Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION

Facility

$43.00

Service Code	NDC 68382091010
Hospital Charge Code	2622
Hospital Revenue Code	250
Min. Negotiated Rate	$27.09
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna Commercial	$36.55
Rate for Payer: Aetna New Business (MI Preferred)	$27.95
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cofinity Commercial	$30.10
Rate for Payer: Cofinity Commercial	$36.98
Rate for Payer: Cofinity Medicare Advantage	$30.10
Rate for Payer: Encore Health Key Benefits Commercial	$34.40
Rate for Payer: Healthscope Commercial	$38.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$36.55
Rate for Payer: PHP Commercial	$36.55
Rate for Payer: Priority Health Cigna Priority Health	$27.95
Rate for Payer: Priority Health SBD	$27.09

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION

Facility

$68.25

Service Code	NDC 63323013013
Hospital Charge Code	2622
Hospital Revenue Code	250
Min. Negotiated Rate	$43.00
Max. Negotiated Rate	$61.42
Rate for Payer: Aetna Commercial	$58.01
Rate for Payer: Aetna New Business (MI Preferred)	$44.36
Rate for Payer: Cash Price	$54.60
Rate for Payer: Cofinity Commercial	$47.78
Rate for Payer: Cofinity Commercial	$58.70
Rate for Payer: Cofinity Medicare Advantage	$47.78
Rate for Payer: Encore Health Key Benefits Commercial	$54.60
Rate for Payer: Healthscope Commercial	$61.42
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$58.01
Rate for Payer: PHP Commercial	$58.01
Rate for Payer: Priority Health Cigna Priority Health	$44.36
Rate for Payer: Priority Health SBD	$43.00

DOXYCYCLINE HYCLATE 100 MG IV MINI-BAG PLUS COMPONENT CUSTOM

Facility

$43.00

Service Code	NDC 68382091010
Hospital Charge Code	301731
Hospital Revenue Code	250
Min. Negotiated Rate	$27.09
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna Commercial	$36.55
Rate for Payer: Aetna New Business (MI Preferred)	$27.95
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cofinity Commercial	$36.98
Rate for Payer: Cofinity Commercial	$30.10
Rate for Payer: Cofinity Medicare Advantage	$30.10
Rate for Payer: Encore Health Key Benefits Commercial	$34.40
Rate for Payer: Healthscope Commercial	$38.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$36.55
Rate for Payer: PHP Commercial	$36.55
Rate for Payer: Priority Health Cigna Priority Health	$27.95
Rate for Payer: Priority Health SBD	$27.09

DOXYCYCLINE HYCLATE 100 MG IV MINI-BAG PLUS COMPONENT CUSTOM

Facility

$43.00

Service Code	NDC 68382091010
Hospital Charge Code	301731
Hospital Revenue Code	250
Min. Negotiated Rate	$17.20
Max. Negotiated Rate	$38.70
Rate for Payer: Aetna Commercial	$36.55
Rate for Payer: Aetna Medicare	$21.50
Rate for Payer: Aetna New Business (MI Preferred)	$27.95
Rate for Payer: BCBS Complete	$17.20
Rate for Payer: Cash Price	$34.40
Rate for Payer: Cofinity Commercial	$30.10
Rate for Payer: Cofinity Commercial	$36.98
Rate for Payer: Cofinity Medicare Advantage	$30.10
Rate for Payer: Encore Health Key Benefits Commercial	$34.40
Rate for Payer: Healthscope Commercial	$38.70
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$36.55
Rate for Payer: PHP Commercial	$36.55
Rate for Payer: Priority Health Cigna Priority Health	$27.95
Rate for Payer: Priority Health SBD	$27.09

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$377.52

Service Code	NDC 50268027915
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$151.01
Max. Negotiated Rate	$339.77
Rate for Payer: Aetna Commercial	$320.89
Rate for Payer: Aetna Medicare	$188.76
Rate for Payer: Aetna New Business (MI Preferred)	$245.39
Rate for Payer: BCBS Complete	$151.01
Rate for Payer: Cash Price	$302.02
Rate for Payer: Cofinity Commercial	$264.26
Rate for Payer: Cofinity Commercial	$324.67
Rate for Payer: Cofinity Medicare Advantage	$264.26
Rate for Payer: Encore Health Key Benefits Commercial	$302.02
Rate for Payer: Healthscope Commercial	$339.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$320.89
Rate for Payer: PHP Commercial	$320.89
Rate for Payer: Priority Health Cigna Priority Health	$245.39
Rate for Payer: Priority Health SBD	$237.84

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$343.20

Service Code	NDC 00904043006
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$137.28
Max. Negotiated Rate	$308.88
Rate for Payer: Aetna Commercial	$291.72
Rate for Payer: Aetna Medicare	$171.60
Rate for Payer: Aetna New Business (MI Preferred)	$223.08
Rate for Payer: BCBS Complete	$137.28
Rate for Payer: Cash Price	$274.56
Rate for Payer: Cofinity Commercial	$240.24
Rate for Payer: Cofinity Commercial	$295.15
Rate for Payer: Cofinity Medicare Advantage	$240.24
Rate for Payer: Encore Health Key Benefits Commercial	$274.56
Rate for Payer: Healthscope Commercial	$308.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$291.72
Rate for Payer: PHP Commercial	$291.72
Rate for Payer: Priority Health Cigna Priority Health	$223.08
Rate for Payer: Priority Health SBD	$216.22

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$8.69

Service Code	NDC 62584069311
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$3.48
Max. Negotiated Rate	$7.82
Rate for Payer: Aetna Commercial	$7.39
Rate for Payer: Aetna Medicare	$4.34
Rate for Payer: Aetna New Business (MI Preferred)	$5.65
Rate for Payer: BCBS Complete	$3.48
Rate for Payer: Cash Price	$6.95
Rate for Payer: Cofinity Commercial	$6.08
Rate for Payer: Cofinity Commercial	$7.47
Rate for Payer: Cofinity Medicare Advantage	$6.08
Rate for Payer: Encore Health Key Benefits Commercial	$6.95
Rate for Payer: Healthscope Commercial	$7.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.39
Rate for Payer: PHP Commercial	$7.39
Rate for Payer: Priority Health Cigna Priority Health	$5.65
Rate for Payer: Priority Health SBD	$5.47

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$198.58

Service Code	NDC 00143211250
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$79.43
Max. Negotiated Rate	$178.72
Rate for Payer: Aetna Commercial	$168.79
Rate for Payer: Aetna Medicare	$99.29
Rate for Payer: Aetna New Business (MI Preferred)	$129.08
Rate for Payer: BCBS Complete	$79.43
Rate for Payer: Cash Price	$158.86
Rate for Payer: Cofinity Commercial	$139.01
Rate for Payer: Cofinity Commercial	$170.78
Rate for Payer: Cofinity Medicare Advantage	$139.01
Rate for Payer: Encore Health Key Benefits Commercial	$158.86
Rate for Payer: Healthscope Commercial	$178.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$168.79
Rate for Payer: PHP Commercial	$168.79
Rate for Payer: Priority Health Cigna Priority Health	$129.08
Rate for Payer: Priority Health SBD	$125.11

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$207.36

Service Code	NDC 00904043004
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$130.64
Max. Negotiated Rate	$186.62
Rate for Payer: Aetna Commercial	$176.26
Rate for Payer: Aetna New Business (MI Preferred)	$134.78
Rate for Payer: Cash Price	$165.89
Rate for Payer: Cofinity Commercial	$145.15
Rate for Payer: Cofinity Commercial	$178.33
Rate for Payer: Cofinity Medicare Advantage	$145.15
Rate for Payer: Encore Health Key Benefits Commercial	$165.89
Rate for Payer: Healthscope Commercial	$186.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$176.26
Rate for Payer: PHP Commercial	$176.26
Rate for Payer: Priority Health Cigna Priority Health	$134.78
Rate for Payer: Priority Health SBD	$130.64

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$343.20

Service Code	NDC 00904043006
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$216.22
Max. Negotiated Rate	$308.88
Rate for Payer: Aetna Commercial	$291.72
Rate for Payer: Aetna New Business (MI Preferred)	$223.08
Rate for Payer: Cash Price	$274.56
Rate for Payer: Cofinity Commercial	$240.24
Rate for Payer: Cofinity Commercial	$295.15
Rate for Payer: Cofinity Medicare Advantage	$240.24
Rate for Payer: Encore Health Key Benefits Commercial	$274.56
Rate for Payer: Healthscope Commercial	$308.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$291.72
Rate for Payer: PHP Commercial	$291.72
Rate for Payer: Priority Health Cigna Priority Health	$223.08
Rate for Payer: Priority Health SBD	$216.22

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$245.20

Service Code	NDC 63739016833
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$98.08
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 Commercial	$171.64
Rate for Payer: Cofinity Commercial	$210.87
Rate for Payer: Cofinity Medicare Advantage	$171.64
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: PHP Commercial	$208.42
Rate for Payer: Priority Health Cigna Priority Health	$159.38
Rate for Payer: Priority Health SBD	$154.48

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$207.36

Service Code	NDC 00904043004
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$82.94
Max. Negotiated Rate	$186.62
Rate for Payer: Aetna Commercial	$176.26
Rate for Payer: Aetna Medicare	$103.68
Rate for Payer: Aetna New Business (MI Preferred)	$134.78
Rate for Payer: BCBS Complete	$82.94
Rate for Payer: Cash Price	$165.89
Rate for Payer: Cofinity Commercial	$145.15
Rate for Payer: Cofinity Commercial	$178.33
Rate for Payer: Cofinity Medicare Advantage	$145.15
Rate for Payer: Encore Health Key Benefits Commercial	$165.89
Rate for Payer: Healthscope Commercial	$186.62
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$176.26
Rate for Payer: PHP Commercial	$176.26
Rate for Payer: Priority Health Cigna Priority Health	$134.78
Rate for Payer: Priority Health SBD	$130.64

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$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 Commercial	$171.64
Rate for Payer: Cofinity Commercial	$210.87
Rate for Payer: Cofinity Medicare Advantage	$171.64
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: PHP Commercial	$208.42
Rate for Payer: Priority Health Cigna Priority Health	$159.38
Rate for Payer: Priority Health SBD	$154.48

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$260.63

Service Code	NDC 62584069321
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$164.20
Max. Negotiated Rate	$234.57
Rate for Payer: Aetna Commercial	$221.54
Rate for Payer: Aetna New Business (MI Preferred)	$169.41
Rate for Payer: Cash Price	$208.50
Rate for Payer: Cofinity Commercial	$182.44
Rate for Payer: Cofinity Commercial	$224.14
Rate for Payer: Cofinity Medicare Advantage	$182.44
Rate for Payer: Encore Health Key Benefits Commercial	$208.50
Rate for Payer: Healthscope Commercial	$234.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$221.54
Rate for Payer: PHP Commercial	$221.54
Rate for Payer: Priority Health Cigna Priority Health	$169.41
Rate for Payer: Priority Health SBD	$164.20

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$7.56

Service Code	NDC 50268027911
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$4.76
Max. Negotiated Rate	$6.80
Rate for Payer: Aetna Commercial	$6.43
Rate for Payer: Aetna New Business (MI Preferred)	$4.91
Rate for Payer: Cash Price	$6.05
Rate for Payer: Cofinity Commercial	$5.29
Rate for Payer: Cofinity Commercial	$6.50
Rate for Payer: Cofinity Medicare Advantage	$5.29
Rate for Payer: Encore Health Key Benefits Commercial	$6.05
Rate for Payer: Healthscope Commercial	$6.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.43
Rate for Payer: PHP Commercial	$6.43
Rate for Payer: Priority Health Cigna Priority Health	$4.91
Rate for Payer: Priority Health SBD	$4.76

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$8.69

Service Code	NDC 62584069311
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$5.47
Max. Negotiated Rate	$7.82
Rate for Payer: Aetna Commercial	$7.39
Rate for Payer: Aetna New Business (MI Preferred)	$5.65
Rate for Payer: Cash Price	$6.95
Rate for Payer: Cofinity Commercial	$6.08
Rate for Payer: Cofinity Commercial	$7.47
Rate for Payer: Cofinity Medicare Advantage	$6.08
Rate for Payer: Encore Health Key Benefits Commercial	$6.95
Rate for Payer: Healthscope Commercial	$7.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$7.39
Rate for Payer: PHP Commercial	$7.39
Rate for Payer: Priority Health Cigna Priority Health	$5.65
Rate for Payer: Priority Health SBD	$5.47

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$377.52

Service Code	NDC 50268027915
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$237.84
Max. Negotiated Rate	$339.77
Rate for Payer: Aetna Commercial	$320.89
Rate for Payer: Aetna New Business (MI Preferred)	$245.39
Rate for Payer: Cash Price	$302.02
Rate for Payer: Cofinity Commercial	$264.26
Rate for Payer: Cofinity Commercial	$324.67
Rate for Payer: Cofinity Medicare Advantage	$264.26
Rate for Payer: Encore Health Key Benefits Commercial	$302.02
Rate for Payer: Healthscope Commercial	$339.77
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$320.89
Rate for Payer: PHP Commercial	$320.89
Rate for Payer: Priority Health Cigna Priority Health	$245.39
Rate for Payer: Priority Health SBD	$237.84

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$260.63

Service Code	NDC 62584069321
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$104.25
Max. Negotiated Rate	$234.57
Rate for Payer: Aetna Commercial	$221.54
Rate for Payer: Aetna Medicare	$130.32
Rate for Payer: Aetna New Business (MI Preferred)	$169.41
Rate for Payer: BCBS Complete	$104.25
Rate for Payer: Cash Price	$208.50
Rate for Payer: Cofinity Commercial	$182.44
Rate for Payer: Cofinity Commercial	$224.14
Rate for Payer: Cofinity Medicare Advantage	$182.44
Rate for Payer: Encore Health Key Benefits Commercial	$208.50
Rate for Payer: Healthscope Commercial	$234.57
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$221.54
Rate for Payer: PHP Commercial	$221.54
Rate for Payer: Priority Health Cigna Priority Health	$169.41
Rate for Payer: Priority Health SBD	$164.20

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$7.56

Service Code	NDC 50268027911
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$6.80
Rate for Payer: Aetna Commercial	$6.43
Rate for Payer: Aetna Medicare	$3.78
Rate for Payer: Aetna New Business (MI Preferred)	$4.91
Rate for Payer: BCBS Complete	$3.02
Rate for Payer: Cash Price	$6.05
Rate for Payer: Cofinity Commercial	$5.29
Rate for Payer: Cofinity Commercial	$6.50
Rate for Payer: Cofinity Medicare Advantage	$5.29
Rate for Payer: Encore Health Key Benefits Commercial	$6.05
Rate for Payer: Healthscope Commercial	$6.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$6.43
Rate for Payer: PHP Commercial	$6.43
Rate for Payer: Priority Health Cigna Priority Health	$4.91
Rate for Payer: Priority Health SBD	$4.76

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$198.58

Service Code	NDC 00143211250
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$125.11
Max. Negotiated Rate	$178.72
Rate for Payer: Aetna Commercial	$168.79
Rate for Payer: Aetna New Business (MI Preferred)	$129.08
Rate for Payer: Cash Price	$158.86
Rate for Payer: Cofinity Commercial	$139.01
Rate for Payer: Cofinity Commercial	$170.78
Rate for Payer: Cofinity Medicare Advantage	$139.01
Rate for Payer: Encore Health Key Benefits Commercial	$158.86
Rate for Payer: Healthscope Commercial	$178.72
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$168.79
Rate for Payer: PHP Commercial	$168.79
Rate for Payer: Priority Health Cigna Priority Health	$129.08
Rate for Payer: Priority Health SBD	$125.11

DOXYLAMINE SUCCINATE 25 MG TABLET

Facility

$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 Commercial	$74.38
Rate for Payer: Cofinity Commercial	$91.38
Rate for Payer: Cofinity Medicare Advantage	$74.38
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: PHP Commercial	$90.31
Rate for Payer: Priority Health Cigna Priority Health	$69.06
Rate for Payer: Priority Health SBD	$66.94

DOXYLAMINE SUCCINATE 25 MG TABLET

Facility

$106.04

Service Code	NDC 70000056701
Hospital Charge Code	14847
Hospital Revenue Code	637
Min. Negotiated Rate	$42.42
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 Commercial	$74.23
Rate for Payer: Cofinity Commercial	$91.19
Rate for Payer: Cofinity Medicare Advantage	$74.23
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: PHP Commercial	$90.13
Rate for Payer: Priority Health Cigna Priority Health	$68.93
Rate for Payer: Priority Health SBD	$66.81

DOXYLAMINE SUCCINATE 25 MG TABLET

Facility

$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 Commercial	$74.23
Rate for Payer: Cofinity Commercial	$91.19
Rate for Payer: Cofinity Medicare Advantage	$74.23
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: PHP Commercial	$90.13
Rate for Payer: Priority Health Cigna Priority Health	$68.93
Rate for Payer: Priority Health SBD	$66.81

DOXYLAMINE SUCCINATE 25 MG TABLET

Facility

$106.25

Service Code	NDC 41167000623
Hospital Charge Code	14847
Hospital Revenue Code	637
Min. Negotiated Rate	$42.50
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 Commercial	$74.38
Rate for Payer: Cofinity Commercial	$91.38
Rate for Payer: Cofinity Medicare Advantage	$74.38
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: PHP Commercial	$90.31
Rate for Payer: Priority Health Cigna Priority Health	$69.06
Rate for Payer: Priority Health SBD	$66.94

DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES

Facility

$940.00

Service Code	CPT 41800
Hospital Revenue Code	361
Min. Negotiated Rate	$67.69
Max. Negotiated Rate	$940.00
Rate for Payer: Aetna Medicare	$131.34
Rate for Payer: Allen County Amish Medical Aid Commercial	$157.86
Rate for Payer: Amish Plain Church Group Commercial	$157.86
Rate for Payer: BCBS Complete	$71.08
Rate for Payer: BCBS MAPPO	$126.29
Rate for Payer: BCBS Trust/PPO	$74.74
Rate for Payer: BCN Commercial	$74.74
Rate for Payer: BCN Medicare Advantage	$126.29
Rate for Payer: Health Alliance Plan Medicare Advantage	$126.29
Rate for Payer: Mclaren Medicaid	$67.69
Rate for Payer: Mclaren Medicare	$126.29
Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage	$132.60
Rate for Payer: Meridian Medicaid	$71.08
Rate for Payer: MI Amish Medical Board Commercial	$145.23
Rate for Payer: Nomi Health Commercial	$378.87
Rate for Payer: PACE Medicare	$119.98
Rate for Payer: PACE SWMI	$126.29
Rate for Payer: PHP Medicare Advantage	$126.29
Rate for Payer: Priority Health Choice Medicaid	$67.69
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$396.95
Rate for Payer: Priority Health Medicare	$126.29
Rate for Payer: Priority Health Narrow Network	$317.56
Rate for Payer: Railroad Medicare Medicare	$126.29
Rate for Payer: UHC All Payor (Choice/PPO)	$159.06
Rate for Payer: UHC Core	$878.00
Rate for Payer: UHC Dual Complete DSNP	$126.29
Rate for Payer: UHC Exchange	$940.00
Rate for Payer: UHC Medicare Advantage	$126.29
Rate for Payer: UHCCP Medicaid	$71.10
Rate for Payer: VA VA	$126.29

Know your out-of-pocket cost for care.

All Charges