Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

ROPINIROLE 1 MG TABLET [21689]

Facility

IP

$0.70

Service Code	NDC 60687-588-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

ROPINIROLE 1 MG TABLET [21689]

Facility

IP

$0.70

Service Code	NDC 60687-588-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

ROPINIROLE 1 MG TABLET [21689]

Facility

OP

$0.70

Service Code	NDC 60687-588-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.42
Rate for Payer: Aetna of CA Government/Medicare	$0.42
Rate for Payer: Cash Price	$0.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.56
Rate for Payer: Health Smart Auto/Commercial	$0.42
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.42
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

ROPINIROLE 2 MG TABLET [21690]

Facility

IP

$0.55

Service Code	NDC 50268-744-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

ROPINIROLE 2 MG TABLET [21690]

Facility

IP

$0.55

Service Code	NDC 50268-744-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

ROPINIROLE 2 MG TABLET [21690]

Facility

IP

$0.14

Service Code	NDC 62332-033-31
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

ROPINIROLE 2 MG TABLET [21690]

Facility

OP

$0.55

Service Code	NDC 50268-744-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

ROPINIROLE 2 MG TABLET [21690]

Facility

OP

$0.55

Service Code	NDC 50268-744-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.33
Rate for Payer: Aetna of CA Government/Medicare	$0.33
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

ROPINIROLE 2 MG TABLET [21690]

Facility

OP

$0.14

Service Code	NDC 62332-033-31
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

ROPIVACAINE (NAROPIN) 0.2 % TELEFLEX PUMP INFUSION [4081416]

Facility

IP

$0.46

Service Code	HCPCS J2795
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

ROPIVACAINE (NAROPIN) 0.2 % TELEFLEX PUMP INFUSION [4081416]

Facility

OP

$0.46

Service Code	HCPCS J2795
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.37
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Commercial	$0.35

ROPIVACAINE (NAROPIN) 0.5 % ON-Q PUMP INFUSION [4081084]

Facility

OP

$0.73

Service Code	HCPCS J2795
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

ROPIVACAINE (NAROPIN) 0.5 % ON-Q PUMP INFUSION [4081084]

Facility

IP

$0.73

Service Code	HCPCS J2795
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.55

ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [18194]

Facility

OP

$1.36

Service Code	HCPCS J2795
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.82
Rate for Payer: Aetna of CA Government/Medicare	$0.82
Rate for Payer: Cash Price	$0.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.09
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Commercial	$1.02

ROPIVACAINE (PF) 10 MG/ML (1 %) INJECTION SOLUTION [18194]

Facility

IP

$1.36

Service Code	HCPCS J2795
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.75
Max. Negotiated Rate	$1.09
Rate for Payer: Cash Price	$0.75
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.09
Rate for Payer: Health Smart Auto/Commercial	$0.82
Rate for Payer: LLUH Dept of Risk Management WC	$0.75
Rate for Payer: Multiplan Commercial	$1.02

ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]

Facility

IP

$0.49

Service Code	HCPCS J2795
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37
Rate for Payer: Multiplan Commercial	$0.50

ROPIVACAINE (PF) 2 MG/ML (0.2 %) INJECTION SOLUTION [18192]

Facility

OP

$0.66

Service Code	HCPCS J2795
Hospital Charge Code	901700025
Hospital Revenue Code	636
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 EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cash Price	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
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: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Commercial	$0.37
Rate for Payer: Multiplan Commercial	$0.50

ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [152917]

Facility

IP

$0.32

Service Code	HCPCS J2795
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.55
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: Multiplan Commercial	$0.55
Rate for Payer: Multiplan Commercial	$0.68
Rate for Payer: Multiplan Commercial	$0.32
Rate for Payer: Multiplan Commercial	$0.26
Rate for Payer: Multiplan Commercial	$0.24
Rate for Payer: Multiplan Commercial	$0.74
Rate for Payer: Multiplan Commercial	$0.65

ROPIVACAINE (PF) 5 MG/ML (0.5 %) INJECTION SOLUTION [152917]

Facility

OP

$0.87

Service Code	HCPCS J2795
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.48
Max. Negotiated Rate	$0.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.19
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.59
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.44
Rate for Payer: Aetna of CA Government/Medicare	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.48
Rate for Payer: Cash Price	$0.55
Rate for Payer: Cash Price	$0.40
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cash Price	$0.50
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.79
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.27
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.70
Rate for Payer: Health Smart Auto/Commercial	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: LLUH Dept of Risk Management WC	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Commercial	$0.74
Rate for Payer: Multiplan Commercial	$0.55
Rate for Payer: Multiplan Commercial	$0.68
Rate for Payer: Multiplan Commercial	$0.24
Rate for Payer: Multiplan Commercial	$0.32
Rate for Payer: Multiplan Commercial	$0.65
Rate for Payer: Multiplan Commercial	$0.26

ROSUVASTATIN 40 MG TABLET [35136]

Facility

IP

$17.90

Service Code	NDC 71205-078-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$14.32
Rate for Payer: Cash Price	$9.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.85
Rate for Payer: Multiplan Commercial	$13.43

ROSUVASTATIN 40 MG TABLET [35136]

Facility

OP

$0.23

Service Code	NDC 68462-264-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
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	$0.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.18
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	$0.17

ROSUVASTATIN 40 MG TABLET [35136]

Facility

IP

$0.23

Service Code	NDC 68462-264-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
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	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Commercial	$0.17

ROSUVASTATIN 40 MG TABLET [35136]

Facility

OP

$17.90

Service Code	NDC 71205-078-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$9.85
Max. Negotiated Rate	$14.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.74
Rate for Payer: Aetna of CA Government/Medicare	$10.74
Rate for Payer: Cash Price	$9.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.32
Rate for Payer: Health Smart Auto/Commercial	$10.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.74
Rate for Payer: LLUH Dept of Risk Management WC	$9.85
Rate for Payer: Multiplan Commercial	$13.43

ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION [70476]

Facility

OP

$58.84

Service Code	HCPCS 90680
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.36
Max. Negotiated Rate	$47.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$35.30
Rate for Payer: Aetna of CA Government/Medicare	$35.30
Rate for Payer: Cash Price	$32.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.07
Rate for Payer: Health Smart Auto/Commercial	$35.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$35.30
Rate for Payer: LLUH Dept of Risk Management WC	$32.36
Rate for Payer: Multiplan Commercial	$44.13

ROTAVIRUS VACCINE LIVE, PENTAVALENT 2 ML ORAL SOLUTION [70476]

Facility

IP

$58.84

Service Code	HCPCS 90680
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$32.36
Max. Negotiated Rate	$47.07
Rate for Payer: Cash Price	$32.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$47.07
Rate for Payer: Health Smart Auto/Commercial	$35.30
Rate for Payer: LLUH Dept of Risk Management WC	$32.36
Rate for Payer: Multiplan Commercial	$44.13

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