Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]

Facility

$0.14

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.26
Rate for Payer: Multiplan Commercial	$0.08
Rate for Payer: Multiplan Commercial	$0.11
Rate for Payer: Multiplan Commercial	$0.36

LIDOCAINE 1 %-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10427]

Facility

$0.11

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.36
Rate for Payer: Multiplan Commercial	$0.26
Rate for Payer: Multiplan Commercial	$0.11
Rate for Payer: Multiplan Commercial	$0.08

LIDOCAINE 1 %-PHENYLEPHRIN 1.5 % IN BALANCED SALT(PF) INTRAOCULAR SOLN [220797]

Facility

$22.68

Service Code	NDC 71266-6360-1
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$12.47
Max. Negotiated Rate	$18.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.61
Rate for Payer: Aetna of CA Government/Medicare	$13.61
Rate for Payer: Cash Price	$12.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.14
Rate for Payer: Health Smart Auto/Commercial	$13.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.61
Rate for Payer: LLUH Dept of Risk Management WC	$12.47
Rate for Payer: Multiplan Commercial	$17.01

LIDOCAINE 1 %-PHENYLEPHRIN 1.5 % IN BALANCED SALT(PF) INTRAOCULAR SOLN [220797]

Facility

$22.68

Service Code	NDC 71266-6360-1
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$12.47
Max. Negotiated Rate	$18.14
Rate for Payer: Cash Price	$12.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$18.14
Rate for Payer: Health Smart Auto/Commercial	$13.61
Rate for Payer: LLUH Dept of Risk Management WC	$12.47
Rate for Payer: Multiplan Commercial	$17.01

LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]

Facility

$0.25

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26
Rate for Payer: Multiplan Commercial	$0.19

LIDOCAINE 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]

Facility

$0.34

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.19
Rate for Payer: Multiplan Commercial	$0.26

LIDOCAINE 2% 100 MG/5 ML SYRINGE - CODE [4080569]

Facility

$1.75

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.05
Rate for Payer: Aetna of CA Government/Medicare	$1.05
Rate for Payer: Cash Price	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.40
Rate for Payer: Health Smart Auto/Commercial	$1.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Commercial	$1.31

LIDOCAINE 2% 100 MG/5 ML SYRINGE - CODE [4080569]

Facility

$1.75

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.96
Max. Negotiated Rate	$1.40
Rate for Payer: Cash Price	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.40
Rate for Payer: Health Smart Auto/Commercial	$1.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: Multiplan Commercial	$1.31

LIDOCAINE 2% MED NEB SOLUTION [192258]

Facility

$0.15

Service Code	NDC 9999-1922-58
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

LIDOCAINE 2% MED NEB SOLUTION [192258]

Facility

$0.15

Service Code	NDC 9999-1922-58
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [120006]

Facility

$1.52

Service Code	NDC 76329-3012-5
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Commercial	$1.14

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [120006]

Facility

$1.52

Service Code	NDC 76329-3012-5
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.84
Max. Negotiated Rate	$1.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.91
Rate for Payer: Aetna of CA Government/Medicare	$0.91
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.22
Rate for Payer: Health Smart Auto/Commercial	$0.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.91
Rate for Payer: LLUH Dept of Risk Management WC	$0.84
Rate for Payer: Multiplan Commercial	$1.14

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [120006]

Facility

$0.84

Service Code	NDC 76329-3013-5
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.63

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [120006]

Facility

$0.84

Service Code	NDC 76329-3013-5
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.63

LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL [230370]

Facility

$7.33

Service Code	NDC 71266-6290-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$5.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.40
Rate for Payer: Aetna of CA Government/Medicare	$4.40
Rate for Payer: Cash Price	$4.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.86
Rate for Payer: Health Smart Auto/Commercial	$4.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.03
Rate for Payer: Multiplan Commercial	$5.50

LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL GEL [230370]

Facility

$7.33

Service Code	NDC 71266-6290-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.03
Max. Negotiated Rate	$5.86
Rate for Payer: Cash Price	$4.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.86
Rate for Payer: Health Smart Auto/Commercial	$4.40
Rate for Payer: LLUH Dept of Risk Management WC	$4.03
Rate for Payer: Multiplan Commercial	$5.50

LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL SOLUTION [219702]

Facility

$5.91

Service Code	NDC 70092-1658-44
Hospital Charge Code	901700003
Hospital Revenue Code	250
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$4.73
Rate for Payer: Cash Price	$3.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.73
Rate for Payer: Health Smart Auto/Commercial	$3.55
Rate for Payer: LLUH Dept of Risk Management WC	$3.25
Rate for Payer: Multiplan Commercial	$4.43

LIDOCAINE 4 %-RACEPINEPHRINE 0.05 %-TETRACAINE 0.5 % TOPICAL SOLUTION [219702]

Facility

$5.91

Service Code	NDC 70092-1658-44
Hospital Charge Code	901700003
Hospital Revenue Code	250
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$4.73
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.55
Rate for Payer: Aetna of CA Government/Medicare	$3.55
Rate for Payer: Cash Price	$3.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.73
Rate for Payer: Health Smart Auto/Commercial	$3.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.55
Rate for Payer: LLUH Dept of Risk Management WC	$3.25
Rate for Payer: Multiplan Commercial	$4.43

LIDOCAINE 4% SOLN FOR MED NEB INH 40 MG/ML 5 ML SOLN [4080622]

Facility

$1.04

Service Code	NDC 99994-806-22
Hospital Charge Code	901700003
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.83
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.83
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Commercial	$0.78

LIDOCAINE 4% SOLN FOR MED NEB INH 40 MG/ML 5 ML SOLN [4080622]

Facility

$1.04

Service Code	NDC 99994-806-22
Hospital Charge Code	901700003
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.83
Rate for Payer: Cash Price	$0.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.83
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Commercial	$0.78

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$1.68

Service Code	NDC 0496-0882-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$0.59

Service Code	NDC 71399-0049-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$0.84

Service Code	NDC 24357-701-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.63

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$1.68

Service Code	NDC 0496-0882-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.01
Rate for Payer: Aetna of CA Government/Medicare	$1.01
Rate for Payer: Cash Price	$0.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.34
Rate for Payer: Health Smart Auto/Commercial	$1.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.92
Rate for Payer: Multiplan Commercial	$1.26

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$0.84

Service Code	NDC 24357-701-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.50
Rate for Payer: Aetna of CA Government/Medicare	$0.50
Rate for Payer: Cash Price	$0.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.67
Rate for Payer: Health Smart Auto/Commercial	$0.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.46
Rate for Payer: Multiplan Commercial	$0.63

Know your out-of-pocket cost for care.

All Charges