|
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION [4455]
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
NDC 0409-4283-01
|
| Hospital Charge Code |
1726013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION [4455]
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
NDC 0409-4283-11
|
| Hospital Charge Code |
1726013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION [4455]
|
Facility
OP
|
$1.16
|
|
|
Service Code
|
NDC 0409-4283-11
|
| Hospital Charge Code |
1726013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Senior |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION [4455]
|
Facility
OP
|
$1.16
|
|
|
Service Code
|
NDC 0409-4283-01
|
| Hospital Charge Code |
1726013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.99 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.62
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.99
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.64
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.87
|
| Rate for Payer: Blue Shield of California Commercial |
$0.72
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.99
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.99
|
| Rate for Payer: Dignity Health Senior |
$0.99
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.74
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Senior |
$0.72
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.99
|
| Rate for Payer: Vantage Medical Group Senior |
$0.99
|
|
|
LIDOCAINE (PF) 40 MG/ML (4 %) INJECTION SOLUTION [4455]
|
Facility
IP
|
$1.16
|
|
|
Service Code
|
NDC 0409-4283-25
|
| Hospital Charge Code |
1726013
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.21 |
| Max. Negotiated Rate |
$0.87 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.80
|
| Rate for Payer: Cash Price |
$0.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.79
|
| Rate for Payer: Heritage Provider Network Senior |
$0.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.29
|
| Rate for Payer: Multiplan Commercial |
$0.87
|
|
|
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE [4457]
|
Facility
IP
|
$3.57
|
|
|
Service Code
|
NDC 0409-4904-34
|
| Hospital Charge Code |
1720132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$2.68 |
| Rate for Payer: Adventist Health Commercial |
$0.71
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.45
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.93
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.42
|
| Rate for Payer: Heritage Provider Network Senior |
$2.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$2.68
|
|
|
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE [4457]
|
Facility
OP
|
$2.46
|
|
|
Service Code
|
NDC 0409-9137-05
|
| Hospital Charge Code |
1720132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$2.09 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.69
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$2.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.35
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.84
|
| Rate for Payer: Blue Shield of California Commercial |
$1.53
|
| Rate for Payer: Blue Shield of California EPN |
$1.44
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.09
|
| Rate for Payer: Dignity Health Senior |
$2.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.52
|
| Rate for Payer: Heritage Provider Network Senior |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.09
|
| Rate for Payer: Vantage Medical Group Senior |
$2.09
|
|
|
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE [4457]
|
Facility
OP
|
$3.57
|
|
|
Service Code
|
NDC 0409-4904-34
|
| Hospital Charge Code |
1720132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.65 |
| Max. Negotiated Rate |
$3.03 |
| Rate for Payer: Adventist Health Commercial |
$0.71
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.45
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.03
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.96
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2.68
|
| Rate for Payer: Blue Shield of California Commercial |
$2.22
|
| Rate for Payer: Blue Shield of California EPN |
$2.10
|
| Rate for Payer: Cash Price |
$1.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.32
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.03
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.03
|
| Rate for Payer: Dignity Health Senior |
$3.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Senior |
$2.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.89
|
| Rate for Payer: Multiplan Commercial |
$2.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.03
|
| Rate for Payer: Vantage Medical Group Senior |
$3.03
|
|
|
LIDOCAINE (PF) 50 MG/5 ML (1 %) INTRAVENOUS SYRINGE [4457]
|
Facility
IP
|
$2.46
|
|
|
Service Code
|
NDC 0409-9137-05
|
| Hospital Charge Code |
1720132
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.45 |
| Max. Negotiated Rate |
$1.84 |
| Rate for Payer: Adventist Health Commercial |
$0.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.69
|
| Rate for Payer: Cash Price |
$1.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.67
|
| Rate for Payer: Heritage Provider Network Senior |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.62
|
| Rate for Payer: Multiplan Commercial |
$1.84
|
|
|
LIDOCAINE (PF) 50 MG/ML (5 %) IN 7.5 % DEXTROSE INTRATHECAL SOLUTION [27396]
|
Facility
IP
|
$5.56
|
|
|
Service Code
|
NDC 0409-4712-01
|
| Hospital Charge Code |
1720572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Adventist Health Commercial |
$1.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.82
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.76
|
| Rate for Payer: Heritage Provider Network Senior |
$3.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$4.17
|
|
|
LIDOCAINE (PF) 50 MG/ML (5 %) IN 7.5 % DEXTROSE INTRATHECAL SOLUTION [27396]
|
Facility
OP
|
$5.56
|
|
|
Service Code
|
NDC 0409-4712-11
|
| Hospital Charge Code |
1720572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Adventist Health Commercial |
$1.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.17
|
| Rate for Payer: Blue Shield of California Commercial |
$3.45
|
| Rate for Payer: Blue Shield of California EPN |
$3.26
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.73
|
| Rate for Payer: Dignity Health Senior |
$4.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.44
|
| Rate for Payer: Heritage Provider Network Senior |
$3.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$4.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.73
|
| Rate for Payer: Vantage Medical Group Senior |
$4.73
|
|
|
LIDOCAINE (PF) 50 MG/ML (5 %) IN 7.5 % DEXTROSE INTRATHECAL SOLUTION [27396]
|
Facility
IP
|
$5.56
|
|
|
Service Code
|
NDC 0409-4712-11
|
| Hospital Charge Code |
1720572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$4.17 |
| Rate for Payer: Adventist Health Commercial |
$1.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.82
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.76
|
| Rate for Payer: Heritage Provider Network Senior |
$3.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$4.17
|
|
|
LIDOCAINE (PF) 50 MG/ML (5 %) IN 7.5 % DEXTROSE INTRATHECAL SOLUTION [27396]
|
Facility
OP
|
$5.56
|
|
|
Service Code
|
NDC 0409-4712-01
|
| Hospital Charge Code |
1720572
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$1.01 |
| Max. Negotiated Rate |
$4.73 |
| Rate for Payer: Adventist Health Commercial |
$1.11
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$3.82
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4.73
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$4.17
|
| Rate for Payer: Blue Shield of California Commercial |
$3.45
|
| Rate for Payer: Blue Shield of California EPN |
$3.26
|
| Rate for Payer: Cash Price |
$2.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$3.61
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4.73
|
| Rate for Payer: Dignity Health Medi-Cal |
$4.73
|
| Rate for Payer: Dignity Health Senior |
$4.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.56
|
| Rate for Payer: Heritage Provider Network Commercial |
$3.44
|
| Rate for Payer: Heritage Provider Network Senior |
$3.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.39
|
| Rate for Payer: Multiplan Commercial |
$4.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$4.73
|
| Rate for Payer: Vantage Medical Group Senior |
$4.73
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [105635]
|
Facility
OP
|
$0.10
|
|
|
Service Code
|
NDC 0409-4278-01
|
| Hospital Charge Code |
1721142
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| 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 |
$0.07
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| 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 |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
LIDOCAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [105635]
|
Facility
IP
|
$0.10
|
|
|
Service Code
|
NDC 0409-4278-01
|
| Hospital Charge Code |
1721142
|
|
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 Non-Gatekeeper |
$0.07
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
LIDOCAINE (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION [14869]
|
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 (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION [14869]
|
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 (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION - FOR PAIN (LLU) [408148692]
|
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 (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE INTRAVENOUS SOLUTION - FOR PAIN (LLU) [408148692]
|
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 (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE IV BOLUS [40814869]
|
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 (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE IV BOLUS [40814869]
|
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 (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE IV PEDS [4081321]
|
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 (PF) 8 MG/ML (0.8 %) IN 5 % DEXTROSE IV PEDS [4081321]
|
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-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
OP
|
$1.70
|
|
|
Service Code
|
NDC 0591-2070-30
|
| Hospital Charge Code |
NDG10434
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.31 |
| Max. Negotiated Rate |
$1.44 |
| Rate for Payer: Adventist Health Commercial |
$0.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.91
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.17
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.94
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.06
|
| Rate for Payer: Blue Shield of California EPN |
$1.00
|
| Rate for Payer: Cash Price |
$0.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.10
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.44
|
| Rate for Payer: Dignity Health Senior |
$1.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.05
|
| Rate for Payer: Heritage Provider Network Senior |
$1.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.31
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.43
|
| Rate for Payer: Multiplan Commercial |
$1.28
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.44
|
| Rate for Payer: Vantage Medical Group Senior |
$1.44
|
|
|
LIDOCAINE-PRILOCAINE 2.5 %-2.5 % TOPICAL CREAM [10434]
|
Facility
IP
|
$1.98
|
|
|
Service Code
|
NDC 0168-0357-05
|
| Hospital Charge Code |
NDG10434B
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.36 |
| Max. Negotiated Rate |
$1.48 |
| Rate for Payer: Adventist Health Commercial |
$0.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.36
|
| Rate for Payer: Cash Price |
$0.89
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.34
|
| Rate for Payer: Heritage Provider Network Senior |
$1.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.50
|
| Rate for Payer: Multiplan Commercial |
$1.48
|
|
