Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14870]

Facility

$0.09

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJECTION. [4081101]

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	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cash Price	$0.19
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	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19
Rate for Payer: Multiplan Commercial	$0.26

LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJECTION. [4081101]

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: Cash Price	$0.14
Rate for Payer: Cash Price	$0.19
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: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19
Rate for Payer: Multiplan Commercial	$0.26

LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]

Facility

$0.62

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cash Price	$0.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.47
Rate for Payer: Multiplan Commercial	$0.99

LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]

Facility

$1.32

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.73
Max. Negotiated Rate	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.73
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.73
Rate for Payer: Multiplan Commercial	$0.99
Rate for Payer: Multiplan Commercial	$0.47

LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]

Facility

$0.74

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.53
Rate for Payer: Multiplan Commercial	$0.56

LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]

Facility

$0.71

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56
Rate for Payer: Multiplan Commercial	$0.53

LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]

Facility

$1.41

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.13
Rate for Payer: Cash Price	$0.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.13
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Commercial	$1.06

LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]

Facility

$1.41

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.85
Rate for Payer: Aetna of CA Government/Medicare	$0.85
Rate for Payer: Cash Price	$0.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.13
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Commercial	$1.06

LIDOCAINE-EPINEPHRINE (PF/NON-PF) 1.5 %-1:200,000 INJECTION SOLUTION. [40815956]

Facility

$0.71

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cash Price	$0.72
Rate for Payer: Cash Price	$0.72
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.05
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.98
Rate for Payer: Multiplan Commercial	$0.98
Rate for Payer: Multiplan Commercial	$0.56
Rate for Payer: Multiplan Commercial	$0.53

LIDOCAINE-EPINEPHRINE (PF/NON-PF) 1.5 %-1:200,000 INJECTION SOLUTION. [40815956]

Facility

$0.74

Service Code	HCPCS J2004
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.79
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.78
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cash Price	$0.72
Rate for Payer: Cash Price	$0.41
Rate for Payer: Cash Price	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.59
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: Health Smart Auto/Commercial	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.78
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.78
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.79
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.72
Rate for Payer: Multiplan Commercial	$0.98
Rate for Payer: Multiplan Commercial	$0.53
Rate for Payer: Multiplan Commercial	$0.56
Rate for Payer: Multiplan Commercial	$0.98

LIDOCAINE/EPI/TETRACAINE (LET) TOPICAL SOLN [4080616]

Facility

$0.17

Service Code	NDC 9408-0616-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.13

LIDOCAINE/EPI/TETRACAINE (LET) TOPICAL SOLN [4080616]

Facility

$0.17

Service Code	NDC 9408-0616-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.13

LIDOCAINE/EPI/TETRACAINE (LET) TOPICAL SOLN [4080616]

Facility

$6.80

Service Code	NDC 71266-6286-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$5.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.08
Rate for Payer: Aetna of CA Government/Medicare	$4.08
Rate for Payer: Cash Price	$3.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.44
Rate for Payer: Health Smart Auto/Commercial	$4.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.08
Rate for Payer: LLUH Dept of Risk Management WC	$3.74
Rate for Payer: Multiplan Commercial	$5.10

LIDOCAINE/EPI/TETRACAINE (LET) TOPICAL SOLN [4080616]

Facility

$6.80

Service Code	NDC 71266-6286-3
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.74
Max. Negotiated Rate	$5.44
Rate for Payer: Cash Price	$3.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.44
Rate for Payer: Health Smart Auto/Commercial	$4.08
Rate for Payer: LLUH Dept of Risk Management WC	$3.74
Rate for Payer: Multiplan Commercial	$5.10

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]

Facility

$0.20

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.15
Rate for Payer: Multiplan Commercial	$0.14

LIDOCAINE HCL 10 MG/ML (1 %) INJECTION SOLUTION [4452]

Facility

$0.20

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Commercial	$0.14
Rate for Payer: Multiplan Commercial	$0.15

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]

Facility

$0.41

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17
Rate for Payer: Multiplan Commercial	$0.31

LIDOCAINE HCL 20 MG/ML (2 %) INJECTION SOLUTION [4454]

Facility

$0.23

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.31
Rate for Payer: Multiplan Commercial	$0.17

LIDOCAINE HCL 2 % MUCOSAL JELLY [4448]

Facility

$1.12

Service Code	NDC 9999-1544-43
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.67
Rate for Payer: Aetna of CA Government/Medicare	$0.67
Rate for Payer: Cash Price	$0.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.84

LIDOCAINE HCL 2 % MUCOSAL JELLY [4448]

Facility

$1.12

Service Code	NDC 9999-1544-43
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.84

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.13

Service Code	NDC 9940-8209-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.13

Service Code	NDC 0054-3500-49
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.49

Service Code	NDC 0121-4950-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.13

Service Code	NDC 9940-8209-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

Know your out-of-pocket cost for care.

All Charges