|
LIDOCAINE 1% AND BUPIVACAINE 0.25% AND HYALURONIDASE EYE BLOCK
|
Facility
|
OP
|
$165.63
|
|
|
Service Code
|
HCPCS J3473
|
| Hospital Charge Code |
158439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.98 |
| Max. Negotiated Rate |
$149.07 |
| Rate for Payer: Aetna American Axle |
$107.66
|
| Rate for Payer: Aetna Commercial |
$140.79
|
| Rate for Payer: Aetna Medicare |
$82.82
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.66
|
| Rate for Payer: BCBS Complete |
$66.25
|
| Rate for Payer: BCBS Trust/PPO |
$0.98
|
| Rate for Payer: BCN Commercial |
$0.98
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cofinity Commercial |
$115.94
|
| Rate for Payer: Cofinity Commercial |
$142.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.50
|
| Rate for Payer: Healthscope Commercial |
$149.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.79
|
| Rate for Payer: PHP Commercial |
$140.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.66
|
| Rate for Payer: Priority Health SBD |
$104.35
|
| Rate for Payer: UMR Bronson Commercial |
$61.28
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.22
|
|
|
LIDOCAINE 1% AND BUPIVACAINE 0.25% AND HYALURONIDASE EYE BLOCK
|
Facility
|
IP
|
$165.63
|
|
|
Service Code
|
HCPCS J3473
|
| Hospital Charge Code |
158439
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$72.88 |
| Max. Negotiated Rate |
$149.07 |
| Rate for Payer: Aetna American Axle |
$107.66
|
| Rate for Payer: Aetna Commercial |
$140.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$107.66
|
| Rate for Payer: Cash Price |
$132.50
|
| Rate for Payer: Cofinity Commercial |
$115.94
|
| Rate for Payer: Cofinity Commercial |
$142.44
|
| Rate for Payer: Cofinity Medicare Advantage |
$115.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$132.50
|
| Rate for Payer: Healthscope Commercial |
$149.07
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$115.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$124.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$140.79
|
| Rate for Payer: PHP Commercial |
$140.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$107.66
|
| Rate for Payer: Priority Health SBD |
$104.35
|
| Rate for Payer: UMR Bronson Commercial |
$72.88
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$124.22
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
OP
|
$44.95
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$40.46 |
| Rate for Payer: Aetna American Axle |
$29.22
|
| Rate for Payer: Aetna American Axle |
$11.31
|
| Rate for Payer: Aetna American Axle |
$10.10
|
| Rate for Payer: Aetna American Axle |
$12.50
|
| Rate for Payer: Aetna American Axle |
$13.27
|
| Rate for Payer: Aetna American Axle |
$15.44
|
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Aetna Commercial |
$20.20
|
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Aetna Commercial |
$13.21
|
| Rate for Payer: Aetna Commercial |
$38.21
|
| Rate for Payer: Aetna Commercial |
$17.35
|
| Rate for Payer: Aetna Medicare |
$22.48
|
| Rate for Payer: Aetna Medicare |
$10.20
|
| Rate for Payer: Aetna Medicare |
$8.70
|
| Rate for Payer: Aetna Medicare |
$11.88
|
| Rate for Payer: Aetna Medicare |
$9.62
|
| Rate for Payer: Aetna Medicare |
$7.77
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.44
|
| Rate for Payer: BCBS Complete |
$9.50
|
| Rate for Payer: BCBS Complete |
$8.16
|
| Rate for Payer: BCBS Complete |
$6.22
|
| Rate for Payer: BCBS Complete |
$7.69
|
| Rate for Payer: BCBS Complete |
$6.96
|
| Rate for Payer: BCBS Complete |
$17.98
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$35.96
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cash Price |
$19.01
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cash Price |
$19.01
|
| Rate for Payer: Cash Price |
$35.96
|
| Rate for Payer: Cash Price |
$16.33
|
| Rate for Payer: Cash Price |
$16.33
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cofinity Commercial |
$13.46
|
| Rate for Payer: Cofinity Commercial |
$31.46
|
| Rate for Payer: Cofinity Commercial |
$12.18
|
| Rate for Payer: Cofinity Commercial |
$13.36
|
| Rate for Payer: Cofinity Commercial |
$10.88
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Cofinity Commercial |
$20.43
|
| Rate for Payer: Cofinity Commercial |
$16.63
|
| Rate for Payer: Cofinity Commercial |
$17.55
|
| Rate for Payer: Cofinity Commercial |
$14.29
|
| Rate for Payer: Cofinity Commercial |
$16.54
|
| Rate for Payer: Cofinity Commercial |
$38.66
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.96
|
| Rate for Payer: Healthscope Commercial |
$21.38
|
| Rate for Payer: Healthscope Commercial |
$40.46
|
| Rate for Payer: Healthscope Commercial |
$18.37
|
| Rate for Payer: Healthscope Commercial |
$17.31
|
| Rate for Payer: Healthscope Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$13.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.63
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.35
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: PHP Commercial |
$17.35
|
| Rate for Payer: PHP Commercial |
$14.79
|
| Rate for Payer: PHP Commercial |
$13.21
|
| Rate for Payer: PHP Commercial |
$20.20
|
| Rate for Payer: PHP Commercial |
$38.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.22
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.31
|
| Rate for Payer: Priority Health SBD |
$14.97
|
| Rate for Payer: Priority Health SBD |
$10.96
|
| Rate for Payer: Priority Health SBD |
$12.11
|
| Rate for Payer: Priority Health SBD |
$12.86
|
| Rate for Payer: Priority Health SBD |
$9.79
|
| Rate for Payer: Priority Health SBD |
$28.32
|
| Rate for Payer: UMR Bronson Commercial |
$8.79
|
| Rate for Payer: UMR Bronson Commercial |
$16.63
|
| Rate for Payer: UMR Bronson Commercial |
$7.12
|
| Rate for Payer: UMR Bronson Commercial |
$5.75
|
| Rate for Payer: UMR Bronson Commercial |
$6.44
|
| Rate for Payer: UMR Bronson Commercial |
$7.55
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.66
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.31
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$15.54
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$6.84 |
| Max. Negotiated Rate |
$13.99 |
| Rate for Payer: Aetna American Axle |
$10.10
|
| Rate for Payer: Aetna American Axle |
$15.44
|
| Rate for Payer: Aetna American Axle |
$13.27
|
| Rate for Payer: Aetna American Axle |
$11.31
|
| Rate for Payer: Aetna American Axle |
$12.50
|
| Rate for Payer: Aetna American Axle |
$29.22
|
| Rate for Payer: Aetna Commercial |
$13.21
|
| Rate for Payer: Aetna Commercial |
$14.79
|
| Rate for Payer: Aetna Commercial |
$17.35
|
| Rate for Payer: Aetna Commercial |
$38.21
|
| Rate for Payer: Aetna Commercial |
$20.20
|
| Rate for Payer: Aetna Commercial |
$16.35
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$10.10
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$29.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$11.31
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$13.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$15.44
|
| Rate for Payer: Cash Price |
$19.01
|
| Rate for Payer: Cash Price |
$16.33
|
| Rate for Payer: Cash Price |
$12.43
|
| Rate for Payer: Cash Price |
$15.38
|
| Rate for Payer: Cash Price |
$13.92
|
| Rate for Payer: Cash Price |
$35.96
|
| Rate for Payer: Cofinity Commercial |
$20.43
|
| Rate for Payer: Cofinity Commercial |
$10.88
|
| Rate for Payer: Cofinity Commercial |
$17.55
|
| Rate for Payer: Cofinity Commercial |
$14.29
|
| Rate for Payer: Cofinity Commercial |
$13.46
|
| Rate for Payer: Cofinity Commercial |
$12.18
|
| Rate for Payer: Cofinity Commercial |
$14.96
|
| Rate for Payer: Cofinity Commercial |
$16.54
|
| Rate for Payer: Cofinity Commercial |
$13.36
|
| Rate for Payer: Cofinity Commercial |
$38.66
|
| Rate for Payer: Cofinity Commercial |
$31.46
|
| Rate for Payer: Cofinity Commercial |
$16.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$14.29
|
| Rate for Payer: Cofinity Medicare Advantage |
$12.18
|
| Rate for Payer: Cofinity Medicare Advantage |
$31.46
|
| Rate for Payer: Cofinity Medicare Advantage |
$16.63
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.88
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.01
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$16.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.92
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.96
|
| Rate for Payer: Healthscope Commercial |
$18.37
|
| Rate for Payer: Healthscope Commercial |
$40.46
|
| Rate for Payer: Healthscope Commercial |
$21.38
|
| Rate for Payer: Healthscope Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$17.31
|
| Rate for Payer: Healthscope Commercial |
$13.99
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$16.63
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.88
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$12.18
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$14.29
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.46
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$31.46
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$17.82
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$33.71
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$13.05
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.66
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.42
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$15.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$17.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.79
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.35
|
| Rate for Payer: PHP Commercial |
$13.21
|
| Rate for Payer: PHP Commercial |
$14.79
|
| Rate for Payer: PHP Commercial |
$17.35
|
| Rate for Payer: PHP Commercial |
$20.20
|
| Rate for Payer: PHP Commercial |
$16.35
|
| Rate for Payer: PHP Commercial |
$38.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.31
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$13.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.50
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.22
|
| Rate for Payer: Priority Health SBD |
$14.97
|
| Rate for Payer: Priority Health SBD |
$12.86
|
| Rate for Payer: Priority Health SBD |
$9.79
|
| Rate for Payer: Priority Health SBD |
$10.96
|
| Rate for Payer: Priority Health SBD |
$12.11
|
| Rate for Payer: Priority Health SBD |
$28.32
|
| Rate for Payer: UMR Bronson Commercial |
$19.78
|
| Rate for Payer: UMR Bronson Commercial |
$7.66
|
| Rate for Payer: UMR Bronson Commercial |
$8.46
|
| Rate for Payer: UMR Bronson Commercial |
$10.45
|
| Rate for Payer: UMR Bronson Commercial |
$8.98
|
| Rate for Payer: UMR Bronson Commercial |
$6.84
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$13.05
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$15.31
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.42
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$17.82
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$33.71
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.66
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$29.53
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$12.99 |
| Max. Negotiated Rate |
$26.58 |
| Rate for Payer: Aetna American Axle |
$19.19
|
| Rate for Payer: Aetna American Axle |
$14.19
|
| Rate for Payer: Aetna American Axle |
$12.68
|
| Rate for Payer: Aetna American Axle |
$23.72
|
| Rate for Payer: Aetna Commercial |
$25.10
|
| Rate for Payer: Aetna Commercial |
$31.02
|
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.19
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$29.19
|
| Rate for Payer: Cofinity Commercial |
$13.65
|
| Rate for Payer: Cofinity Commercial |
$31.38
|
| Rate for Payer: Cofinity Commercial |
$25.54
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Cofinity Commercial |
$15.28
|
| Rate for Payer: Cofinity Commercial |
$18.77
|
| Rate for Payer: Cofinity Commercial |
$25.40
|
| Rate for Payer: Cofinity Commercial |
$16.77
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$25.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.46
|
| Rate for Payer: Healthscope Commercial |
$26.58
|
| Rate for Payer: Healthscope Commercial |
$17.55
|
| Rate for Payer: Healthscope Commercial |
$19.65
|
| Rate for Payer: Healthscope Commercial |
$32.84
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.54
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.67
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.10
|
| Rate for Payer: PHP Commercial |
$25.10
|
| Rate for Payer: PHP Commercial |
$31.02
|
| Rate for Payer: PHP Commercial |
$16.58
|
| Rate for Payer: PHP Commercial |
$18.56
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.68
|
| Rate for Payer: Priority Health SBD |
$22.99
|
| Rate for Payer: Priority Health SBD |
$12.28
|
| Rate for Payer: Priority Health SBD |
$13.75
|
| Rate for Payer: Priority Health SBD |
$18.60
|
| Rate for Payer: UMR Bronson Commercial |
$12.99
|
| Rate for Payer: UMR Bronson Commercial |
$16.06
|
| Rate for Payer: UMR Bronson Commercial |
$9.61
|
| Rate for Payer: UMR Bronson Commercial |
$8.58
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.15
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
OP
|
$36.49
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$32.84 |
| Rate for Payer: Aetna American Axle |
$23.72
|
| Rate for Payer: Aetna American Axle |
$19.19
|
| Rate for Payer: Aetna American Axle |
$12.68
|
| Rate for Payer: Aetna American Axle |
$14.19
|
| Rate for Payer: Aetna Commercial |
$31.02
|
| Rate for Payer: Aetna Commercial |
$18.56
|
| Rate for Payer: Aetna Commercial |
$16.58
|
| Rate for Payer: Aetna Commercial |
$25.10
|
| Rate for Payer: Aetna Medicare |
$14.76
|
| Rate for Payer: Aetna Medicare |
$10.92
|
| Rate for Payer: Aetna Medicare |
$9.75
|
| Rate for Payer: Aetna Medicare |
$18.24
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$23.72
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$12.68
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.19
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$14.19
|
| Rate for Payer: BCBS Complete |
$11.81
|
| Rate for Payer: BCBS Complete |
$7.80
|
| Rate for Payer: BCBS Complete |
$14.60
|
| Rate for Payer: BCBS Complete |
$8.73
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cash Price |
$29.19
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$15.60
|
| Rate for Payer: Cash Price |
$23.62
|
| Rate for Payer: Cash Price |
$29.19
|
| Rate for Payer: Cofinity Commercial |
$31.38
|
| Rate for Payer: Cofinity Commercial |
$18.77
|
| Rate for Payer: Cofinity Commercial |
$13.65
|
| Rate for Payer: Cofinity Commercial |
$16.77
|
| Rate for Payer: Cofinity Commercial |
$15.28
|
| Rate for Payer: Cofinity Commercial |
$20.67
|
| Rate for Payer: Cofinity Commercial |
$25.40
|
| Rate for Payer: Cofinity Commercial |
$25.54
|
| Rate for Payer: Cofinity Medicare Advantage |
$15.28
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.67
|
| Rate for Payer: Cofinity Medicare Advantage |
$13.65
|
| Rate for Payer: Cofinity Medicare Advantage |
$25.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$29.19
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.62
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.60
|
| Rate for Payer: Healthscope Commercial |
$17.55
|
| Rate for Payer: Healthscope Commercial |
$32.84
|
| Rate for Payer: Healthscope Commercial |
$26.58
|
| Rate for Payer: Healthscope Commercial |
$19.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.67
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$13.65
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$15.28
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$25.54
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$27.37
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$14.62
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.15
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$16.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$31.02
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.10
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.58
|
| Rate for Payer: PHP Commercial |
$31.02
|
| Rate for Payer: PHP Commercial |
$18.56
|
| Rate for Payer: PHP Commercial |
$16.58
|
| Rate for Payer: PHP Commercial |
$25.10
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.72
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.68
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.19
|
| Rate for Payer: Priority Health SBD |
$12.28
|
| Rate for Payer: Priority Health SBD |
$18.60
|
| Rate for Payer: Priority Health SBD |
$13.75
|
| Rate for Payer: Priority Health SBD |
$22.99
|
| Rate for Payer: UMR Bronson Commercial |
$7.22
|
| Rate for Payer: UMR Bronson Commercial |
$10.93
|
| Rate for Payer: UMR Bronson Commercial |
$13.50
|
| Rate for Payer: UMR Bronson Commercial |
$8.08
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.15
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$16.37
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$14.62
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$27.37
|
|
|
LIDOCAINE 2 %-EPINEPHRINE BITARTRATE 1:100,000 INJECTION CARTRIDGE
|
Facility
|
OP
|
$7.06
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
118255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna American Axle |
$4.59
|
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: Aetna Medicare |
$3.53
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.59
|
| Rate for Payer: BCBS Complete |
$2.82
|
| Rate for Payer: BCBS Trust/PPO |
$0.05
|
| Rate for Payer: BCN Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cofinity Commercial |
$4.94
|
| Rate for Payer: Cofinity Commercial |
$6.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.65
|
| Rate for Payer: Healthscope Commercial |
$6.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.00
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.59
|
| Rate for Payer: Priority Health SBD |
$4.45
|
| Rate for Payer: UMR Bronson Commercial |
$2.61
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.30
|
|
|
LIDOCAINE 2 %-EPINEPHRINE BITARTRATE 1:100,000 INJECTION CARTRIDGE
|
Facility
|
IP
|
$7.06
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
118255
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.11 |
| Max. Negotiated Rate |
$6.35 |
| Rate for Payer: Aetna American Axle |
$4.59
|
| Rate for Payer: Aetna Commercial |
$6.00
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.59
|
| Rate for Payer: Cash Price |
$5.65
|
| Rate for Payer: Cofinity Commercial |
$4.94
|
| Rate for Payer: Cofinity Commercial |
$6.07
|
| Rate for Payer: Cofinity Medicare Advantage |
$4.94
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.65
|
| Rate for Payer: Healthscope Commercial |
$6.35
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$4.94
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$5.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.00
|
| Rate for Payer: PHP Commercial |
$6.00
|
| Rate for Payer: Priority Health Cigna Priority Health |
$4.59
|
| Rate for Payer: Priority Health SBD |
$4.45
|
| Rate for Payer: UMR Bronson Commercial |
$3.11
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$5.30
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$15.21
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.63 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna American Axle |
$9.89
|
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: Aetna Medicare |
$7.60
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.89
|
| Rate for Payer: BCBS Complete |
$6.08
|
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: Cofinity Commercial |
$10.65
|
| Rate for Payer: Cofinity Commercial |
$13.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.17
|
| Rate for Payer: Healthscope Commercial |
$13.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.93
|
| Rate for Payer: PHP Commercial |
$12.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.89
|
| Rate for Payer: Priority Health SBD |
$9.58
|
| Rate for Payer: UMR Bronson Commercial |
$5.63
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.41
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$15.21
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.69 |
| Max. Negotiated Rate |
$13.69 |
| Rate for Payer: Aetna American Axle |
$9.89
|
| Rate for Payer: Aetna Commercial |
$12.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$9.89
|
| Rate for Payer: Cash Price |
$12.17
|
| Rate for Payer: Cofinity Commercial |
$10.65
|
| Rate for Payer: Cofinity Commercial |
$13.08
|
| Rate for Payer: Cofinity Medicare Advantage |
$10.65
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.17
|
| Rate for Payer: Healthscope Commercial |
$13.69
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$10.65
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$11.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.93
|
| Rate for Payer: PHP Commercial |
$12.93
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.89
|
| Rate for Payer: Priority Health SBD |
$9.58
|
| Rate for Payer: UMR Bronson Commercial |
$6.69
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$11.41
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$27.00
|
|
|
Service Code
|
NDC 76329301305
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.99 |
| Max. Negotiated Rate |
$24.30 |
| Rate for Payer: Aetna American Axle |
$17.55
|
| Rate for Payer: Aetna Commercial |
$22.95
|
| Rate for Payer: Aetna Medicare |
$13.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$17.55
|
| Rate for Payer: BCBS Complete |
$10.80
|
| Rate for Payer: Cash Price |
$21.60
|
| Rate for Payer: Cofinity Commercial |
$18.90
|
| Rate for Payer: Cofinity Commercial |
$23.22
|
| Rate for Payer: Cofinity Medicare Advantage |
$18.90
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.60
|
| Rate for Payer: Healthscope Commercial |
$24.30
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$18.90
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$20.25
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.95
|
| Rate for Payer: PHP Commercial |
$22.95
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.55
|
| Rate for Payer: Priority Health SBD |
$17.01
|
| Rate for Payer: UMR Bronson Commercial |
$9.99
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$20.25
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
IP
|
$29.93
|
|
|
Service Code
|
NDC 71266629001
|
| Hospital Charge Code |
196007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.17 |
| Max. Negotiated Rate |
$26.94 |
| Rate for Payer: UMR Bronson Commercial |
$13.17
|
| Rate for Payer: Priority Health SBD |
$18.86
|
| Rate for Payer: Aetna American Axle |
$19.45
|
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.45
|
| Rate for Payer: Cash Price |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$20.95
|
| Rate for Payer: Cofinity Commercial |
$25.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.94
|
| Rate for Payer: Healthscope Commercial |
$26.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.44
|
| Rate for Payer: PHP Commercial |
$25.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.45
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.45
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
OP
|
$29.93
|
|
|
Service Code
|
NDC 71266629001
|
| Hospital Charge Code |
196007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.07 |
| Max. Negotiated Rate |
$26.94 |
| Rate for Payer: Aetna American Axle |
$19.45
|
| Rate for Payer: Aetna Commercial |
$25.44
|
| Rate for Payer: Aetna Medicare |
$14.96
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$19.45
|
| Rate for Payer: BCBS Complete |
$11.97
|
| Rate for Payer: Cash Price |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$20.95
|
| Rate for Payer: Cofinity Commercial |
$25.74
|
| Rate for Payer: Cofinity Medicare Advantage |
$20.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.94
|
| Rate for Payer: Healthscope Commercial |
$26.94
|
| Rate for Payer: Kalamazoo County Sherrif's Dept Commercial |
$20.95
|
| Rate for Payer: Lakeland Regional Health Systems Commercial |
$22.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.44
|
| Rate for Payer: PHP Commercial |
$25.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.45
|
| Rate for Payer: Priority Health SBD |
$18.86
|
| Rate for Payer: UMR Bronson Commercial |
$11.07
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$22.45
|
|
|
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
|
$30.05
|
|
|
Service Code
|
NDC 00536120215
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.22 |
| Max. Negotiated Rate |
$27.04 |
| 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 |
$27.04
|
| 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
|
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 % 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
|
$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
|
IP
|
$37.56
|
|
|
Service Code
|
NDC 45611000936
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$16.53 |
| Max. Negotiated Rate |
$33.80 |
| Rate for Payer: Aetna American Axle |
$24.41
|
| Rate for Payer: Aetna Commercial |
$31.93
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$24.41
|
| Rate for Payer: Cash Price |
$30.05
|
| Rate for Payer: Cofinity 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 |
$16.53
|
| Rate for Payer: Van Buren County Sheriff Dept. Commercial |
$28.17
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$32.46
|
|
|
Service Code
|
NDC 46581083006
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.01 |
| Max. Negotiated Rate |
$29.21 |
| Rate for Payer: Aetna American Axle |
$21.10
|
| Rate for Payer: Aetna Commercial |
$27.59
|
| Rate for Payer: Aetna Medicare |
$16.23
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.10
|
| Rate for Payer: BCBS Complete |
$12.98
|
| Rate for Payer: Cash Price |
$25.97
|
| Rate for Payer: Cofinity 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
|
$30.05
|
|
|
Service Code
|
NDC 00536120215
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.12 |
| Max. Negotiated Rate |
$27.04 |
| Rate for Payer: Aetna American Axle |
$19.53
|
| Rate for Payer: Aetna Commercial |
$25.54
|
| Rate for Payer: Aetna Medicare |
$15.02
|
| 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 |
$27.04
|
| 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
|
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
|
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
|
$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
|
|
