|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$4.66
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.83 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Aetna Commercial |
$3.96
|
| Rate for Payer: Aetna Medicare |
$2.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.03
|
| Rate for Payer: BCBS Complete |
$1.86
|
| Rate for Payer: Cash Price |
$3.73
|
| Rate for Payer: Cofinity Advantage |
$3.26
|
| Rate for Payer: Cofinity Commercial |
$4.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.73
|
| Rate for Payer: Healthscope Commercial |
$4.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.50
|
| Rate for Payer: PHP Commercial |
$3.96
|
| Rate for Payer: Priority Health SBD |
$2.94
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.03
|
| Rate for Payer: UHC Core |
$2.43
|
| Rate for Payer: UHC Exchange |
$1.83
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$334.31
|
|
|
Service Code
|
NDC 00378180777
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$131.38 |
| Max. Negotiated Rate |
$300.88 |
| Rate for Payer: Aetna Commercial |
$284.16
|
| Rate for Payer: Aetna Medicare |
$167.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.30
|
| Rate for Payer: BCBS Complete |
$133.72
|
| Rate for Payer: Cash Price |
$267.45
|
| Rate for Payer: Cofinity Advantage |
$234.02
|
| Rate for Payer: Cofinity Commercial |
$287.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.45
|
| Rate for Payer: Healthscope Commercial |
$300.88
|
| Rate for Payer: MI Amish Medical Board Commercial |
$267.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$284.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$250.73
|
| Rate for Payer: PHP Commercial |
$284.16
|
| Rate for Payer: Priority Health SBD |
$210.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$217.30
|
| Rate for Payer: UHC Core |
$174.18
|
| Rate for Payer: UHC Exchange |
$131.38
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$4.66
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.94 |
| Max. Negotiated Rate |
$4.19 |
| Rate for Payer: Aetna Commercial |
$3.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.03
|
| Rate for Payer: Cash Price |
$3.73
|
| Rate for Payer: Cofinity Advantage |
$3.26
|
| Rate for Payer: Cofinity Commercial |
$4.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.73
|
| Rate for Payer: Healthscope Commercial |
$4.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.50
|
| Rate for Payer: PHP Commercial |
$3.96
|
| Rate for Payer: Priority Health SBD |
$2.94
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$406.60
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$256.16 |
| Max. Negotiated Rate |
$365.94 |
| Rate for Payer: Aetna Commercial |
$345.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$264.29
|
| Rate for Payer: Cash Price |
$325.28
|
| Rate for Payer: Cofinity Advantage |
$284.62
|
| Rate for Payer: Cofinity Commercial |
$349.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.28
|
| Rate for Payer: Healthscope Commercial |
$365.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$304.95
|
| Rate for Payer: PHP Commercial |
$345.61
|
| Rate for Payer: Priority Health SBD |
$256.16
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$732.68
|
|
|
Service Code
|
NDC 00074659490
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$461.59 |
| Max. Negotiated Rate |
$659.41 |
| Rate for Payer: Aetna Commercial |
$622.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$476.24
|
| Rate for Payer: Cash Price |
$586.14
|
| Rate for Payer: Cofinity Advantage |
$512.88
|
| Rate for Payer: Cofinity Commercial |
$630.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$586.14
|
| Rate for Payer: Healthscope Commercial |
$659.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$622.78
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$549.51
|
| Rate for Payer: PHP Commercial |
$622.78
|
| Rate for Payer: Priority Health SBD |
$461.59
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$334.31
|
|
|
Service Code
|
NDC 00378180777
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$210.62 |
| Max. Negotiated Rate |
$300.88 |
| Rate for Payer: Aetna Commercial |
$284.16
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$217.30
|
| Rate for Payer: Cash Price |
$267.45
|
| Rate for Payer: Cofinity Advantage |
$234.02
|
| Rate for Payer: Cofinity Commercial |
$287.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$267.45
|
| Rate for Payer: Healthscope Commercial |
$300.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$284.16
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$250.73
|
| Rate for Payer: PHP Commercial |
$284.16
|
| Rate for Payer: Priority Health SBD |
$210.62
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$465.50
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$293.26 |
| Max. Negotiated Rate |
$418.95 |
| Rate for Payer: Aetna Commercial |
$395.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$302.57
|
| Rate for Payer: Cash Price |
$372.40
|
| Rate for Payer: Cofinity Advantage |
$325.85
|
| Rate for Payer: Cofinity Commercial |
$400.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$372.40
|
| Rate for Payer: Healthscope Commercial |
$418.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.68
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$349.12
|
| Rate for Payer: PHP Commercial |
$395.68
|
| Rate for Payer: Priority Health SBD |
$293.26
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
OP
|
$17.40
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Aetna Commercial |
$15.04
|
| Rate for Payer: Aetna Commercial |
$13.21
|
| Rate for Payer: Aetna Medicare |
$8.70
|
| Rate for Payer: Aetna Medicare |
$9.62
|
| Rate for Payer: Aetna Medicare |
$8.85
|
| Rate for Payer: Aetna Medicare |
$7.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.31
|
| Rate for Payer: BCBS Complete |
$7.69
|
| Rate for Payer: BCBS Complete |
$6.96
|
| Rate for Payer: BCBS Complete |
$6.22
|
| Rate for Payer: BCBS Complete |
$7.08
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cash Price |
$14.15
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cash Price |
$14.15
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cofinity Advantage |
$13.46
|
| Rate for Payer: Cofinity Advantage |
$10.88
|
| Rate for Payer: Cofinity Advantage |
$12.38
|
| Rate for Payer: Cofinity Advantage |
$12.18
|
| Rate for Payer: Cofinity Commercial |
$13.36
|
| Rate for Payer: Cofinity Commercial |
$16.54
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Cofinity Commercial |
$15.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.92
|
| Rate for Payer: Healthscope Commercial |
$15.92
|
| Rate for Payer: Healthscope Commercial |
$13.99
|
| Rate for Payer: Healthscope Commercial |
$17.31
|
| Rate for Payer: Healthscope Commercial |
$15.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.42
|
| Rate for Payer: PHP Commercial |
$15.04
|
| Rate for Payer: PHP Commercial |
$14.79
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: PHP Commercial |
$13.21
|
| Rate for Payer: Priority Health SBD |
$9.79
|
| Rate for Payer: Priority Health SBD |
$11.14
|
| Rate for Payer: Priority Health SBD |
$12.11
|
| Rate for Payer: Priority Health SBD |
$10.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.79 |
| Max. Negotiated Rate |
$13.99 |
| Rate for Payer: Aetna Commercial |
$13.21
|
| Rate for Payer: Aetna Commercial |
$15.04
|
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.50
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cash Price |
$14.15
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cofinity Advantage |
$12.38
|
| Rate for Payer: Cofinity Advantage |
$10.88
|
| Rate for Payer: Cofinity Advantage |
$12.18
|
| Rate for Payer: Cofinity Advantage |
$13.46
|
| Rate for Payer: Cofinity Commercial |
$16.54
|
| Rate for Payer: Cofinity Commercial |
$15.21
|
| Rate for Payer: Cofinity Commercial |
$13.36
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.43
|
| Rate for Payer: Healthscope Commercial |
$13.99
|
| Rate for Payer: Healthscope Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$15.92
|
| Rate for Payer: Healthscope Commercial |
$17.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.27
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.05
|
| Rate for Payer: PHP Commercial |
$14.79
|
| Rate for Payer: PHP Commercial |
$15.04
|
| Rate for Payer: PHP Commercial |
$13.21
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: Priority Health SBD |
$9.79
|
| Rate for Payer: Priority Health SBD |
$11.14
|
| Rate for Payer: Priority Health SBD |
$10.96
|
| Rate for Payer: Priority Health SBD |
$12.11
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
OP
|
$19.50
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$17.55 |
| Rate for Payer: Aetna Commercial |
$16.57
|
| Rate for Payer: Aetna Commercial |
$18.87
|
| Rate for Payer: Aetna Commercial |
$19.23
|
| Rate for Payer: Aetna Medicare |
$9.75
|
| Rate for Payer: Aetna Medicare |
$11.10
|
| Rate for Payer: Aetna Medicare |
$11.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.70
|
| Rate for Payer: BCBS Complete |
$9.05
|
| Rate for Payer: BCBS Complete |
$7.80
|
| Rate for Payer: BCBS Complete |
$8.88
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cofinity Advantage |
$15.54
|
| Rate for Payer: Cofinity Advantage |
$13.65
|
| Rate for Payer: Cofinity Advantage |
$15.83
|
| Rate for Payer: Cofinity Commercial |
$16.77
|
| Rate for Payer: Cofinity Commercial |
$19.09
|
| Rate for Payer: Cofinity Commercial |
$19.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.60
|
| Rate for Payer: Healthscope Commercial |
$20.36
|
| Rate for Payer: Healthscope Commercial |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$17.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.65
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.96
|
| Rate for Payer: PHP Commercial |
$16.57
|
| Rate for Payer: PHP Commercial |
$18.87
|
| Rate for Payer: PHP Commercial |
$19.23
|
| Rate for Payer: Priority Health SBD |
$12.29
|
| Rate for Payer: Priority Health SBD |
$14.25
|
| Rate for Payer: Priority Health SBD |
$13.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Core |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
| Rate for Payer: UHC Exchange |
$0.07
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$22.20
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.99 |
| Max. Negotiated Rate |
$19.98 |
| Rate for Payer: Aetna Commercial |
$18.87
|
| Rate for Payer: Aetna Commercial |
$16.57
|
| Rate for Payer: Aetna Commercial |
$19.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.68
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cofinity Advantage |
$15.54
|
| Rate for Payer: Cofinity Advantage |
$13.65
|
| Rate for Payer: Cofinity Advantage |
$15.83
|
| Rate for Payer: Cofinity Commercial |
$19.45
|
| Rate for Payer: Cofinity Commercial |
$16.77
|
| Rate for Payer: Cofinity Commercial |
$19.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.10
|
| Rate for Payer: Healthscope Commercial |
$17.55
|
| Rate for Payer: Healthscope Commercial |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$20.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.23
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.96
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.65
|
| Rate for Payer: PHP Commercial |
$16.57
|
| Rate for Payer: PHP Commercial |
$19.23
|
| Rate for Payer: PHP Commercial |
$18.87
|
| Rate for Payer: Priority Health SBD |
$14.25
|
| Rate for Payer: Priority Health SBD |
$12.29
|
| Rate for Payer: Priority Health SBD |
$13.99
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$15.21
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.58 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.89
|
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: Cofinity Advantage |
$10.65
|
| Rate for Payer: Cofinity Commercial |
$13.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.17
|
| Rate for Payer: Healthscope Commercial |
$13.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.41
|
| Rate for Payer: PHP Commercial |
$12.93
|
| Rate for Payer: Priority Health SBD |
$9.58
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$15.21
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.98 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: Aetna Medicare |
$7.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.89
|
| Rate for Payer: BCBS Complete |
$6.08
|
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: Cofinity Advantage |
$10.65
|
| Rate for Payer: Cofinity Commercial |
$13.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.17
|
| Rate for Payer: Healthscope Commercial |
$13.69
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.41
|
| Rate for Payer: PHP Commercial |
$12.93
|
| Rate for Payer: Priority Health SBD |
$9.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.89
|
| Rate for Payer: UHC Core |
$7.92
|
| Rate for Payer: UHC Exchange |
$5.98
|
|
|
LIDOCAINE 2 %-VITAMIN E-ALOE VERA-COLLAGEN TOPICAL GEL
|
Facility
|
IP
|
$16.76
|
|
|
Service Code
|
NDC 66977010005
|
| Hospital Charge Code |
77011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.56 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna Commercial |
$14.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.89
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Cofinity Advantage |
$11.73
|
| Rate for Payer: Cofinity Commercial |
$14.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.41
|
| Rate for Payer: Healthscope Commercial |
$15.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.57
|
| Rate for Payer: PHP Commercial |
$14.25
|
| Rate for Payer: Priority Health SBD |
$10.56
|
|
|
LIDOCAINE 2 %-VITAMIN E-ALOE VERA-COLLAGEN TOPICAL GEL
|
Facility
|
OP
|
$16.76
|
|
|
Service Code
|
NDC 66977010005
|
| Hospital Charge Code |
77011
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.59 |
| Max. Negotiated Rate |
$15.08 |
| Rate for Payer: Aetna Commercial |
$14.25
|
| Rate for Payer: Aetna Medicare |
$8.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.89
|
| Rate for Payer: BCBS Complete |
$6.70
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Cofinity Advantage |
$11.73
|
| Rate for Payer: Cofinity Commercial |
$14.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.41
|
| Rate for Payer: Healthscope Commercial |
$15.08
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.57
|
| Rate for Payer: PHP Commercial |
$14.25
|
| Rate for Payer: Priority Health SBD |
$10.56
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.89
|
| Rate for Payer: UHC Core |
$8.73
|
| Rate for Payer: UHC Exchange |
$6.59
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
IP
|
$29.93
|
|
|
Service Code
|
NDC 71266629001
|
| Hospital Charge Code |
196007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.86 |
| Max. Negotiated Rate |
$26.94 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.45
|
| Rate for Payer: Cash Price |
$23.94
|
| Rate for Payer: Cofinity Advantage |
$20.95
|
| Rate for Payer: Cofinity Commercial |
$25.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.94
|
| Rate for Payer: Healthscope Commercial |
$26.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.45
|
| Rate for Payer: PHP Commercial |
$25.44
|
| Rate for Payer: Priority Health SBD |
$18.86
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
OP
|
$29.93
|
|
|
Service Code
|
NDC 71266629001
|
| Hospital Charge Code |
196007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.76 |
| Max. Negotiated Rate |
$26.94 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna Medicare |
$14.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.45
|
| Rate for Payer: BCBS Complete |
$11.97
|
| Rate for Payer: Cash Price |
$23.94
|
| Rate for Payer: Cofinity Advantage |
$20.95
|
| Rate for Payer: Cofinity Commercial |
$25.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.94
|
| Rate for Payer: Healthscope Commercial |
$26.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.45
|
| Rate for Payer: PHP Commercial |
$25.44
|
| Rate for Payer: Priority Health SBD |
$18.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.45
|
| Rate for Payer: UHC Core |
$15.59
|
| Rate for Payer: UHC Exchange |
$11.76
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$45.36
|
|
|
Service Code
|
NDC 41167005840
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.58 |
| Max. Negotiated Rate |
$40.82 |
| Rate for Payer: Aetna Commercial |
$38.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.48
|
| Rate for Payer: Cash Price |
$36.29
|
| Rate for Payer: Cofinity Advantage |
$31.75
|
| Rate for Payer: Cofinity Commercial |
$39.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.29
|
| Rate for Payer: Healthscope Commercial |
$40.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.02
|
| Rate for Payer: PHP Commercial |
$38.56
|
| Rate for Payer: Priority Health SBD |
$28.58
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$48.73
|
|
|
Service Code
|
NDC 45611000938
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.70 |
| Max. Negotiated Rate |
$43.86 |
| Rate for Payer: Aetna Commercial |
$41.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.67
|
| Rate for Payer: Cash Price |
$38.98
|
| Rate for Payer: Cofinity Advantage |
$34.11
|
| Rate for Payer: Cofinity Commercial |
$41.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.98
|
| Rate for Payer: Healthscope Commercial |
$43.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36.55
|
| Rate for Payer: PHP Commercial |
$41.42
|
| Rate for Payer: Priority Health SBD |
$30.70
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$20.79
|
|
|
Service Code
|
NDC 70000036601
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.17 |
| Max. Negotiated Rate |
$18.71 |
| Rate for Payer: Aetna Commercial |
$17.67
|
| Rate for Payer: Aetna Medicare |
$10.39
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.51
|
| Rate for Payer: BCBS Complete |
$8.32
|
| Rate for Payer: Cash Price |
$16.63
|
| Rate for Payer: Cofinity Advantage |
$14.55
|
| Rate for Payer: Cofinity Commercial |
$17.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.63
|
| Rate for Payer: Healthscope Commercial |
$18.71
|
| Rate for Payer: MI Amish Medical Board Commercial |
$16.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.59
|
| Rate for Payer: PHP Commercial |
$17.67
|
| Rate for Payer: Priority Health SBD |
$13.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.51
|
| Rate for Payer: UHC Core |
$10.83
|
| Rate for Payer: UHC Exchange |
$8.17
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$20.79
|
|
|
Service Code
|
NDC 70000036601
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.10 |
| Max. Negotiated Rate |
$18.71 |
| Rate for Payer: Aetna Commercial |
$17.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.51
|
| Rate for Payer: Cash Price |
$16.63
|
| Rate for Payer: Cofinity Advantage |
$14.55
|
| Rate for Payer: Cofinity Commercial |
$17.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.63
|
| Rate for Payer: Healthscope Commercial |
$18.71
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$15.59
|
| Rate for Payer: PHP Commercial |
$17.67
|
| Rate for Payer: Priority Health SBD |
$13.10
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$45.36
|
|
|
Service Code
|
NDC 41167005840
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.83 |
| Max. Negotiated Rate |
$40.82 |
| Rate for Payer: Aetna Commercial |
$38.56
|
| Rate for Payer: Aetna Medicare |
$22.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.48
|
| Rate for Payer: BCBS Complete |
$18.14
|
| Rate for Payer: Cash Price |
$36.29
|
| Rate for Payer: Cofinity Advantage |
$31.75
|
| Rate for Payer: Cofinity Commercial |
$39.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.29
|
| Rate for Payer: Healthscope Commercial |
$40.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$36.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.02
|
| Rate for Payer: PHP Commercial |
$38.56
|
| Rate for Payer: Priority Health SBD |
$28.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.48
|
| Rate for Payer: UHC Core |
$23.63
|
| Rate for Payer: UHC Exchange |
$17.83
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
NDC 96295013458
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.79 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Advantage |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.04
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health SBD |
$11.79
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$18.20
|
|
|
Service Code
|
NDC 00121097005
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.15 |
| Max. Negotiated Rate |
$16.38 |
| Rate for Payer: Aetna Commercial |
$15.47
|
| Rate for Payer: Aetna Medicare |
$9.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.83
|
| Rate for Payer: BCBS Complete |
$7.28
|
| Rate for Payer: Cash Price |
$14.56
|
| Rate for Payer: Cofinity Advantage |
$12.74
|
| Rate for Payer: Cofinity Commercial |
$15.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.56
|
| Rate for Payer: Healthscope Commercial |
$16.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.47
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.65
|
| Rate for Payer: PHP Commercial |
$15.47
|
| Rate for Payer: Priority Health SBD |
$11.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.83
|
| Rate for Payer: UHC Core |
$9.48
|
| Rate for Payer: UHC Exchange |
$7.15
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$48.73
|
|
|
Service Code
|
NDC 45611000938
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.15 |
| Max. Negotiated Rate |
$43.86 |
| Rate for Payer: Aetna Commercial |
$41.42
|
| Rate for Payer: Aetna Medicare |
$24.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.67
|
| Rate for Payer: BCBS Complete |
$19.49
|
| Rate for Payer: Cash Price |
$38.98
|
| Rate for Payer: Cofinity Advantage |
$34.11
|
| Rate for Payer: Cofinity Commercial |
$41.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.98
|
| Rate for Payer: Healthscope Commercial |
$43.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$38.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36.55
|
| Rate for Payer: PHP Commercial |
$41.42
|
| Rate for Payer: Priority Health SBD |
$30.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31.67
|
| Rate for Payer: UHC Core |
$25.39
|
| Rate for Payer: UHC Exchange |
$19.15
|
|
