|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$116.96
|
|
|
Service Code
|
NDC 24208048510
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$76.02 |
| Max. Negotiated Rate |
$116.96 |
| Rate for Payer: Aetna Commercial |
$105.26
|
| Rate for Payer: ASR ASR |
$113.45
|
| Rate for Payer: ASR Commercial |
$113.45
|
| Rate for Payer: BCBS Trust/PPO |
$95.31
|
| Rate for Payer: BCN Commercial |
$90.68
|
| Rate for Payer: Cash Price |
$93.57
|
| Rate for Payer: Cofinity Commercial |
$109.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.57
|
| Rate for Payer: Healthscope Commercial |
$116.96
|
| Rate for Payer: Healthscope Whirlpool |
$113.45
|
| Rate for Payer: Mclaren Commercial |
$105.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.42
|
| Rate for Payer: Nomi Health Commercial |
$95.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$102.92
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$120.44
|
|
|
Service Code
|
NDC 50383023210
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$78.29 |
| Max. Negotiated Rate |
$120.44 |
| Rate for Payer: Aetna Commercial |
$108.40
|
| Rate for Payer: ASR ASR |
$116.83
|
| Rate for Payer: ASR Commercial |
$116.83
|
| Rate for Payer: BCBS Trust/PPO |
$98.15
|
| Rate for Payer: BCN Commercial |
$93.38
|
| Rate for Payer: Cash Price |
$96.35
|
| Rate for Payer: Cofinity Commercial |
$113.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.35
|
| Rate for Payer: Healthscope Commercial |
$120.44
|
| Rate for Payer: Healthscope Whirlpool |
$116.83
|
| Rate for Payer: Mclaren Commercial |
$108.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.37
|
| Rate for Payer: Nomi Health Commercial |
$98.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.99
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$51.62
|
|
|
Service Code
|
NDC 72266019701
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.55 |
| Max. Negotiated Rate |
$51.62 |
| Rate for Payer: Aetna Commercial |
$46.46
|
| Rate for Payer: ASR ASR |
$50.07
|
| Rate for Payer: ASR Commercial |
$50.07
|
| Rate for Payer: BCBS Trust/PPO |
$42.07
|
| Rate for Payer: BCN Commercial |
$40.02
|
| Rate for Payer: Cash Price |
$41.29
|
| Rate for Payer: Cofinity Commercial |
$48.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.30
|
| Rate for Payer: Healthscope Commercial |
$51.62
|
| Rate for Payer: Healthscope Whirlpool |
$50.07
|
| Rate for Payer: Mclaren Commercial |
$46.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.88
|
| Rate for Payer: Nomi Health Commercial |
$42.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.43
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$120.44
|
|
|
Service Code
|
NDC 50383023210
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.18 |
| Max. Negotiated Rate |
$120.44 |
| Rate for Payer: Aetna Commercial |
$108.40
|
| Rate for Payer: Aetna Medicare |
$60.22
|
| Rate for Payer: ASR ASR |
$116.83
|
| Rate for Payer: ASR Commercial |
$116.83
|
| Rate for Payer: BCBS Complete |
$48.18
|
| Rate for Payer: BCBS Trust/PPO |
$98.63
|
| Rate for Payer: BCN Commercial |
$93.38
|
| Rate for Payer: Cash Price |
$96.35
|
| Rate for Payer: Cofinity Commercial |
$113.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$96.35
|
| Rate for Payer: Healthscope Commercial |
$120.44
|
| Rate for Payer: Healthscope Whirlpool |
$116.83
|
| Rate for Payer: Mclaren Commercial |
$108.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.37
|
| Rate for Payer: Nomi Health Commercial |
$98.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$78.29
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$105.53
|
| Rate for Payer: Priority Health Narrow Network |
$84.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.99
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$51.62
|
|
|
Service Code
|
NDC 72266019701
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.65 |
| Max. Negotiated Rate |
$51.62 |
| Rate for Payer: Aetna Commercial |
$46.46
|
| Rate for Payer: Aetna Medicare |
$25.81
|
| Rate for Payer: ASR ASR |
$50.07
|
| Rate for Payer: ASR Commercial |
$50.07
|
| Rate for Payer: BCBS Complete |
$20.65
|
| Rate for Payer: BCBS Trust/PPO |
$42.27
|
| Rate for Payer: BCN Commercial |
$40.02
|
| Rate for Payer: Cash Price |
$41.29
|
| Rate for Payer: Cofinity Commercial |
$48.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.30
|
| Rate for Payer: Healthscope Commercial |
$51.62
|
| Rate for Payer: Healthscope Whirlpool |
$50.07
|
| Rate for Payer: Mclaren Commercial |
$46.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.88
|
| Rate for Payer: Nomi Health Commercial |
$42.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$33.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$45.23
|
| Rate for Payer: Priority Health Narrow Network |
$36.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.43
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$116.96
|
|
|
Service Code
|
NDC 24208048510
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.78 |
| Max. Negotiated Rate |
$116.96 |
| Rate for Payer: Aetna Commercial |
$105.26
|
| Rate for Payer: Aetna Medicare |
$58.48
|
| Rate for Payer: ASR ASR |
$113.45
|
| Rate for Payer: ASR Commercial |
$113.45
|
| Rate for Payer: BCBS Complete |
$46.78
|
| Rate for Payer: BCBS Trust/PPO |
$95.78
|
| Rate for Payer: BCN Commercial |
$90.68
|
| Rate for Payer: Cash Price |
$93.57
|
| Rate for Payer: Cofinity Commercial |
$109.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$93.57
|
| Rate for Payer: Healthscope Commercial |
$116.96
|
| Rate for Payer: Healthscope Whirlpool |
$113.45
|
| Rate for Payer: Mclaren Commercial |
$105.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.42
|
| Rate for Payer: Nomi Health Commercial |
$95.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$76.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$102.48
|
| Rate for Payer: Priority Health Narrow Network |
$81.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$102.92
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$37.52
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.01 |
| Max. Negotiated Rate |
$37.52 |
| Rate for Payer: Aetna Commercial |
$33.77
|
| Rate for Payer: Aetna Medicare |
$18.76
|
| Rate for Payer: ASR ASR |
$36.39
|
| Rate for Payer: ASR Commercial |
$36.39
|
| Rate for Payer: BCBS Complete |
$15.01
|
| Rate for Payer: BCBS Trust/PPO |
$30.73
|
| Rate for Payer: BCN Commercial |
$29.09
|
| Rate for Payer: Cash Price |
$30.01
|
| Rate for Payer: Cofinity Commercial |
$35.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.02
|
| Rate for Payer: Healthscope Commercial |
$37.52
|
| Rate for Payer: Healthscope Whirlpool |
$36.39
|
| Rate for Payer: Mclaren Commercial |
$33.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.89
|
| Rate for Payer: Nomi Health Commercial |
$30.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.39
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$32.88
|
| Rate for Payer: Priority Health Narrow Network |
$26.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.02
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$37.52
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$24.39 |
| Max. Negotiated Rate |
$37.52 |
| Rate for Payer: Aetna Commercial |
$33.77
|
| Rate for Payer: ASR ASR |
$36.39
|
| Rate for Payer: ASR Commercial |
$36.39
|
| Rate for Payer: BCBS Trust/PPO |
$30.58
|
| Rate for Payer: BCN Commercial |
$29.09
|
| Rate for Payer: Cash Price |
$30.01
|
| Rate for Payer: Cofinity Commercial |
$35.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.02
|
| Rate for Payer: Healthscope Commercial |
$37.52
|
| Rate for Payer: Healthscope Whirlpool |
$36.39
|
| Rate for Payer: Mclaren Commercial |
$33.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.89
|
| Rate for Payer: Nomi Health Commercial |
$30.77
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.02
|
|
|
DOXAZOSIN 4 MG TABLET
|
Facility
|
IP
|
$3.11
|
|
|
Service Code
|
NDC 50268022411
|
| Hospital Charge Code |
9896
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Aetna Commercial |
$2.80
|
| Rate for Payer: ASR ASR |
$3.02
|
| Rate for Payer: ASR Commercial |
$3.02
|
| Rate for Payer: BCBS Trust/PPO |
$2.53
|
| Rate for Payer: BCN Commercial |
$2.41
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.49
|
| Rate for Payer: Healthscope Commercial |
$3.11
|
| Rate for Payer: Healthscope Whirlpool |
$3.02
|
| Rate for Payer: Mclaren Commercial |
$2.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.64
|
| Rate for Payer: Nomi Health Commercial |
$2.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.74
|
|
|
DOXAZOSIN 4 MG TABLET
|
Facility
|
OP
|
$155.52
|
|
|
Service Code
|
NDC 50268022415
|
| Hospital Charge Code |
9896
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$62.21 |
| Max. Negotiated Rate |
$155.52 |
| Rate for Payer: Aetna Commercial |
$139.97
|
| Rate for Payer: Aetna Medicare |
$77.76
|
| Rate for Payer: ASR ASR |
$150.85
|
| Rate for Payer: ASR Commercial |
$150.85
|
| Rate for Payer: BCBS Complete |
$62.21
|
| Rate for Payer: BCBS Trust/PPO |
$127.36
|
| Rate for Payer: BCN Commercial |
$120.57
|
| Rate for Payer: Cash Price |
$124.42
|
| Rate for Payer: Cofinity Commercial |
$146.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.42
|
| Rate for Payer: Healthscope Commercial |
$155.52
|
| Rate for Payer: Healthscope Whirlpool |
$150.85
|
| Rate for Payer: Mclaren Commercial |
$139.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.19
|
| Rate for Payer: Nomi Health Commercial |
$127.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$136.27
|
| Rate for Payer: Priority Health Narrow Network |
$109.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$136.86
|
|
|
DOXAZOSIN 4 MG TABLET
|
Facility
|
IP
|
$155.52
|
|
|
Service Code
|
NDC 50268022415
|
| Hospital Charge Code |
9896
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.09 |
| Max. Negotiated Rate |
$155.52 |
| Rate for Payer: Aetna Commercial |
$139.97
|
| Rate for Payer: ASR ASR |
$150.85
|
| Rate for Payer: ASR Commercial |
$150.85
|
| Rate for Payer: BCBS Trust/PPO |
$126.73
|
| Rate for Payer: BCN Commercial |
$120.57
|
| Rate for Payer: Cash Price |
$124.42
|
| Rate for Payer: Cofinity Commercial |
$146.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$124.42
|
| Rate for Payer: Healthscope Commercial |
$155.52
|
| Rate for Payer: Healthscope Whirlpool |
$150.85
|
| Rate for Payer: Mclaren Commercial |
$139.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$132.19
|
| Rate for Payer: Nomi Health Commercial |
$127.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$101.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$136.86
|
|
|
DOXAZOSIN 4 MG TABLET
|
Facility
|
OP
|
$3.11
|
|
|
Service Code
|
NDC 50268022411
|
| Hospital Charge Code |
9896
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.24 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Aetna Commercial |
$2.80
|
| Rate for Payer: Aetna Medicare |
$1.55
|
| Rate for Payer: ASR ASR |
$3.02
|
| Rate for Payer: ASR Commercial |
$3.02
|
| Rate for Payer: BCBS Complete |
$1.24
|
| Rate for Payer: BCBS Trust/PPO |
$2.55
|
| Rate for Payer: BCN Commercial |
$2.41
|
| Rate for Payer: Cash Price |
$2.49
|
| Rate for Payer: Cofinity Commercial |
$2.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.49
|
| Rate for Payer: Healthscope Commercial |
$3.11
|
| Rate for Payer: Healthscope Whirlpool |
$3.02
|
| Rate for Payer: Mclaren Commercial |
$2.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.64
|
| Rate for Payer: Nomi Health Commercial |
$2.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.02
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.72
|
| Rate for Payer: Priority Health Narrow Network |
$2.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.74
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$275.04
|
|
|
Service Code
|
NDC 00378312501
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$178.78 |
| Max. Negotiated Rate |
$275.04 |
| Rate for Payer: Aetna Commercial |
$247.54
|
| Rate for Payer: ASR ASR |
$266.79
|
| Rate for Payer: ASR Commercial |
$266.79
|
| Rate for Payer: BCBS Trust/PPO |
$224.13
|
| Rate for Payer: BCN Commercial |
$213.24
|
| Rate for Payer: Cash Price |
$220.03
|
| Rate for Payer: Cofinity Commercial |
$258.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.03
|
| Rate for Payer: Healthscope Commercial |
$275.04
|
| Rate for Payer: Healthscope Whirlpool |
$266.79
|
| Rate for Payer: Mclaren Commercial |
$247.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$233.78
|
| Rate for Payer: Nomi Health Commercial |
$225.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$242.04
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
OP
|
$3.40
|
|
|
Service Code
|
NDC 51079043701
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Aetna Commercial |
$3.06
|
| Rate for Payer: Aetna Medicare |
$1.70
|
| Rate for Payer: ASR ASR |
$3.30
|
| Rate for Payer: ASR Commercial |
$3.30
|
| Rate for Payer: BCBS Complete |
$1.36
|
| Rate for Payer: BCBS Trust/PPO |
$2.78
|
| Rate for Payer: BCN Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$3.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.72
|
| Rate for Payer: Healthscope Commercial |
$3.40
|
| Rate for Payer: Healthscope Whirlpool |
$3.30
|
| Rate for Payer: Mclaren Commercial |
$3.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.89
|
| Rate for Payer: Nomi Health Commercial |
$2.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.98
|
| Rate for Payer: Priority Health Narrow Network |
$2.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.99
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 51079043701
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.21 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Aetna Commercial |
$3.06
|
| Rate for Payer: ASR ASR |
$3.30
|
| Rate for Payer: ASR Commercial |
$3.30
|
| Rate for Payer: BCBS Trust/PPO |
$2.77
|
| Rate for Payer: BCN Commercial |
$2.64
|
| Rate for Payer: Cash Price |
$2.72
|
| Rate for Payer: Cofinity Commercial |
$3.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.72
|
| Rate for Payer: Healthscope Commercial |
$3.40
|
| Rate for Payer: Healthscope Whirlpool |
$3.30
|
| Rate for Payer: Mclaren Commercial |
$3.06
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.89
|
| Rate for Payer: Nomi Health Commercial |
$2.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.99
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
OP
|
$275.04
|
|
|
Service Code
|
NDC 00378312501
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$110.02 |
| Max. Negotiated Rate |
$275.04 |
| Rate for Payer: Aetna Commercial |
$247.54
|
| Rate for Payer: Aetna Medicare |
$137.52
|
| Rate for Payer: ASR ASR |
$266.79
|
| Rate for Payer: ASR Commercial |
$266.79
|
| Rate for Payer: BCBS Complete |
$110.02
|
| Rate for Payer: BCBS Trust/PPO |
$225.23
|
| Rate for Payer: BCN Commercial |
$213.24
|
| Rate for Payer: Cash Price |
$220.03
|
| Rate for Payer: Cofinity Commercial |
$258.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$220.03
|
| Rate for Payer: Healthscope Commercial |
$275.04
|
| Rate for Payer: Healthscope Whirlpool |
$266.79
|
| Rate for Payer: Mclaren Commercial |
$247.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$233.78
|
| Rate for Payer: Nomi Health Commercial |
$225.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$178.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$240.99
|
| Rate for Payer: Priority Health Narrow Network |
$192.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$242.04
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$162.93
|
|
|
Service Code
|
NDC 00143314250
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$105.90 |
| Max. Negotiated Rate |
$162.93 |
| Rate for Payer: Aetna Commercial |
$146.64
|
| Rate for Payer: ASR ASR |
$158.04
|
| Rate for Payer: ASR Commercial |
$158.04
|
| Rate for Payer: BCBS Trust/PPO |
$132.77
|
| Rate for Payer: BCN Commercial |
$126.32
|
| Rate for Payer: Cash Price |
$130.34
|
| Rate for Payer: Cofinity Commercial |
$153.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.34
|
| Rate for Payer: Healthscope Commercial |
$162.93
|
| Rate for Payer: Healthscope Whirlpool |
$158.04
|
| Rate for Payer: Mclaren Commercial |
$146.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.49
|
| Rate for Payer: Nomi Health Commercial |
$133.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$143.38
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
OP
|
$290.64
|
|
|
Service Code
|
NDC 53489011902
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$116.26 |
| Max. Negotiated Rate |
$290.64 |
| Rate for Payer: Aetna Commercial |
$261.58
|
| Rate for Payer: Aetna Medicare |
$145.32
|
| Rate for Payer: ASR ASR |
$281.92
|
| Rate for Payer: ASR Commercial |
$281.92
|
| Rate for Payer: BCBS Complete |
$116.26
|
| Rate for Payer: BCBS Trust/PPO |
$238.01
|
| Rate for Payer: BCN Commercial |
$225.33
|
| Rate for Payer: Cash Price |
$232.51
|
| Rate for Payer: Cofinity Commercial |
$273.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.51
|
| Rate for Payer: Healthscope Commercial |
$290.64
|
| Rate for Payer: Healthscope Whirlpool |
$281.92
|
| Rate for Payer: Mclaren Commercial |
$261.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.04
|
| Rate for Payer: Nomi Health Commercial |
$238.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$254.66
|
| Rate for Payer: Priority Health Narrow Network |
$203.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$255.76
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$6.37
|
|
|
Service Code
|
NDC 50268027811
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.14 |
| Max. Negotiated Rate |
$6.37 |
| Rate for Payer: Aetna Commercial |
$5.73
|
| Rate for Payer: ASR ASR |
$6.18
|
| Rate for Payer: ASR Commercial |
$6.18
|
| Rate for Payer: BCBS Trust/PPO |
$5.19
|
| Rate for Payer: BCN Commercial |
$4.94
|
| Rate for Payer: Cash Price |
$5.10
|
| Rate for Payer: Cofinity Commercial |
$5.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.10
|
| Rate for Payer: Healthscope Commercial |
$6.37
|
| Rate for Payer: Healthscope Whirlpool |
$6.18
|
| Rate for Payer: Mclaren Commercial |
$5.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.41
|
| Rate for Payer: Nomi Health Commercial |
$5.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.61
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
OP
|
$318.48
|
|
|
Service Code
|
NDC 50268027815
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$127.39 |
| Max. Negotiated Rate |
$318.48 |
| Rate for Payer: Aetna Commercial |
$286.63
|
| Rate for Payer: Aetna Medicare |
$159.24
|
| Rate for Payer: ASR ASR |
$308.93
|
| Rate for Payer: ASR Commercial |
$308.93
|
| Rate for Payer: BCBS Complete |
$127.39
|
| Rate for Payer: BCBS Trust/PPO |
$260.80
|
| Rate for Payer: BCN Commercial |
$246.92
|
| Rate for Payer: Cash Price |
$254.78
|
| Rate for Payer: Cofinity Commercial |
$299.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.78
|
| Rate for Payer: Healthscope Commercial |
$318.48
|
| Rate for Payer: Healthscope Whirlpool |
$308.93
|
| Rate for Payer: Mclaren Commercial |
$286.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.71
|
| Rate for Payer: Nomi Health Commercial |
$261.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$279.05
|
| Rate for Payer: Priority Health Narrow Network |
$223.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$280.26
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$358.32
|
|
|
Service Code
|
NDC 60687051365
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$232.91 |
| Max. Negotiated Rate |
$358.32 |
| Rate for Payer: Aetna Commercial |
$322.49
|
| Rate for Payer: ASR ASR |
$347.57
|
| Rate for Payer: ASR Commercial |
$347.57
|
| Rate for Payer: BCBS Trust/PPO |
$291.99
|
| Rate for Payer: BCN Commercial |
$277.81
|
| Rate for Payer: Cash Price |
$286.66
|
| Rate for Payer: Cofinity Commercial |
$336.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$286.66
|
| Rate for Payer: Healthscope Commercial |
$358.32
|
| Rate for Payer: Healthscope Whirlpool |
$347.57
|
| Rate for Payer: Mclaren Commercial |
$322.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$304.57
|
| Rate for Payer: Nomi Health Commercial |
$293.82
|
| Rate for Payer: Priority Health Cigna Priority Health |
$232.91
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$315.32
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
OP
|
$7.17
|
|
|
Service Code
|
NDC 60687051311
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.87 |
| Max. Negotiated Rate |
$7.17 |
| Rate for Payer: Aetna Commercial |
$6.45
|
| Rate for Payer: Aetna Medicare |
$3.58
|
| Rate for Payer: ASR ASR |
$6.95
|
| Rate for Payer: ASR Commercial |
$6.95
|
| Rate for Payer: BCBS Complete |
$2.87
|
| Rate for Payer: BCBS Trust/PPO |
$5.87
|
| Rate for Payer: BCN Commercial |
$5.56
|
| Rate for Payer: Cash Price |
$5.73
|
| Rate for Payer: Cofinity Commercial |
$6.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.74
|
| Rate for Payer: Healthscope Commercial |
$7.17
|
| Rate for Payer: Healthscope Whirlpool |
$6.95
|
| Rate for Payer: Mclaren Commercial |
$6.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.09
|
| Rate for Payer: Nomi Health Commercial |
$5.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.66
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.28
|
| Rate for Payer: Priority Health Narrow Network |
$5.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.31
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
OP
|
$162.93
|
|
|
Service Code
|
NDC 00143314250
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.17 |
| Max. Negotiated Rate |
$162.93 |
| Rate for Payer: Aetna Commercial |
$146.64
|
| Rate for Payer: Aetna Medicare |
$81.47
|
| Rate for Payer: ASR ASR |
$158.04
|
| Rate for Payer: ASR Commercial |
$158.04
|
| Rate for Payer: BCBS Complete |
$65.17
|
| Rate for Payer: BCBS Trust/PPO |
$133.42
|
| Rate for Payer: BCN Commercial |
$126.32
|
| Rate for Payer: Cash Price |
$130.34
|
| Rate for Payer: Cofinity Commercial |
$153.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$130.34
|
| Rate for Payer: Healthscope Commercial |
$162.93
|
| Rate for Payer: Healthscope Whirlpool |
$158.04
|
| Rate for Payer: Mclaren Commercial |
$146.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$138.49
|
| Rate for Payer: Nomi Health Commercial |
$133.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$105.90
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$142.76
|
| Rate for Payer: Priority Health Narrow Network |
$114.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$143.38
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$290.64
|
|
|
Service Code
|
NDC 53489011902
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$188.92 |
| Max. Negotiated Rate |
$290.64 |
| Rate for Payer: Aetna Commercial |
$261.58
|
| Rate for Payer: ASR ASR |
$281.92
|
| Rate for Payer: ASR Commercial |
$281.92
|
| Rate for Payer: BCBS Trust/PPO |
$236.84
|
| Rate for Payer: BCN Commercial |
$225.33
|
| Rate for Payer: Cash Price |
$232.51
|
| Rate for Payer: Cofinity Commercial |
$273.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.51
|
| Rate for Payer: Healthscope Commercial |
$290.64
|
| Rate for Payer: Healthscope Whirlpool |
$281.92
|
| Rate for Payer: Mclaren Commercial |
$261.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$247.04
|
| Rate for Payer: Nomi Health Commercial |
$238.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$188.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$255.76
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$318.48
|
|
|
Service Code
|
NDC 50268027815
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$207.01 |
| Max. Negotiated Rate |
$318.48 |
| Rate for Payer: Aetna Commercial |
$286.63
|
| Rate for Payer: ASR ASR |
$308.93
|
| Rate for Payer: ASR Commercial |
$308.93
|
| Rate for Payer: BCBS Trust/PPO |
$259.53
|
| Rate for Payer: BCN Commercial |
$246.92
|
| Rate for Payer: Cash Price |
$254.78
|
| Rate for Payer: Cofinity Commercial |
$299.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$254.78
|
| Rate for Payer: Healthscope Commercial |
$318.48
|
| Rate for Payer: Healthscope Whirlpool |
$308.93
|
| Rate for Payer: Mclaren Commercial |
$286.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$270.71
|
| Rate for Payer: Nomi Health Commercial |
$261.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$280.26
|
|
