|
LIDOCAINE/EPINEPHRINE 1-0.001% MDV 25X20
|
Facility
|
IP
|
$7.98
|
|
|
Service Code
|
NDC 409317801
|
| Hospital Charge Code |
4400448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.39 |
| Max. Negotiated Rate |
$5.19 |
| Rate for Payer: Cash Price |
$5.98
|
| Rate for Payer: Galaxy Health Commercial |
$5.19
|
| Rate for Payer: WellCare Medicare |
$4.39
|
|
|
LIDOCAINE/EPINEPHRINE 1-0.001% MDV 25X20
|
Facility
|
OP
|
$7.98
|
|
|
Service Code
|
NDC 409317801
|
| Hospital Charge Code |
4400448
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$6.38 |
| Rate for Payer: Aetna of NY Commercial |
$5.59
|
| Rate for Payer: Aetna of NY Medicare |
$3.67
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.19
|
| Rate for Payer: Cash Price |
$5.98
|
| Rate for Payer: CDPHP Medicare |
$2.95
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.38
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.38
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.38
|
| Rate for Payer: EmblemHealth Medicaid |
$6.38
|
| Rate for Payer: EmblemHealth Medicare |
$2.71
|
| Rate for Payer: EmblemHealth Select Care |
$5.75
|
| Rate for Payer: Fidelis Medicare |
$3.19
|
| Rate for Payer: Galaxy Health Commercial |
$5.19
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.19
|
| Rate for Payer: Humana Medicare |
$3.19
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.59
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.67
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.99
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.49
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.35
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.20
|
| Rate for Payer: United Healthcare Medicare |
$3.19
|
| Rate for Payer: WellCare Medicare |
$4.39
|
|
|
LIDOCAINE/EPINEPHRINE 2-0.001% MDV 25X30
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
NDC 63323048327
|
| Hospital Charge Code |
4400449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.93 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Commercial |
$4.33
|
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.33
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
LIDOCAINE/EPINEPHRINE 2-0.001% MDV 25X30
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 63323048327
|
| Hospital Charge Code |
4400449
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 10 mL
|
Facility
|
OP
|
$8.00
|
|
|
Service Code
|
NDC 63323020110
|
| Hospital Charge Code |
4401926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.20 |
| Max. Negotiated Rate |
$6.40 |
| Rate for Payer: Aetna of NY Commercial |
$5.60
|
| Rate for Payer: Aetna of NY Medicare |
$3.68
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.20
|
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: CDPHP Medicare |
$2.96
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.40
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.40
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.40
|
| Rate for Payer: EmblemHealth Medicaid |
$6.40
|
| Rate for Payer: EmblemHealth Medicare |
$2.72
|
| Rate for Payer: EmblemHealth Select Care |
$5.76
|
| Rate for Payer: Fidelis Medicare |
$3.20
|
| Rate for Payer: Galaxy Health Commercial |
$5.20
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.20
|
| Rate for Payer: Humana Medicare |
$3.20
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$5.60
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.68
|
| Rate for Payer: MVP Health Care of NY Commercial |
$6.00
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.50
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.36
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.20
|
| Rate for Payer: United Healthcare Medicare |
$3.20
|
| Rate for Payer: WellCare Medicare |
$4.40
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 10 mL
|
Facility
|
IP
|
$8.00
|
|
|
Service Code
|
NDC 63323020110
|
| Hospital Charge Code |
4401926
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.40 |
| Max. Negotiated Rate |
$5.20 |
| Rate for Payer: Cash Price |
$6.00
|
| Rate for Payer: Galaxy Health Commercial |
$5.20
|
| Rate for Payer: WellCare Medicare |
$4.40
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 20 mL
|
Facility
|
IP
|
$14.00
|
|
|
Service Code
|
NDC 55150025220
|
| Hospital Charge Code |
4401925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$7.70 |
| Max. Negotiated Rate |
$9.10 |
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 20 mL
|
Facility
|
OP
|
$14.00
|
|
|
Service Code
|
NDC 55150025220
|
| Hospital Charge Code |
4401925
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$11.20 |
| Rate for Payer: Aetna of NY Commercial |
$9.80
|
| Rate for Payer: Aetna of NY Medicare |
$6.44
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$5.60
|
| Rate for Payer: Cash Price |
$10.50
|
| Rate for Payer: CDPHP Medicare |
$5.18
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$11.20
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$11.20
|
| Rate for Payer: EmblemHealth Medicaid |
$11.20
|
| Rate for Payer: EmblemHealth Medicare |
$4.76
|
| Rate for Payer: EmblemHealth Select Care |
$10.08
|
| Rate for Payer: Fidelis Medicare |
$5.60
|
| Rate for Payer: Galaxy Health Commercial |
$9.10
|
| Rate for Payer: Hamaspik Choice Medicare |
$5.60
|
| Rate for Payer: Humana Medicare |
$5.60
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$9.80
|
| Rate for Payer: Local 1199SEIU Medicare |
$6.44
|
| Rate for Payer: MVP Health Care of NY Commercial |
$10.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$7.88
|
| Rate for Payer: MVP Health Care of NY Medicare |
$5.88
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.10
|
| Rate for Payer: United Healthcare Medicare |
$5.60
|
| Rate for Payer: WellCare Medicare |
$7.70
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 20 mL
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
NDC 409427601
|
| Hospital Charge Code |
4401923
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 20 mL
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
NDC 409427601
|
| Hospital Charge Code |
4401923
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.90 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Aetna of NY Commercial |
$4.20
|
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.80
|
| Rate for Payer: EmblemHealth Medicaid |
$4.80
|
| Rate for Payer: EmblemHealth Medicare |
$2.04
|
| Rate for Payer: EmblemHealth Select Care |
$4.32
|
| Rate for Payer: Fidelis Medicare |
$2.40
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.40
|
| Rate for Payer: Humana Medicare |
$2.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.20
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.38
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.52
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.90
|
| Rate for Payer: United Healthcare Medicare |
$2.40
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 50 mL
|
Facility
|
OP
|
$11.00
|
|
|
Service Code
|
NDC 409427617
|
| Hospital Charge Code |
4401924
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.65 |
| Max. Negotiated Rate |
$8.80 |
| Rate for Payer: Aetna of NY Commercial |
$7.70
|
| Rate for Payer: Aetna of NY Medicare |
$5.06
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$4.40
|
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: CDPHP Medicare |
$4.07
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$8.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$8.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$8.80
|
| Rate for Payer: EmblemHealth Medicaid |
$8.80
|
| Rate for Payer: EmblemHealth Medicare |
$3.74
|
| Rate for Payer: EmblemHealth Select Care |
$7.92
|
| Rate for Payer: Fidelis Medicare |
$4.40
|
| Rate for Payer: Galaxy Health Commercial |
$7.15
|
| Rate for Payer: Hamaspik Choice Medicare |
$4.40
|
| Rate for Payer: Humana Medicare |
$4.40
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$7.70
|
| Rate for Payer: Local 1199SEIU Medicare |
$5.06
|
| Rate for Payer: MVP Health Care of NY Commercial |
$8.25
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$6.19
|
| Rate for Payer: MVP Health Care of NY Medicare |
$4.62
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.65
|
| Rate for Payer: United Healthcare Medicare |
$4.40
|
| Rate for Payer: WellCare Medicare |
$6.05
|
|
|
LIDOCAINE HCL 1% VIAL 10 mg, 50 mL
|
Facility
|
IP
|
$11.00
|
|
|
Service Code
|
NDC 409427617
|
| Hospital Charge Code |
4401924
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$6.05 |
| Max. Negotiated Rate |
$7.15 |
| Rate for Payer: Cash Price |
$8.25
|
| Rate for Payer: Galaxy Health Commercial |
$7.15
|
| Rate for Payer: WellCare Medicare |
$6.05
|
|
|
LIDOCAINE HCL/D7.5W 5-7.5% AMPS 25X2ML
|
Facility
|
IP
|
$30.90
|
|
|
Service Code
|
NDC 409471201
|
| Hospital Charge Code |
4400446
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.00 |
| Max. Negotiated Rate |
$20.09 |
| Rate for Payer: Cash Price |
$23.17
|
| Rate for Payer: Galaxy Health Commercial |
$20.09
|
| Rate for Payer: WellCare Medicare |
$17.00
|
|
|
LIDOCAINE HCL/D7.5W 5-7.5% AMPS 25X2ML
|
Facility
|
OP
|
$30.90
|
|
|
Service Code
|
NDC 409471201
|
| Hospital Charge Code |
4400446
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$4.63 |
| Max. Negotiated Rate |
$24.72 |
| Rate for Payer: Aetna of NY Commercial |
$21.63
|
| Rate for Payer: Aetna of NY Medicare |
$14.21
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$12.36
|
| Rate for Payer: Cash Price |
$23.17
|
| Rate for Payer: CDPHP Medicare |
$11.43
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$24.72
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$24.72
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$24.72
|
| Rate for Payer: EmblemHealth Medicaid |
$24.72
|
| Rate for Payer: EmblemHealth Medicare |
$10.51
|
| Rate for Payer: EmblemHealth Select Care |
$22.25
|
| Rate for Payer: Fidelis Medicare |
$12.36
|
| Rate for Payer: Galaxy Health Commercial |
$20.09
|
| Rate for Payer: Hamaspik Choice Medicare |
$12.36
|
| Rate for Payer: Humana Medicare |
$12.36
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$21.63
|
| Rate for Payer: Local 1199SEIU Medicare |
$14.21
|
| Rate for Payer: MVP Health Care of NY Commercial |
$23.18
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$17.40
|
| Rate for Payer: MVP Health Care of NY Medicare |
$12.98
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$4.63
|
| Rate for Payer: United Healthcare Medicare |
$12.36
|
| Rate for Payer: WellCare Medicare |
$17.00
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
OP
|
$19.57
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4408965
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$15.66 |
| Rate for Payer: Aetna of NY Medicare |
$9.00
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$7.83
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: CDPHP Medicare |
$7.24
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$15.66
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$15.66
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$15.66
|
| Rate for Payer: EmblemHealth Medicaid |
$15.66
|
| Rate for Payer: EmblemHealth Medicare |
$6.65
|
| Rate for Payer: EmblemHealth Select Care |
$14.09
|
| Rate for Payer: Fidelis Medicare |
$7.83
|
| Rate for Payer: Galaxy Health Commercial |
$12.72
|
| Rate for Payer: Hamaspik Choice Medicare |
$7.83
|
| Rate for Payer: Humana Medicare |
$7.83
|
| Rate for Payer: Local 1199SEIU Medicare |
$9.00
|
| Rate for Payer: MVP Health Care of NY Commercial |
$14.68
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$11.02
|
| Rate for Payer: MVP Health Care of NY Medicare |
$8.22
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.05
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.94
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$7.83
|
| Rate for Payer: WellCare Medicare |
$10.76
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
OP
|
$6.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4400442
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$4.80 |
| Rate for Payer: Aetna of NY Medicare |
$2.76
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.40
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: CDPHP Medicare |
$2.22
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.80
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.80
|
| Rate for Payer: EmblemHealth Medicaid |
$4.80
|
| Rate for Payer: EmblemHealth Medicare |
$2.04
|
| Rate for Payer: EmblemHealth Select Care |
$4.32
|
| Rate for Payer: Fidelis Medicare |
$2.40
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.40
|
| Rate for Payer: Humana Medicare |
$2.40
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.76
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.50
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.38
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.52
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.05
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.90
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$2.40
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
IP
|
$15.97
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4409184
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$8.78 |
| Max. Negotiated Rate |
$10.38 |
| Rate for Payer: Aetna of NY Commercial |
$8.78
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Galaxy Health Commercial |
$10.38
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$8.78
|
| Rate for Payer: WellCare Medicare |
$8.78
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
IP
|
$6.00
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4400442
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$3.30 |
| Max. Negotiated Rate |
$3.90 |
| Rate for Payer: Aetna of NY Commercial |
$3.30
|
| Rate for Payer: Cash Price |
$4.50
|
| Rate for Payer: Galaxy Health Commercial |
$3.90
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$3.30
|
| Rate for Payer: WellCare Medicare |
$3.30
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
IP
|
$6.18
|
|
|
Service Code
|
NDC 55150016205
|
| Hospital Charge Code |
4400439
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.40 |
| Max. Negotiated Rate |
$4.02 |
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4400444
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.05
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
OP
|
$7.73
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4400445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$6.18 |
| Rate for Payer: Aetna of NY Medicare |
$3.56
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$3.09
|
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: CDPHP Medicare |
$2.86
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$6.18
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$6.18
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$6.18
|
| Rate for Payer: EmblemHealth Medicaid |
$6.18
|
| Rate for Payer: EmblemHealth Medicare |
$2.63
|
| Rate for Payer: EmblemHealth Select Care |
$5.57
|
| Rate for Payer: Fidelis Medicare |
$3.09
|
| Rate for Payer: Galaxy Health Commercial |
$5.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$3.09
|
| Rate for Payer: Humana Medicare |
$3.09
|
| Rate for Payer: Local 1199SEIU Medicare |
$3.56
|
| Rate for Payer: MVP Health Care of NY Commercial |
$5.80
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$4.35
|
| Rate for Payer: MVP Health Care of NY Medicare |
$3.25
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.05
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$1.16
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$3.09
|
| Rate for Payer: WellCare Medicare |
$4.25
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
IP
|
$19.57
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4408965
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.76 |
| Max. Negotiated Rate |
$12.72 |
| Rate for Payer: Aetna of NY Commercial |
$10.76
|
| Rate for Payer: Cash Price |
$14.68
|
| Rate for Payer: Galaxy Health Commercial |
$12.72
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$10.76
|
| Rate for Payer: WellCare Medicare |
$10.76
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
OP
|
$6.18
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4400443
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$4.94 |
| Rate for Payer: Aetna of NY Medicare |
$2.84
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$2.47
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: Cash Price |
$4.64
|
| Rate for Payer: CDPHP Medicare |
$2.29
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$4.94
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$4.94
|
| Rate for Payer: EmblemHealth Medicaid |
$4.94
|
| Rate for Payer: EmblemHealth Medicare |
$2.10
|
| Rate for Payer: EmblemHealth Select Care |
$4.45
|
| Rate for Payer: Fidelis Medicare |
$2.47
|
| Rate for Payer: Galaxy Health Commercial |
$4.02
|
| Rate for Payer: Hamaspik Choice Medicare |
$2.47
|
| Rate for Payer: Humana Medicare |
$2.47
|
| Rate for Payer: Local 1199SEIU Medicare |
$2.84
|
| Rate for Payer: MVP Health Care of NY Commercial |
$4.63
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$3.48
|
| Rate for Payer: MVP Health Care of NY Medicare |
$2.60
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.05
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$0.93
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$2.47
|
| Rate for Payer: WellCare Medicare |
$3.40
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
OP
|
$15.97
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4409184
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$12.78 |
| Rate for Payer: Aetna of NY Medicare |
$7.35
|
| Rate for Payer: Blue Cross Blue Shield of New York (Empire) Medicare |
$6.39
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: Cash Price |
$11.98
|
| Rate for Payer: CDPHP Medicare |
$5.91
|
| Rate for Payer: EmblemHealth CBP/EPO/PPO/HMO/Network Access |
$12.78
|
| Rate for Payer: EmblemHealth Essential Plan 1/Essential Plan 2 |
$12.78
|
| Rate for Payer: EmblemHealth Essential Plan 3/Essential Plan 4 |
$12.78
|
| Rate for Payer: EmblemHealth Medicaid |
$12.78
|
| Rate for Payer: EmblemHealth Medicare |
$5.43
|
| Rate for Payer: EmblemHealth Select Care |
$11.50
|
| Rate for Payer: Fidelis Medicare |
$6.39
|
| Rate for Payer: Galaxy Health Commercial |
$10.38
|
| Rate for Payer: Hamaspik Choice Medicare |
$6.39
|
| Rate for Payer: Humana Medicare |
$6.39
|
| Rate for Payer: Local 1199SEIU Medicare |
$7.35
|
| Rate for Payer: MVP Health Care of NY Commercial |
$11.98
|
| Rate for Payer: MVP Health Care of NY Individual Exchange/Student Health Plan |
$8.99
|
| Rate for Payer: MVP Health Care of NY Medicare |
$6.71
|
| Rate for Payer: Oxford Health Plans Freedom/Liberty/Metro |
$0.05
|
| Rate for Payer: United Healthcare CHIP/Family Health Plus/Medicaid |
$2.40
|
| Rate for Payer: United Healthcare Commercial |
$0.05
|
| Rate for Payer: United Healthcare Medicare |
$6.39
|
| Rate for Payer: WellCare Medicare |
$8.78
|
|
|
LIDOCAINE HCL INJ FOR IV 10 MG
|
Facility
|
IP
|
$7.73
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
4400445
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$4.25 |
| Max. Negotiated Rate |
$5.02 |
| Rate for Payer: Aetna of NY Commercial |
$4.25
|
| Rate for Payer: Cash Price |
$5.80
|
| Rate for Payer: Galaxy Health Commercial |
$5.02
|
| Rate for Payer: Local 1199SEIU Aetna Signature Administrators |
$4.25
|
| Rate for Payer: WellCare Medicare |
$4.25
|
|
