|
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 |
$5.76 |
| Max. Negotiated Rate |
$27.04 |
| Rate for Payer: Adventist Health Commercial |
$6.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.85
|
| 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 |
$23.86
|
| Rate for Payer: Blue Shield of California Commercial |
$19.75
|
| Rate for Payer: Blue Shield of California EPN |
$18.67
|
| Rate for Payer: Cash Price |
$14.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.04
|
| Rate for Payer: Dignity Health Senior |
$27.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.69
|
| Rate for Payer: Heritage Provider Network Senior |
$19.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.95
|
| Rate for Payer: Multiplan Commercial |
$23.86
|
| 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
|
$3.59
|
|
|
Service Code
|
NDC 0603-1880-16
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.05 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.92
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| 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 |
$2.69
|
| Rate for Payer: Blue Shield of California Commercial |
$2.23
|
| Rate for Payer: Blue Shield of California EPN |
$2.11
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.05
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.05
|
| Rate for Payer: Dignity Health Senior |
$3.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.22
|
| Rate for Payer: Heritage Provider Network Senior |
$2.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
| 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
|
$2.60
|
|
|
Service Code
|
NDC 42858-118-30
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$2.21 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| 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 |
$1.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1.61
|
| Rate for Payer: Blue Shield of California EPN |
$1.53
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.21
|
| Rate for Payer: Dignity Health Senior |
$2.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.61
|
| Rate for Payer: Heritage Provider Network Senior |
$1.61
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
| 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
IP
|
$31.81
|
|
|
Service Code
|
NDC 63481-687-06
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$23.86 |
| Rate for Payer: Adventist Health Commercial |
$6.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.85
|
| Rate for Payer: Cash Price |
$14.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.54
|
| Rate for Payer: Heritage Provider Network Senior |
$21.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.95
|
| Rate for Payer: Multiplan Commercial |
$23.86
|
|
|
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 |
$0.65 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.43
|
| Rate for Payer: Heritage Provider Network Senior |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
|
|
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 |
$5.76 |
| Max. Negotiated Rate |
$27.04 |
| Rate for Payer: Adventist Health Commercial |
$6.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$17.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.85
|
| 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 |
$23.86
|
| Rate for Payer: Blue Shield of California Commercial |
$19.75
|
| Rate for Payer: Blue Shield of California EPN |
$18.67
|
| Rate for Payer: Cash Price |
$14.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.68
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.04
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.04
|
| Rate for Payer: Dignity Health Senior |
$27.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.69
|
| Rate for Payer: Heritage Provider Network Senior |
$19.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.95
|
| Rate for Payer: Multiplan Commercial |
$23.86
|
| 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
IP
|
$2.60
|
|
|
Service Code
|
NDC 42858-118-30
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.47 |
| Max. Negotiated Rate |
$1.95 |
| Rate for Payer: Adventist Health Commercial |
$0.52
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.79
|
| Rate for Payer: Cash Price |
$1.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.76
|
| Rate for Payer: Heritage Provider Network Senior |
$1.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.47
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.65
|
| Rate for Payer: Multiplan Commercial |
$1.95
|
|
|
LIDOCAINE 5 % TOPICAL PATCH [28203]
|
Facility
IP
|
$31.81
|
|
|
Service Code
|
NDC 63481-687-01
|
| Hospital Charge Code |
1743696
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$5.76 |
| Max. Negotiated Rate |
$23.86 |
| Rate for Payer: Adventist Health Commercial |
$6.36
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.85
|
| Rate for Payer: Cash Price |
$14.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$17.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.54
|
| Rate for Payer: Heritage Provider Network Senior |
$21.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.95
|
| Rate for Payer: Multiplan Commercial |
$23.86
|
|
|
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 |
$0.65 |
| Max. Negotiated Rate |
$2.69 |
| Rate for Payer: Adventist Health Commercial |
$0.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.47
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.43
|
| Rate for Payer: Heritage Provider Network Senior |
$2.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.90
|
| Rate for Payer: Multiplan Commercial |
$2.69
|
|
|
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 |
$1.78 |
| Max. Negotiated Rate |
$7.40 |
| Rate for Payer: Adventist Health Commercial |
$1.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.77
|
| Rate for Payer: Cash Price |
$4.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.68
|
| Rate for Payer: Heritage Provider Network Senior |
$6.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.46
|
| Rate for Payer: Multiplan Commercial |
$7.40
|
|
|
LIDOCAINE (8MG/ML) 2 G/250 ML D5W BAG - CODE [4080568]
|
Facility
IP
|
$0.04
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
1771168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.03 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Senior |
$0.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
|
|
LIDOCAINE (8MG/ML) 2 G/250 ML D5W BAG - CODE [4080568]
|
Facility
OP
|
$0.04
|
|
|
Service Code
|
CPT J2001
|
| Hospital Charge Code |
1771168
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$7.00 |
| Rate for Payer: Adventist Health Commercial |
$0.01
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.02
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.04
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cash Price |
$0.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.02
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.03
|
| Rate for Payer: Dignity Health Senior |
$0.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.02
|
| Rate for Payer: Heritage Provider Network Senior |
$0.02
|
| Rate for Payer: IEHP Medi-Cal |
$7.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.01
|
| Rate for Payer: Multiplan Commercial |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.01
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.01
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.03
|
| Rate for Payer: Vantage Medical Group Senior |
$0.03
|
|
|
LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14870]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 0409-3177-16
|
| Hospital Charge Code |
1720426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14870]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 0409-3177-01
|
| Hospital Charge Code |
1720426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14870]
|
Facility
OP
|
$0.09
|
|
|
Service Code
|
NDC 0409-3177-01
|
| Hospital Charge Code |
1720426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
LIDOCAINE-EPINEPHRINE 0.5 %-1:200,000 INJECTION SOLUTION [14870]
|
Facility
IP
|
$0.09
|
|
|
Service Code
|
NDC 0409-3177-16
|
| Hospital Charge Code |
1720426
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJECTION. [4081101]
|
Facility
IP
|
$0.18
|
|
|
Service Code
|
NDC 31382-898-05
|
| Hospital Charge Code |
NDG119809
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.14 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
|
|
LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJECTION. [4081101]
|
Facility
OP
|
$0.18
|
|
|
Service Code
|
NDC 31382-898-05
|
| Hospital Charge Code |
NDG119809
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.10
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.10
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.14
|
| Rate for Payer: Blue Shield of California Commercial |
$0.11
|
| Rate for Payer: Blue Shield of California EPN |
$0.11
|
| Rate for Payer: Cash Price |
$0.08
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.12
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.15
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.15
|
| Rate for Payer: Dignity Health Senior |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Senior |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Vantage Medical Group Senior |
$0.15
|
|
|
LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJECTION. [4081101]
|
Facility
IP
|
$0.20
|
|
|
Service Code
|
NDC 0409-3182-01
|
| Hospital Charge Code |
1720631
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.15 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$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 |
$0.04 |
| Max. Negotiated Rate |
$0.16 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
|
|
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 |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.17
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Blue Shield of California Commercial |
$0.12
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.13
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.17
|
| Rate for Payer: Dignity Health Senior |
$0.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.12
|
| Rate for Payer: Heritage Provider Network Senior |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.15
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.17
|
| Rate for Payer: Vantage Medical Group Senior |
$0.17
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.22 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.22
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.15
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.17
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.22
|
| Rate for Payer: Dignity Health Senior |
$0.22
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.16
|
| Rate for Payer: Heritage Provider Network Senior |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.22
|
| Rate for Payer: Vantage Medical Group Senior |
$0.22
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.18
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
LIDOCAINE-EPINEPHRINE 2 %-1:100,000 INJECTION. [4081101]
|
Facility
OP
|
$0.21
|
|
|
Service Code
|
NDC 0409-3182-02
|
| Hospital Charge Code |
1721211
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.18 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.14
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.18
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.13
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.09
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.18
|
| Rate for Payer: Dignity Health Senior |
$0.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.13
|
| Rate for Payer: Heritage Provider Network Senior |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.05
|
| Rate for Payer: Multiplan Commercial |
$0.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.18
|
| Rate for Payer: Vantage Medical Group Senior |
$0.18
|
|
|
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 |
$0.09 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.35
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.28
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Senior |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
