.51
|
| Rate for Payer: BCBS Trust/PPO |
$82.94
|
| 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 Commercial |
$86.09
|
| Rate for Payer: Nomi Health Commercial |
$83.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.83
|
| Rate for Payer: 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
|
IP
|
$54.72
|
|
|
Service Code
|
NDC 42571016242
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$35.57 |
| Max. Negotiated Rate |
$54.72 |
| Rate for Payer: Aetna Commercial |
$49.25
|
| Rate for Payer: ASR ASR |
$53.08
|
| Rate for Payer: ASR Commercial |
$53.08
|
| Rate for Payer: BCBS Trust/PPO |
$44.59
|
| 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 Commercial |
$46.51
|
| Rate for Payer: Nomi Health Commercial |
$44.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$35.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$48.15
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$423.70
|
|
|
Service Code
|
NDC 65862050301
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$169.48 |
| Max. Negotiated Rate |
$423.70 |
| Rate for Payer: Aetna Commercial |
$381.33
|
| Rate for Payer: Aetna Medicare |
$211.85
|
| Rate for Payer: ASR ASR |
$410.99
|
| Rate for Payer: ASR Commercial |
$410.99
|
| Rate for Payer: BCBS Complete |
$169.48
|
| Rate for Payer: BCBS Trust/PPO |
$346.97
|
| 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 Commercial |
$360.14
|
| Rate for Payer: Nomi Health Commercial |
$347.43
|
| Rate for Payer: Priority Health Cigna Priority Health |
$275.40
|
| Rate for Payer: 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
|
OP
|
$63.27
|
|
|
Service Code
|
NDC 00093227534
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.31 |
| Max. Negotiated Rate |
$63.27 |
| Rate for Payer: Aetna Commercial |
$56.94
|
| Rate for Payer: Aetna Medicare |
$31.64
|
| Rate for Payer: ASR ASR |
$61.37
|
| Rate for Payer: ASR Commercial |
$61.37
|
| Rate for Payer: BCBS Complete |
$25.31
|
| Rate for Payer: BCBS Trust/PPO |
$51.81
|
| Rate for Payer: BCN Commercial |
$49.05
|
| 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 |
$63.27
|
| Rate for Payer: Healthscope Whirlpool |
$61.37
|
| 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: Priority Health Cigna Priority Health |
$41.13
|
| Rate for Payer: 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
|
IP
|
$101.28
|
|
|
Service Code
|
NDC 00781185220
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.83 |
| Max. Negotiated Rate |
$101.28 |
| Rate for Payer: Aetna Commercial |
$91.15
|
| Rate for Payer: ASR ASR |
$98.24
|
| Rate for Payer: ASR Commercial |
$98.24
|
| Rate for Payer: BCBS Trust/PPO |
$82.53
|
| 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 Commercial |
$86.09
|
| Rate for Payer: Nomi Health Commercial |
$83.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$65.83
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$89.13
|
|
|
AMOXICILLIN 875 MG-POTASSIUM CLAVULANATE 125 MG TABLET
|
Facility
|
OP
|
$101.86
|
|
|
Service Code
|
NDC 66685100100
|
| Hospital Charge Code |
33228
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.74 |
| Max. Negotiated Rate |
$101.86 |
| Rate for Payer: Aetna Commercial |
$91.67
|
| Rate for Payer: Aetna Medicare |
$50.93
|
| Rate for Payer: ASR ASR |
$98.80
|
| Rate for Payer: ASR Commercial |
$98.80
|
| Rate for Payer: BCBS Complete |
$40.74
|
| Rate for Payer: BCBS Trust/PPO |
$83.41
|
| Rate for Payer: BCN Commercial |
$78.97
|
| Rate for Payer: Cash Price |
$81.48
|
| Rate for Payer: Cofinity Commercial |
$95.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.49
|
| Rate for Payer: Healthscope Commercial |
$101.86
|
| Rate for Payer: Healthscope Whirlpool |
$98.80
|
| Rate for Payer: Mclaren Commercial |
$91.67
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$86.58
|
| Rate for Payer: Nomi Health Commercial |
$83.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.21
|
| Rate for Payer: 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 |
$89.64
|
|
|
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 |
$13.36 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna Commercial |
$18.50
|
| Rate for Payer: Aetna Commercial |
$16.99
|
| Rate for Payer: ASR ASR |
$19.94
|
| Rate for Payer: ASR ASR |
$18.31
|
| Rate for Payer: ASR Commercial |
$18.31
|
| Rate for Payer: ASR Commercial |
$19.94
|
| Rate for Payer: BCBS Trust/PPO |
$15.39
|
| Rate for Payer: BCBS Trust/PPO |
$16.75
|
| Rate for Payer: BCN Commercial |
$15.94
|
| Rate for Payer: BCN Commercial |
$14.64
|
| Rate for Payer: Cash Price |
$16.45
|
| Rate for Payer: Cash Price |
$15.10
|
| Rate for Payer: Cofinity Commercial |
$17.75
|
| Rate for Payer: Cofinity Commercial |
$19.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.45
|
| Rate for Payer: Healthscope Commercial |
$18.88
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Healthscope Whirlpool |
$18.31
|
| Rate for Payer: Healthscope Whirlpool |
$19.94
|
| Rate for Payer: Mclaren Commercial |
$16.99
|
| Rate for Payer: Mclaren Commercial |
$18.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.48
|
| Rate for Payer: Nomi Health Commercial |
$15.48
|
| Rate for Payer: Nomi Health Commercial |
$16.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.09
|
|
|
AMPICILLIN 1 GRAM SOLUTION FOR INJECTION
|
Facility
|
OP
|
$20.56
|
|
|
Service Code
|
HCPCS J0290
|
| Hospital Charge Code |
469
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.50 |
| Max. Negotiated Rate |
$20.56 |
| Rate for Payer: Aetna Commercial |
$18.50
|
| Rate for Payer: Aetna Commercial |
$16.99
|
| Rate for Payer: Aetna Medicare |
$9.44
|
| Rate for Payer: Aetna Medicare |
$10.28
|
| Rate for Payer: ASR ASR |
$19.94
|
| Rate for Payer: ASR ASR |
$18.31
|
| Rate for Payer: ASR Commercial |
$18.31
|
| Rate for Payer: ASR Commercial |
$19.94
|
| Rate for Payer: BCBS Complete |
$8.22
|
| Rate for Payer: BCBS Complete |
$7.55
|
| Rate for Payer: BCBS Trust/PPO |
$16.84
|
| Rate for Payer: BCBS Trust/PPO |
$15.46
|
| Rate for Payer: BCN Commercial |
$14.64
|
| Rate for Payer: BCN Commercial |
$15.94
|
| Rate for Payer: Cash Price |
$15.10
|
| Rate for Payer: Cash Price |
$15.10
|
| Rate for Payer: Cash Price |
$16.45
|
| Rate for Payer: Cash Price |
$16.45
|
| Rate for Payer: Cofinity Commercial |
$17.75
|
| Rate for Payer: Cofinity Commercial |
$19.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.10
|
| Rate for Payer: Healthscope Commercial |
$20.56
|
| Rate for Payer: Healthscope Commercial |
$18.88
|
| Rate for Payer: Healthscope Whirlpool |
$19.94
|
| Rate for Payer: Healthscope Whirlpool |
$18.31
|
| Rate for Payer: Mclaren Commercial |
$16.99
|
| Rate for Payer: Mclaren Commercial |
$18.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.05
|
| Rate for Payer: Nomi Health Commercial |
$16.86
|
| Rate for Payer: Nomi Health Commercial |
$15.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.27
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.62
|
| Rate for Payer: Priority Health Narrow Network |
$0.50
|
| Rate for Payer: Priority Health Narrow Network |
$0.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$18.09
|
|
