|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$4.66
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.49 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$4.19
|
| Rate for Payer: ASR ASR |
$4.52
|
| Rate for Payer: BCBS Trust/PPO |
$3.82
|
| Rate for Payer: BCN Commercial |
$3.82
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Cofinity Commercial |
$4.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.72
|
| Rate for Payer: Healthscope Commercial |
$4.52
|
| Rate for Payer: Healthscope Whirlpool |
$4.66
|
| Rate for Payer: Mclaren Commercial |
$4.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.96
|
| Rate for Payer: Nomi Health Commercial |
$3.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.10
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$145.94
|
|
|
Service Code
|
NDC 68180096809
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$54.00 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna Commercial |
$131.34
|
| Rate for Payer: Aetna Medicare |
$54.00
|
| Rate for Payer: ASR ASR |
$141.56
|
| Rate for Payer: BCBS Complete |
$58.37
|
| Rate for Payer: BCBS Trust/PPO |
$120.32
|
| Rate for Payer: BCN Commercial |
$120.32
|
| Rate for Payer: Cash Price |
$116.75
|
| Rate for Payer: Cofinity Commercial |
$137.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.75
|
| Rate for Payer: Healthscope Commercial |
$141.56
|
| Rate for Payer: Healthscope Whirlpool |
$145.94
|
| Rate for Payer: Mclaren Commercial |
$131.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$116.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.04
|
| Rate for Payer: Nomi Health Commercial |
$119.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$109.45
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$127.87
|
| Rate for Payer: Priority Health Narrow Network |
$102.30
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$128.42
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$465.50
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$349.12 |
| Max. Negotiated Rate |
$465.50 |
| Rate for Payer: Aetna Commercial |
$418.95
|
| Rate for Payer: ASR ASR |
$451.54
|
| Rate for Payer: BCBS Trust/PPO |
$382.27
|
| Rate for Payer: BCN Commercial |
$382.27
|
| Rate for Payer: Cash Price |
$372.40
|
| Rate for Payer: Cofinity Commercial |
$437.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$372.40
|
| Rate for Payer: Healthscope Commercial |
$451.54
|
| Rate for Payer: Healthscope Whirlpool |
$465.50
|
| Rate for Payer: Mclaren Commercial |
$418.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.68
|
| Rate for Payer: Nomi Health Commercial |
$381.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$349.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$409.64
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$406.60
|
|
|
Service Code
|
NDC 904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$304.95 |
| Max. Negotiated Rate |
$406.60 |
| Rate for Payer: Aetna Commercial |
$365.94
|
| Rate for Payer: ASR ASR |
$394.40
|
| Rate for Payer: BCBS Trust/PPO |
$333.90
|
| Rate for Payer: BCN Commercial |
$333.90
|
| Rate for Payer: Cash Price |
$325.28
|
| Rate for Payer: Cofinity Commercial |
$382.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$325.28
|
| Rate for Payer: Healthscope Commercial |
$394.40
|
| Rate for Payer: Healthscope Whirlpool |
$406.60
|
| Rate for Payer: Mclaren Commercial |
$365.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$345.61
|
| Rate for Payer: Nomi Health Commercial |
$333.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$304.95
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$357.81
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$145.94
|
|
|
Service Code
|
NDC 68180096809
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.45 |
| Max. Negotiated Rate |
$145.94 |
| Rate for Payer: Aetna Commercial |
$131.34
|
| Rate for Payer: ASR ASR |
$141.56
|
| Rate for Payer: BCBS Trust/PPO |
$119.84
|
| Rate for Payer: BCN Commercial |
$119.84
|
| Rate for Payer: Cash Price |
$116.75
|
| Rate for Payer: Cofinity Commercial |
$137.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$116.75
|
| Rate for Payer: Healthscope Commercial |
$141.56
|
| Rate for Payer: Healthscope Whirlpool |
$145.94
|
| Rate for Payer: Mclaren Commercial |
$131.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$124.04
|
| Rate for Payer: Nomi Health Commercial |
$119.67
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$109.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$128.42
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$465.50
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$172.24 |
| Max. Negotiated Rate |
$465.50 |
| Rate for Payer: Aetna Commercial |
$418.95
|
| Rate for Payer: Aetna Medicare |
$172.24
|
| Rate for Payer: ASR ASR |
$451.54
|
| Rate for Payer: BCBS Complete |
$186.20
|
| Rate for Payer: BCBS Trust/PPO |
$383.80
|
| Rate for Payer: BCN Commercial |
$383.80
|
| Rate for Payer: Cash Price |
$372.40
|
| Rate for Payer: Cofinity Commercial |
$437.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$372.40
|
| Rate for Payer: Healthscope Commercial |
$451.54
|
| Rate for Payer: Healthscope Whirlpool |
$465.50
|
| Rate for Payer: Mclaren Commercial |
$418.95
|
| Rate for Payer: MI Amish Medical Board Commercial |
$372.40
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$395.68
|
| Rate for Payer: Nomi Health Commercial |
$381.71
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$349.12
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$407.87
|
| Rate for Payer: Priority Health Narrow Network |
$326.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$409.64
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$4.66
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.72 |
| Max. Negotiated Rate |
$4.66 |
| Rate for Payer: Aetna Commercial |
$4.19
|
| Rate for Payer: Aetna Medicare |
$1.72
|
| Rate for Payer: ASR ASR |
$4.52
|
| Rate for Payer: BCBS Complete |
$1.86
|
| Rate for Payer: BCBS Trust/PPO |
$3.84
|
| Rate for Payer: BCN Commercial |
$3.84
|
| Rate for Payer: Cash Price |
$3.72
|
| Rate for Payer: Cofinity Commercial |
$4.38
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.72
|
| Rate for Payer: Healthscope Commercial |
$4.52
|
| Rate for Payer: Healthscope Whirlpool |
$4.66
|
| Rate for Payer: Mclaren Commercial |
$4.19
|
| Rate for Payer: MI Amish Medical Board Commercial |
$3.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.96
|
| Rate for Payer: Nomi Health Commercial |
$3.82
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.49
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.08
|
| Rate for Payer: Priority Health Narrow Network |
$3.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.10
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$19.31
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.48 |
| Max. Negotiated Rate |
$19.31 |
| Rate for Payer: Aetna Commercial |
$17.38
|
| Rate for Payer: Aetna Commercial |
$40.45
|
| Rate for Payer: ASR ASR |
$43.60
|
| Rate for Payer: ASR ASR |
$18.73
|
| Rate for Payer: BCBS Trust/PPO |
$36.91
|
| Rate for Payer: BCBS Trust/PPO |
$15.86
|
| Rate for Payer: BCN Commercial |
$36.91
|
| Rate for Payer: BCN Commercial |
$15.86
|
| Rate for Payer: Cash Price |
$35.96
|
| Rate for Payer: Cash Price |
$15.45
|
| Rate for Payer: Cofinity Commercial |
$18.15
|
| Rate for Payer: Cofinity Commercial |
$42.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.45
|
| Rate for Payer: Healthscope Commercial |
$18.73
|
| Rate for Payer: Healthscope Commercial |
$43.60
|
| Rate for Payer: Healthscope Whirlpool |
$44.95
|
| Rate for Payer: Healthscope Whirlpool |
$19.31
|
| Rate for Payer: Mclaren Commercial |
$40.45
|
| Rate for Payer: Mclaren Commercial |
$17.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.42
|
| Rate for Payer: Nomi Health Commercial |
$36.85
|
| Rate for Payer: Nomi Health Commercial |
$15.84
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.71
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.55
|
|
|
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 |
$0.01 |
| Max. Negotiated Rate |
$44.95 |
| Rate for Payer: Aetna Commercial |
$40.45
|
| Rate for Payer: Aetna Commercial |
$17.38
|
| Rate for Payer: Aetna Medicare |
$7.15
|
| Rate for Payer: Aetna Medicare |
$16.63
|
| Rate for Payer: ASR ASR |
$43.60
|
| Rate for Payer: ASR ASR |
$18.73
|
| Rate for Payer: BCBS Complete |
$7.73
|
| Rate for Payer: BCBS Complete |
$17.98
|
| Rate for Payer: BCBS Trust/PPO |
$37.06
|
| Rate for Payer: BCBS Trust/PPO |
$15.92
|
| Rate for Payer: BCN Commercial |
$15.92
|
| Rate for Payer: BCN Commercial |
$37.06
|
| Rate for Payer: Cash Price |
$35.96
|
| Rate for Payer: Cash Price |
$15.45
|
| Rate for Payer: Cash Price |
$35.96
|
| Rate for Payer: Cash Price |
$15.45
|
| Rate for Payer: Cofinity Commercial |
$18.15
|
| Rate for Payer: Cofinity Commercial |
$42.25
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.96
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.45
|
| Rate for Payer: Healthscope Commercial |
$43.60
|
| Rate for Payer: Healthscope Commercial |
$18.73
|
| Rate for Payer: Healthscope Whirlpool |
$44.95
|
| Rate for Payer: Healthscope Whirlpool |
$19.31
|
| Rate for Payer: Mclaren Commercial |
$40.45
|
| Rate for Payer: Mclaren Commercial |
$17.38
|
| Rate for Payer: MI Amish Medical Board Commercial |
$35.96
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.20
|
| Rate for Payer: Nomi Health Commercial |
$15.84
|
| Rate for Payer: Nomi Health Commercial |
$36.85
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.48
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$33.71
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.00
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.55
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$19.58
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.69 |
| Max. Negotiated Rate |
$19.58 |
| Rate for Payer: Aetna Commercial |
$17.62
|
| Rate for Payer: Aetna Commercial |
$20.62
|
| Rate for Payer: ASR ASR |
$22.22
|
| Rate for Payer: ASR ASR |
$18.99
|
| Rate for Payer: BCBS Trust/PPO |
$18.81
|
| Rate for Payer: BCBS Trust/PPO |
$16.08
|
| Rate for Payer: BCN Commercial |
$18.81
|
| Rate for Payer: BCN Commercial |
$16.08
|
| Rate for Payer: Cash Price |
$18.33
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cofinity Commercial |
$18.41
|
| Rate for Payer: Cofinity Commercial |
$21.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$18.99
|
| Rate for Payer: Healthscope Commercial |
$22.22
|
| Rate for Payer: Healthscope Whirlpool |
$22.91
|
| Rate for Payer: Healthscope Whirlpool |
$19.58
|
| Rate for Payer: Mclaren Commercial |
$20.62
|
| Rate for Payer: Mclaren Commercial |
$17.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.64
|
| Rate for Payer: Nomi Health Commercial |
$18.79
|
| Rate for Payer: Nomi Health Commercial |
$16.06
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.18
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.16
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
OP
|
$22.91
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$22.91 |
| Rate for Payer: Aetna Commercial |
$20.62
|
| Rate for Payer: Aetna Commercial |
$17.62
|
| Rate for Payer: Aetna Medicare |
$7.24
|
| Rate for Payer: Aetna Medicare |
$8.48
|
| Rate for Payer: ASR ASR |
$22.22
|
| Rate for Payer: ASR ASR |
$18.99
|
| Rate for Payer: BCBS Complete |
$7.83
|
| Rate for Payer: BCBS Complete |
$9.16
|
| Rate for Payer: BCBS Trust/PPO |
$18.89
|
| Rate for Payer: BCBS Trust/PPO |
$16.14
|
| Rate for Payer: BCN Commercial |
$16.14
|
| Rate for Payer: BCN Commercial |
$18.89
|
| Rate for Payer: Cash Price |
$18.33
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cash Price |
$18.33
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cofinity Commercial |
$18.41
|
| Rate for Payer: Cofinity Commercial |
$21.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.33
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.66
|
| Rate for Payer: Healthscope Commercial |
$22.22
|
| Rate for Payer: Healthscope Commercial |
$18.99
|
| Rate for Payer: Healthscope Whirlpool |
$22.91
|
| Rate for Payer: Healthscope Whirlpool |
$19.58
|
| Rate for Payer: Mclaren Commercial |
$20.62
|
| Rate for Payer: Mclaren Commercial |
$17.62
|
| Rate for Payer: MI Amish Medical Board Commercial |
$18.33
|
| Rate for Payer: MI Amish Medical Board Commercial |
$15.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.64
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.47
|
| Rate for Payer: Nomi Health Commercial |
$16.06
|
| Rate for Payer: Nomi Health Commercial |
$18.79
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.69
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$17.18
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.16
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$15.90
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.93 |
| Max. Negotiated Rate |
$15.90 |
| Rate for Payer: Aetna Commercial |
$14.31
|
| Rate for Payer: ASR ASR |
$15.43
|
| Rate for Payer: BCBS Trust/PPO |
$13.06
|
| Rate for Payer: BCN Commercial |
$13.06
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: Cofinity Commercial |
$14.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.72
|
| Rate for Payer: Healthscope Commercial |
$15.43
|
| Rate for Payer: Healthscope Whirlpool |
$15.90
|
| Rate for Payer: Mclaren Commercial |
$14.31
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.52
|
| Rate for Payer: Nomi Health Commercial |
$13.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.93
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.99
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$15.90
|
|
|
Service Code
|
NDC 25021067376
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.88 |
| Max. Negotiated Rate |
$15.90 |
| Rate for Payer: Aetna Commercial |
$14.31
|
| Rate for Payer: Aetna Medicare |
$5.88
|
| Rate for Payer: ASR ASR |
$15.43
|
| Rate for Payer: BCBS Complete |
$6.36
|
| Rate for Payer: BCBS Trust/PPO |
$13.11
|
| Rate for Payer: BCN Commercial |
$13.11
|
| Rate for Payer: Cash Price |
$12.72
|
| Rate for Payer: Cofinity Commercial |
$14.95
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.72
|
| Rate for Payer: Healthscope Commercial |
$15.43
|
| Rate for Payer: Healthscope Whirlpool |
$15.90
|
| Rate for Payer: Mclaren Commercial |
$14.31
|
| Rate for Payer: MI Amish Medical Board Commercial |
$12.72
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.52
|
| Rate for Payer: Nomi Health Commercial |
$13.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$11.93
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$13.93
|
| Rate for Payer: Priority Health Narrow Network |
$11.15
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.99
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$26.85
|
|
|
Service Code
|
NDC 76329301205
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.13 |
| Max. Negotiated Rate |
$26.84 |
| Rate for Payer: Aetna Commercial |
$24.16
|
| Rate for Payer: ASR ASR |
$26.04
|
| Rate for Payer: BCBS Trust/PPO |
$22.05
|
| Rate for Payer: BCN Commercial |
$22.05
|
| Rate for Payer: Cash Price |
$21.48
|
| Rate for Payer: Cofinity Commercial |
$25.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.48
|
| Rate for Payer: Healthscope Commercial |
$26.04
|
| Rate for Payer: Healthscope Whirlpool |
$26.84
|
| Rate for Payer: Mclaren Commercial |
$24.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.82
|
| Rate for Payer: Nomi Health Commercial |
$22.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.62
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
OP
|
$26.85
|
|
|
Service Code
|
NDC 76329301205
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.93 |
| Max. Negotiated Rate |
$26.84 |
| Rate for Payer: Aetna Commercial |
$24.16
|
| Rate for Payer: Aetna Medicare |
$9.93
|
| Rate for Payer: ASR ASR |
$26.04
|
| Rate for Payer: BCBS Complete |
$10.74
|
| Rate for Payer: BCBS Trust/PPO |
$22.13
|
| Rate for Payer: BCN Commercial |
$22.13
|
| Rate for Payer: Cash Price |
$21.48
|
| Rate for Payer: Cofinity Commercial |
$25.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.48
|
| Rate for Payer: Healthscope Commercial |
$26.04
|
| Rate for Payer: Healthscope Whirlpool |
$26.84
|
| Rate for Payer: Mclaren Commercial |
$24.16
|
| Rate for Payer: MI Amish Medical Board Commercial |
$21.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$22.82
|
| Rate for Payer: Nomi Health Commercial |
$22.01
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.13
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$23.52
|
| Rate for Payer: Priority Health Narrow Network |
$18.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$23.62
|
|
|
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 |
$29.93 |
| Rate for Payer: Aetna Commercial |
$26.93
|
| Rate for Payer: Aetna Medicare |
$11.07
|
| Rate for Payer: ASR ASR |
$29.03
|
| Rate for Payer: BCBS Complete |
$11.97
|
| Rate for Payer: BCBS Trust/PPO |
$24.67
|
| Rate for Payer: BCN Commercial |
$24.67
|
| Rate for Payer: Cash Price |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$28.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.94
|
| Rate for Payer: Healthscope Commercial |
$29.03
|
| Rate for Payer: Healthscope Whirlpool |
$29.93
|
| Rate for Payer: Mclaren Commercial |
$26.93
|
| Rate for Payer: MI Amish Medical Board Commercial |
$23.94
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.44
|
| Rate for Payer: Nomi Health Commercial |
$24.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.44
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$26.22
|
| Rate for Payer: Priority Health Narrow Network |
$20.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26.33
|
|
|
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 |
$22.44 |
| Max. Negotiated Rate |
$29.93 |
| Rate for Payer: Aetna Commercial |
$26.93
|
| Rate for Payer: ASR ASR |
$29.03
|
| Rate for Payer: BCBS Trust/PPO |
$24.57
|
| Rate for Payer: BCN Commercial |
$24.57
|
| Rate for Payer: Cash Price |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$28.13
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.94
|
| Rate for Payer: Healthscope Commercial |
$29.03
|
| Rate for Payer: Healthscope Whirlpool |
$29.93
|
| Rate for Payer: Mclaren Commercial |
$26.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.44
|
| Rate for Payer: Nomi Health Commercial |
$24.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.44
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26.33
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$3.71
|
|
|
Service Code
|
NDC 121097001
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.37 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: Aetna Medicare |
$1.37
|
| Rate for Payer: ASR ASR |
$3.59
|
| Rate for Payer: BCBS Complete |
$1.48
|
| Rate for Payer: BCBS Trust/PPO |
$3.06
|
| Rate for Payer: BCN Commercial |
$3.06
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.96
|
| Rate for Payer: Healthscope Commercial |
$3.59
|
| Rate for Payer: Healthscope Whirlpool |
$3.71
|
| Rate for Payer: Mclaren Commercial |
$3.34
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2.96
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.15
|
| Rate for Payer: Nomi Health Commercial |
$3.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.78
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$3.25
|
| Rate for Payer: Priority Health Narrow Network |
$2.60
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.26
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$5.47
|
|
|
Service Code
|
NDC 71399445601
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: Aetna Commercial |
$4.92
|
| Rate for Payer: Aetna Medicare |
$2.02
|
| Rate for Payer: ASR ASR |
$5.31
|
| Rate for Payer: BCBS Complete |
$2.19
|
| Rate for Payer: BCBS Trust/PPO |
$4.51
|
| Rate for Payer: BCN Commercial |
$4.51
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cofinity Commercial |
$5.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.38
|
| Rate for Payer: Healthscope Commercial |
$5.31
|
| Rate for Payer: Healthscope Whirlpool |
$5.47
|
| Rate for Payer: Mclaren Commercial |
$4.92
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.38
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.65
|
| Rate for Payer: Nomi Health Commercial |
$4.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.10
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$4.79
|
| Rate for Payer: Priority Health Narrow Network |
$3.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.82
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
NDC 121097001
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.78 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: ASR ASR |
$3.59
|
| Rate for Payer: BCBS Trust/PPO |
$3.04
|
| Rate for Payer: BCN Commercial |
$3.04
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.96
|
| Rate for Payer: Healthscope Commercial |
$3.59
|
| Rate for Payer: Healthscope Whirlpool |
$3.71
|
| Rate for Payer: Mclaren Commercial |
$3.34
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.15
|
| Rate for Payer: Nomi Health Commercial |
$3.04
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.26
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$27.36
|
|
|
Service Code
|
NDC 71399445605
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.52 |
| Max. Negotiated Rate |
$27.36 |
| Rate for Payer: Aetna Commercial |
$24.62
|
| Rate for Payer: ASR ASR |
$26.54
|
| Rate for Payer: BCBS Trust/PPO |
$22.47
|
| Rate for Payer: BCN Commercial |
$22.47
|
| Rate for Payer: Cash Price |
$21.89
|
| Rate for Payer: Cofinity Commercial |
$25.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.89
|
| Rate for Payer: Healthscope Commercial |
$26.54
|
| Rate for Payer: Healthscope Whirlpool |
$27.36
|
| Rate for Payer: Mclaren Commercial |
$24.62
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.26
|
| Rate for Payer: Nomi Health Commercial |
$22.44
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$20.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.08
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$45.36
|
|
|
Service Code
|
NDC 41167005840
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$34.02 |
| Max. Negotiated Rate |
$45.36 |
| Rate for Payer: Aetna Commercial |
$40.82
|
| Rate for Payer: ASR ASR |
$44.00
|
| Rate for Payer: BCBS Trust/PPO |
$37.25
|
| Rate for Payer: BCN Commercial |
$37.25
|
| Rate for Payer: Cash Price |
$36.29
|
| Rate for Payer: Cofinity Commercial |
$42.64
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$36.29
|
| Rate for Payer: Healthscope Commercial |
$44.00
|
| Rate for Payer: Healthscope Whirlpool |
$45.36
|
| Rate for Payer: Mclaren Commercial |
$40.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.56
|
| Rate for Payer: Nomi Health Commercial |
$37.20
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$34.02
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.92
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$30.43
|
|
|
Service Code
|
NDC 536120215
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.26 |
| Max. Negotiated Rate |
$30.43 |
| Rate for Payer: Aetna Commercial |
$27.39
|
| Rate for Payer: Aetna Medicare |
$11.26
|
| Rate for Payer: ASR ASR |
$29.52
|
| Rate for Payer: BCBS Complete |
$12.17
|
| Rate for Payer: BCBS Trust/PPO |
$25.09
|
| Rate for Payer: BCN Commercial |
$25.09
|
| Rate for Payer: Cash Price |
$24.35
|
| Rate for Payer: Cofinity Commercial |
$28.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$24.35
|
| Rate for Payer: Healthscope Commercial |
$29.52
|
| Rate for Payer: Healthscope Whirlpool |
$30.43
|
| Rate for Payer: Mclaren Commercial |
$27.39
|
| Rate for Payer: MI Amish Medical Board Commercial |
$24.35
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.87
|
| Rate for Payer: Nomi Health Commercial |
$24.95
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$22.82
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$26.66
|
| Rate for Payer: Priority Health Narrow Network |
$21.33
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26.78
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$5.47
|
|
|
Service Code
|
NDC 71399445601
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.10 |
| Max. Negotiated Rate |
$5.47 |
| Rate for Payer: Aetna Commercial |
$4.92
|
| Rate for Payer: ASR ASR |
$5.31
|
| Rate for Payer: BCBS Trust/PPO |
$4.49
|
| Rate for Payer: BCN Commercial |
$4.49
|
| Rate for Payer: Cash Price |
$4.38
|
| Rate for Payer: Cofinity Commercial |
$5.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.38
|
| Rate for Payer: Healthscope Commercial |
$5.31
|
| Rate for Payer: Healthscope Whirlpool |
$5.47
|
| Rate for Payer: Mclaren Commercial |
$4.92
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.65
|
| Rate for Payer: Nomi Health Commercial |
$4.49
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4.10
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.82
|
|
|
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 |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: Aetna Medicare |
$6.93
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: BCBS Complete |
$7.49
|
| Rate for Payer: BCBS Trust/PPO |
$15.43
|
| Rate for Payer: BCN Commercial |
$15.43
|
| Rate for Payer: Cash Price |
$14.98
|
| Rate for Payer: Cofinity Commercial |
$17.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$14.98
|
| Rate for Payer: Healthscope Commercial |
$18.16
|
| Rate for Payer: Healthscope Whirlpool |
$18.72
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: MI Amish Medical Board Commercial |
$14.98
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$14.04
|
| Rate for Payer: Priority Health Cigna Priority Health/HMO/PPO/Tiered Network |
$16.40
|
| Rate for Payer: Priority Health Narrow Network |
$13.12
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
