Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

DEXAMETHASONE INTRAVITREAL INJECTION [192081]

Facility

$0.93

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.08
Rate for Payer: Aetna of CA Government/Medicare	$2.08
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$1.90
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.77
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$2.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$1.90
Rate for Payer: Multiplan Commercial	$2.60
Rate for Payer: Multiplan Commercial	$0.70

DEXAMETHASONE INTRAVITREAL INJECTION [192081]

Facility

$3.46

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.90
Max. Negotiated Rate	$2.77
Rate for Payer: Cash Price	$1.90
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.77
Rate for Payer: Health Smart Auto/Commercial	$2.08
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$1.90
Rate for Payer: Multiplan Commercial	$0.70
Rate for Payer: Multiplan Commercial	$2.60

DEXAMETHASONE ORAL SOLUTION (IV FORM) 4 MG/ML [4080428]

Facility

$0.62

Service Code	HCPCS J8540
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

DEXAMETHASONE ORAL SOLUTION (IV FORM) 4 MG/ML [4080428]

Facility

$0.62

Service Code	HCPCS J8540
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]

Facility

$1.72

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Commercial	$1.29

DEXAMETHASONE SODIUM PHOSPHATE 10 MG/ML INJECTION SOLUTION [2331]

Facility

$1.72

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Commercial	$1.29

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]

Facility

$0.47

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cash Price	$0.64
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Commercial	$0.87
Rate for Payer: Multiplan Commercial	$0.70
Rate for Payer: Multiplan Commercial	$0.35

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SOLUTION [2332]

Facility

$1.16

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.64
Max. Negotiated Rate	$0.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.70
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cash Price	$0.26
Rate for Payer: Cash Price	$0.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: LLUH Dept of Risk Management WC	$0.64
Rate for Payer: Multiplan Commercial	$0.70
Rate for Payer: Multiplan Commercial	$0.35
Rate for Payer: Multiplan Commercial	$0.87

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SYRINGE [114048]

Facility

$3.47

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.08
Rate for Payer: Aetna of CA Government/Medicare	$2.08
Rate for Payer: Cash Price	$1.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.78
Rate for Payer: Health Smart Auto/Commercial	$2.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.08
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Commercial	$2.60

DEXAMETHASONE SODIUM PHOSPHATE 4 MG/ML INJECTION SYRINGE [114048]

Facility

$3.47

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.91
Max. Negotiated Rate	$2.78
Rate for Payer: Cash Price	$1.91
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.78
Rate for Payer: Health Smart Auto/Commercial	$2.08
Rate for Payer: LLUH Dept of Risk Management WC	$1.91
Rate for Payer: Multiplan Commercial	$2.60

DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [118427]

Facility

$5.21

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2.87
Max. Negotiated Rate	$4.17
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cash Price	$4.95
Rate for Payer: Cash Price	$2.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.22
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: Health Smart Auto/Commercial	$3.17
Rate for Payer: Health Smart Auto/Commercial	$3.13
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: LLUH Dept of Risk Management WC	$2.87
Rate for Payer: LLUH Dept of Risk Management WC	$2.90
Rate for Payer: Multiplan Commercial	$6.75
Rate for Payer: Multiplan Commercial	$3.96
Rate for Payer: Multiplan Commercial	$3.91

DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SOLUTION [118427]

Facility

$9.00

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$4.95
Max. Negotiated Rate	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.17
Rate for Payer: Aetna of CA Government/Medicare	$3.13
Rate for Payer: Aetna of CA Government/Medicare	$3.17
Rate for Payer: Aetna of CA Government/Medicare	$5.40
Rate for Payer: Cash Price	$2.90
Rate for Payer: Cash Price	$2.86
Rate for Payer: Cash Price	$4.95
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.22
Rate for Payer: Health Smart Auto/Commercial	$5.40
Rate for Payer: Health Smart Auto/Commercial	$3.17
Rate for Payer: Health Smart Auto/Commercial	$3.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.13
Rate for Payer: LLUH Dept of Risk Management WC	$2.87
Rate for Payer: LLUH Dept of Risk Management WC	$2.90
Rate for Payer: LLUH Dept of Risk Management WC	$4.95
Rate for Payer: Multiplan Commercial	$3.96
Rate for Payer: Multiplan Commercial	$3.91
Rate for Payer: Multiplan Commercial	$6.75

DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE [225593]

Facility

$6.94

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$5.55
Rate for Payer: Cash Price	$3.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.55
Rate for Payer: Health Smart Auto/Commercial	$4.16
Rate for Payer: LLUH Dept of Risk Management WC	$3.82
Rate for Payer: Multiplan Commercial	$5.21

DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE [225593]

Facility

$6.94

Service Code	HCPCS J1100
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$5.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.16
Rate for Payer: Aetna of CA Government/Medicare	$4.16
Rate for Payer: Cash Price	$3.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.55
Rate for Payer: Health Smart Auto/Commercial	$4.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.16
Rate for Payer: LLUH Dept of Risk Management WC	$3.82
Rate for Payer: Multiplan Commercial	$5.21

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$2.02

Service Code	NDC 70860-605-41
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.62
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$2.02

Service Code	NDC 70860-605-41
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.62
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.62
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$3.25

Service Code	NDC 42023-146-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.95
Rate for Payer: Aetna of CA Government/Medicare	$1.95
Rate for Payer: Cash Price	$1.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.60
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Commercial	$2.44

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$3.24

Service Code	NDC 71288-505-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.94
Rate for Payer: Aetna of CA Government/Medicare	$1.94
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$3.15

Service Code	NDC 66794-230-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.89
Rate for Payer: Aetna of CA Government/Medicare	$1.89
Rate for Payer: Cash Price	$1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.52
Rate for Payer: Health Smart Auto/Commercial	$1.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Commercial	$2.36

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$3.25

Service Code	NDC 42023-146-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.60
Rate for Payer: Cash Price	$1.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.60
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Commercial	$2.44

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$7.80

Service Code	NDC 0143-9532-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$6.24
Rate for Payer: Cash Price	$4.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.24
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: Multiplan Commercial	$5.85

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$3.24

Service Code	NDC 71288-505-03
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.94
Rate for Payer: Aetna of CA Government/Medicare	$1.94
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$3.15

Service Code	NDC 66794-230-42
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.89
Rate for Payer: Aetna of CA Government/Medicare	$1.89
Rate for Payer: Cash Price	$1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.52
Rate for Payer: Health Smart Auto/Commercial	$1.89
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Commercial	$2.36

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$7.80

Service Code	NDC 0143-9532-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$6.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.68
Rate for Payer: Aetna of CA Government/Medicare	$4.68
Rate for Payer: Cash Price	$4.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.24
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.68
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: Multiplan Commercial	$5.85

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

$3.24

Service Code	NDC 71288-505-03
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

Know your out-of-pocket cost for care.

All Charges