Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

OP

$3.16

Service Code	NDC 0406-0523-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.90
Rate for Payer: Aetna of CA Government/Medicare	$1.90
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

OP

$0.59

Service Code	NDC 0406-0523-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.47
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

IP

$2.06

Service Code	NDC 68084-710-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.65
Rate for Payer: Cash Price	$1.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.65
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.13
Rate for Payer: Multiplan Commercial	$1.54

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

IP

$3.16

Service Code	NDC 0406-0523-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

OP

$3.16

Service Code	NDC 0406-0523-23
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.90
Rate for Payer: Aetna of CA Government/Medicare	$1.90
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

IP

$2.16

Service Code	NDC 68308-480-47
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.19
Max. Negotiated Rate	$1.73
Rate for Payer: Cash Price	$1.19
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.73
Rate for Payer: Health Smart Auto/Commercial	$1.30
Rate for Payer: LLUH Dept of Risk Management WC	$1.19
Rate for Payer: Multiplan Commercial	$1.62

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

IP

$2.06

Service Code	NDC 68084-710-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.65
Rate for Payer: Cash Price	$1.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.65
Rate for Payer: Health Smart Auto/Commercial	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.13
Rate for Payer: Multiplan Commercial	$1.54

OXYCODONE-ACETAMINOPHEN 10 MG-325 MG TABLET [31864]

Facility

IP

$3.16

Service Code	NDC 0406-0523-62
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.74
Max. Negotiated Rate	$2.53
Rate for Payer: Cash Price	$1.74
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.53
Rate for Payer: Health Smart Auto/Commercial	$1.90
Rate for Payer: LLUH Dept of Risk Management WC	$1.74
Rate for Payer: Multiplan Commercial	$2.37

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

IP

$0.20

Service Code	NDC 42858-102-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

OP

$0.34

Service Code	NDC 0904-7093-61
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

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

OP

$0.22

Service Code	NDC 53746-203-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

IP

$0.22

Service Code	NDC 53746-203-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Commercial	$0.17

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

IP

$0.34

Service Code	NDC 0904-7093-61
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

OXYCODONE-ACETAMINOPHEN 5 MG-325 MG TABLET [5940]

Facility

OP

$0.20

Service Code	NDC 42858-102-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$0.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.12
Rate for Payer: Aetna of CA Government/Medicare	$0.12
Rate for Payer: Cash Price	$0.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.16
Rate for Payer: Health Smart Auto/Commercial	$0.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.12
Rate for Payer: LLUH Dept of Risk Management WC	$0.11
Rate for Payer: Multiplan Commercial	$0.15

OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208667]

Facility

IP

$6.98

Service Code	NDC 59011-410-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.84
Max. Negotiated Rate	$5.58
Rate for Payer: Cash Price	$3.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.58
Rate for Payer: Health Smart Auto/Commercial	$4.19
Rate for Payer: LLUH Dept of Risk Management WC	$3.84
Rate for Payer: Multiplan Commercial	$5.24

OXYCODONE ER 10 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208667]

Facility

OP

$6.98

Service Code	NDC 59011-410-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.84
Max. Negotiated Rate	$5.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.19
Rate for Payer: Aetna of CA Government/Medicare	$4.19
Rate for Payer: Cash Price	$3.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.58
Rate for Payer: Health Smart Auto/Commercial	$4.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.19
Rate for Payer: LLUH Dept of Risk Management WC	$3.84
Rate for Payer: Multiplan Commercial	$5.24

OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208669]

Facility

IP

$13.00

Service Code	NDC 59011-420-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Cash Price	$7.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

OXYCODONE ER 20 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208669]

Facility

OP

$13.00

Service Code	NDC 59011-420-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$7.15
Max. Negotiated Rate	$10.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.80
Rate for Payer: Aetna of CA Government/Medicare	$7.80
Rate for Payer: Cash Price	$7.15
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$10.40
Rate for Payer: Health Smart Auto/Commercial	$7.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.80
Rate for Payer: LLUH Dept of Risk Management WC	$7.15
Rate for Payer: Multiplan Commercial	$9.75

OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208671]

Facility

IP

$22.26

Service Code	NDC 59011-440-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$17.81
Rate for Payer: Cash Price	$12.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.81
Rate for Payer: Health Smart Auto/Commercial	$13.36
Rate for Payer: LLUH Dept of Risk Management WC	$12.24
Rate for Payer: Multiplan Commercial	$16.70

OXYCODONE ER 40 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208671]

Facility

OP

$22.26

Service Code	NDC 59011-440-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$12.24
Max. Negotiated Rate	$17.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.36
Rate for Payer: Aetna of CA Government/Medicare	$13.36
Rate for Payer: Cash Price	$12.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.81
Rate for Payer: Health Smart Auto/Commercial	$13.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.36
Rate for Payer: LLUH Dept of Risk Management WC	$12.24
Rate for Payer: Multiplan Commercial	$16.70

OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208673]

Facility

IP

$38.86

Service Code	NDC 59011-480-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$21.37
Max. Negotiated Rate	$31.09
Rate for Payer: Cash Price	$21.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.09
Rate for Payer: Health Smart Auto/Commercial	$23.32
Rate for Payer: LLUH Dept of Risk Management WC	$21.37
Rate for Payer: Multiplan Commercial	$29.14

OXYCODONE ER 80 MG TABLET,CRUSH RESISTANT,EXTENDED RELEASE 12 HR [208673]

Facility

OP

$38.86

Service Code	NDC 59011-480-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$21.37
Max. Negotiated Rate	$31.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$23.32
Rate for Payer: Aetna of CA Government/Medicare	$23.32
Rate for Payer: Cash Price	$21.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$31.09
Rate for Payer: Health Smart Auto/Commercial	$23.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$23.32
Rate for Payer: LLUH Dept of Risk Management WC	$21.37
Rate for Payer: Multiplan Commercial	$29.14

OXYMETAZOLINE 0.05 % NASAL MIST [114934]

Facility

IP

$0.45

Service Code	NDC 11523-1159-1
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

OXYMETAZOLINE 0.05 % NASAL MIST [114934]

Facility

IP

$0.48

Service Code	NDC 2390002325
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

OXYMETAZOLINE 0.05 % NASAL MIST [114934]

Facility

IP

$0.53

Service Code	NDC 0363-0308-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

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