Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

CARVEDILOL PHOSPHATE ER 10 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77664]

Facility

$9.91

Service Code	NDC 57664-663-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.95
Rate for Payer: Aetna of CA Government/Medicare	$5.95
Rate for Payer: Cash Price	$5.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.93
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Commercial	$7.43

CARVEDILOL PHOSPHATE ER 10 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77664]

Facility

$9.91

Service Code	NDC 69784-713-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.93
Rate for Payer: Cash Price	$5.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.93
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Commercial	$7.43

CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]

Facility

$9.91

Service Code	NDC 69784-714-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.95
Rate for Payer: Aetna of CA Government/Medicare	$5.95
Rate for Payer: Cash Price	$5.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.93
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Commercial	$7.43

CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]

Facility

$9.91

Service Code	NDC 57664-664-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.93
Rate for Payer: Cash Price	$5.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.93
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Commercial	$7.43

CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]

Facility

$9.91

Service Code	NDC 69784-714-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.93
Rate for Payer: Cash Price	$5.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.93
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Commercial	$7.43

CARVEDILOL PHOSPHATE ER 20 MG CAPSULE,EXT.RELEASE24HR MULTIPHASE [77665]

Facility

$9.91

Service Code	NDC 57664-664-83
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.45
Max. Negotiated Rate	$7.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.95
Rate for Payer: Aetna of CA Government/Medicare	$5.95
Rate for Payer: Cash Price	$5.45
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.93
Rate for Payer: Health Smart Auto/Commercial	$5.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.95
Rate for Payer: LLUH Dept of Risk Management WC	$5.45
Rate for Payer: Multiplan Commercial	$7.43

CASPOFUNGIN 50 MG INTRAVENOUS SOLUTION [29567]

Facility

$85.44

Service Code	HCPCS J0637
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$46.99
Max. Negotiated Rate	$68.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.68
Rate for Payer: Aetna of CA Government/Medicare	$51.26
Rate for Payer: Aetna of CA Government/Medicare	$49.68
Rate for Payer: Cash Price	$46.99
Rate for Payer: Cash Price	$45.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$66.24
Rate for Payer: Health Smart Auto/Commercial	$49.68
Rate for Payer: Health Smart Auto/Commercial	$51.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.26
Rate for Payer: LLUH Dept of Risk Management WC	$46.99
Rate for Payer: LLUH Dept of Risk Management WC	$45.54
Rate for Payer: Multiplan Commercial	$64.08
Rate for Payer: Multiplan Commercial	$62.10

CASPOFUNGIN 50 MG INTRAVENOUS SOLUTION [29567]

Facility

$85.44

Service Code	HCPCS J0637
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$46.99
Max. Negotiated Rate	$68.35
Rate for Payer: Cash Price	$46.99
Rate for Payer: Cash Price	$45.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$66.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$68.35
Rate for Payer: Health Smart Auto/Commercial	$49.68
Rate for Payer: Health Smart Auto/Commercial	$51.26
Rate for Payer: LLUH Dept of Risk Management WC	$46.99
Rate for Payer: LLUH Dept of Risk Management WC	$45.54
Rate for Payer: Multiplan Commercial	$62.10
Rate for Payer: Multiplan Commercial	$64.08

CEFACLOR 250 MG/5 ML ORAL SUSPENSION [9434]

Facility

$1.40

Service Code	NDC 16571-071-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Commercial	$1.05

CEFACLOR 250 MG/5 ML ORAL SUSPENSION [9434]

Facility

$1.40

Service Code	NDC 16571-071-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.84
Rate for Payer: Aetna of CA Government/Medicare	$0.84
Rate for Payer: Cash Price	$0.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.84
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Commercial	$1.05

CEFACLOR 500 MG CAPSULE [9431]

Facility

$2.86

Service Code	NDC 61442-172-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.72
Rate for Payer: Aetna of CA Government/Medicare	$1.72
Rate for Payer: Cash Price	$1.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.29
Rate for Payer: Health Smart Auto/Commercial	$1.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.72
Rate for Payer: LLUH Dept of Risk Management WC	$1.57
Rate for Payer: Multiplan Commercial	$2.15

CEFACLOR 500 MG CAPSULE [9431]

Facility

$2.86

Service Code	NDC 61442-172-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.57
Max. Negotiated Rate	$2.29
Rate for Payer: Cash Price	$1.57
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.29
Rate for Payer: Health Smart Auto/Commercial	$1.72
Rate for Payer: LLUH Dept of Risk Management WC	$1.57
Rate for Payer: Multiplan Commercial	$2.15

CEFADROXIL 500 MG CAPSULE [9436]

Facility

$0.71

Service Code	NDC 0093-3196-53
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

CEFADROXIL 500 MG CAPSULE [9436]

Facility

$0.71

Service Code	NDC 0093-3196-53
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

CEFADROXIL 500 MG CAPSULE [9436]

Facility

$0.64

Service Code	NDC 0093-3196-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

CEFADROXIL 500 MG CAPSULE [9436]

Facility

$0.71

Service Code	NDC 68180-180-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

CEFADROXIL 500 MG CAPSULE [9436]

Facility

$0.64

Service Code	NDC 0093-3196-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.48

CEFADROXIL 500 MG CAPSULE [9436]

Facility

$0.71

Service Code	NDC 68180-180-08
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

CEFAZOLIN 10 GRAM SOLUTION FOR INJ (100MG/ML IVPB) [1446]

Facility

$13.26

Service Code	HCPCS J0690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.29
Max. Negotiated Rate	$10.61
Rate for Payer: Cash Price	$7.29
Rate for Payer: Cash Price	$7.92
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	$10.61
Rate for Payer: Health Smart Auto/Commercial	$7.96
Rate for Payer: Health Smart Auto/Commercial	$8.64
Rate for Payer: LLUH Dept of Risk Management WC	$7.29
Rate for Payer: LLUH Dept of Risk Management WC	$7.92
Rate for Payer: Multiplan Commercial	$10.80
Rate for Payer: Multiplan Commercial	$9.95

CEFAZOLIN 10 GRAM SOLUTION FOR INJ (100MG/ML IVPB) [1446]

Facility

$14.40

Service Code	HCPCS J0690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$7.92
Max. Negotiated Rate	$11.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.96
Rate for Payer: Aetna of CA Government/Medicare	$8.64
Rate for Payer: Aetna of CA Government/Medicare	$7.96
Rate for Payer: Cash Price	$7.29
Rate for Payer: Cash Price	$7.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.61
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$11.52
Rate for Payer: Health Smart Auto/Commercial	$8.64
Rate for Payer: Health Smart Auto/Commercial	$7.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.96
Rate for Payer: LLUH Dept of Risk Management WC	$7.29
Rate for Payer: LLUH Dept of Risk Management WC	$7.92
Rate for Payer: Multiplan Commercial	$9.95
Rate for Payer: Multiplan Commercial	$10.80

CEFAZOLIN 10 MG/ML SERIAL DILUTION FOR MIXTURES [4080885]

Facility

$1.72

Service Code	HCPCS J0690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.95
Max. Negotiated Rate	$1.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.25
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$1.25
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$1.15
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.67
Rate for Payer: Health Smart Auto/Commercial	$1.25
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$1.15
Rate for Payer: Multiplan Commercial	$0.71
Rate for Payer: Multiplan Commercial	$1.57
Rate for Payer: Multiplan Commercial	$1.29

CEFAZOLIN 10 MG/ML SERIAL DILUTION FOR MIXTURES [4080885]

Facility

$0.94

Service Code	HCPCS J0690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.52
Max. Negotiated Rate	$0.75
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cash Price	$0.94
Rate for Payer: Cash Price	$1.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Health Smart Auto/Commercial	$1.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.15
Rate for Payer: Multiplan Commercial	$0.71
Rate for Payer: Multiplan Commercial	$1.57
Rate for Payer: Multiplan Commercial	$1.29

CEFAZOLIN 1 GRAM INJECTION (IM) [4080785]

Facility

$2.09

Service Code	HCPCS J0690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$1.67
Rate for Payer: Cash Price	$1.15
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Health Smart Auto/Commercial	$1.25
Rate for Payer: LLUH Dept of Risk Management WC	$1.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: Multiplan Commercial	$0.71
Rate for Payer: Multiplan Commercial	$1.29
Rate for Payer: Multiplan Commercial	$1.57

CEFAZOLIN 1 GRAM INJECTION (IM) [4080785]

Facility

$2.09

Service Code	HCPCS J0690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.15
Max. Negotiated Rate	$1.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.03
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$1.25
Rate for Payer: Aetna of CA Government/Medicare	$1.03
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cash Price	$1.15
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.67
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: Health Smart Auto/Commercial	$1.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$1.15
Rate for Payer: Multiplan Commercial	$0.71
Rate for Payer: Multiplan Commercial	$1.29
Rate for Payer: Multiplan Commercial	$1.57

CEFAZOLIN 1 GRAM SOLUTION FOR INJECTION [1445]

Facility

$1.80

Service Code	HCPCS J0690
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.99
Max. Negotiated Rate	$1.44
Rate for Payer: Cash Price	$0.99
Rate for Payer: Cash Price	$0.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.08
Rate for Payer: Health Smart Auto/Commercial	$1.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.95
Rate for Payer: LLUH Dept of Risk Management WC	$0.99
Rate for Payer: Multiplan Commercial	$1.29
Rate for Payer: Multiplan Commercial	$1.35

Know your out-of-pocket cost for care.

All Charges