|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY
|
Facility
|
IP
|
$26.83
|
|
|
Service Code
|
NDC 00143957710
|
| Hospital Charge Code |
300842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.90 |
| Max. Negotiated Rate |
$24.15 |
| Rate for Payer: Aetna Commercial |
$22.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.44
|
| Rate for Payer: Cash Price |
$21.46
|
| Rate for Payer: Cofinity Advantage |
$18.78
|
| Rate for Payer: Cofinity Commercial |
$23.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.46
|
| Rate for Payer: Healthscope Commercial |
$24.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.12
|
| Rate for Payer: PHP Commercial |
$22.81
|
| Rate for Payer: Priority Health SBD |
$16.90
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY
|
Facility
|
OP
|
$19.00
|
|
|
Service Code
|
NDC 63323020110
|
| Hospital Charge Code |
300842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.47 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna Medicare |
$9.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.35
|
| Rate for Payer: BCBS Complete |
$7.60
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: Cofinity Advantage |
$13.30
|
| Rate for Payer: Cofinity Commercial |
$16.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.20
|
| Rate for Payer: Healthscope Commercial |
$17.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.25
|
| Rate for Payer: PHP Commercial |
$16.15
|
| Rate for Payer: Priority Health SBD |
$11.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.35
|
| Rate for Payer: UHC Core |
$9.90
|
| Rate for Payer: UHC Exchange |
$7.47
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY
|
Facility
|
OP
|
$26.83
|
|
|
Service Code
|
NDC 00143957701
|
| Hospital Charge Code |
300842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.54 |
| Max. Negotiated Rate |
$24.15 |
| Rate for Payer: Aetna Commercial |
$22.81
|
| Rate for Payer: Aetna Medicare |
$13.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.44
|
| Rate for Payer: BCBS Complete |
$10.73
|
| Rate for Payer: Cash Price |
$21.46
|
| Rate for Payer: Cofinity Advantage |
$18.78
|
| Rate for Payer: Cofinity Commercial |
$23.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.46
|
| Rate for Payer: Healthscope Commercial |
$24.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.12
|
| Rate for Payer: PHP Commercial |
$22.81
|
| Rate for Payer: Priority Health SBD |
$16.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.44
|
| Rate for Payer: UHC Core |
$13.98
|
| Rate for Payer: UHC Exchange |
$10.54
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY
|
Facility
|
OP
|
$15.37
|
|
|
Service Code
|
NDC 55150025110
|
| Hospital Charge Code |
300842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.04 |
| Max. Negotiated Rate |
$13.83 |
| Rate for Payer: Aetna Commercial |
$13.06
|
| Rate for Payer: Aetna Medicare |
$7.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.99
|
| Rate for Payer: BCBS Complete |
$6.15
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cofinity Advantage |
$10.76
|
| Rate for Payer: Cofinity Commercial |
$13.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.30
|
| Rate for Payer: Healthscope Commercial |
$13.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.53
|
| Rate for Payer: PHP Commercial |
$13.06
|
| Rate for Payer: Priority Health SBD |
$9.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.99
|
| Rate for Payer: UHC Core |
$8.01
|
| Rate for Payer: UHC Exchange |
$6.04
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY
|
Facility
|
OP
|
$26.83
|
|
|
Service Code
|
NDC 00143957710
|
| Hospital Charge Code |
300842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.54 |
| Max. Negotiated Rate |
$24.15 |
| Rate for Payer: Aetna Commercial |
$22.81
|
| Rate for Payer: Aetna Medicare |
$13.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.44
|
| Rate for Payer: BCBS Complete |
$10.73
|
| Rate for Payer: Cash Price |
$21.46
|
| Rate for Payer: Cofinity Advantage |
$18.78
|
| Rate for Payer: Cofinity Commercial |
$23.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.46
|
| Rate for Payer: Healthscope Commercial |
$24.15
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.12
|
| Rate for Payer: PHP Commercial |
$22.81
|
| Rate for Payer: Priority Health SBD |
$16.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.44
|
| Rate for Payer: UHC Core |
$13.98
|
| Rate for Payer: UHC Exchange |
$10.54
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 63323020110
|
| Hospital Charge Code |
300842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.97 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.35
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: Cofinity Advantage |
$13.30
|
| Rate for Payer: Cofinity Commercial |
$16.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.20
|
| Rate for Payer: Healthscope Commercial |
$17.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.25
|
| Rate for Payer: PHP Commercial |
$16.15
|
| Rate for Payer: Priority Health SBD |
$11.97
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY
|
Facility
|
IP
|
$26.83
|
|
|
Service Code
|
NDC 00143957701
|
| Hospital Charge Code |
300842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.90 |
| Max. Negotiated Rate |
$24.15 |
| Rate for Payer: Aetna Commercial |
$22.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.44
|
| Rate for Payer: Cash Price |
$21.46
|
| Rate for Payer: Cofinity Advantage |
$18.78
|
| Rate for Payer: Cofinity Commercial |
$23.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.46
|
| Rate for Payer: Healthscope Commercial |
$24.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.81
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.12
|
| Rate for Payer: PHP Commercial |
$22.81
|
| Rate for Payer: Priority Health SBD |
$16.90
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$14.21
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.95 |
| Max. Negotiated Rate |
$12.79 |
| Rate for Payer: Aetna Commercial |
$12.08
|
| Rate for Payer: Aetna Commercial |
$14.85
|
| Rate for Payer: Aetna Commercial |
$20.21
|
| Rate for Payer: Aetna Commercial |
$19.72
|
| Rate for Payer: Aetna Commercial |
$14.30
|
| Rate for Payer: Aetna Commercial |
$10.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.36
|
| Rate for Payer: Cash Price |
$18.56
|
| Rate for Payer: Cash Price |
$11.37
|
| Rate for Payer: Cash Price |
$13.98
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cash Price |
$19.02
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Cofinity Advantage |
$12.23
|
| Rate for Payer: Cofinity Advantage |
$8.32
|
| Rate for Payer: Cofinity Advantage |
$16.65
|
| Rate for Payer: Cofinity Advantage |
$9.95
|
| Rate for Payer: Cofinity Advantage |
$16.24
|
| Rate for Payer: Cofinity Advantage |
$11.77
|
| Rate for Payer: Cofinity Commercial |
$12.22
|
| Rate for Payer: Cofinity Commercial |
$10.23
|
| Rate for Payer: Cofinity Commercial |
$14.47
|
| Rate for Payer: Cofinity Commercial |
$20.45
|
| Rate for Payer: Cofinity Commercial |
$15.02
|
| Rate for Payer: Cofinity Commercial |
$19.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.02
|
| Rate for Payer: Healthscope Commercial |
$10.70
|
| Rate for Payer: Healthscope Commercial |
$20.88
|
| Rate for Payer: Healthscope Commercial |
$12.79
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Commercial |
$15.14
|
| Rate for Payer: Healthscope Commercial |
$21.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.10
|
| Rate for Payer: PHP Commercial |
$14.85
|
| Rate for Payer: PHP Commercial |
$12.08
|
| Rate for Payer: PHP Commercial |
$19.72
|
| Rate for Payer: PHP Commercial |
$14.30
|
| Rate for Payer: PHP Commercial |
$10.11
|
| Rate for Payer: PHP Commercial |
$20.21
|
| Rate for Payer: Priority Health SBD |
$10.60
|
| Rate for Payer: Priority Health SBD |
$11.01
|
| Rate for Payer: Priority Health SBD |
$14.62
|
| Rate for Payer: Priority Health SBD |
$7.49
|
| Rate for Payer: Priority Health SBD |
$8.95
|
| Rate for Payer: Priority Health SBD |
$14.98
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
OP
|
$14.21
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$12.79 |
| Rate for Payer: Aetna Commercial |
$12.08
|
| Rate for Payer: Aetna Commercial |
$14.30
|
| Rate for Payer: Aetna Commercial |
$20.21
|
| Rate for Payer: Aetna Commercial |
$10.11
|
| Rate for Payer: Aetna Commercial |
$14.85
|
| Rate for Payer: Aetna Commercial |
$19.72
|
| Rate for Payer: Aetna Medicare |
$5.95
|
| Rate for Payer: Aetna Medicare |
$7.11
|
| Rate for Payer: Aetna Medicare |
$8.41
|
| Rate for Payer: Aetna Medicare |
$11.60
|
| Rate for Payer: Aetna Medicare |
$11.89
|
| Rate for Payer: Aetna Medicare |
$8.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.73
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.93
|
| Rate for Payer: BCBS Complete |
$6.73
|
| Rate for Payer: BCBS Complete |
$9.51
|
| Rate for Payer: BCBS Complete |
$9.28
|
| Rate for Payer: BCBS Complete |
$5.68
|
| Rate for Payer: BCBS Complete |
$4.76
|
| Rate for Payer: BCBS Complete |
$6.99
|
| Rate for Payer: BCBS Trust/PPO |
$0.07
|
| Rate for Payer: BCBS Trust/PPO |
$0.07
|
| Rate for Payer: BCBS Trust/PPO |
$0.07
|
| Rate for Payer: BCBS Trust/PPO |
$0.07
|
| Rate for Payer: BCBS Trust/PPO |
$0.07
|
| Rate for Payer: BCBS Trust/PPO |
$0.07
|
| Rate for Payer: BCN Commercial |
$0.07
|
| Rate for Payer: BCN Commercial |
$0.07
|
| Rate for Payer: BCN Commercial |
$0.07
|
| Rate for Payer: BCN Commercial |
$0.07
|
| Rate for Payer: BCN Commercial |
$0.07
|
| Rate for Payer: BCN Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$18.56
|
| Rate for Payer: Cash Price |
$13.98
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Cash Price |
$11.37
|
| Rate for Payer: Cash Price |
$13.46
|
| Rate for Payer: Cash Price |
$19.02
|
| Rate for Payer: Cash Price |
$18.56
|
| Rate for Payer: Cash Price |
$19.02
|
| Rate for Payer: Cash Price |
$13.98
|
| Rate for Payer: Cash Price |
$11.37
|
| Rate for Payer: Cofinity Advantage |
$8.32
|
| Rate for Payer: Cofinity Advantage |
$16.24
|
| Rate for Payer: Cofinity Advantage |
$12.23
|
| Rate for Payer: Cofinity Advantage |
$16.65
|
| Rate for Payer: Cofinity Advantage |
$11.77
|
| Rate for Payer: Cofinity Advantage |
$9.95
|
| Rate for Payer: Cofinity Commercial |
$14.47
|
| Rate for Payer: Cofinity Commercial |
$12.22
|
| Rate for Payer: Cofinity Commercial |
$10.23
|
| Rate for Payer: Cofinity Commercial |
$20.45
|
| Rate for Payer: Cofinity Commercial |
$15.02
|
| Rate for Payer: Cofinity Commercial |
$19.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.51
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.56
|
| Rate for Payer: Healthscope Commercial |
$21.40
|
| Rate for Payer: Healthscope Commercial |
$20.88
|
| Rate for Payer: Healthscope Commercial |
$15.72
|
| Rate for Payer: Healthscope Commercial |
$15.14
|
| Rate for Payer: Healthscope Commercial |
$12.79
|
| Rate for Payer: Healthscope Commercial |
$10.70
|
| Rate for Payer: MI Amish Medical Board Commercial |
$9.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.02
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.98
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.56
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.11
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$10.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$8.92
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$13.10
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.84
|
| Rate for Payer: PHP Commercial |
$14.85
|
| Rate for Payer: PHP Commercial |
$12.08
|
| Rate for Payer: PHP Commercial |
$14.30
|
| Rate for Payer: PHP Commercial |
$10.11
|
| Rate for Payer: PHP Commercial |
$20.21
|
| Rate for Payer: PHP Commercial |
$19.72
|
| Rate for Payer: Priority Health SBD |
$14.62
|
| Rate for Payer: Priority Health SBD |
$8.95
|
| Rate for Payer: Priority Health SBD |
$14.98
|
| Rate for Payer: Priority Health SBD |
$11.01
|
| Rate for Payer: Priority Health SBD |
$10.60
|
| Rate for Payer: Priority Health SBD |
$7.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.08
|
| Rate for Payer: UHC Core |
$0.08
|
| Rate for Payer: UHC Core |
$0.08
|
| Rate for Payer: UHC Core |
$0.08
|
| Rate for Payer: UHC Core |
$0.08
|
| Rate for Payer: UHC Core |
$0.08
|
| Rate for Payer: UHC Core |
$0.08
|
| Rate for Payer: UHC Exchange |
$0.08
|
| Rate for Payer: UHC Exchange |
$0.08
|
| Rate for Payer: UHC Exchange |
$0.08
|
| Rate for Payer: UHC Exchange |
$0.08
|
| Rate for Payer: UHC Exchange |
$0.08
|
| Rate for Payer: UHC Exchange |
$0.08
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$25.90
|
|
|
Service Code
|
NDC 60432046400
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.32 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Advantage |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.72
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.43
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health SBD |
$16.32
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$35.35
|
|
|
Service Code
|
NDC 00054350049
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.27 |
| Max. Negotiated Rate |
$31.82 |
| Rate for Payer: Aetna Commercial |
$30.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.98
|
| Rate for Payer: Cash Price |
$28.28
|
| Rate for Payer: Cofinity Advantage |
$24.75
|
| Rate for Payer: Cofinity Commercial |
$30.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.28
|
| Rate for Payer: Healthscope Commercial |
$31.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.51
|
| Rate for Payer: PHP Commercial |
$30.05
|
| Rate for Payer: Priority Health SBD |
$22.27
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 09900000339
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.46 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna Commercial |
$4.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.57
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Advantage |
$3.84
|
| Rate for Payer: Cofinity Commercial |
$4.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$4.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.12
|
| Rate for Payer: PHP Commercial |
$4.67
|
| Rate for Payer: Priority Health SBD |
$3.46
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$35.35
|
|
|
Service Code
|
NDC 00054350049
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.89 |
| Max. Negotiated Rate |
$31.82 |
| Rate for Payer: Aetna Commercial |
$30.05
|
| Rate for Payer: Aetna Medicare |
$17.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.98
|
| Rate for Payer: BCBS Complete |
$14.14
|
| Rate for Payer: Cash Price |
$28.28
|
| Rate for Payer: Cofinity Advantage |
$24.75
|
| Rate for Payer: Cofinity Commercial |
$30.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.28
|
| Rate for Payer: Healthscope Commercial |
$31.82
|
| Rate for Payer: MI Amish Medical Board Commercial |
$28.28
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.05
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.51
|
| Rate for Payer: PHP Commercial |
$30.05
|
| Rate for Payer: Priority Health SBD |
$22.27
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.98
|
| Rate for Payer: UHC Core |
$18.42
|
| Rate for Payer: UHC Exchange |
$13.89
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$24.03
|
|
|
Service Code
|
NDC 00121495040
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$21.63 |
| Rate for Payer: Aetna Commercial |
$20.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.62
|
| Rate for Payer: Cash Price |
$19.22
|
| Rate for Payer: Cofinity Advantage |
$16.82
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.22
|
| Rate for Payer: Healthscope Commercial |
$21.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.02
|
| Rate for Payer: PHP Commercial |
$20.43
|
| Rate for Payer: Priority Health SBD |
$15.14
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$318.85
|
|
|
Service Code
|
NDC 62135071242
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.88 |
| Max. Negotiated Rate |
$286.96 |
| Rate for Payer: Aetna Commercial |
$271.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.25
|
| Rate for Payer: Cash Price |
$255.08
|
| Rate for Payer: Cofinity Advantage |
$223.19
|
| Rate for Payer: Cofinity Commercial |
$274.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.08
|
| Rate for Payer: Healthscope Commercial |
$286.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$271.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$239.14
|
| Rate for Payer: PHP Commercial |
$271.02
|
| Rate for Payer: Priority Health SBD |
$200.88
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$24.03
|
|
|
Service Code
|
NDC 00121495015
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$21.63 |
| Rate for Payer: Aetna Commercial |
$20.43
|
| Rate for Payer: Aetna Medicare |
$12.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.62
|
| Rate for Payer: BCBS Complete |
$9.61
|
| Rate for Payer: Cash Price |
$19.22
|
| Rate for Payer: Cofinity Advantage |
$16.82
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.22
|
| Rate for Payer: Healthscope Commercial |
$21.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.02
|
| Rate for Payer: PHP Commercial |
$20.43
|
| Rate for Payer: Priority Health SBD |
$15.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.62
|
| Rate for Payer: UHC Core |
$12.52
|
| Rate for Payer: UHC Exchange |
$9.44
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$318.85
|
|
|
Service Code
|
NDC 62135071242
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$125.31 |
| Max. Negotiated Rate |
$286.96 |
| Rate for Payer: Aetna Commercial |
$271.02
|
| Rate for Payer: Aetna Medicare |
$159.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$207.25
|
| Rate for Payer: BCBS Complete |
$127.54
|
| Rate for Payer: Cash Price |
$255.08
|
| Rate for Payer: Cofinity Advantage |
$223.19
|
| Rate for Payer: Cofinity Commercial |
$274.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$255.08
|
| Rate for Payer: Healthscope Commercial |
$286.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$255.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$271.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$239.14
|
| Rate for Payer: PHP Commercial |
$271.02
|
| Rate for Payer: Priority Health SBD |
$200.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$207.25
|
| Rate for Payer: UHC Core |
$166.12
|
| Rate for Payer: UHC Exchange |
$125.31
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$25.90
|
|
|
Service Code
|
NDC 60432046400
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.18 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna Medicare |
$12.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: BCBS Complete |
$10.36
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Advantage |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.72
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.43
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health SBD |
$16.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.84
|
| Rate for Payer: UHC Core |
$13.49
|
| Rate for Payer: UHC Exchange |
$10.18
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$5.49
|
|
|
Service Code
|
NDC 09900000339
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.16 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna Commercial |
$4.67
|
| Rate for Payer: Aetna Medicare |
$2.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.57
|
| Rate for Payer: BCBS Complete |
$2.20
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Advantage |
$3.84
|
| Rate for Payer: Cofinity Commercial |
$4.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$4.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.12
|
| Rate for Payer: PHP Commercial |
$4.67
|
| Rate for Payer: Priority Health SBD |
$3.46
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.57
|
| Rate for Payer: UHC Core |
$2.86
|
| Rate for Payer: UHC Exchange |
$2.16
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$24.03
|
|
|
Service Code
|
NDC 00121495015
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.14 |
| Max. Negotiated Rate |
$21.63 |
| Rate for Payer: Aetna Commercial |
$20.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.62
|
| Rate for Payer: Cash Price |
$19.22
|
| Rate for Payer: Cofinity Advantage |
$16.82
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.22
|
| Rate for Payer: Healthscope Commercial |
$21.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.02
|
| Rate for Payer: PHP Commercial |
$20.43
|
| Rate for Payer: Priority Health SBD |
$15.14
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$24.03
|
|
|
Service Code
|
NDC 00121495040
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.44 |
| Max. Negotiated Rate |
$21.63 |
| Rate for Payer: Aetna Commercial |
$20.43
|
| Rate for Payer: Aetna Medicare |
$12.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.62
|
| Rate for Payer: BCBS Complete |
$9.61
|
| Rate for Payer: Cash Price |
$19.22
|
| Rate for Payer: Cofinity Advantage |
$16.82
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.22
|
| Rate for Payer: Healthscope Commercial |
$21.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$19.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.43
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.02
|
| Rate for Payer: PHP Commercial |
$20.43
|
| Rate for Payer: Priority Health SBD |
$15.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.62
|
| Rate for Payer: UHC Core |
$12.52
|
| Rate for Payer: UHC Exchange |
$9.44
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$104.13
|
|
|
Service Code
|
NDC 60432046551
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.92 |
| Max. Negotiated Rate |
$93.72 |
| Rate for Payer: Aetna Commercial |
$88.51
|
| Rate for Payer: Aetna Medicare |
$52.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.68
|
| Rate for Payer: BCBS Complete |
$41.65
|
| Rate for Payer: Cash Price |
$83.30
|
| Rate for Payer: Cofinity Advantage |
$72.89
|
| Rate for Payer: Cofinity Commercial |
$89.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.30
|
| Rate for Payer: Healthscope Commercial |
$93.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$83.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$78.10
|
| Rate for Payer: PHP Commercial |
$88.51
|
| Rate for Payer: Priority Health SBD |
$65.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.68
|
| Rate for Payer: UHC Core |
$54.25
|
| Rate for Payer: UHC Exchange |
$40.92
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$104.13
|
|
|
Service Code
|
NDC 60432046551
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$65.60 |
| Max. Negotiated Rate |
$93.72 |
| Rate for Payer: Aetna Commercial |
$88.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.68
|
| Rate for Payer: Cash Price |
$83.30
|
| Rate for Payer: Cofinity Advantage |
$72.89
|
| Rate for Payer: Cofinity Commercial |
$89.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.30
|
| Rate for Payer: Healthscope Commercial |
$93.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$78.10
|
| Rate for Payer: PHP Commercial |
$88.51
|
| Rate for Payer: Priority Health SBD |
$65.60
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$130.20
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$82.03 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna Commercial |
$110.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.63
|
| Rate for Payer: Cash Price |
$104.16
|
| Rate for Payer: Cofinity Advantage |
$91.14
|
| Rate for Payer: Cofinity Commercial |
$111.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.16
|
| Rate for Payer: Healthscope Commercial |
$117.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$97.65
|
| Rate for Payer: PHP Commercial |
$110.67
|
| Rate for Payer: Priority Health SBD |
$82.03
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$76.83
|
|
|
Service Code
|
NDC 00527600480
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.40 |
| Max. Negotiated Rate |
$69.15 |
| Rate for Payer: Aetna Commercial |
$65.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$49.94
|
| Rate for Payer: Cash Price |
$61.46
|
| Rate for Payer: Cofinity Advantage |
$53.78
|
| Rate for Payer: Cofinity Commercial |
$66.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.46
|
| Rate for Payer: Healthscope Commercial |
$69.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$57.62
|
| Rate for Payer: PHP Commercial |
$65.31
|
| Rate for Payer: Priority Health SBD |
$48.40
|
|
