Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

PERPHENAZINE 2 MG TABLET [6157]

Facility

IP

$0.33

Service Code	NDC 64980-290-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]

Facility

IP

$584.61

Service Code	HCPCS J9306
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$321.54
Max. Negotiated Rate	$467.69
Rate for Payer: Cash Price	$321.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$467.69
Rate for Payer: Health Smart Auto/Commercial	$350.77
Rate for Payer: LLUH Dept of Risk Management WC	$321.54
Rate for Payer: Multiplan Commercial	$438.46

PERTUZUMAB 420 MG/14 ML (30 MG/ML) INTRAVENOUS SOLUTION [196616]

Facility

OP

$584.61

Service Code	HCPCS J9306
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$321.54
Max. Negotiated Rate	$467.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$350.77
Rate for Payer: Aetna of CA Government/Medicare	$350.77
Rate for Payer: Cash Price	$321.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$467.69
Rate for Payer: Health Smart Auto/Commercial	$350.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$350.77
Rate for Payer: LLUH Dept of Risk Management WC	$321.54
Rate for Payer: Multiplan Commercial	$438.46

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

IP

$0.38

Service Code	NDC 51293-810-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

IP

$1.02

Service Code	NDC 69367-162-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

OP

$1.02

Service Code	NDC 42192-801-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

IP

$1.02

Service Code	NDC 42192-801-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

OP

$0.38

Service Code	NDC 65162-681-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

IP

$0.38

Service Code	NDC 65162-681-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

OP

$0.38

Service Code	NDC 51293-810-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.23
Rate for Payer: Aetna of CA Government/Medicare	$0.23
Rate for Payer: Cash Price	$0.21
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.30
Rate for Payer: Health Smart Auto/Commercial	$0.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.21
Rate for Payer: Multiplan Commercial	$0.29

PHENAZOPYRIDINE 100 MG TABLET [6193]

Facility

OP

$1.02

Service Code	NDC 69367-162-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.56
Max. Negotiated Rate	$0.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.61
Rate for Payer: Aetna of CA Government/Medicare	$0.61
Rate for Payer: Cash Price	$0.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.61
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.61
Rate for Payer: LLUH Dept of Risk Management WC	$0.56
Rate for Payer: Multiplan Commercial	$0.77

PHENAZOPYRIDINE 200 MG TABLET [6194]

Facility

IP

$0.58

Service Code	NDC 51293-612-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

PHENAZOPYRIDINE 200 MG TABLET [6194]

Facility

OP

$1.98

Service Code	NDC 42937-702-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.19
Rate for Payer: Aetna of CA Government/Medicare	$1.19
Rate for Payer: Cash Price	$1.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$1.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: Multiplan Commercial	$1.49

PHENAZOPYRIDINE 200 MG TABLET [6194]

Facility

OP

$0.58

Service Code	NDC 51293-612-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
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	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
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

PHENAZOPYRIDINE 200 MG TABLET [6194]

Facility

IP

$0.58

Service Code	NDC 65162-682-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

PHENAZOPYRIDINE 200 MG TABLET [6194]

Facility

IP

$1.98

Service Code	NDC 42937-702-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.58
Rate for Payer: Cash Price	$1.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.58
Rate for Payer: Health Smart Auto/Commercial	$1.19
Rate for Payer: LLUH Dept of Risk Management WC	$1.09
Rate for Payer: Multiplan Commercial	$1.49

PHENAZOPYRIDINE 200 MG TABLET [6194]

Facility

OP

$0.58

Service Code	NDC 65162-682-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
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	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
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

PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]

Facility

OP

$1.85

Service Code	NDC 72768-9011-4
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.11
Rate for Payer: Aetna of CA Government/Medicare	$1.11
Rate for Payer: Cash Price	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Commercial	$1.39

PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]

Facility

OP

$0.17

Service Code	NDC 99999-962-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
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	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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	$0.13

PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]

Facility

IP

$1.85

Service Code	NDC 72768-9011-4
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.02
Max. Negotiated Rate	$1.48
Rate for Payer: Cash Price	$1.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.11
Rate for Payer: LLUH Dept of Risk Management WC	$1.02
Rate for Payer: Multiplan Commercial	$1.39

PHENOBARB-HYOSCY-ATROPINE-SCOP 16.2 MG-0.1037 MG-0.0194 MG/5 ML ELIXIR [6225]

Facility

IP

$0.17

Service Code	NDC 99999-962-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.14
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	$0.13

PHENOBARBITAL 16.2 MG TABLET [6215]

Facility

OP

$0.51

Service Code	NDC 51293-625-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

PHENOBARBITAL 16.2 MG TABLET [6215]

Facility

IP

$0.11

Service Code	NDC 16571-671-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

PHENOBARBITAL 16.2 MG TABLET [6215]

Facility

IP

$0.51

Service Code	NDC 51293-625-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

PHENOBARBITAL 16.2 MG TABLET [6215]

Facility

OP

$0.11

Service Code	NDC 16571-671-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

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