Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL CREAM [8114]

Facility

$0.66

Service Code	NDC 45802-065-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.50

TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL OINTMENT [8119]

Facility

$0.65

Service Code	NDC 45802-049-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

TRIAMCINOLONE ACETONIDE 0.5 % TOPICAL OINTMENT [8119]

Facility

$0.65

Service Code	NDC 45802-049-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.39
Rate for Payer: Aetna of CA Government/Medicare	$0.39
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.39
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.39
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.49

TRIAMCINOLONE ACETONIDE 10 MG/ML SUSPENSION FOR INJECTION [11584]

Facility

$2.90

Service Code	HCPCS J3301
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$2.32
Rate for Payer: Cash Price	$1.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.32
Rate for Payer: Health Smart Auto/Commercial	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$1.59
Rate for Payer: Multiplan Commercial	$2.17

TRIAMCINOLONE ACETONIDE 10 MG/ML SUSPENSION FOR INJECTION [11584]

Facility

$2.90

Service Code	HCPCS J3301
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.59
Max. Negotiated Rate	$2.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.74
Rate for Payer: Aetna of CA Government/Medicare	$1.74
Rate for Payer: Cash Price	$1.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.32
Rate for Payer: Health Smart Auto/Commercial	$1.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.74
Rate for Payer: LLUH Dept of Risk Management WC	$1.59
Rate for Payer: Multiplan Commercial	$2.17

TRIAMCINOLONE ACETONIDE 40 MG/ML MED NEB SOLUTION [4080950]

Facility

$11.40

Service Code	NDC 0003-0293-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$9.12
Rate for Payer: Cash Price	$6.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.12
Rate for Payer: Health Smart Auto/Commercial	$6.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.27
Rate for Payer: Multiplan Commercial	$8.55

TRIAMCINOLONE ACETONIDE 40 MG/ML MED NEB SOLUTION [4080950]

Facility

$11.23

Service Code	NDC 0003-0293-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$8.98
Rate for Payer: Cash Price	$6.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Commercial	$8.42

TRIAMCINOLONE ACETONIDE 40 MG/ML MED NEB SOLUTION [4080950]

Facility

$11.23

Service Code	NDC 0003-0293-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.18
Max. Negotiated Rate	$8.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.74
Rate for Payer: Aetna of CA Government/Medicare	$6.74
Rate for Payer: Cash Price	$6.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.98
Rate for Payer: Health Smart Auto/Commercial	$6.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.74
Rate for Payer: LLUH Dept of Risk Management WC	$6.18
Rate for Payer: Multiplan Commercial	$8.42

TRIAMCINOLONE ACETONIDE 40 MG/ML MED NEB SOLUTION [4080950]

Facility

$11.40

Service Code	NDC 0003-0293-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.27
Max. Negotiated Rate	$9.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.84
Rate for Payer: Aetna of CA Government/Medicare	$6.84
Rate for Payer: Cash Price	$6.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.12
Rate for Payer: Health Smart Auto/Commercial	$6.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.84
Rate for Payer: LLUH Dept of Risk Management WC	$6.27
Rate for Payer: Multiplan Commercial	$8.55

TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]

Facility

$10.67

Service Code	HCPCS J3301
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.87
Max. Negotiated Rate	$8.54
Rate for Payer: Cash Price	$5.87
Rate for Payer: Cash Price	$5.42
Rate for Payer: Cash Price	$5.96
Rate for Payer: Cash Price	$5.72
Rate for Payer: Cash Price	$5.34
Rate for Payer: Cash Price	$5.48
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.88
Rate for Payer: Health Smart Auto/Commercial	$5.91
Rate for Payer: Health Smart Auto/Commercial	$6.24
Rate for Payer: Health Smart Auto/Commercial	$6.40
Rate for Payer: Health Smart Auto/Commercial	$6.50
Rate for Payer: Health Smart Auto/Commercial	$5.83
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.34
Rate for Payer: LLUH Dept of Risk Management WC	$5.96
Rate for Payer: LLUH Dept of Risk Management WC	$5.87
Rate for Payer: LLUH Dept of Risk Management WC	$5.42
Rate for Payer: LLUH Dept of Risk Management WC	$5.72
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: Multiplan Commercial	$7.39
Rate for Payer: Multiplan Commercial	$7.28
Rate for Payer: Multiplan Commercial	$7.80
Rate for Payer: Multiplan Commercial	$8.00
Rate for Payer: Multiplan Commercial	$8.12
Rate for Payer: Multiplan Commercial	$7.47

TRIAMCINOLONE ACETONIDE 40 MG/ML SUSPENSION FOR INJECTION [8120]

Facility

$9.96

Service Code	HCPCS J3301
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5.48
Max. Negotiated Rate	$7.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.83
Rate for Payer: Aetna of CA Government/Medicare	$6.50
Rate for Payer: Aetna of CA Government/Medicare	$6.24
Rate for Payer: Aetna of CA Government/Medicare	$5.83
Rate for Payer: Aetna of CA Government/Medicare	$5.98
Rate for Payer: Aetna of CA Government/Medicare	$6.40
Rate for Payer: Aetna of CA Government/Medicare	$5.91
Rate for Payer: Cash Price	$5.42
Rate for Payer: Cash Price	$5.96
Rate for Payer: Cash Price	$5.87
Rate for Payer: Cash Price	$5.34
Rate for Payer: Cash Price	$5.48
Rate for Payer: Cash Price	$5.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.97
Rate for Payer: Health Smart Auto/Commercial	$5.91
Rate for Payer: Health Smart Auto/Commercial	$6.40
Rate for Payer: Health Smart Auto/Commercial	$5.98
Rate for Payer: Health Smart Auto/Commercial	$6.24
Rate for Payer: Health Smart Auto/Commercial	$5.83
Rate for Payer: Health Smart Auto/Commercial	$6.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.50
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.98
Rate for Payer: LLUH Dept of Risk Management WC	$5.34
Rate for Payer: LLUH Dept of Risk Management WC	$5.42
Rate for Payer: LLUH Dept of Risk Management WC	$5.72
Rate for Payer: LLUH Dept of Risk Management WC	$5.96
Rate for Payer: LLUH Dept of Risk Management WC	$5.48
Rate for Payer: LLUH Dept of Risk Management WC	$5.87
Rate for Payer: Multiplan Commercial	$7.28
Rate for Payer: Multiplan Commercial	$8.12
Rate for Payer: Multiplan Commercial	$7.47
Rate for Payer: Multiplan Commercial	$7.39
Rate for Payer: Multiplan Commercial	$7.80
Rate for Payer: Multiplan Commercial	$8.00

TRIAMCINOLONE ACETONIDE 55 MCG NASAL SPRAY AEROSOL [19808]

Facility

$1.34

Service Code	NDC 4116758003
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.80
Rate for Payer: Aetna of CA Government/Medicare	$0.80
Rate for Payer: Cash Price	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.07
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Commercial	$1.00

TRIAMCINOLONE ACETONIDE 55 MCG NASAL SPRAY AEROSOL [19808]

Facility

$1.34

Service Code	NDC 4116758003
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
Rate for Payer: Cash Price	$0.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.07
Rate for Payer: Health Smart Auto/Commercial	$0.80
Rate for Payer: LLUH Dept of Risk Management WC	$0.74
Rate for Payer: Multiplan Commercial	$1.00

TRIAMCINOLONE MOXIFLOXACIN VANCOMYCIN (TRI-MOXI-VANC) OPHTHALMIC INJECTION [4081389]

Facility

$25.00

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Cash Price	$13.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

TRIAMCINOLONE MOXIFLOXACIN VANCOMYCIN (TRI-MOXI-VANC) OPHTHALMIC INJECTION [4081389]

Facility

$25.00

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$13.75
Max. Negotiated Rate	$20.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.00
Rate for Payer: Aetna of CA Government/Medicare	$15.00
Rate for Payer: Cash Price	$13.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.00
Rate for Payer: Health Smart Auto/Commercial	$15.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.00
Rate for Payer: LLUH Dept of Risk Management WC	$13.75
Rate for Payer: Multiplan Commercial	$18.75

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]

Facility

$0.25

Service Code	NDC 72578-090-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]

Facility

$0.26

Service Code	NDC 0781-2074-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]

Facility

$0.27

Service Code	NDC 0527-1632-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.16
Rate for Payer: Aetna of CA Government/Medicare	$0.16
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	$0.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]

Facility

$0.24

Service Code	NDC 0781-2074-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]

Facility

$0.24

Service Code	NDC 0781-2074-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]

Facility

$0.26

Service Code	NDC 0781-2074-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.21
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.21
Rate for Payer: Health Smart Auto/Commercial	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.20

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]

Facility

$0.25

Service Code	NDC 72578-090-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG CAPSULE [12729]

Facility

$0.27

Service Code	NDC 0527-1632-01
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	$0.16
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Commercial	$0.20

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]

Facility

$0.99

Service Code	NDC 68084-750-95
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

TRIAMTERENE 37.5 MG-HYDROCHLOROTHIAZIDE 25 MG TABLET [8132]

Facility

$0.99

Service Code	NDC 68084-750-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.54
Max. Negotiated Rate	$0.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Cash Price	$0.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.74

Know your out-of-pocket cost for care.

All Charges