Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.08

Service Code	NDC 0409-1160-01
Hospital Charge Code	1720220
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
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	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.09

Service Code	NDC 55150-249-50
Hospital Charge Code	1720220
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

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.28

Service Code	NDC 63323-465-01
Hospital Charge Code	1720220
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.08

Service Code	NDC 0409-1160-01
Hospital Charge Code	1720220
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.28

Service Code	NDC 63323-465-57
Hospital Charge Code	1720220
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.09

Service Code	NDC 55150-249-50
Hospital Charge Code	1720220
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

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.08

Service Code	NDC 0409-1160-18
Hospital Charge Code	1720220
Hospital Revenue Code	250
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
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	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.28

Service Code	NDC 63323-465-57
Hospital Charge Code	1720220
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

BUPIVACAINE HCL 0.25 % (2.5 MG/ML) INJECTION SOLUTION [110560]

Facility

$0.28

Service Code	NDC 63323-465-01
Hospital Charge Code	1720220
Hospital Revenue Code	250
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [1223]

Facility

$0.31

Service Code	CPT J0665
Hospital Charge Code	1720254
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23

BUPIVACAINE HCL 0.5 % (5 MG/ML) INJECTION SOLUTION [1223]

Facility

$0.08

Service Code	CPT J0665
Hospital Charge Code	1720254
Hospital Revenue Code	636
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.06

BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION [153079]

Facility

$21.91

Service Code	CPT C9290
Hospital Charge Code	NDG153079
Hospital Revenue Code	636
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$17.53
Rate for Payer: Cash Price	$9.86
Rate for Payer: Cigna of CA HMO/PPO	$17.53
Rate for Payer: Health Smart Auto/Commercial	$13.15
Rate for Payer: LLUH Dept of Risk Management WC	$12.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.43

BUPIVACAINE LIPOSOME(PF) 1.3 %(13.3 MG/ML) SUSPENSION FOR INFILTRATION [153079]

Facility

$21.91

Service Code	CPT C9290
Hospital Charge Code	NDG153079
Hospital Revenue Code	636
Min. Negotiated Rate	$12.05
Max. Negotiated Rate	$16.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.15
Rate for Payer: Aetna of CA Government/Medicare	$13.15
Rate for Payer: Cash Price	$9.86
Rate for Payer: Health Smart Auto/Commercial	$13.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.15
Rate for Payer: LLUH Dept of Risk Management WC	$12.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.43

BUPIVACAINE-MELOXICAM ER 200 MG-6 MG/7 ML SURGICAL SITE INSTILL SOLN [231886]

Facility

$24.39

Service Code	CPT C9088
Hospital Charge Code	NDG231886
Hospital Revenue Code	636
Min. Negotiated Rate	$13.41
Max. Negotiated Rate	$18.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.63
Rate for Payer: Aetna of CA Government/Medicare	$14.63
Rate for Payer: Cash Price	$10.98
Rate for Payer: Health Smart Auto/Commercial	$14.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.63
Rate for Payer: LLUH Dept of Risk Management WC	$13.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.29

BUPIVACAINE-MELOXICAM ER 200 MG-6 MG/7 ML SURGICAL SITE INSTILL SOLN [231886]

Facility

$24.39

Service Code	CPT C9088
Hospital Charge Code	NDG231886
Hospital Revenue Code	636
Min. Negotiated Rate	$13.41
Max. Negotiated Rate	$19.51
Rate for Payer: Cash Price	$10.98
Rate for Payer: Cigna of CA HMO/PPO	$19.51
Rate for Payer: Health Smart Auto/Commercial	$14.63
Rate for Payer: LLUH Dept of Risk Management WC	$13.41
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$18.29

BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]

Facility

$0.22

Service Code	CPT J0665
Hospital Charge Code	1720753
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.63
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]

Facility

$0.30

Service Code	CPT J0665
Hospital Charge Code	1758138
Hospital Revenue Code	636
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.07
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.24
Rate for Payer: Cigna of CA HMO/PPO	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]

Facility

$0.22

Service Code	CPT J0665
Hospital Charge Code	1720753
Hospital Revenue Code	636
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.47
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.47
Rate for Payer: Cash Price	$0.12
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.59

BUPIVACAINE (PF) 0.25 % (2.5 MG/ML) INJECTION SOLUTION [1222]

Facility

$0.30

Service Code	CPT J0665
Hospital Charge Code	1758138
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cash Price	$0.04
Rate for Payer: Cash Price	$0.14
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.07

BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]

Facility

$0.25

Service Code	CPT J3490
Hospital Charge Code	1720754
Hospital Revenue Code	636
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.42
Rate for Payer: Cigna of CA HMO/PPO	$0.20
Rate for Payer: Cigna of CA HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

BUPIVACAINE (PF) 0.5 % (5 MG/ML) INJECTION SOLUTION [105640]

Facility

$0.63

Service Code	CPT J3490
Hospital Charge Code	1720754
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.39

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]

Facility

$2.72

Service Code	NDC 0409-1761-02
Hospital Charge Code	1720900
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.63
Rate for Payer: Aetna of CA Government/Medicare	$1.63
Rate for Payer: Cash Price	$1.22
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.04

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]

Facility

$1.56

Service Code	NDC 0409-3613-11
Hospital Charge Code	1720900
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.17

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]

Facility

$2.72

Service Code	NDC 0409-1761-02
Hospital Charge Code	1720900
Hospital Revenue Code	250
Min. Negotiated Rate	$1.50
Max. Negotiated Rate	$2.18
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cigna of CA HMO/PPO	$2.18
Rate for Payer: Health Smart Auto/Commercial	$1.63
Rate for Payer: LLUH Dept of Risk Management WC	$1.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.04

BUPIVACAINE (PF) 0.75 % (7.5 MG/ML) IN 8.25 % DEXTROSE INJECTION [9316]

Facility

$1.56

Service Code	NDC 0409-3613-01
Hospital Charge Code	1720900
Hospital Revenue Code	250
Min. Negotiated Rate	$0.86
Max. Negotiated Rate	$1.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.94
Rate for Payer: Aetna of CA Government/Medicare	$0.94
Rate for Payer: Cash Price	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.94
Rate for Payer: LLUH Dept of Risk Management WC	$0.86
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.17

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