|
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 |
$309.62 |
| Max. Negotiated Rate |
$633.31 |
| Rate for Payer: Aetna American Axle |
$457.39
|
| Rate for Payer: Aetna Commercial |
$598.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$457.39
|
| Rate for Payer: Cash Price |
$562.94
|
| Rate for Payer: Cofinity Commercial |
$492.58
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$492.58
|
| 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 SBD |
$443.32
|
| Rate for Payer: UMR Bronson Commercial |
$309.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$527.76
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$633.75
|
|
|
Service Code
|
NDC 0074-5182-90
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$278.85 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna American Axle |
$411.94
|
| Rate for Payer: Aetna Commercial |
$538.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.94
|
| Rate for Payer: Cash Price |
$507.00
|
| Rate for Payer: Cofinity Commercial |
$443.62
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$443.62
|
| 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 SBD |
$399.26
|
| Rate for Payer: UMR Bronson Commercial |
$278.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$475.31
|
|
|
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 |
$166.78 |
| Max. Negotiated Rate |
$341.14 |
| Rate for Payer: Aetna American Axle |
$246.38
|
| Rate for Payer: Aetna Commercial |
$322.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$246.38
|
| Rate for Payer: Cash Price |
$303.24
|
| Rate for Payer: Cofinity Commercial |
$265.34
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$265.34
|
| 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 SBD |
$238.80
|
| Rate for Payer: UMR Bronson Commercial |
$166.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$284.29
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$359.10
|
|
|
Service Code
|
NDC 0781-5182-92
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$158.00 |
| Max. Negotiated Rate |
$323.19 |
| Rate for Payer: Aetna American Axle |
$233.42
|
| Rate for Payer: Aetna Commercial |
$305.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$233.42
|
| Rate for Payer: Cash Price |
$287.28
|
| Rate for Payer: Cofinity Commercial |
$251.37
|
| Rate for Payer: Cofinity Commercial |
$308.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$287.28
|
| Rate for Payer: Healthscope Commercial |
$323.19
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$251.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$269.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$305.24
|
| Rate for Payer: PHP Commercial |
$305.24
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.37
|
| Rate for Payer: Priority Health SBD |
$226.23
|
| Rate for Payer: UMR Bronson Commercial |
$158.00
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$269.32
|
|
|
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 |
$115.53 |
| Max. Negotiated Rate |
$236.30 |
| Rate for Payer: Aetna American Axle |
$170.66
|
| Rate for Payer: Aetna Commercial |
$223.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$170.66
|
| Rate for Payer: Cash Price |
$210.05
|
| Rate for Payer: Cofinity Commercial |
$183.79
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$183.79
|
| 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 SBD |
$165.41
|
| Rate for Payer: UMR Bronson Commercial |
$115.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$196.92
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$369.36
|
|
|
Service Code
|
NDC 0378-1807-77
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.52 |
| Max. Negotiated Rate |
$332.42 |
| Rate for Payer: Aetna American Axle |
$240.08
|
| Rate for Payer: Aetna Commercial |
$313.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$240.08
|
| Rate for Payer: Cash Price |
$295.49
|
| Rate for Payer: Cofinity Commercial |
$258.55
|
| Rate for Payer: Cofinity Commercial |
$317.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$295.49
|
| Rate for Payer: Healthscope Commercial |
$332.42
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$258.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$277.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$313.96
|
| Rate for Payer: PHP Commercial |
$313.96
|
| Rate for Payer: Priority Health Cigna Priority Health |
$258.55
|
| Rate for Payer: Priority Health SBD |
$232.70
|
| Rate for Payer: UMR Bronson Commercial |
$162.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$277.02
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$422.88
|
|
|
Service Code
|
NDC 60793-853-01
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$186.07 |
| Max. Negotiated Rate |
$380.59 |
| Rate for Payer: Aetna American Axle |
$274.87
|
| Rate for Payer: Aetna Commercial |
$359.45
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$274.87
|
| Rate for Payer: Cash Price |
$338.30
|
| Rate for Payer: Cofinity Commercial |
$296.02
|
| Rate for Payer: Cofinity Commercial |
$363.68
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$338.30
|
| Rate for Payer: Healthscope Commercial |
$380.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$296.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$317.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$359.45
|
| Rate for Payer: PHP Commercial |
$359.45
|
| Rate for Payer: Priority Health Cigna Priority Health |
$296.02
|
| Rate for Payer: Priority Health SBD |
$266.41
|
| Rate for Payer: UMR Bronson Commercial |
$186.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$317.16
|
|
|
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 |
$278.85 |
| Max. Negotiated Rate |
$570.38 |
| Rate for Payer: Aetna American Axle |
$411.94
|
| Rate for Payer: Aetna Commercial |
$538.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$411.94
|
| Rate for Payer: Cash Price |
$507.00
|
| Rate for Payer: Cofinity Commercial |
$443.62
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$443.62
|
| 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 SBD |
$399.26
|
| Rate for Payer: UMR Bronson Commercial |
$278.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$475.31
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$365.09
|
|
|
Service Code
|
NDC 0781-5183-92
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$160.64 |
| Max. Negotiated Rate |
$328.58 |
| Rate for Payer: Aetna American Axle |
$237.31
|
| Rate for Payer: Aetna Commercial |
$310.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$237.31
|
| Rate for Payer: Cash Price |
$292.07
|
| Rate for Payer: Cofinity Commercial |
$255.56
|
| Rate for Payer: Cofinity Commercial |
$313.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$292.07
|
| Rate for Payer: Healthscope Commercial |
$328.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$255.56
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$273.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$310.33
|
| Rate for Payer: PHP Commercial |
$310.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$255.56
|
| Rate for Payer: Priority Health SBD |
$230.01
|
| Rate for Payer: UMR Bronson Commercial |
$160.64
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$273.82
|
|
|
LICE AND NIT COMB
|
Facility
|
IP
|
$3.45
|
|
|
Service Code
|
NDC 55128-2700-00
|
| Hospital Charge Code |
167001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.52 |
| Max. Negotiated Rate |
$3.10 |
| Rate for Payer: Aetna American Axle |
$2.24
|
| Rate for Payer: Aetna Commercial |
$2.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.24
|
| Rate for Payer: Cash Price |
$2.76
|
| Rate for Payer: Cofinity Commercial |
$2.42
|
| Rate for Payer: Cofinity Commercial |
$2.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.76
|
| Rate for Payer: Healthscope Commercial |
$3.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$2.93
|
| Rate for Payer: PHP Commercial |
$2.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.42
|
| Rate for Payer: Priority Health SBD |
$2.17
|
| Rate for Payer: UMR Bronson Commercial |
$1.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.59
|
|
|
LICE AND NIT COMB
|
Facility
|
IP
|
$0.87
|
|
|
Service Code
|
NDC 25715-0673-23
|
| Hospital Charge Code |
167001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.78 |
| Rate for Payer: Aetna American Axle |
$0.57
|
| Rate for Payer: Aetna Commercial |
$0.74
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$0.57
|
| Rate for Payer: Cash Price |
$0.70
|
| Rate for Payer: Cofinity Commercial |
$0.61
|
| Rate for Payer: Cofinity Commercial |
$0.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$0.70
|
| Rate for Payer: Healthscope Commercial |
$0.78
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$0.61
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$0.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$0.74
|
| Rate for Payer: PHP Commercial |
$0.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$0.61
|
| Rate for Payer: Priority Health SBD |
$0.55
|
| Rate for Payer: UMR Bronson Commercial |
$0.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$0.65
|
|
|
LICE AND NIT COMB
|
Facility
|
IP
|
$8.75
|
|
|
Service Code
|
NDC 64442-6501-97
|
| Hospital Charge Code |
167001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.85 |
| Max. Negotiated Rate |
$7.88 |
| Rate for Payer: Aetna American Axle |
$5.69
|
| Rate for Payer: Aetna Commercial |
$7.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.69
|
| Rate for Payer: Cash Price |
$7.00
|
| Rate for Payer: Cofinity Commercial |
$6.12
|
| Rate for Payer: Cofinity Commercial |
$7.52
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.00
|
| Rate for Payer: Healthscope Commercial |
$7.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$6.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$6.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$7.44
|
| Rate for Payer: PHP Commercial |
$7.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$6.12
|
| Rate for Payer: Priority Health SBD |
$5.51
|
| Rate for Payer: UMR Bronson Commercial |
$3.85
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$6.56
|
|
|
LICE AND NIT COMB
|
Facility
|
IP
|
$4.45
|
|
|
Service Code
|
NDC 7957-3104-50
|
| Hospital Charge Code |
167001
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.96 |
| Max. Negotiated Rate |
$4.00 |
| Rate for Payer: Aetna American Axle |
$2.89
|
| Rate for Payer: Aetna Commercial |
$3.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.89
|
| Rate for Payer: Cash Price |
$3.56
|
| Rate for Payer: Cofinity Commercial |
$3.12
|
| Rate for Payer: Cofinity Commercial |
$3.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.56
|
| Rate for Payer: Healthscope Commercial |
$4.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.12
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.78
|
| Rate for Payer: PHP Commercial |
$3.78
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.12
|
| Rate for Payer: Priority Health SBD |
$2.80
|
| Rate for Payer: UMR Bronson Commercial |
$1.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.34
|
|
|
LIDOCAINE 0.9 % BUFFERED WITH 8.4 % SODIUM BICARB (5 ML) INJ SYRINGE
|
Facility
|
IP
|
$139.20
|
|
|
Service Code
|
NDC 69374-947-50
|
| Hospital Charge Code |
152324
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$61.25 |
| Max. Negotiated Rate |
$125.28 |
| Rate for Payer: Aetna American Axle |
$90.48
|
| Rate for Payer: Aetna Commercial |
$118.32
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$90.48
|
| Rate for Payer: Cash Price |
$111.36
|
| Rate for Payer: Cofinity Commercial |
$119.71
|
| Rate for Payer: Cofinity Commercial |
$97.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$111.36
|
| Rate for Payer: Healthscope Commercial |
$125.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$97.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$104.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$118.32
|
| Rate for Payer: PHP Commercial |
$118.32
|
| Rate for Payer: Priority Health Cigna Priority Health |
$97.44
|
| Rate for Payer: Priority Health SBD |
$87.70
|
| Rate for Payer: UMR Bronson Commercial |
$61.25
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$104.40
|
|
|
LIDOCAINE 10 MG/ML (1 %) INJECTION SOLUTION WRAPPER
|
Facility
|
IP
|
$22.62
|
|
|
Service Code
|
NDC 0409-4279-16
|
| Hospital Charge Code |
200046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$20.36 |
| Rate for Payer: Aetna American Axle |
$14.70
|
| Rate for Payer: Aetna Commercial |
$19.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.70
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cofinity Commercial |
$15.83
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$15.83
|
| 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 SBD |
$14.25
|
| Rate for Payer: UMR Bronson Commercial |
$9.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.96
|
|
|
LIDOCAINE 10 MG/ML (1 %) INJECTION SOLUTION WRAPPER
|
Facility
|
IP
|
$22.62
|
|
|
Service Code
|
NDC 0409-4279-02
|
| Hospital Charge Code |
200046
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.95 |
| Max. Negotiated Rate |
$20.36 |
| Rate for Payer: Aetna American Axle |
$14.70
|
| Rate for Payer: Aetna Commercial |
$19.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.70
|
| Rate for Payer: Cash Price |
$18.10
|
| Rate for Payer: Cofinity Commercial |
$15.83
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$15.83
|
| 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 SBD |
$14.25
|
| Rate for Payer: UMR Bronson Commercial |
$9.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.96
|
|
|
LIDOCAINE 1% AND BUPIVACAINE 0.25% AND HYALURONIDASE EYE BLOCK
|
Facility
|
IP
|
$165.63
|
|
|
Service Code
|
HCPCS J3473
|
| Hospital Charge Code |
158439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.88 |
| Max. Negotiated Rate |
$149.07 |
| Rate for Payer: Aetna American Axle |
$107.66
|
| Rate for Payer: Aetna Commercial |
$140.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.66
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cofinity Commercial |
$115.94
|
| Rate for Payer: Cofinity Commercial |
$142.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.50
|
| Rate for Payer: Healthscope Commercial |
$149.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$140.79
|
| Rate for Payer: PHP Commercial |
$140.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$115.94
|
| Rate for Payer: Priority Health SBD |
$104.35
|
| Rate for Payer: UMR Bronson Commercial |
$72.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.22
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
NDC 0409-3178-18
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$13.99 |
| Rate for Payer: Aetna American Axle |
$10.10
|
| Rate for Payer: Aetna Commercial |
$13.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.10
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cofinity Commercial |
$10.88
|
| Rate for Payer: Cofinity Commercial |
$13.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.43
|
| Rate for Payer: Healthscope Commercial |
$13.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.21
|
| Rate for Payer: PHP Commercial |
$13.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.88
|
| Rate for Payer: Priority Health SBD |
$9.79
|
| Rate for Payer: UMR Bronson Commercial |
$6.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.66
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
NDC 63323-482-03
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.96 |
| Max. Negotiated Rate |
$26.51 |
| Rate for Payer: Aetna American Axle |
$19.15
|
| Rate for Payer: Aetna Commercial |
$25.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.15
|
| Rate for Payer: Cash Price |
$23.57
|
| Rate for Payer: Cofinity Commercial |
$20.62
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$20.62
|
| 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 SBD |
$18.56
|
| Rate for Payer: UMR Bronson Commercial |
$12.96
|
| 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 |
$7.66 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna American Axle |
$11.31
|
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.31
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cofinity Commercial |
$12.18
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$12.18
|
| 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 SBD |
$10.96
|
| Rate for Payer: UMR Bronson Commercial |
$7.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.05
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$20.41
|
|
|
Service Code
|
NDC 9900-0019-40
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.98 |
| Max. Negotiated Rate |
$18.37 |
| Rate for Payer: Aetna American Axle |
$13.27
|
| Rate for Payer: Aetna Commercial |
$17.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.27
|
| Rate for Payer: Cash Price |
$16.33
|
| Rate for Payer: Cofinity Commercial |
$14.29
|
| Rate for Payer: Cofinity Commercial |
$17.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.33
|
| Rate for Payer: Healthscope Commercial |
$18.37
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.35
|
| Rate for Payer: PHP Commercial |
$17.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.29
|
| Rate for Payer: Priority Health SBD |
$12.86
|
| Rate for Payer: UMR Bronson Commercial |
$8.98
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.31
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
NDC 0409-3178-03
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$13.99 |
| Rate for Payer: Aetna American Axle |
$10.10
|
| Rate for Payer: Aetna Commercial |
$13.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.10
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cofinity Commercial |
$10.88
|
| Rate for Payer: Cofinity Commercial |
$13.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.43
|
| Rate for Payer: Healthscope Commercial |
$13.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.88
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.21
|
| Rate for Payer: PHP Commercial |
$13.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.88
|
| Rate for Payer: Priority Health SBD |
$9.79
|
| Rate for Payer: UMR Bronson Commercial |
$6.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.66
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$41.39
|
|
|
Service Code
|
NDC 63323-482-57
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.21 |
| Max. Negotiated Rate |
$37.25 |
| Rate for Payer: Aetna American Axle |
$26.90
|
| Rate for Payer: Aetna Commercial |
$35.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$26.90
|
| Rate for Payer: Cash Price |
$33.11
|
| Rate for Payer: Cofinity Commercial |
$28.97
|
| Rate for Payer: Cofinity Commercial |
$35.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$33.11
|
| Rate for Payer: Healthscope Commercial |
$37.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$28.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$31.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$35.18
|
| Rate for Payer: PHP Commercial |
$35.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$28.97
|
| Rate for Payer: Priority Health SBD |
$26.08
|
| Rate for Payer: UMR Bronson Commercial |
$18.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$31.04
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$17.40
|
|
|
Service Code
|
NDC 0409-3178-16
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.66 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna American Axle |
$11.31
|
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.31
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cofinity Commercial |
$12.18
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$12.18
|
| 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 SBD |
$10.96
|
| Rate for Payer: UMR Bronson Commercial |
$7.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.05
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$23.76
|
|
|
Service Code
|
NDC 63323-482-01
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.45 |
| Max. Negotiated Rate |
$21.38 |
| Rate for Payer: Aetna American Axle |
$15.44
|
| Rate for Payer: Aetna Commercial |
$20.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.44
|
| Rate for Payer: Cash Price |
$19.01
|
| Rate for Payer: Cofinity Commercial |
$16.63
|
| Rate for Payer: Cofinity Commercial |
$20.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.01
|
| Rate for Payer: Healthscope Commercial |
$21.38
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.20
|
| Rate for Payer: PHP Commercial |
$20.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.63
|
| Rate for Payer: Priority Health SBD |
$14.97
|
| Rate for Payer: UMR Bronson Commercial |
$10.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.82
|
|
