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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

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

Facility

OP

$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

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

Facility

IP

$0.21

Service Code	NDC 0409-3182-02
Hospital Charge Code	1721211
Hospital Revenue Code	250
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.16

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

Facility

OP

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

Facility

IP

$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-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]

Facility

IP

$1.02

Service Code	NDC 63323-487-01
Hospital Charge Code	NDG15985B
Hospital Revenue Code	250
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]

Facility

IP

$1.02

Service Code	NDC 63323-487-17
Hospital Charge Code	NDG15985B
Hospital Revenue Code	250
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]

Facility

OP

$1.02

Service Code	NDC 63323-487-01
Hospital Charge Code	NDG15985B
Hospital Revenue Code	250
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]

Facility

IP

$0.47

Service Code	NDC 63323-487-37
Hospital Charge Code	NDG15985
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]

Facility

IP

$0.47

Service Code	NDC 63323-487-07
Hospital Charge Code	NDG15985
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]

Facility

OP

$1.02

Service Code	NDC 63323-487-17
Hospital Charge Code	NDG15985B
Hospital Revenue Code	250
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]

Facility

OP

$0.47

Service Code	NDC 63323-487-07
Hospital Charge Code	NDG15985
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

LIDOCAINE-EPINEPHRINE (PF) 1 %-1:200,000 INJECTION SOLUTION [15985]

Facility

OP

$0.47

Service Code	NDC 63323-487-37
Hospital Charge Code	NDG15985
Hospital Revenue Code	250
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]

Facility

OP

$0.37

Service Code	NDC 0409-3181-11
Hospital Charge Code	1720563
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.28
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	$0.17
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	$0.28

LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]

Facility

IP

$0.37

Service Code	NDC 0409-3181-11
Hospital Charge Code	1720563
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.28

LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]

Facility

OP

$0.63

Service Code	NDC 63323-488-07
Hospital Charge Code	1720563
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]

Facility

IP

$0.63

Service Code	NDC 63323-488-37
Hospital Charge Code	1720563
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna of CA HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]

Facility

OP

$0.63

Service Code	NDC 63323-488-37
Hospital Charge Code	1720563
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]

Facility

OP

$0.37

Service Code	NDC 0409-3181-01
Hospital Charge Code	1720563
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.28
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	$0.17
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	$0.28

LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]

Facility

IP

$0.37

Service Code	NDC 0409-3181-01
Hospital Charge Code	1720563
Hospital Revenue Code	250
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.28

LIDOCAINE-EPINEPHRINE (PF) 1.5 %-1:200,000 INJECTION SOLUTION [15956]

Facility

IP

$0.63

Service Code	NDC 63323-488-07
Hospital Charge Code	1720563
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna of CA HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]

Facility

IP

$1.09

Service Code	NDC 63323-489-27
Hospital Charge Code	1721061
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]

Facility

IP

$1.09

Service Code	NDC 63323-489-02
Hospital Charge Code	1721061
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Cash Price	$0.49
Rate for Payer: Cigna of CA HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]

Facility

OP

$1.09

Service Code	NDC 63323-489-27
Hospital Charge Code	1721061
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

LIDOCAINE-EPINEPHRINE (PF) 2 %-1:200,000 INJECTION SOLUTION [10431]

Facility

OP

$1.09

Service Code	NDC 63323-489-02
Hospital Charge Code	1721061
Hospital Revenue Code	250
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.82

LIDOCAINE-EPINEPHRINE (PF/NON-PF) 1.5 %-1:200,000 INJECTION SOLUTION. [40815956]

Facility

OP

$0.63

Service Code	NDC 63323-488-37
Hospital Charge Code	1720563
Hospital Revenue Code	250
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.28
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

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