|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$16,535.96
|
|
|
Service Code
|
APR-DRG 3042
|
| Min. Negotiated Rate |
$14,950.49 |
| Max. Negotiated Rate |
$16,535.96 |
| Rate for Payer: BCBS Complete |
$16,535.96
|
| Rate for Payer: Mclaren Medicaid |
$15,748.54
|
| Rate for Payer: Meridian Medicaid |
$16,535.96
|
| Rate for Payer: PHP Medicaid |
$14,950.49
|
| Rate for Payer: Priority Health Choice Medicaid |
$15,748.54
|
| Rate for Payer: UHC Medicaid |
$15,748.54
|
| Rate for Payer: UHCCP Medicaid |
$15,748.54
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$31,208.74
|
|
|
Service Code
|
APR-DRG 3044
|
| Min. Negotiated Rate |
$28,216.44 |
| Max. Negotiated Rate |
$31,208.74 |
| Rate for Payer: BCBS Complete |
$31,208.74
|
| Rate for Payer: Mclaren Medicaid |
$29,722.61
|
| Rate for Payer: Meridian Medicaid |
$31,208.74
|
| Rate for Payer: PHP Medicaid |
$28,216.44
|
| Rate for Payer: Priority Health Choice Medicaid |
$29,722.61
|
| Rate for Payer: UHC Medicaid |
$29,722.61
|
| Rate for Payer: UHCCP Medicaid |
$29,722.61
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$24,207.22
|
|
|
Service Code
|
APR-DRG 3043
|
| Min. Negotiated Rate |
$21,886.23 |
| Max. Negotiated Rate |
$24,207.22 |
| Rate for Payer: BCBS Complete |
$24,207.22
|
| Rate for Payer: Mclaren Medicaid |
$23,054.50
|
| Rate for Payer: Meridian Medicaid |
$24,207.22
|
| Rate for Payer: PHP Medicaid |
$21,886.23
|
| Rate for Payer: Priority Health Choice Medicaid |
$23,054.50
|
| Rate for Payer: UHC Medicaid |
$23,054.50
|
| Rate for Payer: UHCCP Medicaid |
$23,054.50
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE EXCEPT FOR CURVATURE OF BACK
|
Facility
|
IP
|
$12,978.53
|
|
|
Service Code
|
APR-DRG 3041
|
| Min. Negotiated Rate |
$11,734.14 |
| Max. Negotiated Rate |
$12,978.53 |
| Rate for Payer: BCBS Complete |
$12,978.53
|
| Rate for Payer: Mclaren Medicaid |
$12,360.50
|
| Rate for Payer: Meridian Medicaid |
$12,978.53
|
| Rate for Payer: PHP Medicaid |
$11,734.14
|
| Rate for Payer: Priority Health Choice Medicaid |
$12,360.50
|
| Rate for Payer: UHC Medicaid |
$12,360.50
|
| Rate for Payer: UHCCP Medicaid |
$12,360.50
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$36,131.27
|
|
|
Service Code
|
APR-DRG 3033
|
| Min. Negotiated Rate |
$32,667.00 |
| Max. Negotiated Rate |
$36,131.27 |
| Rate for Payer: BCBS Complete |
$36,131.27
|
| Rate for Payer: Mclaren Medicaid |
$34,410.74
|
| Rate for Payer: Meridian Medicaid |
$36,131.27
|
| Rate for Payer: PHP Medicaid |
$32,667.00
|
| Rate for Payer: Priority Health Choice Medicaid |
$34,410.74
|
| Rate for Payer: UHC Medicaid |
$34,410.74
|
| Rate for Payer: UHCCP Medicaid |
$34,410.74
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$56,694.96
|
|
|
Service Code
|
APR-DRG 3034
|
| Min. Negotiated Rate |
$51,259.03 |
| Max. Negotiated Rate |
$56,694.96 |
| Rate for Payer: BCBS Complete |
$56,694.96
|
| Rate for Payer: Mclaren Medicaid |
$53,995.20
|
| Rate for Payer: Meridian Medicaid |
$56,694.96
|
| Rate for Payer: PHP Medicaid |
$51,259.03
|
| Rate for Payer: Priority Health Choice Medicaid |
$53,995.20
|
| Rate for Payer: UHC Medicaid |
$53,995.20
|
| Rate for Payer: UHCCP Medicaid |
$53,995.20
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$25,034.46
|
|
|
Service Code
|
APR-DRG 3032
|
| Min. Negotiated Rate |
$22,634.15 |
| Max. Negotiated Rate |
$25,034.46 |
| Rate for Payer: BCBS Complete |
$25,034.46
|
| Rate for Payer: Mclaren Medicaid |
$23,842.34
|
| Rate for Payer: Meridian Medicaid |
$25,034.46
|
| Rate for Payer: PHP Medicaid |
$22,634.15
|
| Rate for Payer: Priority Health Choice Medicaid |
$23,842.34
|
| Rate for Payer: UHC Medicaid |
$23,842.34
|
| Rate for Payer: UHCCP Medicaid |
$23,842.34
|
|
|
DORSAL AND LUMBAR FUSION PROCEDURE FOR CURVATURE OF BACK
|
Facility
|
IP
|
$22,494.99
|
|
|
Service Code
|
APR-DRG 3031
|
| Min. Negotiated Rate |
$20,338.16 |
| Max. Negotiated Rate |
$22,494.99 |
| Rate for Payer: BCBS Complete |
$22,494.99
|
| Rate for Payer: Mclaren Medicaid |
$21,423.80
|
| Rate for Payer: Meridian Medicaid |
$22,494.99
|
| Rate for Payer: PHP Medicaid |
$20,338.16
|
| Rate for Payer: Priority Health Choice Medicaid |
$21,423.80
|
| Rate for Payer: UHC Medicaid |
$21,423.80
|
| Rate for Payer: UHCCP Medicaid |
$21,423.80
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$116.96
|
|
|
Service Code
|
NDC 24208048510
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.27 |
| Max. Negotiated Rate |
$116.96 |
| Rate for Payer: Aetna Commercial |
$105.26
|
| Rate for Payer: Aetna Medicare |
$43.27
|
| Rate for Payer: ASR ASR |
$113.45
|
| Rate for Payer: BCBS Complete |
$46.78
|
| Rate for Payer: BCBS Trust/PPO |
$96.43
|
| Rate for Payer: BCN Commercial |
$96.43
|
| 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 |
$113.45
|
| Rate for Payer: Healthscope Whirlpool |
$116.96
|
| Rate for Payer: Mclaren Commercial |
$105.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$93.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.41
|
| Rate for Payer: Nomi Health Commercial |
$95.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$87.72
|
| Rate for Payer: Priority Health Cigna 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
|
$51.62
|
|
|
Service Code
|
NDC 72266019701
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.10 |
| Max. Negotiated Rate |
$51.62 |
| Rate for Payer: Aetna Commercial |
$46.45
|
| Rate for Payer: Aetna Medicare |
$19.10
|
| Rate for Payer: ASR ASR |
$50.07
|
| Rate for Payer: BCBS Complete |
$20.65
|
| Rate for Payer: BCBS Trust/PPO |
$42.56
|
| Rate for Payer: BCN Commercial |
$42.56
|
| Rate for Payer: Cash Price |
$41.29
|
| Rate for Payer: Cofinity Commercial |
$48.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.29
|
| Rate for Payer: Healthscope Commercial |
$50.07
|
| Rate for Payer: Healthscope Whirlpool |
$51.62
|
| Rate for Payer: Mclaren Commercial |
$46.45
|
| Rate for Payer: MI Amish Medical Board Commercial |
$41.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.87
|
| Rate for Payer: Nomi Health Commercial |
$42.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.71
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$45.23
|
| Rate for Payer: Priority Health Narrow Network |
$36.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.42
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$116.96
|
|
|
Service Code
|
NDC 24208048510
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$87.72 |
| 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 |
$96.05
|
| Rate for Payer: BCN Commercial |
$96.05
|
| 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 |
$113.45
|
| Rate for Payer: Healthscope Whirlpool |
$116.96
|
| Rate for Payer: Mclaren Commercial |
$105.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$99.41
|
| Rate for Payer: Nomi Health Commercial |
$95.90
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$87.72
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$102.92
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$86.03
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$64.52 |
| Max. Negotiated Rate |
$86.03 |
| Rate for Payer: Aetna Commercial |
$77.42
|
| Rate for Payer: ASR ASR |
$83.44
|
| Rate for Payer: BCBS Trust/PPO |
$70.64
|
| Rate for Payer: BCN Commercial |
$70.64
|
| Rate for Payer: Cash Price |
$68.82
|
| Rate for Payer: Cofinity Commercial |
$80.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.82
|
| Rate for Payer: Healthscope Commercial |
$83.44
|
| Rate for Payer: Healthscope Whirlpool |
$86.03
|
| Rate for Payer: Mclaren Commercial |
$77.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.12
|
| Rate for Payer: Nomi Health Commercial |
$70.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.70
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$120.44
|
|
|
Service Code
|
NDC 50383023210
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.56 |
| Max. Negotiated Rate |
$120.44 |
| Rate for Payer: Aetna Commercial |
$108.39
|
| Rate for Payer: Aetna Medicare |
$44.56
|
| Rate for Payer: ASR ASR |
$116.82
|
| Rate for Payer: BCBS Complete |
$48.17
|
| Rate for Payer: BCBS Trust/PPO |
$99.30
|
| Rate for Payer: BCN Commercial |
$99.30
|
| 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 |
$116.82
|
| Rate for Payer: Healthscope Whirlpool |
$120.44
|
| Rate for Payer: Mclaren Commercial |
$108.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$96.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.37
|
| Rate for Payer: Nomi Health Commercial |
$98.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$90.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$105.53
|
| Rate for Payer: Priority Health Narrow Network |
$84.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.98
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$120.44
|
|
|
Service Code
|
NDC 50383023210
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$90.33 |
| Max. Negotiated Rate |
$120.44 |
| Rate for Payer: Aetna Commercial |
$108.39
|
| Rate for Payer: ASR ASR |
$116.82
|
| Rate for Payer: BCBS Trust/PPO |
$98.90
|
| Rate for Payer: BCN Commercial |
$98.90
|
| 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 |
$116.82
|
| Rate for Payer: Healthscope Whirlpool |
$120.44
|
| Rate for Payer: Mclaren Commercial |
$108.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$102.37
|
| Rate for Payer: Nomi Health Commercial |
$98.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$90.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$105.98
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
OP
|
$86.03
|
|
|
Service Code
|
NDC 61314001910
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.83 |
| Max. Negotiated Rate |
$86.03 |
| Rate for Payer: Aetna Commercial |
$77.42
|
| Rate for Payer: Aetna Medicare |
$31.83
|
| Rate for Payer: ASR ASR |
$83.44
|
| Rate for Payer: BCBS Complete |
$34.41
|
| Rate for Payer: BCBS Trust/PPO |
$70.93
|
| Rate for Payer: BCN Commercial |
$70.93
|
| Rate for Payer: Cash Price |
$68.82
|
| Rate for Payer: Cofinity Commercial |
$80.86
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$68.82
|
| Rate for Payer: Healthscope Commercial |
$83.44
|
| Rate for Payer: Healthscope Whirlpool |
$86.03
|
| Rate for Payer: Mclaren Commercial |
$77.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$68.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$73.12
|
| Rate for Payer: Nomi Health Commercial |
$70.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$64.52
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$75.38
|
| Rate for Payer: Priority Health Narrow Network |
$60.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$75.70
|
|
|
DORZOLAMIDE 2 % EYE DROPS
|
Facility
|
IP
|
$51.62
|
|
|
Service Code
|
NDC 72266019701
|
| Hospital Charge Code |
14471
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.71 |
| Max. Negotiated Rate |
$51.62 |
| Rate for Payer: Aetna Commercial |
$46.45
|
| Rate for Payer: ASR ASR |
$50.07
|
| Rate for Payer: BCBS Trust/PPO |
$42.39
|
| Rate for Payer: BCN Commercial |
$42.39
|
| Rate for Payer: Cash Price |
$41.29
|
| Rate for Payer: Cofinity Commercial |
$48.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$41.29
|
| Rate for Payer: Healthscope Commercial |
$50.07
|
| Rate for Payer: Healthscope Whirlpool |
$51.62
|
| Rate for Payer: Mclaren Commercial |
$46.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$43.87
|
| Rate for Payer: Nomi Health Commercial |
$42.32
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$38.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$45.42
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
OP
|
$3.40
|
|
|
Service Code
|
NDC 51079043701
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.26 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Aetna Commercial |
$3.06
|
| Rate for Payer: Aetna Medicare |
$1.26
|
| Rate for Payer: ASR ASR |
$3.30
|
| Rate for Payer: BCBS Complete |
$1.36
|
| Rate for Payer: BCBS Trust/PPO |
$2.80
|
| Rate for Payer: BCN Commercial |
$2.80
|
| 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 |
$3.30
|
| Rate for Payer: Healthscope Whirlpool |
$3.40
|
| Rate for Payer: Mclaren Commercial |
$3.06
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.89
|
| Rate for Payer: Nomi Health Commercial |
$2.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.55
|
| Rate for Payer: Priority Health Cigna 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
|
$275.04
|
|
|
Service Code
|
NDC 378312501
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$206.28 |
| 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 |
$225.86
|
| Rate for Payer: BCN Commercial |
$225.86
|
| 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 |
$266.79
|
| Rate for Payer: Healthscope Whirlpool |
$275.04
|
| 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: Opus (Opus Packaging Group) HMA |
$206.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$242.04
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
IP
|
$3.40
|
|
|
Service Code
|
NDC 51079043701
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.55 |
| Max. Negotiated Rate |
$3.40 |
| Rate for Payer: Aetna Commercial |
$3.06
|
| Rate for Payer: ASR ASR |
$3.30
|
| Rate for Payer: BCBS Trust/PPO |
$2.79
|
| Rate for Payer: BCN Commercial |
$2.79
|
| 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 |
$3.30
|
| Rate for Payer: Healthscope Whirlpool |
$3.40
|
| 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: Opus (Opus Packaging Group) HMA |
$2.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.99
|
|
|
DOXEPIN 25 MG CAPSULE
|
Facility
|
OP
|
$275.04
|
|
|
Service Code
|
NDC 378312501
|
| Hospital Charge Code |
2611
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.76 |
| Max. Negotiated Rate |
$275.04 |
| Rate for Payer: Aetna Commercial |
$247.54
|
| Rate for Payer: Aetna Medicare |
$101.76
|
| Rate for Payer: ASR ASR |
$266.79
|
| Rate for Payer: BCBS Complete |
$110.02
|
| Rate for Payer: BCBS Trust/PPO |
$226.77
|
| Rate for Payer: BCN Commercial |
$226.77
|
| 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 |
$266.79
|
| Rate for Payer: Healthscope Whirlpool |
$275.04
|
| Rate for Payer: Mclaren Commercial |
$247.54
|
| Rate for Payer: MI Amish Medical Board Commercial |
$220.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$233.78
|
| Rate for Payer: Nomi Health Commercial |
$225.53
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$206.28
|
| Rate for Payer: Priority Health Cigna 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
|
$294.00
|
|
|
Service Code
|
NDC 904042806
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$220.50 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: Aetna Commercial |
$264.60
|
| Rate for Payer: ASR ASR |
$285.18
|
| Rate for Payer: BCBS Trust/PPO |
$241.43
|
| Rate for Payer: BCN Commercial |
$241.43
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cofinity Commercial |
$276.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.20
|
| Rate for Payer: Healthscope Commercial |
$285.18
|
| Rate for Payer: Healthscope Whirlpool |
$294.00
|
| Rate for Payer: Mclaren Commercial |
$264.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.90
|
| Rate for Payer: Nomi Health Commercial |
$241.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$220.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$258.72
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
OP
|
$323.52
|
|
|
Service Code
|
NDC 50268027815
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$119.70 |
| Max. Negotiated Rate |
$323.52 |
| Rate for Payer: Aetna Commercial |
$291.17
|
| Rate for Payer: Aetna Medicare |
$119.70
|
| Rate for Payer: ASR ASR |
$313.81
|
| Rate for Payer: BCBS Complete |
$129.41
|
| Rate for Payer: BCBS Trust/PPO |
$266.74
|
| Rate for Payer: BCN Commercial |
$266.74
|
| Rate for Payer: Cash Price |
$258.82
|
| Rate for Payer: Cofinity Commercial |
$304.11
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$258.82
|
| Rate for Payer: Healthscope Commercial |
$313.81
|
| Rate for Payer: Healthscope Whirlpool |
$323.52
|
| Rate for Payer: Mclaren Commercial |
$291.17
|
| Rate for Payer: MI Amish Medical Board Commercial |
$258.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$274.99
|
| Rate for Payer: Nomi Health Commercial |
$265.29
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$242.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$283.47
|
| Rate for Payer: Priority Health Narrow Network |
$226.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$284.70
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
OP
|
$335.52
|
|
|
Service Code
|
NDC 60687051365
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$124.14 |
| Max. Negotiated Rate |
$335.52 |
| Rate for Payer: Aetna Commercial |
$301.97
|
| Rate for Payer: Aetna Medicare |
$124.14
|
| Rate for Payer: ASR ASR |
$325.45
|
| Rate for Payer: BCBS Complete |
$134.21
|
| Rate for Payer: BCBS Trust/PPO |
$276.64
|
| Rate for Payer: BCN Commercial |
$276.64
|
| Rate for Payer: Cash Price |
$268.42
|
| Rate for Payer: Cofinity Commercial |
$315.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$268.42
|
| Rate for Payer: Healthscope Commercial |
$325.45
|
| Rate for Payer: Healthscope Whirlpool |
$335.52
|
| Rate for Payer: Mclaren Commercial |
$301.97
|
| Rate for Payer: MI Amish Medical Board Commercial |
$268.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$285.19
|
| Rate for Payer: Nomi Health Commercial |
$275.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$251.64
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$293.98
|
| Rate for Payer: Priority Health Narrow Network |
$235.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$295.26
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
IP
|
$6.71
|
|
|
Service Code
|
NDC 60687051311
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.03 |
| Max. Negotiated Rate |
$6.71 |
| Rate for Payer: Aetna Commercial |
$6.04
|
| Rate for Payer: ASR ASR |
$6.51
|
| Rate for Payer: BCBS Trust/PPO |
$5.51
|
| Rate for Payer: BCN Commercial |
$5.51
|
| Rate for Payer: Cash Price |
$5.37
|
| Rate for Payer: Cofinity Commercial |
$6.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.37
|
| Rate for Payer: Healthscope Commercial |
$6.51
|
| Rate for Payer: Healthscope Whirlpool |
$6.71
|
| Rate for Payer: Mclaren Commercial |
$6.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$5.70
|
| Rate for Payer: Nomi Health Commercial |
$5.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$5.91
|
|
|
DOXYCYCLINE HYCLATE 100 MG CAPSULE
|
Facility
|
OP
|
$294.00
|
|
|
Service Code
|
NDC 904042806
|
| Hospital Charge Code |
2623
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$108.78 |
| Max. Negotiated Rate |
$294.00 |
| Rate for Payer: Aetna Commercial |
$264.60
|
| Rate for Payer: Aetna Medicare |
$108.78
|
| Rate for Payer: ASR ASR |
$285.18
|
| Rate for Payer: BCBS Complete |
$117.60
|
| Rate for Payer: BCBS Trust/PPO |
$242.40
|
| Rate for Payer: BCN Commercial |
$242.40
|
| Rate for Payer: Cash Price |
$235.20
|
| Rate for Payer: Cofinity Commercial |
$276.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$235.20
|
| Rate for Payer: Healthscope Commercial |
$285.18
|
| Rate for Payer: Healthscope Whirlpool |
$294.00
|
| Rate for Payer: Mclaren Commercial |
$264.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$235.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$249.90
|
| Rate for Payer: Nomi Health Commercial |
$241.08
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$220.50
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$257.60
|
| Rate for Payer: Priority Health Narrow Network |
$206.09
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$258.72
|
|
