|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$4.68
|
|
|
Service Code
|
NDC 51079-440-01
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.85 |
| Max. Negotiated Rate |
$4.21 |
| Rate for Payer: Aetna Commercial |
$3.98
|
| Rate for Payer: BCBS Trust/PPO |
$3.62
|
| Rate for Payer: BCN Commercial |
$3.62
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cofinity Commercial |
$4.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.74
|
| Rate for Payer: Healthscope Commercial |
$4.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.98
|
| Rate for Payer: PHP Commercial |
$3.98
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.07
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.85
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$4.12
|
| Rate for Payer: UHC Core |
$3.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.51
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$313.50
|
|
|
Service Code
|
NDC 0904-6950-61
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$191.20 |
| Max. Negotiated Rate |
$282.15 |
| Rate for Payer: Aetna Commercial |
$266.48
|
| Rate for Payer: BCBS Trust/PPO |
$242.27
|
| Rate for Payer: BCN Commercial |
$242.27
|
| Rate for Payer: Cash Price |
$250.80
|
| Rate for Payer: Cofinity Commercial |
$269.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$250.80
|
| Rate for Payer: Healthscope Commercial |
$282.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$235.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$266.48
|
| Rate for Payer: PHP Commercial |
$266.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$219.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$272.74
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$191.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$275.88
|
| Rate for Payer: UHC Core |
$261.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$235.12
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$328.70
|
|
|
Service Code
|
NDC 60687-464-01
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$200.47 |
| Max. Negotiated Rate |
$295.83 |
| Rate for Payer: Aetna Commercial |
$279.40
|
| Rate for Payer: BCBS Trust/PPO |
$254.02
|
| Rate for Payer: BCN Commercial |
$254.02
|
| Rate for Payer: Cash Price |
$262.96
|
| Rate for Payer: Cofinity Commercial |
$282.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$262.96
|
| Rate for Payer: Healthscope Commercial |
$295.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$246.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$279.40
|
| Rate for Payer: PHP Commercial |
$279.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$230.09
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$285.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$200.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$289.26
|
| Rate for Payer: UHC Core |
$274.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$246.52
|
|
|
LEVOTHYROXINE 50 MCG TABLET
|
Facility
|
IP
|
$3.29
|
|
|
Service Code
|
NDC 60687-464-11
|
| Hospital Charge Code |
4421
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.01 |
| Max. Negotiated Rate |
$2.96 |
| Rate for Payer: Aetna Commercial |
$2.80
|
| Rate for Payer: BCBS Trust/PPO |
$2.54
|
| Rate for Payer: BCN Commercial |
$2.54
|
| Rate for Payer: Cash Price |
$2.63
|
| Rate for Payer: Cofinity Commercial |
$2.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.63
|
| Rate for Payer: Healthscope Commercial |
$2.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.80
|
| Rate for Payer: PHP Commercial |
$2.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.86
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.90
|
| Rate for Payer: UHC Core |
$2.75
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.47
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$379.05
|
|
|
Service Code
|
NDC 0904-6951-61
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$231.18 |
| Max. Negotiated Rate |
$341.14 |
| Rate for Payer: Aetna Commercial |
$322.19
|
| Rate for Payer: BCBS Trust/PPO |
$292.93
|
| Rate for Payer: BCN Commercial |
$292.93
|
| Rate for Payer: Cash Price |
$303.24
|
| Rate for Payer: Cofinity Commercial |
$325.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$303.24
|
| Rate for Payer: Healthscope Commercial |
$341.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$284.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$322.19
|
| Rate for Payer: PHP Commercial |
$322.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$265.34
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$329.77
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$231.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$333.56
|
| Rate for Payer: UHC Core |
$316.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.29
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$262.56
|
|
|
Service Code
|
NDC 51079-441-20
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.14 |
| Max. Negotiated Rate |
$236.30 |
| Rate for Payer: Aetna Commercial |
$223.18
|
| Rate for Payer: BCBS Trust/PPO |
$202.91
|
| Rate for Payer: BCN Commercial |
$202.91
|
| Rate for Payer: Cash Price |
$210.05
|
| Rate for Payer: Cofinity Commercial |
$225.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$210.05
|
| Rate for Payer: Healthscope Commercial |
$236.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$196.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$223.18
|
| Rate for Payer: PHP Commercial |
$223.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$183.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$228.43
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$160.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$231.05
|
| Rate for Payer: UHC Core |
$219.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.92
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$2.63
|
|
|
Service Code
|
NDC 51079-441-01
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.60 |
| Max. Negotiated Rate |
$2.37 |
| Rate for Payer: Aetna Commercial |
$2.24
|
| Rate for Payer: BCBS Trust/PPO |
$2.03
|
| Rate for Payer: BCN Commercial |
$2.03
|
| Rate for Payer: Cash Price |
$2.10
|
| Rate for Payer: Cofinity Commercial |
$2.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.10
|
| Rate for Payer: Healthscope Commercial |
$2.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.24
|
| Rate for Payer: PHP Commercial |
$2.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.31
|
| Rate for Payer: UHC Core |
$2.20
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.97
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$703.68
|
|
|
Service Code
|
NDC 0074-5182-11
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$429.17 |
| Max. Negotiated Rate |
$633.31 |
| Rate for Payer: Aetna Commercial |
$598.13
|
| Rate for Payer: BCBS Trust/PPO |
$543.80
|
| Rate for Payer: BCN Commercial |
$543.80
|
| Rate for Payer: Cash Price |
$562.94
|
| Rate for Payer: Cofinity Commercial |
$605.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$562.94
|
| Rate for Payer: Healthscope Commercial |
$633.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$527.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$598.13
|
| Rate for Payer: PHP Commercial |
$598.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$492.58
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$612.20
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$429.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$619.24
|
| Rate for Payer: UHC Core |
$587.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$527.76
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$380.00
|
|
|
Service Code
|
NDC 0904-6952-61
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$231.76 |
| Max. Negotiated Rate |
$342.00 |
| Rate for Payer: Aetna Commercial |
$323.00
|
| Rate for Payer: BCBS Trust/PPO |
$293.66
|
| Rate for Payer: BCN Commercial |
$293.66
|
| Rate for Payer: Cash Price |
$304.00
|
| Rate for Payer: Cofinity Commercial |
$326.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$304.00
|
| Rate for Payer: Healthscope Commercial |
$342.00
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$285.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$323.00
|
| Rate for Payer: PHP Commercial |
$323.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$266.00
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$330.60
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$231.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$334.40
|
| Rate for Payer: UHC Core |
$317.30
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$285.00
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$3.99
|
|
|
Service Code
|
NDC 60687-486-11
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.43 |
| Max. Negotiated Rate |
$3.59 |
| Rate for Payer: Aetna Commercial |
$3.39
|
| Rate for Payer: BCBS Trust/PPO |
$3.08
|
| Rate for Payer: BCN Commercial |
$3.08
|
| Rate for Payer: Cash Price |
$3.19
|
| Rate for Payer: Cofinity Commercial |
$3.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.19
|
| Rate for Payer: Healthscope Commercial |
$3.59
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.39
|
| Rate for Payer: PHP Commercial |
$3.39
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.79
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$3.47
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.43
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.51
|
| Rate for Payer: UHC Core |
$3.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.99
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$633.75
|
|
|
Service Code
|
NDC 0074-6594-90
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$386.52 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna Commercial |
$538.69
|
| Rate for Payer: BCBS Trust/PPO |
$489.76
|
| Rate for Payer: BCN Commercial |
$489.76
|
| Rate for Payer: Cash Price |
$507.00
|
| Rate for Payer: Cofinity Commercial |
$545.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$507.00
|
| Rate for Payer: Healthscope Commercial |
$570.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$475.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$538.69
|
| Rate for Payer: PHP Commercial |
$538.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$443.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$551.36
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$386.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$557.70
|
| Rate for Payer: UHC Core |
$529.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$475.31
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$241.44
|
|
|
Service Code
|
NDC 42292-038-20
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$147.25 |
| Max. Negotiated Rate |
$217.30 |
| Rate for Payer: Aetna Commercial |
$205.22
|
| Rate for Payer: BCBS Trust/PPO |
$186.58
|
| Rate for Payer: BCN Commercial |
$186.58
|
| Rate for Payer: Cash Price |
$193.15
|
| Rate for Payer: Cofinity Commercial |
$207.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$193.15
|
| Rate for Payer: Healthscope Commercial |
$217.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$181.08
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$205.22
|
| Rate for Payer: PHP Commercial |
$205.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$169.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$210.05
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$147.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$212.47
|
| Rate for Payer: UHC Core |
$201.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$181.08
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$2.42
|
|
|
Service Code
|
NDC 42292-038-01
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.48 |
| Max. Negotiated Rate |
$2.18 |
| Rate for Payer: Aetna Commercial |
$2.06
|
| Rate for Payer: BCBS Trust/PPO |
$1.87
|
| Rate for Payer: BCN Commercial |
$1.87
|
| Rate for Payer: Cash Price |
$1.94
|
| Rate for Payer: Cofinity Commercial |
$2.08
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1.94
|
| Rate for Payer: Healthscope Commercial |
$2.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.06
|
| Rate for Payer: PHP Commercial |
$2.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.69
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.11
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.13
|
| Rate for Payer: UHC Core |
$2.02
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.82
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$399.00
|
|
|
Service Code
|
NDC 60687-486-01
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$243.35 |
| Max. Negotiated Rate |
$359.10 |
| Rate for Payer: Aetna Commercial |
$339.15
|
| Rate for Payer: BCBS Trust/PPO |
$308.35
|
| Rate for Payer: BCN Commercial |
$308.35
|
| Rate for Payer: Cash Price |
$319.20
|
| Rate for Payer: Cofinity Commercial |
$343.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$319.20
|
| Rate for Payer: Healthscope Commercial |
$359.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$299.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$339.15
|
| Rate for Payer: PHP Commercial |
$339.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$279.30
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$347.13
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$243.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$351.12
|
| Rate for Payer: UHC Core |
$333.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$299.25
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
NDC 63323-482-27
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.97 |
| Max. Negotiated Rate |
$26.51 |
| Rate for Payer: Aetna Commercial |
$25.04
|
| Rate for Payer: BCBS Trust/PPO |
$22.77
|
| Rate for Payer: BCN Commercial |
$22.77
|
| Rate for Payer: Cash Price |
$23.57
|
| Rate for Payer: Cofinity Commercial |
$25.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.57
|
| Rate for Payer: Healthscope Commercial |
$26.51
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.04
|
| Rate for Payer: PHP Commercial |
$25.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.62
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$25.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$17.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.92
|
| Rate for Payer: UHC Core |
$24.60
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.10
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$17.40
|
|
|
Service Code
|
NDC 0409-3178-01
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.61 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: BCBS Trust/PPO |
$13.45
|
| Rate for Payer: BCN Commercial |
$13.45
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.92
|
| Rate for Payer: Healthscope Commercial |
$15.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.79
|
| Rate for Payer: PHP Commercial |
$14.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.18
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.61
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.31
|
| Rate for Payer: UHC Core |
$14.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.05
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$22.62
|
|
|
Service Code
|
NDC 0409-3182-01
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.80 |
| Max. Negotiated Rate |
$20.36 |
| Rate for Payer: Aetna Commercial |
$19.23
|
| Rate for Payer: BCBS Trust/PPO |
$17.48
|
| Rate for Payer: BCN Commercial |
$17.48
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cofinity Commercial |
$19.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.10
|
| Rate for Payer: Healthscope Commercial |
$20.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.23
|
| Rate for Payer: PHP Commercial |
$19.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.91
|
| Rate for Payer: UHC Core |
$18.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.96
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$22.62
|
|
|
Service Code
|
NDC 0409-3182-11
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.80 |
| Max. Negotiated Rate |
$20.36 |
| Rate for Payer: Aetna Commercial |
$19.23
|
| Rate for Payer: BCBS Trust/PPO |
$17.48
|
| Rate for Payer: BCN Commercial |
$17.48
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cofinity Commercial |
$19.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.10
|
| Rate for Payer: Healthscope Commercial |
$20.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.23
|
| Rate for Payer: PHP Commercial |
$19.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.83
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.68
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.91
|
| Rate for Payer: UHC Core |
$18.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.96
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$17.98
|
|
|
Service Code
|
NDC 63323-483-27
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.97 |
| Max. Negotiated Rate |
$16.18 |
| Rate for Payer: Aetna Commercial |
$15.28
|
| Rate for Payer: BCBS Trust/PPO |
$13.89
|
| Rate for Payer: BCN Commercial |
$13.89
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cofinity Commercial |
$15.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.38
|
| Rate for Payer: Healthscope Commercial |
$16.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$15.28
|
| Rate for Payer: PHP Commercial |
$15.28
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.59
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$15.64
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.82
|
| Rate for Payer: UHC Core |
$15.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.48
|
|
|
LIDOCAINE 2 %-EPINEPHRINE BITARTRATE 1:100,000 INJECTION CARTRIDGE
|
Facility
|
IP
|
$7.06
|
|
|
Service Code
|
NDC 0362-0898-05
|
| Hospital Charge Code |
118255
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.31 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: BCBS Trust/PPO |
$5.46
|
| Rate for Payer: BCN Commercial |
$5.46
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cofinity Commercial |
$6.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.65
|
| Rate for Payer: Healthscope Commercial |
$6.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$6.00
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.94
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$6.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.21
|
| Rate for Payer: UHC Core |
$5.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.30
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$24.06
|
|
|
Service Code
|
NDC 76329-3012-5
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.67 |
| Max. Negotiated Rate |
$21.65 |
| Rate for Payer: Aetna Commercial |
$20.45
|
| Rate for Payer: BCBS Trust/PPO |
$18.59
|
| Rate for Payer: BCN Commercial |
$18.59
|
| Rate for Payer: Cash Price |
$19.25
|
| Rate for Payer: Cofinity Commercial |
$20.69
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.25
|
| Rate for Payer: Healthscope Commercial |
$21.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.45
|
| Rate for Payer: PHP Commercial |
$20.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.84
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.93
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.67
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.17
|
| Rate for Payer: UHC Core |
$20.09
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.04
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$15.21
|
|
|
Service Code
|
NDC 25021-673-76
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.28 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: BCBS Trust/PPO |
$11.75
|
| Rate for Payer: BCN Commercial |
$11.75
|
| Rate for Payer: Cash Price |
$12.17
|
| 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: Lakeland Regional Health Systems Commercial |
$11.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.93
|
| Rate for Payer: PHP Commercial |
$12.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.65
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$9.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.38
|
| Rate for Payer: UHC Core |
$12.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.41
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$30.10
|
|
|
Service Code
|
NDC 76329-3015-5
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.36 |
| Max. Negotiated Rate |
$27.09 |
| Rate for Payer: Aetna Commercial |
$25.58
|
| Rate for Payer: BCBS Trust/PPO |
$23.26
|
| Rate for Payer: BCN Commercial |
$23.26
|
| Rate for Payer: Cash Price |
$24.08
|
| Rate for Payer: Cofinity Commercial |
$25.89
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.08
|
| Rate for Payer: Healthscope Commercial |
$27.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.58
|
| Rate for Payer: PHP Commercial |
$25.58
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.07
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26.19
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.36
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.49
|
| Rate for Payer: UHC Core |
$25.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.58
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
IP
|
$29.93
|
|
|
Service Code
|
NDC 71266-6290-1
|
| Hospital Charge Code |
196007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.25 |
| Max. Negotiated Rate |
$26.94 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: BCBS Trust/PPO |
$23.13
|
| Rate for Payer: BCN Commercial |
$23.13
|
| Rate for Payer: Cash Price |
$23.94
|
| 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: Lakeland Regional Health Systems Commercial |
$22.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.44
|
| Rate for Payer: PHP Commercial |
$25.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.95
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$18.25
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.34
|
| Rate for Payer: UHC Core |
$24.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.45
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$16.52
|
|
|
Service Code
|
NDC 96295-13458
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.08 |
| Max. Negotiated Rate |
$14.87 |
| Rate for Payer: Aetna Commercial |
$14.04
|
| Rate for Payer: BCBS Trust/PPO |
$12.77
|
| Rate for Payer: BCN Commercial |
$12.77
|
| Rate for Payer: Cash Price |
$13.22
|
| Rate for Payer: Cofinity Commercial |
$14.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.22
|
| Rate for Payer: Healthscope Commercial |
$14.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.39
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.04
|
| Rate for Payer: PHP Commercial |
$14.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$14.37
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$14.54
|
| Rate for Payer: UHC Core |
$13.79
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.39
|
|
