|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$418.00
|
|
|
Service Code
|
NDC 60687048601
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$271.70 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna Commercial |
$355.30
|
| Rate for Payer: BCBS Trust/PPO |
$341.21
|
| Rate for Payer: BCN Commercial |
$323.03
|
| Rate for Payer: Cash Price |
$334.40
|
| Rate for Payer: Cofinity Commercial |
$359.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.40
|
| Rate for Payer: Healthscope Commercial |
$376.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.30
|
| Rate for Payer: Nomi Health Commercial |
$342.76
|
| Rate for Payer: PHP Commercial |
$355.30
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.70
|
| Rate for Payer: Priority Health HMO/PPO |
$363.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$280.06
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$367.84
|
| Rate for Payer: UHC Core |
$349.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.50
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$4.18
|
|
|
Service Code
|
NDC 60687048611
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.99 |
| Max. Negotiated Rate |
$3.76 |
| Rate for Payer: Aetna Commercial |
$3.55
|
| Rate for Payer: Aetna Medicare |
$1.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$1.31
|
| Rate for Payer: Amish Plain Church Group Commercial |
$1.31
|
| Rate for Payer: BCBS Complete |
$1.67
|
| Rate for Payer: BCBS MAPPO |
$1.04
|
| Rate for Payer: BCBS Trust/PPO |
$3.44
|
| Rate for Payer: BCN Commercial |
$3.25
|
| Rate for Payer: BCN Medicare Advantage |
$1.04
|
| Rate for Payer: Cash Price |
$3.34
|
| Rate for Payer: Cofinity Commercial |
$3.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.34
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$1.04
|
| Rate for Payer: Healthscope Commercial |
$3.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.14
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.10
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.55
|
| Rate for Payer: Nomi Health Commercial |
$3.43
|
| Rate for Payer: PACE Senior Care Partners |
$0.99
|
| Rate for Payer: PACE SWMI |
$1.04
|
| Rate for Payer: PHP Commercial |
$3.55
|
| Rate for Payer: PHP Medicare Advantage |
$1.04
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.72
|
| Rate for Payer: Priority Health HMO/PPO |
$3.64
|
| Rate for Payer: Priority Health Medicare |
$1.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$2.80
|
| Rate for Payer: Railroad Medicare Medicare |
$1.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.68
|
| Rate for Payer: UHC Core |
$3.49
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.04
|
| Rate for Payer: UHC Exchange |
$1.04
|
| Rate for Payer: UHC Medicare Advantage |
$1.04
|
| Rate for Payer: VA VA |
$1.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.14
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$386.65
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$91.83 |
| Max. Negotiated Rate |
$347.98 |
| Rate for Payer: Aetna Commercial |
$328.65
|
| Rate for Payer: Aetna Medicare |
$100.53
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$120.83
|
| Rate for Payer: Amish Plain Church Group Commercial |
$120.83
|
| Rate for Payer: BCBS Complete |
$154.66
|
| Rate for Payer: BCBS MAPPO |
$96.66
|
| Rate for Payer: BCBS Trust/PPO |
$317.86
|
| Rate for Payer: BCN Commercial |
$300.62
|
| Rate for Payer: BCN Medicare Advantage |
$96.66
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$332.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$96.66
|
| Rate for Payer: Healthscope Commercial |
$347.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$289.99
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$101.50
|
| Rate for Payer: MI Amish Medical Board Commercial |
$111.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: Nomi Health Commercial |
$317.05
|
| Rate for Payer: PACE Senior Care Partners |
$91.83
|
| Rate for Payer: PACE SWMI |
$96.66
|
| Rate for Payer: PHP Commercial |
$328.65
|
| Rate for Payer: PHP Medicare Advantage |
$96.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: Priority Health HMO/PPO |
$336.39
|
| Rate for Payer: Priority Health Medicare |
$97.63
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$259.06
|
| Rate for Payer: Railroad Medicare Medicare |
$96.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$340.25
|
| Rate for Payer: UHC Core |
$322.85
|
| Rate for Payer: UHC Dual Complete DSNP |
$96.66
|
| Rate for Payer: UHC Exchange |
$96.66
|
| Rate for Payer: UHC Medicare Advantage |
$96.66
|
| Rate for Payer: VA VA |
$96.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$289.99
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$2.51
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.26 |
| Rate for Payer: Aetna Commercial |
$2.13
|
| Rate for Payer: BCBS Trust/PPO |
$2.05
|
| Rate for Payer: BCN Commercial |
$1.94
|
| Rate for Payer: Cash Price |
$2.01
|
| Rate for Payer: Cofinity Commercial |
$2.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.01
|
| Rate for Payer: Healthscope Commercial |
$2.26
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$1.88
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.13
|
| Rate for Payer: Nomi Health Commercial |
$2.06
|
| Rate for Payer: PHP Commercial |
$2.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.63
|
| Rate for Payer: Priority Health HMO/PPO |
$2.18
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$1.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.21
|
| Rate for Payer: UHC Core |
$2.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$1.88
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$418.00
|
|
|
Service Code
|
NDC 60687048601
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$99.28 |
| Max. Negotiated Rate |
$376.20 |
| Rate for Payer: Aetna Commercial |
$355.30
|
| Rate for Payer: Aetna Medicare |
$108.68
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$130.62
|
| Rate for Payer: Amish Plain Church Group Commercial |
$130.62
|
| Rate for Payer: BCBS Complete |
$167.20
|
| Rate for Payer: BCBS MAPPO |
$104.50
|
| Rate for Payer: BCBS Trust/PPO |
$343.64
|
| Rate for Payer: BCN Commercial |
$325.00
|
| Rate for Payer: BCN Medicare Advantage |
$104.50
|
| Rate for Payer: Cash Price |
$334.40
|
| Rate for Payer: Cofinity Commercial |
$359.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$334.40
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$104.50
|
| Rate for Payer: Healthscope Commercial |
$376.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$313.50
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$109.72
|
| Rate for Payer: MI Amish Medical Board Commercial |
$120.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$355.30
|
| Rate for Payer: Nomi Health Commercial |
$342.76
|
| Rate for Payer: PACE Senior Care Partners |
$99.28
|
| Rate for Payer: PACE SWMI |
$104.50
|
| Rate for Payer: PHP Commercial |
$355.30
|
| Rate for Payer: PHP Medicare Advantage |
$104.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$271.70
|
| Rate for Payer: Priority Health HMO/PPO |
$363.66
|
| Rate for Payer: Priority Health Medicare |
$105.54
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$280.06
|
| Rate for Payer: Railroad Medicare Medicare |
$104.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$367.84
|
| Rate for Payer: UHC Core |
$349.03
|
| Rate for Payer: UHC Dual Complete DSNP |
$104.50
|
| Rate for Payer: UHC Exchange |
$104.50
|
| Rate for Payer: UHC Medicare Advantage |
$104.50
|
| Rate for Payer: VA VA |
$104.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$313.50
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$250.56
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$59.51 |
| Max. Negotiated Rate |
$225.50 |
| Rate for Payer: Aetna Commercial |
$212.98
|
| Rate for Payer: Aetna Medicare |
$65.15
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$78.30
|
| Rate for Payer: Amish Plain Church Group Commercial |
$78.30
|
| Rate for Payer: BCBS Complete |
$100.22
|
| Rate for Payer: BCBS MAPPO |
$62.64
|
| Rate for Payer: BCBS Trust/PPO |
$205.99
|
| Rate for Payer: BCN Commercial |
$194.81
|
| Rate for Payer: BCN Medicare Advantage |
$62.64
|
| Rate for Payer: Cash Price |
$200.45
|
| Rate for Payer: Cofinity Commercial |
$215.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.45
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$62.64
|
| Rate for Payer: Healthscope Commercial |
$225.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$187.92
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$65.77
|
| Rate for Payer: MI Amish Medical Board Commercial |
$72.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.98
|
| Rate for Payer: Nomi Health Commercial |
$205.46
|
| Rate for Payer: PACE Senior Care Partners |
$59.51
|
| Rate for Payer: PACE SWMI |
$62.64
|
| Rate for Payer: PHP Commercial |
$212.98
|
| Rate for Payer: PHP Medicare Advantage |
$62.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.86
|
| Rate for Payer: Priority Health HMO/PPO |
$217.99
|
| Rate for Payer: Priority Health Medicare |
$63.27
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$167.88
|
| Rate for Payer: Railroad Medicare Medicare |
$62.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$220.49
|
| Rate for Payer: UHC Core |
$209.22
|
| Rate for Payer: UHC Dual Complete DSNP |
$62.64
|
| Rate for Payer: UHC Exchange |
$62.64
|
| Rate for Payer: UHC Medicare Advantage |
$62.64
|
| Rate for Payer: VA VA |
$62.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$187.92
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
OP
|
$19.23
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.57 |
| Max. Negotiated Rate |
$17.31 |
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Aetna Medicare |
$5.00
|
| Rate for Payer: Aetna Medicare |
$4.52
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.44
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.01
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.44
|
| Rate for Payer: BCBS Complete |
$6.96
|
| Rate for Payer: BCBS Complete |
$7.69
|
| Rate for Payer: BCBS MAPPO |
$4.35
|
| Rate for Payer: BCBS MAPPO |
$4.81
|
| Rate for Payer: BCBS Trust/PPO |
$15.81
|
| Rate for Payer: BCBS Trust/PPO |
$14.30
|
| Rate for Payer: BCN Commercial |
$14.95
|
| Rate for Payer: BCN Commercial |
$13.53
|
| Rate for Payer: BCN Medicare Advantage |
$4.81
|
| Rate for Payer: BCN Medicare Advantage |
$4.35
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Cofinity Commercial |
$16.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.92
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.35
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.81
|
| Rate for Payer: Healthscope Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$17.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.05
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.57
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.05
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.00
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.79
|
| Rate for Payer: Nomi Health Commercial |
$15.77
|
| Rate for Payer: Nomi Health Commercial |
$14.27
|
| Rate for Payer: PACE Senior Care Partners |
$4.57
|
| Rate for Payer: PACE Senior Care Partners |
$4.13
|
| Rate for Payer: PACE SWMI |
$4.81
|
| Rate for Payer: PACE SWMI |
$4.35
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: PHP Commercial |
$14.79
|
| Rate for Payer: PHP Medicare Advantage |
$4.35
|
| Rate for Payer: PHP Medicare Advantage |
$4.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.31
|
| Rate for Payer: Priority Health HMO/PPO |
$15.14
|
| Rate for Payer: Priority Health HMO/PPO |
$16.73
|
| Rate for Payer: Priority Health Medicare |
$4.86
|
| Rate for Payer: Priority Health Medicare |
$4.39
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.88
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.66
|
| Rate for Payer: Railroad Medicare Medicare |
$4.35
|
| Rate for Payer: Railroad Medicare Medicare |
$4.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.92
|
| Rate for Payer: UHC Core |
$16.06
|
| Rate for Payer: UHC Core |
$14.53
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.81
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.35
|
| Rate for Payer: UHC Exchange |
$4.35
|
| Rate for Payer: UHC Exchange |
$4.81
|
| Rate for Payer: UHC Medicare Advantage |
$4.35
|
| Rate for Payer: UHC Medicare Advantage |
$4.81
|
| Rate for Payer: VA VA |
$4.35
|
| Rate for Payer: VA VA |
$4.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.05
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$17.40
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.31 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: BCBS Trust/PPO |
$14.20
|
| Rate for Payer: BCBS Trust/PPO |
$15.70
|
| Rate for Payer: BCN Commercial |
$13.45
|
| Rate for Payer: BCN Commercial |
$14.86
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cofinity Commercial |
$16.54
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.92
|
| Rate for Payer: Healthscope Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$17.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.35
|
| Rate for Payer: Nomi Health Commercial |
$14.27
|
| Rate for Payer: Nomi Health Commercial |
$15.77
|
| Rate for Payer: PHP Commercial |
$14.79
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.31
|
| Rate for Payer: Priority Health HMO/PPO |
$16.73
|
| Rate for Payer: Priority Health HMO/PPO |
$15.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$11.66
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.88
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.31
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.92
|
| Rate for Payer: UHC Core |
$14.53
|
| Rate for Payer: UHC Core |
$16.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.42
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$19.50
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.68 |
| Max. Negotiated Rate |
$17.55 |
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: Aetna Commercial |
$19.23
|
| Rate for Payer: BCBS Trust/PPO |
$15.92
|
| Rate for Payer: BCBS Trust/PPO |
$18.46
|
| Rate for Payer: BCN Commercial |
$15.07
|
| Rate for Payer: BCN Commercial |
$17.48
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cofinity Commercial |
$19.45
|
| Rate for Payer: Cofinity Commercial |
$16.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.60
|
| Rate for Payer: Healthscope Commercial |
$17.55
|
| Rate for Payer: Healthscope Commercial |
$20.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.23
|
| Rate for Payer: Nomi Health Commercial |
$15.99
|
| Rate for Payer: Nomi Health Commercial |
$18.55
|
| Rate for Payer: PHP Commercial |
$16.58
|
| Rate for Payer: PHP Commercial |
$19.23
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.68
|
| Rate for Payer: Priority Health HMO/PPO |
$19.68
|
| Rate for Payer: Priority Health HMO/PPO |
$16.96
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.06
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.91
|
| Rate for Payer: UHC Core |
$16.28
|
| Rate for Payer: UHC Core |
$18.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.96
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
OP
|
$22.62
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$5.37 |
| Max. Negotiated Rate |
$20.36 |
| Rate for Payer: Aetna Commercial |
$19.23
|
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: Aetna Medicare |
$5.88
|
| Rate for Payer: Aetna Medicare |
$5.07
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.09
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$7.07
|
| Rate for Payer: Amish Plain Church Group Commercial |
$7.07
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.09
|
| Rate for Payer: BCBS Complete |
$7.80
|
| Rate for Payer: BCBS Complete |
$9.05
|
| Rate for Payer: BCBS MAPPO |
$4.88
|
| Rate for Payer: BCBS MAPPO |
$5.66
|
| Rate for Payer: BCBS Trust/PPO |
$18.60
|
| Rate for Payer: BCBS Trust/PPO |
$16.03
|
| Rate for Payer: BCN Commercial |
$17.59
|
| Rate for Payer: BCN Commercial |
$15.16
|
| Rate for Payer: BCN Medicare Advantage |
$5.66
|
| Rate for Payer: BCN Medicare Advantage |
$4.88
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cofinity Commercial |
$16.77
|
| Rate for Payer: Cofinity Commercial |
$19.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.60
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.88
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.66
|
| Rate for Payer: Healthscope Commercial |
$17.55
|
| Rate for Payer: Healthscope Commercial |
$20.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.62
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.12
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.94
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.61
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.58
|
| Rate for Payer: Nomi Health Commercial |
$18.55
|
| Rate for Payer: Nomi Health Commercial |
$15.99
|
| Rate for Payer: PACE Senior Care Partners |
$5.37
|
| Rate for Payer: PACE Senior Care Partners |
$4.63
|
| Rate for Payer: PACE SWMI |
$5.66
|
| Rate for Payer: PACE SWMI |
$4.88
|
| Rate for Payer: PHP Commercial |
$19.23
|
| Rate for Payer: PHP Commercial |
$16.58
|
| Rate for Payer: PHP Medicare Advantage |
$4.88
|
| Rate for Payer: PHP Medicare Advantage |
$5.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.68
|
| Rate for Payer: Priority Health HMO/PPO |
$16.96
|
| Rate for Payer: Priority Health HMO/PPO |
$19.68
|
| Rate for Payer: Priority Health Medicare |
$5.71
|
| Rate for Payer: Priority Health Medicare |
$4.92
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$15.16
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$13.06
|
| Rate for Payer: Railroad Medicare Medicare |
$4.88
|
| Rate for Payer: Railroad Medicare Medicare |
$5.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$17.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.91
|
| Rate for Payer: UHC Core |
$18.89
|
| Rate for Payer: UHC Core |
$16.28
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.66
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.88
|
| Rate for Payer: UHC Exchange |
$4.88
|
| Rate for Payer: UHC Exchange |
$5.66
|
| Rate for Payer: UHC Medicare Advantage |
$4.88
|
| Rate for Payer: UHC Medicare Advantage |
$5.66
|
| Rate for Payer: VA VA |
$4.88
|
| Rate for Payer: VA VA |
$5.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.62
|
|
|
LIDOCAINE 2 %-EPINEPHRINE BITARTRATE 1:100,000 INJECTION CARTRIDGE
|
Facility
|
IP
|
$7.06
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
118255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.59 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: BCBS Trust/PPO |
$5.76
|
| 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 Commercial |
$6.00
|
| Rate for Payer: Nomi Health Commercial |
$5.79
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.59
|
| Rate for Payer: Priority Health HMO/PPO |
$6.14
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.73
|
| 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 %-EPINEPHRINE BITARTRATE 1:100,000 INJECTION CARTRIDGE
|
Facility
|
OP
|
$7.06
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
118255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$1.68 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: Aetna Medicare |
$1.84
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$2.21
|
| Rate for Payer: Amish Plain Church Group Commercial |
$2.21
|
| Rate for Payer: BCBS Complete |
$2.82
|
| Rate for Payer: BCBS MAPPO |
$1.76
|
| Rate for Payer: BCBS Trust/PPO |
$5.80
|
| Rate for Payer: BCN Commercial |
$5.49
|
| Rate for Payer: BCN Medicare Advantage |
$1.76
|
| 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: Health Alliance Plan Medicare Advantage |
$1.76
|
| Rate for Payer: Healthscope Commercial |
$6.35
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.30
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$1.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.00
|
| Rate for Payer: Nomi Health Commercial |
$5.79
|
| Rate for Payer: PACE Senior Care Partners |
$1.68
|
| Rate for Payer: PACE SWMI |
$1.76
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: PHP Medicare Advantage |
$1.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.59
|
| Rate for Payer: Priority Health HMO/PPO |
$6.14
|
| Rate for Payer: Priority Health Medicare |
$1.78
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$4.73
|
| Rate for Payer: Railroad Medicare Medicare |
$1.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.21
|
| Rate for Payer: UHC Core |
$5.90
|
| Rate for Payer: UHC Dual Complete DSNP |
$1.76
|
| Rate for Payer: UHC Exchange |
$1.76
|
| Rate for Payer: UHC Medicare Advantage |
$1.76
|
| Rate for Payer: VA VA |
$1.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.30
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$28.70
|
|
|
Service Code
|
NDC 76329301505
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.82 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$24.40
|
| Rate for Payer: Aetna Medicare |
$7.46
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$8.97
|
| Rate for Payer: Amish Plain Church Group Commercial |
$8.97
|
| Rate for Payer: BCBS Complete |
$11.48
|
| Rate for Payer: BCBS MAPPO |
$7.18
|
| Rate for Payer: BCBS Trust/PPO |
$23.59
|
| Rate for Payer: BCN Commercial |
$22.31
|
| Rate for Payer: BCN Medicare Advantage |
$7.18
|
| Rate for Payer: Cash Price |
$22.96
|
| Rate for Payer: Cofinity Commercial |
$24.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.96
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.18
|
| Rate for Payer: Healthscope Commercial |
$25.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.52
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.53
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.40
|
| Rate for Payer: Nomi Health Commercial |
$23.53
|
| Rate for Payer: PACE Senior Care Partners |
$6.82
|
| Rate for Payer: PACE SWMI |
$7.18
|
| Rate for Payer: PHP Commercial |
$24.40
|
| Rate for Payer: PHP Medicare Advantage |
$7.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health HMO/PPO |
$24.97
|
| Rate for Payer: Priority Health Medicare |
$7.25
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.23
|
| Rate for Payer: Railroad Medicare Medicare |
$7.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.26
|
| Rate for Payer: UHC Core |
$23.96
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.18
|
| Rate for Payer: UHC Exchange |
$7.18
|
| Rate for Payer: UHC Medicare Advantage |
$7.18
|
| Rate for Payer: VA VA |
$7.18
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.52
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$28.70
|
|
|
Service Code
|
NDC 76329301505
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.66 |
| Max. Negotiated Rate |
$25.83 |
| Rate for Payer: Aetna Commercial |
$24.40
|
| Rate for Payer: BCBS Trust/PPO |
$23.43
|
| Rate for Payer: BCN Commercial |
$22.18
|
| Rate for Payer: Cash Price |
$22.96
|
| Rate for Payer: Cofinity Commercial |
$24.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.96
|
| Rate for Payer: Healthscope Commercial |
$25.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.52
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.40
|
| Rate for Payer: Nomi Health Commercial |
$23.53
|
| Rate for Payer: PHP Commercial |
$24.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.66
|
| Rate for Payer: Priority Health HMO/PPO |
$24.97
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$19.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.26
|
| Rate for Payer: UHC Core |
$23.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.52
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$21.60
|
|
|
Service Code
|
NDC 76329301205
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.13 |
| Max. Negotiated Rate |
$19.44 |
| Rate for Payer: Aetna Commercial |
$18.36
|
| Rate for Payer: Aetna Medicare |
$5.62
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$6.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$6.75
|
| Rate for Payer: BCBS Complete |
$8.64
|
| Rate for Payer: BCBS MAPPO |
$5.40
|
| Rate for Payer: BCBS Trust/PPO |
$17.76
|
| Rate for Payer: BCN Commercial |
$16.79
|
| Rate for Payer: BCN Medicare Advantage |
$5.40
|
| Rate for Payer: Cash Price |
$17.28
|
| Rate for Payer: Cofinity Commercial |
$18.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.28
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$5.40
|
| Rate for Payer: Healthscope Commercial |
$19.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.20
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$5.67
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.36
|
| Rate for Payer: Nomi Health Commercial |
$17.71
|
| Rate for Payer: PACE Senior Care Partners |
$5.13
|
| Rate for Payer: PACE SWMI |
$5.40
|
| Rate for Payer: PHP Commercial |
$18.36
|
| Rate for Payer: PHP Medicare Advantage |
$5.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.04
|
| Rate for Payer: Priority Health HMO/PPO |
$18.79
|
| Rate for Payer: Priority Health Medicare |
$5.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.47
|
| Rate for Payer: Railroad Medicare Medicare |
$5.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.01
|
| Rate for Payer: UHC Core |
$18.04
|
| Rate for Payer: UHC Dual Complete DSNP |
$5.40
|
| Rate for Payer: UHC Exchange |
$5.40
|
| Rate for Payer: UHC Medicare Advantage |
$5.40
|
| Rate for Payer: VA VA |
$5.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.20
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$21.60
|
|
|
Service Code
|
NDC 76329301205
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.04 |
| Max. Negotiated Rate |
$19.44 |
| Rate for Payer: Aetna Commercial |
$18.36
|
| Rate for Payer: BCBS Trust/PPO |
$17.63
|
| Rate for Payer: BCN Commercial |
$16.69
|
| Rate for Payer: Cash Price |
$17.28
|
| Rate for Payer: Cofinity Commercial |
$18.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.28
|
| Rate for Payer: Healthscope Commercial |
$19.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.36
|
| Rate for Payer: Nomi Health Commercial |
$17.71
|
| Rate for Payer: PHP Commercial |
$18.36
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.04
|
| Rate for Payer: Priority Health HMO/PPO |
$18.79
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$14.47
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.01
|
| Rate for Payer: UHC Core |
$18.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.20
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$15.21
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.89 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: BCBS Trust/PPO |
$12.42
|
| 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 Commercial |
$12.93
|
| Rate for Payer: Nomi Health Commercial |
$12.47
|
| Rate for Payer: PHP Commercial |
$12.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.89
|
| Rate for Payer: Priority Health HMO/PPO |
$13.23
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.19
|
| 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
|
OP
|
$15.21
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.61 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: Aetna Medicare |
$3.95
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$4.75
|
| Rate for Payer: Amish Plain Church Group Commercial |
$4.75
|
| Rate for Payer: BCBS Complete |
$6.08
|
| Rate for Payer: BCBS MAPPO |
$3.80
|
| Rate for Payer: BCBS Trust/PPO |
$12.50
|
| Rate for Payer: BCN Commercial |
$11.83
|
| Rate for Payer: BCN Medicare Advantage |
$3.80
|
| 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: Health Alliance Plan Medicare Advantage |
$3.80
|
| Rate for Payer: Healthscope Commercial |
$13.69
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.41
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$3.99
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.93
|
| Rate for Payer: Nomi Health Commercial |
$12.47
|
| Rate for Payer: PACE Senior Care Partners |
$3.61
|
| Rate for Payer: PACE SWMI |
$3.80
|
| Rate for Payer: PHP Commercial |
$12.93
|
| Rate for Payer: PHP Medicare Advantage |
$3.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.89
|
| Rate for Payer: Priority Health HMO/PPO |
$13.23
|
| Rate for Payer: Priority Health Medicare |
$3.84
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$10.19
|
| Rate for Payer: Railroad Medicare Medicare |
$3.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$13.38
|
| Rate for Payer: UHC Core |
$12.70
|
| Rate for Payer: UHC Dual Complete DSNP |
$3.80
|
| Rate for Payer: UHC Exchange |
$3.80
|
| Rate for Payer: UHC Medicare Advantage |
$3.80
|
| Rate for Payer: VA VA |
$3.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.41
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
OP
|
$29.93
|
|
|
Service Code
|
NDC 71266629001
|
| Hospital Charge Code |
196007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.11 |
| Max. Negotiated Rate |
$26.94 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna Medicare |
$7.78
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.35
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.35
|
| Rate for Payer: BCBS Complete |
$11.97
|
| Rate for Payer: BCBS MAPPO |
$7.48
|
| Rate for Payer: BCBS Trust/PPO |
$24.61
|
| Rate for Payer: BCN Commercial |
$23.27
|
| Rate for Payer: BCN Medicare Advantage |
$7.48
|
| 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: Health Alliance Plan Medicare Advantage |
$7.48
|
| Rate for Payer: Healthscope Commercial |
$26.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.45
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.86
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.44
|
| Rate for Payer: Nomi Health Commercial |
$24.54
|
| Rate for Payer: PACE Senior Care Partners |
$7.11
|
| Rate for Payer: PACE SWMI |
$7.48
|
| Rate for Payer: PHP Commercial |
$25.44
|
| Rate for Payer: PHP Medicare Advantage |
$7.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.45
|
| Rate for Payer: Priority Health HMO/PPO |
$26.04
|
| Rate for Payer: Priority Health Medicare |
$7.56
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.05
|
| Rate for Payer: Railroad Medicare Medicare |
$7.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.34
|
| Rate for Payer: UHC Core |
$24.99
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.48
|
| Rate for Payer: UHC Exchange |
$7.48
|
| Rate for Payer: UHC Medicare Advantage |
$7.48
|
| Rate for Payer: VA VA |
$7.48
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.45
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
IP
|
$29.93
|
|
|
Service Code
|
NDC 71266629001
|
| Hospital Charge Code |
196007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.45 |
| Max. Negotiated Rate |
$26.94 |
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: BCBS Trust/PPO |
$24.43
|
| 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 Commercial |
$25.44
|
| Rate for Payer: Nomi Health Commercial |
$24.54
|
| Rate for Payer: PHP Commercial |
$25.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.45
|
| Rate for Payer: Priority Health HMO/PPO |
$26.04
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.05
|
| 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
|
OP
|
$18.72
|
|
|
Service Code
|
NDC 70000036601
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.45 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Medicare |
$4.87
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$5.85
|
| Rate for Payer: Amish Plain Church Group Commercial |
$5.85
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS MAPPO |
$4.68
|
| Rate for Payer: BCBS Trust/PPO |
$15.39
|
| Rate for Payer: BCN Commercial |
$14.55
|
| Rate for Payer: BCN Medicare Advantage |
$4.68
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$4.68
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.04
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$4.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$5.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: PACE Senior Care Partners |
$4.45
|
| Rate for Payer: PACE SWMI |
$4.68
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: PHP Medicare Advantage |
$4.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO |
$16.29
|
| Rate for Payer: Priority Health Medicare |
$4.73
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.54
|
| Rate for Payer: Railroad Medicare Medicare |
$4.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.47
|
| Rate for Payer: UHC Core |
$15.63
|
| Rate for Payer: UHC Dual Complete DSNP |
$4.68
|
| Rate for Payer: UHC Exchange |
$4.68
|
| Rate for Payer: UHC Medicare Advantage |
$4.68
|
| Rate for Payer: VA VA |
$4.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.04
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$30.05
|
|
|
Service Code
|
NDC 00536120215
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.14 |
| Max. Negotiated Rate |
$27.04 |
| Rate for Payer: Aetna Commercial |
$25.54
|
| Rate for Payer: Aetna Medicare |
$7.81
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$9.39
|
| Rate for Payer: Amish Plain Church Group Commercial |
$9.39
|
| Rate for Payer: BCBS Complete |
$12.02
|
| Rate for Payer: BCBS MAPPO |
$7.51
|
| Rate for Payer: BCBS Trust/PPO |
$24.70
|
| Rate for Payer: BCN Commercial |
$23.36
|
| Rate for Payer: BCN Medicare Advantage |
$7.51
|
| Rate for Payer: Cash Price |
$24.04
|
| Rate for Payer: Cofinity Commercial |
$25.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.04
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$7.51
|
| Rate for Payer: Healthscope Commercial |
$27.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.54
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$7.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$8.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.54
|
| Rate for Payer: Nomi Health Commercial |
$24.64
|
| Rate for Payer: PACE Senior Care Partners |
$7.14
|
| Rate for Payer: PACE SWMI |
$7.51
|
| Rate for Payer: PHP Commercial |
$25.54
|
| Rate for Payer: PHP Medicare Advantage |
$7.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.53
|
| Rate for Payer: Priority Health HMO/PPO |
$26.14
|
| Rate for Payer: Priority Health Medicare |
$7.59
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$20.13
|
| Rate for Payer: Railroad Medicare Medicare |
$7.51
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$26.44
|
| Rate for Payer: UHC Core |
$25.09
|
| Rate for Payer: UHC Dual Complete DSNP |
$7.51
|
| Rate for Payer: UHC Exchange |
$7.51
|
| Rate for Payer: UHC Medicare Advantage |
$7.51
|
| Rate for Payer: VA VA |
$7.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.54
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$104.84
|
|
|
Service Code
|
NDC 00121097030
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$68.15 |
| Max. Negotiated Rate |
$94.36 |
| Rate for Payer: Aetna Commercial |
$89.11
|
| Rate for Payer: BCBS Trust/PPO |
$85.58
|
| Rate for Payer: BCN Commercial |
$81.02
|
| Rate for Payer: Cash Price |
$83.87
|
| Rate for Payer: Cofinity Commercial |
$90.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.87
|
| Rate for Payer: Healthscope Commercial |
$94.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$78.63
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$89.11
|
| Rate for Payer: Nomi Health Commercial |
$85.97
|
| Rate for Payer: PHP Commercial |
$89.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$68.15
|
| Rate for Payer: Priority Health HMO/PPO |
$91.21
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$70.24
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$92.26
|
| Rate for Payer: UHC Core |
$87.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.63
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$45.36
|
|
|
Service Code
|
NDC 41167005840
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.77 |
| Max. Negotiated Rate |
$40.82 |
| Rate for Payer: Aetna Commercial |
$38.56
|
| Rate for Payer: Aetna Medicare |
$11.79
|
| Rate for Payer: Allen County Amish Medical Aid Commercial |
$14.18
|
| Rate for Payer: Amish Plain Church Group Commercial |
$14.18
|
| Rate for Payer: BCBS Complete |
$18.14
|
| Rate for Payer: BCBS MAPPO |
$11.34
|
| Rate for Payer: BCBS Trust/PPO |
$37.29
|
| Rate for Payer: BCN Commercial |
$35.27
|
| Rate for Payer: BCN Medicare Advantage |
$11.34
|
| Rate for Payer: Cash Price |
$36.29
|
| Rate for Payer: Cofinity Commercial |
$39.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.29
|
| Rate for Payer: Health Alliance Plan Medicare Advantage |
$11.34
|
| Rate for Payer: Healthscope Commercial |
$40.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.02
|
| Rate for Payer: Meridian Complete - MI Health Link - DSNP/Wellcare - Medicare Advantage |
$11.91
|
| Rate for Payer: MI Amish Medical Board Commercial |
$13.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.56
|
| Rate for Payer: Nomi Health Commercial |
$37.20
|
| Rate for Payer: PACE Senior Care Partners |
$10.77
|
| Rate for Payer: PACE SWMI |
$11.34
|
| Rate for Payer: PHP Commercial |
$38.56
|
| Rate for Payer: PHP Medicare Advantage |
$11.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.48
|
| Rate for Payer: Priority Health HMO/PPO |
$39.46
|
| Rate for Payer: Priority Health Medicare |
$11.45
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$30.39
|
| Rate for Payer: Railroad Medicare Medicare |
$11.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$39.92
|
| Rate for Payer: UHC Core |
$37.88
|
| Rate for Payer: UHC Dual Complete DSNP |
$11.34
|
| Rate for Payer: UHC Exchange |
$11.34
|
| Rate for Payer: UHC Medicare Advantage |
$11.34
|
| Rate for Payer: VA VA |
$11.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.02
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
NDC 70000036601
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: BCBS Trust/PPO |
$15.28
|
| Rate for Payer: BCN Commercial |
$14.47
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health HMO/PPO |
$16.29
|
| Rate for Payer: Priority Health Narrow/Tiered Network |
$12.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.47
|
| Rate for Payer: UHC Core |
$15.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.04
|
|
