NDC 69034201
Hospitals report these codes with terse, inconsistent chargemaster text. This plain-English title was written by an AI model from that text and has not been reviewed by a person, so it can be wrong. The prices on this page come straight from hospital filings and do not depend on it.
Original text from hospital filings
PHARMACY - EXTENSION OF 025X - DRUGS REQUIRING DETAILED CODING (A)
Low
$21
Average
$524
Median
$40
High
$2.7k
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Reflects negotiated fee schedule rates with commercial payers.
Showing only prices reported under the fee schedule methodology. Choose another in the filter above to change the chart. 49 hospitals; the 90th percentile is 79.6× the 10th. Each bar is a price range and its height is how many hospitals fall in it. Hover a bar, or a row in the ladder, for details.
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| # | Hospital | ||||||
|---|---|---|---|---|---|---|---|
| 1 | St. Peter's Health Helena, MT | $25 | $25 | — | — | 80 | $25 – $25 |
| 2 | Victoria of Texas LP Victoria, TX | $36 | $40 | $21 | 53% | — | $26 – $573 |
| 3 | Victoria of Texas LP Victoria, TX | $36 | $40 | $21 | 53% | — | $26 – $573 |
| 4 | Laredo Texas Hospital Company LP Laredo, TX | $45 | $78 | $71 | 90% | — | $26 – $2.2k |
| 5 | Sanford Medical Center Bismarck Bismarck, ND | $23 | $23 | — | — | — | $23 – $2.8k |
| 6 | USC Arcadia Hospital Arcadia, CA | $324 | $412 | $196 | 48% | — | $61 – $956 |
| 7 | Western Regional Medical Center, Inc. Goodyear, AZ | $26 | $32 | $16 | 50% | — | $17 – $3.7k |
| 8 | Southeastern Regional Medical Center, Inc. Newnan, GA | $27 | $33 | $13 | 39% | — | $24 – $7.1k |
| 9 | Midwestern Regional Medical Center, Inc. Zion, IL | $26 | $31 | $10 | 32% | — | $25 – $8.8k |
| 10 | The Trustees of the University of Pennsylvania D/B/A The Hospital of the University of Pennsylvania Philadelphia, PA | $26 | $497 | $2.0k | 412% | — | $23 – $9.4k |
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