Heights University Hospital

All Charges

Charge

Type

Setting

Price

AMOXICILLIN CLAV SSP 125MG/5ML

Facility

$198.30

Hospital Charge Code	60627284
Hospital Revenue Code	250
Min. Negotiated Rate	$25.78
Max. Negotiated Rate	$99.15
Rate for Payer: Aetna Commercial	$59.49
Rate for Payer: Aetna Medicare Advantage	$59.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$50.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$50.57
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$50.57
Rate for Payer: Cigna Commercial	$99.15
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$25.78
Rate for Payer: Oxford Commercial	$99.15
Rate for Payer: Qualcare PPO/HMO/WC	$29.75
Rate for Payer: UnitedHealthcare Commercial	$99.15

AMOXICILLIN CLAV SSP 125MG/5ML

Facility

$198.30

Hospital Charge Code	60627284
Hospital Revenue Code	250
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$29.75
Rate for Payer: Qualcare PPO/HMO/WC	$29.75

AMOXICILLIN CLAV SSP 125ML

Facility

$90.90

Hospital Charge Code	6016125
Hospital Revenue Code	252
Min. Negotiated Rate	$13.63
Max. Negotiated Rate	$13.63
Rate for Payer: Qualcare PPO/HMO/WC	$13.63

AMOXICILLIN CLAV SSP 125ML

Facility

$90.90

Hospital Charge Code	6016125
Hospital Revenue Code	252
Min. Negotiated Rate	$11.82
Max. Negotiated Rate	$45.45
Rate for Payer: Aetna Commercial	$27.27
Rate for Payer: Aetna Medicare Advantage	$27.27
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$23.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$23.18
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$23.18
Rate for Payer: Cigna Commercial	$45.45
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.82
Rate for Payer: Oxford Commercial	$45.45
Rate for Payer: Qualcare PPO/HMO/WC	$13.63
Rate for Payer: UnitedHealthcare Commercial	$45.45

AMOXICILLIN CLAV SSP 200MG/5ML

Facility

$228.85

Hospital Charge Code	60628937
Hospital Revenue Code	250
Min. Negotiated Rate	$34.33
Max. Negotiated Rate	$34.33
Rate for Payer: Qualcare PPO/HMO/WC	$34.33

AMOXICILLIN CLAV SSP 200MG/5ML

Facility

$228.85

Hospital Charge Code	60628937
Hospital Revenue Code	250
Min. Negotiated Rate	$29.75
Max. Negotiated Rate	$114.42
Rate for Payer: Aetna Commercial	$68.66
Rate for Payer: Aetna Medicare Advantage	$68.66
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$58.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$58.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$58.36
Rate for Payer: Cigna Commercial	$114.42
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$29.75
Rate for Payer: Oxford Commercial	$114.42
Rate for Payer: Qualcare PPO/HMO/WC	$34.33
Rate for Payer: UnitedHealthcare Commercial	$114.42

AMOXICILLIN CLAV SSP 250MG/5ML

Facility

$9.72

Service Code	NDC 43598020451
Hospital Charge Code	60627286
Hospital Revenue Code	250
Min. Negotiated Rate	$1.26
Max. Negotiated Rate	$4.86
Rate for Payer: Aetna Commercial	$2.92
Rate for Payer: Aetna Medicare Advantage	$2.92
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.48
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.48
Rate for Payer: Cigna Commercial	$4.86
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.26
Rate for Payer: Oxford Commercial	$4.86
Rate for Payer: Qualcare PPO/HMO/WC	$1.46
Rate for Payer: UnitedHealthcare Commercial	$4.86

AMOXICILLIN CLAV SSP 250MG/5ML

Facility

$9.72

Service Code	NDC 43598020451
Hospital Charge Code	60627286
Hospital Revenue Code	250
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$1.46
Rate for Payer: Qualcare PPO/HMO/WC	$1.46

AMOXICILLIN CLAV TAB 250MG

Facility

$9.00

Hospital Charge Code	6016265
Hospital Revenue Code	252
Min. Negotiated Rate	$1.17
Max. Negotiated Rate	$4.50
Rate for Payer: Aetna Commercial	$2.70
Rate for Payer: Aetna Medicare Advantage	$2.70
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.29
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.29
Rate for Payer: Cigna Commercial	$4.50
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.17
Rate for Payer: Oxford Commercial	$4.50
Rate for Payer: Qualcare PPO/HMO/WC	$1.35
Rate for Payer: UnitedHealthcare Commercial	$4.50

AMOXICILLIN CLAV TAB 250MG

Facility

$9.00

Hospital Charge Code	6016265
Hospital Revenue Code	252
Min. Negotiated Rate	$1.35
Max. Negotiated Rate	$1.35
Rate for Payer: Qualcare PPO/HMO/WC	$1.35

AMOXICILLIN CLAV TAB 250MG

Facility

$39.66

Service Code	NDC 781187431
Hospital Charge Code	60627285
Hospital Revenue Code	250
Min. Negotiated Rate	$5.95
Max. Negotiated Rate	$5.95
Rate for Payer: Qualcare PPO/HMO/WC	$5.95

AMOXICILLIN CLAV TAB 250MG

Facility

$39.66

Service Code	NDC 781187431
Hospital Charge Code	60627285
Hospital Revenue Code	250
Min. Negotiated Rate	$5.16
Max. Negotiated Rate	$19.83
Rate for Payer: Aetna Commercial	$11.90
Rate for Payer: Aetna Medicare Advantage	$11.90
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$10.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$10.11
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$10.11
Rate for Payer: Cigna Commercial	$19.83
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.16
Rate for Payer: Oxford Commercial	$19.83
Rate for Payer: Qualcare PPO/HMO/WC	$5.95
Rate for Payer: UnitedHealthcare Commercial	$19.83

AMOXICILLIN CLAV TAB 500

Facility

$21.15

Hospital Charge Code	6000418
Hospital Revenue Code	252
Min. Negotiated Rate	$2.75
Max. Negotiated Rate	$10.57
Rate for Payer: Aetna Commercial	$6.34
Rate for Payer: Aetna Medicare Advantage	$6.34
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$5.39
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$5.39
Rate for Payer: Cigna Commercial	$10.57
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.75
Rate for Payer: Oxford Commercial	$10.57
Rate for Payer: Qualcare PPO/HMO/WC	$3.17
Rate for Payer: UnitedHealthcare Commercial	$10.57

AMOXICILLIN CLAV TAB 500

Facility

$21.15

Hospital Charge Code	6000418
Hospital Revenue Code	252
Min. Negotiated Rate	$3.17
Max. Negotiated Rate	$3.17
Rate for Payer: Qualcare PPO/HMO/WC	$3.17

AMOXICILLIN CLAV TAB 500MG

Facility

$25.33

Service Code	NDC 43598020614
Hospital Charge Code	60627287
Hospital Revenue Code	250
Min. Negotiated Rate	$3.80
Max. Negotiated Rate	$3.80
Rate for Payer: Qualcare PPO/HMO/WC	$3.80

AMOXICILLIN CLAV TAB 500MG

Facility

$25.33

Service Code	NDC 43598020614
Hospital Charge Code	60627287
Hospital Revenue Code	250
Min. Negotiated Rate	$3.29
Max. Negotiated Rate	$12.66
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare Advantage	$7.60
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$6.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$6.46
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$6.46
Rate for Payer: Cigna Commercial	$12.66
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.29
Rate for Payer: Oxford Commercial	$12.66
Rate for Payer: Qualcare PPO/HMO/WC	$3.80
Rate for Payer: UnitedHealthcare Commercial	$12.66

AMOXICILLIN CLAV TAB 875MG

Facility

$103.52

Service Code	NDC 43598002114
Hospital Charge Code	60627288
Hospital Revenue Code	250
Min. Negotiated Rate	$15.53
Max. Negotiated Rate	$15.53
Rate for Payer: Qualcare PPO/HMO/WC	$15.53

AMOXICILLIN CLAV TAB 875MG

Facility

$103.52

Service Code	NDC 43598002114
Hospital Charge Code	60627288
Hospital Revenue Code	250
Min. Negotiated Rate	$13.46
Max. Negotiated Rate	$51.76
Rate for Payer: Aetna Commercial	$31.06
Rate for Payer: Aetna Medicare Advantage	$31.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$26.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$26.40
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$26.40
Rate for Payer: Cigna Commercial	$51.76
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$13.46
Rate for Payer: Oxford Commercial	$51.76
Rate for Payer: Qualcare PPO/HMO/WC	$15.53
Rate for Payer: UnitedHealthcare Commercial	$51.76

AMOXICILLIN CLAVULANATE 400MG

Facility

$4.69

Service Code	NDC 781610452
Hospital Charge Code	60628957
Hospital Revenue Code	250
Min. Negotiated Rate	$0.70
Max. Negotiated Rate	$0.70
Rate for Payer: Qualcare PPO/HMO/WC	$0.70

AMOXICILLIN CLAVULANATE 400MG

Facility

$4.69

Service Code	NDC 781610452
Hospital Charge Code	60628957
Hospital Revenue Code	250
Min. Negotiated Rate	$0.61
Max. Negotiated Rate	$2.35
Rate for Payer: Aetna Commercial	$1.41
Rate for Payer: Aetna Medicare Advantage	$1.41
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.20
Rate for Payer: Cigna Commercial	$2.35
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.61
Rate for Payer: Oxford Commercial	$2.35
Rate for Payer: Qualcare PPO/HMO/WC	$0.70
Rate for Payer: UnitedHealthcare Commercial	$2.35

AMOXICILLIN DRP 50MG/ML 15ML

Facility

$2.45

Hospital Charge Code	60627283
Hospital Revenue Code	251
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.37
Rate for Payer: Qualcare PPO/HMO/WC	$0.37

AMOXICILLIN DRP 50MG/ML 15ML

Facility

$2.45

Hospital Charge Code	60627283
Hospital Revenue Code	251
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$1.23
Rate for Payer: Aetna Commercial	$0.74
Rate for Payer: Aetna Medicare Advantage	$0.74
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.62
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.62
Rate for Payer: Cigna Commercial	$1.23
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.32
Rate for Payer: Oxford Commercial	$1.23
Rate for Payer: Qualcare PPO/HMO/WC	$0.37
Rate for Payer: UnitedHealthcare Commercial	$1.23

AMOXICILLIN SSP 125MG

Facility

$3.20

Hospital Charge Code	6023220
Hospital Revenue Code	251
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$1.60
Rate for Payer: Aetna Commercial	$0.96
Rate for Payer: Aetna Medicare Advantage	$0.96
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$0.82
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$0.82
Rate for Payer: Cigna Commercial	$1.60
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$0.42
Rate for Payer: Oxford Commercial	$1.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.48
Rate for Payer: UnitedHealthcare Commercial	$1.60

AMOXICILLIN SSP 125MG

Facility

$3.20

Hospital Charge Code	6023220
Hospital Revenue Code	251
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.48
Rate for Payer: Qualcare PPO/HMO/WC	$0.48

AMOXICILLIN SSP 125MG/5ML

Facility

$5.80

Hospital Charge Code	6014187
Hospital Revenue Code	251
Min. Negotiated Rate	$0.87
Max. Negotiated Rate	$0.87
Rate for Payer: Qualcare PPO/HMO/WC	$0.87

Know your out-of-pocket cost for care.

All Charges