|
LIDOCAINE (PF) 4 MG/ML (0.4 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION
|
Facility
|
OP
|
$37.83
|
|
|
Service Code
|
HCPCS J2002
|
| Hospital Charge Code |
14868
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$34.05 |
| Rate for Payer: Aetna Commercial |
$32.16
|
| Rate for Payer: Aetna Commercial |
$18.87
|
| Rate for Payer: Aetna Medicare |
$11.10
|
| Rate for Payer: Aetna Medicare |
$18.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.43
|
| Rate for Payer: BCBS Complete |
$8.88
|
| Rate for Payer: BCBS Complete |
$15.13
|
| Rate for Payer: BCBS Trust/PPO |
$0.02
|
| Rate for Payer: BCBS Trust/PPO |
$0.02
|
| Rate for Payer: BCN Commercial |
$0.02
|
| Rate for Payer: BCN Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cofinity Advantage |
$26.48
|
| Rate for Payer: Cofinity Advantage |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$32.53
|
| 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 |
$30.26
|
| Rate for Payer: Healthscope Commercial |
$19.98
|
| Rate for Payer: Healthscope Commercial |
$34.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$17.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$30.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.65
|
| Rate for Payer: PHP Commercial |
$32.16
|
| Rate for Payer: PHP Commercial |
$18.87
|
| Rate for Payer: Priority Health SBD |
$23.83
|
| Rate for Payer: Priority Health SBD |
$13.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.02
|
| Rate for Payer: UHC Core |
$0.02
|
| Rate for Payer: UHC Core |
$0.02
|
| Rate for Payer: UHC Exchange |
$0.02
|
| Rate for Payer: UHC Exchange |
$0.02
|
|
|
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$82.44
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4457
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$74.20 |
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Aetna Commercial |
$46.84
|
| Rate for Payer: Aetna Medicare |
$41.22
|
| Rate for Payer: Aetna Medicare |
$27.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.59
|
| Rate for Payer: BCBS Complete |
$32.98
|
| Rate for Payer: BCBS Complete |
$22.04
|
| 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: Cash Price |
$44.08
|
| Rate for Payer: Cash Price |
$44.08
|
| Rate for Payer: Cash Price |
$65.95
|
| Rate for Payer: Cash Price |
$65.95
|
| Rate for Payer: Cofinity Advantage |
$38.57
|
| Rate for Payer: Cofinity Advantage |
$57.71
|
| Rate for Payer: Cofinity Commercial |
$70.90
|
| Rate for Payer: Cofinity Commercial |
$47.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.08
|
| Rate for Payer: Healthscope Commercial |
$49.59
|
| Rate for Payer: Healthscope Commercial |
$74.20
|
| Rate for Payer: MI Amish Medical Board Commercial |
$65.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$44.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$41.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.83
|
| Rate for Payer: PHP Commercial |
$70.07
|
| Rate for Payer: PHP Commercial |
$46.84
|
| Rate for Payer: Priority Health SBD |
$34.71
|
| Rate for Payer: Priority Health SBD |
$51.94
|
| 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 Exchange |
$0.08
|
| Rate for Payer: UHC Exchange |
$0.08
|
|
|
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$55.10
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4457
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$34.71 |
| Max. Negotiated Rate |
$49.59 |
| Rate for Payer: Aetna Commercial |
$46.84
|
| Rate for Payer: Aetna Commercial |
$70.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$35.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$53.59
|
| Rate for Payer: Cash Price |
$44.08
|
| Rate for Payer: Cash Price |
$65.95
|
| Rate for Payer: Cofinity Advantage |
$38.57
|
| Rate for Payer: Cofinity Advantage |
$57.71
|
| Rate for Payer: Cofinity Commercial |
$47.39
|
| Rate for Payer: Cofinity Commercial |
$70.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$44.08
|
| Rate for Payer: Healthscope Commercial |
$74.20
|
| Rate for Payer: Healthscope Commercial |
$49.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$46.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$70.07
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$41.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$61.83
|
| Rate for Payer: PHP Commercial |
$46.84
|
| Rate for Payer: PHP Commercial |
$70.07
|
| Rate for Payer: Priority Health SBD |
$34.71
|
| Rate for Payer: Priority Health SBD |
$51.94
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION
|
Facility
|
OP
|
$56.96
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
105635
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$51.26 |
| Rate for Payer: Aetna Commercial |
$48.42
|
| Rate for Payer: Aetna Commercial |
$13.52
|
| Rate for Payer: Aetna Medicare |
$7.96
|
| Rate for Payer: Aetna Medicare |
$28.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.34
|
| Rate for Payer: BCBS Complete |
$6.36
|
| Rate for Payer: BCBS Complete |
$22.78
|
| 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: Cash Price |
$45.57
|
| Rate for Payer: Cash Price |
$12.73
|
| Rate for Payer: Cash Price |
$45.57
|
| Rate for Payer: Cash Price |
$12.73
|
| Rate for Payer: Cofinity Advantage |
$39.87
|
| Rate for Payer: Cofinity Advantage |
$11.14
|
| Rate for Payer: Cofinity Commercial |
$48.99
|
| Rate for Payer: Cofinity Commercial |
$13.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.57
|
| Rate for Payer: Healthscope Commercial |
$14.32
|
| Rate for Payer: Healthscope Commercial |
$51.26
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.73
|
| Rate for Payer: MI Amish Medical Board Commercial |
$45.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.93
|
| Rate for Payer: PHP Commercial |
$48.42
|
| Rate for Payer: PHP Commercial |
$13.52
|
| Rate for Payer: Priority Health SBD |
$35.88
|
| Rate for Payer: Priority Health SBD |
$10.02
|
| 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 Exchange |
$0.08
|
| Rate for Payer: UHC Exchange |
$0.08
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION
|
Facility
|
IP
|
$56.96
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
105635
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$35.88 |
| Max. Negotiated Rate |
$51.26 |
| Rate for Payer: Aetna Commercial |
$48.42
|
| Rate for Payer: Aetna Commercial |
$13.52
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$37.02
|
| Rate for Payer: Cash Price |
$12.73
|
| Rate for Payer: Cash Price |
$45.57
|
| Rate for Payer: Cofinity Advantage |
$39.87
|
| Rate for Payer: Cofinity Advantage |
$11.14
|
| Rate for Payer: Cofinity Commercial |
$13.68
|
| Rate for Payer: Cofinity Commercial |
$48.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$45.57
|
| Rate for Payer: Healthscope Commercial |
$14.32
|
| Rate for Payer: Healthscope Commercial |
$51.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$48.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.52
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$42.72
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.93
|
| Rate for Payer: PHP Commercial |
$13.52
|
| Rate for Payer: PHP Commercial |
$48.42
|
| Rate for Payer: Priority Health SBD |
$10.02
|
| Rate for Payer: Priority Health SBD |
$35.88
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM
|
Facility
|
OP
|
$23.07
|
|
|
Service Code
|
NDC 00591207026
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.07 |
| Max. Negotiated Rate |
$20.76 |
| Rate for Payer: Aetna Commercial |
$19.61
|
| Rate for Payer: Aetna Medicare |
$11.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.00
|
| Rate for Payer: BCBS Complete |
$9.23
|
| Rate for Payer: Cash Price |
$18.46
|
| Rate for Payer: Cofinity Advantage |
$16.15
|
| Rate for Payer: Cofinity Commercial |
$19.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.46
|
| Rate for Payer: Healthscope Commercial |
$20.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.30
|
| Rate for Payer: PHP Commercial |
$19.61
|
| Rate for Payer: Priority Health SBD |
$14.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.00
|
| Rate for Payer: UHC Core |
$12.02
|
| Rate for Payer: UHC Exchange |
$9.07
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM
|
Facility
|
IP
|
$23.07
|
|
|
Service Code
|
NDC 00591207072
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$20.76 |
| Rate for Payer: Aetna Commercial |
$19.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.00
|
| Rate for Payer: Cash Price |
$18.46
|
| Rate for Payer: Cofinity Advantage |
$16.15
|
| Rate for Payer: Cofinity Commercial |
$19.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.46
|
| Rate for Payer: Healthscope Commercial |
$20.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.30
|
| Rate for Payer: PHP Commercial |
$19.61
|
| Rate for Payer: Priority Health SBD |
$14.53
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM
|
Facility
|
IP
|
$26.90
|
|
|
Service Code
|
NDC 00168035755
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.95 |
| Max. Negotiated Rate |
$24.21 |
| Rate for Payer: Aetna Commercial |
$22.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.48
|
| Rate for Payer: Cash Price |
$21.52
|
| Rate for Payer: Cofinity Advantage |
$18.83
|
| Rate for Payer: Cofinity Commercial |
$23.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.52
|
| Rate for Payer: Healthscope Commercial |
$24.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.18
|
| Rate for Payer: PHP Commercial |
$22.86
|
| Rate for Payer: Priority Health SBD |
$16.95
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM
|
Facility
|
OP
|
$23.07
|
|
|
Service Code
|
NDC 00591207072
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.07 |
| Max. Negotiated Rate |
$20.76 |
| Rate for Payer: Aetna Commercial |
$19.61
|
| Rate for Payer: Aetna Medicare |
$11.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.00
|
| Rate for Payer: BCBS Complete |
$9.23
|
| Rate for Payer: Cash Price |
$18.46
|
| Rate for Payer: Cofinity Advantage |
$16.15
|
| Rate for Payer: Cofinity Commercial |
$19.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.46
|
| Rate for Payer: Healthscope Commercial |
$20.76
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.30
|
| Rate for Payer: PHP Commercial |
$19.61
|
| Rate for Payer: Priority Health SBD |
$14.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.00
|
| Rate for Payer: UHC Core |
$12.02
|
| Rate for Payer: UHC Exchange |
$9.07
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM
|
Facility
|
OP
|
$26.90
|
|
|
Service Code
|
NDC 00168035705
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.57 |
| Max. Negotiated Rate |
$24.21 |
| Rate for Payer: Aetna Commercial |
$22.86
|
| Rate for Payer: Aetna Medicare |
$13.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.48
|
| Rate for Payer: BCBS Complete |
$10.76
|
| Rate for Payer: Cash Price |
$21.52
|
| Rate for Payer: Cofinity Advantage |
$18.83
|
| Rate for Payer: Cofinity Commercial |
$23.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.52
|
| Rate for Payer: Healthscope Commercial |
$24.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.18
|
| Rate for Payer: PHP Commercial |
$22.86
|
| Rate for Payer: Priority Health SBD |
$16.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.48
|
| Rate for Payer: UHC Core |
$14.01
|
| Rate for Payer: UHC Exchange |
$10.57
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM
|
Facility
|
IP
|
$23.07
|
|
|
Service Code
|
NDC 00591207026
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.53 |
| Max. Negotiated Rate |
$20.76 |
| Rate for Payer: Aetna Commercial |
$19.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.00
|
| Rate for Payer: Cash Price |
$18.46
|
| Rate for Payer: Cofinity Advantage |
$16.15
|
| Rate for Payer: Cofinity Commercial |
$19.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.46
|
| Rate for Payer: Healthscope Commercial |
$20.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.30
|
| Rate for Payer: PHP Commercial |
$19.61
|
| Rate for Payer: Priority Health SBD |
$14.53
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM
|
Facility
|
IP
|
$26.90
|
|
|
Service Code
|
NDC 00168035705
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.95 |
| Max. Negotiated Rate |
$24.21 |
| Rate for Payer: Aetna Commercial |
$22.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.48
|
| Rate for Payer: Cash Price |
$21.52
|
| Rate for Payer: Cofinity Advantage |
$18.83
|
| Rate for Payer: Cofinity Commercial |
$23.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.52
|
| Rate for Payer: Healthscope Commercial |
$24.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.18
|
| Rate for Payer: PHP Commercial |
$22.86
|
| Rate for Payer: Priority Health SBD |
$16.95
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM
|
Facility
|
OP
|
$26.90
|
|
|
Service Code
|
NDC 00168035755
|
| Hospital Charge Code |
10434
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.57 |
| Max. Negotiated Rate |
$24.21 |
| Rate for Payer: Aetna Commercial |
$22.86
|
| Rate for Payer: Aetna Medicare |
$13.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.48
|
| Rate for Payer: BCBS Complete |
$10.76
|
| Rate for Payer: Cash Price |
$21.52
|
| Rate for Payer: Cofinity Advantage |
$18.83
|
| Rate for Payer: Cofinity Commercial |
$23.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.52
|
| Rate for Payer: Healthscope Commercial |
$24.21
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.18
|
| Rate for Payer: PHP Commercial |
$22.86
|
| Rate for Payer: Priority Health SBD |
$16.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.48
|
| Rate for Payer: UHC Core |
$14.01
|
| Rate for Payer: UHC Exchange |
$10.57
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
OP
|
$59.61
|
|
|
Service Code
|
NDC 24357070107
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.43 |
| Max. Negotiated Rate |
$53.65 |
| Rate for Payer: Aetna Commercial |
$50.67
|
| Rate for Payer: Aetna Medicare |
$29.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.75
|
| Rate for Payer: BCBS Complete |
$23.84
|
| Rate for Payer: Cash Price |
$47.69
|
| Rate for Payer: Cofinity Advantage |
$41.73
|
| Rate for Payer: Cofinity Commercial |
$51.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.69
|
| Rate for Payer: Healthscope Commercial |
$53.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$47.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.71
|
| Rate for Payer: PHP Commercial |
$50.67
|
| Rate for Payer: Priority Health SBD |
$37.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$38.75
|
| Rate for Payer: UHC Core |
$31.06
|
| Rate for Payer: UHC Exchange |
$23.43
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$14.89
|
|
|
Service Code
|
NDC 00496088207
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.38 |
| Max. Negotiated Rate |
$13.40 |
| Rate for Payer: Aetna Commercial |
$12.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.68
|
| Rate for Payer: Cash Price |
$11.91
|
| Rate for Payer: Cofinity Advantage |
$10.42
|
| Rate for Payer: Cofinity Commercial |
$12.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.91
|
| Rate for Payer: Healthscope Commercial |
$13.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.17
|
| Rate for Payer: PHP Commercial |
$12.66
|
| Rate for Payer: Priority Health SBD |
$9.38
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
OP
|
$14.89
|
|
|
Service Code
|
NDC 00496088207
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.85 |
| Max. Negotiated Rate |
$13.40 |
| Rate for Payer: Aetna Commercial |
$12.66
|
| Rate for Payer: Aetna Medicare |
$7.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.68
|
| Rate for Payer: BCBS Complete |
$5.96
|
| Rate for Payer: Cash Price |
$11.91
|
| Rate for Payer: Cofinity Advantage |
$10.42
|
| Rate for Payer: Cofinity Commercial |
$12.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.91
|
| Rate for Payer: Healthscope Commercial |
$13.40
|
| Rate for Payer: MI Amish Medical Board Commercial |
$11.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.17
|
| Rate for Payer: PHP Commercial |
$12.66
|
| Rate for Payer: Priority Health SBD |
$9.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$9.68
|
| Rate for Payer: UHC Core |
$7.76
|
| Rate for Payer: UHC Exchange |
$5.85
|
|
|
LIDOCAINE-TRANSPARENT DRESSING 4 % TOPICAL KIT
|
Facility
|
IP
|
$59.61
|
|
|
Service Code
|
NDC 24357070107
|
| Hospital Charge Code |
30183
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$37.55 |
| Max. Negotiated Rate |
$53.65 |
| Rate for Payer: Aetna Commercial |
$50.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$38.75
|
| Rate for Payer: Cash Price |
$47.69
|
| Rate for Payer: Cofinity Advantage |
$41.73
|
| Rate for Payer: Cofinity Commercial |
$51.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$47.69
|
| Rate for Payer: Healthscope Commercial |
$53.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$50.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$44.71
|
| Rate for Payer: PHP Commercial |
$50.67
|
| Rate for Payer: Priority Health SBD |
$37.55
|
|
|
LIDOCAINE WITH EPINEPHRINE IN NS 50 ML
|
Facility
|
IP
|
$3.75
|
|
|
Service Code
|
NDC 99000000202
|
| Hospital Charge Code |
158459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.36 |
| Max. Negotiated Rate |
$3.38 |
| Rate for Payer: Aetna Commercial |
$3.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.44
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cofinity Advantage |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.00
|
| Rate for Payer: Healthscope Commercial |
$3.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.81
|
| Rate for Payer: PHP Commercial |
$3.19
|
| Rate for Payer: Priority Health SBD |
$2.36
|
|
|
LIDOCAINE WITH EPINEPHRINE IN NS 50 ML
|
Facility
|
OP
|
$3.75
|
|
|
Service Code
|
NDC 99000000202
|
| Hospital Charge Code |
158459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.47 |
| Max. Negotiated Rate |
$3.38 |
| Rate for Payer: Aetna Commercial |
$3.19
|
| Rate for Payer: Aetna Medicare |
$1.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.44
|
| Rate for Payer: BCBS Complete |
$1.50
|
| Rate for Payer: Cash Price |
$3.00
|
| Rate for Payer: Cofinity Advantage |
$2.62
|
| Rate for Payer: Cofinity Commercial |
$3.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.00
|
| Rate for Payer: Healthscope Commercial |
$3.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.19
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.81
|
| Rate for Payer: PHP Commercial |
$3.19
|
| Rate for Payer: Priority Health SBD |
$2.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.44
|
| Rate for Payer: UHC Core |
$1.95
|
| Rate for Payer: UHC Exchange |
$1.47
|
|
|
LIGATION AND DIVISION OF LONG SAPHENOUS VEIN AT SAPHENOFEMORAL JUNCTION, OR DISTAL INTERRUPTIONS
|
Facility
|
OP
|
$10,174.29
|
|
|
Service Code
|
CPT 37700
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$1,460.54 |
| Max. Negotiated Rate |
$10,174.29 |
| Rate for Payer: Aetna Medicare |
$3,271.98
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$3,932.66
|
| Rate for Payer: Amish Plain Church Group Commercial |
$3,932.66
|
| Rate for Payer: BCBS Complete |
$1,727.85
|
| Rate for Payer: BCBS MAPPO |
$3,146.13
|
| Rate for Payer: BCBS Trust/PPO |
$1,460.54
|
| Rate for Payer: BCN Commercial |
$1,460.54
|
| Rate for Payer: BCN Medicare Advantage |
$3,146.13
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$3,146.13
|
| Rate for Payer: Mclaren Medicaid |
$1,645.43
|
| Rate for Payer: Mclaren Medicare |
$3,146.13
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3,303.44
|
| Rate for Payer: Meridian Medicaid |
$3,303.44
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3,618.05
|
| Rate for Payer: Molina Medicare/Medicaid |
$3,460.74
|
| Rate for Payer: Nomi Health Commercial |
$9,438.39
|
| Rate for Payer: PACE Medicare |
$2,988.82
|
| Rate for Payer: PACE SWMI |
$3,146.13
|
| Rate for Payer: PHP Medicare Advantage |
$3,146.13
|
| Rate for Payer: Priority Health Choice Medicaid |
$1,645.43
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$10,174.29
|
| Rate for Payer: Priority Health Medicare |
$3,146.13
|
| Rate for Payer: Priority Health Tiered Network |
$8,139.43
|
| Rate for Payer: Railroad Medicare Medicare |
$3,146.13
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$3,146.13
|
| Rate for Payer: UHC Medicaid |
$1,645.43
|
| Rate for Payer: UHCCP Medicaid |
$1,645.43
|
| Rate for Payer: VA VA |
$3,146.13
|
|
|
LIGATION OR BIOPSY, TEMPORAL ARTERY
|
Facility
|
OP
|
$5,321.93
|
|
|
Service Code
|
CPT 37609
|
|
Hospital Revenue Code
|
360
|
| Min. Negotiated Rate |
$860.68 |
| Max. Negotiated Rate |
$5,321.93 |
| Rate for Payer: Aetna Medicare |
$1,711.49
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2,057.07
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2,057.07
|
| Rate for Payer: BCBS Complete |
$903.80
|
| Rate for Payer: BCBS MAPPO |
$1,645.66
|
| Rate for Payer: BCBS Trust/PPO |
$2,082.45
|
| Rate for Payer: BCN Commercial |
$2,082.45
|
| Rate for Payer: BCN Medicare Advantage |
$1,645.66
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1,645.66
|
| Rate for Payer: Mclaren Medicaid |
$860.68
|
| Rate for Payer: Mclaren Medicare |
$1,645.66
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1,727.94
|
| Rate for Payer: Meridian Medicaid |
$1,727.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,892.51
|
| Rate for Payer: Molina Medicare/Medicaid |
$1,810.23
|
| Rate for Payer: Nomi Health Commercial |
$4,936.98
|
| Rate for Payer: PACE Medicare |
$1,563.38
|
| Rate for Payer: PACE SWMI |
$1,645.66
|
| Rate for Payer: PHP Medicare Advantage |
$1,645.66
|
| Rate for Payer: Priority Health Choice Medicaid |
$860.68
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$5,321.93
|
| Rate for Payer: Priority Health Medicare |
$1,645.66
|
| Rate for Payer: Priority Health Tiered Network |
$4,257.54
|
| Rate for Payer: Railroad Medicare Medicare |
$1,645.66
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$1,645.66
|
| Rate for Payer: UHC Medicaid |
$860.68
|
| Rate for Payer: UHCCP Medicaid |
$860.68
|
| Rate for Payer: VA VA |
$1,645.66
|
|
|
LIMB REATTACHMENT, HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA
|
Facility
|
IP
|
$109,137.46
|
|
|
Service Code
|
MSDRG 956
|
| Min. Negotiated Rate |
$28,177.31 |
| Max. Negotiated Rate |
$109,137.46 |
| Rate for Payer: Aetna Medicare |
$30,846.74
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$37,075.41
|
| Rate for Payer: Amish Plain Church Group Commercial |
$37,075.41
|
| Rate for Payer: BCBS MAPPO |
$29,660.33
|
| Rate for Payer: BCBS Trust/PPO |
$109,137.46
|
| Rate for Payer: BCN Commercial |
$109,137.46
|
| Rate for Payer: BCN Medicare Advantage |
$29,660.33
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$29,660.33
|
| Rate for Payer: Mclaren Medicare |
$29,660.33
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$31,143.35
|
| Rate for Payer: MI Amish Medical Board Commercial |
$34,109.38
|
| Rate for Payer: Molina Medicare/Medicaid |
$32,626.36
|
| Rate for Payer: Nomi Health Commercial |
$48,542.70
|
| Rate for Payer: PACE Medicare |
$28,177.31
|
| Rate for Payer: PACE SWMI |
$29,660.33
|
| Rate for Payer: PHP Medicare Advantage |
$29,660.33
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Narrow Network |
$60,667.61
|
| Rate for Payer: Priority Health Medicare |
$29,660.33
|
| Rate for Payer: Priority Health Tiered Network |
$48,534.08
|
| Rate for Payer: Railroad Medicare Medicare |
$29,660.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$61,336.90
|
| Rate for Payer: UHC Core |
$51,316.03
|
| Rate for Payer: UHC Dual Complete DSNP/Medicare Advantage |
$29,660.33
|
| Rate for Payer: UHC Exchange |
$41,908.53
|
| Rate for Payer: VA VA |
$29,660.33
|
|
|
LINACLOTIDE 145 MCG CAPSULE
|
Facility
|
OP
|
$971.59
|
|
|
Service Code
|
NDC 00456120130
|
| Hospital Charge Code |
163662
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$381.83 |
| Max. Negotiated Rate |
$874.43 |
| Rate for Payer: Aetna Commercial |
$825.85
|
| Rate for Payer: Aetna Medicare |
$485.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$631.53
|
| Rate for Payer: BCBS Complete |
$388.64
|
| Rate for Payer: Cash Price |
$777.27
|
| Rate for Payer: Cofinity Advantage |
$680.11
|
| Rate for Payer: Cofinity Commercial |
$835.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$777.27
|
| Rate for Payer: Healthscope Commercial |
$874.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$777.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$825.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$728.69
|
| Rate for Payer: PHP Commercial |
$825.85
|
| Rate for Payer: Priority Health SBD |
$612.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$631.53
|
| Rate for Payer: UHC Core |
$506.20
|
| Rate for Payer: UHC Exchange |
$381.83
|
|
|
LINACLOTIDE 145 MCG CAPSULE
|
Facility
|
IP
|
$971.59
|
|
|
Service Code
|
NDC 00456120130
|
| Hospital Charge Code |
163662
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$612.10 |
| Max. Negotiated Rate |
$874.43 |
| Rate for Payer: Aetna Commercial |
$825.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$631.53
|
| Rate for Payer: Cash Price |
$777.27
|
| Rate for Payer: Cofinity Advantage |
$680.11
|
| Rate for Payer: Cofinity Commercial |
$835.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$777.27
|
| Rate for Payer: Healthscope Commercial |
$874.43
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$825.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$728.69
|
| Rate for Payer: PHP Commercial |
$825.85
|
| Rate for Payer: Priority Health SBD |
$612.10
|
|
|
LINACLOTIDE 145 MCG CAPSULE
|
Facility
|
OP
|
$226.27
|
|
|
Service Code
|
NDC 00456120104
|
| Hospital Charge Code |
163662
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.92 |
| Max. Negotiated Rate |
$203.64 |
| Rate for Payer: Aetna Commercial |
$192.33
|
| Rate for Payer: Aetna Medicare |
$113.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$147.08
|
| Rate for Payer: BCBS Complete |
$90.51
|
| Rate for Payer: Cash Price |
$181.02
|
| Rate for Payer: Cofinity Advantage |
$158.39
|
| Rate for Payer: Cofinity Commercial |
$194.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$181.02
|
| Rate for Payer: Healthscope Commercial |
$203.64
|
| Rate for Payer: MI Amish Medical Board Commercial |
$181.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$192.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$169.70
|
| Rate for Payer: PHP Commercial |
$192.33
|
| Rate for Payer: Priority Health SBD |
$142.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$147.08
|
| Rate for Payer: UHC Core |
$117.89
|
| Rate for Payer: UHC Exchange |
$88.92
|
|
