Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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: 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 24357-701-05
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

$0.84

Service Code	NDC 24357-701-05
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

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: 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: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.44

Service Code	NDC 0121-0970-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.15
Rate for Payer: Cash Price	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.15
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.08

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.31

Service Code	NDC 70512-812-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.31

Service Code	NDC 70512-812-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.50

Service Code	NDC 0536-1202-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.90
Rate for Payer: Aetna of CA Government/Medicare	$0.90
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.07

Service Code	NDC 8770143001
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.64
Rate for Payer: Aetna of CA Government/Medicare	$0.64
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.80

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.50

Service Code	NDC 0536-1202-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.07

Service Code	NDC 46122-450-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.64
Rate for Payer: Aetna of CA Government/Medicare	$0.64
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.80

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.07

Service Code	NDC 46122-450-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.80

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.31

Service Code	NDC 0536-1202-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.07

Service Code	NDC 8770143001
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.86
Rate for Payer: Health Smart Auto/Commercial	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.59
Rate for Payer: Multiplan Commercial	$0.80

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.30

Service Code	NDC 0121-0970-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.78
Rate for Payer: Aetna of CA Government/Medicare	$0.78
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.30

Service Code	NDC 0121-0970-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.04
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.22

Service Code	NDC 71399-4456-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.44

Service Code	NDC 0121-0970-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.79
Max. Negotiated Rate	$1.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.86
Rate for Payer: Aetna of CA Government/Medicare	$0.86
Rate for Payer: Cash Price	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.15
Rate for Payer: Health Smart Auto/Commercial	$0.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.86
Rate for Payer: LLUH Dept of Risk Management WC	$0.79
Rate for Payer: Multiplan Commercial	$1.08

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.22

Service Code	NDC 71399-4456-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.73
Rate for Payer: Aetna of CA Government/Medicare	$0.73
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.31

Service Code	NDC 0536-1202-07
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.31

Service Code	NDC 70512-812-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.31

Service Code	NDC 70512-812-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.22

Service Code	NDC 71399-4456-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.22

Service Code	NDC 71399-4456-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.67
Max. Negotiated Rate	$0.98
Rate for Payer: Cash Price	$0.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.98
Rate for Payer: Health Smart Auto/Commercial	$0.73
Rate for Payer: LLUH Dept of Risk Management WC	$0.67
Rate for Payer: Multiplan Commercial	$0.92

Know your out-of-pocket cost for care.

All Charges