|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$33.95
|
|
|
Service Code
|
NDC 00121095003
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.56 |
| Max. Negotiated Rate |
$30.55 |
| Rate for Payer: Aetna American Axle |
$22.07
|
| Rate for Payer: Aetna Commercial |
$28.86
|
| Rate for Payer: Aetna Medicare |
$16.98
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.07
|
| Rate for Payer: BCBS Complete |
$13.58
|
| Rate for Payer: Cash Price |
$27.16
|
| Rate for Payer: Cofinity Advantage |
$23.77
|
| Rate for Payer: Cofinity Commercial |
$29.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.16
|
| Rate for Payer: Healthscope Commercial |
$30.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.46
|
| Rate for Payer: MI Amish Medical Board Commercial |
$27.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.46
|
| Rate for Payer: PHP Commercial |
$28.86
|
| Rate for Payer: Priority Health SBD |
$21.39
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$22.07
|
| Rate for Payer: UHC Core |
$17.69
|
| Rate for Payer: UHC Exchange |
$13.34
|
| Rate for Payer: UMR Bronson Commercial |
$12.56
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.46
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 50383036315
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.57 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna American Axle |
$2.75
|
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna Medicare |
$2.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: BCBS Complete |
$1.69
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$3.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.17
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health SBD |
$2.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.75
|
| Rate for Payer: UHC Core |
$2.20
|
| Rate for Payer: UHC Exchange |
$1.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.17
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$33.95
|
|
|
Service Code
|
NDC 00121095003
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.94 |
| Max. Negotiated Rate |
$30.55 |
| Rate for Payer: Aetna American Axle |
$22.07
|
| Rate for Payer: Aetna Commercial |
$28.86
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.07
|
| Rate for Payer: Cash Price |
$27.16
|
| Rate for Payer: Cofinity Advantage |
$23.77
|
| Rate for Payer: Cofinity Commercial |
$29.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.16
|
| Rate for Payer: Healthscope Commercial |
$30.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$23.77
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.86
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$25.46
|
| Rate for Payer: PHP Commercial |
$28.86
|
| Rate for Payer: Priority Health SBD |
$21.39
|
| Rate for Payer: UMR Bronson Commercial |
$14.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.46
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$25.90
|
|
|
Service Code
|
NDC 60432046400
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.58 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna American Axle |
$16.84
|
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna Medicare |
$12.95
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: BCBS Complete |
$10.36
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Advantage |
$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 |
$19.43
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.02
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.43
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health SBD |
$16.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$16.84
|
| Rate for Payer: UHC Core |
$13.49
|
| Rate for Payer: UHC Exchange |
$10.18
|
| Rate for Payer: UMR Bronson Commercial |
$9.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.43
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$35.70
|
|
|
Service Code
|
NDC 72888012526
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.71 |
| Max. Negotiated Rate |
$32.13 |
| Rate for Payer: Aetna American Axle |
$23.20
|
| Rate for Payer: Aetna Commercial |
$30.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.20
|
| Rate for Payer: Cash Price |
$28.56
|
| Rate for Payer: Cofinity Advantage |
$24.99
|
| Rate for Payer: Cofinity Commercial |
$30.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.56
|
| Rate for Payer: Healthscope Commercial |
$32.13
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.99
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$26.77
|
| Rate for Payer: PHP Commercial |
$30.34
|
| Rate for Payer: Priority Health SBD |
$22.49
|
| Rate for Payer: UMR Bronson Commercial |
$15.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.77
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$104.13
|
|
|
Service Code
|
NDC 60432046550
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.53 |
| Max. Negotiated Rate |
$93.72 |
| Rate for Payer: Aetna American Axle |
$67.68
|
| Rate for Payer: Aetna Commercial |
$88.51
|
| Rate for Payer: Aetna Medicare |
$52.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.68
|
| Rate for Payer: BCBS Complete |
$41.65
|
| Rate for Payer: Cash Price |
$83.30
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$83.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$78.10
|
| Rate for Payer: PHP Commercial |
$88.51
|
| Rate for Payer: Priority Health SBD |
$65.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.68
|
| Rate for Payer: UHC Core |
$54.25
|
| Rate for Payer: UHC Exchange |
$40.92
|
| Rate for Payer: UMR Bronson Commercial |
$38.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.10
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$104.13
|
|
|
Service Code
|
NDC 60432046551
|
| 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 Advantage |
$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 Commercial |
$88.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$78.10
|
| Rate for Payer: PHP Commercial |
$88.51
|
| 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 09900000654
|
| 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 Advantage |
$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 Commercial |
$14.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.64
|
| Rate for Payer: PHP Commercial |
$14.33
|
| 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
|
OP
|
$130.20
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$48.17 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna American Axle |
$84.63
|
| Rate for Payer: Aetna Commercial |
$110.67
|
| Rate for Payer: Aetna Medicare |
$65.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.63
|
| Rate for Payer: BCBS Complete |
$52.08
|
| Rate for Payer: Cash Price |
$104.16
|
| Rate for Payer: Cofinity Advantage |
$91.14
|
| Rate for Payer: Cofinity Commercial |
$111.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.16
|
| Rate for Payer: Healthscope Commercial |
$117.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$91.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$104.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$97.65
|
| Rate for Payer: PHP Commercial |
$110.67
|
| Rate for Payer: Priority Health SBD |
$82.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$84.63
|
| Rate for Payer: UHC Core |
$67.83
|
| Rate for Payer: UHC Exchange |
$51.17
|
| Rate for Payer: UMR Bronson Commercial |
$48.17
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.65
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$76.83
|
|
|
Service Code
|
NDC 00527600480
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$33.81 |
| Max. Negotiated Rate |
$69.15 |
| Rate for Payer: Aetna American Axle |
$49.94
|
| Rate for Payer: Aetna Commercial |
$65.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$49.94
|
| Rate for Payer: Cash Price |
$61.46
|
| Rate for Payer: Cofinity Advantage |
$53.78
|
| Rate for Payer: Cofinity Commercial |
$66.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.46
|
| Rate for Payer: Healthscope Commercial |
$69.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$53.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$57.62
|
| Rate for Payer: PHP Commercial |
$65.31
|
| Rate for Payer: Priority Health SBD |
$48.40
|
| Rate for Payer: UMR Bronson Commercial |
$33.81
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.62
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$76.83
|
|
|
Service Code
|
NDC 00527600480
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.43 |
| Max. Negotiated Rate |
$69.15 |
| Rate for Payer: Aetna American Axle |
$49.94
|
| Rate for Payer: Aetna Commercial |
$65.31
|
| Rate for Payer: Aetna Medicare |
$38.41
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$49.94
|
| Rate for Payer: BCBS Complete |
$30.73
|
| Rate for Payer: Cash Price |
$61.46
|
| Rate for Payer: Cofinity Advantage |
$53.78
|
| Rate for Payer: Cofinity Commercial |
$66.07
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$61.46
|
| Rate for Payer: Healthscope Commercial |
$69.15
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$53.78
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$57.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$61.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$65.31
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$57.62
|
| Rate for Payer: PHP Commercial |
$65.31
|
| Rate for Payer: Priority Health SBD |
$48.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$49.94
|
| Rate for Payer: UHC Core |
$40.03
|
| Rate for Payer: UHC Exchange |
$30.19
|
| Rate for Payer: UMR Bronson Commercial |
$28.43
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$57.62
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$104.13
|
|
|
Service Code
|
NDC 60432046551
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$38.53 |
| Max. Negotiated Rate |
$93.72 |
| Rate for Payer: Aetna American Axle |
$67.68
|
| Rate for Payer: Aetna Commercial |
$88.51
|
| Rate for Payer: Aetna Medicare |
$52.06
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$67.68
|
| Rate for Payer: BCBS Complete |
$41.65
|
| Rate for Payer: Cash Price |
$83.30
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$83.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$88.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$78.10
|
| Rate for Payer: PHP Commercial |
$88.51
|
| Rate for Payer: Priority Health SBD |
$65.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$67.68
|
| Rate for Payer: UHC Core |
$54.25
|
| Rate for Payer: UHC Exchange |
$40.92
|
| Rate for Payer: UMR Bronson Commercial |
$38.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.10
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$16.86
|
|
|
Service Code
|
NDC 09900000654
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.24 |
| Max. Negotiated Rate |
$15.17 |
| Rate for Payer: Aetna American Axle |
$10.96
|
| Rate for Payer: Aetna Commercial |
$14.33
|
| Rate for Payer: Aetna Medicare |
$8.43
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.96
|
| Rate for Payer: BCBS Complete |
$6.74
|
| Rate for Payer: Cash Price |
$13.49
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$13.49
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.33
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$12.64
|
| Rate for Payer: PHP Commercial |
$14.33
|
| Rate for Payer: Priority Health SBD |
$10.62
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$10.96
|
| Rate for Payer: UHC Core |
$8.78
|
| Rate for Payer: UHC Exchange |
$6.63
|
| Rate for Payer: UMR Bronson Commercial |
$6.24
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$12.64
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$104.13
|
|
|
Service Code
|
NDC 60432046550
|
| 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 Advantage |
$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 Commercial |
$88.51
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$78.10
|
| Rate for Payer: PHP Commercial |
$88.51
|
| 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
|
$130.20
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$57.29 |
| Max. Negotiated Rate |
$117.18 |
| Rate for Payer: Aetna American Axle |
$84.63
|
| Rate for Payer: Aetna Commercial |
$110.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$84.63
|
| Rate for Payer: Cash Price |
$104.16
|
| Rate for Payer: Cofinity Advantage |
$91.14
|
| Rate for Payer: Cofinity Commercial |
$111.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$104.16
|
| Rate for Payer: Healthscope Commercial |
$117.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$91.14
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$97.65
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$110.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$97.65
|
| Rate for Payer: PHP Commercial |
$110.67
|
| Rate for Payer: Priority Health SBD |
$82.03
|
| Rate for Payer: UMR Bronson Commercial |
$57.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$97.65
|
|
|
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION
|
Facility
|
OP
|
$125.11
|
|
|
Service Code
|
NDC 76329630005
|
| Hospital Charge Code |
43717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$46.29 |
| Max. Negotiated Rate |
$112.60 |
| Rate for Payer: Aetna American Axle |
$81.32
|
| Rate for Payer: Aetna Commercial |
$106.34
|
| Rate for Payer: Aetna Medicare |
$62.55
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.32
|
| Rate for Payer: BCBS Complete |
$50.04
|
| Rate for Payer: Cash Price |
$100.09
|
| Rate for Payer: Cofinity Advantage |
$87.58
|
| Rate for Payer: Cofinity Commercial |
$107.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.09
|
| Rate for Payer: Healthscope Commercial |
$112.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.83
|
| Rate for Payer: MI Amish Medical Board Commercial |
$100.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$106.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$93.83
|
| Rate for Payer: PHP Commercial |
$106.34
|
| Rate for Payer: Priority Health SBD |
$78.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$81.32
|
| Rate for Payer: UHC Core |
$65.18
|
| Rate for Payer: UHC Exchange |
$49.17
|
| Rate for Payer: UMR Bronson Commercial |
$46.29
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.83
|
|
|
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION
|
Facility
|
IP
|
$3.68
|
|
|
Service Code
|
NDC 09900000915
|
| Hospital Charge Code |
43717
|
|
Hospital Revenue Code
|
250
|
| 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 Advantage |
$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 Commercial |
$3.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.76
|
| Rate for Payer: PHP Commercial |
$3.13
|
| 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 4 % LARYNGOTRACHEAL SOLUTION
|
Facility
|
OP
|
$3.68
|
|
|
Service Code
|
NDC 09900000915
|
| Hospital Charge Code |
43717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.36 |
| Max. Negotiated Rate |
$3.31 |
| Rate for Payer: Aetna American Axle |
$2.39
|
| Rate for Payer: Aetna Commercial |
$3.13
|
| Rate for Payer: Aetna Medicare |
$1.84
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.39
|
| Rate for Payer: BCBS Complete |
$1.47
|
| Rate for Payer: Cash Price |
$2.94
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$2.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.13
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.76
|
| Rate for Payer: PHP Commercial |
$3.13
|
| Rate for Payer: Priority Health SBD |
$2.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$2.39
|
| Rate for Payer: UHC Core |
$1.92
|
| Rate for Payer: UHC Exchange |
$1.45
|
| Rate for Payer: UMR Bronson Commercial |
$1.36
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$2.76
|
|
|
LIDOCAINE HCL 4 % LARYNGOTRACHEAL SOLUTION
|
Facility
|
IP
|
$125.11
|
|
|
Service Code
|
NDC 76329630005
|
| Hospital Charge Code |
43717
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$55.05 |
| Max. Negotiated Rate |
$112.60 |
| Rate for Payer: Aetna American Axle |
$81.32
|
| Rate for Payer: Aetna Commercial |
$106.34
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$81.32
|
| Rate for Payer: Cash Price |
$100.09
|
| Rate for Payer: Cofinity Advantage |
$87.58
|
| Rate for Payer: Cofinity Commercial |
$107.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$100.09
|
| Rate for Payer: Healthscope Commercial |
$112.60
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$87.58
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$93.83
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$106.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$93.83
|
| Rate for Payer: PHP Commercial |
$106.34
|
| Rate for Payer: Priority Health SBD |
$78.82
|
| Rate for Payer: UMR Bronson Commercial |
$55.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$93.83
|
|
|
LIDOCAINE HCL (BULK) 100 % POWDER
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
NDC 51552010609
|
| 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 Advantage |
$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 Commercial |
$38.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.75
|
| Rate for Payer: PHP Commercial |
$38.25
|
| 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 HCL (BULK) 100 % POWDER
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
NDC 51552010609
|
| Hospital Charge Code |
118597
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.65 |
| Max. Negotiated Rate |
$40.50 |
| Rate for Payer: Aetna American Axle |
$29.25
|
| Rate for Payer: Aetna Commercial |
$38.25
|
| Rate for Payer: Aetna Medicare |
$22.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.25
|
| Rate for Payer: BCBS Complete |
$18.00
|
| Rate for Payer: Cash Price |
$36.00
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$36.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.25
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.75
|
| Rate for Payer: PHP Commercial |
$38.25
|
| Rate for Payer: Priority Health SBD |
$28.35
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$29.25
|
| Rate for Payer: UHC Core |
$23.45
|
| Rate for Payer: UHC Exchange |
$17.68
|
| Rate for Payer: UMR Bronson Commercial |
$16.65
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.75
|
|
|
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV (CODE)
|
Facility
|
OP
|
$22.20
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
163705
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.21 |
| Max. Negotiated Rate |
$19.98 |
| Rate for Payer: Aetna American Axle |
$14.43
|
| Rate for Payer: Aetna Commercial |
$18.87
|
| Rate for Payer: Aetna Medicare |
$11.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.43
|
| Rate for Payer: BCBS Complete |
$8.88
|
| Rate for Payer: Cash Price |
$17.76
|
| Rate for Payer: Cofinity Advantage |
$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: MI Amish Medical Board Commercial |
$17.76
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.65
|
| Rate for Payer: PHP Commercial |
$18.87
|
| Rate for Payer: Priority Health SBD |
$13.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$11.10
|
| Rate for Payer: UHC Core |
$11.10
|
| Rate for Payer: UHC Exchange |
$11.10
|
| Rate for Payer: UMR Bronson Commercial |
$8.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.65
|
|
|
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 Advantage |
$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 Commercial |
$18.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$16.65
|
| Rate for Payer: PHP Commercial |
$18.87
|
| 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
|
$25.79
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$11.35 |
| Max. Negotiated Rate |
$23.21 |
| Rate for Payer: Aetna American Axle |
$16.76
|
| Rate for Payer: Aetna American Axle |
$17.49
|
| Rate for Payer: Aetna Commercial |
$21.92
|
| Rate for Payer: Aetna Commercial |
$22.87
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.49
|
| Rate for Payer: Cash Price |
$20.63
|
| Rate for Payer: Cash Price |
$21.53
|
| Rate for Payer: Cofinity Advantage |
$18.84
|
| Rate for Payer: Cofinity Advantage |
$18.05
|
| Rate for Payer: Cofinity Commercial |
$23.14
|
| Rate for Payer: Cofinity Commercial |
$22.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.53
|
| Rate for Payer: Healthscope Commercial |
$23.21
|
| Rate for Payer: Healthscope Commercial |
$24.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.18
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.34
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.18
|
| Rate for Payer: PHP Commercial |
$21.92
|
| Rate for Payer: PHP Commercial |
$22.87
|
| Rate for Payer: Priority Health SBD |
$16.95
|
| Rate for Payer: Priority Health SBD |
$16.25
|
| Rate for Payer: UMR Bronson Commercial |
$11.35
|
| Rate for Payer: UMR Bronson Commercial |
$11.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.18
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$25.79
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$23.21 |
| Rate for Payer: Aetna American Axle |
$16.76
|
| Rate for Payer: Aetna American Axle |
$17.49
|
| Rate for Payer: Aetna Commercial |
$21.92
|
| Rate for Payer: Aetna Commercial |
$22.87
|
| Rate for Payer: Aetna Medicare |
$12.89
|
| Rate for Payer: Aetna Medicare |
$13.46
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.76
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.49
|
| Rate for Payer: BCBS Complete |
$10.76
|
| Rate for Payer: BCBS Complete |
$10.32
|
| Rate for Payer: BCBS Trust/PPO |
$0.10
|
| Rate for Payer: BCBS Trust/PPO |
$0.10
|
| Rate for Payer: BCN Commercial |
$0.10
|
| Rate for Payer: BCN Commercial |
$0.10
|
| Rate for Payer: Cash Price |
$20.63
|
| Rate for Payer: Cash Price |
$21.53
|
| Rate for Payer: Cash Price |
$20.63
|
| Rate for Payer: Cash Price |
$21.53
|
| Rate for Payer: Cofinity Advantage |
$18.05
|
| Rate for Payer: Cofinity Advantage |
$18.84
|
| Rate for Payer: Cofinity Commercial |
$22.18
|
| Rate for Payer: Cofinity Commercial |
$23.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$20.63
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.53
|
| Rate for Payer: Healthscope Commercial |
$23.21
|
| Rate for Payer: Healthscope Commercial |
$24.22
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$19.34
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.18
|
| Rate for Payer: MI Amish Medical Board Commercial |
$20.63
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.53
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.87
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$19.34
|
| Rate for Payer: PHP Commercial |
$21.92
|
| Rate for Payer: PHP Commercial |
$22.87
|
| Rate for Payer: Priority Health SBD |
$16.25
|
| Rate for Payer: Priority Health SBD |
$16.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.08
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$0.08
|
| Rate for Payer: UHC Core |
$0.08
|
| Rate for Payer: UHC Core |
$0.08
|
| Rate for Payer: UHC Exchange |
$0.08
|
| Rate for Payer: UHC Exchange |
$0.08
|
| Rate for Payer: UMR Bronson Commercial |
$9.54
|
| Rate for Payer: UMR Bronson Commercial |
$9.96
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.34
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.18
|
|
