|
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 Commercial |
$113.98
|
| Rate for Payer: Cofinity Commercial |
$92.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.77
|
| 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: PHP Commercial |
$112.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.14
|
| 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 Commercial |
$193.37
|
| Rate for Payer: Cofinity Commercial |
$237.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$193.37
|
| 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: PHP Commercial |
$234.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.56
|
| Rate for Payer: Priority Health SBD |
$174.03
|
| 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
|
IP
|
$198.58
|
|
|
Service Code
|
NDC 00143211250
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.38 |
| Max. Negotiated Rate |
$178.72 |
| Rate for Payer: Aetna American Axle |
$129.08
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$139.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.94
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$87.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.94
|
|
|
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 Commercial |
$113.98
|
| Rate for Payer: Cofinity Commercial |
$92.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.77
|
| 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: PHP Commercial |
$112.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.14
|
| Rate for Payer: Priority Health SBD |
$83.49
|
| 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
|
$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 Commercial |
$152.99
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.99
|
| 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: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.06
|
| 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
|
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 Commercial |
$193.37
|
| Rate for Payer: Cofinity Commercial |
$237.57
|
| Rate for Payer: Cofinity Medicare Advantage |
$193.37
|
| 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: PHP Commercial |
$234.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.56
|
| 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
|
$198.58
|
|
|
Service Code
|
NDC 00143211250
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$73.47 |
| Max. Negotiated Rate |
$178.72 |
| Rate for Payer: Aetna American Axle |
$129.08
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$139.01
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$148.94
|
| 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
|
| Rate for Payer: UMR Bronson Commercial |
$73.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$148.94
|
|
|
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 Commercial |
$264.05
|
| Rate for Payer: Cofinity Commercial |
$324.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$264.05
|
| 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: PHP Commercial |
$320.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$245.19
|
| 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 Commercial |
$329.45
|
| Rate for Payer: Cofinity Commercial |
$404.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$329.45
|
| 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: PHP Commercial |
$400.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.92
|
| Rate for Payer: Priority Health SBD |
$296.50
|
| 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
|
$377.22
|
|
|
Service Code
|
NDC 00378016789
|
| Hospital Charge Code |
2625
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$139.57 |
| Max. Negotiated Rate |
$339.50 |
| Rate for Payer: Aetna American Axle |
$245.19
|
| Rate for Payer: Aetna Commercial |
$320.64
|
| Rate for Payer: Aetna Medicare |
$188.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$245.19
|
| Rate for Payer: BCBS Complete |
$150.89
|
| Rate for Payer: Cash Price |
$301.78
|
| Rate for Payer: Cofinity Commercial |
$264.05
|
| Rate for Payer: Cofinity Commercial |
$324.41
|
| Rate for Payer: Cofinity Medicare Advantage |
$264.05
|
| 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: PHP Commercial |
$320.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$245.19
|
| Rate for Payer: Priority Health SBD |
$237.65
|
| Rate for Payer: UMR Bronson Commercial |
$139.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$282.92
|
|
|
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 Commercial |
$152.99
|
| Rate for Payer: Cofinity Commercial |
$187.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$152.99
|
| 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: PHP Commercial |
$185.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$142.06
|
| Rate for Payer: Priority Health SBD |
$137.69
|
| 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
|
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 Commercial |
$113.98
|
| Rate for Payer: Cofinity Commercial |
$92.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$92.77
|
| 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: PHP Commercial |
$112.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.14
|
| Rate for Payer: Priority Health SBD |
$83.49
|
| 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
|
$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 Commercial |
$329.45
|
| Rate for Payer: Cofinity Commercial |
$404.75
|
| Rate for Payer: Cofinity Medicare Advantage |
$329.45
|
| 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: PHP Commercial |
$400.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$305.92
|
| 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 50 MG CAPSULE
|
Facility
|
OP
|
$230.30
|
|
|
Service Code
|
NDC 00143314150
|
| Hospital Charge Code |
2624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$85.21 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna American Axle |
$149.69
|
| Rate for Payer: Aetna Commercial |
$195.75
|
| Rate for Payer: Aetna Medicare |
$115.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.69
|
| Rate for Payer: BCBS Complete |
$92.12
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$161.21
|
| Rate for Payer: Cofinity Commercial |
$198.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.24
|
| Rate for Payer: Healthscope Commercial |
$207.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$172.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.75
|
| Rate for Payer: PHP Commercial |
$195.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.69
|
| Rate for Payer: Priority Health SBD |
$145.09
|
| Rate for Payer: UMR Bronson Commercial |
$85.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
DOXYCYCLINE HYCLATE 50 MG CAPSULE
|
Facility
|
OP
|
$185.04
|
|
|
Service Code
|
NDC 53489011802
|
| Hospital Charge Code |
2624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.46 |
| Max. Negotiated Rate |
$166.54 |
| Rate for Payer: Aetna American Axle |
$120.28
|
| Rate for Payer: Aetna Commercial |
$157.28
|
| Rate for Payer: Aetna Medicare |
$92.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.28
|
| Rate for Payer: BCBS Complete |
$74.02
|
| Rate for Payer: Cash Price |
$148.03
|
| Rate for Payer: Cofinity Commercial |
$129.53
|
| Rate for Payer: Cofinity Commercial |
$159.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$129.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.03
|
| Rate for Payer: Healthscope Commercial |
$166.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$129.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.28
|
| Rate for Payer: PHP Commercial |
$157.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.28
|
| Rate for Payer: Priority Health SBD |
$116.58
|
| Rate for Payer: UMR Bronson Commercial |
$68.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.78
|
|
|
DOXYCYCLINE HYCLATE 50 MG CAPSULE
|
Facility
|
IP
|
$185.04
|
|
|
Service Code
|
NDC 53489011802
|
| Hospital Charge Code |
2624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.42 |
| Max. Negotiated Rate |
$166.54 |
| Rate for Payer: Aetna American Axle |
$120.28
|
| Rate for Payer: Aetna Commercial |
$157.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$120.28
|
| Rate for Payer: Cash Price |
$148.03
|
| Rate for Payer: Cofinity Commercial |
$129.53
|
| Rate for Payer: Cofinity Commercial |
$159.13
|
| Rate for Payer: Cofinity Medicare Advantage |
$129.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$148.03
|
| Rate for Payer: Healthscope Commercial |
$166.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$129.53
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$138.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$157.28
|
| Rate for Payer: PHP Commercial |
$157.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$120.28
|
| Rate for Payer: Priority Health SBD |
$116.58
|
| Rate for Payer: UMR Bronson Commercial |
$81.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$138.78
|
|
|
DOXYCYCLINE HYCLATE 50 MG CAPSULE
|
Facility
|
IP
|
$230.30
|
|
|
Service Code
|
NDC 00143314150
|
| Hospital Charge Code |
2624
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.33 |
| Max. Negotiated Rate |
$207.27 |
| Rate for Payer: Aetna American Axle |
$149.69
|
| Rate for Payer: Aetna Commercial |
$195.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$149.69
|
| Rate for Payer: Cash Price |
$184.24
|
| Rate for Payer: Cofinity Commercial |
$161.21
|
| Rate for Payer: Cofinity Commercial |
$198.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$161.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$184.24
|
| Rate for Payer: Healthscope Commercial |
$207.27
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$161.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$172.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$195.75
|
| Rate for Payer: PHP Commercial |
$195.75
|
| Rate for Payer: Priority Health Cigna Priority Health |
$149.69
|
| Rate for Payer: Priority Health SBD |
$145.09
|
| Rate for Payer: UMR Bronson Commercial |
$101.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$172.72
|
|
|
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 Commercial |
$142.63
|
| Rate for Payer: Cofinity Commercial |
$175.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$142.63
|
| 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: PHP Commercial |
$173.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.44
|
| Rate for Payer: Priority Health SBD |
$128.37
|
| 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
|
OP
|
$136.80
|
|
|
Service Code
|
NDC 68180065701
|
| Hospital Charge Code |
9902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$50.62 |
| Max. Negotiated Rate |
$123.12 |
| Rate for Payer: Aetna American Axle |
$88.92
|
| Rate for Payer: Aetna Commercial |
$116.28
|
| Rate for Payer: Aetna Medicare |
$68.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.92
|
| Rate for Payer: BCBS Complete |
$54.72
|
| Rate for Payer: Cash Price |
$109.44
|
| Rate for Payer: Cofinity Commercial |
$117.65
|
| Rate for Payer: Cofinity Commercial |
$95.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.44
|
| Rate for Payer: Healthscope Commercial |
$123.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.28
|
| Rate for Payer: PHP Commercial |
$116.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.92
|
| Rate for Payer: Priority Health SBD |
$86.18
|
| Rate for Payer: UMR Bronson Commercial |
$50.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.60
|
|
|
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 Commercial |
$142.63
|
| Rate for Payer: Cofinity Commercial |
$175.23
|
| Rate for Payer: Cofinity Medicare Advantage |
$142.63
|
| 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: PHP Commercial |
$173.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.44
|
| 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
|
IP
|
$136.80
|
|
|
Service Code
|
NDC 68180065701
|
| Hospital Charge Code |
9902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$60.19 |
| Max. Negotiated Rate |
$123.12 |
| Rate for Payer: Aetna American Axle |
$88.92
|
| Rate for Payer: Aetna Commercial |
$116.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$88.92
|
| Rate for Payer: Cash Price |
$109.44
|
| Rate for Payer: Cofinity Commercial |
$117.65
|
| Rate for Payer: Cofinity Commercial |
$95.76
|
| Rate for Payer: Cofinity Medicare Advantage |
$95.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$109.44
|
| Rate for Payer: Healthscope Commercial |
$123.12
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$95.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$102.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$116.28
|
| Rate for Payer: PHP Commercial |
$116.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$88.92
|
| Rate for Payer: Priority Health SBD |
$86.18
|
| Rate for Payer: UMR Bronson Commercial |
$60.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$102.60
|
|
|
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 Commercial |
$55.12
|
| Rate for Payer: Cofinity Commercial |
$67.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.12
|
| 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: PHP Commercial |
$66.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.18
|
| 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 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: 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: PHP Commercial |
$90.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.06
|
| 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
|
$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 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: 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: PHP Commercial |
$90.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.06
|
| Rate for Payer: Priority Health SBD |
$66.94
|
| Rate for Payer: UMR Bronson Commercial |
$39.31
|
| 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 Commercial |
$55.12
|
| Rate for Payer: Cofinity Commercial |
$67.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$55.12
|
| 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: PHP Commercial |
$66.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$51.18
|
| Rate for Payer: Priority Health SBD |
$49.61
|
| Rate for Payer: UMR Bronson Commercial |
$29.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$59.05
|
|
