Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$0.84

Service Code	NDC 24357-701-05
Hospital Charge Code	1781145
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.63
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	$0.38
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 Beech St/Commercial/PHCS	$0.63

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$1.68

Service Code	NDC 0496-0882-06
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

$0.84

Service Code	NDC 24357-701-06
Hospital Charge Code	1781145
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.67
Rate for Payer: Cash Price	$0.38
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.63

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 0496-0882-06
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

LIDOCAINE 4 % TOPICAL CREAM [23461]

Facility

$0.84

Service Code	NDC 24357-701-06
Hospital Charge Code	1781145
Hospital Revenue Code	259
Min. Negotiated Rate	$0.46
Max. Negotiated Rate	$0.63
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	$0.38
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 Beech St/Commercial/PHCS	$0.63

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.31

Service Code	NDC 0536-1202-07
Hospital Charge Code	ERX110425
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$1.05
Rate for Payer: Cash Price	$0.59
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.98

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.07

Service Code	NDC 8770143001
Hospital Charge Code	ERX110425
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.80

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.07

Service Code	NDC 8770143001
Hospital Charge Code	ERX110425
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.80
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	$0.48
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 Beech St/Commercial/PHCS	$0.80

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.07

Service Code	NDC 46122-450-21
Hospital Charge Code	ERX110425
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.86
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.80

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.31

Service Code	NDC 0536-1202-07
Hospital Charge Code	ERX110425
Hospital Revenue Code	259
Min. Negotiated Rate	$0.72
Max. Negotiated Rate	$0.98
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	$0.59
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 Beech St/Commercial/PHCS	$0.98

LIDOCAINE 4 % TOPICAL PATCH [110425]

Facility

$1.07

Service Code	NDC 46122-450-21
Hospital Charge Code	ERX110425
Hospital Revenue Code	259
Min. Negotiated Rate	$0.59
Max. Negotiated Rate	$0.80
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	$0.48
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 Beech St/Commercial/PHCS	$0.80

LIDOCAINE 5 % TOPICAL GEL [154443]

Facility

$0.67

Service Code	NDC 63135-581-10
Hospital Charge Code	NDG154443
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Cash Price	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

LIDOCAINE 5 % TOPICAL GEL [154443]

Facility

$0.67

Service Code	NDC 63135-581-10
Hospital Charge Code	NDG154443
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.50
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	$0.30
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 Beech St/Commercial/PHCS	$0.50

LIDOCAINE 5 % TOPICAL OINTMENT [154444]

Facility

$0.74

Service Code	NDC 69680-120-35
Hospital Charge Code	NDG154444
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.56
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: Cash Price	$0.33
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: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.56

LIDOCAINE 5 % TOPICAL OINTMENT [154444]

Facility

$0.51

Service Code	NDC 64380-789-32
Hospital Charge Code	NDG154444
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

LIDOCAINE 5 % TOPICAL OINTMENT [154444]

Facility

$8.13

Service Code	NDC 0168-0204-37
Hospital Charge Code	NDG154444
Hospital Revenue Code	259
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$6.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.88
Rate for Payer: Aetna of CA Government/Medicare	$4.88
Rate for Payer: Cash Price	$3.66
Rate for Payer: Health Smart Auto/Commercial	$4.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.88
Rate for Payer: LLUH Dept of Risk Management WC	$4.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.10

LIDOCAINE 5 % TOPICAL OINTMENT [154444]

Facility

$3.11

Service Code	NDC 51672-3020-9
Hospital Charge Code	NDG154444
Hospital Revenue Code	259
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$2.33
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.87
Rate for Payer: Aetna of CA Government/Medicare	$1.87
Rate for Payer: Cash Price	$1.40
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.33

LIDOCAINE 5 % TOPICAL OINTMENT [154444]

Facility

$4.48

Service Code	NDC 51672-3020-2
Hospital Charge Code	NDG154444B
Hospital Revenue Code	259
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$3.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.69
Rate for Payer: Aetna of CA Government/Medicare	$2.69
Rate for Payer: Cash Price	$2.02
Rate for Payer: Health Smart Auto/Commercial	$2.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.36

LIDOCAINE 5 % TOPICAL OINTMENT [154444]

Facility

$8.13

Service Code	NDC 0168-0204-37
Hospital Charge Code	NDG154444
Hospital Revenue Code	259
Min. Negotiated Rate	$4.47
Max. Negotiated Rate	$6.50
Rate for Payer: Cash Price	$3.66
Rate for Payer: Cigna of CA HMO/PPO	$6.50
Rate for Payer: Health Smart Auto/Commercial	$4.88
Rate for Payer: LLUH Dept of Risk Management WC	$4.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.10

LIDOCAINE 5 % TOPICAL OINTMENT [154444]

Facility

$3.11

Service Code	NDC 51672-3020-9
Hospital Charge Code	NDG154444
Hospital Revenue Code	259
Min. Negotiated Rate	$1.71
Max. Negotiated Rate	$2.49
Rate for Payer: Cash Price	$1.40
Rate for Payer: Cigna of CA HMO/PPO	$2.49
Rate for Payer: Health Smart Auto/Commercial	$1.87
Rate for Payer: LLUH Dept of Risk Management WC	$1.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.33

LIDOCAINE 5 % TOPICAL OINTMENT [154444]

Facility

$4.48

Service Code	NDC 51672-3020-2
Hospital Charge Code	NDG154444B
Hospital Revenue Code	259
Min. Negotiated Rate	$2.46
Max. Negotiated Rate	$3.58
Rate for Payer: Cash Price	$2.02
Rate for Payer: Cigna of CA HMO/PPO	$3.58
Rate for Payer: Health Smart Auto/Commercial	$2.69
Rate for Payer: LLUH Dept of Risk Management WC	$2.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.36

LIDOCAINE 5 % TOPICAL OINTMENT [154444]

Facility

$0.74

Service Code	NDC 69680-120-35
Hospital Charge Code	NDG154444
Hospital Revenue Code	259
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.59
Rate for Payer: Cash Price	$0.33
Rate for Payer: Cigna of CA HMO/PPO	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.56

LIDOCAINE 5 % TOPICAL OINTMENT [154444]

Facility

$0.51

Service Code	NDC 64380-789-32
Hospital Charge Code	NDG154444
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$2.60

Service Code	NDC 42858-118-30
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$1.43
Max. Negotiated Rate	$1.95
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.56
Rate for Payer: Aetna of CA Government/Medicare	$1.56
Rate for Payer: Cash Price	$1.17
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.95

Know your out-of-pocket cost for care.

All Charges