Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 100 TOPICAL SPONGE [28025]

Facility

$55.39

Service Code	NDC 0009-0342-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$30.46
Max. Negotiated Rate	$44.31
Rate for Payer: Cash Price	$30.46
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.31
Rate for Payer: Health Smart Auto/Commercial	$33.23
Rate for Payer: LLUH Dept of Risk Management WC	$30.46
Rate for Payer: Multiplan Commercial	$41.54

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 200 TOPICAL SPONGE [28026]

Facility

$106.20

Service Code	NDC 0009-0349-03
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$58.41
Max. Negotiated Rate	$84.96
Rate for Payer: Cash Price	$58.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$84.96
Rate for Payer: Health Smart Auto/Commercial	$63.72
Rate for Payer: LLUH Dept of Risk Management WC	$58.41
Rate for Payer: Multiplan Commercial	$79.65

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 200 TOPICAL SPONGE [28026]

Facility

$106.20

Service Code	NDC 0009-0349-03
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$58.41
Max. Negotiated Rate	$84.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$63.72
Rate for Payer: Aetna of CA Government/Medicare	$63.72
Rate for Payer: Cash Price	$58.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$84.96
Rate for Payer: Health Smart Auto/Commercial	$63.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$63.72
Rate for Payer: LLUH Dept of Risk Management WC	$58.41
Rate for Payer: Multiplan Commercial	$79.65

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 4 TOPICAL SPONGE [28023]

Facility

$17.82

Service Code	NDC 0009-0396-05
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.69
Rate for Payer: Aetna of CA Government/Medicare	$10.69
Rate for Payer: Cash Price	$9.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.26
Rate for Payer: Health Smart Auto/Commercial	$10.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.69
Rate for Payer: LLUH Dept of Risk Management WC	$9.80
Rate for Payer: Multiplan Commercial	$13.37

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 4 TOPICAL SPONGE [28023]

Facility

$17.82

Service Code	NDC 0009-0396-05
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$9.80
Max. Negotiated Rate	$14.26
Rate for Payer: Cash Price	$9.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.26
Rate for Payer: Health Smart Auto/Commercial	$10.69
Rate for Payer: LLUH Dept of Risk Management WC	$9.80
Rate for Payer: Multiplan Commercial	$13.37

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE [28024]

Facility

$37.05

Service Code	NDC 0009-0323-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$20.38
Max. Negotiated Rate	$29.64
Rate for Payer: Cash Price	$20.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.64
Rate for Payer: Health Smart Auto/Commercial	$22.23
Rate for Payer: LLUH Dept of Risk Management WC	$20.38
Rate for Payer: Multiplan Commercial	$27.79

GELATIN SPONGE,ABSORBABLE-PORCINE SKIN 50 TOPICAL SPONGE [28024]

Facility

$37.05

Service Code	NDC 0009-0323-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$20.38
Max. Negotiated Rate	$29.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.23
Rate for Payer: Aetna of CA Government/Medicare	$22.23
Rate for Payer: Cash Price	$20.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$29.64
Rate for Payer: Health Smart Auto/Commercial	$22.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.23
Rate for Payer: LLUH Dept of Risk Management WC	$20.38
Rate for Payer: Multiplan Commercial	$27.79

GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]

Facility

$6.65

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$5.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.99
Rate for Payer: Aetna of CA Government/Medicare	$3.99
Rate for Payer: Cash Price	$3.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.32
Rate for Payer: Health Smart Auto/Commercial	$3.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.99
Rate for Payer: LLUH Dept of Risk Management WC	$3.66
Rate for Payer: Multiplan Commercial	$4.99

GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]

Facility

$15.84

Service Code	HCPCS J9196
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$12.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.50
Rate for Payer: Aetna of CA Government/Medicare	$9.50
Rate for Payer: Cash Price	$8.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.67
Rate for Payer: Health Smart Auto/Commercial	$9.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.50
Rate for Payer: LLUH Dept of Risk Management WC	$8.71
Rate for Payer: Multiplan Commercial	$11.88

GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]

Facility

$15.84

Service Code	HCPCS J9196
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$8.71
Max. Negotiated Rate	$12.67
Rate for Payer: Cash Price	$8.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.67
Rate for Payer: Health Smart Auto/Commercial	$9.50
Rate for Payer: LLUH Dept of Risk Management WC	$8.71
Rate for Payer: Multiplan Commercial	$11.88

GEMCITABINE 100 MG/ML INTRAVENOUS SOLUTION [220785]

Facility

$6.65

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$5.32
Rate for Payer: Cash Price	$3.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.32
Rate for Payer: Health Smart Auto/Commercial	$3.99
Rate for Payer: LLUH Dept of Risk Management WC	$3.66
Rate for Payer: Multiplan Commercial	$4.99

GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [191075]

Facility

$2.07

Service Code	NDC 0409-0181-01
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.24
Rate for Payer: Aetna of CA Government/Medicare	$1.24
Rate for Payer: Cash Price	$1.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.66
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.14
Rate for Payer: Multiplan Commercial	$1.55

GEMCITABINE 1 GRAM/26.3 ML (38 MG/ML) INTRAVENOUS SOLUTION [191075]

Facility

$2.07

Service Code	NDC 0409-0181-01
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.66
Rate for Payer: Cash Price	$1.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.66
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.14
Rate for Payer: Multiplan Commercial	$1.55

GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [17122]

Facility

$55.12

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$30.32
Max. Negotiated Rate	$44.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.07
Rate for Payer: Aetna of CA Government/Medicare	$33.07
Rate for Payer: Cash Price	$30.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.10
Rate for Payer: Health Smart Auto/Commercial	$33.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.07
Rate for Payer: LLUH Dept of Risk Management WC	$30.32
Rate for Payer: Multiplan Commercial	$41.34

GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [17122]

Facility

$55.12

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$30.32
Max. Negotiated Rate	$44.10
Rate for Payer: Cash Price	$30.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.10
Rate for Payer: Health Smart Auto/Commercial	$33.07
Rate for Payer: LLUH Dept of Risk Management WC	$30.32
Rate for Payer: Multiplan Commercial	$41.34

GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [400398]

Facility

$55.12

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$30.32
Max. Negotiated Rate	$44.10
Rate for Payer: Cash Price	$30.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.10
Rate for Payer: Health Smart Auto/Commercial	$33.07
Rate for Payer: LLUH Dept of Risk Management WC	$30.32
Rate for Payer: Multiplan Commercial	$41.34

GEMCITABINE 1 GRAM INTRAVENOUS SOLUTION [400398]

Facility

$55.12

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$30.32
Max. Negotiated Rate	$44.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$33.07
Rate for Payer: Aetna of CA Government/Medicare	$33.07
Rate for Payer: Cash Price	$30.31
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$44.10
Rate for Payer: Health Smart Auto/Commercial	$33.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$33.07
Rate for Payer: LLUH Dept of Risk Management WC	$30.32
Rate for Payer: Multiplan Commercial	$41.34

GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION [191077]

Facility

$1.76

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$1.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$1.06
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cash Price	$0.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.91
Rate for Payer: Health Smart Auto/Commercial	$1.06
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.97
Rate for Payer: Multiplan Commercial	$1.32
Rate for Payer: Multiplan Commercial	$0.86

GEMCITABINE 200 MG/5.26 ML (38 MG/ML) INTRAVENOUS SOLUTION [191077]

Facility

$1.14

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.91
Rate for Payer: Cash Price	$0.63
Rate for Payer: Cash Price	$0.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.91
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Health Smart Auto/Commercial	$1.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: LLUH Dept of Risk Management WC	$0.97
Rate for Payer: Multiplan Commercial	$0.86
Rate for Payer: Multiplan Commercial	$1.32

GEMCITABINE 200 MG INTRAVENOUS SOLUTION [17121]

Facility

$14.46

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$11.57
Rate for Payer: Cash Price	$7.95
Rate for Payer: Cash Price	$9.90
Rate for Payer: Cash Price	$6.07
Rate for Payer: Cash Price	$7.34
Rate for Payer: Cash Price	$7.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.82
Rate for Payer: Health Smart Auto/Commercial	$6.62
Rate for Payer: Health Smart Auto/Commercial	$8.00
Rate for Payer: Health Smart Auto/Commercial	$8.64
Rate for Payer: Health Smart Auto/Commercial	$8.68
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.92
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: LLUH Dept of Risk Management WC	$6.07
Rate for Payer: LLUH Dept of Risk Management WC	$7.95
Rate for Payer: LLUH Dept of Risk Management WC	$7.34
Rate for Payer: Multiplan Commercial	$10.01
Rate for Payer: Multiplan Commercial	$10.85
Rate for Payer: Multiplan Commercial	$13.50
Rate for Payer: Multiplan Commercial	$8.27
Rate for Payer: Multiplan Commercial	$10.80

GEMCITABINE 200 MG INTRAVENOUS SOLUTION [17121]

Facility

$14.46

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.95
Max. Negotiated Rate	$11.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.62
Rate for Payer: Aetna of CA Government/Medicare	$8.68
Rate for Payer: Aetna of CA Government/Medicare	$6.62
Rate for Payer: Aetna of CA Government/Medicare	$8.64
Rate for Payer: Aetna of CA Government/Medicare	$8.00
Rate for Payer: Aetna of CA Government/Medicare	$10.80
Rate for Payer: Cash Price	$7.34
Rate for Payer: Cash Price	$7.92
Rate for Payer: Cash Price	$7.95
Rate for Payer: Cash Price	$6.07
Rate for Payer: Cash Price	$9.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.82
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.40
Rate for Payer: Health Smart Auto/Commercial	$8.64
Rate for Payer: Health Smart Auto/Commercial	$8.00
Rate for Payer: Health Smart Auto/Commercial	$10.80
Rate for Payer: Health Smart Auto/Commercial	$8.68
Rate for Payer: Health Smart Auto/Commercial	$6.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.95
Rate for Payer: LLUH Dept of Risk Management WC	$9.90
Rate for Payer: LLUH Dept of Risk Management WC	$7.34
Rate for Payer: LLUH Dept of Risk Management WC	$6.07
Rate for Payer: LLUH Dept of Risk Management WC	$7.92
Rate for Payer: Multiplan Commercial	$13.50
Rate for Payer: Multiplan Commercial	$8.27
Rate for Payer: Multiplan Commercial	$10.01
Rate for Payer: Multiplan Commercial	$10.80
Rate for Payer: Multiplan Commercial	$10.85

GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [191076]

Facility

$2.07

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.14
Max. Negotiated Rate	$1.66
Rate for Payer: Cash Price	$1.14
Rate for Payer: Cash Price	$0.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.66
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: Health Smart Auto/Commercial	$1.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.14
Rate for Payer: Multiplan Commercial	$1.32
Rate for Payer: Multiplan Commercial	$1.55

GEMCITABINE 2 GRAM/52.6 ML (38 MG/ML) INTRAVENOUS SOLUTION [191076]

Facility

$1.76

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.97
Max. Negotiated Rate	$1.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.24
Rate for Payer: Aetna of CA Government/Medicare	$1.24
Rate for Payer: Aetna of CA Government/Medicare	$1.06
Rate for Payer: Cash Price	$1.14
Rate for Payer: Cash Price	$0.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.66
Rate for Payer: Health Smart Auto/Commercial	$1.06
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$1.14
Rate for Payer: Multiplan Commercial	$1.55
Rate for Payer: Multiplan Commercial	$1.32

GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION [105417]

Facility

$136.18

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$74.90
Max. Negotiated Rate	$108.94
Rate for Payer: Cash Price	$74.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$108.94
Rate for Payer: Health Smart Auto/Commercial	$81.71
Rate for Payer: LLUH Dept of Risk Management WC	$74.90
Rate for Payer: Multiplan Commercial	$102.14

GEMCITABINE 2 GRAM INTRAVENOUS SOLUTION [105417]

Facility

$136.18

Service Code	HCPCS J9201
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$74.90
Max. Negotiated Rate	$108.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$81.71
Rate for Payer: Aetna of CA Government/Medicare	$81.71
Rate for Payer: Cash Price	$74.90
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$108.94
Rate for Payer: Health Smart Auto/Commercial	$81.71
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$81.71
Rate for Payer: LLUH Dept of Risk Management WC	$74.90
Rate for Payer: Multiplan Commercial	$102.14

Know your out-of-pocket cost for care.

All Charges