|
lidocaine 1% PF Inj Sol 30 mL [HMC]
|
Facility
|
OP
|
$48.30
|
|
|
Service Code
|
NDC 63323049237
|
| Hospital Charge Code |
3808919
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.32 |
| Max. Negotiated Rate |
$45.88 |
| Rate for Payer: Aetna Commercial |
$43.47
|
| Rate for Payer: Humana Medicare Advantage |
$20.29
|
| Rate for Payer: UnitedHealthcare Commercial |
$45.88
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.32
|
| Rate for Payer: WPPA Medicare Advantage |
$28.98
|
|
|
lidocaine 1% PF Inj Sol 5 mL [HMC]
|
Facility
|
IP
|
$34.75
|
|
|
Service Code
|
NDC 73293000102
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$31.27 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$31.27
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.01
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% PF Inj Sol 5 mL [HMC]
|
Facility
|
IP
|
$43.58
|
|
|
Service Code
|
NDC 63323049257
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$39.22 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$39.22
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.40
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% PF Inj Sol 5 mL [HMC]
|
Facility
|
OP
|
$43.58
|
|
|
Service Code
|
NDC 63323049257
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$17.43 |
| Max. Negotiated Rate |
$41.40 |
| Rate for Payer: Aetna Commercial |
$39.22
|
| Rate for Payer: Humana Medicare Advantage |
$18.30
|
| Rate for Payer: UnitedHealthcare Commercial |
$41.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$17.43
|
| Rate for Payer: WPPA Medicare Advantage |
$26.15
|
|
|
lidocaine 1% PF Inj Sol 5 mL [HMC]
|
Facility
|
OP
|
$34.75
|
|
|
Service Code
|
NDC 73293000102
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$13.90 |
| Max. Negotiated Rate |
$33.01 |
| Rate for Payer: Aetna Commercial |
$31.27
|
| Rate for Payer: Humana Medicare Advantage |
$14.60
|
| Rate for Payer: UnitedHealthcare Commercial |
$33.01
|
| Rate for Payer: UnitedHealthcare Medicaid |
$13.90
|
| Rate for Payer: WPPA Medicare Advantage |
$20.85
|
|
|
lidocaine 1% PF Inj Sol 5 mL [HMC]
|
Facility
|
IP
|
$40.25
|
|
|
Service Code
|
NDC 55150016205
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.23 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$36.23
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.24
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 1% PF Inj Sol 5 mL [HMC]
|
Facility
|
OP
|
$40.25
|
|
|
Service Code
|
NDC 55150016205
|
| Hospital Charge Code |
3850082
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.10 |
| Max. Negotiated Rate |
$38.24 |
| Rate for Payer: Aetna Commercial |
$36.23
|
| Rate for Payer: Humana Medicare Advantage |
$16.91
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.24
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.10
|
| Rate for Payer: WPPA Medicare Advantage |
$24.15
|
|
|
lidocaine 1% PF MDV Inj Sol 50 mL [HMC]
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
NDC 63323048503
|
| Hospital Charge Code |
3350270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$8.00 |
| Max. Negotiated Rate |
$19.00 |
| Rate for Payer: Aetna Commercial |
$18.00
|
| Rate for Payer: Humana Medicare Advantage |
$8.40
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.00
|
| Rate for Payer: UnitedHealthcare Medicaid |
$8.00
|
| Rate for Payer: WPPA Medicare Advantage |
$12.00
|
|
|
lidocaine 1% PF MDV Inj Sol 50 mL [HMC]
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
NDC 63323048503
|
| Hospital Charge Code |
3350270
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$18.00 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$18.00
|
| Rate for Payer: UnitedHealthcare Commercial |
$19.00
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 2% preservative-free 100 mg/5mL Inj Sol [HMC]
|
Facility
|
IP
|
$38.00
|
|
|
Service Code
|
NDC 55150016505
|
| Hospital Charge Code |
3801950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$34.20 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.10
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 2% preservative-free 100 mg/5mL Inj Sol [HMC]
|
Facility
|
IP
|
$27.65
|
|
|
Service Code
|
NDC 68094008125
|
| Hospital Charge Code |
3801950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$24.89 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$24.89
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.27
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 2% preservative-free 100 mg/5mL Inj Sol [HMC]
|
Facility
|
IP
|
$41.54
|
|
|
Service Code
|
NDC 63323049507
|
| Hospital Charge Code |
3801950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$37.39 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$37.39
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.46
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 2% preservative-free 100 mg/5mL Inj Sol [HMC]
|
Facility
|
OP
|
$41.54
|
|
|
Service Code
|
NDC 63323049507
|
| Hospital Charge Code |
3801950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.62 |
| Max. Negotiated Rate |
$39.46 |
| Rate for Payer: Aetna Commercial |
$37.39
|
| Rate for Payer: Humana Medicare Advantage |
$17.45
|
| Rate for Payer: UnitedHealthcare Commercial |
$39.46
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.62
|
| Rate for Payer: WPPA Medicare Advantage |
$24.92
|
|
|
lidocaine 2% preservative-free 100 mg/5mL Inj Sol [HMC]
|
Facility
|
OP
|
$27.65
|
|
|
Service Code
|
NDC 68094008125
|
| Hospital Charge Code |
3801950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$11.06 |
| Max. Negotiated Rate |
$26.27 |
| Rate for Payer: Aetna Commercial |
$24.89
|
| Rate for Payer: Humana Medicare Advantage |
$11.61
|
| Rate for Payer: UnitedHealthcare Commercial |
$26.27
|
| Rate for Payer: UnitedHealthcare Medicaid |
$11.06
|
| Rate for Payer: WPPA Medicare Advantage |
$16.59
|
|
|
lidocaine 2% preservative-free 100 mg/5mL Inj Sol [HMC]
|
Facility
|
OP
|
$40.64
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3802300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.26 |
| Max. Negotiated Rate |
$38.61 |
| Rate for Payer: Aetna Commercial |
$36.58
|
| Rate for Payer: Humana Medicare Advantage |
$17.07
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.61
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.26
|
| Rate for Payer: WPPA Medicare Advantage |
$24.38
|
|
|
lidocaine 2% preservative-free 100 mg/5mL Inj Sol [HMC]
|
Facility
|
OP
|
$38.00
|
|
|
Service Code
|
NDC 55150016505
|
| Hospital Charge Code |
3801950
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$36.10 |
| Rate for Payer: Aetna Commercial |
$34.20
|
| Rate for Payer: Humana Medicare Advantage |
$15.96
|
| Rate for Payer: UnitedHealthcare Commercial |
$36.10
|
| Rate for Payer: UnitedHealthcare Medicaid |
$15.20
|
| Rate for Payer: WPPA Medicare Advantage |
$22.80
|
|
|
lidocaine 2% preservative-free 100 mg/5mL Inj Sol [HMC]
|
Facility
|
IP
|
$40.64
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3802300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.58 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$36.58
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.61
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 2% preservative-free [HMC]
|
Facility
|
IP
|
$49.89
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3802300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$44.90 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$44.90
|
| Rate for Payer: UnitedHealthcare Commercial |
$47.40
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 2% preservative-free [HMC]
|
Facility
|
OP
|
$49.89
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3802300
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$19.96 |
| Max. Negotiated Rate |
$47.40 |
| Rate for Payer: Aetna Commercial |
$44.90
|
| Rate for Payer: Humana Medicare Advantage |
$20.95
|
| Rate for Payer: UnitedHealthcare Commercial |
$47.40
|
| Rate for Payer: UnitedHealthcare Medicaid |
$19.96
|
| Rate for Payer: WPPA Medicare Advantage |
$29.93
|
|
|
lidocaine 5%-0.4% Sol 500 mL [HMC]
|
Facility
|
IP
|
$40.09
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3809221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$36.08 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$36.08
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.09
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 5%-0.4% Sol 500 mL [HMC]
|
Facility
|
OP
|
$40.09
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3809221
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.04 |
| Max. Negotiated Rate |
$38.09 |
| Rate for Payer: Aetna Commercial |
$36.08
|
| Rate for Payer: Humana Medicare Advantage |
$16.84
|
| Rate for Payer: UnitedHealthcare Commercial |
$38.09
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.04
|
| Rate for Payer: WPPA Medicare Advantage |
$24.05
|
|
|
lidocaine 5%-D7.5% Inj Sol 2 mL [HMC]
|
Facility
|
IP
|
$42.23
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3803553
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$38.01 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$38.01
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.12
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine 5%-D7.5% Inj Sol 2 mL [HMC]
|
Facility
|
OP
|
$42.23
|
|
|
Service Code
|
HCPCS J2001
|
| Hospital Charge Code |
3803553
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$16.89 |
| Max. Negotiated Rate |
$40.12 |
| Rate for Payer: Aetna Commercial |
$38.01
|
| Rate for Payer: Humana Medicare Advantage |
$17.74
|
| Rate for Payer: UnitedHealthcare Commercial |
$40.12
|
| Rate for Payer: UnitedHealthcare Medicaid |
$16.89
|
| Rate for Payer: WPPA Medicare Advantage |
$25.34
|
|
|
lidocaine Top 2% Gel w/Appl [HMC]
|
Facility
|
IP
|
$32.60
|
|
|
Service Code
|
NDC 76329301105
|
| Hospital Charge Code |
3808117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$29.34 |
| Max. Negotiated Rate |
$1,200.00 |
| Rate for Payer: Aetna Commercial |
$29.34
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.97
|
| Rate for Payer: WPPA Medicare Advantage |
$1,200.00
|
|
|
lidocaine Top 2% Gel w/Appl [HMC]
|
Facility
|
OP
|
$32.08
|
|
|
Service Code
|
NDC 76329301205
|
| Hospital Charge Code |
3808117
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$12.83 |
| Max. Negotiated Rate |
$30.48 |
| Rate for Payer: Aetna Commercial |
$28.87
|
| Rate for Payer: Humana Medicare Advantage |
$13.47
|
| Rate for Payer: UnitedHealthcare Commercial |
$30.48
|
| Rate for Payer: UnitedHealthcare Medicaid |
$12.83
|
| Rate for Payer: WPPA Medicare Advantage |
$19.25
|
|
