|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$132.53
|
|
|
Service Code
|
NDC 53489012002
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.31 |
| Max. Negotiated Rate |
$119.28 |
| Rate for Payer: Aetna American Axle |
$86.14
|
| Rate for Payer: Aetna Commercial |
$112.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.14
|
| Rate for Payer: Cash Price |
$106.02
|
| Rate for Payer: Cofinity Advantage |
$92.77
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.02
|
| Rate for Payer: Healthscope Commercial |
$119.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$99.40
|
| Rate for Payer: PHP Commercial |
$112.65
|
| Rate for Payer: Priority Health SBD |
$83.49
|
| Rate for Payer: UMR Bronson Commercial |
$58.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.40
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$276.24
|
|
|
Service Code
|
NDC 67405055055
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$102.21 |
| Max. Negotiated Rate |
$248.62 |
| Rate for Payer: Aetna American Axle |
$179.56
|
| Rate for Payer: Aetna Commercial |
$234.80
|
| Rate for Payer: Aetna Medicare |
$138.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.56
|
| Rate for Payer: BCBS Complete |
$110.50
|
| Rate for Payer: Cash Price |
$220.99
|
| Rate for Payer: Cofinity Advantage |
$193.37
|
| Rate for Payer: Cofinity Commercial |
$237.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.99
|
| Rate for Payer: Healthscope Commercial |
$248.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$193.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$220.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$207.18
|
| Rate for Payer: PHP Commercial |
$234.80
|
| Rate for Payer: Priority Health SBD |
$174.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$179.56
|
| Rate for Payer: UHC Core |
$143.92
|
| Rate for Payer: UHC Exchange |
$108.56
|
| Rate for Payer: UMR Bronson Commercial |
$102.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.18
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$218.55
|
|
|
Service Code
|
NDC 42806031250
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$80.86 |
| Max. Negotiated Rate |
$196.69 |
| Rate for Payer: Aetna American Axle |
$142.06
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$152.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.91
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$80.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.91
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$218.55
|
|
|
Service Code
|
NDC 42806031250
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$96.16 |
| Max. Negotiated Rate |
$196.69 |
| Rate for Payer: Aetna American Axle |
$142.06
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$152.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$163.91
|
| 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: UMR Bronson Commercial |
$96.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$163.91
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$132.53
|
|
|
Service Code
|
NDC 72578000118
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.04 |
| Max. Negotiated Rate |
$119.28 |
| Rate for Payer: Aetna American Axle |
$86.14
|
| Rate for Payer: Aetna Commercial |
$112.65
|
| Rate for Payer: Aetna Medicare |
$66.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.14
|
| Rate for Payer: BCBS Complete |
$53.01
|
| Rate for Payer: Cash Price |
$106.02
|
| Rate for Payer: Cofinity Advantage |
$92.77
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.02
|
| Rate for Payer: Healthscope Commercial |
$119.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$106.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$99.40
|
| Rate for Payer: PHP Commercial |
$112.65
|
| Rate for Payer: Priority Health SBD |
$83.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$86.14
|
| Rate for Payer: UHC Core |
$69.05
|
| Rate for Payer: UHC Exchange |
$52.08
|
| Rate for Payer: UMR Bronson Commercial |
$49.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.40
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$276.24
|
|
|
Service Code
|
NDC 67405055055
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$121.55 |
| Max. Negotiated Rate |
$248.62 |
| Rate for Payer: Aetna American Axle |
$179.56
|
| Rate for Payer: Aetna Commercial |
$234.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$179.56
|
| Rate for Payer: Cash Price |
$220.99
|
| Rate for Payer: Cofinity Advantage |
$193.37
|
| Rate for Payer: Cofinity Commercial |
$237.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.99
|
| Rate for Payer: Healthscope Commercial |
$248.62
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$193.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$207.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$234.80
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$207.18
|
| Rate for Payer: PHP Commercial |
$234.80
|
| Rate for Payer: Priority Health SBD |
$174.03
|
| Rate for Payer: UMR Bronson Commercial |
$121.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$207.18
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$132.53
|
|
|
Service Code
|
NDC 53489012002
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.04 |
| Max. Negotiated Rate |
$119.28 |
| Rate for Payer: Aetna American Axle |
$86.14
|
| Rate for Payer: Aetna Commercial |
$112.65
|
| Rate for Payer: Aetna Medicare |
$66.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.14
|
| Rate for Payer: BCBS Complete |
$53.01
|
| Rate for Payer: Cash Price |
$106.02
|
| Rate for Payer: Cofinity Advantage |
$92.77
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.02
|
| Rate for Payer: Healthscope Commercial |
$119.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$106.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$99.40
|
| Rate for Payer: PHP Commercial |
$112.65
|
| Rate for Payer: Priority Health SBD |
$83.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$86.14
|
| Rate for Payer: UHC Core |
$69.05
|
| Rate for Payer: UHC Exchange |
$52.08
|
| Rate for Payer: UMR Bronson Commercial |
$49.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.40
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$377.22
|
|
|
Service Code
|
NDC 00378016789
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$165.98 |
| Max. Negotiated Rate |
$339.50 |
| Rate for Payer: Aetna American Axle |
$245.19
|
| Rate for Payer: Aetna Commercial |
$320.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$245.19
|
| Rate for Payer: Cash Price |
$301.78
|
| Rate for Payer: Cofinity Advantage |
$264.05
|
| Rate for Payer: Cofinity Commercial |
$324.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$301.78
|
| Rate for Payer: Healthscope Commercial |
$339.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$264.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$282.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$320.64
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$282.92
|
| Rate for Payer: PHP Commercial |
$320.64
|
| Rate for Payer: Priority Health SBD |
$237.65
|
| Rate for Payer: UMR Bronson Commercial |
$165.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$282.92
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$470.64
|
|
|
Service Code
|
NDC 00591555350
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$174.14 |
| Max. Negotiated Rate |
$423.58 |
| Rate for Payer: Aetna American Axle |
$305.92
|
| Rate for Payer: Aetna Commercial |
$400.04
|
| Rate for Payer: Aetna Medicare |
$235.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.92
|
| Rate for Payer: BCBS Complete |
$188.26
|
| Rate for Payer: Cash Price |
$376.51
|
| Rate for Payer: Cofinity Advantage |
$329.45
|
| Rate for Payer: Cofinity Commercial |
$404.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.51
|
| Rate for Payer: Healthscope Commercial |
$423.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$376.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$400.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$352.98
|
| Rate for Payer: PHP Commercial |
$400.04
|
| Rate for Payer: Priority Health SBD |
$296.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$305.92
|
| Rate for Payer: UHC Core |
$245.20
|
| Rate for Payer: UHC Exchange |
$184.96
|
| Rate for Payer: UMR Bronson Commercial |
$174.14
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.98
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
OP
|
$183.30
|
|
|
Service Code
|
NDC 00143211250
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.82 |
| Max. Negotiated Rate |
$164.97 |
| Rate for Payer: Aetna American Axle |
$119.14
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$128.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$137.47
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$67.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$137.47
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$470.64
|
|
|
Service Code
|
NDC 00591555350
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.08 |
| Max. Negotiated Rate |
$423.58 |
| Rate for Payer: Aetna American Axle |
$305.92
|
| Rate for Payer: Aetna Commercial |
$400.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$305.92
|
| Rate for Payer: Cash Price |
$376.51
|
| Rate for Payer: Cofinity Advantage |
$329.45
|
| Rate for Payer: Cofinity Commercial |
$404.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$376.51
|
| Rate for Payer: Healthscope Commercial |
$423.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$329.45
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$352.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$400.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$352.98
|
| Rate for Payer: PHP Commercial |
$400.04
|
| Rate for Payer: Priority Health SBD |
$296.50
|
| Rate for Payer: UMR Bronson Commercial |
$207.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$352.98
|
|
|
DOXYCYCLINE HYCLATE 100 MG TABLET
|
Facility
|
IP
|
$132.53
|
|
|
Service Code
|
NDC 72578000118
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.31 |
| Max. Negotiated Rate |
$119.28 |
| Rate for Payer: Aetna American Axle |
$86.14
|
| Rate for Payer: Aetna Commercial |
$112.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.14
|
| Rate for Payer: Cash Price |
$106.02
|
| Rate for Payer: Cofinity Advantage |
$92.77
|
| Rate for Payer: Cofinity Commercial |
$113.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.02
|
| Rate for Payer: Healthscope Commercial |
$119.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$92.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$112.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$99.40
|
| Rate for Payer: PHP Commercial |
$112.65
|
| Rate for Payer: Priority Health SBD |
$83.49
|
| Rate for Payer: UMR Bronson Commercial |
$58.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.40
|
|
|
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$203.76
|
|
|
Service Code
|
NDC 62135041746
|
| Hospital Charge Code |
9902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$89.65 |
| Max. Negotiated Rate |
$183.38 |
| Rate for Payer: Aetna American Axle |
$132.44
|
| Rate for Payer: Aetna Commercial |
$173.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.44
|
| Rate for Payer: Cash Price |
$163.01
|
| Rate for Payer: Cofinity Advantage |
$142.63
|
| Rate for Payer: Cofinity Commercial |
$175.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.01
|
| Rate for Payer: Healthscope Commercial |
$183.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$152.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$152.82
|
| Rate for Payer: PHP Commercial |
$173.20
|
| Rate for Payer: Priority Health SBD |
$128.37
|
| Rate for Payer: UMR Bronson Commercial |
$89.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$152.82
|
|
|
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$203.76
|
|
|
Service Code
|
NDC 62135041746
|
| Hospital Charge Code |
9902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$75.39 |
| Max. Negotiated Rate |
$183.38 |
| Rate for Payer: Aetna American Axle |
$132.44
|
| Rate for Payer: Aetna Commercial |
$173.20
|
| Rate for Payer: Aetna Medicare |
$101.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$132.44
|
| Rate for Payer: BCBS Complete |
$81.50
|
| Rate for Payer: Cash Price |
$163.01
|
| Rate for Payer: Cofinity Advantage |
$142.63
|
| Rate for Payer: Cofinity Commercial |
$175.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$163.01
|
| Rate for Payer: Healthscope Commercial |
$183.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$142.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$152.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$163.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$173.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$152.82
|
| Rate for Payer: PHP Commercial |
$173.20
|
| Rate for Payer: Priority Health SBD |
$128.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$132.44
|
| Rate for Payer: UHC Core |
$106.16
|
| Rate for Payer: UHC Exchange |
$80.08
|
| Rate for Payer: UMR Bronson Commercial |
$75.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$152.82
|
|
|
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$141.84
|
|
|
Service Code
|
NDC 68180065701
|
| Hospital Charge Code |
9902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$62.41 |
| Max. Negotiated Rate |
$127.66 |
| Rate for Payer: Aetna American Axle |
$92.20
|
| Rate for Payer: Aetna Commercial |
$120.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.20
|
| Rate for Payer: Cash Price |
$113.47
|
| Rate for Payer: Cofinity Advantage |
$99.29
|
| Rate for Payer: Cofinity Commercial |
$121.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.47
|
| Rate for Payer: Healthscope Commercial |
$127.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.38
|
| Rate for Payer: PHP Commercial |
$120.56
|
| Rate for Payer: Priority Health SBD |
$89.36
|
| Rate for Payer: UMR Bronson Commercial |
$62.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.38
|
|
|
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
OP
|
$141.84
|
|
|
Service Code
|
NDC 68180065701
|
| Hospital Charge Code |
9902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$52.48 |
| Max. Negotiated Rate |
$127.66 |
| Rate for Payer: Aetna American Axle |
$92.20
|
| Rate for Payer: Aetna Commercial |
$120.56
|
| Rate for Payer: Aetna Medicare |
$70.92
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$92.20
|
| Rate for Payer: BCBS Complete |
$56.74
|
| Rate for Payer: Cash Price |
$113.47
|
| Rate for Payer: Cofinity Advantage |
$99.29
|
| Rate for Payer: Cofinity Commercial |
$121.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.47
|
| Rate for Payer: Healthscope Commercial |
$127.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$99.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$106.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$113.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$106.38
|
| Rate for Payer: PHP Commercial |
$120.56
|
| Rate for Payer: Priority Health SBD |
$89.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$92.20
|
| Rate for Payer: UHC Core |
$73.90
|
| Rate for Payer: UHC Exchange |
$55.74
|
| Rate for Payer: UMR Bronson Commercial |
$52.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$106.38
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET
|
Facility
|
IP
|
$78.74
|
|
|
Service Code
|
NDC 41167000609
|
| Hospital Charge Code |
14847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.65 |
| Max. Negotiated Rate |
$70.87 |
| Rate for Payer: Aetna American Axle |
$51.18
|
| Rate for Payer: Aetna Commercial |
$66.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.18
|
| Rate for Payer: Cash Price |
$62.99
|
| Rate for Payer: Cofinity Advantage |
$55.12
|
| Rate for Payer: Cofinity Commercial |
$67.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.99
|
| Rate for Payer: Healthscope Commercial |
$70.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.05
|
| Rate for Payer: PHP Commercial |
$66.93
|
| Rate for Payer: Priority Health SBD |
$49.61
|
| Rate for Payer: UMR Bronson Commercial |
$34.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.05
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET
|
Facility
|
IP
|
$106.25
|
|
|
Service Code
|
NDC 41167000623
|
| Hospital Charge Code |
14847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.75 |
| Max. Negotiated Rate |
$95.62 |
| Rate for Payer: Aetna American Axle |
$69.06
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$74.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.69
|
| 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: UMR Bronson Commercial |
$46.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.69
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET
|
Facility
|
OP
|
$78.74
|
|
|
Service Code
|
NDC 41167000609
|
| Hospital Charge Code |
14847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.13 |
| Max. Negotiated Rate |
$70.87 |
| Rate for Payer: Aetna American Axle |
$51.18
|
| Rate for Payer: Aetna Commercial |
$66.93
|
| Rate for Payer: Aetna Medicare |
$39.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$51.18
|
| Rate for Payer: BCBS Complete |
$31.50
|
| Rate for Payer: Cash Price |
$62.99
|
| Rate for Payer: Cofinity Advantage |
$55.12
|
| Rate for Payer: Cofinity Commercial |
$67.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$62.99
|
| Rate for Payer: Healthscope Commercial |
$70.87
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$55.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$59.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$62.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$66.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$59.05
|
| Rate for Payer: PHP Commercial |
$66.93
|
| Rate for Payer: Priority Health SBD |
$49.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$51.18
|
| Rate for Payer: UHC Core |
$41.02
|
| Rate for Payer: UHC Exchange |
$30.94
|
| Rate for Payer: UMR Bronson Commercial |
$29.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.05
|
|
|
DOXYLAMINE SUCCINATE 25 MG TABLET
|
Facility
|
OP
|
$106.25
|
|
|
Service Code
|
NDC 41167000623
|
| Hospital Charge Code |
14847
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$39.31 |
| Max. Negotiated Rate |
$95.62 |
| Rate for Payer: Aetna American Axle |
$69.06
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$74.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$79.69
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$39.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$79.69
|
|
|
DRAINAGE OF ABSCESS, CYST, HEMATOMA FROM DENTOALVEOLAR STRUCTURES
|
Facility
|
OP
|
$428.73
|
|
|
Service Code
|
CPT 41800
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$69.33 |
| Max. Negotiated Rate |
$428.73 |
| Rate for Payer: Aetna Medicare |
$137.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$165.71
|
| Rate for Payer: Amish Plain Church Group Commercial |
$165.71
|
| Rate for Payer: BCBS Complete |
$72.81
|
| Rate for Payer: BCBS MAPPO |
$132.57
|
| Rate for Payer: BCBS Trust/PPO |
$157.33
|
| Rate for Payer: BCN Commercial |
$157.33
|
| Rate for Payer: BCN Medicare Advantage |
$132.57
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$132.57
|
| Rate for Payer: Mclaren Medicaid |
$132.57
|
| Rate for Payer: Mclaren Medicare |
$132.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$139.20
|
| Rate for Payer: Meridian Medicaid |
$139.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$152.46
|
| Rate for Payer: Molina Medicare/Medicaid |
$145.83
|
| Rate for Payer: Nomi Health Commercial |
$397.71
|
| Rate for Payer: PACE Medicare |
$125.94
|
| Rate for Payer: PACE SWMI |
$132.57
|
| Rate for Payer: PHP Medicare Advantage |
$132.57
|
| Rate for Payer: Priority Health Choice Medicaid |
$69.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$428.73
|
| Rate for Payer: Priority Health Medicare |
$132.57
|
| Rate for Payer: Priority Health Tiered Network |
$342.98
|
| Rate for Payer: Railroad Medicare Medicare |
$132.57
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$132.57
|
| Rate for Payer: UHC Medicaid |
$69.33
|
| Rate for Payer: UHCCP Medicaid |
$69.33
|
| Rate for Payer: VA VA |
$132.57
|
|
|
DRAINAGE OF FINGER ABSCESS; COMPLICATED (EG, FELON)
|
Facility
|
OP
|
$5,321.93
|
|
|
Service Code
|
CPT 26011
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$860.68 |
| 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 |
$1,114.61
|
| Rate for Payer: BCN Commercial |
$1,114.61
|
| 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 |
$1,645.66
|
| 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
|
|
|
DRAINAGE OF SCROTAL WALL ABSCESS
|
Facility
|
OP
|
$5,321.93
|
|
|
Service Code
|
CPT 55100
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$860.68 |
| 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 |
$980.99
|
| Rate for Payer: BCN Commercial |
$980.99
|
| 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 |
$1,645.66
|
| 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
|
|
|
DRAINAGE OF TENDON SHEATH, DIGIT AND/OR PALM, EACH
|
Facility
|
OP
|
$10,543.31
|
|
|
Service Code
|
CPT 26020
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,705.10 |
| Max. Negotiated Rate |
$10,543.31 |
| Rate for Payer: Aetna Medicare |
$3,390.64
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4,075.29
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4,075.29
|
| Rate for Payer: BCBS Complete |
$1,790.52
|
| Rate for Payer: BCBS MAPPO |
$3,260.23
|
| Rate for Payer: BCBS Trust/PPO |
$2,293.43
|
| Rate for Payer: BCN Commercial |
$2,293.43
|
| Rate for Payer: BCN Medicare Advantage |
$3,260.23
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,260.23
|
| Rate for Payer: Mclaren Medicaid |
$3,260.23
|
| Rate for Payer: Mclaren Medicare |
$3,260.23
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,423.24
|
| Rate for Payer: Meridian Medicaid |
$3,423.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,749.26
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,586.25
|
| Rate for Payer: Nomi Health Commercial |
$9,780.69
|
| Rate for Payer: PACE Medicare |
$3,097.22
|
| Rate for Payer: PACE SWMI |
$3,260.23
|
| Rate for Payer: PHP Medicare Advantage |
$3,260.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,705.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,543.31
|
| Rate for Payer: Priority Health Medicare |
$3,260.23
|
| Rate for Payer: Priority Health Tiered Network |
$8,434.65
|
| Rate for Payer: Railroad Medicare Medicare |
$3,260.23
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,260.23
|
| Rate for Payer: UHC Medicaid |
$1,705.10
|
| Rate for Payer: UHCCP Medicaid |
$1,705.10
|
| Rate for Payer: VA VA |
$3,260.23
|
|
|
DRESSING CHANGE (FOR OTHER THAN BURNS) UNDER ANESTHESIA (OTHER THAN LOCAL)
|
Facility
|
OP
|
$2,381.49
|
|
|
Service Code
|
CPT 15852
|
|
Hospital Revenue Code
|
361
|
| Min. Negotiated Rate |
$297.46 |
| Max. Negotiated Rate |
$2,381.49 |
| Rate for Payer: Aetna Medicare |
$765.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$920.51
|
| Rate for Payer: Amish Plain Church Group Commercial |
$920.51
|
| Rate for Payer: BCBS Complete |
$404.44
|
| Rate for Payer: BCBS MAPPO |
$736.41
|
| Rate for Payer: BCBS Trust/PPO |
$297.46
|
| Rate for Payer: BCN Commercial |
$297.46
|
| Rate for Payer: BCN Medicare Advantage |
$736.41
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$736.41
|
| Rate for Payer: Mclaren Medicaid |
$736.41
|
| Rate for Payer: Mclaren Medicare |
$736.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$773.23
|
| Rate for Payer: Meridian Medicaid |
$773.23
|
| Rate for Payer: MI Amish Medical Board Commercial |
$846.87
|
| Rate for Payer: Molina Medicare/Medicaid |
$810.05
|
| Rate for Payer: Nomi Health Commercial |
$2,209.23
|
| Rate for Payer: PACE Medicare |
$699.59
|
| Rate for Payer: PACE SWMI |
$736.41
|
| Rate for Payer: PHP Medicare Advantage |
$736.41
|
| Rate for Payer: Priority Health Choice Medicaid |
$385.14
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$2,381.49
|
| Rate for Payer: Priority Health Medicare |
$736.41
|
| Rate for Payer: Priority Health Tiered Network |
$1,905.19
|
| Rate for Payer: Railroad Medicare Medicare |
$736.41
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$736.41
|
| Rate for Payer: UHC Medicaid |
$385.14
|
| Rate for Payer: UHCCP Medicaid |
$385.14
|
| Rate for Payer: VA VA |
$736.41
|
|
