|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$386.65
|
|
|
Service Code
|
NDC 00904695161
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$251.32 |
| Max. Negotiated Rate |
$386.65 |
| Rate for Payer: Aetna Commercial |
$347.99
|
| Rate for Payer: ASR ASR |
$375.05
|
| Rate for Payer: ASR Commercial |
$375.05
|
| Rate for Payer: BCBS Trust/PPO |
$315.08
|
| Rate for Payer: BCN Commercial |
$299.77
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$363.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Healthscope Commercial |
$386.65
|
| Rate for Payer: Healthscope Whirlpool |
$375.05
|
| Rate for Payer: Mclaren Commercial |
$347.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: Nomi Health Commercial |
$317.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$340.25
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$2.74
|
|
|
Service Code
|
NDC 51079044101
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.78 |
| Max. Negotiated Rate |
$2.74 |
| Rate for Payer: Aetna Commercial |
$2.47
|
| Rate for Payer: ASR ASR |
$2.66
|
| Rate for Payer: ASR Commercial |
$2.66
|
| Rate for Payer: BCBS Trust/PPO |
$2.23
|
| Rate for Payer: BCN Commercial |
$2.12
|
| Rate for Payer: Cash Price |
$2.19
|
| Rate for Payer: Cofinity Commercial |
$2.58
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.19
|
| Rate for Payer: Healthscope Commercial |
$2.74
|
| Rate for Payer: Healthscope Whirlpool |
$2.66
|
| Rate for Payer: Mclaren Commercial |
$2.47
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.33
|
| Rate for Payer: Nomi Health Commercial |
$2.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.41
|
|
|
LEVOTHYROXINE 75 MCG TABLET
|
Facility
|
IP
|
$273.60
|
|
|
Service Code
|
NDC 51079044120
|
| Hospital Charge Code |
4422
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$177.84 |
| Max. Negotiated Rate |
$273.60 |
| Rate for Payer: Aetna Commercial |
$246.24
|
| Rate for Payer: ASR ASR |
$265.39
|
| Rate for Payer: ASR Commercial |
$265.39
|
| Rate for Payer: BCBS Trust/PPO |
$222.96
|
| Rate for Payer: BCN Commercial |
$212.12
|
| Rate for Payer: Cash Price |
$218.88
|
| Rate for Payer: Cofinity Commercial |
$257.18
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$218.88
|
| Rate for Payer: Healthscope Commercial |
$273.60
|
| Rate for Payer: Healthscope Whirlpool |
$265.39
|
| Rate for Payer: Mclaren Commercial |
$246.24
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$232.56
|
| Rate for Payer: Nomi Health Commercial |
$224.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$177.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$240.77
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$141.71
|
|
|
Service Code
|
NDC 68180096809
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$92.11 |
| Max. Negotiated Rate |
$141.71 |
| Rate for Payer: Aetna Commercial |
$127.54
|
| Rate for Payer: ASR ASR |
$137.46
|
| Rate for Payer: ASR Commercial |
$137.46
|
| Rate for Payer: BCBS Trust/PPO |
$115.48
|
| Rate for Payer: BCN Commercial |
$109.87
|
| Rate for Payer: Cash Price |
$113.36
|
| Rate for Payer: Cofinity Commercial |
$133.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.37
|
| Rate for Payer: Healthscope Commercial |
$141.71
|
| Rate for Payer: Healthscope Whirlpool |
$137.46
|
| Rate for Payer: Mclaren Commercial |
$127.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.45
|
| Rate for Payer: Nomi Health Commercial |
$116.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.70
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$386.65
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$154.66 |
| Max. Negotiated Rate |
$386.65 |
| Rate for Payer: Aetna Commercial |
$347.99
|
| Rate for Payer: Aetna Medicare |
$193.32
|
| Rate for Payer: ASR ASR |
$375.05
|
| Rate for Payer: ASR Commercial |
$375.05
|
| Rate for Payer: BCBS Complete |
$154.66
|
| Rate for Payer: BCBS Trust/PPO |
$316.63
|
| Rate for Payer: BCN Commercial |
$299.77
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$363.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Healthscope Commercial |
$386.65
|
| Rate for Payer: Healthscope Whirlpool |
$375.05
|
| Rate for Payer: Mclaren Commercial |
$347.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: Nomi Health Commercial |
$317.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$338.78
|
| Rate for Payer: Priority Health Narrow Network |
$271.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$340.25
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$250.56
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.86 |
| Max. Negotiated Rate |
$250.56 |
| Rate for Payer: Aetna Commercial |
$225.50
|
| Rate for Payer: ASR ASR |
$243.04
|
| Rate for Payer: ASR Commercial |
$243.04
|
| Rate for Payer: BCBS Trust/PPO |
$204.18
|
| Rate for Payer: BCN Commercial |
$194.26
|
| Rate for Payer: Cash Price |
$200.45
|
| Rate for Payer: Cofinity Commercial |
$235.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.45
|
| Rate for Payer: Healthscope Commercial |
$250.56
|
| Rate for Payer: Healthscope Whirlpool |
$243.04
|
| Rate for Payer: Mclaren Commercial |
$225.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.98
|
| Rate for Payer: Nomi Health Commercial |
$205.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.86
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$220.49
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$250.56
|
|
|
Service Code
|
NDC 42292003820
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$100.22 |
| Max. Negotiated Rate |
$250.56 |
| Rate for Payer: Aetna Commercial |
$225.50
|
| Rate for Payer: Aetna Medicare |
$125.28
|
| Rate for Payer: ASR ASR |
$243.04
|
| Rate for Payer: ASR Commercial |
$243.04
|
| Rate for Payer: BCBS Complete |
$100.22
|
| Rate for Payer: BCBS Trust/PPO |
$205.18
|
| Rate for Payer: BCN Commercial |
$194.26
|
| Rate for Payer: Cash Price |
$200.45
|
| Rate for Payer: Cofinity Commercial |
$235.53
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$200.45
|
| Rate for Payer: Healthscope Commercial |
$250.56
|
| Rate for Payer: Healthscope Whirlpool |
$243.04
|
| Rate for Payer: Mclaren Commercial |
$225.50
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$212.98
|
| Rate for Payer: Nomi Health Commercial |
$205.46
|
| Rate for Payer: Priority Health Cigna Priority Health |
$162.86
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$219.54
|
| Rate for Payer: Priority Health Narrow Network |
$175.64
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$220.49
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$2.51
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.63 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Aetna Commercial |
$2.26
|
| Rate for Payer: ASR ASR |
$2.43
|
| Rate for Payer: ASR Commercial |
$2.43
|
| Rate for Payer: BCBS Trust/PPO |
$2.05
|
| Rate for Payer: BCN Commercial |
$1.95
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cofinity Commercial |
$2.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.01
|
| Rate for Payer: Healthscope Commercial |
$2.51
|
| Rate for Payer: Healthscope Whirlpool |
$2.43
|
| Rate for Payer: Mclaren Commercial |
$2.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.13
|
| Rate for Payer: Nomi Health Commercial |
$2.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.63
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.21
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$141.71
|
|
|
Service Code
|
NDC 68180096809
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$56.68 |
| Max. Negotiated Rate |
$141.71 |
| Rate for Payer: Aetna Commercial |
$127.54
|
| Rate for Payer: Aetna Medicare |
$70.86
|
| Rate for Payer: ASR ASR |
$137.46
|
| Rate for Payer: ASR Commercial |
$137.46
|
| Rate for Payer: BCBS Complete |
$56.68
|
| Rate for Payer: BCBS Trust/PPO |
$116.05
|
| Rate for Payer: BCN Commercial |
$109.87
|
| Rate for Payer: Cash Price |
$113.36
|
| Rate for Payer: Cofinity Commercial |
$133.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$113.37
|
| Rate for Payer: Healthscope Commercial |
$141.71
|
| Rate for Payer: Healthscope Whirlpool |
$137.46
|
| Rate for Payer: Mclaren Commercial |
$127.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$120.45
|
| Rate for Payer: Nomi Health Commercial |
$116.20
|
| Rate for Payer: Priority Health Cigna Priority Health |
$92.11
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$124.17
|
| Rate for Payer: Priority Health Narrow Network |
$99.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$124.70
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
IP
|
$386.65
|
|
|
Service Code
|
NDC 00904695261
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$251.32 |
| Max. Negotiated Rate |
$386.65 |
| Rate for Payer: Aetna Commercial |
$347.99
|
| Rate for Payer: ASR ASR |
$375.05
|
| Rate for Payer: ASR Commercial |
$375.05
|
| Rate for Payer: BCBS Trust/PPO |
$315.08
|
| Rate for Payer: BCN Commercial |
$299.77
|
| Rate for Payer: Cash Price |
$309.32
|
| Rate for Payer: Cofinity Commercial |
$363.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$309.32
|
| Rate for Payer: Healthscope Commercial |
$386.65
|
| Rate for Payer: Healthscope Whirlpool |
$375.05
|
| Rate for Payer: Mclaren Commercial |
$347.99
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$328.65
|
| Rate for Payer: Nomi Health Commercial |
$317.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$251.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$340.25
|
|
|
LEVOTHYROXINE 88 MCG TABLET
|
Facility
|
OP
|
$2.51
|
|
|
Service Code
|
NDC 42292003801
|
| Hospital Charge Code |
10403
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.00 |
| Max. Negotiated Rate |
$2.51 |
| Rate for Payer: Aetna Commercial |
$2.26
|
| Rate for Payer: Aetna Medicare |
$1.25
|
| Rate for Payer: ASR ASR |
$2.43
|
| Rate for Payer: ASR Commercial |
$2.43
|
| Rate for Payer: BCBS Complete |
$1.00
|
| Rate for Payer: BCBS Trust/PPO |
$2.06
|
| Rate for Payer: BCN Commercial |
$1.95
|
| Rate for Payer: Cash Price |
$2.00
|
| Rate for Payer: Cofinity Commercial |
$2.36
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.01
|
| Rate for Payer: Healthscope Commercial |
$2.51
|
| Rate for Payer: Healthscope Whirlpool |
$2.43
|
| Rate for Payer: Mclaren Commercial |
$2.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2.13
|
| Rate for Payer: Nomi Health Commercial |
$2.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$1.63
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$2.20
|
| Rate for Payer: Priority Health Narrow Network |
$1.76
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$2.21
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$44.94
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$29.21 |
| Max. Negotiated Rate |
$44.94 |
| Rate for Payer: Aetna Commercial |
$40.45
|
| Rate for Payer: Aetna Commercial |
$17.38
|
| Rate for Payer: ASR ASR |
$18.73
|
| Rate for Payer: ASR ASR |
$43.59
|
| Rate for Payer: ASR Commercial |
$18.73
|
| Rate for Payer: ASR Commercial |
$43.59
|
| Rate for Payer: BCBS Trust/PPO |
$15.74
|
| Rate for Payer: BCBS Trust/PPO |
$36.62
|
| Rate for Payer: BCN Commercial |
$34.84
|
| Rate for Payer: BCN Commercial |
$14.97
|
| 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 |
$42.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.95
|
| Rate for Payer: Healthscope Commercial |
$19.31
|
| Rate for Payer: Healthscope Commercial |
$44.94
|
| Rate for Payer: Healthscope Whirlpool |
$43.59
|
| Rate for Payer: Healthscope Whirlpool |
$18.73
|
| Rate for Payer: Mclaren Commercial |
$17.38
|
| Rate for Payer: Mclaren Commercial |
$40.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.41
|
| Rate for Payer: Nomi Health Commercial |
$36.85
|
| Rate for Payer: Nomi Health Commercial |
$15.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.99
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.55
|
|
|
LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
OP
|
$19.31
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10427
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$19.31 |
| Rate for Payer: Aetna Commercial |
$17.38
|
| Rate for Payer: Aetna Commercial |
$40.45
|
| Rate for Payer: Aetna Medicare |
$9.65
|
| Rate for Payer: Aetna Medicare |
$22.47
|
| Rate for Payer: ASR ASR |
$18.73
|
| Rate for Payer: ASR ASR |
$43.59
|
| Rate for Payer: ASR Commercial |
$43.59
|
| Rate for Payer: ASR Commercial |
$18.73
|
| Rate for Payer: BCBS Complete |
$7.72
|
| Rate for Payer: BCBS Complete |
$17.98
|
| Rate for Payer: BCBS Trust/PPO |
$15.81
|
| Rate for Payer: BCBS Trust/PPO |
$36.80
|
| Rate for Payer: BCN Commercial |
$34.84
|
| Rate for Payer: BCN Commercial |
$14.97
|
| Rate for Payer: Cash Price |
$15.45
|
| Rate for Payer: Cash Price |
$35.96
|
| Rate for Payer: Cofinity Commercial |
$18.15
|
| Rate for Payer: Cofinity Commercial |
$42.24
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$35.95
|
| Rate for Payer: Healthscope Commercial |
$19.31
|
| Rate for Payer: Healthscope Commercial |
$44.94
|
| Rate for Payer: Healthscope Whirlpool |
$18.73
|
| Rate for Payer: Healthscope Whirlpool |
$43.59
|
| Rate for Payer: Mclaren Commercial |
$17.38
|
| Rate for Payer: Mclaren Commercial |
$40.45
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$38.20
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.41
|
| Rate for Payer: Nomi Health Commercial |
$15.83
|
| Rate for Payer: Nomi Health Commercial |
$36.85
|
| Rate for Payer: Priority Health Cigna Priority Health |
$29.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.55
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.92
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$39.38
|
| Rate for Payer: Priority Health Narrow Network |
$31.50
|
| Rate for Payer: Priority Health Narrow Network |
$13.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.99
|
|
|
LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION
|
Facility
|
IP
|
$22.91
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$14.89 |
| Max. Negotiated Rate |
$22.91 |
| Rate for Payer: Aetna Commercial |
$20.62
|
| Rate for Payer: Aetna Commercial |
$17.62
|
| Rate for Payer: ASR ASR |
$18.99
|
| Rate for Payer: ASR ASR |
$22.22
|
| Rate for Payer: ASR Commercial |
$18.99
|
| Rate for Payer: ASR Commercial |
$22.22
|
| Rate for Payer: BCBS Trust/PPO |
$15.96
|
| Rate for Payer: BCBS Trust/PPO |
$18.67
|
| Rate for Payer: BCN Commercial |
$17.76
|
| Rate for Payer: BCN Commercial |
$15.18
|
| 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 |
$15.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.33
|
| Rate for Payer: Healthscope Commercial |
$19.58
|
| Rate for Payer: Healthscope Commercial |
$22.91
|
| Rate for Payer: Healthscope Whirlpool |
$22.22
|
| Rate for Payer: Healthscope Whirlpool |
$18.99
|
| Rate for Payer: Mclaren Commercial |
$17.62
|
| Rate for Payer: Mclaren Commercial |
$20.62
|
| 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: Priority Health Cigna Priority Health |
$12.73
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.89
|
| 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
|
$19.58
|
|
|
Service Code
|
HCPCS J2004
|
| Hospital Charge Code |
10430
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.83 |
| Max. Negotiated Rate |
$19.58 |
| Rate for Payer: Aetna Commercial |
$17.62
|
| Rate for Payer: Aetna Commercial |
$20.62
|
| Rate for Payer: Aetna Medicare |
$9.79
|
| Rate for Payer: Aetna Medicare |
$11.46
|
| Rate for Payer: ASR ASR |
$18.99
|
| Rate for Payer: ASR ASR |
$22.22
|
| Rate for Payer: ASR Commercial |
$22.22
|
| Rate for Payer: ASR Commercial |
$18.99
|
| Rate for Payer: BCBS Complete |
$7.83
|
| Rate for Payer: BCBS Complete |
$9.16
|
| Rate for Payer: BCBS Trust/PPO |
$16.03
|
| Rate for Payer: BCBS Trust/PPO |
$18.76
|
| Rate for Payer: BCN Commercial |
$17.76
|
| Rate for Payer: BCN Commercial |
$15.18
|
| Rate for Payer: Cash Price |
$15.66
|
| Rate for Payer: Cash Price |
$18.33
|
| Rate for Payer: Cofinity Commercial |
$18.41
|
| Rate for Payer: Cofinity Commercial |
$21.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.66
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.33
|
| Rate for Payer: Healthscope Commercial |
$19.58
|
| Rate for Payer: Healthscope Commercial |
$22.91
|
| Rate for Payer: Healthscope Whirlpool |
$18.99
|
| Rate for Payer: Healthscope Whirlpool |
$22.22
|
| Rate for Payer: Mclaren Commercial |
$17.62
|
| Rate for Payer: Mclaren Commercial |
$20.62
|
| 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 |
$16.06
|
| Rate for Payer: Nomi Health Commercial |
$18.79
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.73
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$17.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.07
|
| Rate for Payer: Priority Health Narrow Network |
$16.06
|
| Rate for Payer: Priority Health Narrow Network |
$13.73
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$17.23
|
|
|
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 |
$6.36 |
| Max. Negotiated Rate |
$15.90 |
| Rate for Payer: Aetna Commercial |
$14.31
|
| Rate for Payer: Aetna Medicare |
$7.95
|
| Rate for Payer: ASR ASR |
$15.42
|
| Rate for Payer: ASR Commercial |
$15.42
|
| Rate for Payer: BCBS Complete |
$6.36
|
| Rate for Payer: BCBS Trust/PPO |
$13.02
|
| Rate for Payer: BCN Commercial |
$12.33
|
| 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 |
$15.90
|
| Rate for Payer: Healthscope Whirlpool |
$15.42
|
| 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: Priority Health Cigna Priority Health |
$10.34
|
| Rate for Payer: 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
|
OP
|
$21.85
|
|
|
Service Code
|
NDC 76329301205
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$8.74 |
| Max. Negotiated Rate |
$21.85 |
| Rate for Payer: Aetna Commercial |
$19.66
|
| Rate for Payer: Aetna Medicare |
$10.93
|
| Rate for Payer: ASR ASR |
$21.19
|
| Rate for Payer: ASR Commercial |
$21.19
|
| Rate for Payer: BCBS Complete |
$8.74
|
| Rate for Payer: BCBS Trust/PPO |
$17.89
|
| Rate for Payer: BCN Commercial |
$16.94
|
| Rate for Payer: Cash Price |
$17.48
|
| Rate for Payer: Cofinity Commercial |
$20.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.48
|
| Rate for Payer: Healthscope Commercial |
$21.85
|
| Rate for Payer: Healthscope Whirlpool |
$21.19
|
| Rate for Payer: Mclaren Commercial |
$19.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.57
|
| Rate for Payer: Nomi Health Commercial |
$17.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$19.14
|
| Rate for Payer: Priority Health Narrow Network |
$15.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.23
|
|
|
LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR
|
Facility
|
IP
|
$21.85
|
|
|
Service Code
|
NDC 76329301205
|
| Hospital Charge Code |
118460
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.20 |
| Max. Negotiated Rate |
$21.85 |
| Rate for Payer: Aetna Commercial |
$19.66
|
| Rate for Payer: ASR ASR |
$21.19
|
| Rate for Payer: ASR Commercial |
$21.19
|
| Rate for Payer: BCBS Trust/PPO |
$17.81
|
| Rate for Payer: BCN Commercial |
$16.94
|
| Rate for Payer: Cash Price |
$17.48
|
| Rate for Payer: Cofinity Commercial |
$20.54
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.48
|
| Rate for Payer: Healthscope Commercial |
$21.85
|
| Rate for Payer: Healthscope Whirlpool |
$21.19
|
| Rate for Payer: Mclaren Commercial |
$19.66
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.57
|
| Rate for Payer: Nomi Health Commercial |
$17.92
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.23
|
|
|
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 |
$10.34 |
| Max. Negotiated Rate |
$15.90 |
| Rate for Payer: Aetna Commercial |
$14.31
|
| Rate for Payer: ASR ASR |
$15.42
|
| Rate for Payer: ASR Commercial |
$15.42
|
| Rate for Payer: BCBS Trust/PPO |
$12.96
|
| Rate for Payer: BCN Commercial |
$12.33
|
| 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 |
$15.90
|
| Rate for Payer: Healthscope Whirlpool |
$15.42
|
| 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: Priority Health Cigna Priority Health |
$10.34
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.99
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
OP
|
$29.92
|
|
|
Service Code
|
NDC 71266629001
|
| Hospital Charge Code |
196007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$11.97 |
| Max. Negotiated Rate |
$29.92 |
| Rate for Payer: Aetna Commercial |
$26.93
|
| Rate for Payer: Aetna Medicare |
$14.96
|
| Rate for Payer: ASR ASR |
$29.02
|
| Rate for Payer: ASR Commercial |
$29.02
|
| Rate for Payer: BCBS Complete |
$11.97
|
| Rate for Payer: BCBS Trust/PPO |
$24.50
|
| Rate for Payer: BCN Commercial |
$23.20
|
| Rate for Payer: Cash Price |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$28.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.94
|
| Rate for Payer: Healthscope Commercial |
$29.92
|
| Rate for Payer: Healthscope Whirlpool |
$29.02
|
| Rate for Payer: Mclaren Commercial |
$26.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.43
|
| Rate for Payer: Nomi Health Commercial |
$24.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$26.22
|
| Rate for Payer: Priority Health Narrow Network |
$20.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26.33
|
|
|
LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL
|
Facility
|
IP
|
$29.92
|
|
|
Service Code
|
NDC 71266629001
|
| Hospital Charge Code |
196007
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$19.45 |
| Max. Negotiated Rate |
$29.92 |
| Rate for Payer: Aetna Commercial |
$26.93
|
| Rate for Payer: ASR ASR |
$29.02
|
| Rate for Payer: ASR Commercial |
$29.02
|
| Rate for Payer: BCBS Trust/PPO |
$24.38
|
| Rate for Payer: BCN Commercial |
$23.20
|
| Rate for Payer: Cash Price |
$23.94
|
| Rate for Payer: Cofinity Commercial |
$28.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$23.94
|
| Rate for Payer: Healthscope Commercial |
$29.92
|
| Rate for Payer: Healthscope Whirlpool |
$29.02
|
| Rate for Payer: Mclaren Commercial |
$26.93
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$25.43
|
| Rate for Payer: Nomi Health Commercial |
$24.53
|
| Rate for Payer: Priority Health Cigna Priority Health |
$19.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$26.33
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
OP
|
$45.36
|
|
|
Service Code
|
NDC 41167005840
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$18.14 |
| Max. Negotiated Rate |
$45.36 |
| Rate for Payer: Aetna Commercial |
$40.82
|
| Rate for Payer: Aetna Medicare |
$22.68
|
| Rate for Payer: ASR ASR |
$44.00
|
| Rate for Payer: ASR Commercial |
$44.00
|
| Rate for Payer: BCBS Complete |
$18.14
|
| Rate for Payer: BCBS Trust/PPO |
$37.15
|
| Rate for Payer: BCN Commercial |
$35.17
|
| 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 |
$45.36
|
| Rate for Payer: Healthscope Whirlpool |
$44.00
|
| 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: Priority Health Cigna Priority Health |
$29.48
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$39.74
|
| Rate for Payer: Priority Health Narrow Network |
$31.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.92
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$18.72
|
|
|
Service Code
|
NDC 96295013458
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.17 |
| Max. Negotiated Rate |
$18.72 |
| Rate for Payer: Aetna Commercial |
$16.85
|
| Rate for Payer: ASR ASR |
$18.16
|
| Rate for Payer: ASR Commercial |
$18.16
|
| Rate for Payer: BCBS Trust/PPO |
$15.25
|
| Rate for Payer: BCN Commercial |
$14.51
|
| 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 |
$18.72
|
| Rate for Payer: Healthscope Whirlpool |
$18.16
|
| Rate for Payer: Mclaren Commercial |
$16.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$15.91
|
| Rate for Payer: Nomi Health Commercial |
$15.35
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.17
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.47
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$3.71
|
|
|
Service Code
|
NDC 00121097001
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.41 |
| Max. Negotiated Rate |
$3.71 |
| Rate for Payer: Aetna Commercial |
$3.34
|
| Rate for Payer: ASR ASR |
$3.60
|
| Rate for Payer: ASR Commercial |
$3.60
|
| Rate for Payer: BCBS Trust/PPO |
$3.02
|
| Rate for Payer: BCN Commercial |
$2.88
|
| Rate for Payer: Cash Price |
$2.96
|
| Rate for Payer: Cofinity Commercial |
$3.49
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2.97
|
| Rate for Payer: Healthscope Commercial |
$3.71
|
| Rate for Payer: Healthscope Whirlpool |
$3.60
|
| 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: Priority Health Cigna Priority Health |
$2.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$3.26
|
|
|
LIDOCAINE 4 % TOPICAL PATCH
|
Facility
|
IP
|
$45.36
|
|
|
Service Code
|
NDC 41167005840
|
| Hospital Charge Code |
108212
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$29.48 |
| Max. Negotiated Rate |
$45.36 |
| Rate for Payer: Aetna Commercial |
$40.82
|
| Rate for Payer: ASR ASR |
$44.00
|
| Rate for Payer: ASR Commercial |
$44.00
|
| Rate for Payer: BCBS Trust/PPO |
$36.96
|
| Rate for Payer: BCN Commercial |
$35.17
|
| 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 |
$45.36
|
| Rate for Payer: Healthscope Whirlpool |
$44.00
|
| 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: Priority Health Cigna Priority Health |
$29.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$39.92
|
|
