Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LIDOCAINE 10 MG/ML (1 %) INJECTION. [4081619]

Facility

$0.77

Service Code	NDC 0409-4713-32
Hospital Charge Code	1721029
Hospital Revenue Code	250
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.46
Rate for Payer: Aetna of CA Government/Medicare	$0.46
Rate for Payer: Cash Price	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.58

LIDOCAINE 10 MG/ML (1 %) INJECTION. [4081619]

Facility

$0.10

Service Code	NDC 0409-4276-16
Hospital Charge Code	1721062
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

LIDOCAINE 10 MG/ML (1 %) INJECTION. [4081619]

Facility

$0.10

Service Code	NDC 0409-4276-01
Hospital Charge Code	1721062
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

LIDOCAINE 10 MG/ML (1 %) INJECTION. [4081619]

Facility

$0.08

Service Code	NDC 0409-4276-02
Hospital Charge Code	1721028
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

LIDOCAINE 10 MG/ML (1 %) INJECTION. [4081619]

Facility

$0.36

Service Code	NDC 55150-159-74
Hospital Charge Code	1721022
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.27

LIDOCAINE 10 MG/ML (1 %) INJECTION. [4081619]

Facility

$0.94

Service Code	NDC 63323-492-57
Hospital Charge Code	1721022
Hospital Revenue Code	250
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.71
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.71

LIDOCAINE 10 MG/ML (1 %) INJECTION. [4081619]

Facility

$1.56

Service Code	NDC 63323-201-02
Hospital Charge Code	1721214
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.17

LIDOCAINE 10 MG/ML (1 %) INJECTION. [4081619]

Facility

$0.20

Service Code	NDC 63323-485-27
Hospital Charge Code	1721062
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.15

LIDOCAINE 1.5% SOLN FOR MED NEB INH 15 MG/ML 20 ML [4080623]

Facility

$0.61

Service Code	NDC 0409-4776-01
Hospital Charge Code	1720570
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.46
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	$0.27
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 Beech St/Commercial/PHCS	$0.46

LIDOCAINE 1.5% SOLN FOR MED NEB INH 15 MG/ML 20 ML [4080623]

Facility

$0.61

Service Code	NDC 0409-4776-01
Hospital Charge Code	1720570
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.46

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

Facility

$0.26

Service Code	NDC 63323-482-27
Hospital Charge Code	1721060
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

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

Facility

$0.42

Service Code	NDC 63323-482-17
Hospital Charge Code	NDG10427A
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.25
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: Multiplan Beech St/Commercial/PHCS	$0.32

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

Facility

$0.42

Service Code	NDC 63323-482-17
Hospital Charge Code	NDG10427A
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

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

Facility

$0.14

Service Code	NDC 0409-3178-01
Hospital Charge Code	1721060
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

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

Facility

$0.26

Service Code	NDC 63323-482-27
Hospital Charge Code	1721060
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

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

Facility

$0.14

Service Code	NDC 0409-3178-01
Hospital Charge Code	1721060
Hospital Revenue Code	250
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 Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
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	$0.08
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.11

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

Facility

$0.11

Service Code	NDC 63323-482-26
Hospital Charge Code	1721060
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
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	$0.05
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 Beech St/Commercial/PHCS	$0.08

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

Facility

$0.26

Service Code	NDC 63323-482-03
Hospital Charge Code	1721060
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

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

Facility

$0.11

Service Code	NDC 63323-482-41
Hospital Charge Code	1721060
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
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	$0.05
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 Beech St/Commercial/PHCS	$0.08

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

Facility

$0.11

Service Code	NDC 63323-482-41
Hospital Charge Code	1721060
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

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

Facility

$0.26

Service Code	NDC 63323-482-03
Hospital Charge Code	1721060
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

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

Facility

$0.11

Service Code	NDC 63323-482-26
Hospital Charge Code	1721060
Hospital Revenue Code	250
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.08

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

Facility

$20.40

Service Code	NDC 71266-6360-1
Hospital Charge Code	NDG220797
Hospital Revenue Code	250
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$15.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.24
Rate for Payer: Aetna of CA Government/Medicare	$12.24
Rate for Payer: Cash Price	$9.18
Rate for Payer: Health Smart Auto/Commercial	$12.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.24
Rate for Payer: LLUH Dept of Risk Management WC	$11.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.30

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

Facility

$20.40

Service Code	NDC 71266-6360-1
Hospital Charge Code	NDG220797
Hospital Revenue Code	250
Min. Negotiated Rate	$11.22
Max. Negotiated Rate	$16.32
Rate for Payer: Cash Price	$9.18
Rate for Payer: Cigna of CA HMO/PPO	$16.32
Rate for Payer: Health Smart Auto/Commercial	$12.24
Rate for Payer: LLUH Dept of Risk Management WC	$11.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.30

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

Facility

$0.26

Service Code	NDC 63323-483-03
Hospital Charge Code	1720631
Hospital Revenue Code	250
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20

Know your out-of-pocket cost for care.

All Charges