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Service Code NDC 45802-216-96
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.15
Max. Negotiated Rate $0.22
Rate for Payer: Cash Price $0.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.22
Rate for Payer: Health Smart Auto/Commercial $0.17
Rate for Payer: LLUH Dept of Risk Management WC $0.15
Rate for Payer: Multiplan Commercial $0.21
Service Code NDC 68084-381-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.32
Max. Negotiated Rate $0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.35
Rate for Payer: Aetna of CA Government/Medicare $0.35
Rate for Payer: Cash Price $0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.47
Rate for Payer: Health Smart Auto/Commercial $0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.35
Rate for Payer: LLUH Dept of Risk Management WC $0.32
Rate for Payer: Multiplan Commercial $0.44
Service Code NDC 0603-2433-21
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.09
Max. Negotiated Rate $0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.10
Rate for Payer: Aetna of CA Government/Medicare $0.10
Rate for Payer: Cash Price $0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.14
Rate for Payer: Health Smart Auto/Commercial $0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.10
Rate for Payer: LLUH Dept of Risk Management WC $0.09
Rate for Payer: Multiplan Commercial $0.13
Service Code NDC 68084-381-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.32
Max. Negotiated Rate $0.47
Rate for Payer: Cash Price $0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.47
Rate for Payer: Health Smart Auto/Commercial $0.35
Rate for Payer: LLUH Dept of Risk Management WC $0.32
Rate for Payer: Multiplan Commercial $0.44
Service Code NDC 68084-381-11
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.32
Max. Negotiated Rate $0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.35
Rate for Payer: Aetna of CA Government/Medicare $0.35
Rate for Payer: Cash Price $0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.47
Rate for Payer: Health Smart Auto/Commercial $0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.35
Rate for Payer: LLUH Dept of Risk Management WC $0.32
Rate for Payer: Multiplan Commercial $0.44
Service Code NDC 0603-2433-21
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.09
Max. Negotiated Rate $0.14
Rate for Payer: Cash Price $0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.14
Rate for Payer: Health Smart Auto/Commercial $0.10
Rate for Payer: LLUH Dept of Risk Management WC $0.09
Rate for Payer: Multiplan Commercial $0.13
Service Code NDC 68084-381-11
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.32
Max. Negotiated Rate $0.47
Rate for Payer: Cash Price $0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.47
Rate for Payer: Health Smart Auto/Commercial $0.35
Rate for Payer: LLUH Dept of Risk Management WC $0.32
Rate for Payer: Multiplan Commercial $0.44
Service Code HCPCS J0515
Hospital Charge Code 901700025
Hospital Revenue Code 636
Min. Negotiated Rate $19.80
Max. Negotiated Rate $28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $21.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $16.92
Rate for Payer: Aetna of CA Government/Medicare $21.60
Rate for Payer: Aetna of CA Government/Medicare $16.92
Rate for Payer: Cash Price $19.80
Rate for Payer: Cash Price $15.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $28.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $22.56
Rate for Payer: Health Smart Auto/Commercial $16.92
Rate for Payer: Health Smart Auto/Commercial $21.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $16.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $21.60
Rate for Payer: LLUH Dept of Risk Management WC $19.80
Rate for Payer: LLUH Dept of Risk Management WC $15.51
Rate for Payer: Multiplan Commercial $27.00
Rate for Payer: Multiplan Commercial $21.15
Service Code HCPCS J0515
Hospital Charge Code 901700025
Hospital Revenue Code 636
Min. Negotiated Rate $19.80
Max. Negotiated Rate $28.80
Rate for Payer: Cash Price $19.80
Rate for Payer: Cash Price $15.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $22.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $28.80
Rate for Payer: Health Smart Auto/Commercial $16.92
Rate for Payer: Health Smart Auto/Commercial $21.60
Rate for Payer: LLUH Dept of Risk Management WC $19.80
Rate for Payer: LLUH Dept of Risk Management WC $15.51
Rate for Payer: Multiplan Commercial $21.15
Rate for Payer: Multiplan Commercial $27.00
Service Code NDC 69315-137-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.10
Max. Negotiated Rate $0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.11
Rate for Payer: Aetna of CA Government/Medicare $0.11
Rate for Payer: Cash Price $0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.15
Rate for Payer: Health Smart Auto/Commercial $0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.11
Rate for Payer: LLUH Dept of Risk Management WC $0.10
Rate for Payer: Multiplan Commercial $0.14
Service Code NDC 0603-2434-21
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.10
Max. Negotiated Rate $0.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.11
Rate for Payer: Aetna of CA Government/Medicare $0.11
Rate for Payer: Cash Price $0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.15
Rate for Payer: Health Smart Auto/Commercial $0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.11
Rate for Payer: LLUH Dept of Risk Management WC $0.10
Rate for Payer: Multiplan Commercial $0.14
Service Code NDC 0603-2434-21
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.10
Max. Negotiated Rate $0.15
Rate for Payer: Cash Price $0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.15
Rate for Payer: Health Smart Auto/Commercial $0.11
Rate for Payer: LLUH Dept of Risk Management WC $0.10
Rate for Payer: Multiplan Commercial $0.14
Service Code NDC 69315-137-01
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.10
Max. Negotiated Rate $0.15
Rate for Payer: Cash Price $0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.15
Rate for Payer: Health Smart Auto/Commercial $0.11
Rate for Payer: LLUH Dept of Risk Management WC $0.10
Rate for Payer: Multiplan Commercial $0.14
Service Code HCPCS J0702
Hospital Charge Code 901700025
Hospital Revenue Code 636
Min. Negotiated Rate $5.76
Max. Negotiated Rate $8.38
Rate for Payer: Cash Price $5.76
Rate for Payer: Cash Price $7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $10.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $8.38
Rate for Payer: Health Smart Auto/Commercial $6.29
Rate for Payer: Health Smart Auto/Commercial $7.93
Rate for Payer: LLUH Dept of Risk Management WC $5.76
Rate for Payer: LLUH Dept of Risk Management WC $7.27
Rate for Payer: Multiplan Commercial $9.91
Rate for Payer: Multiplan Commercial $7.86
Service Code HCPCS J0702
Hospital Charge Code 901700025
Hospital Revenue Code 636
Min. Negotiated Rate $5.76
Max. Negotiated Rate $8.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $6.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $7.93
Rate for Payer: Aetna of CA Government/Medicare $6.29
Rate for Payer: Aetna of CA Government/Medicare $7.93
Rate for Payer: Cash Price $5.76
Rate for Payer: Cash Price $7.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $8.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $10.57
Rate for Payer: Health Smart Auto/Commercial $6.29
Rate for Payer: Health Smart Auto/Commercial $7.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $6.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $7.93
Rate for Payer: LLUH Dept of Risk Management WC $7.27
Rate for Payer: LLUH Dept of Risk Management WC $5.76
Rate for Payer: Multiplan Commercial $7.86
Rate for Payer: Multiplan Commercial $9.91
Service Code NDC 0472-0382-45
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $1.56
Max. Negotiated Rate $2.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $1.70
Rate for Payer: Aetna of CA Government/Medicare $1.70
Rate for Payer: Cash Price $1.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $2.27
Rate for Payer: Health Smart Auto/Commercial $1.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $1.70
Rate for Payer: LLUH Dept of Risk Management WC $1.56
Rate for Payer: Multiplan Commercial $2.13
Service Code NDC 0472-0382-45
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $1.56
Max. Negotiated Rate $2.27
Rate for Payer: Cash Price $1.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $2.27
Rate for Payer: Health Smart Auto/Commercial $1.70
Rate for Payer: LLUH Dept of Risk Management WC $1.56
Rate for Payer: Multiplan Commercial $2.13
Service Code NDC 0168-0057-60
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.44
Max. Negotiated Rate $0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $0.48
Rate for Payer: Aetna of CA Government/Medicare $0.48
Rate for Payer: Cash Price $0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.64
Rate for Payer: Health Smart Auto/Commercial $0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $0.48
Rate for Payer: LLUH Dept of Risk Management WC $0.44
Rate for Payer: Multiplan Commercial $0.60
Service Code NDC 0168-0057-60
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $0.44
Max. Negotiated Rate $0.64
Rate for Payer: Cash Price $0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $0.64
Rate for Payer: Health Smart Auto/Commercial $0.48
Rate for Payer: LLUH Dept of Risk Management WC $0.44
Rate for Payer: Multiplan Commercial $0.60
Service Code NDC 0472-0380-15
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $1.42
Max. Negotiated Rate $2.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $1.55
Rate for Payer: Aetna of CA Government/Medicare $1.55
Rate for Payer: Cash Price $1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $2.07
Rate for Payer: Health Smart Auto/Commercial $1.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $1.55
Rate for Payer: LLUH Dept of Risk Management WC $1.42
Rate for Payer: Multiplan Commercial $1.94
Service Code NDC 0472-0380-15
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $1.42
Max. Negotiated Rate $2.07
Rate for Payer: Cash Price $1.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $2.07
Rate for Payer: Health Smart Auto/Commercial $1.55
Rate for Payer: LLUH Dept of Risk Management WC $1.42
Rate for Payer: Multiplan Commercial $1.94
Service Code NDC 0168-0056-15
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $2.17
Max. Negotiated Rate $3.15
Rate for Payer: Cash Price $2.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $3.15
Rate for Payer: Health Smart Auto/Commercial $2.36
Rate for Payer: LLUH Dept of Risk Management WC $2.17
Rate for Payer: Multiplan Commercial $2.96
Service Code NDC 0472-0381-15
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $1.73
Max. Negotiated Rate $2.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $1.88
Rate for Payer: Aetna of CA Government/Medicare $1.88
Rate for Payer: Cash Price $1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $2.51
Rate for Payer: Health Smart Auto/Commercial $1.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $1.88
Rate for Payer: LLUH Dept of Risk Management WC $1.73
Rate for Payer: Multiplan Commercial $2.35
Service Code NDC 0472-0381-15
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $1.73
Max. Negotiated Rate $2.51
Rate for Payer: Cash Price $1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $2.51
Rate for Payer: Health Smart Auto/Commercial $1.88
Rate for Payer: LLUH Dept of Risk Management WC $1.73
Rate for Payer: Multiplan Commercial $2.35
Service Code NDC 0168-0056-15
Hospital Charge Code 901700029
Hospital Revenue Code 259
Min. Negotiated Rate $2.17
Max. Negotiated Rate $3.15
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO $2.36
Rate for Payer: Aetna of CA Government/Medicare $2.36
Rate for Payer: Cash Price $2.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO $3.15
Rate for Payer: Health Smart Auto/Commercial $2.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage $2.36
Rate for Payer: LLUH Dept of Risk Management WC $2.17
Rate for Payer: Multiplan Commercial $2.96