|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$12.76
|
|
|
Service Code
|
NDC 55150-252-20
|
| Hospital Charge Code |
4452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.61 |
| Max. Negotiated Rate |
$11.48 |
| Rate for Payer: Aetna American Axle |
$8.29
|
| Rate for Payer: Aetna Commercial |
$10.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$8.29
|
| Rate for Payer: Cash Price |
$10.21
|
| Rate for Payer: Cofinity Commercial |
$10.97
|
| Rate for Payer: Cofinity Commercial |
$8.93
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.21
|
| Rate for Payer: Healthscope Commercial |
$11.48
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.93
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.85
|
| Rate for Payer: PHP Commercial |
$10.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.93
|
| Rate for Payer: Priority Health SBD |
$8.04
|
| Rate for Payer: UMR Bronson Commercial |
$5.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.57
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$19.00
|
|
|
Service Code
|
NDC 63323-201-10
|
| Hospital Charge Code |
4452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.36 |
| Max. Negotiated Rate |
$17.10 |
| Rate for Payer: Aetna American Axle |
$12.35
|
| Rate for Payer: Aetna Commercial |
$16.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.35
|
| Rate for Payer: Cash Price |
$15.20
|
| Rate for Payer: Cofinity Commercial |
$13.30
|
| Rate for Payer: Cofinity Commercial |
$16.34
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.20
|
| Rate for Payer: Healthscope Commercial |
$17.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.15
|
| Rate for Payer: PHP Commercial |
$16.15
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.30
|
| Rate for Payer: Priority Health SBD |
$11.97
|
| Rate for Payer: UMR Bronson Commercial |
$8.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.25
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$15.37
|
|
|
Service Code
|
NDC 55150-251-10
|
| Hospital Charge Code |
4452
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$13.83 |
| Rate for Payer: Aetna American Axle |
$9.99
|
| Rate for Payer: Aetna Commercial |
$13.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.99
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cofinity Commercial |
$10.76
|
| Rate for Payer: Cofinity Commercial |
$13.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.30
|
| Rate for Payer: Healthscope Commercial |
$13.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.06
|
| Rate for Payer: PHP Commercial |
$13.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.76
|
| Rate for Payer: Priority Health SBD |
$9.68
|
| Rate for Payer: UMR Bronson Commercial |
$6.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.53
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY
|
Facility
|
IP
|
$15.37
|
|
|
Service Code
|
NDC 55150-251-10
|
| Hospital Charge Code |
300842
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$13.83 |
| Rate for Payer: Aetna American Axle |
$9.99
|
| Rate for Payer: Aetna Commercial |
$13.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.99
|
| Rate for Payer: Cash Price |
$12.30
|
| Rate for Payer: Cofinity Commercial |
$10.76
|
| Rate for Payer: Cofinity Commercial |
$13.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.30
|
| Rate for Payer: Healthscope Commercial |
$13.83
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.76
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.06
|
| Rate for Payer: PHP Commercial |
$13.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.76
|
| Rate for Payer: Priority Health SBD |
$9.68
|
| Rate for Payer: UMR Bronson Commercial |
$6.76
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.53
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$27.38
|
|
|
Service Code
|
NDC 0143-9575-01
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$24.64 |
| Rate for Payer: Aetna American Axle |
$17.80
|
| Rate for Payer: Aetna Commercial |
$23.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.80
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cofinity Commercial |
$19.17
|
| Rate for Payer: Cofinity Commercial |
$23.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.90
|
| Rate for Payer: Healthscope Commercial |
$24.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.27
|
| Rate for Payer: PHP Commercial |
$23.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.17
|
| Rate for Payer: Priority Health SBD |
$17.25
|
| Rate for Payer: UMR Bronson Commercial |
$12.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.54
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$25.53
|
|
|
Service Code
|
NDC 63323-486-05
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$22.98 |
| Rate for Payer: Aetna American Axle |
$16.59
|
| Rate for Payer: Aetna Commercial |
$21.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.59
|
| Rate for Payer: Cash Price |
$20.42
|
| Rate for Payer: Cofinity Commercial |
$17.87
|
| Rate for Payer: Cofinity Commercial |
$21.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.42
|
| Rate for Payer: Healthscope Commercial |
$22.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.70
|
| Rate for Payer: PHP Commercial |
$21.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.87
|
| Rate for Payer: Priority Health SBD |
$16.08
|
| Rate for Payer: UMR Bronson Commercial |
$11.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.15
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$11.89
|
|
|
Service Code
|
NDC 55150-255-20
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.23 |
| Max. Negotiated Rate |
$10.70 |
| Rate for Payer: Aetna American Axle |
$7.73
|
| Rate for Payer: Aetna Commercial |
$10.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.73
|
| Rate for Payer: Cash Price |
$9.51
|
| Rate for Payer: Cofinity Commercial |
$10.23
|
| Rate for Payer: Cofinity Commercial |
$8.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.51
|
| Rate for Payer: Healthscope Commercial |
$10.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.32
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$8.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.11
|
| Rate for Payer: PHP Commercial |
$10.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.32
|
| Rate for Payer: Priority Health SBD |
$7.49
|
| Rate for Payer: UMR Bronson Commercial |
$5.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$8.92
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$27.26
|
|
|
Service Code
|
NDC 0409-4277-16
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$24.53 |
| Rate for Payer: Aetna American Axle |
$17.72
|
| Rate for Payer: Aetna Commercial |
$23.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.72
|
| Rate for Payer: Cash Price |
$21.81
|
| Rate for Payer: Cofinity Commercial |
$19.08
|
| Rate for Payer: Cofinity Commercial |
$23.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.81
|
| Rate for Payer: Healthscope Commercial |
$24.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.17
|
| Rate for Payer: PHP Commercial |
$23.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.08
|
| Rate for Payer: Priority Health SBD |
$17.17
|
| Rate for Payer: UMR Bronson Commercial |
$11.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.44
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$28.86
|
|
|
Service Code
|
NDC 0409-4277-02
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.70 |
| Max. Negotiated Rate |
$25.97 |
| Rate for Payer: Aetna American Axle |
$18.76
|
| Rate for Payer: Aetna Commercial |
$24.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.76
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cofinity Commercial |
$20.20
|
| Rate for Payer: Cofinity Commercial |
$24.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.09
|
| Rate for Payer: Healthscope Commercial |
$25.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.53
|
| Rate for Payer: PHP Commercial |
$24.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.20
|
| Rate for Payer: Priority Health SBD |
$18.18
|
| Rate for Payer: UMR Bronson Commercial |
$12.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.64
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$28.86
|
|
|
Service Code
|
NDC 0409-4277-17
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.70 |
| Max. Negotiated Rate |
$25.97 |
| Rate for Payer: Aetna American Axle |
$18.76
|
| Rate for Payer: Aetna Commercial |
$24.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.76
|
| Rate for Payer: Cash Price |
$23.09
|
| Rate for Payer: Cofinity Commercial |
$20.20
|
| Rate for Payer: Cofinity Commercial |
$24.82
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.09
|
| Rate for Payer: Healthscope Commercial |
$25.97
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.20
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$24.53
|
| Rate for Payer: PHP Commercial |
$24.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$20.20
|
| Rate for Payer: Priority Health SBD |
$18.18
|
| Rate for Payer: UMR Bronson Commercial |
$12.70
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.64
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$31.15
|
|
|
Service Code
|
NDC 55150-256-50
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.71 |
| Max. Negotiated Rate |
$28.04 |
| Rate for Payer: Aetna American Axle |
$20.25
|
| Rate for Payer: Aetna Commercial |
$26.48
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.25
|
| Rate for Payer: Cash Price |
$24.92
|
| Rate for Payer: Cofinity Commercial |
$21.80
|
| Rate for Payer: Cofinity Commercial |
$26.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.92
|
| Rate for Payer: Healthscope Commercial |
$28.04
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.36
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$26.48
|
| Rate for Payer: PHP Commercial |
$26.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.80
|
| Rate for Payer: Priority Health SBD |
$19.62
|
| Rate for Payer: UMR Bronson Commercial |
$13.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.36
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$25.53
|
|
|
Service Code
|
NDC 63323-486-57
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.23 |
| Max. Negotiated Rate |
$22.98 |
| Rate for Payer: Aetna American Axle |
$16.59
|
| Rate for Payer: Aetna Commercial |
$21.70
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.59
|
| Rate for Payer: Cash Price |
$20.42
|
| Rate for Payer: Cofinity Commercial |
$17.87
|
| Rate for Payer: Cofinity Commercial |
$21.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.42
|
| Rate for Payer: Healthscope Commercial |
$22.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.87
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.15
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.70
|
| Rate for Payer: PHP Commercial |
$21.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.87
|
| Rate for Payer: Priority Health SBD |
$16.08
|
| Rate for Payer: UMR Bronson Commercial |
$11.23
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.15
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$27.38
|
|
|
Service Code
|
NDC 0143-9575-10
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$24.64 |
| Rate for Payer: Aetna American Axle |
$17.80
|
| Rate for Payer: Aetna Commercial |
$23.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.80
|
| Rate for Payer: Cash Price |
$21.90
|
| Rate for Payer: Cofinity Commercial |
$19.17
|
| Rate for Payer: Cofinity Commercial |
$23.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.90
|
| Rate for Payer: Healthscope Commercial |
$24.64
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.17
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.27
|
| Rate for Payer: PHP Commercial |
$23.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.17
|
| Rate for Payer: Priority Health SBD |
$17.25
|
| Rate for Payer: UMR Bronson Commercial |
$12.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.54
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$23.78
|
|
|
Service Code
|
NDC 63323-486-17
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$21.40 |
| Rate for Payer: Aetna American Axle |
$15.46
|
| Rate for Payer: Aetna Commercial |
$20.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.46
|
| Rate for Payer: Cash Price |
$19.02
|
| Rate for Payer: Cofinity Commercial |
$16.65
|
| Rate for Payer: Cofinity Commercial |
$20.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.02
|
| Rate for Payer: Healthscope Commercial |
$21.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.21
|
| Rate for Payer: PHP Commercial |
$20.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.65
|
| Rate for Payer: Priority Health SBD |
$14.98
|
| Rate for Payer: UMR Bronson Commercial |
$10.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.84
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$27.26
|
|
|
Service Code
|
NDC 0409-4277-01
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.99 |
| Max. Negotiated Rate |
$24.53 |
| Rate for Payer: Aetna American Axle |
$17.72
|
| Rate for Payer: Aetna Commercial |
$23.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.72
|
| Rate for Payer: Cash Price |
$21.81
|
| Rate for Payer: Cofinity Commercial |
$19.08
|
| Rate for Payer: Cofinity Commercial |
$23.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.81
|
| Rate for Payer: Healthscope Commercial |
$24.53
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.08
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$23.17
|
| Rate for Payer: PHP Commercial |
$23.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.08
|
| Rate for Payer: Priority Health SBD |
$17.17
|
| Rate for Payer: UMR Bronson Commercial |
$11.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.44
|
|
|
LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION
|
Facility
|
IP
|
$23.78
|
|
|
Service Code
|
NDC 63323-486-01
|
| Hospital Charge Code |
4454
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.46 |
| Max. Negotiated Rate |
$21.40 |
| Rate for Payer: Aetna American Axle |
$15.46
|
| Rate for Payer: Aetna Commercial |
$20.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.46
|
| Rate for Payer: Cash Price |
$19.02
|
| Rate for Payer: Cofinity Commercial |
$16.65
|
| Rate for Payer: Cofinity Commercial |
$20.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.02
|
| Rate for Payer: Healthscope Commercial |
$21.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.84
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$20.21
|
| Rate for Payer: PHP Commercial |
$20.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.65
|
| Rate for Payer: Priority Health SBD |
$14.98
|
| Rate for Payer: UMR Bronson Commercial |
$10.46
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.84
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$31.85
|
|
|
Service Code
|
NDC 0054-3500-49
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.01 |
| Max. Negotiated Rate |
$28.66 |
| Rate for Payer: Aetna American Axle |
$20.70
|
| Rate for Payer: Aetna Commercial |
$27.07
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$20.70
|
| Rate for Payer: Cash Price |
$25.48
|
| Rate for Payer: Cofinity Commercial |
$22.30
|
| Rate for Payer: Cofinity Commercial |
$27.39
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.48
|
| Rate for Payer: Healthscope Commercial |
$28.66
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.30
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$23.89
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.07
|
| Rate for Payer: PHP Commercial |
$27.07
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.30
|
| Rate for Payer: Priority Health SBD |
$20.07
|
| Rate for Payer: UMR Bronson Commercial |
$14.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$23.89
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 9900-0003-39
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna American Axle |
$3.57
|
| Rate for Payer: Aetna Commercial |
$4.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.57
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Commercial |
$3.84
|
| Rate for Payer: Cofinity Commercial |
$4.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$4.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$4.67
|
| Rate for Payer: PHP Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.84
|
| Rate for Payer: Priority Health SBD |
$3.46
|
| Rate for Payer: UMR Bronson Commercial |
$2.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.12
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 17856-1393-2
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.28 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Aetna American Axle |
$7.80
|
| Rate for Payer: Aetna Commercial |
$10.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.80
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$8.40
|
| Rate for Payer: Cofinity Commercial |
$10.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.60
|
| Rate for Payer: Healthscope Commercial |
$10.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$10.20
|
| Rate for Payer: PHP Commercial |
$10.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.40
|
| Rate for Payer: Priority Health SBD |
$7.56
|
| Rate for Payer: UMR Bronson Commercial |
$5.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.00
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$15.06
|
|
|
Service Code
|
NDC 0121-0903-40
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Aetna American Axle |
$9.79
|
| Rate for Payer: Aetna Commercial |
$12.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.79
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cofinity Commercial |
$10.54
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.05
|
| Rate for Payer: Healthscope Commercial |
$13.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.80
|
| Rate for Payer: PHP Commercial |
$12.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.54
|
| Rate for Payer: Priority Health SBD |
$9.49
|
| Rate for Payer: UMR Bronson Commercial |
$6.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.30
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$25.90
|
|
|
Service Code
|
NDC 60432-464-00
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.40 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna American Axle |
$16.84
|
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Commercial |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.72
|
| Rate for Payer: Healthscope Commercial |
$23.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.13
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$22.02
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.13
|
| Rate for Payer: Priority Health SBD |
$16.32
|
| Rate for Payer: UMR Bronson Commercial |
$11.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.42
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$15.06
|
|
|
Service Code
|
NDC 0121-0903-15
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Aetna American Axle |
$9.79
|
| Rate for Payer: Aetna Commercial |
$12.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.79
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cofinity Commercial |
$10.54
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.05
|
| Rate for Payer: Healthscope Commercial |
$13.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$12.80
|
| Rate for Payer: PHP Commercial |
$12.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.54
|
| Rate for Payer: Priority Health SBD |
$9.49
|
| Rate for Payer: UMR Bronson Commercial |
$6.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.30
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$32.55
|
|
|
Service Code
|
NDC 0527-6002-74
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna American Axle |
$21.16
|
| Rate for Payer: Aetna Commercial |
$27.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.16
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cofinity Commercial |
$22.78
|
| Rate for Payer: Cofinity Commercial |
$27.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.04
|
| Rate for Payer: Healthscope Commercial |
$29.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$27.67
|
| Rate for Payer: PHP Commercial |
$27.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.78
|
| Rate for Payer: Priority Health SBD |
$20.51
|
| Rate for Payer: UMR Bronson Commercial |
$14.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.41
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$23.45
|
|
|
Service Code
|
NDC 50383-775-04
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$21.10 |
| Rate for Payer: Aetna American Axle |
$15.24
|
| Rate for Payer: Aetna Commercial |
$19.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.24
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Cofinity Commercial |
$16.42
|
| Rate for Payer: Cofinity Commercial |
$20.17
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.76
|
| Rate for Payer: Healthscope Commercial |
$21.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$19.93
|
| Rate for Payer: PHP Commercial |
$19.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.42
|
| Rate for Payer: Priority Health SBD |
$14.77
|
| Rate for Payer: UMR Bronson Commercial |
$10.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.59
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 50383-363-17
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna American Axle |
$2.75
|
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.96
|
| Rate for Payer: Priority Health SBD |
$2.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.17
|
|
