|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$32.55
|
|
|
Service Code
|
NDC 00527600274
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.04 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna American Axle |
$21.16
|
| Rate for Payer: Aetna Commercial |
$27.67
|
| Rate for Payer: Aetna Medicare |
$16.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.16
|
| Rate for Payer: BCBS Complete |
$13.02
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cofinity Commercial |
$22.79
|
| Rate for Payer: Cofinity Commercial |
$27.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.04
|
| Rate for Payer: Healthscope Commercial |
$29.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.67
|
| Rate for Payer: PHP Commercial |
$27.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.16
|
| Rate for Payer: Priority Health SBD |
$20.51
|
| Rate for Payer: UMR Bronson Commercial |
$12.04
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.41
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$35.35
|
|
|
Service Code
|
NDC 00054350049
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.08 |
| Max. Negotiated Rate |
$31.82 |
| Rate for Payer: Aetna American Axle |
$22.98
|
| Rate for Payer: Aetna Commercial |
$30.05
|
| Rate for Payer: Aetna Medicare |
$17.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$22.98
|
| Rate for Payer: BCBS Complete |
$14.14
|
| Rate for Payer: Cash Price |
$28.28
|
| Rate for Payer: Cofinity Commercial |
$24.75
|
| Rate for Payer: Cofinity Commercial |
$30.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.75
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.28
|
| Rate for Payer: Healthscope Commercial |
$31.82
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$24.75
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$26.51
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.05
|
| Rate for Payer: PHP Commercial |
$30.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.98
|
| Rate for Payer: Priority Health SBD |
$22.27
|
| Rate for Payer: UMR Bronson Commercial |
$13.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.51
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$32.55
|
|
|
Service Code
|
NDC 00527600274
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.32 |
| Max. Negotiated Rate |
$29.30 |
| Rate for Payer: Aetna American Axle |
$21.16
|
| Rate for Payer: Aetna Commercial |
$27.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.16
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cofinity Commercial |
$22.79
|
| Rate for Payer: Cofinity Commercial |
$27.99
|
| Rate for Payer: Cofinity Medicare Advantage |
$22.79
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.04
|
| Rate for Payer: Healthscope Commercial |
$29.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$22.79
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$24.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.67
|
| Rate for Payer: PHP Commercial |
$27.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.16
|
| Rate for Payer: Priority Health SBD |
$20.51
|
| Rate for Payer: UMR Bronson Commercial |
$14.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$24.41
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$5.49
|
|
|
Service Code
|
NDC 09900000339
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.42 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna American Axle |
$3.57
|
| Rate for Payer: Aetna Commercial |
$4.67
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.57
|
| Rate for Payer: Cash Price |
$4.39
|
| Rate for Payer: Cofinity Commercial |
$3.84
|
| Rate for Payer: Cofinity Commercial |
$4.72
|
| Rate for Payer: Cofinity Medicare Advantage |
$3.84
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.39
|
| Rate for Payer: Healthscope Commercial |
$4.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$3.84
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$4.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.67
|
| Rate for Payer: PHP Commercial |
$4.67
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.57
|
| Rate for Payer: Priority Health SBD |
$3.46
|
| Rate for Payer: UMR Bronson Commercial |
$2.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$4.12
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
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 Commercial |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.13
|
| 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: Multiplan/Beech St/PHCS Commercial |
$22.02
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.84
|
| Rate for Payer: Priority Health SBD |
$16.32
|
| 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
|
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 Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.66
|
| 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
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 17856139302
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.44 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Aetna American Axle |
$7.80
|
| Rate for Payer: Aetna Commercial |
$10.20
|
| Rate for Payer: Aetna Medicare |
$6.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.80
|
| Rate for Payer: BCBS Complete |
$4.80
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$10.32
|
| Rate for Payer: Cofinity Commercial |
$8.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.60
|
| Rate for Payer: Healthscope Commercial |
$10.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.20
|
| Rate for Payer: PHP Commercial |
$10.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.80
|
| Rate for Payer: Priority Health SBD |
$7.56
|
| Rate for Payer: UMR Bronson Commercial |
$4.44
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.00
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$15.06
|
|
|
Service Code
|
NDC 00121090315
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Aetna American Axle |
$9.79
|
| Rate for Payer: Aetna Commercial |
$12.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.79
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cofinity Commercial |
$10.54
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.05
|
| Rate for Payer: Healthscope Commercial |
$13.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.80
|
| Rate for Payer: PHP Commercial |
$12.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.79
|
| Rate for Payer: Priority Health SBD |
$9.49
|
| Rate for Payer: UMR Bronson Commercial |
$6.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.29
|
|
|
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 Commercial |
$23.77
|
| Rate for Payer: Cofinity Commercial |
$29.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.77
|
| 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: PHP Commercial |
$28.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.07
|
| Rate for Payer: Priority Health SBD |
$21.39
|
| 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
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 50383036317
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna American Axle |
$2.75
|
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.17
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 50383036317
|
| 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 Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.66
|
| 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
|
OP
|
$15.06
|
|
|
Service Code
|
NDC 00121090340
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Aetna American Axle |
$9.79
|
| Rate for Payer: Aetna Commercial |
$12.80
|
| Rate for Payer: Aetna Medicare |
$7.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.79
|
| Rate for Payer: BCBS Complete |
$6.02
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cofinity Commercial |
$10.54
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.05
|
| Rate for Payer: Healthscope Commercial |
$13.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.80
|
| Rate for Payer: PHP Commercial |
$12.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.79
|
| Rate for Payer: Priority Health SBD |
$9.49
|
| Rate for Payer: UMR Bronson Commercial |
$5.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.29
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$4.23
|
|
|
Service Code
|
NDC 50383077517
|
| 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 Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.66
|
| 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
|
OP
|
$15.06
|
|
|
Service Code
|
NDC 00121090315
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.57 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Aetna American Axle |
$9.79
|
| Rate for Payer: Aetna Commercial |
$12.80
|
| Rate for Payer: Aetna Medicare |
$7.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.79
|
| Rate for Payer: BCBS Complete |
$6.02
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cofinity Commercial |
$10.54
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.05
|
| Rate for Payer: Healthscope Commercial |
$13.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.80
|
| Rate for Payer: PHP Commercial |
$12.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.79
|
| Rate for Payer: Priority Health SBD |
$9.49
|
| Rate for Payer: UMR Bronson Commercial |
$5.57
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.29
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$23.45
|
|
|
Service Code
|
NDC 50383077504
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.68 |
| Max. Negotiated Rate |
$21.11 |
| Rate for Payer: Aetna American Axle |
$15.24
|
| Rate for Payer: Aetna Commercial |
$19.93
|
| Rate for Payer: Aetna Medicare |
$11.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.24
|
| Rate for Payer: BCBS Complete |
$9.38
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Cofinity Commercial |
$16.41
|
| Rate for Payer: Cofinity Commercial |
$20.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.76
|
| Rate for Payer: Healthscope Commercial |
$21.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.93
|
| Rate for Payer: PHP Commercial |
$19.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.24
|
| Rate for Payer: Priority Health SBD |
$14.77
|
| Rate for Payer: UMR Bronson Commercial |
$8.68
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.59
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$15.06
|
|
|
Service Code
|
NDC 00121090340
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.63 |
| Max. Negotiated Rate |
$13.55 |
| Rate for Payer: Aetna American Axle |
$9.79
|
| Rate for Payer: Aetna Commercial |
$12.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.79
|
| Rate for Payer: Cash Price |
$12.05
|
| Rate for Payer: Cofinity Commercial |
$10.54
|
| Rate for Payer: Cofinity Commercial |
$12.95
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.05
|
| Rate for Payer: Healthscope Commercial |
$13.55
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.80
|
| Rate for Payer: PHP Commercial |
$12.80
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.79
|
| Rate for Payer: Priority Health SBD |
$9.49
|
| Rate for Payer: UMR Bronson Commercial |
$6.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.29
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$4.23
|
|
|
Service Code
|
NDC 50383077517
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.86 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna American Axle |
$2.75
|
| Rate for Payer: Aetna Commercial |
$3.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$2.75
|
| Rate for Payer: Cash Price |
$3.38
|
| Rate for Payer: Cofinity Commercial |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.64
|
| Rate for Payer: Cofinity Medicare Advantage |
$2.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.38
|
| Rate for Payer: Healthscope Commercial |
$3.81
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$2.96
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$3.17
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.60
|
| Rate for Payer: PHP Commercial |
$3.60
|
| Rate for Payer: Priority Health Cigna Priority Health |
$2.75
|
| Rate for Payer: Priority Health SBD |
$2.66
|
| Rate for Payer: UMR Bronson Commercial |
$1.86
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$3.17
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$23.45
|
|
|
Service Code
|
NDC 50383077504
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$10.32 |
| Max. Negotiated Rate |
$21.11 |
| Rate for Payer: Aetna American Axle |
$15.24
|
| Rate for Payer: Aetna Commercial |
$19.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.24
|
| Rate for Payer: Cash Price |
$18.76
|
| Rate for Payer: Cofinity Commercial |
$16.41
|
| Rate for Payer: Cofinity Commercial |
$20.17
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.41
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.76
|
| Rate for Payer: Healthscope Commercial |
$21.11
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.41
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.93
|
| Rate for Payer: PHP Commercial |
$19.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.24
|
| Rate for Payer: Priority Health SBD |
$14.77
|
| Rate for Payer: UMR Bronson Commercial |
$10.32
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.59
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$25.90
|
|
|
Service Code
|
NDC 60432046400
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.40 |
| Max. Negotiated Rate |
$23.31 |
| Rate for Payer: Aetna American Axle |
$16.84
|
| Rate for Payer: Aetna Commercial |
$22.02
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$16.84
|
| Rate for Payer: Cash Price |
$20.72
|
| Rate for Payer: Cofinity Commercial |
$18.13
|
| Rate for Payer: Cofinity Commercial |
$22.27
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.13
|
| 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: Multiplan/Beech St/PHCS Commercial |
$22.02
|
| Rate for Payer: PHP Commercial |
$22.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.84
|
| Rate for Payer: Priority Health SBD |
$16.32
|
| Rate for Payer: UMR Bronson Commercial |
$11.40
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$19.43
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 17856139302
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.28 |
| Max. Negotiated Rate |
$10.80 |
| Rate for Payer: Aetna American Axle |
$7.80
|
| Rate for Payer: Aetna Commercial |
$10.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$7.80
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$10.32
|
| Rate for Payer: Cofinity Commercial |
$8.40
|
| Rate for Payer: Cofinity Medicare Advantage |
$8.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.60
|
| Rate for Payer: Healthscope Commercial |
$10.80
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$8.40
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$9.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.20
|
| Rate for Payer: PHP Commercial |
$10.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.80
|
| Rate for Payer: Priority Health SBD |
$7.56
|
| Rate for Payer: UMR Bronson Commercial |
$5.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$9.00
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$35.70
|
|
|
Service Code
|
NDC 72888012526
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.21 |
| Max. Negotiated Rate |
$32.13 |
| Rate for Payer: Aetna American Axle |
$23.20
|
| Rate for Payer: Aetna Commercial |
$30.34
|
| Rate for Payer: Aetna Medicare |
$17.85
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.20
|
| Rate for Payer: BCBS Complete |
$14.28
|
| Rate for Payer: Cash Price |
$28.56
|
| Rate for Payer: Cofinity Commercial |
$24.99
|
| Rate for Payer: Cofinity Commercial |
$30.70
|
| Rate for Payer: Cofinity Medicare Advantage |
$24.99
|
| 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: PHP Commercial |
$30.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.20
|
| Rate for Payer: Priority Health SBD |
$22.49
|
| Rate for Payer: UMR Bronson Commercial |
$13.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$26.77
|
|
|
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 Commercial |
$23.77
|
| Rate for Payer: Cofinity Commercial |
$29.20
|
| Rate for Payer: Cofinity Medicare Advantage |
$23.77
|
| 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: PHP Commercial |
$28.86
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.07
|
| 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 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$49.21 |
| Max. Negotiated Rate |
$119.70 |
| Rate for Payer: Aetna American Axle |
$86.45
|
| Rate for Payer: Aetna Commercial |
$113.05
|
| Rate for Payer: Aetna Medicare |
$66.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$86.45
|
| Rate for Payer: BCBS Complete |
$53.20
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cofinity Commercial |
$114.38
|
| Rate for Payer: Cofinity Commercial |
$93.10
|
| Rate for Payer: Cofinity Medicare Advantage |
$93.10
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.40
|
| Rate for Payer: Healthscope Commercial |
$119.70
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$93.10
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$99.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.05
|
| Rate for Payer: PHP Commercial |
$113.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.45
|
| Rate for Payer: Priority Health SBD |
$83.79
|
| Rate for Payer: UMR Bronson Commercial |
$49.21
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$99.75
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$104.13
|
|
|
Service Code
|
NDC 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 Commercial |
$72.89
|
| Rate for Payer: Cofinity Commercial |
$89.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.89
|
| 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: PHP Commercial |
$88.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.68
|
| 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
|
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 Commercial |
$72.89
|
| Rate for Payer: Cofinity Commercial |
$89.55
|
| Rate for Payer: Cofinity Medicare Advantage |
$72.89
|
| 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: PHP Commercial |
$88.51
|
| Rate for Payer: Priority Health Cigna Priority Health |
$67.68
|
| Rate for Payer: Priority Health SBD |
$65.60
|
| Rate for Payer: UMR Bronson Commercial |
$38.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$78.10
|
|
