Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

TIZANIDINE 4 MG TABLET [14793]

Facility

IP

$0.79

Service Code	NDC 50268-760-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.43
Max. Negotiated Rate	$0.63
Rate for Payer: Cash Price	$0.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.63
Rate for Payer: Health Smart Auto/Commercial	$0.47
Rate for Payer: LLUH Dept of Risk Management WC	$0.43
Rate for Payer: Multiplan Commercial	$0.59

TIZANIDINE 4 MG TABLET [14793]

Facility

IP

$0.12

Service Code	NDC 55111-180-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

TIZANIDINE 4 MG TABLET [14793]

Facility

OP

$0.63

Service Code	NDC 0904-6418-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.35
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.38
Rate for Payer: Aetna of CA Government/Medicare	$0.38
Rate for Payer: Cash Price	$0.35
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.38
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.38
Rate for Payer: LLUH Dept of Risk Management WC	$0.35
Rate for Payer: Multiplan Commercial	$0.47

TIZANIDINE 4 MG TABLET [14793]

Facility

IP

$0.12

Service Code	NDC 29300-169-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.07
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

IP

$18.25

Service Code	NDC 0574-4031-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.04
Max. Negotiated Rate	$14.60
Rate for Payer: Cash Price	$10.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.60
Rate for Payer: Health Smart Auto/Commercial	$10.95
Rate for Payer: LLUH Dept of Risk Management WC	$10.04
Rate for Payer: Multiplan Commercial	$13.69

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

IP

$24.34

Service Code	NDC 24208-295-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$19.47
Rate for Payer: Cash Price	$13.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.47
Rate for Payer: Health Smart Auto/Commercial	$14.60
Rate for Payer: LLUH Dept of Risk Management WC	$13.39
Rate for Payer: Multiplan Commercial	$18.25

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

OP

$18.25

Service Code	NDC 0574-4031-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.04
Max. Negotiated Rate	$14.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.95
Rate for Payer: Aetna of CA Government/Medicare	$10.95
Rate for Payer: Cash Price	$10.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.60
Rate for Payer: Health Smart Auto/Commercial	$10.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.95
Rate for Payer: LLUH Dept of Risk Management WC	$10.04
Rate for Payer: Multiplan Commercial	$13.69

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

IP

$18.21

Service Code	NDC 0574-4031-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.02
Max. Negotiated Rate	$14.57
Rate for Payer: Cash Price	$10.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.57
Rate for Payer: Health Smart Auto/Commercial	$10.93
Rate for Payer: LLUH Dept of Risk Management WC	$10.02
Rate for Payer: Multiplan Commercial	$13.66

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

OP

$18.21

Service Code	NDC 0574-4031-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$10.02
Max. Negotiated Rate	$14.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.93
Rate for Payer: Aetna of CA Government/Medicare	$10.93
Rate for Payer: Cash Price	$10.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.57
Rate for Payer: Health Smart Auto/Commercial	$10.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.93
Rate for Payer: LLUH Dept of Risk Management WC	$10.02
Rate for Payer: Multiplan Commercial	$13.66

TOBRAMYCIN 0.3 %-DEXAMETHASONE 0.1 % EYE DROPS,SUSPENSION [11567]

Facility

OP

$24.34

Service Code	NDC 24208-295-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$13.39
Max. Negotiated Rate	$19.47
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$14.60
Rate for Payer: Aetna of CA Government/Medicare	$14.60
Rate for Payer: Cash Price	$13.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$19.47
Rate for Payer: Health Smart Auto/Commercial	$14.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$14.60
Rate for Payer: LLUH Dept of Risk Management WC	$13.39
Rate for Payer: Multiplan Commercial	$18.25

TOBRAMYCIN 0.3 % EYE DROPS [7995]

Facility

OP

$3.72

Service Code	NDC 62332-518-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.23
Rate for Payer: Aetna of CA Government/Medicare	$2.23
Rate for Payer: Cash Price	$2.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Commercial	$2.79

TOBRAMYCIN 0.3 % EYE DROPS [7995]

Facility

OP

$1.20

Service Code	NDC 70069-131-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.72
Rate for Payer: Aetna of CA Government/Medicare	$0.72
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

TOBRAMYCIN 0.3 % EYE DROPS [7995]

Facility

IP

$3.72

Service Code	NDC 62332-518-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Cash Price	$2.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Commercial	$2.79

TOBRAMYCIN 0.3 % EYE DROPS [7995]

Facility

IP

$1.20

Service Code	NDC 70069-131-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.66
Max. Negotiated Rate	$0.96
Rate for Payer: Cash Price	$0.66
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.96
Rate for Payer: Health Smart Auto/Commercial	$0.72
Rate for Payer: LLUH Dept of Risk Management WC	$0.66
Rate for Payer: Multiplan Commercial	$0.90

TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]

Facility

IP

$2.82

Service Code	NDC 24208-290-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.26
Rate for Payer: Cash Price	$1.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Commercial	$2.12

TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]

Facility

OP

$3.72

Service Code	NDC 61314-643-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.23
Rate for Payer: Aetna of CA Government/Medicare	$2.23
Rate for Payer: Cash Price	$2.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Commercial	$2.79

TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]

Facility

IP

$3.72

Service Code	NDC 61314-643-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.05
Max. Negotiated Rate	$2.98
Rate for Payer: Cash Price	$2.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.98
Rate for Payer: Health Smart Auto/Commercial	$2.23
Rate for Payer: LLUH Dept of Risk Management WC	$2.05
Rate for Payer: Multiplan Commercial	$2.79

TOBRAMYCIN 0.3 % EYE DROPS FOR COMPOUNDS [4087995]

Facility

OP

$2.82

Service Code	NDC 24208-290-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.69
Rate for Payer: Aetna of CA Government/Medicare	$1.69
Rate for Payer: Cash Price	$1.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Commercial	$2.12

TOBRAMYCIN 0.3 % EYE OINTMENT [19769]

Facility

OP

$96.00

Service Code	NDC 0078-0813-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$76.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.60
Rate for Payer: Aetna of CA Government/Medicare	$57.60
Rate for Payer: Cash Price	$52.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.80
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: Multiplan Commercial	$72.00

TOBRAMYCIN 0.3 % EYE OINTMENT [19769]

Facility

IP

$96.00

Service Code	NDC 0078-0813-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$52.80
Max. Negotiated Rate	$76.80
Rate for Payer: Cash Price	$52.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.80
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: Multiplan Commercial	$72.00

TOBRAMYCIN 10 MG/ML NEBULIZER SOLUTION (IV FORM) [4080724]

Facility

IP

$7.67

Service Code	NDC 63323-305-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$6.14
Rate for Payer: Cash Price	$4.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.14
Rate for Payer: Health Smart Auto/Commercial	$4.60
Rate for Payer: LLUH Dept of Risk Management WC	$4.22
Rate for Payer: Multiplan Commercial	$5.75

TOBRAMYCIN 10 MG/ML NEBULIZER SOLUTION (IV FORM) [4080724]

Facility

OP

$7.67

Service Code	NDC 63323-305-02
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.22
Max. Negotiated Rate	$6.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.60
Rate for Payer: Aetna of CA Government/Medicare	$4.60
Rate for Payer: Cash Price	$4.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.14
Rate for Payer: Health Smart Auto/Commercial	$4.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.60
Rate for Payer: LLUH Dept of Risk Management WC	$4.22
Rate for Payer: Multiplan Commercial	$5.75

TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION [11565]

Facility

OP

$92.40

Service Code	HCPCS J3260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$50.82
Max. Negotiated Rate	$73.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$55.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$57.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$54.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$51.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$60.12
Rate for Payer: Aetna of CA Government/Medicare	$55.44
Rate for Payer: Aetna of CA Government/Medicare	$60.12
Rate for Payer: Aetna of CA Government/Medicare	$54.00
Rate for Payer: Aetna of CA Government/Medicare	$51.84
Rate for Payer: Aetna of CA Government/Medicare	$57.60
Rate for Payer: Cash Price	$47.52
Rate for Payer: Cash Price	$49.50
Rate for Payer: Cash Price	$50.82
Rate for Payer: Cash Price	$55.11
Rate for Payer: Cash Price	$52.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$73.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.80
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: Health Smart Auto/Commercial	$51.84
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: Health Smart Auto/Commercial	$55.44
Rate for Payer: Health Smart Auto/Commercial	$60.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$60.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$54.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$55.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$51.84
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$50.82
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: LLUH Dept of Risk Management WC	$47.52
Rate for Payer: LLUH Dept of Risk Management WC	$55.11
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: Multiplan Commercial	$72.00
Rate for Payer: Multiplan Commercial	$75.15
Rate for Payer: Multiplan Commercial	$64.80
Rate for Payer: Multiplan Commercial	$67.50
Rate for Payer: Multiplan Commercial	$69.30

TOBRAMYCIN 1.2 GRAM SOLUTION FOR INJECTION [11565]

Facility

IP

$92.40

Service Code	HCPCS J3260
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$50.82
Max. Negotiated Rate	$73.92
Rate for Payer: Cash Price	$50.82
Rate for Payer: Cash Price	$52.80
Rate for Payer: Cash Price	$55.11
Rate for Payer: Cash Price	$47.52
Rate for Payer: Cash Price	$49.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$73.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$72.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$76.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$69.12
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$80.16
Rate for Payer: Health Smart Auto/Commercial	$60.12
Rate for Payer: Health Smart Auto/Commercial	$51.84
Rate for Payer: Health Smart Auto/Commercial	$54.00
Rate for Payer: Health Smart Auto/Commercial	$55.44
Rate for Payer: Health Smart Auto/Commercial	$57.60
Rate for Payer: LLUH Dept of Risk Management WC	$49.50
Rate for Payer: LLUH Dept of Risk Management WC	$52.80
Rate for Payer: LLUH Dept of Risk Management WC	$55.11
Rate for Payer: LLUH Dept of Risk Management WC	$50.82
Rate for Payer: LLUH Dept of Risk Management WC	$47.52
Rate for Payer: Multiplan Commercial	$64.80
Rate for Payer: Multiplan Commercial	$69.30
Rate for Payer: Multiplan Commercial	$72.00
Rate for Payer: Multiplan Commercial	$75.15
Rate for Payer: Multiplan Commercial	$67.50

TOBRAMYCIN 300 MG/5 ML IN 0.225 % SODIUM CHLORIDE FOR NEBULIZATION [22240]

Facility

IP

$2.82

Service Code	NDC 43598-605-56
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.26
Rate for Payer: Cash Price	$1.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.26
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Commercial	$2.12

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