Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

NICOTINE 7 MG/24 HR DAILY TRANSDERMAL PATCH [27860]

Facility

IP

$2.06

Service Code	NDC 0536-5894-88
Hospital Charge Code	1743654
Hospital Revenue Code	259
Min. Negotiated Rate	$1.13
Max. Negotiated Rate	$1.65
Rate for Payer: Cash Price	$0.93
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.54

NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]

Facility

OP

$0.28

Service Code	NDC 46122-734-08
Hospital Charge Code	1712388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]

Facility

IP

$0.43

Service Code	NDC 46122-734-62
Hospital Charge Code	1712388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]

Facility

IP

$0.47

Service Code	NDC 45802-344-03
Hospital Charge Code	1712388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]

Facility

IP

$0.47

Service Code	NDC 45802-344-05
Hospital Charge Code	1712388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]

Facility

OP

$0.47

Service Code	NDC 45802-344-05
Hospital Charge Code	1712388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
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	$0.21
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	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]

Facility

IP

$0.28

Service Code	NDC 46122-734-08
Hospital Charge Code	1712388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]

Facility

OP

$0.43

Service Code	NDC 46122-734-62
Hospital Charge Code	1712388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

NICOTINE (POLACRILEX) 2 MG BUCCAL LOZENGE [34769]

Facility

OP

$0.47

Service Code	NDC 45802-344-03
Hospital Charge Code	1712388
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
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	$0.21
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	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

NICOTINE (POLACRILEX) 2 MG GUM [10717]

Facility

IP

$0.38

Service Code	NDC 0536-1362-06
Hospital Charge Code	1710032
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.30
Rate for Payer: Cash Price	$0.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.29

NICOTINE (POLACRILEX) 2 MG GUM [10717]

Facility

OP

$0.38

Service Code	NDC 0536-1362-06
Hospital Charge Code	1710032
Hospital Revenue Code	259
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$0.29
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	$0.17
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 Beech St/Commercial/PHCS	$0.29

NICOTINE (POLACRILEX) 4 MG BUCCAL LOZENGE [34770]

Facility

IP

$0.42

Service Code	NDC 59779-873-03
Hospital Charge Code	1712389
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

NICOTINE (POLACRILEX) 4 MG BUCCAL LOZENGE [34770]

Facility

IP

$0.50

Service Code	NDC 0113-0873-05
Hospital Charge Code	1712389
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

NICOTINE (POLACRILEX) 4 MG BUCCAL LOZENGE [34770]

Facility

OP

$0.42

Service Code	NDC 59779-873-03
Hospital Charge Code	1712389
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

NICOTINE (POLACRILEX) 4 MG BUCCAL LOZENGE [34770]

Facility

OP

$0.50

Service Code	NDC 0113-0873-05
Hospital Charge Code	1712389
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

NICOTINE (POLACRILEX) 4 MG BUCCAL MINI LOZENGE [216782]

Facility

OP

$0.45

Service Code	NDC 0113-0957-02
Hospital Charge Code	ERX216782
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.34

NICOTINE (POLACRILEX) 4 MG BUCCAL MINI LOZENGE [216782]

Facility

IP

$0.45

Service Code	NDC 0113-0957-02
Hospital Charge Code	ERX216782
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.34

NICOTINE (POLACRILEX) 4 MG GUM [10718]

Facility

IP

$0.47

Service Code	NDC 0536-1372-06
Hospital Charge Code	ERX10718
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

NICOTINE (POLACRILEX) 4 MG GUM [10718]

Facility

OP

$0.47

Service Code	NDC 0536-1372-06
Hospital Charge Code	ERX10718
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
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	$0.21
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	$0.26
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.35

NIFEDIPINE 10 MG CAPSULE [5558]

Facility

IP

$0.46

Service Code	NDC 23155-194-01
Hospital Charge Code	1710588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.37
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.35

NIFEDIPINE 10 MG CAPSULE [5558]

Facility

IP

$1.03

Service Code	NDC 69315-211-01
Hospital Charge Code	1710588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

NIFEDIPINE 10 MG CAPSULE [5558]

Facility

OP

$1.29

Service Code	NDC 42192-615-01
Hospital Charge Code	1710588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.71
Max. Negotiated Rate	$0.97
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.77
Rate for Payer: Aetna of CA Government/Medicare	$0.77
Rate for Payer: Cash Price	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.77
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.77
Rate for Payer: LLUH Dept of Risk Management WC	$0.71
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.97

NIFEDIPINE 10 MG CAPSULE [5558]

Facility

IP

$0.86

Service Code	NDC 43386-440-24
Hospital Charge Code	1710588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.69
Rate for Payer: Cash Price	$0.39
Rate for Payer: Cigna of CA HMO/PPO	$0.69
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

NIFEDIPINE 10 MG CAPSULE [5558]

Facility

OP

$0.86

Service Code	NDC 43386-440-24
Hospital Charge Code	1710588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.47
Max. Negotiated Rate	$0.65
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.52
Rate for Payer: Aetna of CA Government/Medicare	$0.52
Rate for Payer: Cash Price	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.52
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.52
Rate for Payer: LLUH Dept of Risk Management WC	$0.47
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.65

NIFEDIPINE 10 MG CAPSULE [5558]

Facility

OP

$0.46

Service Code	NDC 23155-194-01
Hospital Charge Code	1710588
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.35
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	$0.21
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 Beech St/Commercial/PHCS	$0.35

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