|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
OP
|
$11.89
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.76 |
| Max. Negotiated Rate |
$10.70 |
| Rate for Payer: Aetna Commercial |
$10.11
|
| Rate for Payer: Aetna Commercial |
$12.08
|
| Rate for Payer: Aetna Commercial |
$19.72
|
| Rate for Payer: Aetna Commercial |
$20.21
|
| Rate for Payer: Aetna Commercial |
$24.53
|
| Rate for Payer: Aetna Commercial |
$21.70
|
| Rate for Payer: Aetna Commercial |
$23.17
|
| Rate for Payer: Aetna Medicare |
$11.89
|
| Rate for Payer: Aetna Medicare |
$11.60
|
| Rate for Payer: Aetna Medicare |
$14.43
|
| Rate for Payer: Aetna Medicare |
$12.77
|
| Rate for Payer: Aetna Medicare |
$7.11
|
| Rate for Payer: Aetna Medicare |
$5.95
|
| Rate for Payer: Aetna Medicare |
$13.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.72
|
| 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) |
$15.08
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.73
|
| Rate for Payer: BCBS Complete |
$10.90
|
| Rate for Payer: BCBS Complete |
$5.68
|
| Rate for Payer: BCBS Complete |
$9.51
|
| Rate for Payer: BCBS Complete |
$9.28
|
| Rate for Payer: BCBS Complete |
$4.76
|
| Rate for Payer: BCBS Complete |
$10.21
|
| Rate for Payer: BCBS Complete |
$11.54
|
| Rate for Payer: Cash Price |
$19.02
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Cash Price |
$18.56
|
| Rate for Payer: Cash Price |
$20.42
|
| Rate for Payer: Cash Price |
$11.37
|
| Rate for Payer: Cash Price |
$21.81
|
| Rate for Payer: Cofinity Commercial |
$16.24
|
| Rate for Payer: Cofinity Commercial |
$19.95
|
| Rate for Payer: Cofinity Commercial |
$16.65
|
| Rate for Payer: Cofinity Commercial |
$8.32
|
| Rate for Payer: Cofinity Commercial |
$24.82
|
| Rate for Payer: Cofinity Commercial |
$20.20
|
| Rate for Payer: Cofinity Commercial |
$23.44
|
| Rate for Payer: Cofinity Commercial |
$19.08
|
| Rate for Payer: Cofinity Commercial |
$20.45
|
| Rate for Payer: Cofinity Commercial |
$10.23
|
| Rate for Payer: Cofinity Commercial |
$17.87
|
| Rate for Payer: Cofinity Commercial |
$21.96
|
| Rate for Payer: Cofinity Commercial |
$9.95
|
| Rate for Payer: Cofinity Commercial |
$12.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$9.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.24
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.32
|
| Rate for Payer: Cofinity Medicare Advantage |
$17.87
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.81
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$11.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.51
|
| Rate for Payer: Healthscope Commercial |
$21.40
|
| Rate for Payer: Healthscope Commercial |
$10.70
|
| Rate for Payer: Healthscope Commercial |
$12.79
|
| Rate for Payer: Healthscope Commercial |
$22.98
|
| Rate for Payer: Healthscope Commercial |
$24.53
|
| Rate for Payer: Healthscope Commercial |
$20.88
|
| Rate for Payer: Healthscope Commercial |
$25.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.53
|
| 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: Multiplan/Beech St/PHCS Commercial |
$20.21
|
| Rate for Payer: PHP Commercial |
$10.11
|
| Rate for Payer: PHP Commercial |
$21.70
|
| Rate for Payer: PHP Commercial |
$19.72
|
| Rate for Payer: PHP Commercial |
$23.17
|
| Rate for Payer: PHP Commercial |
$24.53
|
| Rate for Payer: PHP Commercial |
$12.08
|
| Rate for Payer: PHP Commercial |
$20.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.08
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.59
|
| Rate for Payer: Priority Health SBD |
$17.17
|
| Rate for Payer: Priority Health SBD |
$14.62
|
| Rate for Payer: Priority Health SBD |
$18.18
|
| Rate for Payer: Priority Health SBD |
$14.98
|
| Rate for Payer: Priority Health SBD |
$8.95
|
| Rate for Payer: Priority Health SBD |
$7.49
|
| Rate for Payer: Priority Health SBD |
$16.08
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$19.31
|
|
|
Service Code
|
NDC 00121495040
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$17.38 |
| Rate for Payer: Aetna Commercial |
$16.41
|
| Rate for Payer: Aetna Medicare |
$9.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.55
|
| Rate for Payer: BCBS Complete |
$7.72
|
| Rate for Payer: Cash Price |
$15.45
|
| Rate for Payer: Cofinity Commercial |
$13.52
|
| Rate for Payer: Cofinity Commercial |
$16.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.45
|
| Rate for Payer: Healthscope Commercial |
$17.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.41
|
| Rate for Payer: PHP Commercial |
$16.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.55
|
| Rate for Payer: Priority Health SBD |
$12.17
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$19.31
|
|
|
Service Code
|
NDC 00121495015
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$17.38 |
| Rate for Payer: Aetna Commercial |
$16.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.55
|
| Rate for Payer: Cash Price |
$15.45
|
| Rate for Payer: Cofinity Commercial |
$13.52
|
| Rate for Payer: Cofinity Commercial |
$16.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.45
|
| Rate for Payer: Healthscope Commercial |
$17.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.41
|
| Rate for Payer: PHP Commercial |
$16.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.55
|
| Rate for Payer: Priority Health SBD |
$12.17
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$19.31
|
|
|
Service Code
|
NDC 00121495015
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$17.38 |
| Rate for Payer: Aetna Commercial |
$16.41
|
| Rate for Payer: Aetna Medicare |
$9.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.55
|
| Rate for Payer: BCBS Complete |
$7.72
|
| Rate for Payer: Cash Price |
$15.45
|
| Rate for Payer: Cofinity Commercial |
$13.52
|
| Rate for Payer: Cofinity Commercial |
$16.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.45
|
| Rate for Payer: Healthscope Commercial |
$17.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.41
|
| Rate for Payer: PHP Commercial |
$16.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.55
|
| Rate for Payer: Priority Health SBD |
$12.17
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$19.31
|
|
|
Service Code
|
NDC 00121495040
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$17.38 |
| Rate for Payer: Aetna Commercial |
$16.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.55
|
| Rate for Payer: Cash Price |
$15.45
|
| Rate for Payer: Cofinity Commercial |
$13.52
|
| Rate for Payer: Cofinity Commercial |
$16.61
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.45
|
| Rate for Payer: Healthscope Commercial |
$17.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.41
|
| Rate for Payer: PHP Commercial |
$16.41
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.55
|
| Rate for Payer: Priority Health SBD |
$12.17
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 50383077515
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Medicare |
$2.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: BCBS Complete |
$1.69
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.66
|
|
|
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 |
$10.36 |
| 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 Commercial |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.13
|
| 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: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.84
|
| Rate for Payer: Priority Health SBD |
$16.32
|
|
|
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 Commercial |
$223.19
|
| Rate for Payer: Cofinity Commercial |
$274.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.19
|
| 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: PHP Commercial |
$271.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.25
|
| Rate for Payer: Priority Health SBD |
$200.88
|
|
|
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 |
$127.54 |
| 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 Commercial |
$223.19
|
| Rate for Payer: Cofinity Commercial |
$274.21
|
| Rate for Payer: Cofinity Medicare Advantage |
$223.19
|
| 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: PHP Commercial |
$271.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$207.25
|
| Rate for Payer: Priority Health SBD |
$200.88
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 50383077517
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.69 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Medicare |
$2.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: BCBS Complete |
$1.69
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.66
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 50383077517
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.66 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.66
|
|
|
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 Commercial |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.13
|
| 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: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.84
|
| Rate for Payer: Priority Health SBD |
$16.32
|
|
|
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 Commercial |
$3.84
|
| Rate for Payer: Cofinity Commercial |
$4.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.84
|
| 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: PHP Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.57
|
| Rate for Payer: Priority Health SBD |
$3.46
|
|
|
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 |
$2.20 |
| 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 Commercial |
$3.84
|
| Rate for Payer: Cofinity Commercial |
$4.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.84
|
| 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: PHP Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.57
|
| Rate for Payer: Priority Health SBD |
$3.46
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 50383077515
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.66 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.66
|
|
|
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 |
$14.14 |
| 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 Commercial |
$24.75
|
| Rate for Payer: Cofinity Commercial |
$30.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.75
|
| 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: PHP Commercial |
$30.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.98
|
| Rate for Payer: Priority Health SBD |
$22.27
|
|
|
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 Commercial |
$24.75
|
| Rate for Payer: Cofinity Commercial |
$30.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.75
|
| 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: PHP Commercial |
$30.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.98
|
| Rate for Payer: Priority Health SBD |
$22.27
|
|
|
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 Commercial |
$72.89
|
| Rate for Payer: Cofinity Commercial |
$89.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.89
|
| 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: PHP Commercial |
$88.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.68
|
| Rate for Payer: Priority Health SBD |
$65.60
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$83.79 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna Commercial |
$113.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.45
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cofinity Commercial |
$93.10
|
| Rate for Payer: Cofinity Commercial |
$114.38
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.40
|
| Rate for Payer: Healthscope Commercial |
$119.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.05
|
| Rate for Payer: PHP Commercial |
$113.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.45
|
| Rate for Payer: Priority Health SBD |
$83.79
|
|
|
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 |
$41.65 |
| 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 Commercial |
$72.89
|
| Rate for Payer: Cofinity Commercial |
$89.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.89
|
| 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: PHP Commercial |
$88.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.68
|
| Rate for Payer: Priority Health SBD |
$65.60
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.20 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna Commercial |
$113.05
|
| Rate for Payer: Aetna Medicare |
$66.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.45
|
| Rate for Payer: BCBS Complete |
$53.20
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cofinity Commercial |
$114.38
|
| Rate for Payer: Cofinity Commercial |
$93.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.40
|
| Rate for Payer: Healthscope Commercial |
$119.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.05
|
| Rate for Payer: PHP Commercial |
$113.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.45
|
| Rate for Payer: Priority Health SBD |
$83.79
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$71.40
|
|
|
Service Code
|
NDC 52565000950
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$44.98 |
| Max. Negotiated Rate |
$64.26 |
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.41
|
| Rate for Payer: Cash Price |
$57.12
|
| Rate for Payer: Cofinity Commercial |
$49.98
|
| Rate for Payer: Cofinity Commercial |
$61.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.12
|
| Rate for Payer: Healthscope Commercial |
$64.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.69
|
| Rate for Payer: PHP Commercial |
$60.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.41
|
| Rate for Payer: Priority Health SBD |
$44.98
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$71.40
|
|
|
Service Code
|
NDC 52565000950
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.56 |
| Max. Negotiated Rate |
$64.26 |
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Aetna Medicare |
$35.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.41
|
| Rate for Payer: BCBS Complete |
$28.56
|
| Rate for Payer: Cash Price |
$57.12
|
| Rate for Payer: Cofinity Commercial |
$49.98
|
| Rate for Payer: Cofinity Commercial |
$61.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.12
|
| Rate for Payer: Healthscope Commercial |
$64.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.69
|
| Rate for Payer: PHP Commercial |
$60.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.41
|
| Rate for Payer: Priority Health SBD |
$44.98
|
|
|
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION
|
Facility
|
OP
|
$107.59
|
|
|
Service Code
|
NDC 76329630005
|
| Hospital Charge Code |
43717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$43.04 |
| Max. Negotiated Rate |
$96.83 |
| Rate for Payer: Aetna Commercial |
$91.45
|
| Rate for Payer: Aetna Medicare |
$53.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.93
|
| Rate for Payer: BCBS Complete |
$43.04
|
| Rate for Payer: Cash Price |
$86.07
|
| Rate for Payer: Cofinity Commercial |
$75.31
|
| Rate for Payer: Cofinity Commercial |
$92.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.07
|
| Rate for Payer: Healthscope Commercial |
$96.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.45
|
| Rate for Payer: PHP Commercial |
$91.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.93
|
| Rate for Payer: Priority Health SBD |
$67.78
|
|
|
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION
|
Facility
|
IP
|
$107.59
|
|
|
Service Code
|
NDC 76329630005
|
| Hospital Charge Code |
43717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$67.78 |
| Max. Negotiated Rate |
$96.83 |
| Rate for Payer: Aetna Commercial |
$91.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$69.93
|
| Rate for Payer: Cash Price |
$86.07
|
| Rate for Payer: Cofinity Commercial |
$75.31
|
| Rate for Payer: Cofinity Commercial |
$92.53
|
| Rate for Payer: Cofinity Medicare Advantage |
$75.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$86.07
|
| Rate for Payer: Healthscope Commercial |
$96.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$91.45
|
| Rate for Payer: PHP Commercial |
$91.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$69.93
|
| Rate for Payer: Priority Health SBD |
$67.78
|
|
