Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

LEVOTHYROXINE 100 MCG TABLET

Facility

$371.92

Service Code	NDC 0378-1809-77
Hospital Charge Code	4423
Hospital Revenue Code	637
Min. Negotiated Rate	$260.34
Max. Negotiated Rate	$371.92
Rate for Payer: Aetna Commercial	$334.73
Rate for Payer: ASR ASR	$360.76
Rate for Payer: BCBS Trust/PPO	$288.35
Rate for Payer: BCN Commercial	$288.35
Rate for Payer: Cash Price	$297.54
Rate for Payer: Cofinity Commercial	$349.60
Rate for Payer: Encore Health Key Benefits Commercial	$297.54
Rate for Payer: Healthscope Commercial	$371.92
Rate for Payer: Healthscope Whirlpool	$360.76
Rate for Payer: Mclaren Commercial	$334.73
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$316.13
Rate for Payer: Priority Health Cigna Priority Health	$260.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$327.29

LEVOTHYROXINE 200 MCG INTRAVENOUS POWDER FOR SOLUTION

Facility

$538.61

Service Code	NDC 63323-647-10
Hospital Charge Code	4418
Hospital Revenue Code	250
Min. Negotiated Rate	$377.03
Max. Negotiated Rate	$538.61
Rate for Payer: Aetna Commercial	$484.75
Rate for Payer: ASR ASR	$522.45
Rate for Payer: BCBS Trust/PPO	$417.58
Rate for Payer: BCN Commercial	$417.58
Rate for Payer: Cash Price	$430.88
Rate for Payer: Cofinity Commercial	$506.29
Rate for Payer: Encore Health Key Benefits Commercial	$430.89
Rate for Payer: Healthscope Commercial	$538.61
Rate for Payer: Healthscope Whirlpool	$522.45
Rate for Payer: Mclaren Commercial	$484.75
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$457.82
Rate for Payer: Priority Health Cigna Priority Health	$377.03
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$473.98

LEVOTHYROXINE 25 MCG TABLET

Facility

$4.11

Service Code	NDC 51079-444-01
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$2.88
Max. Negotiated Rate	$4.11
Rate for Payer: Aetna Commercial	$3.70
Rate for Payer: ASR ASR	$3.99
Rate for Payer: BCBS Trust/PPO	$3.19
Rate for Payer: BCN Commercial	$3.19
Rate for Payer: Cash Price	$3.29
Rate for Payer: Cofinity Commercial	$3.86
Rate for Payer: Encore Health Key Benefits Commercial	$3.29
Rate for Payer: Healthscope Commercial	$4.11
Rate for Payer: Healthscope Whirlpool	$3.99
Rate for Payer: Mclaren Commercial	$3.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.49
Rate for Payer: Priority Health Cigna Priority Health	$2.88
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$3.62

LEVOTHYROXINE 25 MCG TABLET

Facility

$304.95

Service Code	NDC 60687-453-01
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$213.46
Max. Negotiated Rate	$304.95
Rate for Payer: Aetna Commercial	$274.46
Rate for Payer: ASR ASR	$295.80
Rate for Payer: BCBS Trust/PPO	$236.43
Rate for Payer: BCN Commercial	$236.43
Rate for Payer: Cash Price	$243.96
Rate for Payer: Cofinity Commercial	$286.65
Rate for Payer: Encore Health Key Benefits Commercial	$243.96
Rate for Payer: Healthscope Commercial	$304.95
Rate for Payer: Healthscope Whirlpool	$295.80
Rate for Payer: Mclaren Commercial	$274.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$259.21
Rate for Payer: Priority Health Cigna Priority Health	$213.46
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$268.36

LEVOTHYROXINE 25 MCG TABLET

Facility

$3.05

Service Code	NDC 60687-453-11
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$2.14
Max. Negotiated Rate	$3.05
Rate for Payer: Aetna Commercial	$2.74
Rate for Payer: ASR ASR	$2.96
Rate for Payer: BCBS Trust/PPO	$2.36
Rate for Payer: BCN Commercial	$2.36
Rate for Payer: Cash Price	$2.44
Rate for Payer: Cofinity Commercial	$2.87
Rate for Payer: Encore Health Key Benefits Commercial	$2.44
Rate for Payer: Healthscope Commercial	$3.05
Rate for Payer: Healthscope Whirlpool	$2.96
Rate for Payer: Mclaren Commercial	$2.74
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.59
Rate for Payer: Priority Health Cigna Priority Health	$2.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.68

LEVOTHYROXINE 25 MCG TABLET

Facility

$304.00

Service Code	NDC 0904-6949-61
Hospital Charge Code	4420
Hospital Revenue Code	637
Min. Negotiated Rate	$212.80
Max. Negotiated Rate	$304.00
Rate for Payer: Aetna Commercial	$273.60
Rate for Payer: ASR ASR	$294.88
Rate for Payer: BCBS Trust/PPO	$235.69
Rate for Payer: BCN Commercial	$235.69
Rate for Payer: Cash Price	$243.20
Rate for Payer: Cofinity Commercial	$285.76
Rate for Payer: Encore Health Key Benefits Commercial	$243.20
Rate for Payer: Healthscope Commercial	$304.00
Rate for Payer: Healthscope Whirlpool	$294.88
Rate for Payer: Mclaren Commercial	$273.60
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$258.40
Rate for Payer: Priority Health Cigna Priority Health	$212.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$267.52

LEVOTHYROXINE 50 MCG TABLET

Facility

$313.50

Service Code	NDC 0904-6950-61
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$219.45
Max. Negotiated Rate	$313.50
Rate for Payer: Aetna Commercial	$282.15
Rate for Payer: ASR ASR	$304.10
Rate for Payer: BCBS Trust/PPO	$243.06
Rate for Payer: BCN Commercial	$243.06
Rate for Payer: Cash Price	$250.80
Rate for Payer: Cofinity Commercial	$294.69
Rate for Payer: Encore Health Key Benefits Commercial	$250.80
Rate for Payer: Healthscope Commercial	$313.50
Rate for Payer: Healthscope Whirlpool	$304.10
Rate for Payer: Mclaren Commercial	$282.15
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$266.48
Rate for Payer: Priority Health Cigna Priority Health	$219.45
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$275.88

LEVOTHYROXINE 50 MCG TABLET

Facility

$4.67

Service Code	NDC 51079-440-01
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$3.27
Max. Negotiated Rate	$4.67
Rate for Payer: Aetna Commercial	$4.20
Rate for Payer: ASR ASR	$4.53
Rate for Payer: BCBS Trust/PPO	$3.62
Rate for Payer: BCN Commercial	$3.62
Rate for Payer: Cash Price	$3.74
Rate for Payer: Cofinity Commercial	$4.39
Rate for Payer: Encore Health Key Benefits Commercial	$3.74
Rate for Payer: Healthscope Commercial	$4.67
Rate for Payer: Healthscope Whirlpool	$4.53
Rate for Payer: Mclaren Commercial	$4.20
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.97
Rate for Payer: Priority Health Cigna Priority Health	$3.27
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.11

LEVOTHYROXINE 50 MCG TABLET

Facility

$3.29

Service Code	NDC 60687-464-11
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$2.30
Max. Negotiated Rate	$3.29
Rate for Payer: Aetna Commercial	$2.96
Rate for Payer: ASR ASR	$3.19
Rate for Payer: BCBS Trust/PPO	$2.55
Rate for Payer: BCN Commercial	$2.55
Rate for Payer: Cash Price	$2.63
Rate for Payer: Cofinity Commercial	$3.09
Rate for Payer: Encore Health Key Benefits Commercial	$2.63
Rate for Payer: Healthscope Commercial	$3.29
Rate for Payer: Healthscope Whirlpool	$3.19
Rate for Payer: Mclaren Commercial	$2.96
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.80
Rate for Payer: Priority Health Cigna Priority Health	$2.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.90

LEVOTHYROXINE 50 MCG TABLET

Facility

$328.70

Service Code	NDC 60687-464-01
Hospital Charge Code	4421
Hospital Revenue Code	637
Min. Negotiated Rate	$230.09
Max. Negotiated Rate	$328.70
Rate for Payer: Aetna Commercial	$295.83
Rate for Payer: ASR ASR	$318.84
Rate for Payer: BCBS Trust/PPO	$254.84
Rate for Payer: BCN Commercial	$254.84
Rate for Payer: Cash Price	$262.96
Rate for Payer: Cofinity Commercial	$308.98
Rate for Payer: Encore Health Key Benefits Commercial	$262.96
Rate for Payer: Healthscope Commercial	$328.70
Rate for Payer: Healthscope Whirlpool	$318.84
Rate for Payer: Mclaren Commercial	$295.83
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$279.40
Rate for Payer: Priority Health Cigna Priority Health	$230.09
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$289.26

LEVOTHYROXINE 75 MCG TABLET

Facility

$2.63

Service Code	NDC 51079-441-01
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$1.84
Max. Negotiated Rate	$2.63
Rate for Payer: Aetna Commercial	$2.37
Rate for Payer: ASR ASR	$2.55
Rate for Payer: BCBS Trust/PPO	$2.04
Rate for Payer: BCN Commercial	$2.04
Rate for Payer: Cash Price	$2.10
Rate for Payer: Cofinity Commercial	$2.47
Rate for Payer: Encore Health Key Benefits Commercial	$2.10
Rate for Payer: Healthscope Commercial	$2.63
Rate for Payer: Healthscope Whirlpool	$2.55
Rate for Payer: Mclaren Commercial	$2.37
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.24
Rate for Payer: Priority Health Cigna Priority Health	$1.84
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.31

LEVOTHYROXINE 75 MCG TABLET

Facility

$359.10

Service Code	NDC 0781-5182-92
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$251.37
Max. Negotiated Rate	$359.10
Rate for Payer: Aetna Commercial	$323.19
Rate for Payer: ASR ASR	$348.33
Rate for Payer: BCBS Trust/PPO	$278.41
Rate for Payer: BCN Commercial	$278.41
Rate for Payer: Cash Price	$287.28
Rate for Payer: Cofinity Commercial	$337.55
Rate for Payer: Encore Health Key Benefits Commercial	$287.28
Rate for Payer: Healthscope Commercial	$359.10
Rate for Payer: Healthscope Whirlpool	$348.33
Rate for Payer: Mclaren Commercial	$323.19
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$305.24
Rate for Payer: Priority Health Cigna Priority Health	$251.37
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$316.01

LEVOTHYROXINE 75 MCG TABLET

Facility

$262.56

Service Code	NDC 51079-441-20
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$183.79
Max. Negotiated Rate	$262.56
Rate for Payer: Aetna Commercial	$236.30
Rate for Payer: ASR ASR	$254.68
Rate for Payer: BCBS Trust/PPO	$203.56
Rate for Payer: BCN Commercial	$203.56
Rate for Payer: Cash Price	$210.05
Rate for Payer: Cofinity Commercial	$246.81
Rate for Payer: Encore Health Key Benefits Commercial	$210.05
Rate for Payer: Healthscope Commercial	$262.56
Rate for Payer: Healthscope Whirlpool	$254.68
Rate for Payer: Mclaren Commercial	$236.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$223.18
Rate for Payer: Priority Health Cigna Priority Health	$183.79
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$231.05

LEVOTHYROXINE 75 MCG TABLET

Facility

$379.05

Service Code	NDC 0904-6951-61
Hospital Charge Code	4422
Hospital Revenue Code	637
Min. Negotiated Rate	$265.34
Max. Negotiated Rate	$379.05
Rate for Payer: Aetna Commercial	$341.14
Rate for Payer: ASR ASR	$367.68
Rate for Payer: BCBS Trust/PPO	$293.88
Rate for Payer: BCN Commercial	$293.88
Rate for Payer: Cash Price	$303.24
Rate for Payer: Cofinity Commercial	$356.31
Rate for Payer: Encore Health Key Benefits Commercial	$303.24
Rate for Payer: Healthscope Commercial	$379.05
Rate for Payer: Healthscope Whirlpool	$367.68
Rate for Payer: Mclaren Commercial	$341.14
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$322.19
Rate for Payer: Priority Health Cigna Priority Health	$265.34
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$333.56

LEVOTHYROXINE 88 MCG TABLET

Facility

$124.78

Service Code	NDC 68180-968-09
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$87.35
Max. Negotiated Rate	$124.78
Rate for Payer: Aetna Commercial	$112.30
Rate for Payer: ASR ASR	$121.04
Rate for Payer: BCBS Trust/PPO	$96.74
Rate for Payer: BCN Commercial	$96.74
Rate for Payer: Cash Price	$99.83
Rate for Payer: Cofinity Commercial	$117.29
Rate for Payer: Encore Health Key Benefits Commercial	$99.82
Rate for Payer: Healthscope Commercial	$124.78
Rate for Payer: Healthscope Whirlpool	$121.04
Rate for Payer: Mclaren Commercial	$112.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$106.06
Rate for Payer: Priority Health Cigna Priority Health	$87.35
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$109.81

LEVOTHYROXINE 88 MCG TABLET

Facility

$380.00

Service Code	NDC 0904-6952-61
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$266.00
Max. Negotiated Rate	$380.00
Rate for Payer: Aetna Commercial	$342.00
Rate for Payer: ASR ASR	$368.60
Rate for Payer: BCBS Trust/PPO	$294.61
Rate for Payer: BCN Commercial	$294.61
Rate for Payer: Cash Price	$304.00
Rate for Payer: Cofinity Commercial	$357.20
Rate for Payer: Encore Health Key Benefits Commercial	$304.00
Rate for Payer: Healthscope Commercial	$380.00
Rate for Payer: Healthscope Whirlpool	$368.60
Rate for Payer: Mclaren Commercial	$342.00
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$323.00
Rate for Payer: Priority Health Cigna Priority Health	$266.00
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$334.40

LEVOTHYROXINE 88 MCG TABLET

Facility

$241.44

Service Code	NDC 42292-038-20
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$169.01
Max. Negotiated Rate	$241.44
Rate for Payer: Aetna Commercial	$217.30
Rate for Payer: ASR ASR	$234.20
Rate for Payer: BCBS Trust/PPO	$187.19
Rate for Payer: BCN Commercial	$187.19
Rate for Payer: Cash Price	$193.15
Rate for Payer: Cofinity Commercial	$226.95
Rate for Payer: Encore Health Key Benefits Commercial	$193.15
Rate for Payer: Healthscope Commercial	$241.44
Rate for Payer: Healthscope Whirlpool	$234.20
Rate for Payer: Mclaren Commercial	$217.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$205.22
Rate for Payer: Priority Health Cigna Priority Health	$169.01
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$212.47

LEVOTHYROXINE 88 MCG TABLET

Facility

$2.42

Service Code	NDC 42292-038-01
Hospital Charge Code	10403
Hospital Revenue Code	637
Min. Negotiated Rate	$1.69
Max. Negotiated Rate	$2.42
Rate for Payer: Aetna Commercial	$2.18
Rate for Payer: ASR ASR	$2.35
Rate for Payer: BCBS Trust/PPO	$1.88
Rate for Payer: BCN Commercial	$1.88
Rate for Payer: Cash Price	$1.93
Rate for Payer: Cofinity Commercial	$2.27
Rate for Payer: Encore Health Key Benefits Commercial	$1.94
Rate for Payer: Healthscope Commercial	$2.42
Rate for Payer: Healthscope Whirlpool	$2.35
Rate for Payer: Mclaren Commercial	$2.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$2.06
Rate for Payer: Priority Health Cigna Priority Health	$1.69
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2.13

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

Facility

$41.38

Service Code	NDC 63323-482-57
Hospital Charge Code	10427
Hospital Revenue Code	250
Min. Negotiated Rate	$28.97
Max. Negotiated Rate	$41.38
Rate for Payer: Aetna Commercial	$37.24
Rate for Payer: ASR ASR	$40.14
Rate for Payer: BCBS Trust/PPO	$32.08
Rate for Payer: BCN Commercial	$32.08
Rate for Payer: Cash Price	$33.11
Rate for Payer: Cofinity Commercial	$38.90
Rate for Payer: Encore Health Key Benefits Commercial	$33.10
Rate for Payer: Healthscope Commercial	$41.38
Rate for Payer: Healthscope Whirlpool	$40.14
Rate for Payer: Mclaren Commercial	$37.24
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$35.17
Rate for Payer: Priority Health Cigna Priority Health	$28.97
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$36.41

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

Facility

$22.91

Service Code	NDC 0409-3182-11
Hospital Charge Code	10430
Hospital Revenue Code	250
Min. Negotiated Rate	$16.04
Max. Negotiated Rate	$22.91
Rate for Payer: Aetna Commercial	$20.62
Rate for Payer: ASR ASR	$22.22
Rate for Payer: BCBS Trust/PPO	$17.76
Rate for Payer: BCN Commercial	$17.76
Rate for Payer: Cash Price	$18.33
Rate for Payer: Cofinity Commercial	$21.54
Rate for Payer: Encore Health Key Benefits Commercial	$18.33
Rate for Payer: Healthscope Commercial	$22.91
Rate for Payer: Healthscope Whirlpool	$22.22
Rate for Payer: Mclaren Commercial	$20.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$19.47
Rate for Payer: Priority Health Cigna Priority Health	$16.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.16

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

Facility

$18.07

Service Code	NDC 63323-483-03
Hospital Charge Code	10430
Hospital Revenue Code	250
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$18.07
Rate for Payer: Aetna Commercial	$16.26
Rate for Payer: ASR ASR	$17.53
Rate for Payer: BCBS Trust/PPO	$14.01
Rate for Payer: BCN Commercial	$14.01
Rate for Payer: Cash Price	$14.45
Rate for Payer: Cofinity Commercial	$16.99
Rate for Payer: Encore Health Key Benefits Commercial	$14.46
Rate for Payer: Healthscope Commercial	$18.07
Rate for Payer: Healthscope Whirlpool	$17.53
Rate for Payer: Mclaren Commercial	$16.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15.36
Rate for Payer: Priority Health Cigna Priority Health	$12.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15.90

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

Facility

$22.91

Service Code	NDC 0409-3182-01
Hospital Charge Code	10430
Hospital Revenue Code	250
Min. Negotiated Rate	$16.04
Max. Negotiated Rate	$22.91
Rate for Payer: Aetna Commercial	$20.62
Rate for Payer: ASR ASR	$22.22
Rate for Payer: BCBS Trust/PPO	$17.76
Rate for Payer: BCN Commercial	$17.76
Rate for Payer: Cash Price	$18.33
Rate for Payer: Cofinity Commercial	$21.54
Rate for Payer: Encore Health Key Benefits Commercial	$18.33
Rate for Payer: Healthscope Commercial	$22.91
Rate for Payer: Healthscope Whirlpool	$22.22
Rate for Payer: Mclaren Commercial	$20.62
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$19.47
Rate for Payer: Priority Health Cigna Priority Health	$16.04
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$20.16

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

Facility

$18.07

Service Code	NDC 63323-483-27
Hospital Charge Code	10430
Hospital Revenue Code	250
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$18.07
Rate for Payer: Aetna Commercial	$16.26
Rate for Payer: ASR ASR	$17.53
Rate for Payer: BCBS Trust/PPO	$14.01
Rate for Payer: BCN Commercial	$14.01
Rate for Payer: Cash Price	$14.45
Rate for Payer: Cofinity Commercial	$16.99
Rate for Payer: Encore Health Key Benefits Commercial	$14.46
Rate for Payer: Healthscope Commercial	$18.07
Rate for Payer: Healthscope Whirlpool	$17.53
Rate for Payer: Mclaren Commercial	$16.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$15.36
Rate for Payer: Priority Health Cigna Priority Health	$12.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$15.90

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR

Facility

$24.05

Service Code	NDC 76329-3012-5
Hospital Charge Code	118460
Hospital Revenue Code	637
Min. Negotiated Rate	$16.84
Max. Negotiated Rate	$24.05
Rate for Payer: Aetna Commercial	$21.64
Rate for Payer: ASR ASR	$23.33
Rate for Payer: BCBS Trust/PPO	$18.65
Rate for Payer: BCN Commercial	$18.65
Rate for Payer: Cash Price	$19.24
Rate for Payer: Cofinity Commercial	$22.61
Rate for Payer: Encore Health Key Benefits Commercial	$19.24
Rate for Payer: Healthscope Commercial	$24.05
Rate for Payer: Healthscope Whirlpool	$23.33
Rate for Payer: Mclaren Commercial	$21.64
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$20.44
Rate for Payer: Priority Health Cigna Priority Health	$16.84
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.16

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR

Facility

$15.90

Service Code	NDC 25021-673-76
Hospital Charge Code	118460
Hospital Revenue Code	637
Min. Negotiated Rate	$11.13
Max. Negotiated Rate	$15.90
Rate for Payer: Aetna Commercial	$14.31
Rate for Payer: ASR ASR	$15.42
Rate for Payer: BCBS Trust/PPO	$12.33
Rate for Payer: BCN Commercial	$12.33
Rate for Payer: Cash Price	$12.72
Rate for Payer: Cofinity Commercial	$14.95
Rate for Payer: Encore Health Key Benefits Commercial	$12.72
Rate for Payer: Healthscope Commercial	$15.90
Rate for Payer: Healthscope Whirlpool	$15.42
Rate for Payer: Mclaren Commercial	$14.31
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$13.52
Rate for Payer: Priority Health Cigna Priority Health	$11.13
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.99

Know your out-of-pocket cost for care.

All Charges