|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$24.42
|
|
|
Service Code
|
NDC 76329301105
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| 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 Advantage |
$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 Commercial |
$20.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.32
|
| Rate for Payer: PHP Commercial |
$20.76
|
| 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
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$24.42
|
|
|
Service Code
|
NDC 76329301105
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.04 |
| Max. Negotiated Rate |
$21.98 |
| Rate for Payer: Aetna American Axle |
$15.87
|
| Rate for Payer: Aetna Commercial |
$20.76
|
| Rate for Payer: Aetna Medicare |
$12.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.87
|
| Rate for Payer: BCBS Complete |
$9.77
|
| Rate for Payer: Cash Price |
$19.54
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$19.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$18.32
|
| Rate for Payer: PHP Commercial |
$20.76
|
| Rate for Payer: Priority Health SBD |
$15.38
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$15.87
|
| Rate for Payer: UHC Core |
$12.72
|
| Rate for Payer: UHC Exchange |
$9.60
|
| Rate for Payer: UMR Bronson Commercial |
$9.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$18.32
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$39.55
|
|
|
Service Code
|
NDC 76329301505
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$17.40 |
| Max. Negotiated Rate |
$35.59 |
| Rate for Payer: Aetna American Axle |
$25.71
|
| Rate for Payer: Aetna Commercial |
$33.62
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.71
|
| Rate for Payer: Cash Price |
$31.64
|
| Rate for Payer: Cofinity Advantage |
$27.68
|
| Rate for Payer: Cofinity Commercial |
$34.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.64
|
| Rate for Payer: Healthscope Commercial |
$35.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.66
|
| Rate for Payer: PHP Commercial |
$33.62
|
| Rate for Payer: Priority Health SBD |
$24.92
|
| Rate for Payer: UMR Bronson Commercial |
$17.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.66
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$15.21
|
|
|
Service Code
|
NDC 25021067376
|
| 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 Advantage |
$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 Commercial |
$12.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.41
|
| Rate for Payer: PHP Commercial |
$12.93
|
| 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 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$39.55
|
|
|
Service Code
|
NDC 76329301505
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.63 |
| Max. Negotiated Rate |
$35.59 |
| Rate for Payer: Aetna American Axle |
$25.71
|
| Rate for Payer: Aetna Commercial |
$33.62
|
| Rate for Payer: Aetna Medicare |
$19.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$25.71
|
| Rate for Payer: BCBS Complete |
$15.82
|
| Rate for Payer: Cash Price |
$31.64
|
| Rate for Payer: Cofinity Advantage |
$27.68
|
| Rate for Payer: Cofinity Commercial |
$34.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$31.64
|
| Rate for Payer: Healthscope Commercial |
$35.59
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$27.68
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$29.66
|
| Rate for Payer: MI Amish Medical Board Commercial |
$31.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$33.62
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$29.66
|
| Rate for Payer: PHP Commercial |
$33.62
|
| Rate for Payer: Priority Health SBD |
$24.92
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$25.71
|
| Rate for Payer: UHC Core |
$20.61
|
| Rate for Payer: UHC Exchange |
$15.54
|
| Rate for Payer: UMR Bronson Commercial |
$14.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$29.66
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$27.93
|
|
|
Service Code
|
NDC 76329301305
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.33 |
| Max. Negotiated Rate |
$25.14 |
| Rate for Payer: Aetna American Axle |
$18.15
|
| Rate for Payer: Aetna Commercial |
$23.74
|
| Rate for Payer: Aetna Medicare |
$13.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.15
|
| Rate for Payer: BCBS Complete |
$11.17
|
| Rate for Payer: Cash Price |
$22.34
|
| Rate for Payer: Cofinity Advantage |
$19.55
|
| Rate for Payer: Cofinity Commercial |
$24.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.34
|
| Rate for Payer: Healthscope Commercial |
$25.14
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.55
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$22.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.74
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.95
|
| Rate for Payer: PHP Commercial |
$23.74
|
| Rate for Payer: Priority Health SBD |
$17.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$18.15
|
| Rate for Payer: UHC Core |
$14.55
|
| Rate for Payer: UHC Exchange |
$10.98
|
| Rate for Payer: UMR Bronson Commercial |
$10.33
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.95
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
OP
|
$29.93
|
|
|
Service Code
|
NDC 71266629001
|
| Hospital Charge Code |
196007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$26.94 |
| Rate for Payer: Aetna American Axle |
$19.45
|
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna Medicare |
$14.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.45
|
| Rate for Payer: BCBS Complete |
$11.97
|
| Rate for Payer: Cash Price |
$23.94
|
| Rate for Payer: Cofinity Advantage |
$20.95
|
| Rate for Payer: Cofinity Commercial |
$25.74
|
| 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: MI Amish Medical Board Commercial |
$23.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.45
|
| Rate for Payer: PHP Commercial |
$25.44
|
| Rate for Payer: Priority Health SBD |
$18.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.45
|
| Rate for Payer: UHC Core |
$15.59
|
| Rate for Payer: UHC Exchange |
$11.76
|
| Rate for Payer: UMR Bronson Commercial |
$11.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.45
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
IP
|
$29.93
|
|
|
Service Code
|
NDC 71266629001
|
| 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 Advantage |
$20.95
|
| Rate for Payer: Cofinity Commercial |
$25.74
|
| 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 Commercial |
$25.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.45
|
| Rate for Payer: PHP Commercial |
$25.44
|
| 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
|
$26.01
|
|
|
Service Code
|
NDC 70000055701
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.44 |
| Max. Negotiated Rate |
$23.41 |
| Rate for Payer: Aetna American Axle |
$16.91
|
| Rate for Payer: Aetna Commercial |
$22.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.91
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cofinity Advantage |
$18.21
|
| Rate for Payer: Cofinity Commercial |
$22.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.81
|
| Rate for Payer: Healthscope Commercial |
$23.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.51
|
| Rate for Payer: PHP Commercial |
$22.11
|
| Rate for Payer: Priority Health SBD |
$16.39
|
| Rate for Payer: UMR Bronson Commercial |
$11.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.51
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$48.73
|
|
|
Service Code
|
NDC 45611000938
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.03 |
| Max. Negotiated Rate |
$43.86 |
| Rate for Payer: Aetna American Axle |
$31.67
|
| Rate for Payer: Aetna Commercial |
$41.42
|
| Rate for Payer: Aetna Medicare |
$24.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$31.67
|
| Rate for Payer: BCBS Complete |
$19.49
|
| Rate for Payer: Cash Price |
$38.98
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$38.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$41.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36.55
|
| Rate for Payer: PHP Commercial |
$41.42
|
| Rate for Payer: Priority Health SBD |
$30.70
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$31.67
|
| Rate for Payer: UHC Core |
$25.39
|
| Rate for Payer: UHC Exchange |
$19.15
|
| Rate for Payer: UMR Bronson Commercial |
$18.03
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$36.55
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$37.56
|
|
|
Service Code
|
NDC 45611000936
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.90 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Aetna American Axle |
$24.41
|
| Rate for Payer: Aetna Commercial |
$31.93
|
| Rate for Payer: Aetna Medicare |
$18.78
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.41
|
| Rate for Payer: BCBS Complete |
$15.02
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$30.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.17
|
| Rate for Payer: PHP Commercial |
$31.93
|
| Rate for Payer: Priority Health SBD |
$23.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$24.41
|
| Rate for Payer: UHC Core |
$19.57
|
| Rate for Payer: UHC Exchange |
$14.76
|
| Rate for Payer: UMR Bronson Commercial |
$13.90
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.17
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$26.01
|
|
|
Service Code
|
NDC 70000055701
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.62 |
| Max. Negotiated Rate |
$23.41 |
| Rate for Payer: Aetna American Axle |
$16.91
|
| Rate for Payer: Aetna Commercial |
$22.11
|
| Rate for Payer: Aetna Medicare |
$13.01
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.91
|
| Rate for Payer: BCBS Complete |
$10.40
|
| Rate for Payer: Cash Price |
$20.81
|
| Rate for Payer: Cofinity Advantage |
$18.21
|
| Rate for Payer: Cofinity Commercial |
$22.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.81
|
| Rate for Payer: Healthscope Commercial |
$23.41
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.21
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.51
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.81
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.11
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.51
|
| Rate for Payer: PHP Commercial |
$22.11
|
| Rate for Payer: Priority Health SBD |
$16.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.91
|
| Rate for Payer: UHC Core |
$13.55
|
| Rate for Payer: UHC Exchange |
$10.22
|
| Rate for Payer: UMR Bronson Commercial |
$9.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.51
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$48.73
|
|
|
Service Code
|
NDC 45611000938
|
| 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 Advantage |
$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 Commercial |
$41.42
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$36.55
|
| Rate for Payer: PHP Commercial |
$41.42
|
| 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 % TOPICAL PATCH
|
Facility
|
OP
|
$45.36
|
|
|
Service Code
|
NDC 41167005840
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.78 |
| Max. Negotiated Rate |
$40.82 |
| Rate for Payer: Aetna American Axle |
$29.48
|
| Rate for Payer: Aetna Commercial |
$38.56
|
| Rate for Payer: Aetna Medicare |
$22.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.48
|
| Rate for Payer: BCBS Complete |
$18.14
|
| Rate for Payer: Cash Price |
$36.29
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$36.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.02
|
| Rate for Payer: PHP Commercial |
$38.56
|
| Rate for Payer: Priority Health SBD |
$28.58
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.48
|
| Rate for Payer: UHC Core |
$23.63
|
| Rate for Payer: UHC Exchange |
$17.83
|
| Rate for Payer: UMR Bronson Commercial |
$16.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.02
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
NDC 96295013458
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.24 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna American Axle |
$12.17
|
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Advantage |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.04
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.04
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health SBD |
$11.79
|
| Rate for Payer: UMR Bronson Commercial |
$8.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.04
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$32.46
|
|
|
Service Code
|
NDC 46581083006
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$29.21 |
| Rate for Payer: Aetna American Axle |
$21.10
|
| Rate for Payer: Aetna Commercial |
$27.59
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.10
|
| Rate for Payer: Cash Price |
$25.97
|
| Rate for Payer: Cofinity Advantage |
$22.72
|
| Rate for Payer: Cofinity Commercial |
$27.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.97
|
| Rate for Payer: Healthscope Commercial |
$29.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.34
|
| Rate for Payer: PHP Commercial |
$27.59
|
| Rate for Payer: Priority Health SBD |
$20.45
|
| Rate for Payer: UMR Bronson Commercial |
$14.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.34
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$30.44
|
|
|
Service Code
|
NDC 00536120215
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Aetna American Axle |
$19.79
|
| Rate for Payer: Aetna Commercial |
$25.87
|
| Rate for Payer: Aetna Medicare |
$15.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.79
|
| Rate for Payer: BCBS Complete |
$12.18
|
| Rate for Payer: Cash Price |
$24.35
|
| Rate for Payer: Cofinity Advantage |
$21.31
|
| Rate for Payer: Cofinity Commercial |
$26.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.35
|
| Rate for Payer: Healthscope Commercial |
$27.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.83
|
| Rate for Payer: PHP Commercial |
$25.87
|
| Rate for Payer: Priority Health SBD |
$19.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$19.79
|
| Rate for Payer: UHC Core |
$15.86
|
| Rate for Payer: UHC Exchange |
$11.96
|
| Rate for Payer: UMR Bronson Commercial |
$11.26
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.83
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$18.72
|
|
|
Service Code
|
NDC 96295013458
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.93 |
| Max. Negotiated Rate |
$16.85 |
| Rate for Payer: Aetna American Axle |
$12.17
|
| Rate for Payer: Aetna Commercial |
$15.91
|
| Rate for Payer: Aetna Medicare |
$9.36
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.17
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Advantage |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$16.85
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.04
|
| Rate for Payer: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health SBD |
$11.79
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$12.17
|
| Rate for Payer: UHC Core |
$9.75
|
| Rate for Payer: UHC Exchange |
$7.36
|
| Rate for Payer: UMR Bronson Commercial |
$6.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.04
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$45.36
|
|
|
Service Code
|
NDC 41167005840
|
| 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 Advantage |
$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 Commercial |
$38.56
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.02
|
| Rate for Payer: PHP Commercial |
$38.56
|
| 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
|
$37.56
|
|
|
Service Code
|
NDC 45611000936
|
| 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 Advantage |
$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 Commercial |
$31.93
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$28.17
|
| Rate for Payer: PHP Commercial |
$31.93
|
| 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
|
OP
|
$32.46
|
|
|
Service Code
|
NDC 46581083006
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$29.21 |
| Rate for Payer: Aetna American Axle |
$21.10
|
| Rate for Payer: Aetna Commercial |
$27.59
|
| Rate for Payer: Aetna Medicare |
$16.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.10
|
| Rate for Payer: BCBS Complete |
$12.98
|
| Rate for Payer: Cash Price |
$25.97
|
| Rate for Payer: Cofinity Advantage |
$22.72
|
| Rate for Payer: Cofinity Commercial |
$27.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$25.97
|
| Rate for Payer: Healthscope Commercial |
$29.21
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.72
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$25.97
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.59
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.34
|
| Rate for Payer: PHP Commercial |
$27.59
|
| Rate for Payer: Priority Health SBD |
$20.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.10
|
| Rate for Payer: UHC Core |
$16.91
|
| Rate for Payer: UHC Exchange |
$12.76
|
| Rate for Payer: UMR Bronson Commercial |
$12.01
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.34
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$30.44
|
|
|
Service Code
|
NDC 00536120215
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.39 |
| Max. Negotiated Rate |
$27.40 |
| Rate for Payer: Aetna American Axle |
$19.79
|
| Rate for Payer: Aetna Commercial |
$25.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.79
|
| Rate for Payer: Cash Price |
$24.35
|
| Rate for Payer: Cofinity Advantage |
$21.31
|
| Rate for Payer: Cofinity Commercial |
$26.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.35
|
| Rate for Payer: Healthscope Commercial |
$27.40
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.31
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.83
|
| Rate for Payer: PHP Commercial |
$25.87
|
| Rate for Payer: Priority Health SBD |
$19.18
|
| Rate for Payer: UMR Bronson Commercial |
$13.39
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.83
|
|
|
LIDOCAINE 4 % WITH EPINEPHRINE TOPICAL SOLUTION
|
Facility
|
IP
|
$599.82
|
|
|
Service Code
|
NDC 09900000211
|
| 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 Advantage |
$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 |
$449.87
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$509.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$449.87
|
| Rate for Payer: PHP Commercial |
$509.85
|
| 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 |
$449.87
|
|
|
LIDOCAINE 4 % WITH EPINEPHRINE TOPICAL SOLUTION
|
Facility
|
OP
|
$599.82
|
|
|
Service Code
|
NDC 09900000211
|
| Hospital Charge Code |
155018
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$221.93 |
| Max. Negotiated Rate |
$539.84 |
| Rate for Payer: Aetna American Axle |
$389.88
|
| Rate for Payer: Aetna Commercial |
$509.85
|
| Rate for Payer: Aetna Medicare |
$299.91
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$389.88
|
| Rate for Payer: BCBS Complete |
$239.93
|
| Rate for Payer: Cash Price |
$479.86
|
| Rate for Payer: Cofinity Advantage |
$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 |
$449.87
|
| Rate for Payer: MI Amish Medical Board Commercial |
$479.86
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$509.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$449.87
|
| Rate for Payer: PHP Commercial |
$509.85
|
| Rate for Payer: Priority Health SBD |
$377.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$389.88
|
| Rate for Payer: UHC Core |
$312.51
|
| Rate for Payer: UHC Exchange |
$235.73
|
| Rate for Payer: UMR Bronson Commercial |
$221.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$449.87
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
OP
|
$97.65
|
|
|
Service Code
|
NDC 51672302002
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.13 |
| Max. Negotiated Rate |
$87.89 |
| Rate for Payer: Aetna American Axle |
$63.47
|
| Rate for Payer: Aetna Commercial |
$83.00
|
| Rate for Payer: Aetna Medicare |
$48.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$63.47
|
| Rate for Payer: BCBS Complete |
$39.06
|
| Rate for Payer: Cash Price |
$78.12
|
| Rate for Payer: Cofinity Advantage |
$68.36
|
| Rate for Payer: Cofinity Commercial |
$83.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$78.12
|
| Rate for Payer: Healthscope Commercial |
$87.89
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$68.36
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$73.24
|
| Rate for Payer: MI Amish Medical Board Commercial |
$78.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$83.00
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$73.24
|
| Rate for Payer: PHP Commercial |
$83.00
|
| Rate for Payer: Priority Health SBD |
$61.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$63.47
|
| Rate for Payer: UHC Core |
$50.88
|
| Rate for Payer: UHC Exchange |
$38.38
|
| Rate for Payer: UMR Bronson Commercial |
$36.13
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$73.24
|
|
