Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

BALANCED SALT SOLUTION NON-SURGICAL NO.6 EYE [118648]

Facility

OP

$0.10

Service Code	NDC 59390-175-13
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

BALANCED SALT SOLUTION NON-SURGICAL NO.6 EYE [118648]

Facility

IP

$0.10

Service Code	NDC 59390-175-13
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

BALSALAZIDE 750 MG CAPSULE [29299]

Facility

IP

$1.95

Service Code	NDC 50268-102-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.56
Rate for Payer: Cash Price	$1.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.56
Rate for Payer: Health Smart Auto/Commercial	$1.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.07
Rate for Payer: Multiplan Commercial	$1.46

BALSALAZIDE 750 MG CAPSULE [29299]

Facility

OP

$1.95

Service Code	NDC 50268-102-13
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.17
Rate for Payer: Aetna of CA Government/Medicare	$1.17
Rate for Payer: Cash Price	$1.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.56
Rate for Payer: Health Smart Auto/Commercial	$1.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.07
Rate for Payer: Multiplan Commercial	$1.46

BALSALAZIDE 750 MG CAPSULE [29299]

Facility

OP

$1.95

Service Code	NDC 50268-102-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.17
Rate for Payer: Aetna of CA Government/Medicare	$1.17
Rate for Payer: Cash Price	$1.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.56
Rate for Payer: Health Smart Auto/Commercial	$1.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.07
Rate for Payer: Multiplan Commercial	$1.46

BALSALAZIDE 750 MG CAPSULE [29299]

Facility

IP

$0.90

Service Code	NDC 0054-0079-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

BALSALAZIDE 750 MG CAPSULE [29299]

Facility

IP

$1.95

Service Code	NDC 50268-102-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.07
Max. Negotiated Rate	$1.56
Rate for Payer: Cash Price	$1.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.56
Rate for Payer: Health Smart Auto/Commercial	$1.17
Rate for Payer: LLUH Dept of Risk Management WC	$1.07
Rate for Payer: Multiplan Commercial	$1.46

BALSALAZIDE 750 MG CAPSULE [29299]

Facility

OP

$0.68

Service Code	NDC 0378-6750-82
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

BALSALAZIDE 750 MG CAPSULE [29299]

Facility

IP

$0.68

Service Code	NDC 0378-6750-82
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

BALSALAZIDE 750 MG CAPSULE [29299]

Facility

OP

$0.90

Service Code	NDC 0054-0079-28
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

BALSAM PERU-CASTOR OIL TOPICAL OINTMENT IN PACKET [223630]

Facility

OP

$1.50

Service Code	NDC 58980-780-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.90
Rate for Payer: Aetna of CA Government/Medicare	$0.90
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

BALSAM PERU-CASTOR OIL TOPICAL OINTMENT IN PACKET [223630]

Facility

IP

$1.50

Service Code	NDC 58980-780-50
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.83
Max. Negotiated Rate	$1.20
Rate for Payer: Cash Price	$0.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.20
Rate for Payer: Health Smart Auto/Commercial	$0.90
Rate for Payer: LLUH Dept of Risk Management WC	$0.83
Rate for Payer: Multiplan Commercial	$1.12

BANANA FLAKES-TRANSGALACTOOLIGOSACCHARIDE ORAL POWDER PACKET [37930]

Facility

IP

$1.09

Service Code	NDC 9468808470
Hospital Charge Code	901700016
Hospital Revenue Code	271
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$0.82

BANANA FLAKES-TRANSGALACTOOLIGOSACCHARIDE ORAL POWDER PACKET [37930]

Facility

OP

$1.09

Service Code	NDC 9468808470
Hospital Charge Code	901700016
Hospital Revenue Code	271
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.65
Rate for Payer: Aetna of CA Government/Medicare	$0.65
Rate for Payer: Cash Price	$0.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.87
Rate for Payer: Health Smart Auto/Commercial	$0.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.65
Rate for Payer: LLUH Dept of Risk Management WC	$0.60
Rate for Payer: Multiplan Commercial	$0.82

BARICITINIB 1 MG TABLET [225594]

Facility

OP

$110.70

Service Code	NDC 0002-4732-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$60.88
Max. Negotiated Rate	$88.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$66.42
Rate for Payer: Aetna of CA Government/Medicare	$66.42
Rate for Payer: Cash Price	$60.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.56
Rate for Payer: Health Smart Auto/Commercial	$66.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$66.42
Rate for Payer: LLUH Dept of Risk Management WC	$60.88
Rate for Payer: Multiplan Commercial	$83.03

BARICITINIB 1 MG TABLET [225594]

Facility

IP

$110.70

Service Code	NDC 0002-4732-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$60.88
Max. Negotiated Rate	$88.56
Rate for Payer: Cash Price	$60.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.56
Rate for Payer: Health Smart Auto/Commercial	$66.42
Rate for Payer: LLUH Dept of Risk Management WC	$60.88
Rate for Payer: Multiplan Commercial	$83.03

BARICITINIB 2 MG TABLET [221907]

Facility

IP

$110.70

Service Code	HCPCS J8499
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$60.88
Max. Negotiated Rate	$88.56
Rate for Payer: Cash Price	$60.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.56
Rate for Payer: Health Smart Auto/Commercial	$66.42
Rate for Payer: LLUH Dept of Risk Management WC	$60.88
Rate for Payer: Multiplan Commercial	$83.03

BARICITINIB 2 MG TABLET [221907]

Facility

OP

$110.70

Service Code	HCPCS J8499
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$60.88
Max. Negotiated Rate	$88.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$66.42
Rate for Payer: Aetna of CA Government/Medicare	$66.42
Rate for Payer: Cash Price	$60.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$88.56
Rate for Payer: Health Smart Auto/Commercial	$66.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$66.42
Rate for Payer: LLUH Dept of Risk Management WC	$60.88
Rate for Payer: Multiplan Commercial	$83.03

BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]

Facility

IP

$0.03

Service Code	NDC 32909-167-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

BARIUM SULFATE 105 % (W/V), 58 % (W/W) ORAL SUSPENSION [97296]

Facility

OP

$0.03

Service Code	NDC 32909-167-55
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.02
Rate for Payer: Aetna of CA Government/Medicare	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [223877]

Facility

OP

$0.26

Service Code	NDC 32909-121-07
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

BARIUM SULFATE 40 % (W/V), 29 % (W/W) (1,500 CPS) ORAL SUSPENSION [223877]

Facility

IP

$0.26

Service Code	NDC 32909-121-07
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

BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]

Facility

OP

$0.16

Service Code	NDC 32909-750-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
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	$0.13
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	$0.12

BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]

Facility

IP

$0.16

Service Code	NDC 32909-750-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
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	$0.12

BARIUM SULFATE 96 % (W/W) ORAL POWDER FOR SUSPENSION [13031]

Facility

IP

$0.03

Service Code	NDC 32909-750-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Commercial	$0.02

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