Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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	$0.21
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 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]

Facility

$0.20

Service Code	NDC 63323-483-57
Hospital Charge Code	NDG10430
Hospital Revenue Code	250
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.12
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: Multiplan Beech St/Commercial/PHCS	$0.15

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

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

Facility

$0.26

Service Code	NDC 63323-483-27
Hospital Charge Code	1720631
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 20 MG/ML (2 %)-EPINEPHRINE 1:100,000 INJECTION SOLUTION [10430]

Facility

$0.26

Service Code	NDC 63323-483-27
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

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

Facility

$1.19

Service Code	NDC 0409-1323-05
Hospital Charge Code	1720703
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.95
Rate for Payer: Cash Price	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.95
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

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

Facility

$1.19

Service Code	NDC 0409-1323-05
Hospital Charge Code	1720703
Hospital Revenue Code	250
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

LIDOCAINE 2% MED NEB SOLUTION [192258]

Facility

$0.15

Service Code	NDC 9999-1922-58
Hospital Charge Code	1721121
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.07
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 Beech St/Commercial/PHCS	$0.11

LIDOCAINE 2% MED NEB SOLUTION [192258]

Facility

$0.15

Service Code	NDC 9999-1922-58
Hospital Charge Code	1721121
Hospital Revenue Code	250
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.07
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.11

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [120006]

Facility

$1.38

Service Code	NDC 76329-3012-5
Hospital Charge Code	NDG120006D
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.83
Rate for Payer: Aetna of CA Government/Medicare	$0.83
Rate for Payer: Cash Price	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.04

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [120006]

Facility

$0.77

Service Code	NDC 76329-3013-5
Hospital Charge Code	NDG120006
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 2 % MUCOSAL JELLY IN APPLICATOR [120006]

Facility

$0.77

Service Code	NDC 76329-3013-5
Hospital Charge Code	NDG120006
Hospital Revenue Code	250
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of CA HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.58

LIDOCAINE 2 % MUCOSAL JELLY IN APPLICATOR [120006]

Facility

$1.38

Service Code	NDC 76329-3012-5
Hospital Charge Code	NDG120006D
Hospital Revenue Code	250
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.10
Rate for Payer: Cash Price	$0.62
Rate for Payer: Cigna of CA HMO/PPO	$1.10
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.04

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

Facility

$5.70

Service Code	NDC 71266-6290-1
Hospital Charge Code	NDG230370
Hospital Revenue Code	259
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$4.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.42
Rate for Payer: Aetna of CA Government/Medicare	$3.42
Rate for Payer: Cash Price	$2.57
Rate for Payer: Health Smart Auto/Commercial	$3.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.42
Rate for Payer: LLUH Dept of Risk Management WC	$3.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.28

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

Facility

$5.70

Service Code	NDC 71266-6290-1
Hospital Charge Code	NDG230370
Hospital Revenue Code	259
Min. Negotiated Rate	$3.14
Max. Negotiated Rate	$4.56
Rate for Payer: Cash Price	$2.57
Rate for Payer: Cigna of CA HMO/PPO	$4.56
Rate for Payer: Health Smart Auto/Commercial	$3.42
Rate for Payer: LLUH Dept of Risk Management WC	$3.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.28

LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL SOLUTION KIT [199855]

Facility

$1.18

Service Code	NDC 51552-1345-1
Hospital Charge Code	NDG2868
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.94
Rate for Payer: Cash Price	$0.53
Rate for Payer: Cigna of CA HMO/PPO	$0.94
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

LIDOCAINE 4 %-EPINEPHRINE 0.18 %-TETRACAINE 0.5 % TOPICAL SOLUTION KIT [199855]

Facility

$1.18

Service Code	NDC 51552-1345-1
Hospital Charge Code	NDG2868
Hospital Revenue Code	259
Min. Negotiated Rate	$0.65
Max. Negotiated Rate	$0.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.71
Rate for Payer: Aetna of CA Government/Medicare	$0.71
Rate for Payer: Cash Price	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.71
Rate for Payer: LLUH Dept of Risk Management WC	$0.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.89

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

Facility

$5.91

Service Code	NDC 70092-1658-44
Hospital Charge Code	1743677
Hospital Revenue Code	259
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$4.43
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	$2.66
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 Beech St/Commercial/PHCS	$4.43

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

Facility

$5.04

Service Code	NDC 71266-6286-3
Hospital Charge Code	1743677
Hospital Revenue Code	259
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$3.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.02
Rate for Payer: Aetna of CA Government/Medicare	$3.02
Rate for Payer: Cash Price	$2.27
Rate for Payer: Health Smart Auto/Commercial	$3.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.02
Rate for Payer: LLUH Dept of Risk Management WC	$2.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.78

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

Facility

$5.91

Service Code	NDC 70092-1658-44
Hospital Charge Code	1743677
Hospital Revenue Code	259
Min. Negotiated Rate	$3.25
Max. Negotiated Rate	$4.73
Rate for Payer: Cash Price	$2.66
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$4.43

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

Facility

$5.04

Service Code	NDC 71266-6286-3
Hospital Charge Code	1743677
Hospital Revenue Code	259
Min. Negotiated Rate	$2.77
Max. Negotiated Rate	$4.03
Rate for Payer: Cash Price	$2.27
Rate for Payer: Cigna of CA HMO/PPO	$4.03
Rate for Payer: Health Smart Auto/Commercial	$3.02
Rate for Payer: LLUH Dept of Risk Management WC	$2.77
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.78

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	1782009
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.83
Rate for Payer: Cash Price	$0.47
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$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	1782009
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.78
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	$0.47
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 Beech St/Commercial/PHCS	$0.78

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$1.68

Service Code	NDC 0496-0882-05
Hospital Charge Code	1781145
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.26
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	$0.76
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 Beech St/Commercial/PHCS	$1.26

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$1.68

Service Code	NDC 0496-0882-05
Hospital Charge Code	1781145
Hospital Revenue Code	259
Min. Negotiated Rate	$0.92
Max. Negotiated Rate	$1.34
Rate for Payer: Cash Price	$0.76
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.26

Know your out-of-pocket cost for care.

All Charges