|
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 Commercial |
$34.11
|
| Rate for Payer: Cofinity Commercial |
$41.91
|
| Rate for Payer: Cofinity Medicare Advantage |
$34.11
|
| 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: PHP Commercial |
$41.42
|
| Rate for Payer: Priority Health Cigna Priority Health |
$31.67
|
| Rate for Payer: Priority Health SBD |
$30.70
|
| 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
|
$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 Commercial |
$31.75
|
| Rate for Payer: Cofinity Commercial |
$39.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.75
|
| 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: PHP Commercial |
$38.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.48
|
| Rate for Payer: Priority Health SBD |
$28.58
|
| Rate for Payer: UMR Bronson Commercial |
$16.78
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$34.02
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$23.33
|
|
|
Service Code
|
NDC 70000055701
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.63 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna American Axle |
$15.16
|
| Rate for Payer: Aetna Commercial |
$19.83
|
| Rate for Payer: Aetna Medicare |
$11.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.16
|
| Rate for Payer: BCBS Complete |
$9.33
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: Cofinity Commercial |
$16.33
|
| Rate for Payer: Cofinity Commercial |
$20.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.66
|
| Rate for Payer: Healthscope Commercial |
$21.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.83
|
| Rate for Payer: PHP Commercial |
$19.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.16
|
| Rate for Payer: Priority Health SBD |
$14.70
|
| Rate for Payer: UMR Bronson Commercial |
$8.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.50
|
|
|
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 Commercial |
$31.75
|
| Rate for Payer: Cofinity Commercial |
$39.01
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.75
|
| 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: PHP Commercial |
$38.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.48
|
| 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
|
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 Commercial |
$26.29
|
| Rate for Payer: Cofinity Commercial |
$32.30
|
| Rate for Payer: Cofinity Medicare Advantage |
$26.29
|
| 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: PHP Commercial |
$31.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.41
|
| Rate for Payer: Priority Health SBD |
$23.66
|
| 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
|
$30.05
|
|
|
Service Code
|
NDC 00536120215
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$27.05 |
| Rate for Payer: Aetna American Axle |
$19.53
|
| Rate for Payer: Aetna Commercial |
$25.54
|
| Rate for Payer: Aetna Medicare |
$15.03
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.53
|
| Rate for Payer: BCBS Complete |
$12.02
|
| Rate for Payer: Cash Price |
$24.04
|
| Rate for Payer: Cofinity Commercial |
$21.04
|
| Rate for Payer: Cofinity Commercial |
$25.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.04
|
| Rate for Payer: Healthscope Commercial |
$27.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.54
|
| Rate for Payer: PHP Commercial |
$25.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.53
|
| Rate for Payer: Priority Health SBD |
$18.93
|
| Rate for Payer: UMR Bronson Commercial |
$11.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.54
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$30.05
|
|
|
Service Code
|
NDC 00536120215
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.22 |
| Max. Negotiated Rate |
$27.05 |
| Rate for Payer: Aetna American Axle |
$19.53
|
| Rate for Payer: Aetna Commercial |
$25.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.53
|
| Rate for Payer: Cash Price |
$24.04
|
| Rate for Payer: Cofinity Commercial |
$21.04
|
| Rate for Payer: Cofinity Commercial |
$25.84
|
| Rate for Payer: Cofinity Medicare Advantage |
$21.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.04
|
| Rate for Payer: Healthscope Commercial |
$27.05
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$21.04
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.54
|
| Rate for Payer: PHP Commercial |
$25.54
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.53
|
| Rate for Payer: Priority Health SBD |
$18.93
|
| Rate for Payer: UMR Bronson Commercial |
$13.22
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.54
|
|
|
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 Commercial |
$22.72
|
| Rate for Payer: Cofinity Commercial |
$27.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.72
|
| 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: PHP Commercial |
$27.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.10
|
| Rate for Payer: Priority Health SBD |
$20.45
|
| 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
|
$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 Commercial |
$22.72
|
| Rate for Payer: Cofinity Commercial |
$27.92
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.72
|
| 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: PHP Commercial |
$27.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.10
|
| 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
|
$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 Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| 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: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: Priority Health SBD |
$11.79
|
| 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
|
$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 Commercial |
$13.10
|
| Rate for Payer: Cofinity Commercial |
$16.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.10
|
| 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: PHP Commercial |
$15.91
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| 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
|
$23.33
|
|
|
Service Code
|
NDC 70000055701
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.27 |
| Max. Negotiated Rate |
$21.00 |
| Rate for Payer: Aetna American Axle |
$15.16
|
| Rate for Payer: Aetna Commercial |
$19.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.16
|
| Rate for Payer: Cash Price |
$18.66
|
| Rate for Payer: Cofinity Commercial |
$16.33
|
| Rate for Payer: Cofinity Commercial |
$20.06
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.66
|
| Rate for Payer: Healthscope Commercial |
$21.00
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.33
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.83
|
| Rate for Payer: PHP Commercial |
$19.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.16
|
| Rate for Payer: Priority Health SBD |
$14.70
|
| Rate for Payer: UMR Bronson Commercial |
$10.27
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.50
|
|
|
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 Commercial |
$419.87
|
| Rate for Payer: Cofinity Commercial |
$515.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$419.87
|
| 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: PHP Commercial |
$509.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$389.88
|
| 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 Commercial |
$419.87
|
| Rate for Payer: Cofinity Commercial |
$515.85
|
| Rate for Payer: Cofinity Medicare Advantage |
$419.87
|
| 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: PHP Commercial |
$509.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$389.88
|
| Rate for Payer: Priority Health SBD |
$377.89
|
| Rate for Payer: UMR Bronson Commercial |
$221.93
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$449.87
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
IP
|
$70.58
|
|
|
Service Code
|
NDC 69680012035
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$31.06 |
| Max. Negotiated Rate |
$63.52 |
| Rate for Payer: Aetna American Axle |
$45.88
|
| Rate for Payer: Aetna Commercial |
$59.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.88
|
| Rate for Payer: Cash Price |
$56.46
|
| Rate for Payer: Cofinity Commercial |
$49.41
|
| Rate for Payer: Cofinity Commercial |
$60.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.46
|
| Rate for Payer: Healthscope Commercial |
$63.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.99
|
| Rate for Payer: PHP Commercial |
$59.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.88
|
| Rate for Payer: Priority Health SBD |
$44.47
|
| Rate for Payer: UMR Bronson Commercial |
$31.06
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.94
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
IP
|
$28.29
|
|
|
Service Code
|
NDC 70752011303
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.45 |
| Max. Negotiated Rate |
$25.46 |
| Rate for Payer: Aetna American Axle |
$18.39
|
| Rate for Payer: Aetna Commercial |
$24.05
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.39
|
| Rate for Payer: Cash Price |
$22.63
|
| Rate for Payer: Cofinity Commercial |
$19.80
|
| Rate for Payer: Cofinity Commercial |
$24.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.63
|
| Rate for Payer: Healthscope Commercial |
$25.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.05
|
| Rate for Payer: PHP Commercial |
$24.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.39
|
| Rate for Payer: Priority Health SBD |
$17.82
|
| Rate for Payer: UMR Bronson Commercial |
$12.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.22
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
OP
|
$36.60
|
|
|
Service Code
|
NDC 65162091838
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.54 |
| Max. Negotiated Rate |
$32.94 |
| Rate for Payer: Aetna American Axle |
$23.79
|
| Rate for Payer: Aetna Commercial |
$31.11
|
| Rate for Payer: Aetna Medicare |
$18.30
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.79
|
| Rate for Payer: BCBS Complete |
$14.64
|
| Rate for Payer: Cash Price |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$25.62
|
| Rate for Payer: Cofinity Commercial |
$31.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$25.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.28
|
| Rate for Payer: Healthscope Commercial |
$32.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.11
|
| Rate for Payer: PHP Commercial |
$31.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.79
|
| Rate for Payer: Priority Health SBD |
$23.06
|
| Rate for Payer: UMR Bronson Commercial |
$13.54
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.45
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
OP
|
$28.29
|
|
|
Service Code
|
NDC 70752011303
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.47 |
| Max. Negotiated Rate |
$25.46 |
| Rate for Payer: Aetna American Axle |
$18.39
|
| Rate for Payer: Aetna Commercial |
$24.05
|
| Rate for Payer: Aetna Medicare |
$14.14
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$18.39
|
| Rate for Payer: BCBS Complete |
$11.32
|
| Rate for Payer: Cash Price |
$22.63
|
| Rate for Payer: Cofinity Commercial |
$19.80
|
| Rate for Payer: Cofinity Commercial |
$24.33
|
| Rate for Payer: Cofinity Medicare Advantage |
$19.80
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$22.63
|
| Rate for Payer: Healthscope Commercial |
$25.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$19.80
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$21.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$24.05
|
| Rate for Payer: PHP Commercial |
$24.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$18.39
|
| Rate for Payer: Priority Health SBD |
$17.82
|
| Rate for Payer: UMR Bronson Commercial |
$10.47
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$21.22
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
OP
|
$737.67
|
|
|
Service Code
|
NDC 00168020437
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$272.94 |
| Max. Negotiated Rate |
$663.90 |
| Rate for Payer: Aetna American Axle |
$479.49
|
| Rate for Payer: Aetna Commercial |
$627.02
|
| Rate for Payer: Aetna Medicare |
$368.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$479.49
|
| Rate for Payer: BCBS Complete |
$295.07
|
| Rate for Payer: Cash Price |
$590.14
|
| Rate for Payer: Cofinity Commercial |
$516.37
|
| Rate for Payer: Cofinity Commercial |
$634.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$516.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$590.14
|
| Rate for Payer: Healthscope Commercial |
$663.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$516.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$553.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$627.02
|
| Rate for Payer: PHP Commercial |
$627.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$479.49
|
| Rate for Payer: Priority Health SBD |
$464.73
|
| Rate for Payer: UMR Bronson Commercial |
$272.94
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$553.25
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
OP
|
$34.36
|
|
|
Service Code
|
NDC 52565000814
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.71 |
| Max. Negotiated Rate |
$30.92 |
| Rate for Payer: Aetna American Axle |
$22.33
|
| Rate for Payer: Aetna Commercial |
$29.21
|
| Rate for Payer: Aetna Medicare |
$17.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.33
|
| Rate for Payer: BCBS Complete |
$13.74
|
| Rate for Payer: Cash Price |
$27.49
|
| Rate for Payer: Cofinity Commercial |
$24.05
|
| Rate for Payer: Cofinity Commercial |
$29.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.49
|
| Rate for Payer: Healthscope Commercial |
$30.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.21
|
| Rate for Payer: PHP Commercial |
$29.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.33
|
| Rate for Payer: Priority Health SBD |
$21.65
|
| Rate for Payer: UMR Bronson Commercial |
$12.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.77
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
IP
|
$36.60
|
|
|
Service Code
|
NDC 65162091838
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$32.94 |
| Rate for Payer: Aetna American Axle |
$23.79
|
| Rate for Payer: Aetna Commercial |
$31.11
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.79
|
| Rate for Payer: Cash Price |
$29.28
|
| Rate for Payer: Cofinity Commercial |
$25.62
|
| Rate for Payer: Cofinity Commercial |
$31.48
|
| Rate for Payer: Cofinity Medicare Advantage |
$25.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.28
|
| Rate for Payer: Healthscope Commercial |
$32.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.11
|
| Rate for Payer: PHP Commercial |
$31.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.79
|
| Rate for Payer: Priority Health SBD |
$23.06
|
| Rate for Payer: UMR Bronson Commercial |
$16.10
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.45
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
IP
|
$34.36
|
|
|
Service Code
|
NDC 52565000814
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$15.12 |
| Max. Negotiated Rate |
$30.92 |
| Rate for Payer: Aetna American Axle |
$22.33
|
| Rate for Payer: Aetna Commercial |
$29.21
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.33
|
| Rate for Payer: Cash Price |
$27.49
|
| Rate for Payer: Cofinity Commercial |
$24.05
|
| Rate for Payer: Cofinity Commercial |
$29.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.05
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$27.49
|
| Rate for Payer: Healthscope Commercial |
$30.92
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$25.77
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$29.21
|
| Rate for Payer: PHP Commercial |
$29.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.33
|
| Rate for Payer: Priority Health SBD |
$21.65
|
| Rate for Payer: UMR Bronson Commercial |
$15.12
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$25.77
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
OP
|
$81.38
|
|
|
Service Code
|
NDC 51672302009
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$30.11 |
| Max. Negotiated Rate |
$73.24 |
| Rate for Payer: Aetna American Axle |
$52.90
|
| Rate for Payer: Aetna Commercial |
$69.17
|
| Rate for Payer: Aetna Medicare |
$40.69
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$52.90
|
| Rate for Payer: BCBS Complete |
$32.55
|
| Rate for Payer: Cash Price |
$65.10
|
| Rate for Payer: Cofinity Commercial |
$56.97
|
| Rate for Payer: Cofinity Commercial |
$69.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$56.97
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$65.10
|
| Rate for Payer: Healthscope Commercial |
$73.24
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$56.97
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$61.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$69.17
|
| Rate for Payer: PHP Commercial |
$69.17
|
| Rate for Payer: Priority Health Cigna Priority Health |
$52.90
|
| Rate for Payer: Priority Health SBD |
$51.27
|
| Rate for Payer: UMR Bronson Commercial |
$30.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$61.03
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
IP
|
$737.67
|
|
|
Service Code
|
NDC 00168020437
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$324.57 |
| Max. Negotiated Rate |
$663.90 |
| Rate for Payer: Aetna American Axle |
$479.49
|
| Rate for Payer: Aetna Commercial |
$627.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$479.49
|
| Rate for Payer: Cash Price |
$590.14
|
| Rate for Payer: Cofinity Commercial |
$516.37
|
| Rate for Payer: Cofinity Commercial |
$634.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$516.37
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$590.14
|
| Rate for Payer: Healthscope Commercial |
$663.90
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$516.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$553.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$627.02
|
| Rate for Payer: PHP Commercial |
$627.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$479.49
|
| Rate for Payer: Priority Health SBD |
$464.73
|
| Rate for Payer: UMR Bronson Commercial |
$324.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$553.25
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT
|
Facility
|
OP
|
$70.58
|
|
|
Service Code
|
NDC 69680012035
|
| Hospital Charge Code |
159107
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$26.11 |
| Max. Negotiated Rate |
$63.52 |
| Rate for Payer: Aetna American Axle |
$45.88
|
| Rate for Payer: Aetna Commercial |
$59.99
|
| Rate for Payer: Aetna Medicare |
$35.29
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$45.88
|
| Rate for Payer: BCBS Complete |
$28.23
|
| Rate for Payer: Cash Price |
$56.46
|
| Rate for Payer: Cofinity Commercial |
$49.41
|
| Rate for Payer: Cofinity Commercial |
$60.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$49.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$56.46
|
| Rate for Payer: Healthscope Commercial |
$63.52
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$49.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$52.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$59.99
|
| Rate for Payer: PHP Commercial |
$59.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$45.88
|
| Rate for Payer: Priority Health SBD |
$44.47
|
| Rate for Payer: UMR Bronson Commercial |
$26.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$52.94
|
|
