Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]

Facility

OP

$42.60

Service Code	NDC 53436-084-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$23.43
Max. Negotiated Rate	$34.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.56
Rate for Payer: Aetna of CA Government/Medicare	$25.56
Rate for Payer: Cash Price	$23.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$34.08
Rate for Payer: Health Smart Auto/Commercial	$25.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.56
Rate for Payer: LLUH Dept of Risk Management WC	$23.43
Rate for Payer: Multiplan Commercial	$31.95

PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]

Facility

IP

$42.60

Service Code	NDC 53436-084-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$23.43
Max. Negotiated Rate	$34.08
Rate for Payer: Cash Price	$23.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$34.08
Rate for Payer: Health Smart Auto/Commercial	$25.56
Rate for Payer: LLUH Dept of Risk Management WC	$23.43
Rate for Payer: Multiplan Commercial	$31.95

PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]

Facility

IP

$42.60

Service Code	NDC 53436-084-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$23.43
Max. Negotiated Rate	$34.08
Rate for Payer: Cash Price	$23.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$34.08
Rate for Payer: Health Smart Auto/Commercial	$25.56
Rate for Payer: LLUH Dept of Risk Management WC	$23.43
Rate for Payer: Multiplan Commercial	$31.95

PATIROMER CALCIUM SORBITEX 8.4 GRAM ORAL POWDER PACKET [211785]

Facility

OP

$42.60

Service Code	NDC 53436-084-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$23.43
Max. Negotiated Rate	$34.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$25.56
Rate for Payer: Aetna of CA Government/Medicare	$25.56
Rate for Payer: Cash Price	$23.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$34.08
Rate for Payer: Health Smart Auto/Commercial	$25.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$25.56
Rate for Payer: LLUH Dept of Risk Management WC	$23.43
Rate for Payer: Multiplan Commercial	$31.95

PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]

Facility

OP

$0.14

Service Code	NDC 1650008619
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
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	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
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	$0.08
Rate for Payer: Multiplan Commercial	$0.11

PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]

Facility

IP

$0.07

Service Code	NDC 1650007814
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

PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]

Facility

IP

$0.09

Service Code	NDC 1650007818
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]

Facility

OP

$0.03

Service Code	NDC 8068104900
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

PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]

Facility

IP

$0.03

Service Code	NDC 8068104900
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

PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]

Facility

OP

$0.07

Service Code	NDC 1650007814
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

PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]

Facility

IP

$0.14

Service Code	NDC 1650008619
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.11
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

PEDIATRIC MULTIVITAMIN CHEWABLE TABLET (WRAP) [408206149]

Facility

OP

$0.09

Service Code	NDC 1650007818
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
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	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
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	$0.05
Rate for Payer: Multiplan Commercial	$0.07

PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS [228315]

Facility

OP

$0.20

Service Code	NDC 0087040203
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

PEDIATRIC MULTIVITAMIN NO.192 250 MCG-50 MG-10 MCG/ML ORAL DROPS [228315]

Facility

IP

$0.20

Service Code	NDC 0087040203
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

PEDIATRIC MULTIVITAMIN NO.61-VIT D3 3,000 UNIT-VIT K 800 MCG CAPSULE [206186]

Facility

IP

$0.66

Service Code	NDC 5820400406
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.53
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.50

PEDIATRIC MULTIVITAMIN NO.61-VIT D3 3,000 UNIT-VIT K 800 MCG CAPSULE [206186]

Facility

OP

$0.66

Service Code	NDC 5820400406
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.50

PEDI NUTRITION WITH IRON LACTOSE-FREE 0.03 GRAM-1 KCAL/ML ORAL LIQUID [120893]

Facility

IP

$0.01

Service Code	NDC 4390033511
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

PEDI NUTRITION WITH IRON LACTOSE-FREE 0.03 GRAM-1 KCAL/ML ORAL LIQUID [120893]

Facility

OP

$0.01

Service Code	NDC 4390033511
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]

Facility

IP

$0.02

Service Code	NDC 64380-766-21
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

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]

Facility

OP

$0.01

Service Code	NDC 52268-100-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]

Facility

IP

$0.01

Service Code	NDC 43386-090-19
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]

Facility

OP

$0.01

Service Code	NDC 43386-090-19
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
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: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]

Facility

OP

$0.02

Service Code	NDC 64380-766-21
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

PEG 3350-ELECTROLYTES 236 GRAM-22.74 GRAM-6.74 GRAM-5.86 GRAM SOLUTION [10839]

Facility

IP

$0.01

Service Code	NDC 52268-100-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.01
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	$0.01

PEG 400-HYPROMELLOSE-GLYCERIN 1 %-0.2 %-0.2 % EYE DROPS [41412]

Facility

OP

$0.14

Service Code	NDC 57896-181-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.11
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	$0.11
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	$0.08
Rate for Payer: Multiplan Commercial	$0.11

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