Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 50 MCG TABLET

Facility

$80.37

Service Code	NDC 16729044815
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$32.15
Max. Negotiated Rate	$72.33
Rate for Payer: Aetna Commercial	$68.31
Rate for Payer: Aetna Medicare	$40.19
Rate for Payer: Aetna New Business (MI Preferred)	$52.24
Rate for Payer: BCBS Complete	$32.15
Rate for Payer: Cash Price	$64.30
Rate for Payer: Cofinity Commercial	$56.26
Rate for Payer: Cofinity Commercial	$69.12
Rate for Payer: Cofinity Medicare Advantage	$56.26
Rate for Payer: Encore Health Key Benefits Commercial	$64.30
Rate for Payer: Healthscope Commercial	$72.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$68.31
Rate for Payer: PHP Commercial	$68.31
Rate for Payer: Priority Health Cigna Priority Health	$52.24
Rate for Payer: Priority Health SBD	$50.63

LEVOTHYROXINE 50 MCG TABLET

Facility

$297.54

Service Code	NDC 00378180377
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$119.02
Max. Negotiated Rate	$267.79
Rate for Payer: Aetna Commercial	$252.91
Rate for Payer: Aetna Medicare	$148.77
Rate for Payer: Aetna New Business (MI Preferred)	$193.40
Rate for Payer: BCBS Complete	$119.02
Rate for Payer: Cash Price	$238.03
Rate for Payer: Cofinity Commercial	$208.28
Rate for Payer: Cofinity Commercial	$255.88
Rate for Payer: Cofinity Medicare Advantage	$208.28
Rate for Payer: Encore Health Key Benefits Commercial	$238.03
Rate for Payer: Healthscope Commercial	$267.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$252.91
Rate for Payer: PHP Commercial	$252.91
Rate for Payer: Priority Health Cigna Priority Health	$193.40
Rate for Payer: Priority Health SBD	$187.45

LEVOTHYROXINE 50 MCG TABLET

Facility

$80.37

Service Code	NDC 16729044815
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$50.63
Max. Negotiated Rate	$72.33
Rate for Payer: Aetna Commercial	$68.31
Rate for Payer: Aetna New Business (MI Preferred)	$52.24
Rate for Payer: Cash Price	$64.30
Rate for Payer: Cofinity Commercial	$56.26
Rate for Payer: Cofinity Commercial	$69.12
Rate for Payer: Cofinity Medicare Advantage	$56.26
Rate for Payer: Encore Health Key Benefits Commercial	$64.30
Rate for Payer: Healthscope Commercial	$72.33
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$68.31
Rate for Payer: PHP Commercial	$68.31
Rate for Payer: Priority Health Cigna Priority Health	$52.24
Rate for Payer: Priority Health SBD	$50.63

LEVOTHYROXINE 50 MCG TABLET

Facility

$697.25

Service Code	NDC 00074455290
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$439.27
Max. Negotiated Rate	$627.52
Rate for Payer: Aetna Commercial	$592.66
Rate for Payer: Aetna New Business (MI Preferred)	$453.21
Rate for Payer: Cash Price	$557.80
Rate for Payer: Cofinity Commercial	$488.07
Rate for Payer: Cofinity Commercial	$599.63
Rate for Payer: Cofinity Medicare Advantage	$488.07
Rate for Payer: Encore Health Key Benefits Commercial	$557.80
Rate for Payer: Healthscope Commercial	$627.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$592.66
Rate for Payer: PHP Commercial	$592.66
Rate for Payer: Priority Health Cigna Priority Health	$453.21
Rate for Payer: Priority Health SBD	$439.27

LEVOTHYROXINE 50 MCG TABLET

Facility

$697.25

Service Code	NDC 00074455290
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$278.90
Max. Negotiated Rate	$627.52
Rate for Payer: Aetna Commercial	$592.66
Rate for Payer: Aetna Medicare	$348.62
Rate for Payer: Aetna New Business (MI Preferred)	$453.21
Rate for Payer: BCBS Complete	$278.90
Rate for Payer: Cash Price	$557.80
Rate for Payer: Cofinity Commercial	$488.07
Rate for Payer: Cofinity Commercial	$599.63
Rate for Payer: Cofinity Medicare Advantage	$488.07
Rate for Payer: Encore Health Key Benefits Commercial	$557.80
Rate for Payer: Healthscope Commercial	$627.52
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$592.66
Rate for Payer: PHP Commercial	$592.66
Rate for Payer: Priority Health Cigna Priority Health	$453.21
Rate for Payer: Priority Health SBD	$439.27

LEVOTHYROXINE 50 MCG TABLET

Facility

$2.47

Service Code	NDC 51079044001
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$2.22
Rate for Payer: Aetna Commercial	$2.10
Rate for Payer: Aetna Medicare	$1.24
Rate for Payer: Aetna New Business (MI Preferred)	$1.61
Rate for Payer: BCBS Complete	$0.99
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cofinity Commercial	$1.73
Rate for Payer: Cofinity Commercial	$2.12
Rate for Payer: Cofinity Medicare Advantage	$1.73
Rate for Payer: Encore Health Key Benefits Commercial	$1.98
Rate for Payer: Healthscope Commercial	$2.22
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.10
Rate for Payer: PHP Commercial	$2.10
Rate for Payer: Priority Health Cigna Priority Health	$1.61
Rate for Payer: Priority Health SBD	$1.56

LEVOTHYROXINE 75 MCG TABLET

Facility

$329.18

Service Code	NDC 00378180577
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$131.67
Max. Negotiated Rate	$296.26
Rate for Payer: Aetna Commercial	$279.80
Rate for Payer: Aetna Medicare	$164.59
Rate for Payer: Aetna New Business (MI Preferred)	$213.97
Rate for Payer: BCBS Complete	$131.67
Rate for Payer: Cash Price	$263.34
Rate for Payer: Cofinity Commercial	$230.43
Rate for Payer: Cofinity Commercial	$283.09
Rate for Payer: Cofinity Medicare Advantage	$230.43
Rate for Payer: Encore Health Key Benefits Commercial	$263.34
Rate for Payer: Healthscope Commercial	$296.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$279.80
Rate for Payer: PHP Commercial	$279.80
Rate for Payer: Priority Health Cigna Priority Health	$213.97
Rate for Payer: Priority Health SBD	$207.38

LEVOTHYROXINE 75 MCG TABLET

Facility

$2.74

Service Code	NDC 51079044101
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$1.10
Max. Negotiated Rate	$2.47
Rate for Payer: Aetna Commercial	$2.33
Rate for Payer: Aetna Medicare	$1.37
Rate for Payer: Aetna New Business (MI Preferred)	$1.78
Rate for Payer: BCBS Complete	$1.10
Rate for Payer: Cash Price	$2.19
Rate for Payer: Cofinity Commercial	$1.92
Rate for Payer: Cofinity Commercial	$2.36
Rate for Payer: Cofinity Medicare Advantage	$1.92
Rate for Payer: Encore Health Key Benefits Commercial	$2.19
Rate for Payer: Healthscope Commercial	$2.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.33
Rate for Payer: PHP Commercial	$2.33
Rate for Payer: Priority Health Cigna Priority Health	$1.78
Rate for Payer: Priority Health SBD	$1.73

LEVOTHYROXINE 75 MCG TABLET

Facility

$273.60

Service Code	NDC 51079044120
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$172.37
Max. Negotiated Rate	$246.24
Rate for Payer: Aetna Commercial	$232.56
Rate for Payer: Aetna New Business (MI Preferred)	$177.84
Rate for Payer: Cash Price	$218.88
Rate for Payer: Cofinity Commercial	$191.52
Rate for Payer: Cofinity Commercial	$235.30
Rate for Payer: Cofinity Medicare Advantage	$191.52
Rate for Payer: Encore Health Key Benefits Commercial	$218.88
Rate for Payer: Healthscope Commercial	$246.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$232.56
Rate for Payer: PHP Commercial	$232.56
Rate for Payer: Priority Health Cigna Priority Health	$177.84
Rate for Payer: Priority Health SBD	$172.37

LEVOTHYROXINE 75 MCG TABLET

Facility

$2.74

Service Code	NDC 51079044101
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.47
Rate for Payer: Aetna Commercial	$2.33
Rate for Payer: Aetna New Business (MI Preferred)	$1.78
Rate for Payer: Cash Price	$2.19
Rate for Payer: Cofinity Commercial	$1.92
Rate for Payer: Cofinity Commercial	$2.36
Rate for Payer: Cofinity Medicare Advantage	$1.92
Rate for Payer: Encore Health Key Benefits Commercial	$2.19
Rate for Payer: Healthscope Commercial	$2.47
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.33
Rate for Payer: PHP Commercial	$2.33
Rate for Payer: Priority Health Cigna Priority Health	$1.78
Rate for Payer: Priority Health SBD	$1.73

LEVOTHYROXINE 75 MCG TABLET

Facility

$697.68

Service Code	NDC 00074518290
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$279.07
Max. Negotiated Rate	$627.91
Rate for Payer: Aetna Commercial	$593.03
Rate for Payer: Aetna Medicare	$348.84
Rate for Payer: Aetna New Business (MI Preferred)	$453.49
Rate for Payer: BCBS Complete	$279.07
Rate for Payer: Cash Price	$558.14
Rate for Payer: Cofinity Commercial	$488.38
Rate for Payer: Cofinity Commercial	$600.00
Rate for Payer: Cofinity Medicare Advantage	$488.38
Rate for Payer: Encore Health Key Benefits Commercial	$558.14
Rate for Payer: Healthscope Commercial	$627.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$593.03
Rate for Payer: PHP Commercial	$593.03
Rate for Payer: Priority Health Cigna Priority Health	$453.49
Rate for Payer: Priority Health SBD	$439.54

LEVOTHYROXINE 75 MCG TABLET

Facility

$329.18

Service Code	NDC 00378180577
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$207.38
Max. Negotiated Rate	$296.26
Rate for Payer: Aetna Commercial	$279.80
Rate for Payer: Aetna New Business (MI Preferred)	$213.97
Rate for Payer: Cash Price	$263.34
Rate for Payer: Cofinity Commercial	$230.43
Rate for Payer: Cofinity Commercial	$283.09
Rate for Payer: Cofinity Medicare Advantage	$230.43
Rate for Payer: Encore Health Key Benefits Commercial	$263.34
Rate for Payer: Healthscope Commercial	$296.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$279.80
Rate for Payer: PHP Commercial	$279.80
Rate for Payer: Priority Health Cigna Priority Health	$213.97
Rate for Payer: Priority Health SBD	$207.38

LEVOTHYROXINE 75 MCG TABLET

Facility

$697.68

Service Code	NDC 00074518290
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$439.54
Max. Negotiated Rate	$627.91
Rate for Payer: Aetna Commercial	$593.03
Rate for Payer: Aetna New Business (MI Preferred)	$453.49
Rate for Payer: Cash Price	$558.14
Rate for Payer: Cofinity Commercial	$488.38
Rate for Payer: Cofinity Commercial	$600.00
Rate for Payer: Cofinity Medicare Advantage	$488.38
Rate for Payer: Encore Health Key Benefits Commercial	$558.14
Rate for Payer: Healthscope Commercial	$627.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$593.03
Rate for Payer: PHP Commercial	$593.03
Rate for Payer: Priority Health Cigna Priority Health	$453.49
Rate for Payer: Priority Health SBD	$439.54

LEVOTHYROXINE 75 MCG TABLET

Facility

$273.60

Service Code	NDC 51079044120
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$109.44
Max. Negotiated Rate	$246.24
Rate for Payer: Aetna Commercial	$232.56
Rate for Payer: Aetna Medicare	$136.80
Rate for Payer: Aetna New Business (MI Preferred)	$177.84
Rate for Payer: BCBS Complete	$109.44
Rate for Payer: Cash Price	$218.88
Rate for Payer: Cofinity Commercial	$191.52
Rate for Payer: Cofinity Commercial	$235.30
Rate for Payer: Cofinity Medicare Advantage	$191.52
Rate for Payer: Encore Health Key Benefits Commercial	$218.88
Rate for Payer: Healthscope Commercial	$246.24
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$232.56
Rate for Payer: PHP Commercial	$232.56
Rate for Payer: Priority Health Cigna Priority Health	$177.84
Rate for Payer: Priority Health SBD	$172.37

LEVOTHYROXINE 88 MCG TABLET

Facility

$250.56

Service Code	NDC 42292003820
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$100.22
Max. Negotiated Rate	$225.50
Rate for Payer: Aetna Commercial	$212.98
Rate for Payer: Aetna Medicare	$125.28
Rate for Payer: Aetna New Business (MI Preferred)	$162.86
Rate for Payer: BCBS Complete	$100.22
Rate for Payer: Cash Price	$200.45
Rate for Payer: Cofinity Commercial	$175.39
Rate for Payer: Cofinity Commercial	$215.48
Rate for Payer: Cofinity Medicare Advantage	$175.39
Rate for Payer: Encore Health Key Benefits Commercial	$200.45
Rate for Payer: Healthscope Commercial	$225.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$212.98
Rate for Payer: PHP Commercial	$212.98
Rate for Payer: Priority Health Cigna Priority Health	$162.86
Rate for Payer: Priority Health SBD	$157.85

LEVOTHYROXINE 88 MCG TABLET

Facility

$334.31

Service Code	NDC 00378180777
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$133.72
Max. Negotiated Rate	$300.88
Rate for Payer: Aetna Commercial	$284.16
Rate for Payer: Aetna Medicare	$167.16
Rate for Payer: Aetna New Business (MI Preferred)	$217.30
Rate for Payer: BCBS Complete	$133.72
Rate for Payer: Cash Price	$267.45
Rate for Payer: Cofinity Commercial	$234.02
Rate for Payer: Cofinity Commercial	$287.51
Rate for Payer: Cofinity Medicare Advantage	$234.02
Rate for Payer: Encore Health Key Benefits Commercial	$267.45
Rate for Payer: Healthscope Commercial	$300.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$284.16
Rate for Payer: PHP Commercial	$284.16
Rate for Payer: Priority Health Cigna Priority Health	$217.30
Rate for Payer: Priority Health SBD	$210.62

LEVOTHYROXINE 88 MCG TABLET

Facility

$2.51

Service Code	NDC 42292003801
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$1.58
Max. Negotiated Rate	$2.26
Rate for Payer: Aetna Commercial	$2.13
Rate for Payer: Aetna New Business (MI Preferred)	$1.63
Rate for Payer: Cash Price	$2.01
Rate for Payer: Cofinity Commercial	$1.76
Rate for Payer: Cofinity Commercial	$2.16
Rate for Payer: Cofinity Medicare Advantage	$1.76
Rate for Payer: Encore Health Key Benefits Commercial	$2.01
Rate for Payer: Healthscope Commercial	$2.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.13
Rate for Payer: PHP Commercial	$2.13
Rate for Payer: Priority Health Cigna Priority Health	$1.63
Rate for Payer: Priority Health SBD	$1.58

LEVOTHYROXINE 88 MCG TABLET

Facility

$334.31

Service Code	NDC 00378180777
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$210.62
Max. Negotiated Rate	$300.88
Rate for Payer: Aetna Commercial	$284.16
Rate for Payer: Aetna New Business (MI Preferred)	$217.30
Rate for Payer: Cash Price	$267.45
Rate for Payer: Cofinity Commercial	$234.02
Rate for Payer: Cofinity Commercial	$287.51
Rate for Payer: Cofinity Medicare Advantage	$234.02
Rate for Payer: Encore Health Key Benefits Commercial	$267.45
Rate for Payer: Healthscope Commercial	$300.88
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$284.16
Rate for Payer: PHP Commercial	$284.16
Rate for Payer: Priority Health Cigna Priority Health	$217.30
Rate for Payer: Priority Health SBD	$210.62

LEVOTHYROXINE 88 MCG TABLET

Facility

$697.68

Service Code	NDC 00074659490
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$279.07
Max. Negotiated Rate	$627.91
Rate for Payer: Aetna Commercial	$593.03
Rate for Payer: Aetna Medicare	$348.84
Rate for Payer: Aetna New Business (MI Preferred)	$453.49
Rate for Payer: BCBS Complete	$279.07
Rate for Payer: Cash Price	$558.14
Rate for Payer: Cofinity Commercial	$488.38
Rate for Payer: Cofinity Commercial	$600.00
Rate for Payer: Cofinity Medicare Advantage	$488.38
Rate for Payer: Encore Health Key Benefits Commercial	$558.14
Rate for Payer: Healthscope Commercial	$627.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$593.03
Rate for Payer: PHP Commercial	$593.03
Rate for Payer: Priority Health Cigna Priority Health	$453.49
Rate for Payer: Priority Health SBD	$439.54

LEVOTHYROXINE 88 MCG TABLET

Facility

$697.68

Service Code	NDC 00074659490
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$439.54
Max. Negotiated Rate	$627.91
Rate for Payer: Aetna Commercial	$593.03
Rate for Payer: Aetna New Business (MI Preferred)	$453.49
Rate for Payer: Cash Price	$558.14
Rate for Payer: Cofinity Commercial	$488.38
Rate for Payer: Cofinity Commercial	$600.00
Rate for Payer: Cofinity Medicare Advantage	$488.38
Rate for Payer: Encore Health Key Benefits Commercial	$558.14
Rate for Payer: Healthscope Commercial	$627.91
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$593.03
Rate for Payer: PHP Commercial	$593.03
Rate for Payer: Priority Health Cigna Priority Health	$453.49
Rate for Payer: Priority Health SBD	$439.54

LEVOTHYROXINE 88 MCG TABLET

Facility

$250.56

Service Code	NDC 42292003820
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$157.85
Max. Negotiated Rate	$225.50
Rate for Payer: Aetna Commercial	$212.98
Rate for Payer: Aetna New Business (MI Preferred)	$162.86
Rate for Payer: Cash Price	$200.45
Rate for Payer: Cofinity Commercial	$175.39
Rate for Payer: Cofinity Commercial	$215.48
Rate for Payer: Cofinity Medicare Advantage	$175.39
Rate for Payer: Encore Health Key Benefits Commercial	$200.45
Rate for Payer: Healthscope Commercial	$225.50
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$212.98
Rate for Payer: PHP Commercial	$212.98
Rate for Payer: Priority Health Cigna Priority Health	$162.86
Rate for Payer: Priority Health SBD	$157.85

LEVOTHYROXINE 88 MCG TABLET

Facility

$2.51

Service Code	NDC 42292003801
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$2.26
Rate for Payer: Aetna Commercial	$2.13
Rate for Payer: Aetna Medicare	$1.25
Rate for Payer: Aetna New Business (MI Preferred)	$1.63
Rate for Payer: BCBS Complete	$1.00
Rate for Payer: Cash Price	$2.01
Rate for Payer: Cofinity Commercial	$1.76
Rate for Payer: Cofinity Commercial	$2.16
Rate for Payer: Cofinity Medicare Advantage	$1.76
Rate for Payer: Encore Health Key Benefits Commercial	$2.01
Rate for Payer: Healthscope Commercial	$2.26
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$2.13
Rate for Payer: PHP Commercial	$2.13
Rate for Payer: Priority Health Cigna Priority Health	$1.63
Rate for Payer: Priority Health SBD	$1.58

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION

Facility

$15.54

Service Code	HCPCS J2004
Hospital Charge Code	10427
Hospital Revenue Code	636
Min. Negotiated Rate	$6.22
Max. Negotiated Rate	$13.99
Rate for Payer: Aetna Commercial	$13.21
Rate for Payer: Aetna Commercial	$16.35
Rate for Payer: Aetna Commercial	$14.79
Rate for Payer: Aetna Medicare	$9.62
Rate for Payer: Aetna Medicare	$7.77
Rate for Payer: Aetna Medicare	$8.70
Rate for Payer: Aetna New Business (MI Preferred)	$12.50
Rate for Payer: Aetna New Business (MI Preferred)	$10.10
Rate for Payer: Aetna New Business (MI Preferred)	$11.31
Rate for Payer: BCBS Complete	$6.96
Rate for Payer: BCBS Complete	$6.22
Rate for Payer: BCBS Complete	$7.69
Rate for Payer: Cash Price	$15.38
Rate for Payer: Cash Price	$12.43
Rate for Payer: Cash Price	$13.92
Rate for Payer: Cofinity Commercial	$16.54
Rate for Payer: Cofinity Commercial	$13.36
Rate for Payer: Cofinity Commercial	$10.88
Rate for Payer: Cofinity Commercial	$14.96
Rate for Payer: Cofinity Commercial	$12.18
Rate for Payer: Cofinity Commercial	$13.46
Rate for Payer: Cofinity Medicare Advantage	$12.18
Rate for Payer: Cofinity Medicare Advantage	$10.88
Rate for Payer: Cofinity Medicare Advantage	$13.46
Rate for Payer: Encore Health Key Benefits Commercial	$13.92
Rate for Payer: Encore Health Key Benefits Commercial	$15.38
Rate for Payer: Encore Health Key Benefits Commercial	$12.43
Rate for Payer: Healthscope Commercial	$15.66
Rate for Payer: Healthscope Commercial	$13.99
Rate for Payer: Healthscope Commercial	$17.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$14.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.35
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.21
Rate for Payer: PHP Commercial	$14.79
Rate for Payer: PHP Commercial	$13.21
Rate for Payer: PHP Commercial	$16.35
Rate for Payer: Priority Health Cigna Priority Health	$10.10
Rate for Payer: Priority Health Cigna Priority Health	$12.50
Rate for Payer: Priority Health Cigna Priority Health	$11.31
Rate for Payer: Priority Health SBD	$12.11
Rate for Payer: Priority Health SBD	$10.96
Rate for Payer: Priority Health SBD	$9.79

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION

Facility

$17.40

Service Code	HCPCS J2004
Hospital Charge Code	10427
Hospital Revenue Code	636
Min. Negotiated Rate	$10.96
Max. Negotiated Rate	$15.66
Rate for Payer: Aetna Commercial	$14.79
Rate for Payer: Aetna Commercial	$13.21
Rate for Payer: Aetna Commercial	$16.35
Rate for Payer: Aetna New Business (MI Preferred)	$11.31
Rate for Payer: Aetna New Business (MI Preferred)	$10.10
Rate for Payer: Aetna New Business (MI Preferred)	$12.50
Rate for Payer: Cash Price	$12.43
Rate for Payer: Cash Price	$15.38
Rate for Payer: Cash Price	$13.92
Rate for Payer: Cofinity Commercial	$10.88
Rate for Payer: Cofinity Commercial	$13.36
Rate for Payer: Cofinity Commercial	$12.18
Rate for Payer: Cofinity Commercial	$14.96
Rate for Payer: Cofinity Commercial	$13.46
Rate for Payer: Cofinity Commercial	$16.54
Rate for Payer: Cofinity Medicare Advantage	$10.88
Rate for Payer: Cofinity Medicare Advantage	$13.46
Rate for Payer: Cofinity Medicare Advantage	$12.18
Rate for Payer: Encore Health Key Benefits Commercial	$12.43
Rate for Payer: Encore Health Key Benefits Commercial	$13.92
Rate for Payer: Encore Health Key Benefits Commercial	$15.38
Rate for Payer: Healthscope Commercial	$13.99
Rate for Payer: Healthscope Commercial	$15.66
Rate for Payer: Healthscope Commercial	$17.31
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$13.21
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$14.79
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.35
Rate for Payer: PHP Commercial	$14.79
Rate for Payer: PHP Commercial	$16.35
Rate for Payer: PHP Commercial	$13.21
Rate for Payer: Priority Health Cigna Priority Health	$12.50
Rate for Payer: Priority Health Cigna Priority Health	$11.31
Rate for Payer: Priority Health Cigna Priority Health	$10.10
Rate for Payer: Priority Health SBD	$12.11
Rate for Payer: Priority Health SBD	$10.96
Rate for Payer: Priority Health SBD	$9.79

LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION

Facility

$19.50

Service Code	HCPCS J2004
Hospital Charge Code	10430
Hospital Revenue Code	636
Min. Negotiated Rate	$7.80
Max. Negotiated Rate	$17.55
Rate for Payer: Aetna Commercial	$16.57
Rate for Payer: Aetna Commercial	$19.23
Rate for Payer: Aetna Commercial	$18.56
Rate for Payer: Aetna Medicare	$11.31
Rate for Payer: Aetna Medicare	$9.75
Rate for Payer: Aetna Medicare	$10.91
Rate for Payer: Aetna New Business (MI Preferred)	$14.70
Rate for Payer: Aetna New Business (MI Preferred)	$12.68
Rate for Payer: Aetna New Business (MI Preferred)	$14.19
Rate for Payer: BCBS Complete	$8.73
Rate for Payer: BCBS Complete	$7.80
Rate for Payer: BCBS Complete	$9.05
Rate for Payer: Cash Price	$18.10
Rate for Payer: Cash Price	$15.60
Rate for Payer: Cash Price	$17.46
Rate for Payer: Cofinity Commercial	$19.45
Rate for Payer: Cofinity Commercial	$16.77
Rate for Payer: Cofinity Commercial	$13.65
Rate for Payer: Cofinity Commercial	$18.77
Rate for Payer: Cofinity Commercial	$15.28
Rate for Payer: Cofinity Commercial	$15.83
Rate for Payer: Cofinity Medicare Advantage	$15.28
Rate for Payer: Cofinity Medicare Advantage	$13.65
Rate for Payer: Cofinity Medicare Advantage	$15.83
Rate for Payer: Encore Health Key Benefits Commercial	$17.46
Rate for Payer: Encore Health Key Benefits Commercial	$18.10
Rate for Payer: Encore Health Key Benefits Commercial	$15.60
Rate for Payer: Healthscope Commercial	$19.65
Rate for Payer: Healthscope Commercial	$17.55
Rate for Payer: Healthscope Commercial	$20.36
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$18.56
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$19.23
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$16.57
Rate for Payer: PHP Commercial	$18.56
Rate for Payer: PHP Commercial	$16.57
Rate for Payer: PHP Commercial	$19.23
Rate for Payer: Priority Health Cigna Priority Health	$12.68
Rate for Payer: Priority Health Cigna Priority Health	$14.70
Rate for Payer: Priority Health Cigna Priority Health	$14.19
Rate for Payer: Priority Health SBD	$14.25
Rate for Payer: Priority Health SBD	$13.75
Rate for Payer: Priority Health SBD	$12.29

Know your out-of-pocket cost for care.

All Charges