Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS

Facility

$27.37

Service Code	NDC 24208-486-10
Hospital Charge Code	22982
Hospital Revenue Code	637
Min. Negotiated Rate	$17.24
Max. Negotiated Rate	$24.63
Rate for Payer: Aetna Commercial	$23.26
Rate for Payer: Aetna New Business (MI Preferred)	$17.79
Rate for Payer: Cash Price	$21.90
Rate for Payer: Cofinity Commercial	$19.16
Rate for Payer: Cofinity Commercial	$23.54
Rate for Payer: Healthscope Commercial	$24.63
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$23.26
Rate for Payer: PHP Commercial	$23.26
Rate for Payer: Priority Health Cigna Priority Health	$19.16
Rate for Payer: Priority Health SBD	$17.24

DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS

Facility

$162.75

Service Code	NDC 50383-233-10
Hospital Charge Code	22982
Hospital Revenue Code	637
Min. Negotiated Rate	$102.53
Max. Negotiated Rate	$146.48
Rate for Payer: Aetna Commercial	$138.34
Rate for Payer: Aetna New Business (MI Preferred)	$105.79
Rate for Payer: Cash Price	$130.20
Rate for Payer: Cofinity Commercial	$113.92
Rate for Payer: Cofinity Commercial	$139.96
Rate for Payer: Healthscope Commercial	$146.48
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$138.34
Rate for Payer: PHP Commercial	$138.34
Rate for Payer: Priority Health Cigna Priority Health	$113.92
Rate for Payer: Priority Health SBD	$102.53

DORZOLAMIDE 2 % EYE DROPS

Facility

$37.04

Service Code	NDC 61314-019-10
Hospital Charge Code	14471
Hospital Revenue Code	637
Min. Negotiated Rate	$23.34
Max. Negotiated Rate	$33.34
Rate for Payer: Aetna Commercial	$31.48
Rate for Payer: Aetna New Business (MI Preferred)	$24.08
Rate for Payer: Cash Price	$29.63
Rate for Payer: Cofinity Commercial	$25.93
Rate for Payer: Cofinity Commercial	$31.85
Rate for Payer: Healthscope Commercial	$33.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$31.48
Rate for Payer: PHP Commercial	$31.48
Rate for Payer: Priority Health Cigna Priority Health	$25.93
Rate for Payer: Priority Health SBD	$23.34

DORZOLAMIDE 2 % EYE DROPS

Facility

$36.63

Service Code	NDC 50383-232-10
Hospital Charge Code	14471
Hospital Revenue Code	637
Min. Negotiated Rate	$23.08
Max. Negotiated Rate	$32.97
Rate for Payer: Aetna Commercial	$31.14
Rate for Payer: Aetna New Business (MI Preferred)	$23.81
Rate for Payer: Cash Price	$29.30
Rate for Payer: Cofinity Commercial	$31.50
Rate for Payer: Cofinity Commercial	$25.64
Rate for Payer: Healthscope Commercial	$32.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$31.14
Rate for Payer: PHP Commercial	$31.14
Rate for Payer: Priority Health Cigna Priority Health	$25.64
Rate for Payer: Priority Health SBD	$23.08

DORZOLAMIDE 2 % EYE DROPS

Facility

$116.96

Service Code	NDC 24208-485-10
Hospital Charge Code	14471
Hospital Revenue Code	637
Min. Negotiated Rate	$73.68
Max. Negotiated Rate	$105.26
Rate for Payer: Aetna Commercial	$99.42
Rate for Payer: Aetna New Business (MI Preferred)	$76.02
Rate for Payer: Cash Price	$93.57
Rate for Payer: Cofinity Commercial	$100.59
Rate for Payer: Cofinity Commercial	$81.87
Rate for Payer: Healthscope Commercial	$105.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$99.42
Rate for Payer: PHP Commercial	$99.42
Rate for Payer: Priority Health Cigna Priority Health	$81.87
Rate for Payer: Priority Health SBD	$73.68

DOXEPIN 100 MG CAPSULE

Facility

$720.48

Service Code	NDC 0904-7055-61
Hospital Charge Code	2609
Hospital Revenue Code	637
Min. Negotiated Rate	$453.90
Max. Negotiated Rate	$648.43
Rate for Payer: Aetna Commercial	$612.41
Rate for Payer: Aetna New Business (MI Preferred)	$468.31
Rate for Payer: Cash Price	$576.38
Rate for Payer: Cofinity Commercial	$504.34
Rate for Payer: Cofinity Commercial	$619.61
Rate for Payer: Healthscope Commercial	$648.43
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$612.41
Rate for Payer: PHP Commercial	$612.41
Rate for Payer: Priority Health Cigna Priority Health	$504.34
Rate for Payer: Priority Health SBD	$453.90

DOXEPIN 10 MG CAPSULE

Facility

$241.92

Service Code	NDC 51079-436-20
Hospital Charge Code	2608
Hospital Revenue Code	637
Min. Negotiated Rate	$152.41
Max. Negotiated Rate	$217.73
Rate for Payer: Aetna Commercial	$205.63
Rate for Payer: Aetna New Business (MI Preferred)	$157.25
Rate for Payer: Cash Price	$193.54
Rate for Payer: Cofinity Commercial	$169.34
Rate for Payer: Cofinity Commercial	$208.05
Rate for Payer: Healthscope Commercial	$217.73
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$205.63
Rate for Payer: PHP Commercial	$205.63
Rate for Payer: Priority Health Cigna Priority Health	$169.34
Rate for Payer: Priority Health SBD	$152.41

DOXEPIN 10 MG CAPSULE

Facility

$2.42

Service Code	NDC 51079-436-01
Hospital Charge Code	2608
Hospital Revenue Code	637
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.18
Rate for Payer: Aetna Commercial	$2.06
Rate for Payer: Aetna New Business (MI Preferred)	$1.57
Rate for Payer: Cash Price	$1.94
Rate for Payer: Cofinity Commercial	$1.69
Rate for Payer: Cofinity Commercial	$2.08
Rate for Payer: Healthscope Commercial	$2.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.06
Rate for Payer: PHP Commercial	$2.06
Rate for Payer: Priority Health Cigna Priority Health	$1.69
Rate for Payer: Priority Health SBD	$1.52

DOXEPIN 25 MG CAPSULE

Facility

$319.20

Service Code	NDC 51079-437-20
Hospital Charge Code	2611
Hospital Revenue Code	637
Min. Negotiated Rate	$201.10
Max. Negotiated Rate	$287.28
Rate for Payer: Aetna Commercial	$271.32
Rate for Payer: Aetna New Business (MI Preferred)	$207.48
Rate for Payer: Cash Price	$255.36
Rate for Payer: Cofinity Commercial	$223.44
Rate for Payer: Cofinity Commercial	$274.51
Rate for Payer: Healthscope Commercial	$287.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$271.32
Rate for Payer: PHP Commercial	$271.32
Rate for Payer: Priority Health Cigna Priority Health	$223.44
Rate for Payer: Priority Health SBD	$201.10

DOXEPIN 25 MG CAPSULE

Facility

$3.20

Service Code	NDC 51079-437-01
Hospital Charge Code	2611
Hospital Revenue Code	637
Min. Negotiated Rate	$2.02
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna Commercial	$2.72
Rate for Payer: Aetna New Business (MI Preferred)	$2.08
Rate for Payer: Cash Price	$2.56
Rate for Payer: Cofinity Commercial	$2.24
Rate for Payer: Cofinity Commercial	$2.75
Rate for Payer: Healthscope Commercial	$2.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.72
Rate for Payer: PHP Commercial	$2.72
Rate for Payer: Priority Health Cigna Priority Health	$2.24
Rate for Payer: Priority Health SBD	$2.02

DOXORUBICIN 20 MG/10 ML INTRAVENOUS SOLUTION

Facility

$305.04

Service Code	HCPCS J9000
Hospital Charge Code	118503
Hospital Revenue Code	636
Min. Negotiated Rate	$9.71
Max. Negotiated Rate	$274.54
Rate for Payer: Aetna Commercial	$259.28
Rate for Payer: Aetna New Business (MI Preferred)	$198.28
Rate for Payer: BCBS Complete	$122.02
Rate for Payer: BCBS Trust/PPO	$9.71
Rate for Payer: Cash Price	$244.03
Rate for Payer: Cash Price	$244.03
Rate for Payer: Cofinity Commercial	$213.53
Rate for Payer: Cofinity Commercial	$262.33
Rate for Payer: Healthscope Commercial	$274.54
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$259.28
Rate for Payer: PHP Commercial	$259.28
Rate for Payer: Priority Health Cigna Priority Health	$213.53
Rate for Payer: Priority Health SBD	$192.18

DOXORUBICIN 50 MG/25 ML INTRAVENOUS SOLUTION

Facility

$226.02

Service Code	HCPCS J9000
Hospital Charge Code	118501
Hospital Revenue Code	636
Min. Negotiated Rate	$9.71
Max. Negotiated Rate	$203.42
Rate for Payer: Aetna Commercial	$192.12
Rate for Payer: Aetna Commercial	$154.22
Rate for Payer: Aetna Commercial	$218.35
Rate for Payer: Aetna Commercial	$235.35
Rate for Payer: Aetna Commercial	$210.84
Rate for Payer: Aetna Commercial	$243.08
Rate for Payer: Aetna New Business (MI Preferred)	$161.23
Rate for Payer: Aetna New Business (MI Preferred)	$117.93
Rate for Payer: Aetna New Business (MI Preferred)	$146.91
Rate for Payer: Aetna New Business (MI Preferred)	$185.89
Rate for Payer: Aetna New Business (MI Preferred)	$179.97
Rate for Payer: Aetna New Business (MI Preferred)	$166.97
Rate for Payer: BCBS Complete	$114.39
Rate for Payer: BCBS Complete	$90.41
Rate for Payer: BCBS Complete	$72.57
Rate for Payer: BCBS Complete	$99.22
Rate for Payer: BCBS Complete	$110.75
Rate for Payer: BCBS Complete	$102.75
Rate for Payer: BCBS Trust/PPO	$9.71
Rate for Payer: BCBS Trust/PPO	$9.71
Rate for Payer: BCBS Trust/PPO	$9.71
Rate for Payer: BCBS Trust/PPO	$9.71
Rate for Payer: BCBS Trust/PPO	$9.71
Rate for Payer: BCBS Trust/PPO	$9.71
Rate for Payer: Cash Price	$180.82
Rate for Payer: Cash Price	$145.14
Rate for Payer: Cash Price	$228.78
Rate for Payer: Cash Price	$198.44
Rate for Payer: Cash Price	$198.44
Rate for Payer: Cash Price	$145.14
Rate for Payer: Cash Price	$221.50
Rate for Payer: Cash Price	$205.50
Rate for Payer: Cash Price	$221.50
Rate for Payer: Cash Price	$180.82
Rate for Payer: Cash Price	$205.50
Rate for Payer: Cash Price	$228.78
Rate for Payer: Cofinity Commercial	$193.82
Rate for Payer: Cofinity Commercial	$156.03
Rate for Payer: Cofinity Commercial	$200.19
Rate for Payer: Cofinity Commercial	$127.00
Rate for Payer: Cofinity Commercial	$179.82
Rate for Payer: Cofinity Commercial	$220.92
Rate for Payer: Cofinity Commercial	$245.94
Rate for Payer: Cofinity Commercial	$158.21
Rate for Payer: Cofinity Commercial	$173.64
Rate for Payer: Cofinity Commercial	$213.32
Rate for Payer: Cofinity Commercial	$194.38
Rate for Payer: Cofinity Commercial	$238.12
Rate for Payer: Healthscope Commercial	$203.42
Rate for Payer: Healthscope Commercial	$163.29
Rate for Payer: Healthscope Commercial	$223.24
Rate for Payer: Healthscope Commercial	$231.19
Rate for Payer: Healthscope Commercial	$249.19
Rate for Payer: Healthscope Commercial	$257.38
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$192.12
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$235.35
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$243.08
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$154.22
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$218.35
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$210.84
Rate for Payer: PHP Commercial	$218.35
Rate for Payer: PHP Commercial	$210.84
Rate for Payer: PHP Commercial	$235.35
Rate for Payer: PHP Commercial	$192.12
Rate for Payer: PHP Commercial	$154.22
Rate for Payer: PHP Commercial	$243.08
Rate for Payer: Priority Health Cigna Priority Health	$173.64
Rate for Payer: Priority Health Cigna Priority Health	$200.19
Rate for Payer: Priority Health Cigna Priority Health	$158.21
Rate for Payer: Priority Health Cigna Priority Health	$179.82
Rate for Payer: Priority Health Cigna Priority Health	$127.00
Rate for Payer: Priority Health Cigna Priority Health	$193.82
Rate for Payer: Priority Health SBD	$142.39
Rate for Payer: Priority Health SBD	$114.30
Rate for Payer: Priority Health SBD	$161.83
Rate for Payer: Priority Health SBD	$156.27
Rate for Payer: Priority Health SBD	$180.17
Rate for Payer: Priority Health SBD	$174.43

DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION

Facility

$951.40

Service Code	HCPCS Q2050
Hospital Charge Code	27431
Hospital Revenue Code	636
Min. Negotiated Rate	$599.38
Max. Negotiated Rate	$856.26
Rate for Payer: Aetna Commercial	$808.69
Rate for Payer: Aetna Commercial	$1,220.34
Rate for Payer: Aetna New Business (MI Preferred)	$933.20
Rate for Payer: Aetna New Business (MI Preferred)	$618.41
Rate for Payer: Cash Price	$1,148.55
Rate for Payer: Cash Price	$761.12
Rate for Payer: Cofinity Commercial	$818.20
Rate for Payer: Cofinity Commercial	$665.98
Rate for Payer: Cofinity Commercial	$1,004.98
Rate for Payer: Cofinity Commercial	$1,234.69
Rate for Payer: Healthscope Commercial	$1,292.12
Rate for Payer: Healthscope Commercial	$856.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$808.69
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,220.34
Rate for Payer: PHP Commercial	$1,220.34
Rate for Payer: PHP Commercial	$808.69
Rate for Payer: Priority Health Cigna Priority Health	$1,004.98
Rate for Payer: Priority Health Cigna Priority Health	$665.98
Rate for Payer: Priority Health SBD	$904.48
Rate for Payer: Priority Health SBD	$599.38

DOXORUBICIN, PEGYLATED LIPOSOMAL 2 MG/ML INTRAVENOUS SUSPENSION

Facility

$897.60

Service Code	HCPCS Q2050
Hospital Charge Code	27431
Hospital Revenue Code	636
Min. Negotiated Rate	$46.76
Max. Negotiated Rate	$807.84
Rate for Payer: Aetna Commercial	$762.96
Rate for Payer: Aetna Commercial	$808.69
Rate for Payer: Aetna Commercial	$1,220.34
Rate for Payer: Aetna Medicare	$88.90
Rate for Payer: Aetna Medicare	$88.90
Rate for Payer: Aetna Medicare	$88.90
Rate for Payer: Aetna New Business (MI Preferred)	$618.41
Rate for Payer: Aetna New Business (MI Preferred)	$583.44
Rate for Payer: Aetna New Business (MI Preferred)	$933.20
Rate for Payer: Allen County Amish Medical Aid Commercial	$106.86
Rate for Payer: Allen County Amish Medical Aid Commercial	$106.86
Rate for Payer: Allen County Amish Medical Aid Commercial	$106.86
Rate for Payer: Amish Plain Church Group Commercial	$106.86
Rate for Payer: Amish Plain Church Group Commercial	$106.86
Rate for Payer: Amish Plain Church Group Commercial	$106.86
Rate for Payer: BCBS Complete	$49.10
Rate for Payer: BCBS Complete	$49.10
Rate for Payer: BCBS Complete	$49.10
Rate for Payer: BCBS MAPPO	$85.48
Rate for Payer: BCBS MAPPO	$85.48
Rate for Payer: BCBS MAPPO	$85.48
Rate for Payer: BCBS Trust/PPO	$253.06
Rate for Payer: BCBS Trust/PPO	$253.06
Rate for Payer: BCBS Trust/PPO	$253.06
Rate for Payer: BCN Medicare Advantage	$85.48
Rate for Payer: BCN Medicare Advantage	$85.48
Rate for Payer: BCN Medicare Advantage	$85.48
Rate for Payer: Cash Price	$718.08
Rate for Payer: Cash Price	$761.12
Rate for Payer: Cash Price	$761.12
Rate for Payer: Cash Price	$1,148.55
Rate for Payer: Cash Price	$1,148.55
Rate for Payer: Cash Price	$718.08
Rate for Payer: Cofinity Commercial	$665.98
Rate for Payer: Cofinity Commercial	$1,004.98
Rate for Payer: Cofinity Commercial	$1,234.69
Rate for Payer: Cofinity Commercial	$818.20
Rate for Payer: Cofinity Commercial	$628.32
Rate for Payer: Cofinity Commercial	$771.94
Rate for Payer: Health Alliance Plan Medicare Advantage	$85.48
Rate for Payer: Health Alliance Plan Medicare Advantage	$85.48
Rate for Payer: Health Alliance Plan Medicare Advantage	$85.48
Rate for Payer: Healthscope Commercial	$807.84
Rate for Payer: Healthscope Commercial	$856.26
Rate for Payer: Healthscope Commercial	$1,292.12
Rate for Payer: Mclaren Medicaid	$46.76
Rate for Payer: Mclaren Medicaid	$46.76
Rate for Payer: Mclaren Medicaid	$46.76
Rate for Payer: Mclaren Medicare	$85.48
Rate for Payer: Mclaren Medicare	$85.48
Rate for Payer: Mclaren Medicare	$85.48
Rate for Payer: Meridian Medicaid	$49.10
Rate for Payer: Meridian Medicaid	$49.10
Rate for Payer: Meridian Medicaid	$49.10
Rate for Payer: Meridian Wellcare - Medicare Advantage	$89.76
Rate for Payer: Meridian Wellcare - Medicare Advantage	$89.76
Rate for Payer: Meridian Wellcare - Medicare Advantage	$89.76
Rate for Payer: MI Amish Medical Board Commercial	$98.31
Rate for Payer: MI Amish Medical Board Commercial	$98.31
Rate for Payer: MI Amish Medical Board Commercial	$98.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$808.69
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$1,220.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$762.96
Rate for Payer: PACE Medicare	$81.21
Rate for Payer: PACE Medicare	$81.21
Rate for Payer: PACE Medicare	$81.21
Rate for Payer: PACE SWMI	$85.48
Rate for Payer: PACE SWMI	$85.48
Rate for Payer: PACE SWMI	$85.48
Rate for Payer: PHP Commercial	$808.69
Rate for Payer: PHP Commercial	$1,220.34
Rate for Payer: PHP Commercial	$762.96
Rate for Payer: PHP Medicare Advantage	$85.48
Rate for Payer: PHP Medicare Advantage	$85.48
Rate for Payer: PHP Medicare Advantage	$85.48
Rate for Payer: Priority Health Choice Medicaid	$46.76
Rate for Payer: Priority Health Choice Medicaid	$46.76
Rate for Payer: Priority Health Choice Medicaid	$46.76
Rate for Payer: Priority Health Cigna Priority Health	$1,004.98
Rate for Payer: Priority Health Cigna Priority Health	$665.98
Rate for Payer: Priority Health Cigna Priority Health	$628.32
Rate for Payer: Priority Health Medicare	$85.48
Rate for Payer: Priority Health Medicare	$85.48
Rate for Payer: Priority Health Medicare	$85.48
Rate for Payer: Priority Health SBD	$565.49
Rate for Payer: Priority Health SBD	$904.48
Rate for Payer: Priority Health SBD	$599.38
Rate for Payer: Railroad Medicare Medicare	$85.48
Rate for Payer: Railroad Medicare Medicare	$85.48
Rate for Payer: Railroad Medicare Medicare	$85.48
Rate for Payer: UHC Dual Complete DSNP	$85.48
Rate for Payer: UHC Dual Complete DSNP	$85.48
Rate for Payer: UHC Dual Complete DSNP	$85.48
Rate for Payer: UHC Medicare Advantage	$88.05
Rate for Payer: UHC Medicare Advantage	$88.05
Rate for Payer: UHC Medicare Advantage	$88.05
Rate for Payer: VA VA	$85.48
Rate for Payer: VA VA	$85.48
Rate for Payer: VA VA	$85.48

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION

Facility

$68.25

Service Code	NDC 63323-130-11
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: Healthscope Commercial	$61.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$58.01
Rate for Payer: PHP Commercial	$58.01
Rate for Payer: Priority Health Cigna Priority Health	$47.78
Rate for Payer: Priority Health SBD	$43.00

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION

Facility

$74.09

Service Code	NDC 0143-9381-10
Hospital Charge Code	2622
Hospital Revenue Code	250
Min. Negotiated Rate	$46.68
Max. Negotiated Rate	$66.68
Rate for Payer: Aetna Commercial	$62.98
Rate for Payer: Aetna New Business (MI Preferred)	$48.16
Rate for Payer: Cash Price	$59.27
Rate for Payer: Cofinity Commercial	$51.86
Rate for Payer: Cofinity Commercial	$63.72
Rate for Payer: Healthscope Commercial	$66.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$62.98
Rate for Payer: PHP Commercial	$62.98
Rate for Payer: Priority Health Cigna Priority Health	$51.86
Rate for Payer: Priority Health SBD	$46.68

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION

Facility

$54.76

Service Code	NDC 68382-910-10
Hospital Charge Code	2622
Hospital Revenue Code	250
Min. Negotiated Rate	$34.50
Max. Negotiated Rate	$49.28
Rate for Payer: Aetna Commercial	$46.55
Rate for Payer: Aetna New Business (MI Preferred)	$35.59
Rate for Payer: Cash Price	$43.81
Rate for Payer: Cofinity Commercial	$38.33
Rate for Payer: Cofinity Commercial	$47.09
Rate for Payer: Healthscope Commercial	$49.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$46.55
Rate for Payer: PHP Commercial	$46.55
Rate for Payer: Priority Health Cigna Priority Health	$38.33
Rate for Payer: Priority Health SBD	$34.50

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION

Facility

$54.76

Service Code	NDC 68382-910-01
Hospital Charge Code	2622
Hospital Revenue Code	250
Min. Negotiated Rate	$34.50
Max. Negotiated Rate	$49.28
Rate for Payer: Aetna Commercial	$46.55
Rate for Payer: Aetna New Business (MI Preferred)	$35.59
Rate for Payer: Cash Price	$43.81
Rate for Payer: Cofinity Commercial	$38.33
Rate for Payer: Cofinity Commercial	$47.09
Rate for Payer: Healthscope Commercial	$49.28
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$46.55
Rate for Payer: PHP Commercial	$46.55
Rate for Payer: Priority Health Cigna Priority Health	$38.33
Rate for Payer: Priority Health SBD	$34.50

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION

Facility

$74.09

Service Code	NDC 0143-9381-01
Hospital Charge Code	2622
Hospital Revenue Code	250
Min. Negotiated Rate	$46.68
Max. Negotiated Rate	$66.68
Rate for Payer: Aetna Commercial	$62.98
Rate for Payer: Aetna New Business (MI Preferred)	$48.16
Rate for Payer: Cash Price	$59.27
Rate for Payer: Cofinity Commercial	$51.86
Rate for Payer: Cofinity Commercial	$63.72
Rate for Payer: Healthscope Commercial	$66.68
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$62.98
Rate for Payer: PHP Commercial	$62.98
Rate for Payer: Priority Health Cigna Priority Health	$51.86
Rate for Payer: Priority Health SBD	$46.68

DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION

Facility

$68.25

Service Code	NDC 63323-130-13
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: Healthscope Commercial	$61.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$58.01
Rate for Payer: PHP Commercial	$58.01
Rate for Payer: Priority Health Cigna Priority Health	$47.78
Rate for Payer: Priority Health SBD	$43.00

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$204.05

Service Code	NDC 0904-0430-04
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$128.55
Max. Negotiated Rate	$183.64
Rate for Payer: Aetna Commercial	$173.44
Rate for Payer: Aetna New Business (MI Preferred)	$132.63
Rate for Payer: Cash Price	$163.24
Rate for Payer: Cofinity Commercial	$142.84
Rate for Payer: Cofinity Commercial	$175.48
Rate for Payer: Healthscope Commercial	$183.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$173.44
Rate for Payer: PHP Commercial	$173.44
Rate for Payer: Priority Health Cigna Priority Health	$142.84
Rate for Payer: Priority Health SBD	$128.55

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$211.50

Service Code	NDC 0143-2112-50
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$133.24
Max. Negotiated Rate	$190.35
Rate for Payer: Aetna Commercial	$179.78
Rate for Payer: Aetna New Business (MI Preferred)	$137.48
Rate for Payer: Cash Price	$169.20
Rate for Payer: Cofinity Commercial	$148.05
Rate for Payer: Cofinity Commercial	$181.89
Rate for Payer: Healthscope Commercial	$190.35
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$179.78
Rate for Payer: PHP Commercial	$179.78
Rate for Payer: Priority Health Cigna Priority Health	$148.05
Rate for Payer: Priority Health SBD	$133.24

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$343.44

Service Code	NDC 50268-279-15
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$216.37
Max. Negotiated Rate	$309.10
Rate for Payer: Aetna Commercial	$291.92
Rate for Payer: Aetna New Business (MI Preferred)	$223.24
Rate for Payer: Cash Price	$274.75
Rate for Payer: Cofinity Commercial	$240.41
Rate for Payer: Cofinity Commercial	$295.36
Rate for Payer: Healthscope Commercial	$309.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$291.92
Rate for Payer: PHP Commercial	$291.92
Rate for Payer: Priority Health Cigna Priority Health	$240.41
Rate for Payer: Priority Health SBD	$216.37

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$338.64

Service Code	NDC 0904-0430-06
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$213.34
Max. Negotiated Rate	$304.78
Rate for Payer: Aetna Commercial	$287.84
Rate for Payer: Aetna New Business (MI Preferred)	$220.12
Rate for Payer: Cash Price	$270.91
Rate for Payer: Cofinity Commercial	$237.05
Rate for Payer: Cofinity Commercial	$291.23
Rate for Payer: Healthscope Commercial	$304.78
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$287.84
Rate for Payer: PHP Commercial	$287.84
Rate for Payer: Priority Health Cigna Priority Health	$237.05
Rate for Payer: Priority Health SBD	$213.34

DOXYCYCLINE HYCLATE 100 MG TABLET

Facility

$248.31

Service Code	NDC 62584-693-21
Hospital Charge Code	2625
Hospital Revenue Code	637
Min. Negotiated Rate	$156.44
Max. Negotiated Rate	$223.48
Rate for Payer: Aetna Commercial	$211.06
Rate for Payer: Aetna New Business (MI Preferred)	$161.40
Rate for Payer: Cash Price	$198.65
Rate for Payer: Cofinity Commercial	$173.82
Rate for Payer: Cofinity Commercial	$213.55
Rate for Payer: Healthscope Commercial	$223.48
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$211.06
Rate for Payer: PHP Commercial	$211.06
Rate for Payer: Priority Health Cigna Priority Health	$173.82
Rate for Payer: Priority Health SBD	$156.44

Know your out-of-pocket cost for care.

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