|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$218.55
|
|
|
Service Code
|
NDC 42806031050
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.89 |
| Max. Negotiated Rate |
$196.69 |
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: Aetna Medicare |
$109.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.06
|
| Rate for Payer: BCBS Complete |
$87.42
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Advantage |
$152.99
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.84
|
| Rate for Payer: Healthscope Commercial |
$196.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$174.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$185.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$163.91
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health SBD |
$137.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$142.06
|
| Rate for Payer: UHC Core |
$113.86
|
| Rate for Payer: UHC Exchange |
$85.89
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$218.55
|
|
|
Service Code
|
NDC 27808023401
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.69 |
| Max. Negotiated Rate |
$196.69 |
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.06
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Advantage |
$152.99
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.84
|
| Rate for Payer: Healthscope Commercial |
$196.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$185.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$163.91
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health SBD |
$137.69
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$7.73
|
|
|
Service Code
|
NDC 50268027911
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.87 |
| Max. Negotiated Rate |
$6.96 |
| Rate for Payer: Aetna Commercial |
$6.57
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.02
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Cofinity Advantage |
$5.41
|
| Rate for Payer: Cofinity Commercial |
$6.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.18
|
| Rate for Payer: Healthscope Commercial |
$6.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.80
|
| Rate for Payer: PHP Commercial |
$6.57
|
| Rate for Payer: Priority Health SBD |
$4.87
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$213.41
|
|
|
Service Code
|
NDC 00904043004
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.87 |
| Max. Negotiated Rate |
$192.07 |
| Rate for Payer: Aetna Commercial |
$181.40
|
| Rate for Payer: Aetna Medicare |
$106.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.72
|
| Rate for Payer: BCBS Complete |
$85.36
|
| Rate for Payer: Cash Price |
$170.73
|
| Rate for Payer: Cofinity Advantage |
$149.39
|
| Rate for Payer: Cofinity Commercial |
$183.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.73
|
| Rate for Payer: Healthscope Commercial |
$192.07
|
| Rate for Payer: MI Amish Medical Board Commercial |
$170.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.06
|
| Rate for Payer: PHP Commercial |
$181.40
|
| Rate for Payer: Priority Health SBD |
$134.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$138.72
|
| Rate for Payer: UHC Core |
$111.19
|
| Rate for Payer: UHC Exchange |
$83.87
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$243.98
|
|
|
Service Code
|
NDC 62584069321
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$95.88 |
| Max. Negotiated Rate |
$219.58 |
| Rate for Payer: Aetna Commercial |
$207.38
|
| Rate for Payer: Aetna Medicare |
$121.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.59
|
| Rate for Payer: BCBS Complete |
$97.59
|
| Rate for Payer: Cash Price |
$195.18
|
| Rate for Payer: Cofinity Advantage |
$170.79
|
| Rate for Payer: Cofinity Commercial |
$209.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.18
|
| Rate for Payer: Healthscope Commercial |
$219.58
|
| Rate for Payer: MI Amish Medical Board Commercial |
$195.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$182.99
|
| Rate for Payer: PHP Commercial |
$207.38
|
| Rate for Payer: Priority Health SBD |
$153.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$158.59
|
| Rate for Payer: UHC Core |
$127.11
|
| Rate for Payer: UHC Exchange |
$95.88
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$351.12
|
|
|
Service Code
|
NDC 00904043006
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$221.21 |
| Max. Negotiated Rate |
$316.01 |
| Rate for Payer: Aetna Commercial |
$298.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$228.23
|
| Rate for Payer: Cash Price |
$280.90
|
| Rate for Payer: Cofinity Advantage |
$245.78
|
| Rate for Payer: Cofinity Commercial |
$301.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.90
|
| Rate for Payer: Healthscope Commercial |
$316.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$298.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$263.34
|
| Rate for Payer: PHP Commercial |
$298.45
|
| Rate for Payer: Priority Health SBD |
$221.21
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$245.20
|
|
|
Service Code
|
NDC 63739016833
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.48 |
| Max. Negotiated Rate |
$220.68 |
| Rate for Payer: Aetna Commercial |
$208.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.38
|
| Rate for Payer: Cash Price |
$196.16
|
| Rate for Payer: Cofinity Advantage |
$171.64
|
| Rate for Payer: Cofinity Commercial |
$210.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.16
|
| Rate for Payer: Healthscope Commercial |
$220.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$183.90
|
| Rate for Payer: PHP Commercial |
$208.42
|
| Rate for Payer: Priority Health SBD |
$154.48
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$243.98
|
|
|
Service Code
|
NDC 62584069321
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$153.71 |
| Max. Negotiated Rate |
$219.58 |
| Rate for Payer: Aetna Commercial |
$207.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$158.59
|
| Rate for Payer: Cash Price |
$195.18
|
| Rate for Payer: Cofinity Advantage |
$170.79
|
| Rate for Payer: Cofinity Commercial |
$209.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$195.18
|
| Rate for Payer: Healthscope Commercial |
$219.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$207.38
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$182.99
|
| Rate for Payer: PHP Commercial |
$207.38
|
| Rate for Payer: Priority Health SBD |
$153.71
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$213.41
|
|
|
Service Code
|
NDC 00904043004
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$134.45 |
| Max. Negotiated Rate |
$192.07 |
| Rate for Payer: Aetna Commercial |
$181.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$138.72
|
| Rate for Payer: Cash Price |
$170.73
|
| Rate for Payer: Cofinity Advantage |
$149.39
|
| Rate for Payer: Cofinity Commercial |
$183.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$170.73
|
| Rate for Payer: Healthscope Commercial |
$192.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$181.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$160.06
|
| Rate for Payer: PHP Commercial |
$181.40
|
| Rate for Payer: Priority Health SBD |
$134.45
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$183.30
|
|
|
Service Code
|
NDC 00143211250
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$72.04 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna Commercial |
$155.81
|
| Rate for Payer: Aetna Medicare |
$91.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.14
|
| Rate for Payer: BCBS Complete |
$73.32
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Advantage |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$164.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$146.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$137.47
|
| Rate for Payer: PHP Commercial |
$155.81
|
| Rate for Payer: Priority Health SBD |
$115.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$119.14
|
| Rate for Payer: UHC Core |
$95.50
|
| Rate for Payer: UHC Exchange |
$72.04
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$218.55
|
|
|
Service Code
|
NDC 27808023401
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.89 |
| Max. Negotiated Rate |
$196.69 |
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: Aetna Medicare |
$109.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.06
|
| Rate for Payer: BCBS Complete |
$87.42
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Advantage |
$152.99
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.84
|
| Rate for Payer: Healthscope Commercial |
$196.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$174.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$185.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$163.91
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health SBD |
$137.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$142.06
|
| Rate for Payer: UHC Core |
$113.86
|
| Rate for Payer: UHC Exchange |
$85.89
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$351.12
|
|
|
Service Code
|
NDC 00904043006
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.99 |
| Max. Negotiated Rate |
$316.01 |
| Rate for Payer: Aetna Commercial |
$298.45
|
| Rate for Payer: Aetna Medicare |
$175.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$228.23
|
| Rate for Payer: BCBS Complete |
$140.45
|
| Rate for Payer: Cash Price |
$280.90
|
| Rate for Payer: Cofinity Advantage |
$245.78
|
| Rate for Payer: Cofinity Commercial |
$301.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$280.90
|
| Rate for Payer: Healthscope Commercial |
$316.01
|
| Rate for Payer: MI Amish Medical Board Commercial |
$280.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$298.45
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$263.34
|
| Rate for Payer: PHP Commercial |
$298.45
|
| Rate for Payer: Priority Health SBD |
$221.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$228.23
|
| Rate for Payer: UHC Core |
$182.93
|
| Rate for Payer: UHC Exchange |
$137.99
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$8.14
|
|
|
Service Code
|
NDC 62584069311
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.20 |
| Max. Negotiated Rate |
$7.33 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna Medicare |
$4.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.29
|
| Rate for Payer: BCBS Complete |
$3.26
|
| Rate for Payer: Cash Price |
$6.51
|
| Rate for Payer: Cofinity Advantage |
$5.70
|
| Rate for Payer: Cofinity Commercial |
$7.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.51
|
| Rate for Payer: Healthscope Commercial |
$7.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.11
|
| Rate for Payer: PHP Commercial |
$6.92
|
| Rate for Payer: Priority Health SBD |
$5.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.29
|
| Rate for Payer: UHC Core |
$4.24
|
| Rate for Payer: UHC Exchange |
$3.20
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$218.55
|
|
|
Service Code
|
NDC 42806031050
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$137.69 |
| Max. Negotiated Rate |
$196.69 |
| Rate for Payer: Aetna Commercial |
$185.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$142.06
|
| Rate for Payer: Cash Price |
$174.84
|
| Rate for Payer: Cofinity Advantage |
$152.99
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$174.84
|
| Rate for Payer: Healthscope Commercial |
$196.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$185.77
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$163.91
|
| Rate for Payer: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health SBD |
$137.69
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$183.30
|
|
|
Service Code
|
NDC 00143211250
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$115.48 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna Commercial |
$155.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$119.14
|
| Rate for Payer: Cash Price |
$146.64
|
| Rate for Payer: Cofinity Advantage |
$128.31
|
| Rate for Payer: Cofinity Commercial |
$157.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.64
|
| Rate for Payer: Healthscope Commercial |
$164.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$155.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$137.47
|
| Rate for Payer: PHP Commercial |
$155.81
|
| Rate for Payer: Priority Health SBD |
$115.48
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$7.73
|
|
|
Service Code
|
NDC 50268027911
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.04 |
| Max. Negotiated Rate |
$6.96 |
| Rate for Payer: Aetna Commercial |
$6.57
|
| Rate for Payer: Aetna Medicare |
$3.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.02
|
| Rate for Payer: BCBS Complete |
$3.09
|
| Rate for Payer: Cash Price |
$6.18
|
| Rate for Payer: Cofinity Advantage |
$5.41
|
| Rate for Payer: Cofinity Commercial |
$6.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.18
|
| Rate for Payer: Healthscope Commercial |
$6.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.80
|
| Rate for Payer: PHP Commercial |
$6.57
|
| Rate for Payer: Priority Health SBD |
$4.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.02
|
| Rate for Payer: UHC Core |
$4.03
|
| Rate for Payer: UHC Exchange |
$3.04
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$8.14
|
|
|
Service Code
|
NDC 62584069311
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$7.33 |
| Rate for Payer: Aetna Commercial |
$6.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.29
|
| Rate for Payer: Cash Price |
$6.51
|
| Rate for Payer: Cofinity Advantage |
$5.70
|
| Rate for Payer: Cofinity Commercial |
$7.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.51
|
| Rate for Payer: Healthscope Commercial |
$7.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.11
|
| Rate for Payer: PHP Commercial |
$6.92
|
| Rate for Payer: Priority Health SBD |
$5.13
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$386.16
|
|
|
Service Code
|
NDC 50268027915
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$151.76 |
| Max. Negotiated Rate |
$347.54 |
| Rate for Payer: Aetna Commercial |
$328.24
|
| Rate for Payer: Aetna Medicare |
$193.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$251.00
|
| Rate for Payer: BCBS Complete |
$154.46
|
| Rate for Payer: Cash Price |
$308.93
|
| Rate for Payer: Cofinity Advantage |
$270.31
|
| Rate for Payer: Cofinity Commercial |
$332.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.93
|
| Rate for Payer: Healthscope Commercial |
$347.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$308.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.62
|
| Rate for Payer: PHP Commercial |
$328.24
|
| Rate for Payer: Priority Health SBD |
$243.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$251.00
|
| Rate for Payer: UHC Core |
$201.19
|
| Rate for Payer: UHC Exchange |
$151.76
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$245.20
|
|
|
Service Code
|
NDC 63739016833
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.36 |
| Max. Negotiated Rate |
$220.68 |
| Rate for Payer: Aetna Commercial |
$208.42
|
| Rate for Payer: Aetna Medicare |
$122.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$159.38
|
| Rate for Payer: BCBS Complete |
$98.08
|
| Rate for Payer: Cash Price |
$196.16
|
| Rate for Payer: Cofinity Advantage |
$171.64
|
| Rate for Payer: Cofinity Commercial |
$210.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$196.16
|
| Rate for Payer: Healthscope Commercial |
$220.68
|
| Rate for Payer: MI Amish Medical Board Commercial |
$196.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$208.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$183.90
|
| Rate for Payer: PHP Commercial |
$208.42
|
| Rate for Payer: Priority Health SBD |
$154.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$159.38
|
| Rate for Payer: UHC Core |
$127.75
|
| Rate for Payer: UHC Exchange |
$96.36
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$386.16
|
|
|
Service Code
|
NDC 50268027915
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$243.28 |
| Max. Negotiated Rate |
$347.54 |
| Rate for Payer: Aetna Commercial |
$328.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$251.00
|
| Rate for Payer: Cash Price |
$308.93
|
| Rate for Payer: Cofinity Advantage |
$270.31
|
| Rate for Payer: Cofinity Commercial |
$332.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$308.93
|
| Rate for Payer: Healthscope Commercial |
$347.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.24
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$289.62
|
| Rate for Payer: PHP Commercial |
$328.24
|
| Rate for Payer: Priority Health SBD |
$243.28
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET
|
Facility
|
OP
|
$106.25
|
|
|
Service Code
|
NDC 41167000623
|
| Hospital Charge Code |
14847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.76 |
| Max. Negotiated Rate |
$95.62 |
| Rate for Payer: Aetna Commercial |
$90.31
|
| Rate for Payer: Aetna Medicare |
$53.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.06
|
| Rate for Payer: BCBS Complete |
$42.50
|
| Rate for Payer: Cash Price |
$85.00
|
| Rate for Payer: Cofinity Advantage |
$74.38
|
| Rate for Payer: Cofinity Commercial |
$91.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.00
|
| Rate for Payer: Healthscope Commercial |
$95.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$85.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$79.69
|
| Rate for Payer: PHP Commercial |
$90.31
|
| Rate for Payer: Priority Health SBD |
$66.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$69.06
|
| Rate for Payer: UHC Core |
$55.36
|
| Rate for Payer: UHC Exchange |
$41.76
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET
|
Facility
|
IP
|
$106.04
|
|
|
Service Code
|
NDC 70000056701
|
| Hospital Charge Code |
14847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.81 |
| Max. Negotiated Rate |
$95.44 |
| Rate for Payer: Aetna Commercial |
$90.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.93
|
| Rate for Payer: Cash Price |
$84.83
|
| Rate for Payer: Cofinity Advantage |
$74.23
|
| Rate for Payer: Cofinity Commercial |
$91.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.83
|
| Rate for Payer: Healthscope Commercial |
$95.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$79.53
|
| Rate for Payer: PHP Commercial |
$90.13
|
| Rate for Payer: Priority Health SBD |
$66.81
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET
|
Facility
|
OP
|
$106.04
|
|
|
Service Code
|
NDC 70000056701
|
| Hospital Charge Code |
14847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.67 |
| Max. Negotiated Rate |
$95.44 |
| Rate for Payer: Aetna Commercial |
$90.13
|
| Rate for Payer: Aetna Medicare |
$53.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$68.93
|
| Rate for Payer: BCBS Complete |
$42.42
|
| Rate for Payer: Cash Price |
$84.83
|
| Rate for Payer: Cofinity Advantage |
$74.23
|
| Rate for Payer: Cofinity Commercial |
$91.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$84.83
|
| Rate for Payer: Healthscope Commercial |
$95.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$84.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$79.53
|
| Rate for Payer: PHP Commercial |
$90.13
|
| Rate for Payer: Priority Health SBD |
$66.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$68.93
|
| Rate for Payer: UHC Core |
$55.25
|
| Rate for Payer: UHC Exchange |
$41.67
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET
|
Facility
|
IP
|
$106.25
|
|
|
Service Code
|
NDC 41167000623
|
| Hospital Charge Code |
14847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$66.94 |
| Max. Negotiated Rate |
$95.62 |
| Rate for Payer: Aetna Commercial |
$90.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.06
|
| Rate for Payer: Cash Price |
$85.00
|
| Rate for Payer: Cofinity Advantage |
$74.38
|
| Rate for Payer: Cofinity Commercial |
$91.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$85.00
|
| Rate for Payer: Healthscope Commercial |
$95.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$90.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$79.69
|
| Rate for Payer: PHP Commercial |
$90.31
|
| Rate for Payer: Priority Health SBD |
$66.94
|
|
|
DRAINAGE OF SCROTAL WALL ABSCESS
|
Facility
|
OP
|
$5,321.93
|
|
|
Service Code
|
CPT 55100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$596.92 |
| Max. Negotiated Rate |
$5,321.93 |
| Rate for Payer: Aetna Medicare |
$1,711.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,057.07
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,057.07
|
| Rate for Payer: BCBS Complete |
$903.80
|
| Rate for Payer: BCBS MAPPO |
$1,645.66
|
| Rate for Payer: BCBS Trust/PPO |
$596.92
|
| Rate for Payer: BCN Commercial |
$596.92
|
| Rate for Payer: BCN Medicare Advantage |
$1,645.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,645.66
|
| Rate for Payer: Mclaren Medicaid |
$860.68
|
| Rate for Payer: Mclaren Medicare |
$1,645.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,727.94
|
| Rate for Payer: Meridian Medicaid |
$1,727.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,892.51
|
| Rate for Payer: Molina Medicare/Medicaid |
$1,810.23
|
| Rate for Payer: Nomi Health Commercial |
$4,936.98
|
| Rate for Payer: PACE Medicare |
$1,563.38
|
| Rate for Payer: PACE SWMI |
$1,645.66
|
| Rate for Payer: PHP Medicare Advantage |
$1,645.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$860.68
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$5,321.93
|
| Rate for Payer: Priority Health Medicare |
$1,645.66
|
| Rate for Payer: Priority Health Tiered Network |
$4,257.54
|
| Rate for Payer: Railroad Medicare Medicare |
$1,645.66
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$1,645.66
|
| Rate for Payer: UHC Medicaid |
$860.68
|
| Rate for Payer: UHCCP Medicaid |
$860.68
|
| Rate for Payer: VA VA |
$1,645.66
|
|
