Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

ACETAMINOPHEN 500 MG TABLET [102]

Facility

IP

$0.02

Service Code	NDC 57896-204-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

IP

$0.02

Service Code	NDC 0904-6730-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

IP

$0.02

Service Code	NDC 57896-201-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

IP

$0.05

Service Code	NDC 50580-457-70
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.03
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

ACETAMINOPHEN 500 MG TABLET [102]

Facility

OP

$0.02

Service Code	NDC 0904-6730-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

OP

$0.05

Service Code	NDC 50580-457-70
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	$0.03
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 Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Commercial	$0.04

ACETAMINOPHEN 500 MG TABLET [102]

Facility

OP

$0.02

Service Code	NDC 57896-204-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

ACETAMINOPHEN 500 MG TABLET [102]

Facility

IP

$0.02

Service Code	NDC 57896-221-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Commercial	$0.02

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

IP

$0.34

Service Code	NDC 45802-730-32
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

OP

$0.34

Service Code	NDC 45802-730-32
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

OP

$0.34

Service Code	NDC 45802-730-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

ACETAMINOPHEN 650 MG RECTAL SUPPOSITORY [105]

Facility

IP

$0.34

Service Code	NDC 45802-730-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.19
Max. Negotiated Rate	$0.27
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: Multiplan Commercial	$0.26

ACETAMINOPHEN 80 MG CHEWABLE TABLET [99]

Facility

OP

$0.08

Service Code	NDC 0904-5791-46
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	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
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	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

ACETAMINOPHEN 80 MG CHEWABLE TABLET [99]

Facility

IP

$0.08

Service Code	NDC 0904-5791-46
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	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.04
Rate for Payer: Multiplan Commercial	$0.06

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

OP

$1.12

Service Code	NDC 51672-2114-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.67
Rate for Payer: Aetna of CA Government/Medicare	$0.67
Rate for Payer: Cash Price	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.84

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

IP

$1.12

Service Code	NDC 51672-2114-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.84

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

IP

$1.12

Service Code	NDC 51672-2114-2
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.84

ACETAMINOPHEN 80 MG RECTAL SUPPOSITORY [8946]

Facility

OP

$1.12

Service Code	NDC 51672-2114-0
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.67
Rate for Payer: Aetna of CA Government/Medicare	$0.67
Rate for Payer: Cash Price	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.67
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.67
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Commercial	$0.84

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

IP

$3.22

Service Code	NDC 50268-054-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Cash Price	$1.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

OP

$3.22

Service Code	NDC 50268-054-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.93
Rate for Payer: Aetna of CA Government/Medicare	$1.93
Rate for Payer: Cash Price	$1.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

IP

$0.42

Service Code	NDC 70756-721-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

OP

$0.42

Service Code	NDC 70756-721-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

IP

$3.22

Service Code	NDC 50268-054-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Cash Price	$1.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

ACETAZOLAMIDE 250 MG TABLET [113]

Facility

OP

$3.22

Service Code	NDC 50268-054-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.77
Max. Negotiated Rate	$2.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.93
Rate for Payer: Aetna of CA Government/Medicare	$1.93
Rate for Payer: Cash Price	$1.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.58
Rate for Payer: Health Smart Auto/Commercial	$1.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.93
Rate for Payer: LLUH Dept of Risk Management WC	$1.77
Rate for Payer: Multiplan Commercial	$2.42

ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]

Facility

IP

$52.75

Service Code	HCPCS J1120
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$29.01
Max. Negotiated Rate	$42.20
Rate for Payer: Cash Price	$29.01
Rate for Payer: Cash Price	$26.40
Rate for Payer: Cash Price	$20.79
Rate for Payer: Cash Price	$26.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.24
Rate for Payer: Health Smart Auto/Commercial	$28.58
Rate for Payer: Health Smart Auto/Commercial	$22.68
Rate for Payer: Health Smart Auto/Commercial	$31.65
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: LLUH Dept of Risk Management WC	$26.20
Rate for Payer: LLUH Dept of Risk Management WC	$20.79
Rate for Payer: LLUH Dept of Risk Management WC	$29.01
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: Multiplan Commercial	$39.56
Rate for Payer: Multiplan Commercial	$28.35
Rate for Payer: Multiplan Commercial	$35.73
Rate for Payer: Multiplan Commercial	$36.00

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