Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

LEUCOVORIN CALCIUM 10 MG/ML INJECTION SOLUTION [15370]

Facility

OP

$2.84

Service Code	CPT J0640
Hospital Charge Code	NDG15370A
Hospital Revenue Code	636
Min. Negotiated Rate	$1.56
Max. Negotiated Rate	$2.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.70
Rate for Payer: Aetna of CA Government/Medicare	$1.70
Rate for Payer: Cash Price	$1.28
Rate for Payer: Health Smart Auto/Commercial	$1.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.70
Rate for Payer: LLUH Dept of Risk Management WC	$1.56
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.13

LEUCOVORIN CALCIUM 10 MG TABLET [4395]

Facility

IP

$6.65

Service Code	NDC 69315-185-24
Hospital Charge Code	1712574
Hospital Revenue Code	259
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$5.32
Rate for Payer: Cash Price	$2.99
Rate for Payer: Cigna of CA HMO/PPO	$5.32
Rate for Payer: Health Smart Auto/Commercial	$3.99
Rate for Payer: LLUH Dept of Risk Management WC	$3.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.99

LEUCOVORIN CALCIUM 10 MG TABLET [4395]

Facility

IP

$7.48

Service Code	NDC 0054-4497-05
Hospital Charge Code	1712574
Hospital Revenue Code	259
Min. Negotiated Rate	$4.11
Max. Negotiated Rate	$5.98
Rate for Payer: Cash Price	$3.37
Rate for Payer: Cigna of CA HMO/PPO	$5.98
Rate for Payer: Health Smart Auto/Commercial	$4.49
Rate for Payer: LLUH Dept of Risk Management WC	$4.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.61

LEUCOVORIN CALCIUM 10 MG TABLET [4395]

Facility

IP

$7.48

Service Code	NDC 69315-185-12
Hospital Charge Code	1712574
Hospital Revenue Code	259
Min. Negotiated Rate	$4.11
Max. Negotiated Rate	$5.98
Rate for Payer: Cash Price	$3.37
Rate for Payer: Cigna of CA HMO/PPO	$5.98
Rate for Payer: Health Smart Auto/Commercial	$4.49
Rate for Payer: LLUH Dept of Risk Management WC	$4.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.61

LEUCOVORIN CALCIUM 10 MG TABLET [4395]

Facility

IP

$6.65

Service Code	NDC 0054-4497-10
Hospital Charge Code	1712574
Hospital Revenue Code	259
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$5.32
Rate for Payer: Cash Price	$2.99
Rate for Payer: Cigna of CA HMO/PPO	$5.32
Rate for Payer: Health Smart Auto/Commercial	$3.99
Rate for Payer: LLUH Dept of Risk Management WC	$3.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.99

LEUCOVORIN CALCIUM 10 MG TABLET [4395]

Facility

OP

$7.48

Service Code	NDC 0054-4497-05
Hospital Charge Code	1712574
Hospital Revenue Code	259
Min. Negotiated Rate	$4.11
Max. Negotiated Rate	$5.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.49
Rate for Payer: Aetna of CA Government/Medicare	$4.49
Rate for Payer: Cash Price	$3.37
Rate for Payer: Health Smart Auto/Commercial	$4.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.49
Rate for Payer: LLUH Dept of Risk Management WC	$4.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.61

LEUCOVORIN CALCIUM 10 MG TABLET [4395]

Facility

OP

$6.65

Service Code	NDC 69315-185-24
Hospital Charge Code	1712574
Hospital Revenue Code	259
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$4.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.99
Rate for Payer: Aetna of CA Government/Medicare	$3.99
Rate for Payer: Cash Price	$2.99
Rate for Payer: Health Smart Auto/Commercial	$3.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.99
Rate for Payer: LLUH Dept of Risk Management WC	$3.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.99

LEUCOVORIN CALCIUM 10 MG TABLET [4395]

Facility

OP

$6.65

Service Code	NDC 0054-4497-10
Hospital Charge Code	1712574
Hospital Revenue Code	259
Min. Negotiated Rate	$3.66
Max. Negotiated Rate	$4.99
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.99
Rate for Payer: Aetna of CA Government/Medicare	$3.99
Rate for Payer: Cash Price	$2.99
Rate for Payer: Health Smart Auto/Commercial	$3.99
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.99
Rate for Payer: LLUH Dept of Risk Management WC	$3.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.99

LEUCOVORIN CALCIUM 10 MG TABLET [4395]

Facility

OP

$7.48

Service Code	NDC 69315-185-12
Hospital Charge Code	1712574
Hospital Revenue Code	259
Min. Negotiated Rate	$4.11
Max. Negotiated Rate	$5.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.49
Rate for Payer: Aetna of CA Government/Medicare	$4.49
Rate for Payer: Cash Price	$3.37
Rate for Payer: Health Smart Auto/Commercial	$4.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.49
Rate for Payer: LLUH Dept of Risk Management WC	$4.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.61

LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]

Facility

IP

$48.00

Service Code	CPT J0640
Hospital Charge Code	ERX15426
Hospital Revenue Code	636
Min. Negotiated Rate	$26.40
Max. Negotiated Rate	$38.40
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$12.96
Rate for Payer: Cash Price	$12.45
Rate for Payer: Cigna of CA HMO/PPO	$22.14
Rate for Payer: Cigna of CA HMO/PPO	$38.40
Rate for Payer: Cigna of CA HMO/PPO	$23.04
Rate for Payer: Health Smart Auto/Commercial	$17.28
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Health Smart Auto/Commercial	$16.60
Rate for Payer: LLUH Dept of Risk Management WC	$15.84
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: LLUH Dept of Risk Management WC	$15.22
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.75

LEUCOVORIN CALCIUM 200 MG SOLUTION FOR INJECTION [15426]

Facility

OP

$27.67

Service Code	CPT J0640
Hospital Charge Code	ERX15426
Hospital Revenue Code	636
Min. Negotiated Rate	$15.22
Max. Negotiated Rate	$20.75
Rate for Payer: Cash Price	$12.45
Rate for Payer: Health Smart Auto/Commercial	$17.28
Rate for Payer: Health Smart Auto/Commercial	$16.60
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$16.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$17.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.80
Rate for Payer: Aetna of CA Government/Medicare	$16.60
Rate for Payer: Aetna of CA Government/Medicare	$28.80
Rate for Payer: Aetna of CA Government/Medicare	$17.28
Rate for Payer: Cash Price	$21.60
Rate for Payer: Cash Price	$12.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$17.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$16.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.80
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: LLUH Dept of Risk Management WC	$15.22
Rate for Payer: LLUH Dept of Risk Management WC	$15.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$36.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$21.60
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$20.75

LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]

Facility

OP

$21.12

Service Code	CPT J0640
Hospital Charge Code	1720720
Hospital Revenue Code	636
Min. Negotiated Rate	$11.62
Max. Negotiated Rate	$15.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.67
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.40
Rate for Payer: Aetna of CA Government/Medicare	$13.64
Rate for Payer: Aetna of CA Government/Medicare	$50.40
Rate for Payer: Aetna of CA Government/Medicare	$18.72
Rate for Payer: Aetna of CA Government/Medicare	$12.67
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cash Price	$10.23
Rate for Payer: Cash Price	$9.50
Rate for Payer: Cash Price	$14.04
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: Health Smart Auto/Commercial	$12.67
Rate for Payer: Health Smart Auto/Commercial	$18.72
Rate for Payer: Health Smart Auto/Commercial	$13.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: LLUH Dept of Risk Management WC	$17.16
Rate for Payer: LLUH Dept of Risk Management WC	$11.62
Rate for Payer: LLUH Dept of Risk Management WC	$12.51
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.40

LEUCOVORIN CALCIUM 350 MG SOLUTION FOR INJECTION [4393]

Facility

IP

$22.74

Service Code	CPT J0640
Hospital Charge Code	1720720
Hospital Revenue Code	636
Min. Negotiated Rate	$12.51
Max. Negotiated Rate	$18.19
Rate for Payer: Cash Price	$10.23
Rate for Payer: Cash Price	$9.50
Rate for Payer: Cash Price	$37.80
Rate for Payer: Cash Price	$14.04
Rate for Payer: Cigna of CA HMO/PPO	$67.20
Rate for Payer: Cigna of CA HMO/PPO	$24.96
Rate for Payer: Cigna of CA HMO/PPO	$16.90
Rate for Payer: Cigna of CA HMO/PPO	$18.19
Rate for Payer: Health Smart Auto/Commercial	$18.72
Rate for Payer: Health Smart Auto/Commercial	$13.64
Rate for Payer: Health Smart Auto/Commercial	$12.67
Rate for Payer: Health Smart Auto/Commercial	$50.40
Rate for Payer: LLUH Dept of Risk Management WC	$12.51
Rate for Payer: LLUH Dept of Risk Management WC	$46.20
Rate for Payer: LLUH Dept of Risk Management WC	$17.16
Rate for Payer: LLUH Dept of Risk Management WC	$11.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$15.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$23.40

LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]

Facility

OP

$120.00

Service Code	CPT J0640
Hospital Charge Code	ERX23617
Hospital Revenue Code	636
Min. Negotiated Rate	$66.00
Max. Negotiated Rate	$90.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$72.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$62.06
Rate for Payer: Aetna of CA Government/Medicare	$62.06
Rate for Payer: Aetna of CA Government/Medicare	$72.00
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cash Price	$46.54
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$62.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$62.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$72.00
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$56.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$77.57

LEUCOVORIN CALCIUM 500 MG SOLUTION FOR INJECTION [23617]

Facility

IP

$103.43

Service Code	CPT J0640
Hospital Charge Code	ERX23617
Hospital Revenue Code	636
Min. Negotiated Rate	$56.89
Max. Negotiated Rate	$82.74
Rate for Payer: Cash Price	$46.54
Rate for Payer: Cash Price	$54.00
Rate for Payer: Cigna of CA HMO/PPO	$96.00
Rate for Payer: Cigna of CA HMO/PPO	$82.74
Rate for Payer: Health Smart Auto/Commercial	$72.00
Rate for Payer: Health Smart Auto/Commercial	$62.06
Rate for Payer: LLUH Dept of Risk Management WC	$66.00
Rate for Payer: LLUH Dept of Risk Management WC	$56.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$77.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$90.00

LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]

Facility

IP

$12.00

Service Code	CPT J0640
Hospital Charge Code	1720078
Hospital Revenue Code	636
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.60
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$2.85
Rate for Payer: Cigna of CA HMO/PPO	$5.07
Rate for Payer: Cigna of CA HMO/PPO	$9.60
Rate for Payer: Health Smart Auto/Commercial	$3.80
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.76
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.00

LEUCOVORIN CALCIUM 50 MG SOLUTION FOR INJECTION [4394]

Facility

OP

$12.00

Service Code	CPT J0640
Hospital Charge Code	1720078
Hospital Revenue Code	636
Min. Negotiated Rate	$6.60
Max. Negotiated Rate	$9.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.80
Rate for Payer: Aetna of CA Government/Medicare	$7.20
Rate for Payer: Aetna of CA Government/Medicare	$3.80
Rate for Payer: Cash Price	$5.40
Rate for Payer: Cash Price	$2.85
Rate for Payer: Health Smart Auto/Commercial	$7.20
Rate for Payer: Health Smart Auto/Commercial	$3.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.20
Rate for Payer: LLUH Dept of Risk Management WC	$6.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.49
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$9.00
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.76

LEUCOVORIN CALCIUM 5 MG TABLET [4398]

Facility

IP

$1.34

Service Code	NDC 69315-184-03
Hospital Charge Code	1711174
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.00

LEUCOVORIN CALCIUM 5 MG TABLET [4398]

Facility

OP

$1.89

Service Code	NDC 0054-8496-19
Hospital Charge Code	1711174
Hospital Revenue Code	259
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.13
Rate for Payer: Aetna of CA Government/Medicare	$1.13
Rate for Payer: Cash Price	$0.85
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.42

LEUCOVORIN CALCIUM 5 MG TABLET [4398]

Facility

OP

$1.34

Service Code	NDC 69315-184-03
Hospital Charge Code	1711174
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.00
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	$0.60
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 Beech St/Commercial/PHCS	$1.00

LEUCOVORIN CALCIUM 5 MG TABLET [4398]

Facility

IP

$1.34

Service Code	NDC 0054-4496-13
Hospital Charge Code	1711174
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.07
Rate for Payer: Cash Price	$0.60
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.00

LEUCOVORIN CALCIUM 5 MG TABLET [4398]

Facility

IP

$1.89

Service Code	NDC 0054-8496-19
Hospital Charge Code	1711174
Hospital Revenue Code	259
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.51
Rate for Payer: Cash Price	$0.85
Rate for Payer: Cigna of CA HMO/PPO	$1.51
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.04
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.42

LEUCOVORIN CALCIUM 5 MG TABLET [4398]

Facility

OP

$1.34

Service Code	NDC 0054-4496-13
Hospital Charge Code	1711174
Hospital Revenue Code	259
Min. Negotiated Rate	$0.74
Max. Negotiated Rate	$1.00
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	$0.60
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 Beech St/Commercial/PHCS	$1.00

LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]

Facility

IP

$5,881.22

Service Code	CPT J1950
Hospital Charge Code	ERX21044
Hospital Revenue Code	636
Min. Negotiated Rate	$3,234.67
Max. Negotiated Rate	$4,704.98
Rate for Payer: Cash Price	$2,646.55
Rate for Payer: Cigna of CA HMO/PPO	$4,704.98
Rate for Payer: Health Smart Auto/Commercial	$3,528.73
Rate for Payer: LLUH Dept of Risk Management WC	$3,234.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,410.92

LEUPROLIDE 11.25 MG (3 MONTH) INTRAMUSCULAR SYRINGE KIT [21044]

Facility

OP

$5,881.22

Service Code	CPT J1950
Hospital Charge Code	ERX21044
Hospital Revenue Code	636
Min. Negotiated Rate	$3,234.67
Max. Negotiated Rate	$4,410.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3,528.73
Rate for Payer: Aetna of CA Government/Medicare	$3,528.73
Rate for Payer: Cash Price	$2,646.55
Rate for Payer: Health Smart Auto/Commercial	$3,528.73
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3,528.73
Rate for Payer: LLUH Dept of Risk Management WC	$3,234.67
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4,410.92

<<
<
487
488
489
490
491
492
493
494
495
496
>
>>