Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$35.70

Service Code	NDC 72888-125-26
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$24.99
Max. Negotiated Rate	$35.70
Rate for Payer: Aetna Commercial	$32.13
Rate for Payer: ASR ASR	$34.63
Rate for Payer: BCBS Trust/PPO	$27.68
Rate for Payer: BCN Commercial	$27.68
Rate for Payer: Cash Price	$28.56
Rate for Payer: Cofinity Commercial	$33.56
Rate for Payer: Encore Health Key Benefits Commercial	$28.56
Rate for Payer: Healthscope Commercial	$35.70
Rate for Payer: Healthscope Whirlpool	$34.63
Rate for Payer: Mclaren Commercial	$32.13
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$30.34
Rate for Payer: Priority Health Cigna Priority Health	$24.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$31.42

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$15.05

Service Code	NDC 0121-0903-40
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$10.54
Max. Negotiated Rate	$15.05
Rate for Payer: Aetna Commercial	$13.54
Rate for Payer: ASR ASR	$14.60
Rate for Payer: BCBS Trust/PPO	$11.67
Rate for Payer: BCN Commercial	$11.67
Rate for Payer: Cash Price	$12.04
Rate for Payer: Cofinity Commercial	$14.15
Rate for Payer: Encore Health Key Benefits Commercial	$12.04
Rate for Payer: Healthscope Commercial	$15.05
Rate for Payer: Healthscope Whirlpool	$14.60
Rate for Payer: Mclaren Commercial	$13.54
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.79
Rate for Payer: Priority Health Cigna Priority Health	$10.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.24

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$12.00

Service Code	NDC 17856-0775-2
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$8.40
Max. Negotiated Rate	$12.00
Rate for Payer: Aetna Commercial	$10.80
Rate for Payer: ASR ASR	$11.64
Rate for Payer: BCBS Trust/PPO	$9.30
Rate for Payer: BCN Commercial	$9.30
Rate for Payer: Cash Price	$9.60
Rate for Payer: Cofinity Commercial	$11.28
Rate for Payer: Encore Health Key Benefits Commercial	$9.60
Rate for Payer: Healthscope Commercial	$12.00
Rate for Payer: Healthscope Whirlpool	$11.64
Rate for Payer: Mclaren Commercial	$10.80
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$10.20
Rate for Payer: Priority Health Cigna Priority Health	$8.40
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$10.56

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$4.68

Service Code	NDC 9900-0003-39
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$4.68
Rate for Payer: Aetna Commercial	$4.21
Rate for Payer: ASR ASR	$4.54
Rate for Payer: BCBS Trust/PPO	$3.63
Rate for Payer: BCN Commercial	$3.63
Rate for Payer: Cash Price	$3.74
Rate for Payer: Cofinity Commercial	$4.40
Rate for Payer: Encore Health Key Benefits Commercial	$3.74
Rate for Payer: Healthscope Commercial	$4.68
Rate for Payer: Healthscope Whirlpool	$4.54
Rate for Payer: Mclaren Commercial	$4.21
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$3.98
Rate for Payer: Priority Health Cigna Priority Health	$3.28
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4.12

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$35.70

Service Code	NDC 50383-775-04
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$24.99
Max. Negotiated Rate	$35.70
Rate for Payer: Aetna Commercial	$32.13
Rate for Payer: ASR ASR	$34.63
Rate for Payer: BCBS Trust/PPO	$27.68
Rate for Payer: BCN Commercial	$27.68
Rate for Payer: Cash Price	$28.56
Rate for Payer: Cofinity Commercial	$33.56
Rate for Payer: Encore Health Key Benefits Commercial	$28.56
Rate for Payer: Healthscope Commercial	$35.70
Rate for Payer: Healthscope Whirlpool	$34.63
Rate for Payer: Mclaren Commercial	$32.13
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$30.34
Rate for Payer: Priority Health Cigna Priority Health	$24.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$31.42

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	$22.30
Max. Negotiated Rate	$31.85
Rate for Payer: Aetna Commercial	$28.66
Rate for Payer: ASR ASR	$30.89
Rate for Payer: BCBS Trust/PPO	$24.69
Rate for Payer: BCN Commercial	$24.69
Rate for Payer: Cash Price	$25.48
Rate for Payer: Cofinity Commercial	$29.94
Rate for Payer: Encore Health Key Benefits Commercial	$25.48
Rate for Payer: Healthscope Commercial	$31.85
Rate for Payer: Healthscope Whirlpool	$30.89
Rate for Payer: Mclaren Commercial	$28.66
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$27.07
Rate for Payer: Priority Health Cigna Priority Health	$22.30
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$28.03

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$15.05

Service Code	NDC 0121-0903-15
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$10.54
Max. Negotiated Rate	$15.05
Rate for Payer: Aetna Commercial	$13.54
Rate for Payer: ASR ASR	$14.60
Rate for Payer: BCBS Trust/PPO	$11.67
Rate for Payer: BCN Commercial	$11.67
Rate for Payer: Cash Price	$12.04
Rate for Payer: Cofinity Commercial	$14.15
Rate for Payer: Encore Health Key Benefits Commercial	$12.04
Rate for Payer: Healthscope Commercial	$15.05
Rate for Payer: Healthscope Whirlpool	$14.60
Rate for Payer: Mclaren Commercial	$13.54
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$12.79
Rate for Payer: Priority Health Cigna Priority Health	$10.54
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$13.24

LIDOCAINE HCL 2 % MUCOSAL VISCOUS SOLUTION

Facility

$32.55

Service Code	NDC 0527-6002-74
Hospital Charge Code	109454
Hospital Revenue Code	637
Min. Negotiated Rate	$22.78
Max. Negotiated Rate	$32.55
Rate for Payer: Aetna Commercial	$29.30
Rate for Payer: ASR ASR	$31.57
Rate for Payer: BCBS Trust/PPO	$25.24
Rate for Payer: BCN Commercial	$25.24
Rate for Payer: Cash Price	$26.04
Rate for Payer: Cofinity Commercial	$30.60
Rate for Payer: Encore Health Key Benefits Commercial	$26.04
Rate for Payer: Healthscope Commercial	$32.55
Rate for Payer: Healthscope Whirlpool	$31.57
Rate for Payer: Mclaren Commercial	$29.30
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$27.67
Rate for Payer: Priority Health Cigna Priority Health	$22.78
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$28.64

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION

Facility

$91.17

Service Code	NDC 0527-6004-80
Hospital Charge Code	4450
Hospital Revenue Code	637
Min. Negotiated Rate	$63.82
Max. Negotiated Rate	$91.17
Rate for Payer: Aetna Commercial	$82.05
Rate for Payer: ASR ASR	$88.43
Rate for Payer: BCBS Trust/PPO	$70.68
Rate for Payer: BCN Commercial	$70.68
Rate for Payer: Cash Price	$72.94
Rate for Payer: Cofinity Commercial	$85.70
Rate for Payer: Encore Health Key Benefits Commercial	$72.94
Rate for Payer: Healthscope Commercial	$91.17
Rate for Payer: Healthscope Whirlpool	$88.43
Rate for Payer: Mclaren Commercial	$82.05
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$77.49
Rate for Payer: Priority Health Cigna Priority Health	$63.82
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$80.23

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION

Facility

$133.00

Service Code	NDC 0054-3505-47
Hospital Charge Code	4450
Hospital Revenue Code	637
Min. Negotiated Rate	$93.10
Max. Negotiated Rate	$133.00
Rate for Payer: Aetna Commercial	$119.70
Rate for Payer: ASR ASR	$129.01
Rate for Payer: BCBS Trust/PPO	$103.11
Rate for Payer: BCN Commercial	$103.11
Rate for Payer: Cash Price	$106.40
Rate for Payer: Cofinity Commercial	$125.02
Rate for Payer: Encore Health Key Benefits Commercial	$106.40
Rate for Payer: Healthscope Commercial	$133.00
Rate for Payer: Healthscope Whirlpool	$129.01
Rate for Payer: Mclaren Commercial	$119.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$113.05
Rate for Payer: Priority Health Cigna Priority Health	$93.10
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$117.04

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION

Facility

$71.40

Service Code	NDC 52565-009-50
Hospital Charge Code	4450
Hospital Revenue Code	637
Min. Negotiated Rate	$49.98
Max. Negotiated Rate	$71.40
Rate for Payer: Aetna Commercial	$64.26
Rate for Payer: ASR ASR	$69.26
Rate for Payer: BCBS Trust/PPO	$55.36
Rate for Payer: BCN Commercial	$55.36
Rate for Payer: Cash Price	$57.12
Rate for Payer: Cofinity Commercial	$67.12
Rate for Payer: Encore Health Key Benefits Commercial	$57.12
Rate for Payer: Healthscope Commercial	$71.40
Rate for Payer: Healthscope Whirlpool	$69.26
Rate for Payer: Mclaren Commercial	$64.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$60.69
Rate for Payer: Priority Health Cigna Priority Health	$49.98
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$62.83

LIDOCAINE IN D5W (PF) 4 MG/ML (0.4 %) IV (CODE)

Facility

$30.04

Service Code	HCPCS J2001
Hospital Charge Code	163705
Hospital Revenue Code	636
Min. Negotiated Rate	$21.03
Max. Negotiated Rate	$30.04
Rate for Payer: Aetna Commercial	$27.04
Rate for Payer: Aetna Commercial	$32.04
Rate for Payer: ASR ASR	$34.53
Rate for Payer: ASR ASR	$29.14
Rate for Payer: BCBS Trust/PPO	$23.29
Rate for Payer: BCBS Trust/PPO	$27.60
Rate for Payer: BCN Commercial	$23.29
Rate for Payer: BCN Commercial	$27.60
Rate for Payer: Cash Price	$24.03
Rate for Payer: Cash Price	$28.48
Rate for Payer: Cofinity Commercial	$33.46
Rate for Payer: Cofinity Commercial	$28.24
Rate for Payer: Encore Health Key Benefits Commercial	$24.03
Rate for Payer: Encore Health Key Benefits Commercial	$28.48
Rate for Payer: Healthscope Commercial	$35.60
Rate for Payer: Healthscope Commercial	$30.04
Rate for Payer: Healthscope Whirlpool	$29.14
Rate for Payer: Healthscope Whirlpool	$34.53
Rate for Payer: Mclaren Commercial	$32.04
Rate for Payer: Mclaren Commercial	$27.04
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$30.26
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$25.53
Rate for Payer: Priority Health Cigna Priority Health	$21.03
Rate for Payer: Priority Health Cigna Priority Health	$24.92
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$26.44
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$31.33

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE

Facility

$19.36

Service Code	NDC 0409-4903-34
Hospital Charge Code	4459
Hospital Revenue Code	250
Min. Negotiated Rate	$13.55
Max. Negotiated Rate	$19.36
Rate for Payer: Aetna Commercial	$17.42
Rate for Payer: ASR ASR	$18.78
Rate for Payer: BCBS Trust/PPO	$15.01
Rate for Payer: BCN Commercial	$15.01
Rate for Payer: Cash Price	$15.49
Rate for Payer: Cofinity Commercial	$18.20
Rate for Payer: Encore Health Key Benefits Commercial	$15.49
Rate for Payer: Healthscope Commercial	$19.36
Rate for Payer: Healthscope Whirlpool	$18.78
Rate for Payer: Mclaren Commercial	$17.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.46
Rate for Payer: Priority Health Cigna Priority Health	$13.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.04

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE

Facility

$20.20

Service Code	NDC 0409-1323-05
Hospital Charge Code	4459
Hospital Revenue Code	250
Min. Negotiated Rate	$14.14
Max. Negotiated Rate	$20.20
Rate for Payer: Aetna Commercial	$18.18
Rate for Payer: ASR ASR	$19.59
Rate for Payer: BCBS Trust/PPO	$15.66
Rate for Payer: BCN Commercial	$15.66
Rate for Payer: Cash Price	$16.16
Rate for Payer: Cofinity Commercial	$18.99
Rate for Payer: Encore Health Key Benefits Commercial	$16.16
Rate for Payer: Healthscope Commercial	$20.20
Rate for Payer: Healthscope Whirlpool	$19.59
Rate for Payer: Mclaren Commercial	$18.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.17
Rate for Payer: Priority Health Cigna Priority Health	$14.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.78

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE

Facility

$24.96

Service Code	NDC 76329-3390-1
Hospital Charge Code	4459
Hospital Revenue Code	250
Min. Negotiated Rate	$17.47
Max. Negotiated Rate	$24.96
Rate for Payer: Aetna Commercial	$22.46
Rate for Payer: ASR ASR	$24.21
Rate for Payer: BCBS Trust/PPO	$19.35
Rate for Payer: BCN Commercial	$19.35
Rate for Payer: Cash Price	$19.97
Rate for Payer: Cofinity Commercial	$23.46
Rate for Payer: Encore Health Key Benefits Commercial	$19.97
Rate for Payer: Healthscope Commercial	$24.96
Rate for Payer: Healthscope Whirlpool	$24.21
Rate for Payer: Mclaren Commercial	$22.46
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.22
Rate for Payer: Priority Health Cigna Priority Health	$17.47
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.96

LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRINGE (CODE)

Facility

$20.20

Service Code	NDC 0409-1323-05
Hospital Charge Code	163704
Hospital Revenue Code	250
Min. Negotiated Rate	$14.14
Max. Negotiated Rate	$20.20
Rate for Payer: Aetna Commercial	$18.18
Rate for Payer: ASR ASR	$19.59
Rate for Payer: BCBS Trust/PPO	$15.66
Rate for Payer: BCN Commercial	$15.66
Rate for Payer: Cash Price	$16.16
Rate for Payer: Cofinity Commercial	$18.99
Rate for Payer: Encore Health Key Benefits Commercial	$16.16
Rate for Payer: Healthscope Commercial	$20.20
Rate for Payer: Healthscope Whirlpool	$19.59
Rate for Payer: Mclaren Commercial	$18.18
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$17.17
Rate for Payer: Priority Health Cigna Priority Health	$14.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.78

LIDOCAINE (PF) 100 MG/5 ML (2 %) IV SYRINGE (CODE)

Facility

$19.36

Service Code	NDC 0409-4903-34
Hospital Charge Code	163704
Hospital Revenue Code	250
Min. Negotiated Rate	$13.55
Max. Negotiated Rate	$19.36
Rate for Payer: Aetna Commercial	$17.42
Rate for Payer: ASR ASR	$18.78
Rate for Payer: BCBS Trust/PPO	$15.01
Rate for Payer: BCN Commercial	$15.01
Rate for Payer: Cash Price	$15.49
Rate for Payer: Cofinity Commercial	$18.20
Rate for Payer: Encore Health Key Benefits Commercial	$15.49
Rate for Payer: Healthscope Commercial	$19.36
Rate for Payer: Healthscope Whirlpool	$18.78
Rate for Payer: Mclaren Commercial	$17.42
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.46
Rate for Payer: Priority Health Cigna Priority Health	$13.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$17.04

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

Facility

$18.92

Service Code	NDC 55150-159-74
Hospital Charge Code	103888
Hospital Revenue Code	250
Min. Negotiated Rate	$13.24
Max. Negotiated Rate	$18.92
Rate for Payer: Aetna Commercial	$17.03
Rate for Payer: ASR ASR	$18.35
Rate for Payer: BCBS Trust/PPO	$14.67
Rate for Payer: BCN Commercial	$14.67
Rate for Payer: Cash Price	$15.14
Rate for Payer: Cofinity Commercial	$17.78
Rate for Payer: Encore Health Key Benefits Commercial	$15.14
Rate for Payer: Healthscope Commercial	$18.92
Rate for Payer: Healthscope Whirlpool	$18.35
Rate for Payer: Mclaren Commercial	$17.03
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$16.08
Rate for Payer: Priority Health Cigna Priority Health	$13.24
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$16.65

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

Facility

$24.94

Service Code	NDC 0143-9595-25
Hospital Charge Code	103888
Hospital Revenue Code	250
Min. Negotiated Rate	$17.46
Max. Negotiated Rate	$24.94
Rate for Payer: Aetna Commercial	$22.45
Rate for Payer: ASR ASR	$24.19
Rate for Payer: BCBS Trust/PPO	$19.34
Rate for Payer: BCN Commercial	$19.34
Rate for Payer: Cash Price	$19.95
Rate for Payer: Cofinity Commercial	$23.44
Rate for Payer: Encore Health Key Benefits Commercial	$19.95
Rate for Payer: Healthscope Commercial	$24.94
Rate for Payer: Healthscope Whirlpool	$24.19
Rate for Payer: Mclaren Commercial	$22.45
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.20
Rate for Payer: Priority Health Cigna Priority Health	$17.46
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.95

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

Facility

$16.79

Service Code	NDC 55150-158-72
Hospital Charge Code	103888
Hospital Revenue Code	250
Min. Negotiated Rate	$11.75
Max. Negotiated Rate	$16.79
Rate for Payer: Aetna Commercial	$15.11
Rate for Payer: ASR ASR	$16.29
Rate for Payer: BCBS Trust/PPO	$13.02
Rate for Payer: BCN Commercial	$13.02
Rate for Payer: Cash Price	$13.43
Rate for Payer: Cofinity Commercial	$15.78
Rate for Payer: Encore Health Key Benefits Commercial	$13.43
Rate for Payer: Healthscope Commercial	$16.79
Rate for Payer: Healthscope Whirlpool	$16.29
Rate for Payer: Mclaren Commercial	$15.11
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$14.27
Rate for Payer: Priority Health Cigna Priority Health	$11.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$14.78

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

Facility

$24.94

Service Code	NDC 0143-9595-01
Hospital Charge Code	103888
Hospital Revenue Code	250
Min. Negotiated Rate	$17.46
Max. Negotiated Rate	$24.94
Rate for Payer: Aetna Commercial	$22.45
Rate for Payer: ASR ASR	$24.19
Rate for Payer: BCBS Trust/PPO	$19.34
Rate for Payer: BCN Commercial	$19.34
Rate for Payer: Cash Price	$19.95
Rate for Payer: Cofinity Commercial	$23.44
Rate for Payer: Encore Health Key Benefits Commercial	$19.95
Rate for Payer: Healthscope Commercial	$24.94
Rate for Payer: Healthscope Whirlpool	$24.19
Rate for Payer: Mclaren Commercial	$22.45
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$21.20
Rate for Payer: Priority Health Cigna Priority Health	$17.46
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$21.95

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

Facility

$27.05

Service Code	NDC 63323-492-57
Hospital Charge Code	103888
Hospital Revenue Code	250
Min. Negotiated Rate	$18.94
Max. Negotiated Rate	$27.05
Rate for Payer: Aetna Commercial	$24.34
Rate for Payer: ASR ASR	$26.24
Rate for Payer: BCBS Trust/PPO	$20.97
Rate for Payer: BCN Commercial	$20.97
Rate for Payer: Cash Price	$21.64
Rate for Payer: Cofinity Commercial	$25.43
Rate for Payer: Encore Health Key Benefits Commercial	$21.64
Rate for Payer: Healthscope Commercial	$27.05
Rate for Payer: Healthscope Whirlpool	$26.24
Rate for Payer: Mclaren Commercial	$24.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.99
Rate for Payer: Priority Health Cigna Priority Health	$18.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$23.80

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

Facility

$27.05

Service Code	NDC 63323-492-09
Hospital Charge Code	103888
Hospital Revenue Code	250
Min. Negotiated Rate	$18.94
Max. Negotiated Rate	$27.05
Rate for Payer: Aetna Commercial	$24.34
Rate for Payer: ASR ASR	$26.24
Rate for Payer: BCBS Trust/PPO	$20.97
Rate for Payer: BCN Commercial	$20.97
Rate for Payer: Cash Price	$21.64
Rate for Payer: Cofinity Commercial	$25.43
Rate for Payer: Encore Health Key Benefits Commercial	$21.64
Rate for Payer: Healthscope Commercial	$27.05
Rate for Payer: Healthscope Whirlpool	$26.24
Rate for Payer: Mclaren Commercial	$24.34
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$22.99
Rate for Payer: Priority Health Cigna Priority Health	$18.94
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$23.80

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

Facility

$46.33

Service Code	NDC 63323-492-37
Hospital Charge Code	103888
Hospital Revenue Code	250
Min. Negotiated Rate	$32.43
Max. Negotiated Rate	$46.33
Rate for Payer: Aetna Commercial	$41.70
Rate for Payer: ASR ASR	$44.94
Rate for Payer: BCBS Trust/PPO	$35.92
Rate for Payer: BCN Commercial	$35.92
Rate for Payer: Cash Price	$37.06
Rate for Payer: Cofinity Commercial	$43.55
Rate for Payer: Encore Health Key Benefits Commercial	$37.06
Rate for Payer: Healthscope Commercial	$46.33
Rate for Payer: Healthscope Whirlpool	$44.94
Rate for Payer: Mclaren Commercial	$41.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$39.38
Rate for Payer: Priority Health Cigna Priority Health	$32.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$40.77

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

Facility

$46.33

Service Code	NDC 63323-492-07
Hospital Charge Code	103888
Hospital Revenue Code	250
Min. Negotiated Rate	$32.43
Max. Negotiated Rate	$46.33
Rate for Payer: Aetna Commercial	$41.70
Rate for Payer: ASR ASR	$44.94
Rate for Payer: BCBS Trust/PPO	$35.92
Rate for Payer: BCN Commercial	$35.92
Rate for Payer: Cash Price	$37.06
Rate for Payer: Cofinity Commercial	$43.55
Rate for Payer: Encore Health Key Benefits Commercial	$37.06
Rate for Payer: Healthscope Commercial	$46.33
Rate for Payer: Healthscope Whirlpool	$44.94
Rate for Payer: Mclaren Commercial	$41.70
Rate for Payer: Multiplan/Beech St/PHCS Multiplan/Beech St/PHCS	$39.38
Rate for Payer: Priority Health Cigna Priority Health	$32.43
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$40.77

Know your out-of-pocket cost for care.

All Charges