Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

ACETAZOLAMIDE 500 MG SOLUTION FOR INJECTION [114]

Facility

OP

$37.80

Service Code	HCPCS J1120
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$20.79
Max. Negotiated Rate	$30.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$22.68
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$31.65
Rate for Payer: Aetna of CA Government/Medicare	$31.65
Rate for Payer: Aetna of CA Government/Medicare	$28.58
Rate for Payer: Aetna of CA Government/Medicare	$22.68
Rate for Payer: Aetna of CA Government/Medicare	$28.80
Rate for Payer: Cash Price	$20.79
Rate for Payer: Cash Price	$29.01
Rate for Payer: Cash Price	$26.20
Rate for Payer: Cash Price	$26.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$30.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$38.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$42.20
Rate for Payer: Health Smart Auto/Commercial	$31.65
Rate for Payer: Health Smart Auto/Commercial	$28.80
Rate for Payer: Health Smart Auto/Commercial	$28.58
Rate for Payer: Health Smart Auto/Commercial	$22.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$31.65
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$22.68
Rate for Payer: LLUH Dept of Risk Management WC	$29.01
Rate for Payer: LLUH Dept of Risk Management WC	$20.79
Rate for Payer: LLUH Dept of Risk Management WC	$26.40
Rate for Payer: LLUH Dept of Risk Management WC	$26.20
Rate for Payer: Multiplan Commercial	$35.73
Rate for Payer: Multiplan Commercial	$36.00
Rate for Payer: Multiplan Commercial	$39.56
Rate for Payer: Multiplan Commercial	$28.35

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

IP

$5.31

Service Code	NDC 50268-042-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$2.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

OP

$0.90

Service Code	NDC 42571-243-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

IP

$0.60

Service Code	NDC 50742-233-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

IP

$5.31

Service Code	NDC 50268-042-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Cash Price	$2.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

OP

$5.31

Service Code	NDC 50268-042-12
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.19
Rate for Payer: Aetna of CA Government/Medicare	$3.19
Rate for Payer: Cash Price	$2.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

OP

$5.31

Service Code	NDC 50268-042-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.19
Rate for Payer: Aetna of CA Government/Medicare	$3.19
Rate for Payer: Cash Price	$2.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.25
Rate for Payer: Health Smart Auto/Commercial	$3.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.19
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

IP

$0.90

Service Code	NDC 42571-243-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

ACETAZOLAMIDE ER 500 MG CAPSULE,EXTENDED RELEASE [8962]

Facility

OP

$0.60

Service Code	NDC 50742-233-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]

Facility

IP

$2.77

Service Code	NDC 9994-0802-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.22
Rate for Payer: Cash Price	$1.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.22
Rate for Payer: Health Smart Auto/Commercial	$1.66
Rate for Payer: LLUH Dept of Risk Management WC	$1.52
Rate for Payer: Multiplan Commercial	$2.08

ACETAZOLAMIDE ORAL SUSPENSION COMPOUND 25 MG/ML [4080233]

Facility

OP

$2.77

Service Code	NDC 9994-0802-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.52
Max. Negotiated Rate	$2.22
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.66
Rate for Payer: Aetna of CA Government/Medicare	$1.66
Rate for Payer: Cash Price	$1.52
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.22
Rate for Payer: Health Smart Auto/Commercial	$1.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.66
Rate for Payer: LLUH Dept of Risk Management WC	$1.52
Rate for Payer: Multiplan Commercial	$2.08

ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]

Facility

OP

$0.01

Service Code	NDC 0264-2304-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
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: Cash Price	$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

ACETIC ACID 0.25 % IRRIGATION SOLUTION [8963]

Facility

IP

$0.01

Service Code	NDC 0264-2304-00
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cash Price	$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

ACETIC ACID 2 % EAR SOLUTION [17801]

Facility

OP

$2.24

Service Code	NDC 52817-816-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Cash Price	$1.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.68

ACETIC ACID 2 % EAR SOLUTION [17801]

Facility

IP

$2.24

Service Code	NDC 52817-816-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Cash Price	$1.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.68

ACETIC ACID (BULK) 3 % LIQUID [15091]

Facility

OP

$0.04

Service Code	NDC 5155200516
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
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	$0.03
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	$0.03

ACETIC ACID (BULK) 3 % LIQUID [15091]

Facility

IP

$0.04

Service Code	NDC 5155200516
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.03
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	$0.03

ACETYLCHOLINE CHLORIDE (10 MG/ML) BASE FOR IC MIXTURE [4088832559]

Facility

OP

$156.68

Service Code	NDC 24208-539-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$86.17
Max. Negotiated Rate	$125.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$94.01
Rate for Payer: Aetna of CA Government/Medicare	$94.01
Rate for Payer: Cash Price	$86.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.34
Rate for Payer: Health Smart Auto/Commercial	$94.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$94.01
Rate for Payer: LLUH Dept of Risk Management WC	$86.17
Rate for Payer: Multiplan Commercial	$117.51

ACETYLCHOLINE CHLORIDE (10 MG/ML) BASE FOR IC MIXTURE [4088832559]

Facility

IP

$156.68

Service Code	NDC 24208-539-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$86.17
Max. Negotiated Rate	$125.34
Rate for Payer: Cash Price	$86.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.34
Rate for Payer: Health Smart Auto/Commercial	$94.01
Rate for Payer: LLUH Dept of Risk Management WC	$86.17
Rate for Payer: Multiplan Commercial	$117.51

ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [32559]

Facility

OP

$156.68

Service Code	NDC 24208-539-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$86.17
Max. Negotiated Rate	$125.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$94.01
Rate for Payer: Aetna of CA Government/Medicare	$94.01
Rate for Payer: Cash Price	$86.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.34
Rate for Payer: Health Smart Auto/Commercial	$94.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$94.01
Rate for Payer: LLUH Dept of Risk Management WC	$86.17
Rate for Payer: Multiplan Commercial	$117.51

ACETYLCHOLINE CHLORIDE 1 % (10 MG/ML) INTRAOCULAR KIT [32559]

Facility

IP

$156.68

Service Code	NDC 24208-539-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$86.17
Max. Negotiated Rate	$125.34
Rate for Payer: Cash Price	$86.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$125.34
Rate for Payer: Health Smart Auto/Commercial	$94.01
Rate for Payer: LLUH Dept of Risk Management WC	$86.17
Rate for Payer: Multiplan Commercial	$117.51

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

OP

$4.37

Service Code	NDC 63323-695-04
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.40
Max. Negotiated Rate	$3.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.62
Rate for Payer: Aetna of CA Government/Medicare	$2.62
Rate for Payer: Cash Price	$2.40
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.50
Rate for Payer: Health Smart Auto/Commercial	$2.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.62
Rate for Payer: LLUH Dept of Risk Management WC	$2.40
Rate for Payer: Multiplan Commercial	$3.28

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

IP

$3.83

Service Code	NDC 63323-695-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.11
Max. Negotiated Rate	$3.06
Rate for Payer: Cash Price	$2.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.06
Rate for Payer: Health Smart Auto/Commercial	$2.30
Rate for Payer: LLUH Dept of Risk Management WC	$2.11
Rate for Payer: Multiplan Commercial	$2.87

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

IP

$0.80

Service Code	NDC 0409-3307-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

ACETYLCYSTEINE 100 MG/ML (10 %) SOLUTION [122]

Facility

OP

$0.80

Service Code	NDC 0409-3307-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Commercial	$0.60

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