|
DOBUTAMINE 500 MG/250 ML (2,000 MCG/ML) IN 5 % DEXTROSE IV
|
Facility
|
IP
|
$80.33
|
|
|
Service Code
|
HCPCS J1250
|
| Hospital Charge Code |
18315
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$56.23 |
| Max. Negotiated Rate |
$80.33 |
| Rate for Payer: Aetna Commercial |
$72.30
|
| Rate for Payer: ASR ASR |
$77.92
|
| Rate for Payer: BCBS Trust/PPO |
$62.28
|
| Rate for Payer: BCN Commercial |
$62.28
|
| Rate for Payer: Cash Price |
$64.26
|
| Rate for Payer: Cofinity Commercial |
$75.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$64.26
|
| Rate for Payer: Healthscope Commercial |
$80.33
|
| Rate for Payer: Healthscope Whirlpool |
$77.92
|
| Rate for Payer: Mclaren Commercial |
$72.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$68.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$56.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$70.69
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
IP
|
$183.70
|
|
|
Service Code
|
NDC 60687-129-01
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$128.59 |
| Max. Negotiated Rate |
$183.70 |
| Rate for Payer: Aetna Commercial |
$165.33
|
| Rate for Payer: ASR ASR |
$178.19
|
| Rate for Payer: BCBS Trust/PPO |
$142.42
|
| Rate for Payer: BCN Commercial |
$142.42
|
| Rate for Payer: Cash Price |
$146.96
|
| Rate for Payer: Cofinity Commercial |
$172.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$146.96
|
| Rate for Payer: Healthscope Commercial |
$183.70
|
| Rate for Payer: Healthscope Whirlpool |
$178.19
|
| Rate for Payer: Mclaren Commercial |
$165.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$156.14
|
| Rate for Payer: Priority Health Cigna Priority Health |
$128.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$161.66
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
IP
|
$1.84
|
|
|
Service Code
|
NDC 60687-129-11
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.29 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Aetna Commercial |
$1.66
|
| Rate for Payer: ASR ASR |
$1.78
|
| Rate for Payer: BCBS Trust/PPO |
$1.43
|
| Rate for Payer: BCN Commercial |
$1.43
|
| Rate for Payer: Cash Price |
$1.47
|
| Rate for Payer: Cofinity Commercial |
$1.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.47
|
| Rate for Payer: Healthscope Commercial |
$1.84
|
| Rate for Payer: Healthscope Whirlpool |
$1.78
|
| Rate for Payer: Mclaren Commercial |
$1.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$1.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$1.62
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
IP
|
$88.20
|
|
|
Service Code
|
NDC 0904-6998-60
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$61.74 |
| Max. Negotiated Rate |
$88.20 |
| Rate for Payer: Aetna Commercial |
$79.38
|
| Rate for Payer: ASR ASR |
$85.55
|
| Rate for Payer: BCBS Trust/PPO |
$68.38
|
| Rate for Payer: BCN Commercial |
$68.38
|
| Rate for Payer: Cash Price |
$70.56
|
| Rate for Payer: Cofinity Commercial |
$82.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$70.56
|
| Rate for Payer: Healthscope Commercial |
$88.20
|
| Rate for Payer: Healthscope Whirlpool |
$85.55
|
| Rate for Payer: Mclaren Commercial |
$79.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$74.97
|
| Rate for Payer: Priority Health Cigna Priority Health |
$61.74
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$77.62
|
|
|
DOCUSATE SODIUM 100 MG CAPSULE
|
Facility
|
IP
|
$189.00
|
|
|
Service Code
|
NDC 63739-478-10
|
| Hospital Charge Code |
2566
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$132.30 |
| Max. Negotiated Rate |
$189.00 |
| Rate for Payer: Aetna Commercial |
$170.10
|
| Rate for Payer: ASR ASR |
$183.33
|
| Rate for Payer: BCBS Trust/PPO |
$146.53
|
| Rate for Payer: BCN Commercial |
$146.53
|
| Rate for Payer: Cash Price |
$151.20
|
| Rate for Payer: Cofinity Commercial |
$177.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$151.20
|
| Rate for Payer: Healthscope Commercial |
$189.00
|
| Rate for Payer: Healthscope Whirlpool |
$183.33
|
| Rate for Payer: Mclaren Commercial |
$170.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$160.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$132.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$166.32
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$59.22
|
|
|
Service Code
|
NDC 43547-275-09
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.45 |
| Max. Negotiated Rate |
$59.22 |
| Rate for Payer: Aetna Commercial |
$53.30
|
| Rate for Payer: ASR ASR |
$57.44
|
| Rate for Payer: BCBS Trust/PPO |
$45.91
|
| Rate for Payer: BCN Commercial |
$45.91
|
| Rate for Payer: Cash Price |
$47.38
|
| Rate for Payer: Cofinity Commercial |
$55.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.38
|
| Rate for Payer: Healthscope Commercial |
$59.22
|
| Rate for Payer: Healthscope Whirlpool |
$57.44
|
| Rate for Payer: Mclaren Commercial |
$53.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$50.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$41.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$52.11
|
|
|
DONEPEZIL 5 MG TABLET
|
Facility
|
IP
|
$256.15
|
|
|
Service Code
|
NDC 0904-6477-61
|
| Hospital Charge Code |
18786
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$179.30 |
| Max. Negotiated Rate |
$256.15 |
| Rate for Payer: Aetna Commercial |
$230.54
|
| Rate for Payer: ASR ASR |
$248.47
|
| Rate for Payer: BCBS Trust/PPO |
$198.59
|
| Rate for Payer: BCN Commercial |
$198.59
|
| Rate for Payer: Cash Price |
$204.92
|
| Rate for Payer: Cofinity Commercial |
$240.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$204.92
|
| Rate for Payer: Healthscope Commercial |
$256.15
|
| Rate for Payer: Healthscope Whirlpool |
$248.47
|
| Rate for Payer: Mclaren Commercial |
$230.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$217.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$179.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$225.41
|
|
|
DOPAMINE 400 MG/250 ML (1,600 MCG/ML) IN 5 % DEXTROSE INTRAVENOUS SOLN
|
Facility
|
IP
|
$71.14
|
|
|
Service Code
|
HCPCS J1265
|
| Hospital Charge Code |
14845
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$49.80 |
| Max. Negotiated Rate |
$71.14 |
| Rate for Payer: Aetna Commercial |
$64.03
|
| Rate for Payer: ASR ASR |
$69.01
|
| Rate for Payer: BCBS Trust/PPO |
$55.15
|
| Rate for Payer: BCN Commercial |
$55.15
|
| Rate for Payer: Cash Price |
$56.92
|
| Rate for Payer: Cofinity Commercial |
$66.87
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.91
|
| Rate for Payer: Healthscope Commercial |
$71.14
|
| Rate for Payer: Healthscope Whirlpool |
$69.01
|
| Rate for Payer: Mclaren Commercial |
$64.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.47
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.60
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$120.44
|
|
|
Service Code
|
NDC 50383-232-10
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$84.31 |
| Max. Negotiated Rate |
$120.44 |
| Rate for Payer: Aetna Commercial |
$108.40
|
| Rate for Payer: ASR ASR |
$116.83
|
| Rate for Payer: BCBS Trust/PPO |
$93.38
|
| 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 Multiplan/Beech St/PHCS |
$102.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$84.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.99
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$116.96
|
|
|
Service Code
|
NDC 24208-485-10
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$81.87 |
| Max. Negotiated Rate |
$116.96 |
| Rate for Payer: Aetna Commercial |
$105.26
|
| Rate for Payer: ASR ASR |
$113.45
|
| Rate for Payer: BCBS Trust/PPO |
$90.68
|
| 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 Multiplan/Beech St/PHCS |
$99.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$81.87
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$102.92
|
|
|
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 |
$25.93 |
| Max. Negotiated Rate |
$37.04 |
| Rate for Payer: Aetna Commercial |
$33.34
|
| Rate for Payer: ASR ASR |
$35.93
|
| Rate for Payer: BCBS Trust/PPO |
$28.72
|
| Rate for Payer: BCN Commercial |
$28.72
|
| Rate for Payer: Cash Price |
$29.63
|
| Rate for Payer: Cofinity Commercial |
$34.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.63
|
| Rate for Payer: Healthscope Commercial |
$37.04
|
| Rate for Payer: Healthscope Whirlpool |
$35.93
|
| Rate for Payer: Mclaren Commercial |
$33.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$25.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$32.60
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$3.19
|
|
|
Service Code
|
NDC 51079-437-01
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.23 |
| Max. Negotiated Rate |
$3.19 |
| Rate for Payer: Aetna Commercial |
$2.87
|
| Rate for Payer: ASR ASR |
$3.09
|
| Rate for Payer: BCBS Trust/PPO |
$2.47
|
| Rate for Payer: BCN Commercial |
$2.47
|
| Rate for Payer: Cash Price |
$2.55
|
| Rate for Payer: Cofinity Commercial |
$3.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.55
|
| Rate for Payer: Healthscope Commercial |
$3.19
|
| Rate for Payer: Healthscope Whirlpool |
$3.09
|
| Rate for Payer: Mclaren Commercial |
$2.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.81
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$275.04
|
|
|
Service Code
|
NDC 0378-3125-01
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$192.53 |
| Max. Negotiated Rate |
$275.04 |
| Rate for Payer: Aetna Commercial |
$247.54
|
| Rate for Payer: ASR ASR |
$266.79
|
| Rate for Payer: BCBS Trust/PPO |
$213.24
|
| 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 Multiplan/Beech St/PHCS |
$233.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$192.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$242.04
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$290.88
|
|
|
Service Code
|
NDC 50268-278-15
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.62 |
| Max. Negotiated Rate |
$290.88 |
| Rate for Payer: Aetna Commercial |
$261.79
|
| Rate for Payer: ASR ASR |
$282.15
|
| Rate for Payer: BCBS Trust/PPO |
$225.52
|
| Rate for Payer: BCN Commercial |
$225.52
|
| Rate for Payer: Cash Price |
$232.70
|
| Rate for Payer: Cofinity Commercial |
$273.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$232.70
|
| Rate for Payer: Healthscope Commercial |
$290.88
|
| Rate for Payer: Healthscope Whirlpool |
$282.15
|
| Rate for Payer: Mclaren Commercial |
$261.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$247.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$255.97
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$282.96
|
|
|
Service Code
|
NDC 0904-0428-06
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$198.07 |
| Max. Negotiated Rate |
$282.96 |
| Rate for Payer: Aetna Commercial |
$254.66
|
| Rate for Payer: ASR ASR |
$274.47
|
| Rate for Payer: BCBS Trust/PPO |
$219.38
|
| Rate for Payer: BCN Commercial |
$219.38
|
| Rate for Payer: Cash Price |
$226.37
|
| Rate for Payer: Cofinity Commercial |
$265.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$226.37
|
| Rate for Payer: Healthscope Commercial |
$282.96
|
| Rate for Payer: Healthscope Whirlpool |
$274.47
|
| Rate for Payer: Mclaren Commercial |
$254.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$240.52
|
| Rate for Payer: Priority Health Cigna Priority Health |
$198.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$249.00
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$162.93
|
|
|
Service Code
|
NDC 0143-3142-50
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$114.05 |
| Max. Negotiated Rate |
$162.93 |
| Rate for Payer: Aetna Commercial |
$146.64
|
| Rate for Payer: ASR ASR |
$158.04
|
| Rate for Payer: BCBS Trust/PPO |
$126.32
|
| 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 Multiplan/Beech St/PHCS |
$138.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$114.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$143.38
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$7.03
|
|
|
Service Code
|
NDC 60687-513-11
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.92 |
| Max. Negotiated Rate |
$7.03 |
| Rate for Payer: Aetna Commercial |
$6.33
|
| Rate for Payer: ASR ASR |
$6.82
|
| Rate for Payer: BCBS Trust/PPO |
$5.45
|
| Rate for Payer: BCN Commercial |
$5.45
|
| Rate for Payer: Cash Price |
$5.62
|
| Rate for Payer: Cofinity Commercial |
$6.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.62
|
| Rate for Payer: Healthscope Commercial |
$7.03
|
| Rate for Payer: Healthscope Whirlpool |
$6.82
|
| Rate for Payer: Mclaren Commercial |
$6.33
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$5.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$6.19
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$290.64
|
|
|
Service Code
|
NDC 53489-119-02
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$203.45 |
| Max. Negotiated Rate |
$290.64 |
| Rate for Payer: Aetna Commercial |
$261.58
|
| Rate for Payer: ASR ASR |
$281.92
|
| Rate for Payer: BCBS Trust/PPO |
$225.33
|
| 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 Multiplan/Beech St/PHCS |
$247.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$203.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$255.76
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$351.36
|
|
|
Service Code
|
NDC 60687-513-65
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$245.95 |
| Max. Negotiated Rate |
$351.36 |
| Rate for Payer: Aetna Commercial |
$316.22
|
| Rate for Payer: ASR ASR |
$340.82
|
| Rate for Payer: BCBS Trust/PPO |
$272.41
|
| Rate for Payer: BCN Commercial |
$272.41
|
| Rate for Payer: Cash Price |
$281.09
|
| Rate for Payer: Cofinity Commercial |
$330.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$281.09
|
| Rate for Payer: Healthscope Commercial |
$351.36
|
| Rate for Payer: Healthscope Whirlpool |
$340.82
|
| Rate for Payer: Mclaren Commercial |
$316.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$298.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$245.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$309.20
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$5.82
|
|
|
Service Code
|
NDC 50268-278-11
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.07 |
| Max. Negotiated Rate |
$5.82 |
| Rate for Payer: Aetna Commercial |
$5.24
|
| Rate for Payer: ASR ASR |
$5.65
|
| Rate for Payer: BCBS Trust/PPO |
$4.51
|
| Rate for Payer: BCN Commercial |
$4.51
|
| Rate for Payer: Cash Price |
$4.65
|
| Rate for Payer: Cofinity Commercial |
$5.47
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.66
|
| Rate for Payer: Healthscope Commercial |
$5.82
|
| Rate for Payer: Healthscope Whirlpool |
$5.65
|
| Rate for Payer: Mclaren Commercial |
$5.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.12
|
|
|
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 |
$48.30 |
| Max. Negotiated Rate |
$69.00 |
| Rate for Payer: Aetna Commercial |
$62.10
|
| Rate for Payer: ASR ASR |
$66.93
|
| Rate for Payer: BCBS Trust/PPO |
$53.50
|
| Rate for Payer: BCN Commercial |
$53.50
|
| Rate for Payer: Cash Price |
$55.20
|
| Rate for Payer: Cofinity Commercial |
$64.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$55.20
|
| Rate for Payer: Healthscope Commercial |
$69.00
|
| Rate for Payer: Healthscope Whirlpool |
$66.93
|
| Rate for Payer: Mclaren Commercial |
$62.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$58.65
|
| Rate for Payer: Priority Health Cigna Priority Health |
$48.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$60.72
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$57.63
|
|
|
Service Code
|
NDC 68382-910-01
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.34 |
| Max. Negotiated Rate |
$57.63 |
| Rate for Payer: Aetna Commercial |
$51.87
|
| Rate for Payer: ASR ASR |
$55.90
|
| Rate for Payer: BCBS Trust/PPO |
$44.68
|
| Rate for Payer: BCN Commercial |
$44.68
|
| Rate for Payer: Cash Price |
$46.10
|
| Rate for Payer: Cofinity Commercial |
$54.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.10
|
| Rate for Payer: Healthscope Commercial |
$57.63
|
| Rate for Payer: Healthscope Whirlpool |
$55.90
|
| Rate for Payer: Mclaren Commercial |
$51.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$50.71
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$68.25
|
|
|
Service Code
|
NDC 63323-130-03
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$47.78 |
| Max. Negotiated Rate |
$68.25 |
| Rate for Payer: Aetna Commercial |
$61.42
|
| Rate for Payer: ASR ASR |
$66.20
|
| Rate for Payer: BCBS Trust/PPO |
$52.91
|
| Rate for Payer: BCN Commercial |
$52.91
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cofinity Commercial |
$64.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.60
|
| Rate for Payer: Healthscope Commercial |
$68.25
|
| Rate for Payer: Healthscope Whirlpool |
$66.20
|
| Rate for Payer: Mclaren Commercial |
$61.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$58.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$60.06
|
|
|
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 |
$47.78 |
| Max. Negotiated Rate |
$68.25 |
| Rate for Payer: Aetna Commercial |
$61.42
|
| Rate for Payer: ASR ASR |
$66.20
|
| Rate for Payer: BCBS Trust/PPO |
$52.91
|
| Rate for Payer: BCN Commercial |
$52.91
|
| Rate for Payer: Cash Price |
$54.60
|
| Rate for Payer: Cofinity Commercial |
$64.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$54.60
|
| Rate for Payer: Healthscope Commercial |
$68.25
|
| Rate for Payer: Healthscope Whirlpool |
$66.20
|
| Rate for Payer: Mclaren Commercial |
$61.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$58.01
|
| Rate for Payer: Priority Health Cigna Priority Health |
$47.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$60.06
|
|
|
DOXYCYCLINE HYCLATE 100 MG INTRAVENOUS POWDER FOR SOLUTION
|
Facility
|
IP
|
$57.63
|
|
|
Service Code
|
NDC 68382-910-10
|
| Hospital Charge Code |
2622
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.34 |
| Max. Negotiated Rate |
$57.63 |
| Rate for Payer: Aetna Commercial |
$51.87
|
| Rate for Payer: ASR ASR |
$55.90
|
| Rate for Payer: BCBS Trust/PPO |
$44.68
|
| Rate for Payer: BCN Commercial |
$44.68
|
| Rate for Payer: Cash Price |
$46.10
|
| Rate for Payer: Cofinity Commercial |
$54.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$46.10
|
| Rate for Payer: Healthscope Commercial |
$57.63
|
| Rate for Payer: Healthscope Whirlpool |
$55.90
|
| Rate for Payer: Mclaren Commercial |
$51.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$48.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$40.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$50.71
|
|
