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Service Code NDC 0574-7045-12
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $14.53
Max. Negotiated Rate $21.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $15.85
Rate for Payer: Aetna of CA Government/Medicare $15.85
Rate for Payer: Cash Price $14.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $21.14
Rate for Payer: Health Smart Auto/Commercial $15.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $15.85
Rate for Payer: LLUH Dept of Risk Management WC $14.53
Rate for Payer: Multiplan Commercial $19.82
Service Code NDC 0574-7045-12
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $14.53
Max. Negotiated Rate $21.14
Rate for Payer: Cash Price $14.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $21.14
Rate for Payer: Health Smart Auto/Commercial $15.85
Rate for Payer: LLUH Dept of Risk Management WC $14.53
Rate for Payer: Multiplan Commercial $19.82
Service Code NDC 0574-7045-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $14.53
Max. Negotiated Rate $21.14
Rate for Payer: Cash Price $14.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $21.14
Rate for Payer: Health Smart Auto/Commercial $15.85
Rate for Payer: LLUH Dept of Risk Management WC $14.53
Rate for Payer: Multiplan Commercial $19.82
Service Code NDC 0574-7045-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $14.53
Max. Negotiated Rate $21.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $15.85
Rate for Payer: Aetna of CA Government/Medicare $15.85
Rate for Payer: Cash Price $14.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $21.14
Rate for Payer: Health Smart Auto/Commercial $15.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $15.85
Rate for Payer: LLUH Dept of Risk Management WC $14.53
Rate for Payer: Multiplan Commercial $19.82
Service Code NDC 0574-7040-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $17.66
Max. Negotiated Rate $25.69
Rate for Payer: Cash Price $17.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $25.69
Rate for Payer: Health Smart Auto/Commercial $19.27
Rate for Payer: LLUH Dept of Risk Management WC $17.66
Rate for Payer: Multiplan Commercial $24.08
Service Code NDC 0574-7040-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $17.66
Max. Negotiated Rate $25.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $19.27
Rate for Payer: Aetna of CA Government/Medicare $19.27
Rate for Payer: Cash Price $17.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $25.69
Rate for Payer: Health Smart Auto/Commercial $19.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $19.27
Rate for Payer: LLUH Dept of Risk Management WC $17.66
Rate for Payer: Multiplan Commercial $24.08
Service Code NDC 0574-7040-12
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $17.66
Max. Negotiated Rate $25.69
Rate for Payer: Cash Price $17.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $25.69
Rate for Payer: Health Smart Auto/Commercial $19.27
Rate for Payer: LLUH Dept of Risk Management WC $17.66
Rate for Payer: Multiplan Commercial $24.08
Service Code NDC 0574-7040-12
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $17.66
Max. Negotiated Rate $25.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $19.27
Rate for Payer: Aetna of CA Government/Medicare $19.27
Rate for Payer: Cash Price $17.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $25.69
Rate for Payer: Health Smart Auto/Commercial $19.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $19.27
Rate for Payer: LLUH Dept of Risk Management WC $17.66
Rate for Payer: Multiplan Commercial $24.08
Service Code NDC 43547-336-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.07
Max. Negotiated Rate $0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.07
Rate for Payer: Aetna of CA Government/Medicare $0.07
Rate for Payer: Cash Price $0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.10
Rate for Payer: Health Smart Auto/Commercial $0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.07
Rate for Payer: LLUH Dept of Risk Management WC $0.07
Rate for Payer: Multiplan Commercial $0.09
Service Code NDC 50268-110-15
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.45
Max. Negotiated Rate $0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.49
Rate for Payer: Aetna of CA Government/Medicare $0.49
Rate for Payer: Cash Price $0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.66
Rate for Payer: Health Smart Auto/Commercial $0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.49
Rate for Payer: LLUH Dept of Risk Management WC $0.45
Rate for Payer: Multiplan Commercial $0.62
Service Code NDC 50268-110-15
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.45
Max. Negotiated Rate $0.66
Rate for Payer: Cash Price $0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.66
Rate for Payer: Health Smart Auto/Commercial $0.49
Rate for Payer: LLUH Dept of Risk Management WC $0.45
Rate for Payer: Multiplan Commercial $0.62
Service Code NDC 50268-110-11
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.45
Max. Negotiated Rate $0.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.49
Rate for Payer: Aetna of CA Government/Medicare $0.49
Rate for Payer: Cash Price $0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.66
Rate for Payer: Health Smart Auto/Commercial $0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.49
Rate for Payer: LLUH Dept of Risk Management WC $0.45
Rate for Payer: Multiplan Commercial $0.62
Service Code NDC 43547-336-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.07
Max. Negotiated Rate $0.10
Rate for Payer: Cash Price $0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.10
Rate for Payer: Health Smart Auto/Commercial $0.07
Rate for Payer: LLUH Dept of Risk Management WC $0.07
Rate for Payer: Multiplan Commercial $0.09
Service Code NDC 65162-752-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.06
Max. Negotiated Rate $0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.06
Rate for Payer: Aetna of CA Government/Medicare $0.06
Rate for Payer: Cash Price $0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.08
Rate for Payer: Health Smart Auto/Commercial $0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.06
Rate for Payer: LLUH Dept of Risk Management WC $0.06
Rate for Payer: Multiplan Commercial $0.08
Service Code NDC 50268-110-11
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.45
Max. Negotiated Rate $0.66
Rate for Payer: Cash Price $0.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.66
Rate for Payer: Health Smart Auto/Commercial $0.49
Rate for Payer: LLUH Dept of Risk Management WC $0.45
Rate for Payer: Multiplan Commercial $0.62
Service Code NDC 65162-752-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.06
Max. Negotiated Rate $0.08
Rate for Payer: Cash Price $0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.08
Rate for Payer: Health Smart Auto/Commercial $0.06
Rate for Payer: LLUH Dept of Risk Management WC $0.06
Rate for Payer: Multiplan Commercial $0.08
Service Code NDC 65862-116-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.06
Max. Negotiated Rate $0.08
Rate for Payer: Cash Price $0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.08
Rate for Payer: Health Smart Auto/Commercial $0.06
Rate for Payer: LLUH Dept of Risk Management WC $0.06
Rate for Payer: Multiplan Commercial $0.08
Service Code NDC 65862-116-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.06
Max. Negotiated Rate $0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.06
Rate for Payer: Aetna of CA Government/Medicare $0.06
Rate for Payer: Cash Price $0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.08
Rate for Payer: Health Smart Auto/Commercial $0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.06
Rate for Payer: LLUH Dept of Risk Management WC $0.06
Rate for Payer: Multiplan Commercial $0.08
Service Code NDC 65862-117-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.06
Max. Negotiated Rate $0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.06
Rate for Payer: Aetna of CA Government/Medicare $0.06
Rate for Payer: Cash Price $0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.08
Rate for Payer: Health Smart Auto/Commercial $0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.06
Rate for Payer: LLUH Dept of Risk Management WC $0.06
Rate for Payer: Multiplan Commercial $0.08
Service Code NDC 65162-753-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.08
Max. Negotiated Rate $0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.08
Rate for Payer: Aetna of CA Government/Medicare $0.08
Rate for Payer: Cash Price $0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.11
Rate for Payer: Health Smart Auto/Commercial $0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.08
Rate for Payer: LLUH Dept of Risk Management WC $0.08
Rate for Payer: Multiplan Commercial $0.11
Service Code NDC 50268-111-15
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.47
Max. Negotiated Rate $0.69
Rate for Payer: Cash Price $0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.69
Rate for Payer: Health Smart Auto/Commercial $0.52
Rate for Payer: LLUH Dept of Risk Management WC $0.47
Rate for Payer: Multiplan Commercial $0.65
Service Code NDC 43547-337-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.08
Max. Negotiated Rate $0.11
Rate for Payer: Cash Price $0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.11
Rate for Payer: Health Smart Auto/Commercial $0.08
Rate for Payer: LLUH Dept of Risk Management WC $0.08
Rate for Payer: Multiplan Commercial $0.11
Service Code NDC 43547-337-10
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.08
Max. Negotiated Rate $0.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.08
Rate for Payer: Aetna of CA Government/Medicare $0.08
Rate for Payer: Cash Price $0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.11
Rate for Payer: Health Smart Auto/Commercial $0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.08
Rate for Payer: LLUH Dept of Risk Management WC $0.08
Rate for Payer: Multiplan Commercial $0.11
Service Code NDC 65862-117-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.06
Max. Negotiated Rate $0.08
Rate for Payer: Cash Price $0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.08
Rate for Payer: Health Smart Auto/Commercial $0.06
Rate for Payer: LLUH Dept of Risk Management WC $0.06
Rate for Payer: Multiplan Commercial $0.08
Service Code NDC 50268-111-11
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.47
Max. Negotiated Rate $0.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.52
Rate for Payer: Aetna of CA Government/Medicare $0.52
Rate for Payer: Cash Price $0.47
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.69
Rate for Payer: Health Smart Auto/Commercial $0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.52
Rate for Payer: LLUH Dept of Risk Management WC $0.47
Rate for Payer: Multiplan Commercial $0.65