Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

doxycycline 100 mg IV Inj [HMC]

Facility

IP

$63.49

Service Code	NDC 63323013011
Hospital Charge Code	3800341
Hospital Revenue Code	250
Min. Negotiated Rate	$57.14
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$57.14
Rate for Payer: UnitedHealthcare Commercial	$60.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxycycline 100 mg IV Inj [HMC]

Facility

OP

$59.10

Service Code	NDC 67457043710
Hospital Charge Code	3800341
Hospital Revenue Code	250
Min. Negotiated Rate	$23.64
Max. Negotiated Rate	$56.15
Rate for Payer: Aetna Commercial	$53.19
Rate for Payer: Humana Medicare Advantage	$24.82
Rate for Payer: UnitedHealthcare Commercial	$56.15
Rate for Payer: UnitedHealthcare Medicaid	$23.64
Rate for Payer: WPPA Medicare Advantage	$35.46

doxycycline hyclate 100 mg Pow [HMC]

Facility

OP

$65.18

Service Code	NDC 66794023741
Hospital Charge Code	3800341
Hospital Revenue Code	250
Min. Negotiated Rate	$26.07
Max. Negotiated Rate	$61.92
Rate for Payer: Aetna Commercial	$58.66
Rate for Payer: Humana Medicare Advantage	$27.38
Rate for Payer: UnitedHealthcare Commercial	$61.92
Rate for Payer: UnitedHealthcare Medicaid	$26.07
Rate for Payer: WPPA Medicare Advantage	$39.11

doxycycline hyclate 100 mg Pow [HMC]

Facility

IP

$65.18

Service Code	NDC 66794023741
Hospital Charge Code	3800341
Hospital Revenue Code	250
Min. Negotiated Rate	$58.66
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$58.66
Rate for Payer: UnitedHealthcare Commercial	$61.92
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxycycline hyclate 100 mg Tab [HMC]

Facility

IP

$18.64

Service Code	NDC 00904043004
Hospital Charge Code	3805302
Hospital Revenue Code	250
Min. Negotiated Rate	$16.78
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.78
Rate for Payer: UnitedHealthcare Commercial	$17.71
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxycycline hyclate 100 mg Tab [HMC]

Facility

OP

$18.83

Service Code	NDC 00143211250
Hospital Charge Code	3805302
Hospital Revenue Code	250
Min. Negotiated Rate	$7.53
Max. Negotiated Rate	$17.89
Rate for Payer: Aetna Commercial	$16.95
Rate for Payer: Humana Medicare Advantage	$7.91
Rate for Payer: UnitedHealthcare Commercial	$17.89
Rate for Payer: UnitedHealthcare Medicaid	$7.53
Rate for Payer: WPPA Medicare Advantage	$11.30

doxycycline hyclate 100 mg Tab [HMC]

Facility

OP

$18.97

Service Code	NDC 62584069321
Hospital Charge Code	3805302
Hospital Revenue Code	250
Min. Negotiated Rate	$7.59
Max. Negotiated Rate	$18.02
Rate for Payer: Aetna Commercial	$17.07
Rate for Payer: Humana Medicare Advantage	$7.97
Rate for Payer: UnitedHealthcare Commercial	$18.02
Rate for Payer: UnitedHealthcare Medicaid	$7.59
Rate for Payer: WPPA Medicare Advantage	$11.38

doxycycline hyclate 100 mg Tab [HMC]

Facility

IP

$18.83

Service Code	NDC 00143211250
Hospital Charge Code	3805302
Hospital Revenue Code	250
Min. Negotiated Rate	$16.95
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$16.95
Rate for Payer: UnitedHealthcare Commercial	$17.89
Rate for Payer: WPPA Medicare Advantage	$1,200.00

doxycycline hyclate 100 mg Tab [HMC]

Facility

OP

$18.64

Service Code	NDC 00904043004
Hospital Charge Code	3805302
Hospital Revenue Code	250
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$17.71
Rate for Payer: Aetna Commercial	$16.78
Rate for Payer: Humana Medicare Advantage	$7.83
Rate for Payer: UnitedHealthcare Commercial	$17.71
Rate for Payer: UnitedHealthcare Medicaid	$7.46
Rate for Payer: WPPA Medicare Advantage	$11.18

doxycycline hyclate 100 mg Tab [HMC]

Facility

IP

$18.97

Service Code	NDC 62584069321
Hospital Charge Code	3805302
Hospital Revenue Code	250
Min. Negotiated Rate	$17.07
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$17.07
Rate for Payer: UnitedHealthcare Commercial	$18.02
Rate for Payer: WPPA Medicare Advantage	$1,200.00

DPS HAERTOE CCI STD Kit 1.25 K-Wire/ -S

Facility

OP

$4,876.00

Hospital Charge Code	3258326
Hospital Revenue Code	270
Min. Negotiated Rate	$1,950.40
Max. Negotiated Rate	$4,632.20
Rate for Payer: Aetna Commercial	$4,388.40
Rate for Payer: Humana Medicare Advantage	$2,047.92
Rate for Payer: UnitedHealthcare Commercial	$4,632.20
Rate for Payer: UnitedHealthcare Medicaid	$1,950.40
Rate for Payer: WPPA Medicare Advantage	$2,925.60

DPS HAERTOE CCI STD Kit 1.25 K-Wire/ -S

Facility

IP

$4,876.00

Hospital Charge Code	3258326
Hospital Revenue Code	270
Min. Negotiated Rate	$1,200.00
Max. Negotiated Rate	$4,632.20
Rate for Payer: Aetna Commercial	$4,388.40
Rate for Payer: UnitedHealthcare Commercial	$4,632.20
Rate for Payer: WPPA Medicare Advantage	$1,200.00

D. Pteronyssinus (D1) IgE QST

Facility

IP

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1009
Hospital Revenue Code	300
Min. Negotiated Rate	$24.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: WPPA Medicare Advantage	$1,200.00

D. Pteronyssinus (D1) IgE QST

Facility

OP

$27.00

Service Code	HCPCS 86003
Hospital Charge Code	LAB1009
Hospital Revenue Code	300
Min. Negotiated Rate	$5.22
Max. Negotiated Rate	$25.65
Rate for Payer: Aetna Commercial	$24.30
Rate for Payer: Blue Cross Blue Shield of Kansas Commercial	$15.51
Rate for Payer: Humana Medicare Advantage	$11.34
Rate for Payer: UnitedHealthcare Commercial	$25.65
Rate for Payer: UnitedHealthcare Medicaid	$5.22
Rate for Payer: WPPA Medicare Advantage	$16.20

Drain 10mm Jackson Pratt

Facility

IP

$75.51

Hospital Charge Code	3257347
Hospital Revenue Code	270
Min. Negotiated Rate	$67.96
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$67.96
Rate for Payer: UnitedHealthcare Commercial	$71.73
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drain 10mm Jackson Pratt

Facility

OP

$75.51

Hospital Charge Code	3257347
Hospital Revenue Code	270
Min. Negotiated Rate	$30.20
Max. Negotiated Rate	$71.73
Rate for Payer: Aetna Commercial	$67.96
Rate for Payer: Humana Medicare Advantage	$31.71
Rate for Payer: UnitedHealthcare Commercial	$71.73
Rate for Payer: UnitedHealthcare Medicaid	$30.20
Rate for Payer: WPPA Medicare Advantage	$45.31

Drain 7mm Jackson Pratt

Facility

OP

$98.00

Hospital Charge Code	3257354
Hospital Revenue Code	270
Min. Negotiated Rate	$39.20
Max. Negotiated Rate	$93.10
Rate for Payer: Aetna Commercial	$88.20
Rate for Payer: Humana Medicare Advantage	$41.16
Rate for Payer: UnitedHealthcare Commercial	$93.10
Rate for Payer: UnitedHealthcare Medicaid	$39.20
Rate for Payer: WPPA Medicare Advantage	$58.80

Drain 7mm Jackson Pratt

Facility

IP

$98.00

Hospital Charge Code	3257354
Hospital Revenue Code	270
Min. Negotiated Rate	$88.20
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$88.20
Rate for Payer: UnitedHealthcare Commercial	$93.10
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drainage Bag 600ml for Urine Catheters including Nephrostomy

Facility

OP

$37.00

Hospital Charge Code	3252055
Hospital Revenue Code	270
Min. Negotiated Rate	$14.80
Max. Negotiated Rate	$35.15
Rate for Payer: Aetna Commercial	$33.30
Rate for Payer: Humana Medicare Advantage	$15.54
Rate for Payer: UnitedHealthcare Commercial	$35.15
Rate for Payer: UnitedHealthcare Medicaid	$14.80
Rate for Payer: WPPA Medicare Advantage	$22.20

Drainage Bag 600ml for Urine Catheters including Nephrostomy

Facility

IP

$37.00

Hospital Charge Code	3252055
Hospital Revenue Code	270
Min. Negotiated Rate	$33.30
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$33.30
Rate for Payer: UnitedHealthcare Commercial	$35.15
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drainage for Gallbladder Fluid

Facility

IP

$71.00

Hospital Charge Code	3252060
Hospital Revenue Code	270
Min. Negotiated Rate	$63.90
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drainage for Gallbladder Fluid

Facility

OP

$71.00

Hospital Charge Code	3252060
Hospital Revenue Code	270
Min. Negotiated Rate	$28.40
Max. Negotiated Rate	$67.45
Rate for Payer: Aetna Commercial	$63.90
Rate for Payer: Humana Medicare Advantage	$29.82
Rate for Payer: UnitedHealthcare Commercial	$67.45
Rate for Payer: UnitedHealthcare Medicaid	$28.40
Rate for Payer: WPPA Medicare Advantage	$42.60

Drain Blake 15fr Round Hubless Full-Fluted Silicone channel drain

Facility

OP

$52.97

Hospital Charge Code	3257348
Hospital Revenue Code	270
Min. Negotiated Rate	$21.19
Max. Negotiated Rate	$50.32
Rate for Payer: Aetna Commercial	$47.67
Rate for Payer: Humana Medicare Advantage	$22.25
Rate for Payer: UnitedHealthcare Commercial	$50.32
Rate for Payer: UnitedHealthcare Medicaid	$21.19
Rate for Payer: WPPA Medicare Advantage	$31.78

Drain Blake 15fr Round Hubless Full-Fluted Silicone channel drain

Facility

IP

$52.97

Hospital Charge Code	3257348
Hospital Revenue Code	270
Min. Negotiated Rate	$47.67
Max. Negotiated Rate	$1,200.00
Rate for Payer: Aetna Commercial	$47.67
Rate for Payer: UnitedHealthcare Commercial	$50.32
Rate for Payer: WPPA Medicare Advantage	$1,200.00

Drain with Trocar, Silicone Channel, Round Hubless, Full-Fluted, Radiopaque,19FR

Facility

OP

$68.36

Hospital Charge Code	3257341
Hospital Revenue Code	270
Min. Negotiated Rate	$27.34
Max. Negotiated Rate	$64.94
Rate for Payer: Aetna Commercial	$61.52
Rate for Payer: Humana Medicare Advantage	$28.71
Rate for Payer: UnitedHealthcare Commercial	$64.94
Rate for Payer: UnitedHealthcare Medicaid	$27.34
Rate for Payer: WPPA Medicare Advantage	$41.02

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