Bronson Battle Creek

All Charges

Charge

Type

Setting

Price

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

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR

Facility

$15.21

Service Code	NDC 25021067376
Hospital Charge Code	118460
Hospital Revenue Code	637
Min. Negotiated Rate	$6.08
Max. Negotiated Rate	$13.69
Rate for Payer: Aetna Commercial	$12.93
Rate for Payer: Aetna Medicare	$7.61
Rate for Payer: Aetna New Business (MI Preferred)	$9.89
Rate for Payer: BCBS Complete	$6.08
Rate for Payer: Cash Price	$12.17
Rate for Payer: Cofinity Commercial	$10.65
Rate for Payer: Cofinity Commercial	$13.08
Rate for Payer: Cofinity Medicare Advantage	$10.65
Rate for Payer: Encore Health Key Benefits Commercial	$12.17
Rate for Payer: Healthscope Commercial	$13.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.93
Rate for Payer: PHP Commercial	$12.93
Rate for Payer: Priority Health Cigna Priority Health	$9.89
Rate for Payer: Priority Health SBD	$9.58

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR

Facility

$15.21

Service Code	NDC 25021067376
Hospital Charge Code	118460
Hospital Revenue Code	637
Min. Negotiated Rate	$9.58
Max. Negotiated Rate	$13.69
Rate for Payer: Aetna Commercial	$12.93
Rate for Payer: Aetna New Business (MI Preferred)	$9.89
Rate for Payer: Cash Price	$12.17
Rate for Payer: Cofinity Commercial	$10.65
Rate for Payer: Cofinity Commercial	$13.08
Rate for Payer: Cofinity Medicare Advantage	$10.65
Rate for Payer: Encore Health Key Benefits Commercial	$12.17
Rate for Payer: Healthscope Commercial	$13.69
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.93
Rate for Payer: PHP Commercial	$12.93
Rate for Payer: Priority Health Cigna Priority Health	$9.89
Rate for Payer: Priority Health SBD	$9.58

LIDOCAINE 2 %-VITAMIN E-ALOE VERA-COLLAGEN TOPICAL GEL

Facility

$14.62

Service Code	NDC 66977010005
Hospital Charge Code	77011
Hospital Revenue Code	637
Min. Negotiated Rate	$9.21
Max. Negotiated Rate	$13.16
Rate for Payer: Aetna Commercial	$12.43
Rate for Payer: Aetna New Business (MI Preferred)	$9.50
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cofinity Commercial	$10.23
Rate for Payer: Cofinity Commercial	$12.57
Rate for Payer: Cofinity Medicare Advantage	$10.23
Rate for Payer: Encore Health Key Benefits Commercial	$11.70
Rate for Payer: Healthscope Commercial	$13.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.43
Rate for Payer: PHP Commercial	$12.43
Rate for Payer: Priority Health Cigna Priority Health	$9.50
Rate for Payer: Priority Health SBD	$9.21

LIDOCAINE 2 %-VITAMIN E-ALOE VERA-COLLAGEN TOPICAL GEL

Facility

$14.62

Service Code	NDC 66977010005
Hospital Charge Code	77011
Hospital Revenue Code	637
Min. Negotiated Rate	$5.85
Max. Negotiated Rate	$13.16
Rate for Payer: Aetna Commercial	$12.43
Rate for Payer: Aetna Medicare	$7.31
Rate for Payer: Aetna New Business (MI Preferred)	$9.50
Rate for Payer: BCBS Complete	$5.85
Rate for Payer: Cash Price	$11.70
Rate for Payer: Cofinity Commercial	$10.23
Rate for Payer: Cofinity Commercial	$12.57
Rate for Payer: Cofinity Medicare Advantage	$10.23
Rate for Payer: Encore Health Key Benefits Commercial	$11.70
Rate for Payer: Healthscope Commercial	$13.16
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$12.43
Rate for Payer: PHP Commercial	$12.43
Rate for Payer: Priority Health Cigna Priority Health	$9.50
Rate for Payer: Priority Health SBD	$9.21

LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL

Facility

$29.93

Service Code	NDC 71266629001
Hospital Charge Code	196007
Hospital Revenue Code	637
Min. Negotiated Rate	$11.97
Max. Negotiated Rate	$26.94
Rate for Payer: Aetna Commercial	$25.44
Rate for Payer: Aetna Medicare	$14.96
Rate for Payer: Aetna New Business (MI Preferred)	$19.45
Rate for Payer: BCBS Complete	$11.97
Rate for Payer: Cash Price	$23.94
Rate for Payer: Cofinity Commercial	$20.95
Rate for Payer: Cofinity Commercial	$25.74
Rate for Payer: Cofinity Medicare Advantage	$20.95
Rate for Payer: Encore Health Key Benefits Commercial	$23.94
Rate for Payer: Healthscope Commercial	$26.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$25.44
Rate for Payer: PHP Commercial	$25.44
Rate for Payer: Priority Health Cigna Priority Health	$19.45
Rate for Payer: Priority Health SBD	$18.86

LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL

Facility

$29.93

Service Code	NDC 71266629001
Hospital Charge Code	196007
Hospital Revenue Code	637
Min. Negotiated Rate	$18.86
Max. Negotiated Rate	$26.94
Rate for Payer: Aetna Commercial	$25.44
Rate for Payer: Aetna New Business (MI Preferred)	$19.45
Rate for Payer: Cash Price	$23.94
Rate for Payer: Cofinity Commercial	$20.95
Rate for Payer: Cofinity Commercial	$25.74
Rate for Payer: Cofinity Medicare Advantage	$20.95
Rate for Payer: Encore Health Key Benefits Commercial	$23.94
Rate for Payer: Healthscope Commercial	$26.94
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$25.44
Rate for Payer: PHP Commercial	$25.44
Rate for Payer: Priority Health Cigna Priority Health	$19.45
Rate for Payer: Priority Health SBD	$18.86

LIDOCAINE 4 % TOPICAL PATCH

Facility

$18.72

Service Code	NDC 70000036601
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$11.79
Max. Negotiated Rate	$16.85
Rate for Payer: Aetna Commercial	$15.91
Rate for Payer: Aetna New Business (MI Preferred)	$12.17
Rate for Payer: Cash Price	$14.98
Rate for Payer: Cofinity Commercial	$13.10
Rate for Payer: Cofinity Commercial	$16.10
Rate for Payer: Cofinity Medicare Advantage	$13.10
Rate for Payer: Encore Health Key Benefits Commercial	$14.98
Rate for Payer: Healthscope Commercial	$16.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.91
Rate for Payer: PHP Commercial	$15.91
Rate for Payer: Priority Health Cigna Priority Health	$12.17
Rate for Payer: Priority Health SBD	$11.79

LIDOCAINE 4 % TOPICAL PATCH

Facility

$3.64

Service Code	NDC 00121097001
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$1.46
Max. Negotiated Rate	$3.28
Rate for Payer: Aetna Commercial	$3.09
Rate for Payer: Aetna Medicare	$1.82
Rate for Payer: Aetna New Business (MI Preferred)	$2.37
Rate for Payer: BCBS Complete	$1.46
Rate for Payer: Cash Price	$2.91
Rate for Payer: Cofinity Commercial	$2.55
Rate for Payer: Cofinity Commercial	$3.13
Rate for Payer: Cofinity Medicare Advantage	$2.55
Rate for Payer: Encore Health Key Benefits Commercial	$2.91
Rate for Payer: Healthscope Commercial	$3.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.09
Rate for Payer: PHP Commercial	$3.09
Rate for Payer: Priority Health Cigna Priority Health	$2.37
Rate for Payer: Priority Health SBD	$2.29

LIDOCAINE 4 % TOPICAL PATCH

Facility

$48.73

Service Code	NDC 45611000938
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$19.49
Max. Negotiated Rate	$43.86
Rate for Payer: Aetna Commercial	$41.42
Rate for Payer: Aetna Medicare	$24.36
Rate for Payer: Aetna New Business (MI Preferred)	$31.67
Rate for Payer: BCBS Complete	$19.49
Rate for Payer: Cash Price	$38.98
Rate for Payer: Cofinity Commercial	$34.11
Rate for Payer: Cofinity Commercial	$41.91
Rate for Payer: Cofinity Medicare Advantage	$34.11
Rate for Payer: Encore Health Key Benefits Commercial	$38.98
Rate for Payer: Healthscope Commercial	$43.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$41.42
Rate for Payer: PHP Commercial	$41.42
Rate for Payer: Priority Health Cigna Priority Health	$31.67
Rate for Payer: Priority Health SBD	$30.70

LIDOCAINE 4 % TOPICAL PATCH

Facility

$48.73

Service Code	NDC 45611000938
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$30.70
Max. Negotiated Rate	$43.86
Rate for Payer: Aetna Commercial	$41.42
Rate for Payer: Aetna New Business (MI Preferred)	$31.67
Rate for Payer: Cash Price	$38.98
Rate for Payer: Cofinity Commercial	$34.11
Rate for Payer: Cofinity Commercial	$41.91
Rate for Payer: Cofinity Medicare Advantage	$34.11
Rate for Payer: Encore Health Key Benefits Commercial	$38.98
Rate for Payer: Healthscope Commercial	$43.86
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$41.42
Rate for Payer: PHP Commercial	$41.42
Rate for Payer: Priority Health Cigna Priority Health	$31.67
Rate for Payer: Priority Health SBD	$30.70

LIDOCAINE 4 % TOPICAL PATCH

Facility

$18.20

Service Code	NDC 00121097005
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$7.28
Max. Negotiated Rate	$16.38
Rate for Payer: Aetna Commercial	$15.47
Rate for Payer: Aetna Medicare	$9.10
Rate for Payer: Aetna New Business (MI Preferred)	$11.83
Rate for Payer: BCBS Complete	$7.28
Rate for Payer: Cash Price	$14.56
Rate for Payer: Cofinity Commercial	$12.74
Rate for Payer: Cofinity Commercial	$15.65
Rate for Payer: Cofinity Medicare Advantage	$12.74
Rate for Payer: Encore Health Key Benefits Commercial	$14.56
Rate for Payer: Healthscope Commercial	$16.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.47
Rate for Payer: PHP Commercial	$15.47
Rate for Payer: Priority Health Cigna Priority Health	$11.83
Rate for Payer: Priority Health SBD	$11.47

LIDOCAINE 4 % TOPICAL PATCH

Facility

$18.20

Service Code	NDC 00121097005
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$11.47
Max. Negotiated Rate	$16.38
Rate for Payer: Aetna Commercial	$15.47
Rate for Payer: Aetna New Business (MI Preferred)	$11.83
Rate for Payer: Cash Price	$14.56
Rate for Payer: Cofinity Commercial	$12.74
Rate for Payer: Cofinity Commercial	$15.65
Rate for Payer: Cofinity Medicare Advantage	$12.74
Rate for Payer: Encore Health Key Benefits Commercial	$14.56
Rate for Payer: Healthscope Commercial	$16.38
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.47
Rate for Payer: PHP Commercial	$15.47
Rate for Payer: Priority Health Cigna Priority Health	$11.83
Rate for Payer: Priority Health SBD	$11.47

LIDOCAINE 4 % TOPICAL PATCH

Facility

$3.64

Service Code	NDC 00121097001
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$2.29
Max. Negotiated Rate	$3.28
Rate for Payer: Aetna Commercial	$3.09
Rate for Payer: Aetna New Business (MI Preferred)	$2.37
Rate for Payer: Cash Price	$2.91
Rate for Payer: Cofinity Commercial	$2.55
Rate for Payer: Cofinity Commercial	$3.13
Rate for Payer: Cofinity Medicare Advantage	$2.55
Rate for Payer: Encore Health Key Benefits Commercial	$2.91
Rate for Payer: Healthscope Commercial	$3.28
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3.09
Rate for Payer: PHP Commercial	$3.09
Rate for Payer: Priority Health Cigna Priority Health	$2.37
Rate for Payer: Priority Health SBD	$2.29

LIDOCAINE 4 % TOPICAL PATCH

Facility

$18.72

Service Code	NDC 70000036601
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$16.85
Rate for Payer: Aetna Commercial	$15.91
Rate for Payer: Aetna Medicare	$9.36
Rate for Payer: Aetna New Business (MI Preferred)	$12.17
Rate for Payer: BCBS Complete	$7.49
Rate for Payer: Cash Price	$14.98
Rate for Payer: Cofinity Commercial	$13.10
Rate for Payer: Cofinity Commercial	$16.10
Rate for Payer: Cofinity Medicare Advantage	$13.10
Rate for Payer: Encore Health Key Benefits Commercial	$14.98
Rate for Payer: Healthscope Commercial	$16.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.91
Rate for Payer: PHP Commercial	$15.91
Rate for Payer: Priority Health Cigna Priority Health	$12.17
Rate for Payer: Priority Health SBD	$11.79

LIDOCAINE 4 % TOPICAL PATCH

Facility

$30.05

Service Code	NDC 00536120215
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$12.02
Max. Negotiated Rate	$27.05
Rate for Payer: Aetna Commercial	$25.54
Rate for Payer: Aetna Medicare	$15.03
Rate for Payer: Aetna New Business (MI Preferred)	$19.53
Rate for Payer: BCBS Complete	$12.02
Rate for Payer: Cash Price	$24.04
Rate for Payer: Cofinity Commercial	$21.04
Rate for Payer: Cofinity Commercial	$25.84
Rate for Payer: Cofinity Medicare Advantage	$21.04
Rate for Payer: Encore Health Key Benefits Commercial	$24.04
Rate for Payer: Healthscope Commercial	$27.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$25.54
Rate for Payer: PHP Commercial	$25.54
Rate for Payer: Priority Health Cigna Priority Health	$19.53
Rate for Payer: Priority Health SBD	$18.93

LIDOCAINE 4 % TOPICAL PATCH

Facility

$30.05

Service Code	NDC 00536120215
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$18.93
Max. Negotiated Rate	$27.05
Rate for Payer: Aetna Commercial	$25.54
Rate for Payer: Aetna New Business (MI Preferred)	$19.53
Rate for Payer: Cash Price	$24.04
Rate for Payer: Cofinity Commercial	$21.04
Rate for Payer: Cofinity Commercial	$25.84
Rate for Payer: Cofinity Medicare Advantage	$21.04
Rate for Payer: Encore Health Key Benefits Commercial	$24.04
Rate for Payer: Healthscope Commercial	$27.05
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$25.54
Rate for Payer: PHP Commercial	$25.54
Rate for Payer: Priority Health Cigna Priority Health	$19.53
Rate for Payer: Priority Health SBD	$18.93

LIDOCAINE 4 % TOPICAL PATCH

Facility

$45.36

Service Code	NDC 41167005840
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$28.58
Max. Negotiated Rate	$40.82
Rate for Payer: Aetna Commercial	$38.56
Rate for Payer: Aetna New Business (MI Preferred)	$29.48
Rate for Payer: Cash Price	$36.29
Rate for Payer: Cofinity Commercial	$31.75
Rate for Payer: Cofinity Commercial	$39.01
Rate for Payer: Cofinity Medicare Advantage	$31.75
Rate for Payer: Encore Health Key Benefits Commercial	$36.29
Rate for Payer: Healthscope Commercial	$40.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$38.56
Rate for Payer: PHP Commercial	$38.56
Rate for Payer: Priority Health Cigna Priority Health	$29.48
Rate for Payer: Priority Health SBD	$28.58

LIDOCAINE 4 % TOPICAL PATCH

Facility

$18.72

Service Code	NDC 96295013458
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$11.79
Max. Negotiated Rate	$16.85
Rate for Payer: Aetna Commercial	$15.91
Rate for Payer: Aetna New Business (MI Preferred)	$12.17
Rate for Payer: Cash Price	$14.98
Rate for Payer: Cofinity Commercial	$13.10
Rate for Payer: Cofinity Commercial	$16.10
Rate for Payer: Cofinity Medicare Advantage	$13.10
Rate for Payer: Encore Health Key Benefits Commercial	$14.98
Rate for Payer: Healthscope Commercial	$16.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.91
Rate for Payer: PHP Commercial	$15.91
Rate for Payer: Priority Health Cigna Priority Health	$12.17
Rate for Payer: Priority Health SBD	$11.79

LIDOCAINE 4 % TOPICAL PATCH

Facility

$45.36

Service Code	NDC 41167005840
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$18.14
Max. Negotiated Rate	$40.82
Rate for Payer: Aetna Commercial	$38.56
Rate for Payer: Aetna Medicare	$22.68
Rate for Payer: Aetna New Business (MI Preferred)	$29.48
Rate for Payer: BCBS Complete	$18.14
Rate for Payer: Cash Price	$36.29
Rate for Payer: Cofinity Commercial	$31.75
Rate for Payer: Cofinity Commercial	$39.01
Rate for Payer: Cofinity Medicare Advantage	$31.75
Rate for Payer: Encore Health Key Benefits Commercial	$36.29
Rate for Payer: Healthscope Commercial	$40.82
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$38.56
Rate for Payer: PHP Commercial	$38.56
Rate for Payer: Priority Health Cigna Priority Health	$29.48
Rate for Payer: Priority Health SBD	$28.58

LIDOCAINE 4 % TOPICAL PATCH

Facility

$18.72

Service Code	NDC 96295013458
Hospital Charge Code	108212
Hospital Revenue Code	637
Min. Negotiated Rate	$7.49
Max. Negotiated Rate	$16.85
Rate for Payer: Aetna Commercial	$15.91
Rate for Payer: Aetna Medicare	$9.36
Rate for Payer: Aetna New Business (MI Preferred)	$12.17
Rate for Payer: BCBS Complete	$7.49
Rate for Payer: Cash Price	$14.98
Rate for Payer: Cofinity Commercial	$13.10
Rate for Payer: Cofinity Commercial	$16.10
Rate for Payer: Cofinity Medicare Advantage	$13.10
Rate for Payer: Encore Health Key Benefits Commercial	$14.98
Rate for Payer: Healthscope Commercial	$16.85
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$15.91
Rate for Payer: PHP Commercial	$15.91
Rate for Payer: Priority Health Cigna Priority Health	$12.17
Rate for Payer: Priority Health SBD	$11.79

LIDOCAINE 4 % WITH EPINEPHRINE TOPICAL SOLUTION

Facility

$599.82

Service Code	NDC 09900000211
Hospital Charge Code	155018
Hospital Revenue Code	250
Min. Negotiated Rate	$239.93
Max. Negotiated Rate	$539.84
Rate for Payer: Aetna Commercial	$509.85
Rate for Payer: Aetna Medicare	$299.91
Rate for Payer: Aetna New Business (MI Preferred)	$389.88
Rate for Payer: BCBS Complete	$239.93
Rate for Payer: Cash Price	$479.86
Rate for Payer: Cofinity Commercial	$419.87
Rate for Payer: Cofinity Commercial	$515.85
Rate for Payer: Cofinity Medicare Advantage	$419.87
Rate for Payer: Encore Health Key Benefits Commercial	$479.86
Rate for Payer: Healthscope Commercial	$539.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$509.85
Rate for Payer: PHP Commercial	$509.85
Rate for Payer: Priority Health Cigna Priority Health	$389.88
Rate for Payer: Priority Health SBD	$377.89

LIDOCAINE 4 % WITH EPINEPHRINE TOPICAL SOLUTION

Facility

$599.82

Service Code	NDC 09900000211
Hospital Charge Code	155018
Hospital Revenue Code	250
Min. Negotiated Rate	$377.89
Max. Negotiated Rate	$539.84
Rate for Payer: Aetna Commercial	$509.85
Rate for Payer: Aetna New Business (MI Preferred)	$389.88
Rate for Payer: Cash Price	$479.86
Rate for Payer: Cofinity Commercial	$419.87
Rate for Payer: Cofinity Commercial	$515.85
Rate for Payer: Cofinity Medicare Advantage	$419.87
Rate for Payer: Encore Health Key Benefits Commercial	$479.86
Rate for Payer: Healthscope Commercial	$539.84
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$509.85
Rate for Payer: PHP Commercial	$509.85
Rate for Payer: Priority Health Cigna Priority Health	$389.88
Rate for Payer: Priority Health SBD	$377.89

LIDOCAINE 5 % TOPICAL OINTMENT

Facility

$737.67

Service Code	NDC 00168020437
Hospital Charge Code	159107
Hospital Revenue Code	637
Min. Negotiated Rate	$464.73
Max. Negotiated Rate	$663.90
Rate for Payer: Aetna Commercial	$627.02
Rate for Payer: Aetna New Business (MI Preferred)	$479.49
Rate for Payer: Cash Price	$590.14
Rate for Payer: Cofinity Commercial	$516.37
Rate for Payer: Cofinity Commercial	$634.40
Rate for Payer: Cofinity Medicare Advantage	$516.37
Rate for Payer: Encore Health Key Benefits Commercial	$590.14
Rate for Payer: Healthscope Commercial	$663.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$627.02
Rate for Payer: PHP Commercial	$627.02
Rate for Payer: Priority Health Cigna Priority Health	$479.49
Rate for Payer: Priority Health SBD	$464.73

LIDOCAINE 5 % TOPICAL OINTMENT

Facility

$737.67

Service Code	NDC 00168020437
Hospital Charge Code	159107
Hospital Revenue Code	637
Min. Negotiated Rate	$295.07
Max. Negotiated Rate	$663.90
Rate for Payer: Aetna Commercial	$627.02
Rate for Payer: Aetna Medicare	$368.83
Rate for Payer: Aetna New Business (MI Preferred)	$479.49
Rate for Payer: BCBS Complete	$295.07
Rate for Payer: Cash Price	$590.14
Rate for Payer: Cofinity Commercial	$516.37
Rate for Payer: Cofinity Commercial	$634.40
Rate for Payer: Cofinity Medicare Advantage	$516.37
Rate for Payer: Encore Health Key Benefits Commercial	$590.14
Rate for Payer: Healthscope Commercial	$663.90
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$627.02
Rate for Payer: PHP Commercial	$627.02
Rate for Payer: Priority Health Cigna Priority Health	$479.49
Rate for Payer: Priority Health SBD	$464.73

Know your out-of-pocket cost for care.

All Charges