|
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
|
$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
|
$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 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$71.40
|
|
|
Service Code
|
NDC 52565-009-50
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.42 |
| Max. Negotiated Rate |
$64.26 |
| Rate for Payer: Aetna American Axle |
$46.41
|
| Rate for Payer: Aetna Commercial |
$60.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$46.41
|
| Rate for Payer: Cash Price |
$57.12
|
| Rate for Payer: Cofinity Commercial |
$49.98
|
| Rate for Payer: Cofinity Commercial |
$61.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.12
|
| Rate for Payer: Healthscope Commercial |
$64.26
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.98
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$53.55
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$60.69
|
| Rate for Payer: PHP Commercial |
$60.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$49.98
|
| Rate for Payer: Priority Health SBD |
$44.98
|
| Rate for Payer: UMR Bronson Commercial |
$31.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$53.55
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$104.13
|
|
|
Service Code
|
NDC 60432-465-50
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.82 |
| Max. Negotiated Rate |
$93.72 |
| Rate for Payer: Aetna American Axle |
$67.68
|
| Rate for Payer: Aetna Commercial |
$88.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.68
|
| Rate for Payer: Cash Price |
$83.30
|
| Rate for Payer: Cofinity Commercial |
$72.89
|
| Rate for Payer: Cofinity Commercial |
$89.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.30
|
| Rate for Payer: Healthscope Commercial |
$93.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$78.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$88.51
|
| Rate for Payer: PHP Commercial |
$88.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.89
|
| Rate for Payer: Priority Health SBD |
$65.60
|
| Rate for Payer: UMR Bronson Commercial |
$45.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.10
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$16.86
|
|
|
Service Code
|
NDC 9900-0006-54
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.42 |
| Max. Negotiated Rate |
$15.17 |
| Rate for Payer: Aetna American Axle |
$10.96
|
| Rate for Payer: Aetna Commercial |
$14.33
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.96
|
| Rate for Payer: Cash Price |
$13.49
|
| Rate for Payer: Cofinity Commercial |
$11.80
|
| Rate for Payer: Cofinity Commercial |
$14.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.49
|
| Rate for Payer: Healthscope Commercial |
$15.17
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$14.33
|
| Rate for Payer: PHP Commercial |
$14.33
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.80
|
| Rate for Payer: Priority Health SBD |
$10.62
|
| Rate for Payer: UMR Bronson Commercial |
$7.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.64
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$91.18
|
|
|
Service Code
|
NDC 0527-6004-80
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$40.12 |
| Max. Negotiated Rate |
$82.06 |
| Rate for Payer: Aetna American Axle |
$59.27
|
| Rate for Payer: Aetna Commercial |
$77.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$59.27
|
| Rate for Payer: Cash Price |
$72.94
|
| Rate for Payer: Cofinity Commercial |
$63.83
|
| Rate for Payer: Cofinity Commercial |
$78.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.94
|
| Rate for Payer: Healthscope Commercial |
$82.06
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$63.83
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$68.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$77.50
|
| Rate for Payer: PHP Commercial |
$77.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$63.83
|
| Rate for Payer: Priority Health SBD |
$57.44
|
| Rate for Payer: UMR Bronson Commercial |
$40.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$68.38
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
NDC 0054-3505-47
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.52 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna American Axle |
$86.45
|
| Rate for Payer: Aetna Commercial |
$113.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.45
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cofinity Commercial |
$114.38
|
| Rate for Payer: Cofinity Commercial |
$93.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.40
|
| Rate for Payer: Healthscope Commercial |
$119.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$113.05
|
| Rate for Payer: PHP Commercial |
$113.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$93.10
|
| Rate for Payer: Priority Health SBD |
$83.79
|
| Rate for Payer: UMR Bronson Commercial |
$58.52
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.75
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$104.13
|
|
|
Service Code
|
NDC 60432-465-51
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$45.82 |
| Max. Negotiated Rate |
$93.72 |
| Rate for Payer: Aetna American Axle |
$67.68
|
| Rate for Payer: Aetna Commercial |
$88.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.68
|
| Rate for Payer: Cash Price |
$83.30
|
| Rate for Payer: Cofinity Commercial |
$72.89
|
| Rate for Payer: Cofinity Commercial |
$89.55
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$83.30
|
| Rate for Payer: Healthscope Commercial |
$93.72
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$72.89
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$78.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$88.51
|
| Rate for Payer: PHP Commercial |
$88.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$72.89
|
| Rate for Payer: Priority Health SBD |
$65.60
|
| Rate for Payer: UMR Bronson Commercial |
$45.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.10
|
|
|
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION
|
Facility
|
IP
|
$94.56
|
|
|
Service Code
|
NDC 76329-6300-5
|
| Hospital Charge Code |
43717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$41.61 |
| Max. Negotiated Rate |
$85.10 |
| Rate for Payer: Aetna American Axle |
$61.46
|
| Rate for Payer: Aetna Commercial |
$80.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$61.46
|
| Rate for Payer: Cash Price |
$75.65
|
| Rate for Payer: Cofinity Commercial |
$66.19
|
| Rate for Payer: Cofinity Commercial |
$81.32
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$75.65
|
| Rate for Payer: Healthscope Commercial |
$85.10
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$66.19
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$70.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$80.38
|
| Rate for Payer: PHP Commercial |
$80.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$66.19
|
| Rate for Payer: Priority Health SBD |
$59.57
|
| Rate for Payer: UMR Bronson Commercial |
$41.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$70.92
|
|
|
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION
|
Facility
|
IP
|
$3.68
|
|
|
Service Code
|
NDC 9900-0009-15
|
| Hospital Charge Code |
43717
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.62 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Aetna American Axle |
$2.39
|
| Rate for Payer: Aetna Commercial |
$3.13
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.39
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cofinity Commercial |
$2.58
|
| Rate for Payer: Cofinity Commercial |
$3.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.94
|
| Rate for Payer: Healthscope Commercial |
$3.31
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$2.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$3.13
|
| Rate for Payer: PHP Commercial |
$3.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.58
|
| Rate for Payer: Priority Health SBD |
$2.32
|
| Rate for Payer: UMR Bronson Commercial |
$1.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.76
|
|
|
LIDOCAINE HCL (BULK) 100 % POWDER
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 51552-0106-9
|
| Hospital Charge Code |
118597
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.80 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: Aetna American Axle |
$29.25
|
| Rate for Payer: Aetna Commercial |
$38.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.25
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cofinity Commercial |
$31.50
|
| Rate for Payer: Cofinity Commercial |
$38.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.00
|
| Rate for Payer: Healthscope Commercial |
$40.50
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.50
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$38.25
|
| Rate for Payer: PHP Commercial |
$38.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.50
|
| Rate for Payer: Priority Health SBD |
$28.35
|
| Rate for Payer: UMR Bronson Commercial |
$19.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.75
|
|
|
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV (CODE)
|
Facility
|
IP
|
$22.20
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
163705
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.77 |
| Max. Negotiated Rate |
$19.98 |
| Rate for Payer: Aetna American Axle |
$14.43
|
| Rate for Payer: Aetna Commercial |
$18.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.43
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$19.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.76
|
| Rate for Payer: Healthscope Commercial |
$19.98
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$18.87
|
| Rate for Payer: PHP Commercial |
$18.87
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.54
|
| Rate for Payer: Priority Health SBD |
$13.99
|
| Rate for Payer: UMR Bronson Commercial |
$9.77
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.65
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$19.12
|
|
|
Service Code
|
NDC 0409-4903-34
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$17.21 |
| Rate for Payer: Aetna American Axle |
$12.43
|
| Rate for Payer: Aetna Commercial |
$16.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.43
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cofinity Commercial |
$13.38
|
| Rate for Payer: Cofinity Commercial |
$16.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.30
|
| Rate for Payer: Healthscope Commercial |
$17.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.25
|
| Rate for Payer: PHP Commercial |
$16.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.38
|
| Rate for Payer: Priority Health SBD |
$12.05
|
| Rate for Payer: UMR Bronson Commercial |
$8.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.34
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$19.99
|
|
|
Service Code
|
NDC 0409-1323-05
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$17.99 |
| Rate for Payer: Aetna American Axle |
$12.99
|
| Rate for Payer: Aetna Commercial |
$16.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.99
|
| Rate for Payer: Cash Price |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$13.99
|
| Rate for Payer: Cofinity Commercial |
$17.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.99
|
| Rate for Payer: Healthscope Commercial |
$17.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.99
|
| Rate for Payer: PHP Commercial |
$16.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.99
|
| Rate for Payer: Priority Health SBD |
$12.59
|
| Rate for Payer: UMR Bronson Commercial |
$8.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.99
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$19.12
|
|
|
Service Code
|
NDC 0409-4903-11
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$17.21 |
| Rate for Payer: Aetna American Axle |
$12.43
|
| Rate for Payer: Aetna Commercial |
$16.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.43
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cofinity Commercial |
$13.38
|
| Rate for Payer: Cofinity Commercial |
$16.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.30
|
| Rate for Payer: Healthscope Commercial |
$17.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.25
|
| Rate for Payer: PHP Commercial |
$16.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.38
|
| Rate for Payer: Priority Health SBD |
$12.05
|
| Rate for Payer: UMR Bronson Commercial |
$8.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.34
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRINGE (CODE)
|
Facility
|
IP
|
$19.99
|
|
|
Service Code
|
NDC 0409-1323-05
|
| Hospital Charge Code |
163704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.80 |
| Max. Negotiated Rate |
$17.99 |
| Rate for Payer: Aetna American Axle |
$12.99
|
| Rate for Payer: Aetna Commercial |
$16.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.99
|
| Rate for Payer: Cash Price |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$13.99
|
| Rate for Payer: Cofinity Commercial |
$17.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.99
|
| Rate for Payer: Healthscope Commercial |
$17.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.99
|
| Rate for Payer: PHP Commercial |
$16.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.99
|
| Rate for Payer: Priority Health SBD |
$12.59
|
| Rate for Payer: UMR Bronson Commercial |
$8.80
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.99
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRINGE (CODE)
|
Facility
|
IP
|
$19.12
|
|
|
Service Code
|
NDC 0409-4903-34
|
| Hospital Charge Code |
163704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.41 |
| Max. Negotiated Rate |
$17.21 |
| Rate for Payer: Aetna American Axle |
$12.43
|
| Rate for Payer: Aetna Commercial |
$16.25
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.43
|
| Rate for Payer: Cash Price |
$15.30
|
| Rate for Payer: Cofinity Commercial |
$13.38
|
| Rate for Payer: Cofinity Commercial |
$16.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.30
|
| Rate for Payer: Healthscope Commercial |
$17.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.38
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$16.25
|
| Rate for Payer: PHP Commercial |
$16.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.38
|
| Rate for Payer: Priority Health SBD |
$12.05
|
| Rate for Payer: UMR Bronson Commercial |
$8.41
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.34
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
OP
|
$25.35
|
|
|
Service Code
|
NDC 63323-492-27
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.38 |
| Max. Negotiated Rate |
$22.82 |
| Rate for Payer: Aetna American Axle |
$16.48
|
| Rate for Payer: Aetna Commercial |
$21.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.48
|
| Rate for Payer: BCBS Complete |
$10.14
|
| Rate for Payer: Cash Price |
$20.28
|
| Rate for Payer: Cofinity Commercial |
$17.74
|
| Rate for Payer: Cofinity Commercial |
$21.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.28
|
| Rate for Payer: Healthscope Commercial |
$22.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.74
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.01
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.55
|
| Rate for Payer: PHP Commercial |
$21.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.74
|
| Rate for Payer: Priority Health SBD |
$15.97
|
| Rate for Payer: UMR Bronson Commercial |
$9.38
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.01
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$16.05
|
|
|
Service Code
|
NDC 0409-4713-32
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.06 |
| Max. Negotiated Rate |
$14.44 |
| Rate for Payer: Aetna American Axle |
$10.43
|
| Rate for Payer: Aetna Commercial |
$13.64
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.43
|
| Rate for Payer: Cash Price |
$12.84
|
| Rate for Payer: Cofinity Commercial |
$11.24
|
| Rate for Payer: Cofinity Commercial |
$13.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.84
|
| Rate for Payer: Healthscope Commercial |
$14.44
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$11.24
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$12.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$13.64
|
| Rate for Payer: PHP Commercial |
$13.64
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.24
|
| Rate for Payer: Priority Health SBD |
$10.11
|
| Rate for Payer: UMR Bronson Commercial |
$7.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.04
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$10.65
|
|
|
Service Code
|
NDC 70756-640-82
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna American Axle |
$6.92
|
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.92
|
| Rate for Payer: Cash Price |
$8.52
|
| Rate for Payer: Cofinity Commercial |
$7.46
|
| Rate for Payer: Cofinity Commercial |
$9.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.52
|
| Rate for Payer: Healthscope Commercial |
$9.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.05
|
| Rate for Payer: PHP Commercial |
$9.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.46
|
| Rate for Payer: Priority Health SBD |
$6.71
|
| Rate for Payer: UMR Bronson Commercial |
$4.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.99
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$10.65
|
|
|
Service Code
|
NDC 70756-640-25
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.69 |
| Max. Negotiated Rate |
$9.58 |
| Rate for Payer: Aetna American Axle |
$6.92
|
| Rate for Payer: Aetna Commercial |
$9.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.92
|
| Rate for Payer: Cash Price |
$8.52
|
| Rate for Payer: Cofinity Commercial |
$7.46
|
| Rate for Payer: Cofinity Commercial |
$9.16
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$8.52
|
| Rate for Payer: Healthscope Commercial |
$9.58
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$7.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$7.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$9.05
|
| Rate for Payer: PHP Commercial |
$9.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.46
|
| Rate for Payer: Priority Health SBD |
$6.71
|
| Rate for Payer: UMR Bronson Commercial |
$4.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$7.99
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$24.94
|
|
|
Service Code
|
NDC 0143-9595-25
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$10.97 |
| Max. Negotiated Rate |
$22.45 |
| Rate for Payer: Aetna American Axle |
$16.21
|
| Rate for Payer: Aetna Commercial |
$21.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.21
|
| Rate for Payer: Cash Price |
$19.95
|
| Rate for Payer: Cofinity Commercial |
$17.46
|
| Rate for Payer: Cofinity Commercial |
$21.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.95
|
| Rate for Payer: Healthscope Commercial |
$22.45
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$17.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$18.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$21.20
|
| Rate for Payer: PHP Commercial |
$21.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.46
|
| Rate for Payer: Priority Health SBD |
$15.71
|
| Rate for Payer: UMR Bronson Commercial |
$10.97
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.70
|
|
|
LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$22.62
|
|
|
Service Code
|
NDC 0409-4279-16
|
| Hospital Charge Code |
103888
|
|
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 (PF) 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$46.33
|
|
|
Service Code
|
NDC 63323-492-07
|
| Hospital Charge Code |
103888
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$20.39 |
| Max. Negotiated Rate |
$41.70 |
| Rate for Payer: Aetna American Axle |
$30.11
|
| Rate for Payer: Aetna Commercial |
$39.38
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$30.11
|
| Rate for Payer: Cash Price |
$37.06
|
| Rate for Payer: Cofinity Commercial |
$32.43
|
| Rate for Payer: Cofinity Commercial |
$39.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$37.06
|
| Rate for Payer: Healthscope Commercial |
$41.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$32.43
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$34.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS |
$39.38
|
| Rate for Payer: PHP Commercial |
$39.38
|
| Rate for Payer: Priority Health Cigna Priority Health |
$32.43
|
| Rate for Payer: Priority Health SBD |
$29.19
|
| Rate for Payer: UMR Bronson Commercial |
$20.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.75
|
|
