Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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: 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

$0.49

Service Code	NDC 0121-4950-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
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: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.49

Service Code	NDC 0121-4950-15
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 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 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

$0.96

Service Code	NDC 0054-3505-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

$0.67

Service Code	NDC 0527-6004-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

$0.96

Service Code	NDC 0054-3505-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

$0.67

Service Code	NDC 0527-6004-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.50

LIDOCAINE HCL 5 MG/ML (0.5 %) INJECTION SOLUTION [4451]

Facility

$0.11

Service Code	HCPCS J2003
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

LIDOCAINE HCL 5 MG/ML (0.5 %) INJECTION SOLUTION [4451]

Facility

$0.11

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

Facility

$1.82

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.46
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cash Price	$0.96
Rate for Payer: Cash Price	$1.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.72
Rate for Payer: Health Smart Auto/Commercial	$1.29
Rate for Payer: Health Smart Auto/Commercial	$1.05
Rate for Payer: Health Smart Auto/Commercial	$1.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: LLUH Dept of Risk Management WC	$1.18
Rate for Payer: Multiplan Commercial	$1.61
Rate for Payer: Multiplan Commercial	$1.31
Rate for Payer: Multiplan Commercial	$1.36

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

Facility

$1.82

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.00
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.29
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: Aetna of CA Government/Medicare	$1.29
Rate for Payer: Aetna of CA Government/Medicare	$1.09
Rate for Payer: Cash Price	$1.18
Rate for Payer: Cash Price	$1.00
Rate for Payer: Cash Price	$0.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.40
Rate for Payer: Health Smart Auto/Commercial	$1.09
Rate for Payer: Health Smart Auto/Commercial	$1.29
Rate for Payer: Health Smart Auto/Commercial	$1.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.09
Rate for Payer: LLUH Dept of Risk Management WC	$1.00
Rate for Payer: LLUH Dept of Risk Management WC	$0.96
Rate for Payer: LLUH Dept of Risk Management WC	$1.18
Rate for Payer: Multiplan Commercial	$1.31
Rate for Payer: Multiplan Commercial	$1.61
Rate for Payer: Multiplan Commercial	$1.36

LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [103888]

Facility

$1.42

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.78
Max. Negotiated Rate	$1.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.85
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.52
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
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	$0.47
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	$1.14
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.43
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.85
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.53
Rate for Payer: Multiplan Commercial	$0.44
Rate for Payer: Multiplan Commercial	$1.06
Rate for Payer: Multiplan Commercial	$0.71
Rate for Payer: Multiplan Commercial	$0.10
Rate for Payer: Multiplan Commercial	$0.31

LIDOCAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [103888]

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: Cash Price	$0.23
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cash Price	$0.78
Rate for Payer: Cash Price	$0.52
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	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.85
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.78
Rate for Payer: Multiplan Commercial	$0.71
Rate for Payer: Multiplan Commercial	$0.44
Rate for Payer: Multiplan Commercial	$0.31
Rate for Payer: Multiplan Commercial	$0.10
Rate for Payer: Multiplan Commercial	$1.06
Rate for Payer: Multiplan Commercial	$0.53

LIDOCAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION [4453]

Facility

$0.61

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.46

LIDOCAINE (PF) 15 MG/ML (1.5 %) INJECTION SOLUTION [4453]

Facility

$0.61

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
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: Multiplan Commercial	$0.46

LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [103889]

Facility

$0.61

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.46
Rate for Payer: Multiplan Commercial	$0.65

LIDOCAINE (PF) 20 MG/ML (2 %) INJECTION SOLUTION [103889]

Facility

$0.86

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.34
Rate for Payer: Cash Price	$0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Commercial	$0.65
Rate for Payer: Multiplan Commercial	$0.46

LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION [118084]

Facility

$0.90

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

LIDOCAINE (PF) 20 MG/ML (2 %) INTRAVENOUS SOLUTION [118084]

Facility

$0.90

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION [4455]

Facility

$1.16

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.70
Rate for Payer: Aetna of CA Government/Medicare	$0.70
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.93
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.87

LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION [4455]

Facility

$1.16

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.93
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.87

LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE [4457]

Facility

$3.60

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$2.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.18
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$3.13
Rate for Payer: LLUH Dept of Risk Management WC	$2.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$3.92

LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE [4457]

Facility

$3.60

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.13
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$3.13
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$2.87
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.18
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$3.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.13
Rate for Payer: LLUH Dept of Risk Management WC	$2.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$3.92

LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [105635]

Facility

$0.10

Service Code	HCPCS J2003
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

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