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Service Code NDC 0904-6773-61
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.03
Max. Negotiated Rate $0.05
Rate for Payer: Cash Price $0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.05
Rate for Payer: Health Smart Auto/Commercial $0.04
Rate for Payer: LLUH Dept of Risk Management WC $0.03
Rate for Payer: Multiplan Commercial $0.05
Service Code NDC 50580-458-11
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.03
Max. Negotiated Rate $0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.04
Rate for Payer: Aetna of CA Government/Medicare $0.04
Rate for Payer: Cash Price $0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.05
Rate for Payer: Health Smart Auto/Commercial $0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.04
Rate for Payer: LLUH Dept of Risk Management WC $0.03
Rate for Payer: Multiplan Commercial $0.05
Service Code NDC 71399-8014-1
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.02
Max. Negotiated Rate $0.03
Rate for Payer: Cash Price $0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.03
Rate for Payer: Health Smart Auto/Commercial $0.02
Rate for Payer: LLUH Dept of Risk Management WC $0.02
Rate for Payer: Multiplan Commercial $0.03
Service Code NDC 57896-102-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.01
Rate for Payer: Aetna of CA Government/Medicare $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.01
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.01
Service Code NDC 71399-8014-1
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.02
Max. Negotiated Rate $0.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.02
Rate for Payer: Aetna of CA Government/Medicare $0.02
Rate for Payer: Cash Price $0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.03
Rate for Payer: Health Smart Auto/Commercial $0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.02
Rate for Payer: LLUH Dept of Risk Management WC $0.02
Rate for Payer: Multiplan Commercial $0.03
Service Code NDC 5789610110
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.01
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.01
Service Code NDC 57896-104-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.01
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.01
Service Code NDC 50580-458-11
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.03
Max. Negotiated Rate $0.05
Rate for Payer: Cash Price $0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.05
Rate for Payer: Health Smart Auto/Commercial $0.04
Rate for Payer: LLUH Dept of Risk Management WC $0.03
Rate for Payer: Multiplan Commercial $0.05
Service Code NDC 0904-6773-61
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.03
Max. Negotiated Rate $0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.04
Rate for Payer: Aetna of CA Government/Medicare $0.04
Rate for Payer: Cash Price $0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.05
Rate for Payer: Health Smart Auto/Commercial $0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.04
Rate for Payer: LLUH Dept of Risk Management WC $0.03
Rate for Payer: Multiplan Commercial $0.05
Service Code NDC 57896-102-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.01
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.01
Service Code NDC 0536-1327-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.01
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.01
Service Code NDC 0536-1327-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.01
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.01
Rate for Payer: Aetna of CA Government/Medicare $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.01
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.01
Service Code NDC 57896-102-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.01
Rate for Payer: Aetna of CA Government/Medicare $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.02
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.02
Service Code HCPCS J0136
Hospital Charge Code 901700025
Hospital Revenue Code 636
Min. Negotiated Rate $0.08
Max. Negotiated Rate $0.12
Rate for Payer: Cash Price $0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.12
Rate for Payer: Health Smart Auto/Commercial $0.09
Rate for Payer: LLUH Dept of Risk Management WC $0.08
Rate for Payer: Multiplan Commercial $0.11
Service Code HCPCS J0136
Hospital Charge Code 901700025
Hospital Revenue Code 636
Min. Negotiated Rate $0.08
Max. Negotiated Rate $0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.09
Rate for Payer: Aetna of CA Government/Medicare $0.09
Rate for Payer: Cash Price $0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.12
Rate for Payer: Health Smart Auto/Commercial $0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.09
Rate for Payer: LLUH Dept of Risk Management WC $0.08
Rate for Payer: Multiplan Commercial $0.11
Service Code NDC 57896-204-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.02
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.02
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.02
Service Code NDC 50580-457-70
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.03
Max. Negotiated Rate $0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.03
Rate for Payer: Aetna of CA Government/Medicare $0.03
Rate for Payer: Cash Price $0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.04
Rate for Payer: Health Smart Auto/Commercial $0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.03
Rate for Payer: LLUH Dept of Risk Management WC $0.03
Rate for Payer: Multiplan Commercial $0.04
Service Code NDC 57896-201-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.01
Rate for Payer: Aetna of CA Government/Medicare $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.02
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.02
Service Code NDC 57896-204-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.01
Rate for Payer: Aetna of CA Government/Medicare $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.02
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.02
Service Code NDC 57896-201-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.02
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.02
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.02
Service Code NDC 57896-201-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.01
Rate for Payer: Aetna of CA Government/Medicare $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.02
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.02
Service Code NDC 57896-219-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.01
Rate for Payer: Aetna of CA Government/Medicare $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.02
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.02
Service Code NDC 0904-6730-80
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.01
Max. Negotiated Rate $0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.01
Rate for Payer: Aetna of CA Government/Medicare $0.01
Rate for Payer: Cash Price $0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.02
Rate for Payer: Health Smart Auto/Commercial $0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.01
Rate for Payer: LLUH Dept of Risk Management WC $0.01
Rate for Payer: Multiplan Commercial $0.02
Service Code NDC 50580-457-70
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.03
Max. Negotiated Rate $0.04
Rate for Payer: Cash Price $0.03
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.04
Rate for Payer: Health Smart Auto/Commercial $0.03
Rate for Payer: LLUH Dept of Risk Management WC $0.03
Rate for Payer: Multiplan Commercial $0.04
Service Code NDC 0904-6730-60
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.02
Max. Negotiated Rate $0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.02
Rate for Payer: Aetna of CA Government/Medicare $0.02
Rate for Payer: Cash Price $0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.02
Rate for Payer: Health Smart Auto/Commercial $0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.02
Rate for Payer: LLUH Dept of Risk Management WC $0.02
Rate for Payer: Multiplan Commercial $0.02