|
LIDOCAINE HCL (PF) 2 % IJ SOLN
|
Facility
|
OP
|
$0.86
|
|
|
Service Code
|
NDC 6332349507
|
| Hospital Charge Code |
6332349507
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.30 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.47
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.43
|
| Rate for Payer: Aetna Government |
$0.43
|
| Rate for Payer: Brighton Health Commercial |
$0.65
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.69
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.59
|
| Rate for Payer: EmblemHealth Commercial |
$0.43
|
| Rate for Payer: Group Health Inc Commercial |
$0.43
|
| Rate for Payer: Group Health Inc Medicare |
$0.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.43
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.43
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.56
|
|
|
LIDOCAINE HCL (PF) 2 % IJ SOLN
|
Facility
|
IP
|
$0.83
|
|
|
Service Code
|
NDC 6332349603
|
| Hospital Charge Code |
6332349603
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.42
|
|
|
LIDOCAINE HCL (PF) 2 % IJ SOLN
|
Facility
|
OP
|
$0.72
|
|
|
Service Code
|
NDC 5515016505
|
| Hospital Charge Code |
5515016505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$0.58 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.40
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.36
|
| Rate for Payer: Aetna Government |
$0.36
|
| Rate for Payer: Brighton Health Commercial |
$0.54
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.58
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.49
|
| Rate for Payer: EmblemHealth Commercial |
$0.36
|
| Rate for Payer: Group Health Inc Commercial |
$0.36
|
| Rate for Payer: Group Health Inc Medicare |
$0.25
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.36
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.36
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.47
|
|
|
LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY
|
Facility
|
IP
|
$0.77
|
|
|
Service Code
|
NDC 7632930135
|
| Hospital Charge Code |
7632930135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.38 |
| Max. Negotiated Rate |
$0.38 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
|
|
LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY
|
Facility
|
IP
|
$1.38
|
|
|
Service Code
|
NDC 7632930125
|
| Hospital Charge Code |
7632930125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$0.69 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.69
|
|
|
LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY
|
Facility
|
OP
|
$1.38
|
|
|
Service Code
|
NDC 7632930125
|
| Hospital Charge Code |
7632930125
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.48 |
| Max. Negotiated Rate |
$1.10 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.76
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.69
|
| Rate for Payer: Aetna Government |
$0.69
|
| Rate for Payer: Brighton Health Commercial |
$1.03
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.10
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.94
|
| Rate for Payer: EmblemHealth Commercial |
$0.69
|
| Rate for Payer: Group Health Inc Commercial |
$0.69
|
| Rate for Payer: Group Health Inc Medicare |
$0.48
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.69
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.69
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.90
|
|
|
LIDOCAINE HCL URETHRAL/MUCOSAL 2 % EX PRSY
|
Facility
|
OP
|
$0.77
|
|
|
Service Code
|
NDC 7632930135
|
| Hospital Charge Code |
7632930135
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.62 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.42
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.38
|
| Rate for Payer: Aetna Government |
$0.38
|
| Rate for Payer: Brighton Health Commercial |
$0.58
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.62
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.52
|
| Rate for Payer: EmblemHealth Commercial |
$0.38
|
| Rate for Payer: Group Health Inc Commercial |
$0.38
|
| Rate for Payer: Group Health Inc Medicare |
$0.27
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.38
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.38
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.50
|
|
|
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN
|
Facility
|
OP
|
$0.02
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
0338040903
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.03
|
| Rate for Payer: Aetna Government |
$0.03
|
| Rate for Payer: Brighton Health Commercial |
$0.01
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.01
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.01
|
| Rate for Payer: EmblemHealth Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Commercial |
$0.01
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.01
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.01
|
|
|
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN
|
Facility
|
IP
|
$0.02
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
0338040903
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.01 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.01
|
|
|
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN
|
Facility
|
IP
|
$0.04
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
0264959420
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.02 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.02
|
|
|
LIDOCAINE IN D5W 4-5 MG/ML-% IV SOLN
|
Facility
|
OP
|
$0.04
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
0264959420
|
|
Hospital Revenue Code
|
258
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.02
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.03
|
| Rate for Payer: Aetna Government |
$0.03
|
| Rate for Payer: Brighton Health Commercial |
$0.03
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.03
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.02
|
| Rate for Payer: EmblemHealth Commercial |
$0.02
|
| Rate for Payer: Group Health Inc Commercial |
$0.02
|
| Rate for Payer: Group Health Inc Medicare |
$0.01
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.02
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.02
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.02
|
|
|
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA
|
Facility
|
OP
|
$1.59
|
|
|
Service Code
|
NDC 8103302505
|
| Hospital Charge Code |
8103302505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.80
|
| Rate for Payer: Aetna Government |
$0.80
|
| Rate for Payer: Brighton Health Commercial |
$1.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.08
|
| Rate for Payer: EmblemHealth Commercial |
$0.80
|
| Rate for Payer: Group Health Inc Commercial |
$0.80
|
| Rate for Payer: Group Health Inc Medicare |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.03
|
|
|
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA
|
Facility
|
OP
|
$1.84
|
|
|
Service Code
|
NDC 6233258204
|
| Hospital Charge Code |
6233258204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.64 |
| Max. Negotiated Rate |
$1.47 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$1.01
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.92
|
| Rate for Payer: Aetna Government |
$0.92
|
| Rate for Payer: Brighton Health Commercial |
$1.38
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.47
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.25
|
| Rate for Payer: EmblemHealth Commercial |
$0.92
|
| Rate for Payer: Group Health Inc Commercial |
$0.92
|
| Rate for Payer: Group Health Inc Medicare |
$0.64
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.92
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.92
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.19
|
|
|
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA
|
Facility
|
IP
|
$1.59
|
|
|
Service Code
|
NDC 8103302551
|
| Hospital Charge Code |
8103302551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.80
|
|
|
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA
|
Facility
|
OP
|
$1.59
|
|
|
Service Code
|
NDC 8103302551
|
| Hospital Charge Code |
8103302551
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$1.27 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.87
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.80
|
| Rate for Payer: Aetna Government |
$0.80
|
| Rate for Payer: Brighton Health Commercial |
$1.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$1.27
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$1.08
|
| Rate for Payer: EmblemHealth Commercial |
$0.80
|
| Rate for Payer: Group Health Inc Commercial |
$0.80
|
| Rate for Payer: Group Health Inc Medicare |
$0.56
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.80
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.80
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$1.03
|
|
|
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA
|
Facility
|
IP
|
$1.84
|
|
|
Service Code
|
NDC 6233258204
|
| Hospital Charge Code |
6233258204
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.92 |
| Max. Negotiated Rate |
$0.92 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.92
|
|
|
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX CREA
|
Facility
|
IP
|
$1.59
|
|
|
Service Code
|
NDC 8103302505
|
| Hospital Charge Code |
8103302505
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.80 |
| Max. Negotiated Rate |
$0.80 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.80
|
|
|
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX KIT
|
Facility
|
IP
|
$49.58
|
|
|
Service Code
|
NDC 0168035756
|
| Hospital Charge Code |
0168035756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.79 |
| Max. Negotiated Rate |
$24.79 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.79
|
|
|
LIDOCAINE-PRILOCAINE 2.5-2.5 % EX KIT
|
Facility
|
OP
|
$49.58
|
|
|
Service Code
|
NDC 0168035756
|
| Hospital Charge Code |
0168035756
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.35 |
| Max. Negotiated Rate |
$39.66 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$27.27
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$24.79
|
| Rate for Payer: Aetna Government |
$24.79
|
| Rate for Payer: Brighton Health Commercial |
$37.19
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$39.66
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$33.71
|
| Rate for Payer: EmblemHealth Commercial |
$24.79
|
| Rate for Payer: Group Health Inc Commercial |
$24.79
|
| Rate for Payer: Group Health Inc Medicare |
$17.35
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$24.79
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$24.79
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$32.23
|
|
|
LIDOCAINE VISCOUS HCL 2 % MT SOLN
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 6043246400
|
| Hospital Charge Code |
6043246400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.07
|
|
|
LIDOCAINE VISCOUS HCL 2 % MT SOLN
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 0054350049
|
| Hospital Charge Code |
0054350049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.07
|
|
|
LIDOCAINE VISCOUS HCL 2 % MT SOLN
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 0054350049
|
| Hospital Charge Code |
0054350049
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.07
|
| Rate for Payer: Aetna Government |
$0.07
|
| Rate for Payer: Brighton Health Commercial |
$0.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.09
|
| Rate for Payer: EmblemHealth Commercial |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.07
|
| Rate for Payer: Group Health Inc Medicare |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.09
|
|
|
LIDOCAINE VISCOUS HCL 2 % MT SOLN
|
Facility
|
IP
|
$0.31
|
|
|
Service Code
|
NDC 0121090340
|
| Hospital Charge Code |
0121090340
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.16
|
|
|
LIDOCAINE VISCOUS HCL 2 % MT SOLN
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 6043246400
|
| Hospital Charge Code |
6043246400
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.07
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.07
|
| Rate for Payer: Aetna Government |
$0.07
|
| Rate for Payer: Brighton Health Commercial |
$0.10
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.11
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.09
|
| Rate for Payer: EmblemHealth Commercial |
$0.07
|
| Rate for Payer: Group Health Inc Commercial |
$0.07
|
| Rate for Payer: Group Health Inc Medicare |
$0.05
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.07
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.07
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.09
|
|
|
LIDOCAINE VISCOUS HCL 2 % MT SOLN
|
Facility
|
OP
|
$0.31
|
|
|
Service Code
|
NDC 0121090340
|
| Hospital Charge Code |
0121090340
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.25 |
| Rate for Payer: 1199SEIU National Benefit Fund Commercial |
$0.17
|
| Rate for Payer: Aetna Gatekeeper/Non-Gatekeeper |
$0.16
|
| Rate for Payer: Aetna Government |
$0.16
|
| Rate for Payer: Brighton Health Commercial |
$0.23
|
| Rate for Payer: Cigna HMO/Network Benefit Plan/Open Access |
$0.25
|
| Rate for Payer: Cigna LocalPlus Benefit Plan |
$0.21
|
| Rate for Payer: EmblemHealth Commercial |
$0.16
|
| Rate for Payer: Group Health Inc Commercial |
$0.16
|
| Rate for Payer: Group Health Inc Medicare |
$0.11
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$0.16
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$0.16
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$0.20
|
|
