Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

PROGESTERONE 50 MG/ML INTRAMUSCULAR OIL [6597]

Facility

IP

$2.40

Service Code	HCPCS J2675
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80

PROGESTERONE MICRONIZED 100 MG CAPSULE [23122]

Facility

OP

$0.24

Service Code	NDC 59651-152-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

PROGESTERONE MICRONIZED 100 MG CAPSULE [23122]

Facility

OP

$0.48

Service Code	NDC 65162-807-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.36

PROGESTERONE MICRONIZED 100 MG CAPSULE [23122]

Facility

IP

$0.24

Service Code	NDC 59651-152-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.19
Rate for Payer: Cash Price	$0.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.18

PROGESTERONE MICRONIZED 100 MG CAPSULE [23122]

Facility

IP

$0.48

Service Code	NDC 65162-807-10
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

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

IP

$11.70

Service Code	NDC 51672-5296-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

IP

$11.70

Service Code	NDC 0713-0536-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

OP

$11.70

Service Code	NDC 0713-0536-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

IP

$11.70

Service Code	NDC 0713-0536-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

OP

$11.70

Service Code	NDC 0713-0536-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

IP

$11.70

Service Code	NDC 51672-5296-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

OP

$11.70

Service Code	NDC 51672-5296-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 12.5 MG RECTAL SUPPOSITORY [11143]

Facility

OP

$11.70

Service Code	NDC 51672-5296-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

OP

$0.14

Service Code	NDC 68001-161-00
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

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

OP

$0.07

Service Code	NDC 10702-002-01
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

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

IP

$0.14

Service Code	NDC 68001-161-00
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

PROMETHAZINE 12.5 MG TABLET [6621]

Facility

IP

$0.07

Service Code	NDC 10702-002-01
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

PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]

Facility

IP

$2.22

Service Code	HCPCS J2550
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.22
Max. Negotiated Rate	$1.78
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.78
Rate for Payer: Health Smart Auto/Commercial	$1.33
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.22
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.67
Rate for Payer: Multiplan Commercial	$1.80

PROMETHAZINE 25 MG/ML INJECTION SOLUTION [6618]

Facility

OP

$2.40

Service Code	HCPCS J2550
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.32
Max. Negotiated Rate	$1.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.33
Rate for Payer: Aetna of CA Government/Medicare	$1.33
Rate for Payer: Aetna of CA Government/Medicare	$1.44
Rate for Payer: Cash Price	$1.22
Rate for Payer: Cash Price	$1.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.78
Rate for Payer: Health Smart Auto/Commercial	$1.44
Rate for Payer: Health Smart Auto/Commercial	$1.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.44
Rate for Payer: LLUH Dept of Risk Management WC	$1.22
Rate for Payer: LLUH Dept of Risk Management WC	$1.32
Rate for Payer: Multiplan Commercial	$1.80
Rate for Payer: Multiplan Commercial	$1.67

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

OP

$11.70

Service Code	NDC 0713-0526-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

IP

$11.70

Service Code	NDC 51672-5297-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

IP

$11.70

Service Code	NDC 45802-759-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

IP

$11.70

Service Code	NDC 0713-0526-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

OP

$11.70

Service Code	NDC 45802-759-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

PROMETHAZINE 25 MG RECTAL SUPPOSITORY [11144]

Facility

OP

$11.70

Service Code	NDC 51672-5297-1
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.43
Max. Negotiated Rate	$9.36
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$7.02
Rate for Payer: Aetna of CA Government/Medicare	$7.02
Rate for Payer: Cash Price	$6.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.36
Rate for Payer: Health Smart Auto/Commercial	$7.02
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$7.02
Rate for Payer: LLUH Dept of Risk Management WC	$6.43
Rate for Payer: Multiplan Commercial	$8.78

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