Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

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

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$31.81

Service Code	NDC 63481-687-01
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.45
Rate for Payer: Cash Price	$14.31
Rate for Payer: Cigna of CA HMO/PPO	$25.45
Rate for Payer: Health Smart Auto/Commercial	$19.09
Rate for Payer: LLUH Dept of Risk Management WC	$17.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.86

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$3.59

Service Code	NDC 0591-3525-30
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.87
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cigna of CA HMO/PPO	$2.87
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.69

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$3.59

Service Code	NDC 0603-1880-10
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.15
Rate for Payer: Aetna of CA Government/Medicare	$2.15
Rate for Payer: Cash Price	$1.62
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.69

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$9.86

Service Code	NDC 0378-9055-16
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$5.42
Max. Negotiated Rate	$7.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.92
Rate for Payer: Aetna of CA Government/Medicare	$5.92
Rate for Payer: Cash Price	$4.44
Rate for Payer: Health Smart Auto/Commercial	$5.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.92
Rate for Payer: LLUH Dept of Risk Management WC	$5.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.40

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$3.59

Service Code	NDC 0603-1880-16
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.15
Rate for Payer: Aetna of CA Government/Medicare	$2.15
Rate for Payer: Cash Price	$1.62
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.69

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$3.59

Service Code	NDC 0603-1880-16
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.87
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cigna of CA HMO/PPO	$2.87
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.69

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$3.59

Service Code	NDC 0603-1880-10
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.87
Rate for Payer: Cash Price	$1.62
Rate for Payer: Cigna of CA HMO/PPO	$2.87
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.69

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$31.81

Service Code	NDC 63481-687-06
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$23.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.09
Rate for Payer: Aetna of CA Government/Medicare	$19.09
Rate for Payer: Cash Price	$14.31
Rate for Payer: Health Smart Auto/Commercial	$19.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.09
Rate for Payer: LLUH Dept of Risk Management WC	$17.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.86

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$31.81

Service Code	NDC 63481-687-06
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$25.45
Rate for Payer: Cash Price	$14.31
Rate for Payer: Cigna of CA HMO/PPO	$25.45
Rate for Payer: Health Smart Auto/Commercial	$19.09
Rate for Payer: LLUH Dept of Risk Management WC	$17.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.86

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$9.86

Service Code	NDC 0378-9055-93
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$5.42
Max. Negotiated Rate	$7.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.92
Rate for Payer: Aetna of CA Government/Medicare	$5.92
Rate for Payer: Cash Price	$4.44
Rate for Payer: Health Smart Auto/Commercial	$5.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.92
Rate for Payer: LLUH Dept of Risk Management WC	$5.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.40

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$31.81

Service Code	NDC 63481-687-01
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$17.50
Max. Negotiated Rate	$23.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.09
Rate for Payer: Aetna of CA Government/Medicare	$19.09
Rate for Payer: Cash Price	$14.31
Rate for Payer: Health Smart Auto/Commercial	$19.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.09
Rate for Payer: LLUH Dept of Risk Management WC	$17.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.86

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	$2.08
Rate for Payer: Cash Price	$1.17
Rate for Payer: Cigna of CA HMO/PPO	$2.08
Rate for Payer: Health Smart Auto/Commercial	$1.56
Rate for Payer: LLUH Dept of Risk Management WC	$1.43
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.95

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$3.59

Service Code	NDC 0591-3525-30
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$1.97
Max. Negotiated Rate	$2.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.15
Rate for Payer: Aetna of CA Government/Medicare	$2.15
Rate for Payer: Cash Price	$1.62
Rate for Payer: Health Smart Auto/Commercial	$2.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.15
Rate for Payer: LLUH Dept of Risk Management WC	$1.97
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.69

LIDOCAINE 5 % TOPICAL PATCH [28203]

Facility

$9.86

Service Code	NDC 0378-9055-16
Hospital Charge Code	1743696
Hospital Revenue Code	259
Min. Negotiated Rate	$5.42
Max. Negotiated Rate	$7.89
Rate for Payer: Cash Price	$4.44
Rate for Payer: Cigna of CA HMO/PPO	$7.89
Rate for Payer: Health Smart Auto/Commercial	$5.92
Rate for Payer: LLUH Dept of Risk Management WC	$5.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$7.40

LIDOCAINE (8MG/ML) 2 G/250 ML D5W BAG - CODE [4080568]

Facility

$0.04

Service Code	CPT J2001
Hospital Charge Code	1771168
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

LIDOCAINE (8MG/ML) 2 G/250 ML D5W BAG - CODE [4080568]

Facility

$0.04

Service Code	CPT J2001
Hospital Charge Code	1771168
Hospital Revenue Code	636
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.03

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

Facility

$0.09

Service Code	NDC 0409-3177-01
Hospital Charge Code	1720426
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
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	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

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

Facility

$0.09

Service Code	NDC 0409-3177-01
Hospital Charge Code	1720426
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.07

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

Facility

$0.09

Service Code	NDC 0409-3177-16
Hospital Charge Code	1720426
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
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	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

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

Facility

$0.09

Service Code	NDC 0409-3177-16
Hospital Charge Code	1720426
Hospital Revenue Code	250
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.07

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

Facility

$0.18

Service Code	NDC 31382-898-05
Hospital Charge Code	NDG119809
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

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

Facility

$0.18

Service Code	NDC 31382-898-05
Hospital Charge Code	NDG119809
Hospital Revenue Code	250
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

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

Facility

$0.20

Service Code	NDC 0409-3182-01
Hospital Charge Code	1720631
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-EPINEPHRINE 2 %-1:100,000 INJECTION. [4081101]

Facility

$0.20

Service Code	NDC 0409-3182-01
Hospital Charge Code	1720631
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

Know your out-of-pocket cost for care.

All Charges