Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.13

Service Code	NDC 9940-8209-15
Hospital Charge Code	1716025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.13

Service Code	NDC 0054-3500-49
Hospital Charge Code	NDG111639
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.30

Service Code	NDC 0121-0903-40
Hospital Charge Code	1716025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.30

Service Code	NDC 0121-0903-40
Hospital Charge Code	1716025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.30

Service Code	NDC 0121-0903-15
Hospital Charge Code	1716025
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

LIDOCAINE HCL 2 % MUCOSAL SOLUTION [111639]

Facility

$0.13

Service Code	NDC 0054-3500-49
Hospital Charge Code	NDG111639
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
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	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

$0.77

Service Code	NDC 60432-465-50
Hospital Charge Code	1743336
Hospital Revenue Code	259
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 HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

$0.77

Service Code	NDC 60432-465-51
Hospital Charge Code	1743336
Hospital Revenue Code	259
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 HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

$0.67

Service Code	NDC 0527-6004-80
Hospital Charge Code	1743336
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 HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

$0.67

Service Code	NDC 0527-6004-80
Hospital Charge Code	1743336
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

LIDOCAINE HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

$0.77

Service Code	NDC 60432-465-51
Hospital Charge Code	1743336
Hospital Revenue Code	259
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 HCL 4 % (40 MG/ML) MUCOSAL SOLUTION [4450]

Facility

$0.77

Service Code	NDC 60432-465-50
Hospital Charge Code	1743336
Hospital Revenue Code	259
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 HCL 5 MG/ML (0.5 %) INJECTION SOLUTION [4451]

Facility

$0.11

Service Code	NDC 0409-4275-01
Hospital Charge Code	1721020
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 HCL 5 MG/ML (0.5 %) INJECTION SOLUTION [4451]

Facility

$0.11

Service Code	NDC 0409-4275-01
Hospital Charge Code	1721020
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 HCL 5 MG/ML (0.5 %) INJECTION SOLUTION [4451]

Facility

$0.11

Service Code	NDC 0409-4275-16
Hospital Charge Code	1721020
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 HCL 5 MG/ML (0.5 %) INJECTION SOLUTION [4451]

Facility

$0.11

Service Code	NDC 0409-4275-16
Hospital Charge Code	1721020
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 (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

Facility

$1.24

Service Code	NDC 0409-4903-11
Hospital Charge Code	1720703
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.74
Rate for Payer: Aetna of CA Government/Medicare	$0.74
Rate for Payer: Cash Price	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.93

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

Facility

$1.24

Service Code	NDC 0409-4903-11
Hospital Charge Code	1720703
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.99
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cigna of CA HMO/PPO	$0.99
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.93

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

Facility

$1.78

Service Code	NDC 76329-3390-1
Hospital Charge Code	1720703
Hospital Revenue Code	250
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.42
Rate for Payer: Cash Price	$0.80
Rate for Payer: Cigna of CA HMO/PPO	$1.42
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

Facility

$1.78

Service Code	NDC 76329-3390-1
Hospital Charge Code	1720703
Hospital Revenue Code	250
Min. Negotiated Rate	$0.98
Max. Negotiated Rate	$1.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.07
Rate for Payer: Aetna of CA Government/Medicare	$1.07
Rate for Payer: Cash Price	$0.80
Rate for Payer: Health Smart Auto/Commercial	$1.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.98
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.34

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

Facility

$1.19

Service Code	NDC 0409-1323-15
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 (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

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 (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

Facility

$1.24

Service Code	NDC 0409-4903-34
Hospital Charge Code	1720703
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.74
Rate for Payer: Aetna of CA Government/Medicare	$0.74
Rate for Payer: Cash Price	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.93

LIDOCAINE (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

Facility

$1.19

Service Code	NDC 0409-1323-15
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 (PF) 100 MG/5 ML (2 %) INTRAVENOUS SYRINGE [4459]

Facility

$1.24

Service Code	NDC 0409-4903-34
Hospital Charge Code	1720703
Hospital Revenue Code	250
Min. Negotiated Rate	$0.68
Max. Negotiated Rate	$0.99
Rate for Payer: Cash Price	$0.56
Rate for Payer: Cigna of CA HMO/PPO	$0.99
Rate for Payer: Health Smart Auto/Commercial	$0.74
Rate for Payer: LLUH Dept of Risk Management WC	$0.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.93

Know your out-of-pocket cost for care.

All Charges