Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

IP

$0.05

Service Code	NDC 5976237201
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
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

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

IP

$0.06

Service Code	NDC 0228202910
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

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

IP

$0.44

Service Code	NDC 6068738811
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

IP

$0.44

Service Code	NDC 6068738801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

OP

$0.44

Service Code	NDC 6068738801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

OP

$0.05

Service Code	NDC 5976237201
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	$0.02
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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

OP

$0.06

Service Code	NDC 0228202910
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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

ALPRAZOLAM 0.5 MG TABLET [325]

Facility

OP

$0.44

Service Code	NDC 6068738811
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Commercial	$0.33

ALPRAZOLAM 1 MG TABLET [326]

Facility

IP

$0.05

Service Code	NDC 6586267801
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
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

ALPRAZOLAM 1 MG TABLET [326]

Facility

OP

$0.05

Service Code	NDC 6586267801
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	$0.02
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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

ALPRAZOLAM 1 MG TABLET [326]

Facility

OP

$0.06

Service Code	NDC 5976237211
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 Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.05

ALPRAZOLAM 1 MG TABLET [326]

Facility

IP

$0.06

Service Code	NDC 5976237211
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

ALTEPLASE 100 MG INTRAVENOUS SOLUTION [9002]

Facility

IP

$10,560.43

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5,808.24
Max. Negotiated Rate	$8,448.34
Rate for Payer: Cash Price	$4,752.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8,448.34
Rate for Payer: Health Smart Auto/Commercial	$6,336.26
Rate for Payer: LLUH Dept of Risk Management WC	$5,808.24
Rate for Payer: Multiplan Commercial	$7,920.32

ALTEPLASE 100 MG INTRAVENOUS SOLUTION [9002]

Facility

OP

$10,560.43

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$95.09
Max. Negotiated Rate	$8,448.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6,336.26
Rate for Payer: Aetna of CA Government/Medicare	$6,336.26
Rate for Payer: Cash Price	$4,752.19
Rate for Payer: Cash Price	$4,752.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8,448.34
Rate for Payer: Health Smart Auto/Commercial	$6,336.26
Rate for Payer: Intervalley Health Plan Commercial	$95.09
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$6,336.26
Rate for Payer: LLUH Dept of Risk Management WC	$5,808.24
Rate for Payer: Multiplan Commercial	$7,920.32

ALTEPLASE 100 MG INTRAVENOUS SOLUTION (ACUTE THROMBOEMBOLIC STROKE) [4081495]

Facility

IP

$10,560.43

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$5,808.24
Max. Negotiated Rate	$8,448.34
Rate for Payer: Cash Price	$4,752.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8,448.34
Rate for Payer: Health Smart Auto/Commercial	$6,336.26
Rate for Payer: LLUH Dept of Risk Management WC	$5,808.24
Rate for Payer: Multiplan Commercial	$7,920.32

ALTEPLASE 100 MG INTRAVENOUS SOLUTION (ACUTE THROMBOEMBOLIC STROKE) [4081495]

Facility

OP

$10,560.43

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$95.09
Max. Negotiated Rate	$8,448.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6,336.26
Rate for Payer: Aetna of CA Government/Medicare	$6,336.26
Rate for Payer: Cash Price	$4,752.19
Rate for Payer: Cash Price	$4,752.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$8,448.34
Rate for Payer: Health Smart Auto/Commercial	$6,336.26
Rate for Payer: Intervalley Health Plan Commercial	$95.09
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$6,336.26
Rate for Payer: LLUH Dept of Risk Management WC	$5,808.24
Rate for Payer: Multiplan Commercial	$7,920.32

ALTEPLASE 1 MG/2 ML SYRINGE [408189]

Facility

OP

$52.80

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.04
Max. Negotiated Rate	$95.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.68
Rate for Payer: Aetna of CA Government/Medicare	$31.68
Rate for Payer: Cash Price	$23.76
Rate for Payer: Cash Price	$23.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.24
Rate for Payer: Health Smart Auto/Commercial	$31.68
Rate for Payer: Intervalley Health Plan Commercial	$95.09
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$31.68
Rate for Payer: LLUH Dept of Risk Management WC	$29.04
Rate for Payer: Multiplan Commercial	$39.60

ALTEPLASE 1 MG/2 ML SYRINGE [408189]

Facility

IP

$52.80

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.04
Max. Negotiated Rate	$42.24
Rate for Payer: Cash Price	$23.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.24
Rate for Payer: Health Smart Auto/Commercial	$31.68
Rate for Payer: LLUH Dept of Risk Management WC	$29.04
Rate for Payer: Multiplan Commercial	$39.60

ALTEPLASE 2 MG INTRA-ARTERIAL SOLUTION FOR IR [40823708]

Facility

IP

$52.80

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.04
Max. Negotiated Rate	$42.24
Rate for Payer: Cash Price	$23.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.24
Rate for Payer: Health Smart Auto/Commercial	$31.68
Rate for Payer: LLUH Dept of Risk Management WC	$29.04
Rate for Payer: Multiplan Commercial	$39.60

ALTEPLASE 2 MG INTRA-ARTERIAL SOLUTION FOR IR [40823708]

Facility

OP

$52.80

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.04
Max. Negotiated Rate	$95.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.68
Rate for Payer: Aetna of CA Government/Medicare	$31.68
Rate for Payer: Cash Price	$23.76
Rate for Payer: Cash Price	$23.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.24
Rate for Payer: Health Smart Auto/Commercial	$31.68
Rate for Payer: Intervalley Health Plan Commercial	$95.09
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$31.68
Rate for Payer: LLUH Dept of Risk Management WC	$29.04
Rate for Payer: Multiplan Commercial	$39.60

ALTEPLASE 50 MG INTRAVENOUS SOLUTION [9003]

Facility

OP

$5,280.22

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$95.09
Max. Negotiated Rate	$4,224.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,168.13
Rate for Payer: Aetna of CA Government/Medicare	$3,168.13
Rate for Payer: Cash Price	$2,376.10
Rate for Payer: Cash Price	$2,376.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,224.18
Rate for Payer: Health Smart Auto/Commercial	$3,168.13
Rate for Payer: Intervalley Health Plan Commercial	$95.09
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$3,168.13
Rate for Payer: LLUH Dept of Risk Management WC	$2,904.12
Rate for Payer: Multiplan Commercial	$3,960.16

ALTEPLASE 50 MG INTRAVENOUS SOLUTION [9003]

Facility

IP

$5,280.22

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$2,904.12
Max. Negotiated Rate	$4,224.18
Rate for Payer: Cash Price	$2,376.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4,224.18
Rate for Payer: Health Smart Auto/Commercial	$3,168.13
Rate for Payer: LLUH Dept of Risk Management WC	$2,904.12
Rate for Payer: Multiplan Commercial	$3,960.16

ALTEPLASE INTRAVENTRICULAR 1 MG/2 ML SYRINGE [40820125]

Facility

IP

$52.80

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.04
Max. Negotiated Rate	$42.24
Rate for Payer: Cash Price	$23.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.24
Rate for Payer: Health Smart Auto/Commercial	$31.68
Rate for Payer: LLUH Dept of Risk Management WC	$29.04
Rate for Payer: Multiplan Commercial	$39.60

ALTEPLASE INTRAVENTRICULAR 1 MG/2 ML SYRINGE [40820125]

Facility

OP

$52.80

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.04
Max. Negotiated Rate	$95.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.68
Rate for Payer: Aetna of CA Government/Medicare	$31.68
Rate for Payer: Cash Price	$23.76
Rate for Payer: Cash Price	$23.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.24
Rate for Payer: Health Smart Auto/Commercial	$31.68
Rate for Payer: Intervalley Health Plan Commercial	$95.09
Rate for Payer: Kaiser Foundation Hospitals Commercial/Medi-Cal/Medicare Advantage	$31.68
Rate for Payer: LLUH Dept of Risk Management WC	$29.04
Rate for Payer: Multiplan Commercial	$39.60

ALTEPLASE SYRINGE 1 MG/2 ML FOR NEBULIZATION [4081953]

Facility

IP

$52.80

Service Code	HCPCS J2997
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.04
Max. Negotiated Rate	$42.24
Rate for Payer: Cash Price	$23.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.24
Rate for Payer: Health Smart Auto/Commercial	$31.68
Rate for Payer: LLUH Dept of Risk Management WC	$29.04
Rate for Payer: Multiplan Commercial	$39.60

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