|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$42.30
|
|
|
Service Code
|
NDC 43547-275-03
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$25.80 |
| Max. Negotiated Rate |
$38.07 |
| Rate for Payer: Aetna Commercial |
$35.96
|
| Rate for Payer: BCBS Trust/PPO |
$32.69
|
| Rate for Payer: BCN Commercial |
$32.69
|
| Rate for Payer: Cash Price |
$33.84
|
| Rate for Payer: Cofinity Commercial |
$36.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.84
|
| Rate for Payer: Healthscope Commercial |
$38.07
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$35.96
|
| Rate for Payer: PHP Commercial |
$35.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.61
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$36.80
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$25.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$37.22
|
| Rate for Payer: UHC Core |
$35.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.72
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
IP
|
$71.15
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$43.39 |
| Max. Negotiated Rate |
$64.04 |
| Rate for Payer: Aetna Commercial |
$60.48
|
| Rate for Payer: BCBS Trust/PPO |
$54.98
|
| Rate for Payer: BCN Commercial |
$54.98
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$61.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.92
|
| Rate for Payer: Healthscope Commercial |
$64.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.48
|
| Rate for Payer: PHP Commercial |
$60.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$61.90
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$43.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$62.61
|
| Rate for Payer: UHC Core |
$59.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.36
|
|
|
DORZOLAMIDE 22.3 MG-TIMOLOL 6.8 MG/ML EYE DROPS
|
Facility
|
IP
|
$27.37
|
|
|
Service Code
|
NDC 24208-486-10
|
| Hospital Charge Code |
22982
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.69 |
| Max. Negotiated Rate |
$24.63 |
| Rate for Payer: Aetna Commercial |
$23.26
|
| Rate for Payer: BCBS Trust/PPO |
$21.15
|
| Rate for Payer: BCN Commercial |
$21.15
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cofinity Commercial |
$23.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.90
|
| Rate for Payer: Healthscope Commercial |
$24.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.53
|
| 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 HMO/PPO/Tiered Network |
$23.81
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.09
|
| Rate for Payer: UHC Core |
$22.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.53
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$37.04
|
|
|
Service Code
|
NDC 61314-019-10
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.59 |
| Max. Negotiated Rate |
$33.34 |
| Rate for Payer: Aetna Commercial |
$31.48
|
| Rate for Payer: BCBS Trust/PPO |
$28.62
|
| Rate for Payer: BCN Commercial |
$28.62
|
| Rate for Payer: Cash Price |
$29.63
|
| Rate for Payer: Cofinity Commercial |
$31.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.63
|
| Rate for Payer: Healthscope Commercial |
$33.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.78
|
| 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 HMO/PPO/Tiered Network |
$32.22
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.60
|
| Rate for Payer: UHC Core |
$30.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.78
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$36.63
|
|
|
Service Code
|
NDC 50383-232-10
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.34 |
| Max. Negotiated Rate |
$32.97 |
| Rate for Payer: Aetna Commercial |
$31.14
|
| Rate for Payer: BCBS Trust/PPO |
$28.31
|
| Rate for Payer: BCN Commercial |
$28.31
|
| Rate for Payer: Cash Price |
$29.30
|
| Rate for Payer: Cofinity Commercial |
$31.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.30
|
| Rate for Payer: Healthscope Commercial |
$32.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.47
|
| 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 HMO/PPO/Tiered Network |
$31.87
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$22.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$32.23
|
| Rate for Payer: UHC Core |
$30.59
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.47
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$319.20
|
|
|
Service Code
|
NDC 51079-437-20
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$194.68 |
| Max. Negotiated Rate |
$287.28 |
| Rate for Payer: Aetna Commercial |
$271.32
|
| Rate for Payer: BCBS Trust/PPO |
$246.68
|
| Rate for Payer: BCN Commercial |
$246.68
|
| Rate for Payer: Cash Price |
$255.36
|
| Rate for Payer: Cofinity Commercial |
$274.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.36
|
| Rate for Payer: Healthscope Commercial |
$287.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$239.40
|
| 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 HMO/PPO/Tiered Network |
$277.70
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$194.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$280.90
|
| Rate for Payer: UHC Core |
$266.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$239.40
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$3.20
|
|
|
Service Code
|
NDC 51079-437-01
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$2.88 |
| Rate for Payer: Aetna Commercial |
$2.72
|
| Rate for Payer: BCBS Trust/PPO |
$2.47
|
| Rate for Payer: BCN Commercial |
$2.47
|
| Rate for Payer: Cash Price |
$2.56
|
| Rate for Payer: Cofinity Commercial |
$2.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.56
|
| Rate for Payer: Healthscope Commercial |
$2.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.40
|
| 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 HMO/PPO/Tiered Network |
$2.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.82
|
| Rate for Payer: UHC Core |
$2.67
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.40
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$423.00
|
|
|
Service Code
|
NDC 69238-1170-9
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$257.99 |
| Max. Negotiated Rate |
$380.70 |
| Rate for Payer: Aetna Commercial |
$359.55
|
| Rate for Payer: BCBS Trust/PPO |
$326.89
|
| Rate for Payer: BCN Commercial |
$326.89
|
| Rate for Payer: Cash Price |
$338.40
|
| Rate for Payer: Cofinity Commercial |
$363.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.40
|
| Rate for Payer: Healthscope Commercial |
$380.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$359.55
|
| Rate for Payer: PHP Commercial |
$359.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$368.01
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$257.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$372.24
|
| Rate for Payer: UHC Core |
$353.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.25
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$68.25
|
|
|
Service Code
|
NDC 63323-130-11
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.63 |
| Max. Negotiated Rate |
$61.42 |
| Rate for Payer: Aetna Commercial |
$58.01
|
| Rate for Payer: BCBS Trust/PPO |
$52.74
|
| Rate for Payer: BCN Commercial |
$52.74
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cofinity Commercial |
$58.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.60
|
| Rate for Payer: Healthscope Commercial |
$61.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.19
|
| 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 HMO/PPO/Tiered Network |
$59.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$41.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.06
|
| Rate for Payer: UHC Core |
$56.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.19
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
NDC 67457-437-10
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.08 |
| Max. Negotiated Rate |
$62.10 |
| Rate for Payer: Aetna Commercial |
$58.65
|
| Rate for Payer: BCBS Trust/PPO |
$53.32
|
| Rate for Payer: BCN Commercial |
$53.32
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cofinity Commercial |
$59.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.20
|
| Rate for Payer: Healthscope Commercial |
$62.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$58.65
|
| Rate for Payer: PHP Commercial |
$58.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$60.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.72
|
| Rate for Payer: UHC Core |
$57.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.75
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$54.76
|
|
|
Service Code
|
NDC 68382-910-10
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.40 |
| Max. Negotiated Rate |
$49.28 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: BCBS Trust/PPO |
$42.32
|
| Rate for Payer: BCN Commercial |
$42.32
|
| Rate for Payer: Cash Price |
$43.81
|
| Rate for Payer: Cofinity Commercial |
$47.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.81
|
| Rate for Payer: Healthscope Commercial |
$49.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.07
|
| 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 HMO/PPO/Tiered Network |
$47.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$33.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$48.19
|
| Rate for Payer: UHC Core |
$45.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.07
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$54.76
|
|
|
Service Code
|
NDC 68382-910-01
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$33.40 |
| Max. Negotiated Rate |
$49.28 |
| Rate for Payer: Aetna Commercial |
$46.55
|
| Rate for Payer: BCBS Trust/PPO |
$42.32
|
| Rate for Payer: BCN Commercial |
$42.32
|
| Rate for Payer: Cash Price |
$43.81
|
| Rate for Payer: Cofinity Commercial |
$47.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$43.81
|
| Rate for Payer: Healthscope Commercial |
$49.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$41.07
|
| 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 HMO/PPO/Tiered Network |
$47.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$33.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$48.19
|
| Rate for Payer: UHC Core |
$45.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$41.07
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$69.00
|
|
|
Service Code
|
NDC 67457-437-00
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$42.08 |
| Max. Negotiated Rate |
$62.10 |
| Rate for Payer: Aetna Commercial |
$58.65
|
| Rate for Payer: BCBS Trust/PPO |
$53.32
|
| Rate for Payer: BCN Commercial |
$53.32
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cofinity Commercial |
$59.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.20
|
| Rate for Payer: Healthscope Commercial |
$62.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$58.65
|
| Rate for Payer: PHP Commercial |
$58.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$60.03
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$42.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.72
|
| Rate for Payer: UHC Core |
$57.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.75
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$68.25
|
|
|
Service Code
|
NDC 63323-130-13
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$41.63 |
| Max. Negotiated Rate |
$61.42 |
| Rate for Payer: Aetna Commercial |
$58.01
|
| Rate for Payer: BCBS Trust/PPO |
$52.74
|
| Rate for Payer: BCN Commercial |
$52.74
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cofinity Commercial |
$58.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.60
|
| Rate for Payer: Healthscope Commercial |
$61.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$51.19
|
| 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 HMO/PPO/Tiered Network |
$59.38
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$41.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$60.06
|
| Rate for Payer: UHC Core |
$56.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$51.19
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE
|
Facility
|
IP
|
$148.08
|
|
|
Service Code
|
NDC 50268-281-15
|
| Hospital Charge Code |
9900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.31 |
| Max. Negotiated Rate |
$133.27 |
| Rate for Payer: Aetna Commercial |
$125.87
|
| Rate for Payer: BCBS Trust/PPO |
$114.44
|
| Rate for Payer: BCN Commercial |
$114.44
|
| Rate for Payer: Cash Price |
$118.46
|
| Rate for Payer: Cofinity Commercial |
$127.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$118.46
|
| Rate for Payer: Healthscope Commercial |
$133.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$111.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$125.87
|
| Rate for Payer: PHP Commercial |
$125.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$103.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$128.83
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$90.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$130.31
|
| Rate for Payer: UHC Core |
$123.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$111.06
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE
|
Facility
|
IP
|
$5.86
|
|
|
Service Code
|
NDC 68084-743-33
|
| Hospital Charge Code |
9900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.57 |
| Max. Negotiated Rate |
$5.27 |
| Rate for Payer: Aetna Commercial |
$4.98
|
| Rate for Payer: BCBS Trust/PPO |
$4.53
|
| Rate for Payer: BCN Commercial |
$4.53
|
| Rate for Payer: Cash Price |
$4.69
|
| Rate for Payer: Cofinity Commercial |
$5.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.69
|
| Rate for Payer: Healthscope Commercial |
$5.27
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.98
|
| Rate for Payer: PHP Commercial |
$4.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.10
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$5.10
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$3.57
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.16
|
| Rate for Payer: UHC Core |
$4.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.40
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE
|
Facility
|
IP
|
$2.97
|
|
|
Service Code
|
NDC 50268-281-11
|
| Hospital Charge Code |
9900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCN Commercial |
$2.30
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cofinity Commercial |
$2.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.38
|
| Rate for Payer: Healthscope Commercial |
$2.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.52
|
| Rate for Payer: PHP Commercial |
$2.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.61
|
| Rate for Payer: UHC Core |
$2.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.23
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE
|
Facility
|
IP
|
$2.97
|
|
|
Service Code
|
NDC 68084-743-11
|
| Hospital Charge Code |
9900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.81 |
| Max. Negotiated Rate |
$2.67 |
| Rate for Payer: Aetna Commercial |
$2.52
|
| Rate for Payer: BCBS Trust/PPO |
$2.30
|
| Rate for Payer: BCN Commercial |
$2.30
|
| Rate for Payer: Cash Price |
$2.38
|
| Rate for Payer: Cofinity Commercial |
$2.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.38
|
| Rate for Payer: Healthscope Commercial |
$2.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.52
|
| Rate for Payer: PHP Commercial |
$2.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.08
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.58
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.61
|
| Rate for Payer: UHC Core |
$2.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.23
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE
|
Facility
|
IP
|
$101.65
|
|
|
Service Code
|
NDC 68180-652-08
|
| Hospital Charge Code |
9900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.00 |
| Max. Negotiated Rate |
$91.48 |
| Rate for Payer: Aetna Commercial |
$86.40
|
| Rate for Payer: BCBS Trust/PPO |
$78.56
|
| Rate for Payer: BCN Commercial |
$78.56
|
| Rate for Payer: Cash Price |
$81.32
|
| Rate for Payer: Cofinity Commercial |
$87.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$81.32
|
| Rate for Payer: Healthscope Commercial |
$91.48
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$76.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$86.40
|
| Rate for Payer: PHP Commercial |
$86.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$71.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$88.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$62.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$89.45
|
| Rate for Payer: UHC Core |
$84.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$76.24
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE
|
Facility
|
IP
|
$117.03
|
|
|
Service Code
|
NDC 68084-743-32
|
| Hospital Charge Code |
9900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$71.38 |
| Max. Negotiated Rate |
$105.33 |
| Rate for Payer: Aetna Commercial |
$99.48
|
| Rate for Payer: BCBS Trust/PPO |
$90.44
|
| Rate for Payer: BCN Commercial |
$90.44
|
| Rate for Payer: Cash Price |
$93.62
|
| Rate for Payer: Cofinity Commercial |
$100.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.62
|
| Rate for Payer: Healthscope Commercial |
$105.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$87.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$99.48
|
| Rate for Payer: PHP Commercial |
$99.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$101.82
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$71.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$102.99
|
| Rate for Payer: UHC Core |
$97.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$87.77
|
|
|
DOXYCYCLINE MONOHYDRATE 100 MG CAPSULE
|
Facility
|
IP
|
$88.85
|
|
|
Service Code
|
NDC 68084-743-21
|
| Hospital Charge Code |
9900
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.19 |
| Max. Negotiated Rate |
$79.96 |
| Rate for Payer: Aetna Commercial |
$75.52
|
| Rate for Payer: BCBS Trust/PPO |
$68.66
|
| Rate for Payer: BCN Commercial |
$68.66
|
| Rate for Payer: Cash Price |
$71.08
|
| Rate for Payer: Cofinity Commercial |
$76.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$71.08
|
| Rate for Payer: Healthscope Commercial |
$79.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$66.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$75.52
|
| Rate for Payer: PHP Commercial |
$75.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$62.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$77.30
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$54.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$78.19
|
| Rate for Payer: UHC Core |
$74.19
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$66.64
|
|
|
DOXYCYCLINE MONOHYDRATE 25 MG/5 ML ORAL SUSPENSION
|
Facility
|
IP
|
$135.36
|
|
|
Service Code
|
NDC 68180-657-01
|
| Hospital Charge Code |
9902
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$82.56 |
| Max. Negotiated Rate |
$121.82 |
| Rate for Payer: Aetna Commercial |
$115.06
|
| Rate for Payer: BCBS Trust/PPO |
$104.61
|
| Rate for Payer: BCN Commercial |
$104.61
|
| Rate for Payer: Cash Price |
$108.29
|
| Rate for Payer: Cofinity Commercial |
$116.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$108.29
|
| Rate for Payer: Healthscope Commercial |
$121.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$101.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$115.06
|
| Rate for Payer: PHP Commercial |
$115.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$94.75
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$117.76
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$82.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$119.12
|
| Rate for Payer: UHC Core |
$113.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$101.52
|
|
|
DROPERIDOL 2.5 MG/ML INJECTION SOLUTION
|
Facility
|
IP
|
$52.44
|
|
|
Service Code
|
HCPCS J1790
|
| Hospital Charge Code |
2654
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$31.98 |
| Max. Negotiated Rate |
$47.20 |
| Rate for Payer: Aetna Commercial |
$44.57
|
| Rate for Payer: BCBS Trust/PPO |
$40.53
|
| Rate for Payer: BCN Commercial |
$40.53
|
| Rate for Payer: Cash Price |
$41.95
|
| Rate for Payer: Cofinity Commercial |
$45.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.95
|
| Rate for Payer: Healthscope Commercial |
$47.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$39.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$44.57
|
| Rate for Payer: PHP Commercial |
$44.57
|
| Rate for Payer: Priority Health Cigna Priority Health |
$36.71
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$45.62
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$31.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$46.15
|
| Rate for Payer: UHC Core |
$43.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$39.33
|
|
|
DRUG TEST PRESUMPTIVE READ BY INSTR ASSISTED DIRECT OPTICAL OBS
|
Professional
|
Both
|
$16.00
|
|
|
Service Code
|
HCPCS G0478
|
| Min. Negotiated Rate |
$6.40 |
| Max. Negotiated Rate |
$16.78 |
| Rate for Payer: BCBS Complete |
$6.40
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Cash Price |
$12.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$16.78
|
|
|
DRUG TEST PRESUMPTIVE USING IMMUNOASSAY
|
Professional
|
Both
|
$80.00
|
|
|
Service Code
|
HCPCS G0479
|
| Min. Negotiated Rate |
$32.00 |
| Max. Negotiated Rate |
$67.44 |
| Rate for Payer: BCBS Complete |
$32.00
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Cash Price |
$64.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$67.44
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$67.44
|
|
