|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$23.76
|
|
|
Service Code
|
NDC 63323-482-17
|
| 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
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$23.76
|
|
|
Service Code
|
NDC 0409-3178-17
|
| 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
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$23.76
|
|
|
Service Code
|
NDC 0409-3178-02
|
| 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
|
|
|
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
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$29.53
|
|
|
Service Code
|
NDC 0409-3182-02
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.99 |
| Max. Negotiated Rate |
$26.58 |
| Rate for Payer: Aetna American Axle |
$19.19
|
| Rate for Payer: Aetna Commercial |
$25.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.19
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Cofinity Commercial |
$25.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.62
|
| Rate for Payer: Healthscope Commercial |
$26.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$25.10
|
| Rate for Payer: PHP Commercial |
$25.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.67
|
| Rate for Payer: Priority Health SBD |
$18.60
|
| Rate for Payer: UMR Bronson Commercial |
$12.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.15
|
|
|
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 |
$7.91 |
| Max. Negotiated Rate |
$16.18 |
| Rate for Payer: Aetna American Axle |
$11.69
|
| Rate for Payer: Aetna Commercial |
$15.28
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.69
|
| Rate for Payer: Cash Price |
$14.38
|
| Rate for Payer: Cofinity Commercial |
$12.59
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$12.59
|
| 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 SBD |
$11.33
|
| Rate for Payer: UMR Bronson Commercial |
$7.91
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.48
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$33.60
|
|
|
Service Code
|
NDC 63323-483-57
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.78 |
| Max. Negotiated Rate |
$30.24 |
| Rate for Payer: Aetna American Axle |
$21.84
|
| Rate for Payer: Aetna Commercial |
$28.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.84
|
| Rate for Payer: Cash Price |
$26.88
|
| Rate for Payer: Cofinity Commercial |
$23.52
|
| Rate for Payer: Cofinity Commercial |
$28.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.88
|
| Rate for Payer: Healthscope Commercial |
$30.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.52
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$28.56
|
| Rate for Payer: PHP Commercial |
$28.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.52
|
| Rate for Payer: Priority Health SBD |
$21.17
|
| Rate for Payer: UMR Bronson Commercial |
$14.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.20
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$21.83
|
|
|
Service Code
|
NDC 0409-3182-03
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.61 |
| Max. Negotiated Rate |
$19.65 |
| Rate for Payer: Aetna American Axle |
$14.19
|
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.19
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cofinity Commercial |
$15.28
|
| Rate for Payer: Cofinity Commercial |
$18.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.46
|
| Rate for Payer: Healthscope Commercial |
$19.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.28
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.56
|
| Rate for Payer: PHP Commercial |
$18.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.28
|
| Rate for Payer: Priority Health SBD |
$13.75
|
| Rate for Payer: UMR Bronson Commercial |
$9.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.37
|
|
|
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 |
$3.11 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna American Axle |
$4.59
|
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.59
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cofinity Commercial |
$4.94
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$4.94
|
| 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 SBD |
$4.45
|
| Rate for Payer: UMR Bronson Commercial |
$3.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.30
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$26.82
|
|
|
Service Code
|
NDC 76329-3013-5
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.92 |
| Max. Negotiated Rate |
$24.14 |
| Rate for Payer: Aetna American Axle |
$17.43
|
| Rate for Payer: Aetna Commercial |
$22.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.43
|
| Rate for Payer: BCBS Complete |
$10.73
|
| Rate for Payer: Cash Price |
$21.46
|
| Rate for Payer: Cofinity Commercial |
$18.77
|
| Rate for Payer: Cofinity Commercial |
$23.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.46
|
| Rate for Payer: Healthscope Commercial |
$24.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.80
|
| Rate for Payer: PHP Commercial |
$22.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.77
|
| Rate for Payer: Priority Health SBD |
$16.90
|
| Rate for Payer: UMR Bronson Commercial |
$9.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.12
|
|
|
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 |
$6.69 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna American Axle |
$9.89
|
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.89
|
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: Cofinity Commercial |
$10.65
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$10.65
|
| 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 SBD |
$9.58
|
| Rate for Payer: UMR Bronson Commercial |
$6.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.41
|
|
|
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 |
$13.17 |
| Max. Negotiated Rate |
$26.94 |
| Rate for Payer: Aetna American Axle |
$19.45
|
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.45
|
| Rate for Payer: Cash Price |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$25.74
|
| Rate for Payer: Cofinity Commercial |
$20.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.94
|
| Rate for Payer: Healthscope Commercial |
$26.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.95
|
| 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 SBD |
$18.86
|
| Rate for Payer: UMR Bronson Commercial |
$13.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.45
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$44.85
|
|
|
Service Code
|
NDC 46581-830-06
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.73 |
| Max. Negotiated Rate |
$40.36 |
| Rate for Payer: Aetna American Axle |
$29.15
|
| Rate for Payer: Aetna Commercial |
$38.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.15
|
| Rate for Payer: Cash Price |
$35.88
|
| Rate for Payer: Cofinity Commercial |
$31.40
|
| Rate for Payer: Cofinity Commercial |
$38.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.88
|
| Rate for Payer: Healthscope Commercial |
$40.36
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.12
|
| Rate for Payer: PHP Commercial |
$38.12
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.40
|
| Rate for Payer: Priority Health SBD |
$28.26
|
| Rate for Payer: UMR Bronson Commercial |
$19.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.64
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$16.52
|
|
|
Service Code
|
NDC 96295-13458
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.27 |
| Max. Negotiated Rate |
$14.87 |
| Rate for Payer: Aetna American Axle |
$10.74
|
| Rate for Payer: Aetna Commercial |
$14.04
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.74
|
| Rate for Payer: Cash Price |
$13.22
|
| Rate for Payer: Cofinity Commercial |
$11.56
|
| 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: Kalamazoo County Sherrif's Dept Commercial |
$11.56
|
| 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 SBD |
$10.41
|
| Rate for Payer: UMR Bronson Commercial |
$7.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.39
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$45.36
|
|
|
Service Code
|
NDC 4116705840
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.96 |
| Max. Negotiated Rate |
$40.82 |
| Rate for Payer: Aetna American Axle |
$29.48
|
| Rate for Payer: Aetna Commercial |
$38.56
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.48
|
| Rate for Payer: Cash Price |
$36.29
|
| Rate for Payer: Cofinity Commercial |
$31.75
|
| Rate for Payer: Cofinity Commercial |
$39.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.29
|
| Rate for Payer: Healthscope Commercial |
$40.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.56
|
| Rate for Payer: PHP Commercial |
$38.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.75
|
| Rate for Payer: Priority Health SBD |
$28.58
|
| Rate for Payer: UMR Bronson Commercial |
$19.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.02
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$23.33
|
|
|
Service Code
|
NDC 70000-0557-1
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.27 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna American Axle |
$15.16
|
| Rate for Payer: Aetna Commercial |
$19.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.16
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: Cofinity Commercial |
$16.33
|
| Rate for Payer: Cofinity Commercial |
$20.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.66
|
| Rate for Payer: Healthscope Commercial |
$21.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.83
|
| Rate for Payer: PHP Commercial |
$19.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.33
|
| Rate for Payer: Priority Health SBD |
$14.70
|
| Rate for Payer: UMR Bronson Commercial |
$10.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.50
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$37.56
|
|
|
Service Code
|
NDC 4561100936
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.53 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Aetna American Axle |
$24.41
|
| Rate for Payer: Aetna Commercial |
$31.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.41
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cofinity Commercial |
$26.29
|
| Rate for Payer: Cofinity Commercial |
$32.30
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.05
|
| Rate for Payer: Healthscope Commercial |
$33.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$26.29
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$28.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$31.93
|
| Rate for Payer: PHP Commercial |
$31.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$26.29
|
| Rate for Payer: Priority Health SBD |
$23.66
|
| Rate for Payer: UMR Bronson Commercial |
$16.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.17
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$27.17
|
|
|
Service Code
|
NDC 0536-1202-15
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.95 |
| Max. Negotiated Rate |
$24.45 |
| Rate for Payer: Aetna American Axle |
$17.66
|
| Rate for Payer: Aetna Commercial |
$23.09
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.66
|
| Rate for Payer: Cash Price |
$21.74
|
| Rate for Payer: Cofinity Commercial |
$19.02
|
| Rate for Payer: Cofinity Commercial |
$23.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.74
|
| Rate for Payer: Healthscope Commercial |
$24.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.02
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.09
|
| Rate for Payer: PHP Commercial |
$23.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.02
|
| Rate for Payer: Priority Health SBD |
$17.12
|
| Rate for Payer: UMR Bronson Commercial |
$11.95
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.38
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$48.73
|
|
|
Service Code
|
NDC 4561100938
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.44 |
| Max. Negotiated Rate |
$43.86 |
| Rate for Payer: Aetna American Axle |
$31.67
|
| Rate for Payer: Aetna Commercial |
$41.42
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.67
|
| Rate for Payer: Cash Price |
$38.98
|
| Rate for Payer: Cofinity Commercial |
$34.11
|
| Rate for Payer: Cofinity Commercial |
$41.91
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$38.98
|
| Rate for Payer: Healthscope Commercial |
$43.86
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.11
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.42
|
| Rate for Payer: PHP Commercial |
$41.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.11
|
| Rate for Payer: Priority Health SBD |
$30.70
|
| Rate for Payer: UMR Bronson Commercial |
$21.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.55
|
|
|
LIDOCAINE 4 % WITH EPINEPHRINE TOPICAL SOLUTION
|
Facility
|
IP
|
$599.82
|
|
|
Service Code
|
NDC 9900-0002-11
|
| Hospital Charge Code |
155018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$263.92 |
| Max. Negotiated Rate |
$539.84 |
| Rate for Payer: Aetna American Axle |
$389.88
|
| Rate for Payer: Aetna Commercial |
$509.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$389.88
|
| Rate for Payer: Cash Price |
$479.86
|
| Rate for Payer: Cofinity Commercial |
$419.87
|
| Rate for Payer: Cofinity Commercial |
$515.85
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$479.86
|
| Rate for Payer: Healthscope Commercial |
$539.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$419.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$449.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$509.85
|
| Rate for Payer: PHP Commercial |
$509.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$419.87
|
| Rate for Payer: Priority Health SBD |
$377.89
|
| Rate for Payer: UMR Bronson Commercial |
$263.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$449.86
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
IP
|
$372.54
|
|
|
Service Code
|
NDC 51672-3020-2
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$163.92 |
| Max. Negotiated Rate |
$335.29 |
| Rate for Payer: Aetna American Axle |
$242.15
|
| Rate for Payer: Aetna Commercial |
$316.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$242.15
|
| Rate for Payer: Cash Price |
$298.03
|
| Rate for Payer: Cofinity Commercial |
$260.78
|
| Rate for Payer: Cofinity Commercial |
$320.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$298.03
|
| Rate for Payer: Healthscope Commercial |
$335.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$260.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$279.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$316.66
|
| Rate for Payer: PHP Commercial |
$316.66
|
| Rate for Payer: Priority Health Cigna Priority Health |
$260.78
|
| Rate for Payer: Priority Health SBD |
$234.70
|
| Rate for Payer: UMR Bronson Commercial |
$163.92
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$279.40
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
IP
|
$34.36
|
|
|
Service Code
|
NDC 52565-008-14
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$30.92 |
| Rate for Payer: Aetna American Axle |
$22.33
|
| Rate for Payer: Aetna Commercial |
$29.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.33
|
| Rate for Payer: Cash Price |
$27.49
|
| Rate for Payer: Cofinity Commercial |
$24.05
|
| Rate for Payer: Cofinity Commercial |
$29.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.49
|
| Rate for Payer: Healthscope Commercial |
$30.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.21
|
| Rate for Payer: PHP Commercial |
$29.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.05
|
| Rate for Payer: Priority Health SBD |
$21.65
|
| Rate for Payer: UMR Bronson Commercial |
$15.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.77
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
IP
|
$70.58
|
|
|
Service Code
|
NDC 69680-120-35
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.06 |
| Max. Negotiated Rate |
$63.52 |
| Rate for Payer: Aetna American Axle |
$45.88
|
| Rate for Payer: Aetna Commercial |
$59.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.88
|
| Rate for Payer: Cash Price |
$56.46
|
| Rate for Payer: Cofinity Commercial |
$49.41
|
| Rate for Payer: Cofinity Commercial |
$60.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.46
|
| Rate for Payer: Healthscope Commercial |
$63.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$59.99
|
| Rate for Payer: PHP Commercial |
$59.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.41
|
| Rate for Payer: Priority Health SBD |
$44.47
|
| Rate for Payer: UMR Bronson Commercial |
$31.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.94
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
IP
|
$24.56
|
|
|
Service Code
|
NDC 70752-113-03
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.81 |
| Max. Negotiated Rate |
$22.10 |
| Rate for Payer: Aetna American Axle |
$15.96
|
| Rate for Payer: Aetna Commercial |
$20.88
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.96
|
| Rate for Payer: Cash Price |
$19.65
|
| Rate for Payer: Cofinity Commercial |
$17.19
|
| Rate for Payer: Cofinity Commercial |
$21.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.65
|
| Rate for Payer: Healthscope Commercial |
$22.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.88
|
| Rate for Payer: PHP Commercial |
$20.88
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.19
|
| Rate for Payer: Priority Health SBD |
$15.47
|
| Rate for Payer: UMR Bronson Commercial |
$10.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.42
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
IP
|
$781.21
|
|
|
Service Code
|
NDC 0168-0204-37
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$343.73 |
| Max. Negotiated Rate |
$703.09 |
| Rate for Payer: Aetna American Axle |
$507.79
|
| Rate for Payer: Aetna Commercial |
$664.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$507.79
|
| Rate for Payer: Cash Price |
$624.97
|
| Rate for Payer: Cofinity Commercial |
$546.85
|
| Rate for Payer: Cofinity Commercial |
$671.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$624.97
|
| Rate for Payer: Healthscope Commercial |
$703.09
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$546.85
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$585.91
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$664.03
|
| Rate for Payer: PHP Commercial |
$664.03
|
| Rate for Payer: Priority Health Cigna Priority Health |
$546.85
|
| Rate for Payer: Priority Health SBD |
$492.16
|
| Rate for Payer: UMR Bronson Commercial |
$343.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$585.91
|
|
