Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION

Facility

$28.12

Service Code	NDC 0143-9577-10
Hospital Charge Code	4452
Hospital Revenue Code	250
Min. Negotiated Rate	$17.72
Max. Negotiated Rate	$25.31
Rate for Payer: Aetna Commercial	$23.90
Rate for Payer: Aetna New Business (MI Preferred)	$18.28
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cofinity Commercial	$19.68
Rate for Payer: Cofinity Commercial	$24.18
Rate for Payer: Healthscope Commercial	$25.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$23.90
Rate for Payer: PHP Commercial	$23.90
Rate for Payer: Priority Health Cigna Priority Health	$19.68
Rate for Payer: Priority Health SBD	$17.72

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION

Facility

$19.00

Service Code	NDC 63323-201-10
Hospital Charge Code	4452
Hospital Revenue Code	250
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna New Business (MI Preferred)	$12.35
Rate for Payer: Cash Price	$15.20
Rate for Payer: Cofinity Commercial	$13.30
Rate for Payer: Cofinity Commercial	$16.34
Rate for Payer: Healthscope Commercial	$17.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.15
Rate for Payer: PHP Commercial	$16.15
Rate for Payer: Priority Health Cigna Priority Health	$13.30
Rate for Payer: Priority Health SBD	$11.97

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION

Facility

$16.94

Service Code	NDC 63323-201-02
Hospital Charge Code	4452
Hospital Revenue Code	250
Min. Negotiated Rate	$6.78
Max. Negotiated Rate	$15.25
Rate for Payer: Aetna Commercial	$14.40
Rate for Payer: Aetna New Business (MI Preferred)	$11.01
Rate for Payer: BCBS Complete	$6.78
Rate for Payer: Cash Price	$13.55
Rate for Payer: Cofinity Commercial	$11.86
Rate for Payer: Cofinity Commercial	$14.57
Rate for Payer: Healthscope Commercial	$15.25
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14.40
Rate for Payer: PHP Commercial	$14.40
Rate for Payer: Priority Health Cigna Priority Health	$11.86
Rate for Payer: Priority Health SBD	$10.67

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION

Facility

$28.12

Service Code	NDC 0143-9577-01
Hospital Charge Code	4452
Hospital Revenue Code	250
Min. Negotiated Rate	$17.72
Max. Negotiated Rate	$25.31
Rate for Payer: Aetna Commercial	$23.90
Rate for Payer: Aetna New Business (MI Preferred)	$18.28
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cofinity Commercial	$19.68
Rate for Payer: Cofinity Commercial	$24.18
Rate for Payer: Healthscope Commercial	$25.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$23.90
Rate for Payer: PHP Commercial	$23.90
Rate for Payer: Priority Health Cigna Priority Health	$19.68
Rate for Payer: Priority Health SBD	$17.72

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION

Facility

$16.94

Service Code	NDC 63323-201-02
Hospital Charge Code	4452
Hospital Revenue Code	250
Min. Negotiated Rate	$10.67
Max. Negotiated Rate	$15.25
Rate for Payer: Aetna Commercial	$14.40
Rate for Payer: Aetna New Business (MI Preferred)	$11.01
Rate for Payer: Cash Price	$13.55
Rate for Payer: Cofinity Commercial	$11.86
Rate for Payer: Cofinity Commercial	$14.57
Rate for Payer: Healthscope Commercial	$15.25
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14.40
Rate for Payer: PHP Commercial	$14.40
Rate for Payer: Priority Health Cigna Priority Health	$11.86
Rate for Payer: Priority Health SBD	$10.67

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY

Facility

$28.12

Service Code	NDC 0143-9577-01
Hospital Charge Code	300842
Hospital Revenue Code	250
Min. Negotiated Rate	$17.72
Max. Negotiated Rate	$25.31
Rate for Payer: Aetna Commercial	$23.90
Rate for Payer: Aetna New Business (MI Preferred)	$18.28
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cofinity Commercial	$19.68
Rate for Payer: Cofinity Commercial	$24.18
Rate for Payer: Healthscope Commercial	$25.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$23.90
Rate for Payer: PHP Commercial	$23.90
Rate for Payer: Priority Health Cigna Priority Health	$19.68
Rate for Payer: Priority Health SBD	$17.72

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY

Facility

$19.00

Service Code	NDC 63323-201-10
Hospital Charge Code	300842
Hospital Revenue Code	250
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$17.10
Rate for Payer: Aetna Commercial	$16.15
Rate for Payer: Aetna New Business (MI Preferred)	$12.35
Rate for Payer: Cash Price	$15.20
Rate for Payer: Cofinity Commercial	$13.30
Rate for Payer: Cofinity Commercial	$16.34
Rate for Payer: Healthscope Commercial	$17.10
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.15
Rate for Payer: PHP Commercial	$16.15
Rate for Payer: Priority Health Cigna Priority Health	$13.30
Rate for Payer: Priority Health SBD	$11.97

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY

Facility

$28.12

Service Code	NDC 0143-9577-10
Hospital Charge Code	300842
Hospital Revenue Code	250
Min. Negotiated Rate	$17.72
Max. Negotiated Rate	$25.31
Rate for Payer: Aetna Commercial	$23.90
Rate for Payer: Aetna New Business (MI Preferred)	$18.28
Rate for Payer: Cash Price	$22.50
Rate for Payer: Cofinity Commercial	$19.68
Rate for Payer: Cofinity Commercial	$24.18
Rate for Payer: Healthscope Commercial	$25.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$23.90
Rate for Payer: PHP Commercial	$23.90
Rate for Payer: Priority Health Cigna Priority Health	$19.68
Rate for Payer: Priority Health SBD	$17.72

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION-DIALYSIS ONLY

Facility

$15.37

Service Code	NDC 55150-251-10
Hospital Charge Code	300842
Hospital Revenue Code	250
Min. Negotiated Rate	$9.68
Max. Negotiated Rate	$13.83
Rate for Payer: Aetna Commercial	$13.06
Rate for Payer: Aetna New Business (MI Preferred)	$9.99
Rate for Payer: Cash Price	$12.30
Rate for Payer: Cofinity Commercial	$13.22
Rate for Payer: Cofinity Commercial	$10.76
Rate for Payer: Healthscope Commercial	$13.83
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.06
Rate for Payer: PHP Commercial	$13.06
Rate for Payer: Priority Health Cigna Priority Health	$10.76
Rate for Payer: Priority Health SBD	$9.68

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$14.21

Service Code	NDC 55150-254-10
Hospital Charge Code	4454
Hospital Revenue Code	250
Min. Negotiated Rate	$8.95
Max. Negotiated Rate	$12.79
Rate for Payer: Aetna Commercial	$12.08
Rate for Payer: Aetna New Business (MI Preferred)	$9.24
Rate for Payer: Cash Price	$11.37
Rate for Payer: Cofinity Commercial	$12.22
Rate for Payer: Cofinity Commercial	$9.95
Rate for Payer: Healthscope Commercial	$12.79
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.08
Rate for Payer: PHP Commercial	$12.08
Rate for Payer: Priority Health Cigna Priority Health	$9.95
Rate for Payer: Priority Health SBD	$8.95

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$27.26

Service Code	NDC 0409-4277-16
Hospital Charge Code	4454
Hospital Revenue Code	250
Min. Negotiated Rate	$17.17
Max. Negotiated Rate	$24.53
Rate for Payer: Aetna Commercial	$23.17
Rate for Payer: Aetna New Business (MI Preferred)	$17.72
Rate for Payer: Cash Price	$21.81
Rate for Payer: Cofinity Commercial	$19.08
Rate for Payer: Cofinity Commercial	$23.44
Rate for Payer: Healthscope Commercial	$24.53
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$23.17
Rate for Payer: PHP Commercial	$23.17
Rate for Payer: Priority Health Cigna Priority Health	$19.08
Rate for Payer: Priority Health SBD	$17.17

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$23.20

Service Code	NDC 63323-486-02
Hospital Charge Code	4454
Hospital Revenue Code	250
Min. Negotiated Rate	$14.62
Max. Negotiated Rate	$20.88
Rate for Payer: Aetna Commercial	$19.72
Rate for Payer: Aetna New Business (MI Preferred)	$15.08
Rate for Payer: Cash Price	$18.56
Rate for Payer: Cofinity Commercial	$16.24
Rate for Payer: Cofinity Commercial	$19.95
Rate for Payer: Healthscope Commercial	$20.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$19.72
Rate for Payer: PHP Commercial	$19.72
Rate for Payer: Priority Health Cigna Priority Health	$16.24
Rate for Payer: Priority Health SBD	$14.62

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$27.26

Service Code	NDC 0409-4277-01
Hospital Charge Code	4454
Hospital Revenue Code	250
Min. Negotiated Rate	$17.17
Max. Negotiated Rate	$24.53
Rate for Payer: Aetna Commercial	$23.17
Rate for Payer: Aetna New Business (MI Preferred)	$17.72
Rate for Payer: Cash Price	$21.81
Rate for Payer: Cofinity Commercial	$19.08
Rate for Payer: Cofinity Commercial	$23.44
Rate for Payer: Healthscope Commercial	$24.53
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$23.17
Rate for Payer: PHP Commercial	$23.17
Rate for Payer: Priority Health Cigna Priority Health	$19.08
Rate for Payer: Priority Health SBD	$17.17

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$28.86

Service Code	NDC 0409-4277-02
Hospital Charge Code	4454
Hospital Revenue Code	250
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$25.97
Rate for Payer: Aetna Commercial	$24.53
Rate for Payer: Aetna New Business (MI Preferred)	$18.76
Rate for Payer: Cash Price	$23.09
Rate for Payer: Cofinity Commercial	$20.20
Rate for Payer: Cofinity Commercial	$24.82
Rate for Payer: Healthscope Commercial	$25.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$24.53
Rate for Payer: PHP Commercial	$24.53
Rate for Payer: Priority Health Cigna Priority Health	$20.20
Rate for Payer: Priority Health SBD	$18.18

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$23.20

Service Code	NDC 63323-486-27
Hospital Charge Code	4454
Hospital Revenue Code	250
Min. Negotiated Rate	$14.62
Max. Negotiated Rate	$20.88
Rate for Payer: Aetna Commercial	$19.72
Rate for Payer: Aetna New Business (MI Preferred)	$15.08
Rate for Payer: Cash Price	$18.56
Rate for Payer: Cofinity Commercial	$16.24
Rate for Payer: Cofinity Commercial	$19.95
Rate for Payer: Healthscope Commercial	$20.88
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$19.72
Rate for Payer: PHP Commercial	$19.72
Rate for Payer: Priority Health Cigna Priority Health	$16.24
Rate for Payer: Priority Health SBD	$14.62

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$25.53

Service Code	NDC 63323-486-57
Hospital Charge Code	4454
Hospital Revenue Code	250
Min. Negotiated Rate	$16.08
Max. Negotiated Rate	$22.98
Rate for Payer: Aetna Commercial	$21.70
Rate for Payer: Aetna New Business (MI Preferred)	$16.59
Rate for Payer: Cash Price	$20.42
Rate for Payer: Cofinity Commercial	$17.87
Rate for Payer: Cofinity Commercial	$21.96
Rate for Payer: Healthscope Commercial	$22.98
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.70
Rate for Payer: PHP Commercial	$21.70
Rate for Payer: Priority Health Cigna Priority Health	$17.87
Rate for Payer: Priority Health SBD	$16.08

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$28.86

Service Code	NDC 0409-4277-17
Hospital Charge Code	4454
Hospital Revenue Code	250
Min. Negotiated Rate	$18.18
Max. Negotiated Rate	$25.97
Rate for Payer: Aetna Commercial	$24.53
Rate for Payer: Aetna New Business (MI Preferred)	$18.76
Rate for Payer: Cash Price	$23.09
Rate for Payer: Cofinity Commercial	$20.20
Rate for Payer: Cofinity Commercial	$24.82
Rate for Payer: Healthscope Commercial	$25.97
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$24.53
Rate for Payer: PHP Commercial	$24.53
Rate for Payer: Priority Health Cigna Priority Health	$20.20
Rate for Payer: Priority Health SBD	$18.18

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$23.78

Service Code	NDC 63323-486-17
Hospital Charge Code	4454
Hospital Revenue Code	250
Min. Negotiated Rate	$14.98
Max. Negotiated Rate	$21.40
Rate for Payer: Aetna Commercial	$20.21
Rate for Payer: Aetna New Business (MI Preferred)	$15.46
Rate for Payer: Cash Price	$19.02
Rate for Payer: Cofinity Commercial	$16.65
Rate for Payer: Cofinity Commercial	$20.45
Rate for Payer: Healthscope Commercial	$21.40
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$20.21
Rate for Payer: PHP Commercial	$20.21
Rate for Payer: Priority Health Cigna Priority Health	$16.65
Rate for Payer: Priority Health SBD	$14.98

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION

Facility

$11.89

Service Code	NDC 55150-255-20
Hospital Charge Code	4454
Hospital Revenue Code	250
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$10.70
Rate for Payer: Aetna Commercial	$10.11
Rate for Payer: Aetna New Business (MI Preferred)	$7.73
Rate for Payer: Cash Price	$9.51
Rate for Payer: Cofinity Commercial	$10.23
Rate for Payer: Cofinity Commercial	$8.32
Rate for Payer: Healthscope Commercial	$10.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.11
Rate for Payer: PHP Commercial	$10.11
Rate for Payer: Priority Health Cigna Priority Health	$8.32
Rate for Payer: Priority Health SBD	$7.49

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$31.85

Service Code	NDC 0054-3500-49
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$20.07
Max. Negotiated Rate	$28.66
Rate for Payer: Aetna Commercial	$27.07
Rate for Payer: Aetna New Business (MI Preferred)	$20.70
Rate for Payer: Cash Price	$25.48
Rate for Payer: Cofinity Commercial	$22.30
Rate for Payer: Cofinity Commercial	$27.39
Rate for Payer: Healthscope Commercial	$28.66
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$27.07
Rate for Payer: PHP Commercial	$27.07
Rate for Payer: Priority Health Cigna Priority Health	$22.30
Rate for Payer: Priority Health SBD	$20.07

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$4.23

Service Code	NDC 50383-775-17
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$3.81
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Aetna New Business (MI Preferred)	$2.75
Rate for Payer: Cash Price	$3.38
Rate for Payer: Cofinity Commercial	$2.96
Rate for Payer: Cofinity Commercial	$3.64
Rate for Payer: Healthscope Commercial	$3.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.60
Rate for Payer: PHP Commercial	$3.60
Rate for Payer: Priority Health Cigna Priority Health	$2.96
Rate for Payer: Priority Health SBD	$2.66

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$318.85

Service Code	NDC 62135-712-42
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$200.88
Max. Negotiated Rate	$286.96
Rate for Payer: Aetna Commercial	$271.02
Rate for Payer: Aetna New Business (MI Preferred)	$207.25
Rate for Payer: Cash Price	$255.08
Rate for Payer: Cofinity Commercial	$223.20
Rate for Payer: Cofinity Commercial	$274.21
Rate for Payer: Healthscope Commercial	$286.96
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$271.02
Rate for Payer: PHP Commercial	$271.02
Rate for Payer: Priority Health Cigna Priority Health	$223.20
Rate for Payer: Priority Health SBD	$200.88

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$4.23

Service Code	NDC 50383-775-15
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$2.66
Max. Negotiated Rate	$3.81
Rate for Payer: Aetna Commercial	$3.60
Rate for Payer: Aetna New Business (MI Preferred)	$2.75
Rate for Payer: Cash Price	$3.38
Rate for Payer: Cofinity Commercial	$2.96
Rate for Payer: Cofinity Commercial	$3.64
Rate for Payer: Healthscope Commercial	$3.81
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.60
Rate for Payer: PHP Commercial	$3.60
Rate for Payer: Priority Health Cigna Priority Health	$2.96
Rate for Payer: Priority Health SBD	$2.66

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$25.90

Service Code	NDC 60432-464-00
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$16.32
Max. Negotiated Rate	$23.31
Rate for Payer: Aetna Commercial	$22.02
Rate for Payer: Aetna New Business (MI Preferred)	$16.84
Rate for Payer: Cash Price	$20.72
Rate for Payer: Cofinity Commercial	$18.13
Rate for Payer: Cofinity Commercial	$22.27
Rate for Payer: Healthscope Commercial	$23.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.02
Rate for Payer: PHP Commercial	$22.02
Rate for Payer: Priority Health Cigna Priority Health	$18.13
Rate for Payer: Priority Health SBD	$16.32

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$5.49

Service Code	NDC 9900-0003-39
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$3.46
Max. Negotiated Rate	$4.94
Rate for Payer: Aetna Commercial	$4.67
Rate for Payer: Aetna New Business (MI Preferred)	$3.57
Rate for Payer: Cash Price	$4.39
Rate for Payer: Cofinity Commercial	$3.84
Rate for Payer: Cofinity Commercial	$4.72
Rate for Payer: Healthscope Commercial	$4.94
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$4.67
Rate for Payer: PHP Commercial	$4.67
Rate for Payer: Priority Health Cigna Priority Health	$3.84
Rate for Payer: Priority Health SBD	$3.46

Know your out-of-pocket cost for care.

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