|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
OP
|
$15.52
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$15.52 |
| Rate for Payer: Aetna Commercial |
$13.97
|
| Rate for Payer: Aetna Commercial |
$17.23
|
| Rate for Payer: Aetna Commercial |
$11.74
|
| Rate for Payer: Aetna Commercial |
$22.18
|
| Rate for Payer: Aetna Commercial |
$11.48
|
| Rate for Payer: Aetna Commercial |
$22.31
|
| Rate for Payer: Aetna Commercial |
$19.65
|
| Rate for Payer: Aetna Commercial |
$14.88
|
| Rate for Payer: Aetna Commercial |
$15.31
|
| Rate for Payer: Aetna Medicare |
$6.52
|
| Rate for Payer: Aetna Medicare |
$7.76
|
| Rate for Payer: Aetna Medicare |
$9.57
|
| Rate for Payer: Aetna Medicare |
$8.50
|
| Rate for Payer: Aetna Medicare |
$10.92
|
| Rate for Payer: Aetna Medicare |
$12.32
|
| Rate for Payer: Aetna Medicare |
$12.40
|
| Rate for Payer: Aetna Medicare |
$8.26
|
| Rate for Payer: Aetna Medicare |
$6.38
|
| Rate for Payer: ASR ASR |
$16.50
|
| Rate for Payer: ASR ASR |
$16.03
|
| Rate for Payer: ASR ASR |
$12.66
|
| Rate for Payer: ASR ASR |
$15.05
|
| Rate for Payer: ASR ASR |
$12.38
|
| Rate for Payer: ASR ASR |
$24.05
|
| Rate for Payer: ASR ASR |
$23.91
|
| Rate for Payer: ASR ASR |
$21.18
|
| Rate for Payer: ASR ASR |
$18.57
|
| Rate for Payer: ASR Commercial |
$24.05
|
| Rate for Payer: ASR Commercial |
$16.50
|
| Rate for Payer: ASR Commercial |
$16.03
|
| Rate for Payer: ASR Commercial |
$12.66
|
| Rate for Payer: ASR Commercial |
$23.91
|
| Rate for Payer: ASR Commercial |
$21.18
|
| Rate for Payer: ASR Commercial |
$15.05
|
| Rate for Payer: ASR Commercial |
$12.38
|
| Rate for Payer: ASR Commercial |
$18.57
|
| Rate for Payer: BCBS Complete |
$5.10
|
| Rate for Payer: BCBS Complete |
$8.73
|
| Rate for Payer: BCBS Complete |
$6.80
|
| Rate for Payer: BCBS Complete |
$7.66
|
| Rate for Payer: BCBS Complete |
$6.61
|
| Rate for Payer: BCBS Complete |
$5.22
|
| Rate for Payer: BCBS Complete |
$9.92
|
| Rate for Payer: BCBS Complete |
$9.86
|
| Rate for Payer: BCBS Complete |
$6.21
|
| Rate for Payer: BCBS Trust/PPO |
$12.71
|
| Rate for Payer: BCBS Trust/PPO |
$10.69
|
| Rate for Payer: BCBS Trust/PPO |
$20.30
|
| Rate for Payer: BCBS Trust/PPO |
$20.19
|
| Rate for Payer: BCBS Trust/PPO |
$13.93
|
| Rate for Payer: BCBS Trust/PPO |
$17.88
|
| Rate for Payer: BCBS Trust/PPO |
$15.67
|
| Rate for Payer: BCBS Trust/PPO |
$13.54
|
| Rate for Payer: BCBS Trust/PPO |
$10.45
|
| Rate for Payer: BCN Commercial |
$16.92
|
| Rate for Payer: BCN Commercial |
$19.11
|
| Rate for Payer: BCN Commercial |
$9.89
|
| Rate for Payer: BCN Commercial |
$13.19
|
| Rate for Payer: BCN Commercial |
$19.22
|
| Rate for Payer: BCN Commercial |
$12.03
|
| Rate for Payer: BCN Commercial |
$14.84
|
| Rate for Payer: BCN Commercial |
$10.12
|
| Rate for Payer: BCN Commercial |
$12.82
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cash Price |
$10.21
|
| Rate for Payer: Cash Price |
$10.44
|
| Rate for Payer: Cash Price |
$10.44
|
| Rate for Payer: Cash Price |
$10.21
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cash Price |
$13.22
|
| Rate for Payer: Cash Price |
$13.22
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Cash Price |
$15.31
|
| Rate for Payer: Cash Price |
$15.31
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cash Price |
$19.72
|
| Rate for Payer: Cash Price |
$19.72
|
| Rate for Payer: Cash Price |
$19.83
|
| Rate for Payer: Cash Price |
$19.83
|
| Rate for Payer: Cofinity Commercial |
$20.52
|
| Rate for Payer: Cofinity Commercial |
$12.27
|
| Rate for Payer: Cofinity Commercial |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$23.17
|
| Rate for Payer: Cofinity Commercial |
$23.30
|
| Rate for Payer: Cofinity Commercial |
$14.59
|
| Rate for Payer: Cofinity Commercial |
$11.99
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$17.99
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.42
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.46
|
| Rate for Payer: Healthscope Commercial |
$19.14
|
| Rate for Payer: Healthscope Commercial |
$12.76
|
| Rate for Payer: Healthscope Commercial |
$13.05
|
| Rate for Payer: Healthscope Commercial |
$16.53
|
| Rate for Payer: Healthscope Commercial |
$15.52
|
| Rate for Payer: Healthscope Commercial |
$21.83
|
| Rate for Payer: Healthscope Commercial |
$24.79
|
| Rate for Payer: Healthscope Commercial |
$17.01
|
| Rate for Payer: Healthscope Commercial |
$24.65
|
| Rate for Payer: Healthscope Whirlpool |
$15.05
|
| Rate for Payer: Healthscope Whirlpool |
$24.05
|
| Rate for Payer: Healthscope Whirlpool |
$18.57
|
| Rate for Payer: Healthscope Whirlpool |
$23.91
|
| Rate for Payer: Healthscope Whirlpool |
$16.03
|
| Rate for Payer: Healthscope Whirlpool |
$12.38
|
| Rate for Payer: Healthscope Whirlpool |
$16.50
|
| Rate for Payer: Healthscope Whirlpool |
$21.18
|
| Rate for Payer: Healthscope Whirlpool |
$12.66
|
| Rate for Payer: Mclaren Commercial |
$13.97
|
| Rate for Payer: Mclaren Commercial |
$15.31
|
| Rate for Payer: Mclaren Commercial |
$17.23
|
| Rate for Payer: Mclaren Commercial |
$22.18
|
| Rate for Payer: Mclaren Commercial |
$11.48
|
| Rate for Payer: Mclaren Commercial |
$22.31
|
| Rate for Payer: Mclaren Commercial |
$19.65
|
| Rate for Payer: Mclaren Commercial |
$14.88
|
| Rate for Payer: Mclaren Commercial |
$11.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.19
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.95
|
| Rate for Payer: Nomi Health Commercial |
$12.73
|
| Rate for Payer: Nomi Health Commercial |
$10.46
|
| Rate for Payer: Nomi Health Commercial |
$17.90
|
| Rate for Payer: Nomi Health Commercial |
$13.95
|
| Rate for Payer: Nomi Health Commercial |
$20.33
|
| Rate for Payer: Nomi Health Commercial |
$10.70
|
| Rate for Payer: Nomi Health Commercial |
$15.69
|
| Rate for Payer: Nomi Health Commercial |
$13.55
|
| Rate for Payer: Nomi Health Commercial |
$20.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.11
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.74
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$0.01
|
| Rate for Payer: 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: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: Priority Health Narrow Network |
$0.01
|
| Rate for Payer: Priority Health Narrow 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 |
$11.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.97
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.82
|
|
|
LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION
|
Facility
|
IP
|
$12.76
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4452
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.29 |
| Max. Negotiated Rate |
$12.76 |
| Rate for Payer: Aetna Commercial |
$11.48
|
| Rate for Payer: Aetna Commercial |
$22.18
|
| Rate for Payer: Aetna Commercial |
$19.65
|
| Rate for Payer: Aetna Commercial |
$17.23
|
| Rate for Payer: Aetna Commercial |
$15.31
|
| Rate for Payer: Aetna Commercial |
$13.97
|
| Rate for Payer: Aetna Commercial |
$22.31
|
| Rate for Payer: Aetna Commercial |
$14.88
|
| Rate for Payer: Aetna Commercial |
$11.74
|
| Rate for Payer: ASR ASR |
$24.05
|
| Rate for Payer: ASR ASR |
$16.50
|
| Rate for Payer: ASR ASR |
$16.03
|
| Rate for Payer: ASR ASR |
$12.66
|
| Rate for Payer: ASR ASR |
$12.38
|
| Rate for Payer: ASR ASR |
$18.57
|
| Rate for Payer: ASR ASR |
$15.05
|
| Rate for Payer: ASR ASR |
$21.18
|
| Rate for Payer: ASR ASR |
$23.91
|
| Rate for Payer: ASR Commercial |
$24.05
|
| Rate for Payer: ASR Commercial |
$18.57
|
| Rate for Payer: ASR Commercial |
$16.50
|
| Rate for Payer: ASR Commercial |
$23.91
|
| Rate for Payer: ASR Commercial |
$21.18
|
| Rate for Payer: ASR Commercial |
$12.38
|
| Rate for Payer: ASR Commercial |
$12.66
|
| Rate for Payer: ASR Commercial |
$16.03
|
| Rate for Payer: ASR Commercial |
$15.05
|
| Rate for Payer: BCBS Trust/PPO |
$13.47
|
| Rate for Payer: BCBS Trust/PPO |
$15.60
|
| Rate for Payer: BCBS Trust/PPO |
$13.86
|
| Rate for Payer: BCBS Trust/PPO |
$10.40
|
| Rate for Payer: BCBS Trust/PPO |
$10.63
|
| Rate for Payer: BCBS Trust/PPO |
$12.65
|
| Rate for Payer: BCBS Trust/PPO |
$20.20
|
| Rate for Payer: BCBS Trust/PPO |
$20.09
|
| Rate for Payer: BCBS Trust/PPO |
$17.79
|
| Rate for Payer: BCN Commercial |
$9.89
|
| Rate for Payer: BCN Commercial |
$13.19
|
| Rate for Payer: BCN Commercial |
$19.22
|
| Rate for Payer: BCN Commercial |
$14.84
|
| Rate for Payer: BCN Commercial |
$19.11
|
| Rate for Payer: BCN Commercial |
$12.82
|
| Rate for Payer: BCN Commercial |
$12.03
|
| Rate for Payer: BCN Commercial |
$16.92
|
| Rate for Payer: BCN Commercial |
$10.12
|
| Rate for Payer: Cash Price |
$13.22
|
| Rate for Payer: Cash Price |
$17.46
|
| Rate for Payer: Cash Price |
$13.60
|
| Rate for Payer: Cash Price |
$10.44
|
| Rate for Payer: Cash Price |
$19.72
|
| Rate for Payer: Cash Price |
$15.31
|
| Rate for Payer: Cash Price |
$10.21
|
| Rate for Payer: Cash Price |
$19.83
|
| Rate for Payer: Cash Price |
$12.41
|
| Rate for Payer: Cofinity Commercial |
$17.99
|
| Rate for Payer: Cofinity Commercial |
$15.54
|
| Rate for Payer: Cofinity Commercial |
$23.17
|
| Rate for Payer: Cofinity Commercial |
$20.52
|
| Rate for Payer: Cofinity Commercial |
$11.99
|
| Rate for Payer: Cofinity Commercial |
$15.99
|
| Rate for Payer: Cofinity Commercial |
$12.27
|
| Rate for Payer: Cofinity Commercial |
$23.30
|
| Rate for Payer: Cofinity Commercial |
$14.59
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.22
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.83
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.72
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.31
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$17.46
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$13.61
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.21
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$10.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.42
|
| Rate for Payer: Healthscope Commercial |
$19.14
|
| Rate for Payer: Healthscope Commercial |
$15.52
|
| Rate for Payer: Healthscope Commercial |
$16.53
|
| Rate for Payer: Healthscope Commercial |
$13.05
|
| Rate for Payer: Healthscope Commercial |
$12.76
|
| Rate for Payer: Healthscope Commercial |
$17.01
|
| Rate for Payer: Healthscope Commercial |
$21.83
|
| Rate for Payer: Healthscope Commercial |
$24.65
|
| Rate for Payer: Healthscope Commercial |
$24.79
|
| Rate for Payer: Healthscope Whirlpool |
$21.18
|
| Rate for Payer: Healthscope Whirlpool |
$24.05
|
| Rate for Payer: Healthscope Whirlpool |
$12.38
|
| Rate for Payer: Healthscope Whirlpool |
$16.50
|
| Rate for Payer: Healthscope Whirlpool |
$16.03
|
| Rate for Payer: Healthscope Whirlpool |
$12.66
|
| Rate for Payer: Healthscope Whirlpool |
$23.91
|
| Rate for Payer: Healthscope Whirlpool |
$18.57
|
| Rate for Payer: Healthscope Whirlpool |
$15.05
|
| Rate for Payer: Mclaren Commercial |
$15.31
|
| Rate for Payer: Mclaren Commercial |
$22.18
|
| Rate for Payer: Mclaren Commercial |
$22.31
|
| Rate for Payer: Mclaren Commercial |
$11.74
|
| Rate for Payer: Mclaren Commercial |
$13.97
|
| Rate for Payer: Mclaren Commercial |
$19.65
|
| Rate for Payer: Mclaren Commercial |
$11.48
|
| Rate for Payer: Mclaren Commercial |
$14.88
|
| Rate for Payer: Mclaren Commercial |
$17.23
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.27
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$18.56
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$21.07
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.85
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$11.09
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$14.46
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$13.19
|
| Rate for Payer: Nomi Health Commercial |
$13.95
|
| Rate for Payer: Nomi Health Commercial |
$15.69
|
| Rate for Payer: Nomi Health Commercial |
$20.33
|
| Rate for Payer: Nomi Health Commercial |
$17.90
|
| Rate for Payer: Nomi Health Commercial |
$10.46
|
| Rate for Payer: Nomi Health Commercial |
$13.55
|
| Rate for Payer: Nomi Health Commercial |
$12.73
|
| Rate for Payer: Nomi Health Commercial |
$10.70
|
| Rate for Payer: Nomi Health Commercial |
$20.21
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.44
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$14.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.74
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.48
|
| Rate for Payer: Priority Health Cigna Priority Health |
$10.09
|
| Rate for Payer: Priority Health Cigna Priority Health |
$8.29
|
| Rate for Payer: Priority Health Cigna Priority Health |
$11.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$16.11
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.66
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$19.21
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$11.48
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.84
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$14.97
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
NDC 17856077502
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.80 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: ASR ASR |
$11.64
|
| Rate for Payer: ASR Commercial |
$11.64
|
| Rate for Payer: BCBS Trust/PPO |
$9.78
|
| Rate for Payer: BCN Commercial |
$9.30
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$11.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.60
|
| Rate for Payer: Healthscope Commercial |
$12.00
|
| Rate for Payer: Healthscope Whirlpool |
$11.64
|
| Rate for Payer: Mclaren Commercial |
$10.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.20
|
| Rate for Payer: Nomi Health Commercial |
$9.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.80
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.56
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$4.68
|
|
|
Service Code
|
NDC 09900000339
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.04 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$4.21
|
| Rate for Payer: ASR ASR |
$4.54
|
| Rate for Payer: ASR Commercial |
$4.54
|
| Rate for Payer: BCBS Trust/PPO |
$3.81
|
| Rate for Payer: BCN Commercial |
$3.63
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cofinity Commercial |
$4.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.74
|
| Rate for Payer: Healthscope Commercial |
$4.68
|
| Rate for Payer: Healthscope Whirlpool |
$4.54
|
| Rate for Payer: Mclaren Commercial |
$4.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.98
|
| Rate for Payer: Nomi Health Commercial |
$3.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.04
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.12
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$19.30
|
|
|
Service Code
|
NDC 00121495015
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.54 |
| Max. Negotiated Rate |
$19.30 |
| Rate for Payer: Aetna Commercial |
$17.37
|
| Rate for Payer: ASR ASR |
$18.72
|
| Rate for Payer: ASR Commercial |
$18.72
|
| Rate for Payer: BCBS Trust/PPO |
$15.73
|
| Rate for Payer: BCN Commercial |
$14.96
|
| Rate for Payer: Cash Price |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$18.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.44
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Whirlpool |
$18.72
|
| Rate for Payer: Mclaren Commercial |
$17.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.40
|
| Rate for Payer: Nomi Health Commercial |
$15.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.98
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$15.05
|
|
|
Service Code
|
NDC 00121090315
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.02 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Aetna Commercial |
$13.54
|
| Rate for Payer: Aetna Medicare |
$7.52
|
| Rate for Payer: ASR ASR |
$14.60
|
| Rate for Payer: ASR Commercial |
$14.60
|
| Rate for Payer: BCBS Complete |
$6.02
|
| Rate for Payer: BCBS Trust/PPO |
$12.32
|
| Rate for Payer: BCN Commercial |
$11.67
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cofinity Commercial |
$14.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.04
|
| Rate for Payer: Healthscope Commercial |
$15.05
|
| Rate for Payer: Healthscope Whirlpool |
$14.60
|
| Rate for Payer: Mclaren Commercial |
$13.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.79
|
| Rate for Payer: Nomi Health Commercial |
$12.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.19
|
| Rate for Payer: Priority Health Narrow Network |
$10.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.24
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$35.70
|
|
|
Service Code
|
NDC 72888012526
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.20 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: Aetna Commercial |
$32.13
|
| Rate for Payer: ASR ASR |
$34.63
|
| Rate for Payer: ASR Commercial |
$34.63
|
| Rate for Payer: BCBS Trust/PPO |
$29.09
|
| Rate for Payer: BCN Commercial |
$27.68
|
| Rate for Payer: Cash Price |
$28.56
|
| Rate for Payer: Cofinity Commercial |
$33.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.56
|
| Rate for Payer: Healthscope Commercial |
$35.70
|
| Rate for Payer: Healthscope Whirlpool |
$34.63
|
| Rate for Payer: Mclaren Commercial |
$32.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.34
|
| Rate for Payer: Nomi Health Commercial |
$29.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.42
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$15.05
|
|
|
Service Code
|
NDC 00121090340
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$6.02 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Aetna Commercial |
$13.54
|
| Rate for Payer: Aetna Medicare |
$7.52
|
| Rate for Payer: ASR ASR |
$14.60
|
| Rate for Payer: ASR Commercial |
$14.60
|
| Rate for Payer: BCBS Complete |
$6.02
|
| Rate for Payer: BCBS Trust/PPO |
$12.32
|
| Rate for Payer: BCN Commercial |
$11.67
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cofinity Commercial |
$14.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.04
|
| Rate for Payer: Healthscope Commercial |
$15.05
|
| Rate for Payer: Healthscope Whirlpool |
$14.60
|
| Rate for Payer: Mclaren Commercial |
$13.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.79
|
| Rate for Payer: Nomi Health Commercial |
$12.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.78
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$13.19
|
| Rate for Payer: Priority Health Narrow Network |
$10.55
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.24
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$32.55
|
|
|
Service Code
|
NDC 00527600274
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$21.16 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$29.30
|
| Rate for Payer: ASR ASR |
$31.57
|
| Rate for Payer: ASR Commercial |
$31.57
|
| Rate for Payer: BCBS Trust/PPO |
$26.52
|
| Rate for Payer: BCN Commercial |
$25.24
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cofinity Commercial |
$30.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.04
|
| Rate for Payer: Healthscope Commercial |
$32.55
|
| Rate for Payer: Healthscope Whirlpool |
$31.57
|
| Rate for Payer: Mclaren Commercial |
$29.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.67
|
| Rate for Payer: Nomi Health Commercial |
$26.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.16
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.64
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$5.04
|
|
|
Service Code
|
NDC 50383077515
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.02 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna Commercial |
$4.54
|
| Rate for Payer: Aetna Medicare |
$2.52
|
| Rate for Payer: ASR ASR |
$4.89
|
| Rate for Payer: ASR Commercial |
$4.89
|
| Rate for Payer: BCBS Complete |
$2.02
|
| Rate for Payer: BCBS Trust/PPO |
$4.13
|
| Rate for Payer: BCN Commercial |
$3.91
|
| Rate for Payer: Cash Price |
$4.03
|
| Rate for Payer: Cofinity Commercial |
$4.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.03
|
| Rate for Payer: Healthscope Commercial |
$5.04
|
| Rate for Payer: Healthscope Whirlpool |
$4.89
|
| Rate for Payer: Mclaren Commercial |
$4.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.28
|
| Rate for Payer: Nomi Health Commercial |
$4.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.28
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.42
|
| Rate for Payer: Priority Health Narrow Network |
$3.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.44
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$35.70
|
|
|
Service Code
|
NDC 72888012526
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: Aetna Commercial |
$32.13
|
| Rate for Payer: Aetna Medicare |
$17.85
|
| Rate for Payer: ASR ASR |
$34.63
|
| Rate for Payer: ASR Commercial |
$34.63
|
| Rate for Payer: BCBS Complete |
$14.28
|
| Rate for Payer: BCBS Trust/PPO |
$29.23
|
| Rate for Payer: BCN Commercial |
$27.68
|
| Rate for Payer: Cash Price |
$28.56
|
| Rate for Payer: Cofinity Commercial |
$33.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.56
|
| Rate for Payer: Healthscope Commercial |
$35.70
|
| Rate for Payer: Healthscope Whirlpool |
$34.63
|
| Rate for Payer: Mclaren Commercial |
$32.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.34
|
| Rate for Payer: Nomi Health Commercial |
$29.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31.28
|
| Rate for Payer: Priority Health Narrow Network |
$25.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.42
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
NDC 17856077502
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.80 |
| Max. Negotiated Rate |
$12.00 |
| Rate for Payer: Aetna Commercial |
$10.80
|
| Rate for Payer: Aetna Medicare |
$6.00
|
| Rate for Payer: ASR ASR |
$11.64
|
| Rate for Payer: ASR Commercial |
$11.64
|
| Rate for Payer: BCBS Complete |
$4.80
|
| Rate for Payer: BCBS Trust/PPO |
$9.83
|
| Rate for Payer: BCN Commercial |
$9.30
|
| Rate for Payer: Cash Price |
$9.60
|
| Rate for Payer: Cofinity Commercial |
$11.28
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$9.60
|
| Rate for Payer: Healthscope Commercial |
$12.00
|
| Rate for Payer: Healthscope Whirlpool |
$11.64
|
| Rate for Payer: Mclaren Commercial |
$10.80
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$10.20
|
| Rate for Payer: Nomi Health Commercial |
$9.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$7.80
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$10.51
|
| Rate for Payer: Priority Health Narrow Network |
$8.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$10.56
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$19.30
|
|
|
Service Code
|
NDC 00121495040
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.54 |
| Max. Negotiated Rate |
$19.30 |
| Rate for Payer: Aetna Commercial |
$17.37
|
| Rate for Payer: ASR ASR |
$18.72
|
| Rate for Payer: ASR Commercial |
$18.72
|
| Rate for Payer: BCBS Trust/PPO |
$15.73
|
| Rate for Payer: BCN Commercial |
$14.96
|
| Rate for Payer: Cash Price |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$18.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.44
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Whirlpool |
$18.72
|
| Rate for Payer: Mclaren Commercial |
$17.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.40
|
| Rate for Payer: Nomi Health Commercial |
$15.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.54
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.98
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$15.05
|
|
|
Service Code
|
NDC 00121090340
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.78 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Aetna Commercial |
$13.54
|
| Rate for Payer: ASR ASR |
$14.60
|
| Rate for Payer: ASR Commercial |
$14.60
|
| Rate for Payer: BCBS Trust/PPO |
$12.26
|
| Rate for Payer: BCN Commercial |
$11.67
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cofinity Commercial |
$14.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.04
|
| Rate for Payer: Healthscope Commercial |
$15.05
|
| Rate for Payer: Healthscope Whirlpool |
$14.60
|
| Rate for Payer: Mclaren Commercial |
$13.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.79
|
| Rate for Payer: Nomi Health Commercial |
$12.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.24
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$5.04
|
|
|
Service Code
|
NDC 50383077515
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.28 |
| Max. Negotiated Rate |
$5.04 |
| Rate for Payer: Aetna Commercial |
$4.54
|
| Rate for Payer: ASR ASR |
$4.89
|
| Rate for Payer: ASR Commercial |
$4.89
|
| Rate for Payer: BCBS Trust/PPO |
$4.11
|
| Rate for Payer: BCN Commercial |
$3.91
|
| Rate for Payer: Cash Price |
$4.03
|
| Rate for Payer: Cofinity Commercial |
$4.74
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.03
|
| Rate for Payer: Healthscope Commercial |
$5.04
|
| Rate for Payer: Healthscope Whirlpool |
$4.89
|
| Rate for Payer: Mclaren Commercial |
$4.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.28
|
| Rate for Payer: Nomi Health Commercial |
$4.13
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.44
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$35.35
|
|
|
Service Code
|
NDC 00054350049
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$22.98 |
| Max. Negotiated Rate |
$35.35 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: ASR ASR |
$34.29
|
| Rate for Payer: ASR Commercial |
$34.29
|
| Rate for Payer: BCBS Trust/PPO |
$28.81
|
| Rate for Payer: BCN Commercial |
$27.41
|
| Rate for Payer: Cash Price |
$28.28
|
| Rate for Payer: Cofinity Commercial |
$33.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.28
|
| Rate for Payer: Healthscope Commercial |
$35.35
|
| Rate for Payer: Healthscope Whirlpool |
$34.29
|
| Rate for Payer: Mclaren Commercial |
$31.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.05
|
| Rate for Payer: Nomi Health Commercial |
$28.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.98
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.11
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$35.70
|
|
|
Service Code
|
NDC 50383077504
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.28 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: Aetna Commercial |
$32.13
|
| Rate for Payer: Aetna Medicare |
$17.85
|
| Rate for Payer: ASR ASR |
$34.63
|
| Rate for Payer: ASR Commercial |
$34.63
|
| Rate for Payer: BCBS Complete |
$14.28
|
| Rate for Payer: BCBS Trust/PPO |
$29.23
|
| Rate for Payer: BCN Commercial |
$27.68
|
| Rate for Payer: Cash Price |
$28.56
|
| Rate for Payer: Cofinity Commercial |
$33.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.56
|
| Rate for Payer: Healthscope Commercial |
$35.70
|
| Rate for Payer: Healthscope Whirlpool |
$34.63
|
| Rate for Payer: Mclaren Commercial |
$32.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.34
|
| Rate for Payer: Nomi Health Commercial |
$29.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.20
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$31.28
|
| Rate for Payer: Priority Health Narrow Network |
$25.03
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.42
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$35.35
|
|
|
Service Code
|
NDC 00054350049
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$14.14 |
| Max. Negotiated Rate |
$35.35 |
| Rate for Payer: Aetna Commercial |
$31.82
|
| Rate for Payer: Aetna Medicare |
$17.68
|
| Rate for Payer: ASR ASR |
$34.29
|
| Rate for Payer: ASR Commercial |
$34.29
|
| Rate for Payer: BCBS Complete |
$14.14
|
| Rate for Payer: BCBS Trust/PPO |
$28.95
|
| Rate for Payer: BCN Commercial |
$27.41
|
| Rate for Payer: Cash Price |
$28.28
|
| Rate for Payer: Cofinity Commercial |
$33.23
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.28
|
| Rate for Payer: Healthscope Commercial |
$35.35
|
| Rate for Payer: Healthscope Whirlpool |
$34.29
|
| Rate for Payer: Mclaren Commercial |
$31.82
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.05
|
| Rate for Payer: Nomi Health Commercial |
$28.99
|
| Rate for Payer: Priority Health Cigna Priority Health |
$22.98
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$30.97
|
| Rate for Payer: Priority Health Narrow Network |
$24.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.11
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$19.30
|
|
|
Service Code
|
NDC 00121495040
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$19.30 |
| Rate for Payer: Aetna Commercial |
$17.37
|
| Rate for Payer: Aetna Medicare |
$9.65
|
| Rate for Payer: ASR ASR |
$18.72
|
| Rate for Payer: ASR Commercial |
$18.72
|
| Rate for Payer: BCBS Complete |
$7.72
|
| Rate for Payer: BCBS Trust/PPO |
$15.80
|
| Rate for Payer: BCN Commercial |
$14.96
|
| Rate for Payer: Cash Price |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$18.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.44
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Whirlpool |
$18.72
|
| Rate for Payer: Mclaren Commercial |
$17.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.40
|
| Rate for Payer: Nomi Health Commercial |
$15.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.91
|
| Rate for Payer: Priority Health Narrow Network |
$13.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.98
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$4.68
|
|
|
Service Code
|
NDC 09900000339
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1.87 |
| Max. Negotiated Rate |
$4.68 |
| Rate for Payer: Aetna Commercial |
$4.21
|
| Rate for Payer: Aetna Medicare |
$2.34
|
| Rate for Payer: ASR ASR |
$4.54
|
| Rate for Payer: ASR Commercial |
$4.54
|
| Rate for Payer: BCBS Complete |
$1.87
|
| Rate for Payer: BCBS Trust/PPO |
$3.83
|
| Rate for Payer: BCN Commercial |
$3.63
|
| Rate for Payer: Cash Price |
$3.74
|
| Rate for Payer: Cofinity Commercial |
$4.40
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$3.74
|
| Rate for Payer: Healthscope Commercial |
$4.68
|
| Rate for Payer: Healthscope Whirlpool |
$4.54
|
| Rate for Payer: Mclaren Commercial |
$4.21
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$3.98
|
| Rate for Payer: Nomi Health Commercial |
$3.84
|
| Rate for Payer: Priority Health Cigna Priority Health |
$3.04
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$4.10
|
| Rate for Payer: Priority Health Narrow Network |
$3.28
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$4.12
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$19.30
|
|
|
Service Code
|
NDC 00121495015
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$7.72 |
| Max. Negotiated Rate |
$19.30 |
| Rate for Payer: Aetna Commercial |
$17.37
|
| Rate for Payer: Aetna Medicare |
$9.65
|
| Rate for Payer: ASR ASR |
$18.72
|
| Rate for Payer: ASR Commercial |
$18.72
|
| Rate for Payer: BCBS Complete |
$7.72
|
| Rate for Payer: BCBS Trust/PPO |
$15.80
|
| Rate for Payer: BCN Commercial |
$14.96
|
| Rate for Payer: Cash Price |
$15.44
|
| Rate for Payer: Cofinity Commercial |
$18.14
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$15.44
|
| Rate for Payer: Healthscope Commercial |
$19.30
|
| Rate for Payer: Healthscope Whirlpool |
$18.72
|
| Rate for Payer: Mclaren Commercial |
$17.37
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$16.40
|
| Rate for Payer: Nomi Health Commercial |
$15.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$12.54
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$16.91
|
| Rate for Payer: Priority Health Narrow Network |
$13.53
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$16.98
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$35.70
|
|
|
Service Code
|
NDC 50383077504
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$23.20 |
| Max. Negotiated Rate |
$35.70 |
| Rate for Payer: Aetna Commercial |
$32.13
|
| Rate for Payer: ASR ASR |
$34.63
|
| Rate for Payer: ASR Commercial |
$34.63
|
| Rate for Payer: BCBS Trust/PPO |
$29.09
|
| Rate for Payer: BCN Commercial |
$27.68
|
| Rate for Payer: Cash Price |
$28.56
|
| Rate for Payer: Cofinity Commercial |
$33.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$28.56
|
| Rate for Payer: Healthscope Commercial |
$35.70
|
| Rate for Payer: Healthscope Whirlpool |
$34.63
|
| Rate for Payer: Mclaren Commercial |
$32.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$30.34
|
| Rate for Payer: Nomi Health Commercial |
$29.27
|
| Rate for Payer: Priority Health Cigna Priority Health |
$23.20
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$31.42
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
IP
|
$15.05
|
|
|
Service Code
|
NDC 00121090315
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$9.78 |
| Max. Negotiated Rate |
$15.05 |
| Rate for Payer: Aetna Commercial |
$13.54
|
| Rate for Payer: ASR ASR |
$14.60
|
| Rate for Payer: ASR Commercial |
$14.60
|
| Rate for Payer: BCBS Trust/PPO |
$12.26
|
| Rate for Payer: BCN Commercial |
$11.67
|
| Rate for Payer: Cash Price |
$12.04
|
| Rate for Payer: Cofinity Commercial |
$14.15
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$12.04
|
| Rate for Payer: Healthscope Commercial |
$15.05
|
| Rate for Payer: Healthscope Whirlpool |
$14.60
|
| Rate for Payer: Mclaren Commercial |
$13.54
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$12.79
|
| Rate for Payer: Nomi Health Commercial |
$12.34
|
| Rate for Payer: Priority Health Cigna Priority Health |
$9.78
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$13.24
|
|
|
LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION
|
Facility
|
OP
|
$32.55
|
|
|
Service Code
|
NDC 00527600274
|
| Hospital Charge Code |
109454
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$13.02 |
| Max. Negotiated Rate |
$32.55 |
| Rate for Payer: Aetna Commercial |
$29.30
|
| Rate for Payer: Aetna Medicare |
$16.28
|
| Rate for Payer: ASR ASR |
$31.57
|
| Rate for Payer: ASR Commercial |
$31.57
|
| Rate for Payer: BCBS Complete |
$13.02
|
| Rate for Payer: BCBS Trust/PPO |
$26.66
|
| Rate for Payer: BCN Commercial |
$25.24
|
| Rate for Payer: Cash Price |
$26.04
|
| Rate for Payer: Cofinity Commercial |
$30.60
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.04
|
| Rate for Payer: Healthscope Commercial |
$32.55
|
| Rate for Payer: Healthscope Whirlpool |
$31.57
|
| Rate for Payer: Mclaren Commercial |
$29.30
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.67
|
| Rate for Payer: Nomi Health Commercial |
$26.69
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.16
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$28.52
|
| Rate for Payer: Priority Health Narrow Network |
$22.82
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$28.64
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$90.47
|
|
|
Service Code
|
NDC 00527600480
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$58.81 |
| Max. Negotiated Rate |
$90.47 |
| Rate for Payer: Aetna Commercial |
$81.42
|
| Rate for Payer: ASR ASR |
$87.76
|
| Rate for Payer: ASR Commercial |
$87.76
|
| Rate for Payer: BCBS Trust/PPO |
$73.72
|
| Rate for Payer: BCN Commercial |
$70.14
|
| Rate for Payer: Cash Price |
$72.38
|
| Rate for Payer: Cofinity Commercial |
$85.04
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$72.38
|
| Rate for Payer: Healthscope Commercial |
$90.47
|
| Rate for Payer: Healthscope Whirlpool |
$87.76
|
| Rate for Payer: Mclaren Commercial |
$81.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$76.90
|
| Rate for Payer: Nomi Health Commercial |
$74.19
|
| Rate for Payer: Priority Health Cigna Priority Health |
$58.81
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$79.61
|
|
