|
LIDOCAINE (BULK) POWDER
|
Facility
|
IP
|
$278.35
|
|
|
Service Code
|
NDC 38779-0081-5
|
| Hospital Charge Code |
12855
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$122.47 |
| Max. Negotiated Rate |
$250.52 |
| Rate for Payer: Aetna American Axle |
$180.93
|
| Rate for Payer: Aetna Commercial |
$236.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$180.93
|
| Rate for Payer: Cash Price |
$222.68
|
| Rate for Payer: Cofinity Commercial |
$194.84
|
| Rate for Payer: Cofinity Commercial |
$239.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$222.68
|
| Rate for Payer: Healthscope Commercial |
$250.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$194.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$208.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$236.60
|
| Rate for Payer: PHP Commercial |
$236.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$194.84
|
| Rate for Payer: Priority Health SBD |
$175.36
|
| Rate for Payer: UMR Bronson Commercial |
$122.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$208.76
|
|
|
LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$28.93
|
|
|
Service Code
|
NDC 63323-481-57
|
| Hospital Charge Code |
14870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.73 |
| Max. Negotiated Rate |
$26.04 |
| Rate for Payer: Aetna American Axle |
$18.80
|
| Rate for Payer: Aetna Commercial |
$24.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.80
|
| Rate for Payer: Cash Price |
$23.14
|
| Rate for Payer: Cofinity Commercial |
$20.25
|
| Rate for Payer: Cofinity Commercial |
$24.88
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.14
|
| Rate for Payer: Healthscope Commercial |
$26.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.25
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.59
|
| Rate for Payer: PHP Commercial |
$24.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.25
|
| Rate for Payer: Priority Health SBD |
$18.23
|
| Rate for Payer: UMR Bronson Commercial |
$12.73
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.70
|
|
|
LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$16.28
|
|
|
Service Code
|
NDC 0409-3177-01
|
| Hospital Charge Code |
14870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$14.65 |
| Rate for Payer: Aetna American Axle |
$10.58
|
| Rate for Payer: Aetna Commercial |
$13.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.58
|
| Rate for Payer: Cash Price |
$13.02
|
| Rate for Payer: Cofinity Commercial |
$11.40
|
| Rate for Payer: Cofinity Commercial |
$14.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.02
|
| Rate for Payer: Healthscope Commercial |
$14.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.84
|
| Rate for Payer: PHP Commercial |
$13.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.40
|
| Rate for Payer: Priority Health SBD |
$10.26
|
| Rate for Payer: UMR Bronson Commercial |
$7.16
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.21
|
|
|
LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$10.25
|
|
|
Service Code
|
NDC 9900-0018-46
|
| Hospital Charge Code |
14870
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.51 |
| Max. Negotiated Rate |
$9.22 |
| Rate for Payer: Aetna American Axle |
$6.66
|
| Rate for Payer: Aetna Commercial |
$8.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.66
|
| Rate for Payer: Cash Price |
$8.20
|
| Rate for Payer: Cofinity Commercial |
$7.18
|
| Rate for Payer: Cofinity Commercial |
$8.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.20
|
| Rate for Payer: Healthscope Commercial |
$9.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.18
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$8.71
|
| Rate for Payer: PHP Commercial |
$8.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.18
|
| Rate for Payer: Priority Health SBD |
$6.46
|
| Rate for Payer: UMR Bronson Commercial |
$4.51
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.69
|
|
|
LIDOCAINE-EPINEPHRINE 1 %-1:100,000 INJECTION (COA)
|
Facility
|
IP
|
$29.46
|
|
|
Service Code
|
NDC 63323-482-27
|
| Hospital Charge Code |
168937
|
|
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-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$48.87
|
|
|
Service Code
|
NDC 63323-487-07
|
| Hospital Charge Code |
15985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$43.98 |
| Rate for Payer: Aetna American Axle |
$31.77
|
| Rate for Payer: Aetna Commercial |
$41.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.77
|
| Rate for Payer: Cash Price |
$39.10
|
| Rate for Payer: Cofinity Commercial |
$34.21
|
| Rate for Payer: Cofinity Commercial |
$42.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.10
|
| Rate for Payer: Healthscope Commercial |
$43.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.54
|
| Rate for Payer: PHP Commercial |
$41.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.21
|
| Rate for Payer: Priority Health SBD |
$30.79
|
| Rate for Payer: UMR Bronson Commercial |
$21.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.65
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$48.87
|
|
|
Service Code
|
NDC 63323-487-37
|
| Hospital Charge Code |
15985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$21.50 |
| Max. Negotiated Rate |
$43.98 |
| Rate for Payer: Aetna American Axle |
$31.77
|
| Rate for Payer: Aetna Commercial |
$41.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.77
|
| Rate for Payer: Cash Price |
$39.10
|
| Rate for Payer: Cofinity Commercial |
$34.21
|
| Rate for Payer: Cofinity Commercial |
$42.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$39.10
|
| Rate for Payer: Healthscope Commercial |
$43.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$34.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$36.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$41.54
|
| Rate for Payer: PHP Commercial |
$41.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$34.21
|
| Rate for Payer: Priority Health SBD |
$30.79
|
| Rate for Payer: UMR Bronson Commercial |
$21.50
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.65
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$35.07
|
|
|
Service Code
|
NDC 63323-487-17
|
| Hospital Charge Code |
15985
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.43 |
| Max. Negotiated Rate |
$31.56 |
| Rate for Payer: Aetna American Axle |
$22.80
|
| Rate for Payer: Aetna Commercial |
$29.81
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.80
|
| Rate for Payer: Cash Price |
$28.06
|
| Rate for Payer: Cofinity Commercial |
$24.55
|
| Rate for Payer: Cofinity Commercial |
$30.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.06
|
| Rate for Payer: Healthscope Commercial |
$31.56
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$29.81
|
| Rate for Payer: PHP Commercial |
$29.81
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.55
|
| Rate for Payer: Priority Health SBD |
$22.09
|
| Rate for Payer: UMR Bronson Commercial |
$15.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.30
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$24.17
|
|
|
Service Code
|
NDC 0409-3181-01
|
| Hospital Charge Code |
15956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$21.75 |
| Rate for Payer: Aetna American Axle |
$15.71
|
| Rate for Payer: Aetna Commercial |
$20.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.71
|
| Rate for Payer: Cash Price |
$19.34
|
| Rate for Payer: Cofinity Commercial |
$16.92
|
| Rate for Payer: Cofinity Commercial |
$20.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.34
|
| Rate for Payer: Healthscope Commercial |
$21.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.54
|
| Rate for Payer: PHP Commercial |
$20.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.92
|
| Rate for Payer: Priority Health SBD |
$15.23
|
| Rate for Payer: UMR Bronson Commercial |
$10.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.13
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$39.57
|
|
|
Service Code
|
NDC 63323-488-17
|
| Hospital Charge Code |
15956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.41 |
| Max. Negotiated Rate |
$35.61 |
| Rate for Payer: Aetna American Axle |
$25.72
|
| Rate for Payer: Aetna Commercial |
$33.63
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.72
|
| Rate for Payer: Cash Price |
$31.66
|
| Rate for Payer: Cofinity Commercial |
$27.70
|
| Rate for Payer: Cofinity Commercial |
$34.03
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.66
|
| Rate for Payer: Healthscope Commercial |
$35.61
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.70
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.68
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.63
|
| Rate for Payer: PHP Commercial |
$33.63
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.70
|
| Rate for Payer: Priority Health SBD |
$24.93
|
| Rate for Payer: UMR Bronson Commercial |
$17.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.68
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$64.62
|
|
|
Service Code
|
NDC 63323-488-37
|
| Hospital Charge Code |
15956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.43 |
| Max. Negotiated Rate |
$58.16 |
| Rate for Payer: Aetna American Axle |
$42.00
|
| Rate for Payer: Aetna Commercial |
$54.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.00
|
| Rate for Payer: Cash Price |
$51.70
|
| Rate for Payer: Cofinity Commercial |
$45.23
|
| Rate for Payer: Cofinity Commercial |
$55.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.70
|
| Rate for Payer: Healthscope Commercial |
$58.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$54.93
|
| Rate for Payer: PHP Commercial |
$54.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.23
|
| Rate for Payer: Priority Health SBD |
$40.71
|
| Rate for Payer: UMR Bronson Commercial |
$28.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.46
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$64.62
|
|
|
Service Code
|
NDC 63323-488-07
|
| Hospital Charge Code |
15956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$28.43 |
| Max. Negotiated Rate |
$58.16 |
| Rate for Payer: Aetna American Axle |
$42.00
|
| Rate for Payer: Aetna Commercial |
$54.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$42.00
|
| Rate for Payer: Cash Price |
$51.70
|
| Rate for Payer: Cofinity Commercial |
$45.23
|
| Rate for Payer: Cofinity Commercial |
$55.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$51.70
|
| Rate for Payer: Healthscope Commercial |
$58.16
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$45.23
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$48.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$54.93
|
| Rate for Payer: PHP Commercial |
$54.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.23
|
| Rate for Payer: Priority Health SBD |
$40.71
|
| Rate for Payer: UMR Bronson Commercial |
$28.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$48.46
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$24.17
|
|
|
Service Code
|
NDC 0409-3181-11
|
| Hospital Charge Code |
15956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.63 |
| Max. Negotiated Rate |
$21.75 |
| Rate for Payer: Aetna American Axle |
$15.71
|
| Rate for Payer: Aetna Commercial |
$20.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.71
|
| Rate for Payer: Cash Price |
$19.34
|
| Rate for Payer: Cofinity Commercial |
$16.92
|
| Rate for Payer: Cofinity Commercial |
$20.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.34
|
| Rate for Payer: Healthscope Commercial |
$21.75
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.92
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.54
|
| Rate for Payer: PHP Commercial |
$20.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.92
|
| Rate for Payer: Priority Health SBD |
$15.23
|
| Rate for Payer: UMR Bronson Commercial |
$10.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.13
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$35.38
|
|
|
Service Code
|
NDC 63323-488-31
|
| Hospital Charge Code |
15956
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.57 |
| Max. Negotiated Rate |
$31.84 |
| Rate for Payer: Aetna American Axle |
$23.00
|
| Rate for Payer: Aetna Commercial |
$30.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.00
|
| Rate for Payer: Cash Price |
$28.30
|
| Rate for Payer: Cofinity Commercial |
$24.77
|
| Rate for Payer: Cofinity Commercial |
$30.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.30
|
| Rate for Payer: Healthscope Commercial |
$31.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$30.07
|
| Rate for Payer: PHP Commercial |
$30.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.77
|
| Rate for Payer: Priority Health SBD |
$22.29
|
| Rate for Payer: UMR Bronson Commercial |
$15.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.54
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$20.58
|
|
|
Service Code
|
NDC 0409-3183-11
|
| Hospital Charge Code |
10431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$18.52 |
| Rate for Payer: Aetna American Axle |
$13.38
|
| Rate for Payer: Aetna Commercial |
$17.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.38
|
| Rate for Payer: Cash Price |
$16.46
|
| Rate for Payer: Cofinity Commercial |
$14.41
|
| Rate for Payer: Cofinity Commercial |
$17.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.46
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.49
|
| Rate for Payer: PHP Commercial |
$17.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.41
|
| Rate for Payer: Priority Health SBD |
$12.97
|
| Rate for Payer: UMR Bronson Commercial |
$9.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.44
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$39.52
|
|
|
Service Code
|
NDC 63323-489-21
|
| Hospital Charge Code |
10431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.39 |
| Max. Negotiated Rate |
$35.57 |
| Rate for Payer: Aetna American Axle |
$25.69
|
| Rate for Payer: Aetna Commercial |
$33.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.69
|
| Rate for Payer: Cash Price |
$31.62
|
| Rate for Payer: Cofinity Commercial |
$27.66
|
| Rate for Payer: Cofinity Commercial |
$33.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.62
|
| Rate for Payer: Healthscope Commercial |
$35.57
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$33.59
|
| Rate for Payer: PHP Commercial |
$33.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$27.66
|
| Rate for Payer: Priority Health SBD |
$24.90
|
| Rate for Payer: UMR Bronson Commercial |
$17.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.64
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$74.76
|
|
|
Service Code
|
NDC 63323-489-02
|
| Hospital Charge Code |
10431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.89 |
| Max. Negotiated Rate |
$67.28 |
| Rate for Payer: Aetna American Axle |
$48.59
|
| Rate for Payer: Aetna Commercial |
$63.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.59
|
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Cofinity Commercial |
$52.33
|
| Rate for Payer: Cofinity Commercial |
$64.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.81
|
| Rate for Payer: Healthscope Commercial |
$67.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.55
|
| Rate for Payer: PHP Commercial |
$63.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.33
|
| Rate for Payer: Priority Health SBD |
$47.10
|
| Rate for Payer: UMR Bronson Commercial |
$32.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.07
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$20.58
|
|
|
Service Code
|
NDC 0409-3183-01
|
| Hospital Charge Code |
10431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.06 |
| Max. Negotiated Rate |
$18.52 |
| Rate for Payer: Aetna American Axle |
$13.38
|
| Rate for Payer: Aetna Commercial |
$17.49
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.38
|
| Rate for Payer: Cash Price |
$16.46
|
| Rate for Payer: Cofinity Commercial |
$14.41
|
| Rate for Payer: Cofinity Commercial |
$17.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.46
|
| Rate for Payer: Healthscope Commercial |
$18.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$17.49
|
| Rate for Payer: PHP Commercial |
$17.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.41
|
| Rate for Payer: Priority Health SBD |
$12.97
|
| Rate for Payer: UMR Bronson Commercial |
$9.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.44
|
|
|
LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION
|
Facility
|
IP
|
$74.76
|
|
|
Service Code
|
NDC 63323-489-27
|
| Hospital Charge Code |
10431
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.89 |
| Max. Negotiated Rate |
$67.28 |
| Rate for Payer: Aetna American Axle |
$48.59
|
| Rate for Payer: Aetna Commercial |
$63.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$48.59
|
| Rate for Payer: Cash Price |
$59.81
|
| Rate for Payer: Cofinity Commercial |
$52.33
|
| Rate for Payer: Cofinity Commercial |
$64.29
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$59.81
|
| Rate for Payer: Healthscope Commercial |
$67.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$52.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$56.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$63.55
|
| Rate for Payer: PHP Commercial |
$63.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.33
|
| Rate for Payer: Priority Health SBD |
$47.10
|
| Rate for Payer: UMR Bronson Commercial |
$32.89
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$56.07
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$24.36
|
|
|
Service Code
|
NDC 63323-485-27
|
| Hospital Charge Code |
4452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.72 |
| Max. Negotiated Rate |
$21.92 |
| Rate for Payer: Aetna American Axle |
$15.83
|
| Rate for Payer: Aetna Commercial |
$20.71
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.83
|
| Rate for Payer: Cash Price |
$19.49
|
| Rate for Payer: Cofinity Commercial |
$17.05
|
| Rate for Payer: Cofinity Commercial |
$20.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.49
|
| Rate for Payer: Healthscope Commercial |
$21.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.71
|
| Rate for Payer: PHP Commercial |
$20.71
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.05
|
| Rate for Payer: Priority Health SBD |
$15.35
|
| Rate for Payer: UMR Bronson Commercial |
$10.72
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.27
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$12.47
|
|
|
Service Code
|
NDC 0409-4276-01
|
| Hospital Charge Code |
4452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.49 |
| Max. Negotiated Rate |
$11.22 |
| Rate for Payer: Aetna American Axle |
$8.11
|
| Rate for Payer: Aetna Commercial |
$10.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.11
|
| Rate for Payer: Cash Price |
$9.98
|
| Rate for Payer: Cofinity Commercial |
$10.72
|
| Rate for Payer: Cofinity Commercial |
$8.73
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.98
|
| Rate for Payer: Healthscope Commercial |
$11.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.73
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.60
|
| Rate for Payer: PHP Commercial |
$10.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.73
|
| Rate for Payer: Priority Health SBD |
$7.86
|
| Rate for Payer: UMR Bronson Commercial |
$5.49
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.35
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$16.94
|
|
|
Service Code
|
NDC 63323-201-02
|
| Hospital Charge Code |
4452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.45 |
| Max. Negotiated Rate |
$15.25 |
| Rate for Payer: Aetna American Axle |
$11.01
|
| Rate for Payer: Aetna Commercial |
$14.40
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.01
|
| Rate for Payer: Cash Price |
$13.55
|
| Rate for Payer: Cofinity Commercial |
$11.86
|
| Rate for Payer: Cofinity Commercial |
$14.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.55
|
| Rate for Payer: Healthscope Commercial |
$15.25
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.86
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.40
|
| Rate for Payer: PHP Commercial |
$14.40
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.86
|
| Rate for Payer: Priority Health SBD |
$10.67
|
| Rate for Payer: UMR Bronson Commercial |
$7.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.70
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$21.83
|
|
|
Service Code
|
NDC 0409-4276-02
|
| Hospital Charge Code |
4452
|
|
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 HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$24.92
|
|
|
Service Code
|
NDC 55150-253-50
|
| Hospital Charge Code |
4452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.96 |
| Max. Negotiated Rate |
$22.43 |
| Rate for Payer: Aetna American Axle |
$16.20
|
| Rate for Payer: Aetna Commercial |
$21.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.20
|
| Rate for Payer: Cash Price |
$19.94
|
| Rate for Payer: Cofinity Commercial |
$17.44
|
| Rate for Payer: Cofinity Commercial |
$21.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.94
|
| Rate for Payer: Healthscope Commercial |
$22.43
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.44
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.18
|
| Rate for Payer: PHP Commercial |
$21.18
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.44
|
| Rate for Payer: Priority Health SBD |
$15.70
|
| Rate for Payer: UMR Bronson Commercial |
$10.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.69
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$24.42
|
|
|
Service Code
|
NDC 63323-485-57
|
| Hospital Charge Code |
4452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.74 |
| Max. Negotiated Rate |
$21.98 |
| Rate for Payer: Aetna American Axle |
$15.87
|
| Rate for Payer: Aetna Commercial |
$20.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.87
|
| Rate for Payer: Cash Price |
$19.54
|
| Rate for Payer: Cofinity Commercial |
$17.09
|
| Rate for Payer: Cofinity Commercial |
$21.00
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.54
|
| Rate for Payer: Healthscope Commercial |
$21.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.09
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.76
|
| Rate for Payer: PHP Commercial |
$20.76
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.09
|
| Rate for Payer: Priority Health SBD |
$15.38
|
| Rate for Payer: UMR Bronson Commercial |
$10.74
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.32
|
|
