|
LIDOCAINE 5 % TOPICAL GEL [154443]
|
Facility
OP
|
$0.67
|
|
|
Service Code
|
NDC 63135-581-10
|
| Hospital Charge Code |
NDG154443
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.16 |
| Max. Negotiated Rate |
$0.57 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.37
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.40
|
| Rate for Payer: BCBS Transplant Transplant |
$0.40
|
| Rate for Payer: Blue Shield of California Commercial |
$0.49
|
| Rate for Payer: Blue Shield of California EPN |
$0.39
|
| Rate for Payer: Cash Price |
$0.30
|
| Rate for Payer: Cigna of CA HMO |
$0.47
|
| Rate for Payer: Cigna of CA PPO |
$0.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.57
|
| Rate for Payer: Dignity Health Media |
$0.57
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.57
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.27
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.27
|
| Rate for Payer: Galaxy Health WC |
$0.57
|
| Rate for Payer: Global Benefits Group Commercial |
$0.40
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.16
|
| Rate for Payer: Multiplan Commercial |
$0.54
|
| Rate for Payer: Networks By Design Commercial |
$0.44
|
| Rate for Payer: Prime Health Services Commercial |
$0.57
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.34
|
| Rate for Payer: United Healthcare All Other HMO |
$0.34
|
| Rate for Payer: United Healthcare HMO Rider |
$0.34
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.57
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.57
|
| Rate for Payer: Vantage Medical Group Senior |
$0.57
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [154444]
|
Facility
OP
|
$3.11
|
|
|
Service Code
|
NDC 51672-3020-9
|
| Hospital Charge Code |
NDG154444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.04
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.64
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.71
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.71
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.85
|
| Rate for Payer: BCBS Transplant Transplant |
$1.87
|
| Rate for Payer: Blue Shield of California Commercial |
$2.29
|
| Rate for Payer: Blue Shield of California EPN |
$1.82
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO |
$2.18
|
| Rate for Payer: Cigna of CA PPO |
$2.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.64
|
| Rate for Payer: Dignity Health Media |
$2.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.24
|
| Rate for Payer: Galaxy Health WC |
$2.64
|
| Rate for Payer: Global Benefits Group Commercial |
$1.87
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.33
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Networks By Design Commercial |
$2.02
|
| Rate for Payer: Prime Health Services Commercial |
$2.64
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.87
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.87
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.87
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.56
|
| Rate for Payer: United Healthcare All Other HMO |
$1.56
|
| Rate for Payer: United Healthcare HMO Rider |
$1.56
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.56
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.64
|
| Rate for Payer: Vantage Medical Group Senior |
$2.64
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [154444]
|
Facility
OP
|
$4.48
|
|
|
Service Code
|
NDC 51672-3020-2
|
| Hospital Charge Code |
NDG154444B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.94
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.81
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.46
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.67
|
| Rate for Payer: BCBS Transplant Transplant |
$2.69
|
| Rate for Payer: Blue Shield of California Commercial |
$3.30
|
| Rate for Payer: Blue Shield of California EPN |
$2.62
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cigna of CA HMO |
$3.14
|
| Rate for Payer: Cigna of CA PPO |
$3.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.81
|
| Rate for Payer: Dignity Health Media |
$3.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.79
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.79
|
| Rate for Payer: Galaxy Health WC |
$3.81
|
| Rate for Payer: Global Benefits Group Commercial |
$2.69
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$3.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.58
|
| Rate for Payer: Networks By Design Commercial |
$2.91
|
| Rate for Payer: Prime Health Services Commercial |
$3.81
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.69
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.24
|
| Rate for Payer: United Healthcare All Other HMO |
$2.24
|
| Rate for Payer: United Healthcare HMO Rider |
$2.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.81
|
| Rate for Payer: Vantage Medical Group Senior |
$3.81
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [154444]
|
Facility
IP
|
$0.74
|
|
|
Service Code
|
NDC 69680-120-35
|
| Hospital Charge Code |
NDG154444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Blue Shield of California Commercial |
$0.53
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.52
|
| Rate for Payer: Cigna of CA PPO |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.63
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Networks By Design Commercial |
$0.48
|
| Rate for Payer: Prime Health Services Commercial |
$0.63
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [154444]
|
Facility
OP
|
$0.74
|
|
|
Service Code
|
NDC 69680-120-35
|
| Hospital Charge Code |
NDG154444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.63 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.49
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.41
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.41
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.44
|
| Rate for Payer: BCBS Transplant Transplant |
$0.44
|
| Rate for Payer: Blue Shield of California Commercial |
$0.55
|
| Rate for Payer: Blue Shield of California EPN |
$0.43
|
| Rate for Payer: Cash Price |
$0.33
|
| Rate for Payer: Cigna of CA HMO |
$0.52
|
| Rate for Payer: Cigna of CA PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.63
|
| Rate for Payer: Dignity Health Media |
$0.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.30
|
| Rate for Payer: Galaxy Health WC |
$0.63
|
| Rate for Payer: Global Benefits Group Commercial |
$0.44
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: Networks By Design Commercial |
$0.48
|
| Rate for Payer: Prime Health Services Commercial |
$0.63
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.44
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.44
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.44
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.37
|
| Rate for Payer: United Healthcare All Other HMO |
$0.37
|
| Rate for Payer: United Healthcare HMO Rider |
$0.37
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.37
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.63
|
| Rate for Payer: Vantage Medical Group Senior |
$0.63
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [154444]
|
Facility
OP
|
$0.51
|
|
|
Service Code
|
NDC 64380-789-32
|
| Hospital Charge Code |
NDG154444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.30
|
| Rate for Payer: BCBS Transplant Transplant |
$0.31
|
| Rate for Payer: Blue Shield of California Commercial |
$0.38
|
| Rate for Payer: Blue Shield of California EPN |
$0.30
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.43
|
| Rate for Payer: Dignity Health Media |
$0.43
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$0.38
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.26
|
| Rate for Payer: United Healthcare All Other HMO |
$0.26
|
| Rate for Payer: United Healthcare HMO Rider |
$0.26
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.43
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Vantage Medical Group Senior |
$0.43
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [154444]
|
Facility
IP
|
$4.48
|
|
|
Service Code
|
NDC 51672-3020-2
|
| Hospital Charge Code |
NDG154444B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.08 |
| Max. Negotiated Rate |
$3.81 |
| Rate for Payer: Blue Shield of California Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California EPN |
$2.29
|
| Rate for Payer: Cash Price |
$2.02
|
| Rate for Payer: Cigna of CA HMO |
$3.14
|
| Rate for Payer: Cigna of CA PPO |
$3.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.79
|
| Rate for Payer: Galaxy Health WC |
$3.81
|
| Rate for Payer: Global Benefits Group Commercial |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.58
|
| Rate for Payer: Networks By Design Commercial |
$2.91
|
| Rate for Payer: Prime Health Services Commercial |
$3.81
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [154444]
|
Facility
IP
|
$3.11
|
|
|
Service Code
|
NDC 51672-3020-9
|
| Hospital Charge Code |
NDG154444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.75 |
| Max. Negotiated Rate |
$2.64 |
| Rate for Payer: Blue Shield of California Commercial |
$2.21
|
| Rate for Payer: Blue Shield of California EPN |
$1.59
|
| Rate for Payer: Cash Price |
$1.40
|
| Rate for Payer: Cigna of CA HMO |
$2.18
|
| Rate for Payer: Cigna of CA PPO |
$2.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.24
|
| Rate for Payer: Galaxy Health WC |
$2.64
|
| Rate for Payer: Global Benefits Group Commercial |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.75
|
| Rate for Payer: Multiplan Commercial |
$2.49
|
| Rate for Payer: Networks By Design Commercial |
$2.02
|
| Rate for Payer: Prime Health Services Commercial |
$2.64
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [154444]
|
Facility
IP
|
$8.13
|
|
|
Service Code
|
NDC 0168-0204-37
|
| Hospital Charge Code |
NDG154444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$6.91 |
| Rate for Payer: Blue Shield of California Commercial |
$5.79
|
| Rate for Payer: Blue Shield of California EPN |
$4.16
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cigna of CA HMO |
$5.69
|
| Rate for Payer: Cigna of CA PPO |
$5.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.25
|
| Rate for Payer: Galaxy Health WC |
$6.91
|
| Rate for Payer: Global Benefits Group Commercial |
$4.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Multiplan Commercial |
$6.50
|
| Rate for Payer: Networks By Design Commercial |
$5.28
|
| Rate for Payer: Prime Health Services Commercial |
$6.91
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [154444]
|
Facility
OP
|
$8.13
|
|
|
Service Code
|
NDC 0168-0204-37
|
| Hospital Charge Code |
NDG154444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.95 |
| Max. Negotiated Rate |
$6.91 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.33
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$6.91
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.47
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$4.84
|
| Rate for Payer: BCBS Transplant Transplant |
$4.88
|
| Rate for Payer: Blue Shield of California Commercial |
$5.99
|
| Rate for Payer: Blue Shield of California EPN |
$4.75
|
| Rate for Payer: Cash Price |
$3.66
|
| Rate for Payer: Cigna of CA HMO |
$5.69
|
| Rate for Payer: Cigna of CA PPO |
$5.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$6.91
|
| Rate for Payer: Dignity Health Media |
$6.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$6.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.25
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.25
|
| Rate for Payer: Galaxy Health WC |
$6.91
|
| Rate for Payer: Global Benefits Group Commercial |
$4.88
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$6.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.95
|
| Rate for Payer: Multiplan Commercial |
$6.50
|
| Rate for Payer: Networks By Design Commercial |
$5.28
|
| Rate for Payer: Prime Health Services Commercial |
$6.91
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$4.88
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$4.88
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$4.88
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.06
|
| Rate for Payer: United Healthcare All Other HMO |
$4.06
|
| Rate for Payer: United Healthcare HMO Rider |
$4.06
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$6.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$6.91
|
| Rate for Payer: Vantage Medical Group Senior |
$6.91
|
|
|
LIDOCAINE 5 % TOPICAL OINTMENT [154444]
|
Facility
IP
|
$0.51
|
|
|
Service Code
|
NDC 64380-789-32
|
| Hospital Charge Code |
NDG154444
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.43 |
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.26
|
| Rate for Payer: Cash Price |
$0.23
|
| Rate for Payer: Cigna of CA HMO |
$0.36
|
| Rate for Payer: Cigna of CA PPO |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.20
|
| Rate for Payer: Galaxy Health WC |
$0.43
|
| Rate for Payer: Global Benefits Group Commercial |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.41
|
| Rate for Payer: Networks By Design Commercial |
$0.33
|
| Rate for Payer: Prime Health Services Commercial |
$0.43
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
IP
|
$9.86
|
|
|
Service Code
|
NDC 0378-9055-93
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$8.38 |
| Rate for Payer: Blue Shield of California Commercial |
$7.02
|
| Rate for Payer: Blue Shield of California EPN |
$5.05
|
| Rate for Payer: Cash Price |
$4.44
|
| Rate for Payer: Cigna of CA HMO |
$6.90
|
| Rate for Payer: Cigna of CA PPO |
$6.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.94
|
| Rate for Payer: Galaxy Health WC |
$8.38
|
| Rate for Payer: Global Benefits Group Commercial |
$5.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$7.89
|
| Rate for Payer: Networks By Design Commercial |
$6.41
|
| Rate for Payer: Prime Health Services Commercial |
$8.38
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
IP
|
$9.86
|
|
|
Service Code
|
NDC 0378-9055-16
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$8.38 |
| Rate for Payer: Blue Shield of California Commercial |
$7.02
|
| Rate for Payer: Blue Shield of California EPN |
$5.05
|
| Rate for Payer: Cash Price |
$4.44
|
| Rate for Payer: Cigna of CA HMO |
$6.90
|
| Rate for Payer: Cigna of CA PPO |
$6.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.94
|
| Rate for Payer: Galaxy Health WC |
$8.38
|
| Rate for Payer: Global Benefits Group Commercial |
$5.92
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$7.89
|
| Rate for Payer: Networks By Design Commercial |
$6.41
|
| Rate for Payer: Prime Health Services Commercial |
$8.38
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
OP
|
$9.86
|
|
|
Service Code
|
NDC 0378-9055-16
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$8.38 |
| Rate for Payer: Aetna of CA HMO/PPO |
$6.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.87
|
| Rate for Payer: BCBS Transplant Transplant |
$5.92
|
| Rate for Payer: Blue Shield of California Commercial |
$7.27
|
| Rate for Payer: Blue Shield of California EPN |
$5.76
|
| Rate for Payer: Cash Price |
$4.44
|
| Rate for Payer: Cigna of CA HMO |
$6.90
|
| Rate for Payer: Cigna of CA PPO |
$6.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.38
|
| Rate for Payer: Dignity Health Media |
$8.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.94
|
| Rate for Payer: Galaxy Health WC |
$8.38
|
| Rate for Payer: Global Benefits Group Commercial |
$5.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$7.89
|
| Rate for Payer: Networks By Design Commercial |
$6.41
|
| Rate for Payer: Prime Health Services Commercial |
$8.38
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.93
|
| Rate for Payer: United Healthcare All Other HMO |
$4.93
|
| Rate for Payer: United Healthcare HMO Rider |
$4.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8.38
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
OP
|
$31.81
|
|
|
Service Code
|
NDC 63481-687-01
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.63 |
| Max. Negotiated Rate |
$27.04 |
| Rate for Payer: Aetna of CA HMO/PPO |
$20.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.95
|
| Rate for Payer: BCBS Transplant Transplant |
$19.09
|
| Rate for Payer: Blue Shield of California Commercial |
$23.44
|
| Rate for Payer: Blue Shield of California EPN |
$18.58
|
| Rate for Payer: Cash Price |
$14.31
|
| Rate for Payer: Cigna of CA HMO |
$22.27
|
| Rate for Payer: Cigna of CA PPO |
$22.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.04
|
| Rate for Payer: Dignity Health Media |
$27.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.72
|
| Rate for Payer: Galaxy Health WC |
$27.04
|
| Rate for Payer: Global Benefits Group Commercial |
$19.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$23.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.63
|
| Rate for Payer: Multiplan Commercial |
$25.45
|
| Rate for Payer: Networks By Design Commercial |
$20.68
|
| Rate for Payer: Prime Health Services Commercial |
$27.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$19.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.90
|
| Rate for Payer: United Healthcare All Other HMO |
$15.90
|
| Rate for Payer: United Healthcare HMO Rider |
$15.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.04
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.04
|
| Rate for Payer: Vantage Medical Group Senior |
$27.04
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
OP
|
$9.86
|
|
|
Service Code
|
NDC 0378-9055-93
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.37 |
| Max. Negotiated Rate |
$8.38 |
| Rate for Payer: Cigna of CA PPO |
$6.90
|
| Rate for Payer: Cigna of CA HMO |
$6.90
|
| Rate for Payer: Aetna of CA HMO/PPO |
$6.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$8.38
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$5.42
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$5.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.87
|
| Rate for Payer: BCBS Transplant Transplant |
$5.92
|
| Rate for Payer: Blue Shield of California Commercial |
$7.27
|
| Rate for Payer: Blue Shield of California EPN |
$5.76
|
| Rate for Payer: Cash Price |
$4.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$8.38
|
| Rate for Payer: Dignity Health Media |
$8.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.94
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.94
|
| Rate for Payer: Galaxy Health WC |
$8.38
|
| Rate for Payer: Global Benefits Group Commercial |
$5.92
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$7.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$6.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.37
|
| Rate for Payer: Multiplan Commercial |
$7.89
|
| Rate for Payer: Networks By Design Commercial |
$6.41
|
| Rate for Payer: Prime Health Services Commercial |
$8.38
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$5.92
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.92
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.92
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.93
|
| Rate for Payer: United Healthcare All Other HMO |
$4.93
|
| Rate for Payer: United Healthcare HMO Rider |
$4.93
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.93
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$8.38
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.38
|
| Rate for Payer: Vantage Medical Group Senior |
$8.38
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
OP
|
$3.59
|
|
|
Service Code
|
NDC 0603-1880-10
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.14
|
| Rate for Payer: BCBS Transplant Transplant |
$2.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.05
|
| Rate for Payer: Dignity Health Media |
$3.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.05
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
| Rate for Payer: Networks By Design Commercial |
$2.33
|
| Rate for Payer: Prime Health Services Commercial |
$3.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO |
$1.80
|
| Rate for Payer: United Healthcare HMO Rider |
$1.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.05
|
| Rate for Payer: Vantage Medical Group Senior |
$3.05
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
IP
|
$3.59
|
|
|
Service Code
|
NDC 0603-1880-16
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.84
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.05
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
| Rate for Payer: Networks By Design Commercial |
$2.33
|
| Rate for Payer: Prime Health Services Commercial |
$3.05
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
IP
|
$3.59
|
|
|
Service Code
|
NDC 0603-1880-10
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.05
|
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.84
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
| Rate for Payer: Networks By Design Commercial |
$2.33
|
| Rate for Payer: Prime Health Services Commercial |
$3.05
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
OP
|
$2.60
|
|
|
Service Code
|
NDC 42858-118-30
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.71
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.43
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.43
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.55
|
| Rate for Payer: BCBS Transplant Transplant |
$1.56
|
| Rate for Payer: Blue Shield of California Commercial |
$1.92
|
| Rate for Payer: Blue Shield of California EPN |
$1.52
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Media |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$1.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$1.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.56
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.56
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.30
|
| Rate for Payer: United Healthcare All Other HMO |
$1.30
|
| Rate for Payer: United Healthcare HMO Rider |
$1.30
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.30
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.21
|
| Rate for Payer: Vantage Medical Group Senior |
$2.21
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
OP
|
$3.59
|
|
|
Service Code
|
NDC 0591-3525-30
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.14
|
| Rate for Payer: BCBS Transplant Transplant |
$2.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.05
|
| Rate for Payer: Dignity Health Media |
$3.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.05
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
| Rate for Payer: Networks By Design Commercial |
$2.33
|
| Rate for Payer: Prime Health Services Commercial |
$3.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO |
$1.80
|
| Rate for Payer: United Healthcare HMO Rider |
$1.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.05
|
| Rate for Payer: Vantage Medical Group Senior |
$3.05
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
IP
|
$3.59
|
|
|
Service Code
|
NDC 0591-3525-30
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Blue Shield of California Commercial |
$2.56
|
| Rate for Payer: Blue Shield of California EPN |
$1.84
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.05
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Multiplan Commercial |
$2.87
|
| Rate for Payer: Networks By Design Commercial |
$2.33
|
| Rate for Payer: Prime Health Services Commercial |
$3.05
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
IP
|
$2.60
|
|
|
Service Code
|
NDC 42858-118-30
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.62 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Blue Shield of California Commercial |
$1.85
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO |
$1.82
|
| Rate for Payer: Cigna of CA PPO |
$1.82
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.04
|
| Rate for Payer: Galaxy Health WC |
$2.21
|
| Rate for Payer: Global Benefits Group Commercial |
$1.56
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$2.08
|
| Rate for Payer: Networks By Design Commercial |
$1.69
|
| Rate for Payer: Prime Health Services Commercial |
$2.21
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
OP
|
$3.59
|
|
|
Service Code
|
NDC 0603-1880-16
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.86 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Multiplan Commercial |
$2.87
|
| Rate for Payer: Networks By Design Commercial |
$2.33
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.35
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.05
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.97
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.97
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.14
|
| Rate for Payer: BCBS Transplant Transplant |
$2.15
|
| Rate for Payer: Blue Shield of California Commercial |
$2.65
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO |
$2.51
|
| Rate for Payer: Cigna of CA PPO |
$2.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.05
|
| Rate for Payer: Dignity Health Media |
$3.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.44
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.44
|
| Rate for Payer: Galaxy Health WC |
$3.05
|
| Rate for Payer: Global Benefits Group Commercial |
$2.15
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$2.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.37
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.86
|
| Rate for Payer: Prime Health Services Commercial |
$3.05
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$2.15
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.15
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.15
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.80
|
| Rate for Payer: United Healthcare All Other HMO |
$1.80
|
| Rate for Payer: United Healthcare HMO Rider |
$1.80
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.80
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.05
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.05
|
| Rate for Payer: Vantage Medical Group Senior |
$3.05
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
OP
|
$31.81
|
|
|
Service Code
|
NDC 63481-687-06
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$7.63 |
| Max. Negotiated Rate |
$27.04 |
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.04
|
| Rate for Payer: Vantage Medical Group Senior |
$27.04
|
| Rate for Payer: Aetna of CA HMO/PPO |
$20.86
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$27.04
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$17.50
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$17.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$18.95
|
| Rate for Payer: BCBS Transplant Transplant |
$19.09
|
| Rate for Payer: Blue Shield of California Commercial |
$23.44
|
| Rate for Payer: Blue Shield of California EPN |
$18.58
|
| Rate for Payer: Cash Price |
$14.31
|
| Rate for Payer: Cigna of CA HMO |
$22.27
|
| Rate for Payer: Cigna of CA PPO |
$22.27
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.04
|
| Rate for Payer: Dignity Health Media |
$27.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.72
|
| Rate for Payer: EPIC Health Plan Transplant |
$12.72
|
| Rate for Payer: Galaxy Health WC |
$27.04
|
| Rate for Payer: Global Benefits Group Commercial |
$19.09
|
| Rate for Payer: Health Plan of Nevada - Sierra Transplant Other |
$23.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$21.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.63
|
| Rate for Payer: Multiplan Commercial |
$25.45
|
| Rate for Payer: Networks By Design Commercial |
$20.68
|
| Rate for Payer: Prime Health Services Commercial |
$27.04
|
| Rate for Payer: Redlands Yucaipa Medical Group Commercial/Senior |
$19.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$19.09
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$19.09
|
| Rate for Payer: United Healthcare All Other Commercial |
$15.90
|
| Rate for Payer: United Healthcare All Other HMO |
$15.90
|
| Rate for Payer: United Healthcare HMO Rider |
$15.90
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$15.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.04
|
|
