|
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
|
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 |
$16.27
|
| 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 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
|
$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
|
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 |
$7.53
|
| 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
|
$35.35
|
|
|
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
|
$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 |
$16.41
|
| 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
|
$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
|
$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 |
$7.53
|
| 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
|
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
|
$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 |
$16.41
|
| 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
|
$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 |
$16.41
|
| 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 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$133.00
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$86.45 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$119.70
|
| Rate for Payer: ASR ASR |
$129.01
|
| Rate for Payer: ASR Commercial |
$129.01
|
| Rate for Payer: BCBS Trust/PPO |
$108.38
|
| Rate for Payer: BCN Commercial |
$103.11
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cofinity Commercial |
$125.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.40
|
| Rate for Payer: Healthscope Commercial |
$133.00
|
| Rate for Payer: Healthscope Whirlpool |
$129.01
|
| Rate for Payer: Mclaren Commercial |
$119.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.05
|
| Rate for Payer: Nomi Health Commercial |
$109.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$117.04
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$133.00
|
|
|
Service Code
|
NDC 00054350547
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$53.20 |
| Max. Negotiated Rate |
$133.00 |
| Rate for Payer: Aetna Commercial |
$119.70
|
| Rate for Payer: Aetna Medicare |
$66.50
|
| Rate for Payer: ASR ASR |
$129.01
|
| Rate for Payer: ASR Commercial |
$129.01
|
| Rate for Payer: BCBS Complete |
$53.20
|
| Rate for Payer: BCBS Trust/PPO |
$108.91
|
| Rate for Payer: BCN Commercial |
$103.11
|
| Rate for Payer: Cash Price |
$106.40
|
| Rate for Payer: Cofinity Commercial |
$125.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$106.40
|
| Rate for Payer: Healthscope Commercial |
$133.00
|
| Rate for Payer: Healthscope Whirlpool |
$129.01
|
| Rate for Payer: Mclaren Commercial |
$119.70
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$113.05
|
| Rate for Payer: Nomi Health Commercial |
$109.06
|
| Rate for Payer: Priority Health Cigna Priority Health |
$86.45
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$116.53
|
| Rate for Payer: Priority Health Narrow Network |
$93.23
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$117.04
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
IP
|
$71.40
|
|
|
Service Code
|
NDC 52565000950
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$46.41 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Aetna Commercial |
$64.26
|
| Rate for Payer: ASR ASR |
$69.26
|
| Rate for Payer: ASR Commercial |
$69.26
|
| Rate for Payer: BCBS Trust/PPO |
$58.18
|
| Rate for Payer: BCN Commercial |
$55.36
|
| Rate for Payer: Cash Price |
$57.12
|
| Rate for Payer: Cofinity Commercial |
$67.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.12
|
| Rate for Payer: Healthscope Commercial |
$71.40
|
| Rate for Payer: Healthscope Whirlpool |
$69.26
|
| Rate for Payer: Mclaren Commercial |
$64.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.69
|
| Rate for Payer: Nomi Health Commercial |
$58.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.41
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.83
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$90.47
|
|
|
Service Code
|
NDC 00527600480
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$36.19 |
| Max. Negotiated Rate |
$90.47 |
| Rate for Payer: Aetna Commercial |
$81.42
|
| Rate for Payer: Aetna Medicare |
$45.23
|
| Rate for Payer: ASR ASR |
$87.76
|
| Rate for Payer: ASR Commercial |
$87.76
|
| Rate for Payer: BCBS Complete |
$36.19
|
| Rate for Payer: BCBS Trust/PPO |
$74.09
|
| 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: Priority Health HMO/PPO/Tiered Network |
$79.27
|
| Rate for Payer: Priority Health Narrow Network |
$63.42
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$79.61
|
|
|
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
|
|
|
LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION
|
Facility
|
OP
|
$71.40
|
|
|
Service Code
|
NDC 52565000950
|
| Hospital Charge Code |
4450
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$28.56 |
| Max. Negotiated Rate |
$71.40 |
| Rate for Payer: Aetna Commercial |
$64.26
|
| Rate for Payer: Aetna Medicare |
$35.70
|
| Rate for Payer: ASR ASR |
$69.26
|
| Rate for Payer: ASR Commercial |
$69.26
|
| Rate for Payer: BCBS Complete |
$28.56
|
| Rate for Payer: BCBS Trust/PPO |
$58.47
|
| Rate for Payer: BCN Commercial |
$55.36
|
| Rate for Payer: Cash Price |
$57.12
|
| Rate for Payer: Cofinity Commercial |
$67.12
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$57.12
|
| Rate for Payer: Healthscope Commercial |
$71.40
|
| Rate for Payer: Healthscope Whirlpool |
$69.26
|
| Rate for Payer: Mclaren Commercial |
$64.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$60.69
|
| Rate for Payer: Nomi Health Commercial |
$58.55
|
| Rate for Payer: Priority Health Cigna Priority Health |
$46.41
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$62.56
|
| Rate for Payer: Priority Health Narrow Network |
$50.05
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$62.83
|
|
|
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV (CODE)
|
Facility
|
OP
|
$33.38
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
163705
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$13.35 |
| Max. Negotiated Rate |
$33.38 |
| Rate for Payer: Aetna Commercial |
$30.04
|
| Rate for Payer: Aetna Commercial |
$34.05
|
| Rate for Payer: Aetna Medicare |
$16.69
|
| Rate for Payer: Aetna Medicare |
$18.91
|
| Rate for Payer: ASR ASR |
$32.38
|
| Rate for Payer: ASR ASR |
$36.70
|
| Rate for Payer: ASR Commercial |
$36.70
|
| Rate for Payer: ASR Commercial |
$32.38
|
| Rate for Payer: BCBS Complete |
$13.35
|
| Rate for Payer: BCBS Complete |
$15.13
|
| Rate for Payer: BCBS Trust/PPO |
$27.33
|
| Rate for Payer: BCBS Trust/PPO |
$30.98
|
| Rate for Payer: BCN Commercial |
$29.33
|
| Rate for Payer: BCN Commercial |
$25.88
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: Cofinity Commercial |
$31.38
|
| Rate for Payer: Cofinity Commercial |
$35.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.26
|
| Rate for Payer: Healthscope Commercial |
$33.38
|
| Rate for Payer: Healthscope Commercial |
$37.83
|
| Rate for Payer: Healthscope Whirlpool |
$32.38
|
| Rate for Payer: Healthscope Whirlpool |
$36.70
|
| Rate for Payer: Mclaren Commercial |
$30.04
|
| Rate for Payer: Mclaren Commercial |
$34.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.37
|
| Rate for Payer: Nomi Health Commercial |
$27.37
|
| Rate for Payer: Nomi Health Commercial |
$31.02
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.59
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.70
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$29.25
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$33.15
|
| Rate for Payer: Priority Health Narrow Network |
$26.52
|
| Rate for Payer: Priority Health Narrow Network |
$23.40
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.29
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.37
|
|
|
LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV (CODE)
|
Facility
|
IP
|
$37.83
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
163705
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$24.59 |
| Max. Negotiated Rate |
$37.83 |
| Rate for Payer: Aetna Commercial |
$34.05
|
| Rate for Payer: Aetna Commercial |
$30.04
|
| Rate for Payer: ASR ASR |
$32.38
|
| Rate for Payer: ASR ASR |
$36.70
|
| Rate for Payer: ASR Commercial |
$32.38
|
| Rate for Payer: ASR Commercial |
$36.70
|
| Rate for Payer: BCBS Trust/PPO |
$27.20
|
| Rate for Payer: BCBS Trust/PPO |
$30.83
|
| Rate for Payer: BCN Commercial |
$29.33
|
| Rate for Payer: BCN Commercial |
$25.88
|
| Rate for Payer: Cash Price |
$30.26
|
| Rate for Payer: Cash Price |
$26.70
|
| Rate for Payer: Cofinity Commercial |
$31.38
|
| Rate for Payer: Cofinity Commercial |
$35.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.70
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$30.26
|
| Rate for Payer: Healthscope Commercial |
$33.38
|
| Rate for Payer: Healthscope Commercial |
$37.83
|
| Rate for Payer: Healthscope Whirlpool |
$36.70
|
| Rate for Payer: Healthscope Whirlpool |
$32.38
|
| Rate for Payer: Mclaren Commercial |
$30.04
|
| Rate for Payer: Mclaren Commercial |
$34.05
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$32.16
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$28.37
|
| Rate for Payer: Nomi Health Commercial |
$31.02
|
| Rate for Payer: Nomi Health Commercial |
$27.37
|
| Rate for Payer: Priority Health Cigna Priority Health |
$21.70
|
| Rate for Payer: Priority Health Cigna Priority Health |
$24.59
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$29.37
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$33.29
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE
|
Facility
|
OP
|
$23.47
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$23.47 |
| Rate for Payer: Aetna Commercial |
$21.12
|
| Rate for Payer: Aetna Commercial |
$22.00
|
| Rate for Payer: Aetna Commercial |
$24.69
|
| Rate for Payer: Aetna Medicare |
$12.22
|
| Rate for Payer: Aetna Medicare |
$13.71
|
| Rate for Payer: Aetna Medicare |
$11.73
|
| Rate for Payer: ASR ASR |
$23.72
|
| Rate for Payer: ASR ASR |
$22.77
|
| Rate for Payer: ASR ASR |
$26.61
|
| Rate for Payer: ASR Commercial |
$26.61
|
| Rate for Payer: ASR Commercial |
$23.72
|
| Rate for Payer: ASR Commercial |
$22.77
|
| Rate for Payer: BCBS Complete |
$9.39
|
| Rate for Payer: BCBS Complete |
$9.78
|
| Rate for Payer: BCBS Complete |
$10.97
|
| Rate for Payer: BCBS Trust/PPO |
$19.22
|
| Rate for Payer: BCBS Trust/PPO |
$20.02
|
| Rate for Payer: BCBS Trust/PPO |
$22.46
|
| Rate for Payer: BCN Commercial |
$21.27
|
| Rate for Payer: BCN Commercial |
$18.20
|
| Rate for Payer: BCN Commercial |
$18.96
|
| Rate for Payer: Cash Price |
$19.56
|
| Rate for Payer: Cash Price |
$18.78
|
| Rate for Payer: Cash Price |
$21.95
|
| Rate for Payer: Cofinity Commercial |
$25.78
|
| Rate for Payer: Cofinity Commercial |
$22.06
|
| Rate for Payer: Cofinity Commercial |
$22.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.94
|
| Rate for Payer: Healthscope Commercial |
$23.47
|
| Rate for Payer: Healthscope Commercial |
$24.45
|
| Rate for Payer: Healthscope Commercial |
$27.43
|
| Rate for Payer: Healthscope Whirlpool |
$23.72
|
| Rate for Payer: Healthscope Whirlpool |
$22.77
|
| Rate for Payer: Healthscope Whirlpool |
$26.61
|
| Rate for Payer: Mclaren Commercial |
$21.12
|
| Rate for Payer: Mclaren Commercial |
$22.00
|
| Rate for Payer: Mclaren Commercial |
$24.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.95
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.32
|
| Rate for Payer: Nomi Health Commercial |
$19.25
|
| Rate for Payer: Nomi Health Commercial |
$20.05
|
| Rate for Payer: Nomi Health Commercial |
$22.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.89
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.42
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.56
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$24.03
|
| Rate for Payer: Priority Health Narrow Network |
$19.23
|
| Rate for Payer: Priority Health Narrow Network |
$16.45
|
| Rate for Payer: Priority Health Narrow Network |
$17.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.65
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.14
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE
|
Facility
|
IP
|
$24.45
|
|
|
Service Code
|
HCPCS J2003
|
| Hospital Charge Code |
4459
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$15.89 |
| Max. Negotiated Rate |
$24.45 |
| Rate for Payer: Aetna Commercial |
$22.00
|
| Rate for Payer: Aetna Commercial |
$21.12
|
| Rate for Payer: Aetna Commercial |
$24.69
|
| Rate for Payer: ASR ASR |
$22.77
|
| Rate for Payer: ASR ASR |
$23.72
|
| Rate for Payer: ASR ASR |
$26.61
|
| Rate for Payer: ASR Commercial |
$23.72
|
| Rate for Payer: ASR Commercial |
$22.77
|
| Rate for Payer: ASR Commercial |
$26.61
|
| Rate for Payer: BCBS Trust/PPO |
$22.35
|
| Rate for Payer: BCBS Trust/PPO |
$19.13
|
| Rate for Payer: BCBS Trust/PPO |
$19.92
|
| Rate for Payer: BCN Commercial |
$18.20
|
| Rate for Payer: BCN Commercial |
$21.27
|
| Rate for Payer: BCN Commercial |
$18.96
|
| Rate for Payer: Cash Price |
$19.56
|
| Rate for Payer: Cash Price |
$18.78
|
| Rate for Payer: Cash Price |
$21.95
|
| Rate for Payer: Cofinity Commercial |
$25.78
|
| Rate for Payer: Cofinity Commercial |
$22.06
|
| Rate for Payer: Cofinity Commercial |
$22.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.56
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.78
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$21.94
|
| Rate for Payer: Healthscope Commercial |
$23.47
|
| Rate for Payer: Healthscope Commercial |
$24.45
|
| Rate for Payer: Healthscope Commercial |
$27.43
|
| Rate for Payer: Healthscope Whirlpool |
$23.72
|
| Rate for Payer: Healthscope Whirlpool |
$22.77
|
| Rate for Payer: Healthscope Whirlpool |
$26.61
|
| Rate for Payer: Mclaren Commercial |
$22.00
|
| Rate for Payer: Mclaren Commercial |
$21.12
|
| Rate for Payer: Mclaren Commercial |
$24.69
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$23.32
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.78
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.95
|
| Rate for Payer: Nomi Health Commercial |
$20.05
|
| Rate for Payer: Nomi Health Commercial |
$19.25
|
| Rate for Payer: Nomi Health Commercial |
$22.49
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.26
|
| Rate for Payer: Priority Health Cigna Priority Health |
$17.83
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.89
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.52
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$24.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.65
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRINGE (CODE)
|
Facility
|
OP
|
$24.45
|
|
|
Service Code
|
NDC 00409132305
|
| Hospital Charge Code |
163704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.78 |
| Max. Negotiated Rate |
$24.45 |
| Rate for Payer: Aetna Commercial |
$22.00
|
| Rate for Payer: Aetna Medicare |
$12.22
|
| Rate for Payer: ASR ASR |
$23.72
|
| Rate for Payer: ASR Commercial |
$23.72
|
| Rate for Payer: BCBS Complete |
$9.78
|
| Rate for Payer: BCBS Trust/PPO |
$20.02
|
| Rate for Payer: BCN Commercial |
$18.96
|
| Rate for Payer: Cash Price |
$19.56
|
| Rate for Payer: Cofinity Commercial |
$22.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$19.56
|
| Rate for Payer: Healthscope Commercial |
$24.45
|
| Rate for Payer: Healthscope Whirlpool |
$23.72
|
| Rate for Payer: Mclaren Commercial |
$22.00
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$20.78
|
| Rate for Payer: Nomi Health Commercial |
$20.05
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.89
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$21.42
|
| Rate for Payer: Priority Health Narrow Network |
$17.14
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$21.52
|
|
|
LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRINGE (CODE)
|
Facility
|
OP
|
$23.47
|
|
|
Service Code
|
NDC 00409490334
|
| Hospital Charge Code |
163704
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$9.39 |
| Max. Negotiated Rate |
$23.47 |
| Rate for Payer: Aetna Commercial |
$21.12
|
| Rate for Payer: Aetna Medicare |
$11.73
|
| Rate for Payer: ASR ASR |
$22.77
|
| Rate for Payer: ASR Commercial |
$22.77
|
| Rate for Payer: BCBS Complete |
$9.39
|
| Rate for Payer: BCBS Trust/PPO |
$19.22
|
| Rate for Payer: BCN Commercial |
$18.20
|
| Rate for Payer: Cash Price |
$18.78
|
| Rate for Payer: Cofinity Commercial |
$22.06
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$18.78
|
| Rate for Payer: Healthscope Commercial |
$23.47
|
| Rate for Payer: Healthscope Whirlpool |
$22.77
|
| Rate for Payer: Mclaren Commercial |
$21.12
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$19.95
|
| Rate for Payer: Nomi Health Commercial |
$19.25
|
| Rate for Payer: Priority Health Cigna Priority Health |
$15.26
|
| Rate for Payer: Priority Health HMO/PPO/Tiered Network |
$20.56
|
| Rate for Payer: Priority Health Narrow Network |
$16.45
|
| Rate for Payer: UHC All Payor (Choice/PPO) + Core |
$20.65
|
|
