Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

HYDROXYZINE HCL 50 MG/ML INTRAMUSCULAR SOLUTION [3770]

Facility

OP

$40.45

Service Code	HCPCS J3410
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$22.25
Max. Negotiated Rate	$32.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.27
Rate for Payer: Aetna of CA Government/Medicare	$24.27
Rate for Payer: Cash Price	$22.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$32.36
Rate for Payer: Health Smart Auto/Commercial	$24.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.27
Rate for Payer: LLUH Dept of Risk Management WC	$22.25
Rate for Payer: Multiplan Commercial	$30.34

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

OP

$0.13

Service Code	NDC 16571-115-01
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	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
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	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

IP

$0.45

Service Code	NDC 42806-161-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

IP

$0.17

Service Code	NDC 9992-0012-01
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

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

OP

$0.10

Service Code	NDC 23155-502-01
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	$0.05
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

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

IP

$0.13

Service Code	NDC 0093-5062-01
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	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

IP

$0.10

Service Code	NDC 23155-502-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
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

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

OP

$0.17

Service Code	NDC 10702-012-01
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

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

IP

$0.17

Service Code	NDC 10702-012-01
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

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

IP

$0.13

Service Code	NDC 16571-115-01
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	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

OP

$0.13

Service Code	NDC 0093-5062-01
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	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
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	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.10

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

OP

$0.17

Service Code	NDC 9992-0012-01
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

HYDROXYZINE HCL 50 MG TABLET [3775]

Facility

OP

$0.45

Service Code	NDC 42806-161-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.34

HYDROXYZINE ORAL SOLUTION (IV FORM) 50 MG/ML [4080433]

Facility

OP

$2.40

Service Code	NDC 9994-0804-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

HYDROXYZINE ORAL SOLUTION (IV FORM) 50 MG/ML [4080433]

Facility

IP

$2.40

Service Code	NDC 9994-0804-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

HYDROXYZINE PAMOATE 25 MG CAPSULE [3777]

Facility

IP

$0.17

Service Code	NDC 0555-0323-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
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

HYDROXYZINE PAMOATE 25 MG CAPSULE [3777]

Facility

OP

$0.17

Service Code	NDC 0555-0323-02
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	$0.10
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

HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE [17381]

Facility

IP

$273.92

Service Code	HCPCS J7325
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$150.66
Max. Negotiated Rate	$219.14
Rate for Payer: Cash Price	$150.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$219.14
Rate for Payer: Health Smart Auto/Commercial	$164.35
Rate for Payer: LLUH Dept of Risk Management WC	$150.66
Rate for Payer: Multiplan Commercial	$205.44

HYLAN G-F 20 16 MG/2 ML INTRA-ARTICULAR SYRINGE [17381]

Facility

OP

$273.92

Service Code	HCPCS J7325
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$150.66
Max. Negotiated Rate	$219.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$164.35
Rate for Payer: Aetna of CA Government/Medicare	$164.35
Rate for Payer: Cash Price	$150.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$219.14
Rate for Payer: Health Smart Auto/Commercial	$164.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$164.35
Rate for Payer: LLUH Dept of Risk Management WC	$150.66
Rate for Payer: Multiplan Commercial	$205.44

HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]

Facility

IP

$0.07

Service Code	NDC 54838-511-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
Rate for Payer: Cash Price	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

HYOSCYAMINE 0.125 MG/5 ML ORAL ELIXIR [3781]

Facility

OP

$0.07

Service Code	NDC 54838-511-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.04
Max. Negotiated Rate	$0.06
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	$0.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.05

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]

Facility

IP

$0.54

Service Code	NDC 42192-339-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

HYOSCYAMINE 0.125 MG SUBLINGUAL TABLET [17023]

Facility

OP

$0.54

Service Code	NDC 42192-339-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]

Facility

OP

$129.60

Service Code	HCPCS J1980
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$71.28
Max. Negotiated Rate	$103.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$77.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$47.52
Rate for Payer: Aetna of CA Government/Medicare	$47.52
Rate for Payer: Aetna of CA Government/Medicare	$77.76
Rate for Payer: Cash Price	$43.56
Rate for Payer: Cash Price	$71.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$103.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$63.36
Rate for Payer: Health Smart Auto/Commercial	$77.76
Rate for Payer: Health Smart Auto/Commercial	$47.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$77.76
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$47.52
Rate for Payer: LLUH Dept of Risk Management WC	$71.28
Rate for Payer: LLUH Dept of Risk Management WC	$43.56
Rate for Payer: Multiplan Commercial	$59.40
Rate for Payer: Multiplan Commercial	$97.20

HYOSCYAMINE 0.5 MG/ML INJECTION SOLUTION [10239]

Facility

IP

$79.20

Service Code	HCPCS J1980
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$43.56
Max. Negotiated Rate	$63.36
Rate for Payer: Cash Price	$43.56
Rate for Payer: Cash Price	$71.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$103.68
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$63.36
Rate for Payer: Health Smart Auto/Commercial	$47.52
Rate for Payer: Health Smart Auto/Commercial	$77.76
Rate for Payer: LLUH Dept of Risk Management WC	$71.28
Rate for Payer: LLUH Dept of Risk Management WC	$43.56
Rate for Payer: Multiplan Commercial	$97.20
Rate for Payer: Multiplan Commercial	$59.40

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