|
lidocaine 0.4%-D5W Inj Sol 250 mL [HMC]
|
Facility
|
IP
|
$42.56
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3809221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.30 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$38.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.43
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 0.4%-D5W Inj Sol 250 mL [HMC]
|
Facility
|
OP
|
$42.56
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3809221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.02 |
| Max. Negotiated Rate |
$40.43 |
| Rate for Payer: Aetna Commercial |
$38.30
|
| Rate for Payer: Humana Medicare Advantage |
$17.88
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.43
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.02
|
| Rate for Payer: WPPA Medicare Advantage |
$25.54
|
|
|
lidocaine 0.4%-D5W Inj Sol 500 mL [HMC]
|
Facility
|
IP
|
$40.40
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3809221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.36 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$36.36
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.38
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 0.4%-D5W Inj Sol 500 mL [HMC]
|
Facility
|
OP
|
$40.40
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3809221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.16 |
| Max. Negotiated Rate |
$38.38 |
| Rate for Payer: Aetna Commercial |
$36.36
|
| Rate for Payer: Humana Medicare Advantage |
$16.97
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.38
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.16
|
| Rate for Payer: WPPA Medicare Advantage |
$24.24
|
|
|
lidocaine 1% Inj Sol mdv 10 mL [HMC]
|
Facility
|
IP
|
$36.20
|
|
|
Service Code
|
NDC 55150025110
|
| Hospital Charge Code |
3803950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$32.58 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$32.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.39
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% Inj Sol mdv 10 mL [HMC]
|
Facility
|
OP
|
$34.64
|
|
|
Service Code
|
NDC 63323020110
|
| Hospital Charge Code |
3803950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.86 |
| Max. Negotiated Rate |
$32.91 |
| Rate for Payer: Aetna Commercial |
$31.18
|
| Rate for Payer: Humana Medicare Advantage |
$14.55
|
| Rate for Payer: UnitedHealthcare Commercial |
$32.91
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.86
|
| Rate for Payer: WPPA Medicare Advantage |
$20.78
|
|
|
lidocaine 1% Inj Sol mdv 10 mL [HMC]
|
Facility
|
IP
|
$34.64
|
|
|
Service Code
|
NDC 63323020110
|
| Hospital Charge Code |
3803950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.18 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$31.18
|
| Rate for Payer: UnitedHealthcare Commercial |
$32.91
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% Inj Sol mdv 10 mL [HMC]
|
Facility
|
OP
|
$36.20
|
|
|
Service Code
|
NDC 55150025110
|
| Hospital Charge Code |
3803950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$14.48 |
| Max. Negotiated Rate |
$34.39 |
| Rate for Payer: Aetna Commercial |
$32.58
|
| Rate for Payer: Humana Medicare Advantage |
$15.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$34.39
|
| Rate for Payer: UnitedHealthcare Medicaid |
$14.48
|
| Rate for Payer: WPPA Medicare Advantage |
$21.72
|
|
|
lidocaine 1% Inj Sol MDV 20 mL [HMC]
|
Facility
|
OP
|
$29.51
|
|
|
Service Code
|
NDC 00409427601
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$11.80 |
| Max. Negotiated Rate |
$28.03 |
| Rate for Payer: Aetna Commercial |
$26.56
|
| Rate for Payer: Humana Medicare Advantage |
$12.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.03
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.80
|
| Rate for Payer: WPPA Medicare Advantage |
$17.71
|
|
|
lidocaine 1% Inj Sol MDV 20 mL [HMC]
|
Facility
|
IP
|
$29.51
|
|
|
Service Code
|
NDC 00409427601
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$26.56 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$26.56
|
| Rate for Payer: UnitedHealthcare Commercial |
$28.03
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% Inj Sol MDV 20 mL [HMC]
|
Facility
|
IP
|
$42.20
|
|
|
Service Code
|
NDC 55150025220
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$37.98 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$37.98
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% Inj Sol MDV 20 mL [HMC]
|
Facility
|
OP
|
$42.20
|
|
|
Service Code
|
NDC 55150025220
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$16.88 |
| Max. Negotiated Rate |
$40.09 |
| Rate for Payer: Aetna Commercial |
$37.98
|
| Rate for Payer: Humana Medicare Advantage |
$17.72
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.88
|
| Rate for Payer: WPPA Medicare Advantage |
$25.32
|
|
|
lidocaine 1% Inj Sol MDV 50 mL [HMC]
|
Facility
|
IP
|
$20.33
|
|
|
Service Code
|
NDC 00143957710
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$18.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.31
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% Inj Sol MDV 50 mL [HMC]
|
Facility
|
OP
|
$20.33
|
|
|
Service Code
|
NDC 00143957710
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$19.31 |
| Rate for Payer: Aetna Commercial |
$18.30
|
| Rate for Payer: Humana Medicare Advantage |
$8.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.13
|
| Rate for Payer: WPPA Medicare Advantage |
$12.20
|
|
|
lidocaine 1% Inj Sol MDV 50 mL [HMC]
|
Facility
|
OP
|
$20.33
|
|
|
Service Code
|
NDC 00143957710
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.13 |
| Max. Negotiated Rate |
$19.31 |
| Rate for Payer: Aetna Commercial |
$18.30
|
| Rate for Payer: Humana Medicare Advantage |
$8.54
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.31
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.13
|
| Rate for Payer: WPPA Medicare Advantage |
$12.20
|
|
|
lidocaine 1% Inj Sol MDV 50 mL [HMC]
|
Facility
|
IP
|
$20.33
|
|
|
Service Code
|
NDC 00143957710
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.30 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$18.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.31
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% Inj Sol MDV 50 mL [HMC]
|
Facility
|
IP
|
$20.69
|
|
|
Service Code
|
NDC 63323048557
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$18.62 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$18.62
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.66
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% Inj Sol MDV 50 mL [HMC]
|
Facility
|
OP
|
$20.69
|
|
|
Service Code
|
NDC 63323048557
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$8.28 |
| Max. Negotiated Rate |
$19.66 |
| Rate for Payer: Aetna Commercial |
$18.62
|
| Rate for Payer: Humana Medicare Advantage |
$8.69
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.66
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.28
|
| Rate for Payer: WPPA Medicare Advantage |
$12.41
|
|
|
lidocaine 1% PF Inj Sol 10 mL [HMC]
|
Facility
|
IP
|
$41.42
|
|
|
Service Code
|
NDC 63323049297
|
| Hospital Charge Code |
3803554
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.28 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$37.28
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.35
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% PF Inj Sol 10 mL [HMC]
|
Facility
|
OP
|
$41.42
|
|
|
Service Code
|
NDC 63323049297
|
| Hospital Charge Code |
3803554
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.57 |
| Max. Negotiated Rate |
$39.35 |
| Rate for Payer: Aetna Commercial |
$37.28
|
| Rate for Payer: Humana Medicare Advantage |
$17.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.35
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.57
|
| Rate for Payer: WPPA Medicare Advantage |
$24.85
|
|
|
lidocaine 1% PF Inj Sol 10 mL syr [HMC]
|
Facility
|
OP
|
$45.27
|
|
|
Service Code
|
NDC 70092116946
|
| Hospital Charge Code |
3803554
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.11 |
| Max. Negotiated Rate |
$43.01 |
| Rate for Payer: Aetna Commercial |
$40.74
|
| Rate for Payer: Humana Medicare Advantage |
$19.01
|
| Rate for Payer: UnitedHealthcare Commercial |
$43.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$18.11
|
| Rate for Payer: WPPA Medicare Advantage |
$27.16
|
|
|
lidocaine 1% PF Inj Sol 10 mL syr [HMC]
|
Facility
|
IP
|
$45.27
|
|
|
Service Code
|
NDC 70092116946
|
| Hospital Charge Code |
3803554
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$40.74 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$40.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$43.01
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% PF Inj Sol 2 mL [HMC]
|
Facility
|
IP
|
$30.75
|
|
|
Service Code
|
NDC 63323049280
|
| Hospital Charge Code |
3808919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$27.68 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$27.68
|
| Rate for Payer: UnitedHealthcare Commercial |
$29.21
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% PF Inj Sol 2 mL [HMC]
|
Facility
|
OP
|
$30.75
|
|
|
Service Code
|
NDC 63323049280
|
| Hospital Charge Code |
3808919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.30 |
| Max. Negotiated Rate |
$29.21 |
| Rate for Payer: Aetna Commercial |
$27.68
|
| Rate for Payer: Humana Medicare Advantage |
$12.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$29.21
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.30
|
| Rate for Payer: WPPA Medicare Advantage |
$18.45
|
|
|
lidocaine 1% PF Inj Sol 30 mL [HMC]
|
Facility
|
IP
|
$48.30
|
|
|
Service Code
|
NDC 63323049237
|
| Hospital Charge Code |
3808919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$43.47 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$43.47
|
| Rate for Payer: UnitedHealthcare Commercial |
$45.88
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
