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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

TRETINOIN MICROSPHERES 0.1 % TOPICAL GEL [19468]

Facility

OP

$21.00

Service Code	NDC 0187-5140-45
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$11.55
Max. Negotiated Rate	$16.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.60
Rate for Payer: Aetna of CA Government/Medicare	$12.60
Rate for Payer: Cash Price	$11.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$16.80
Rate for Payer: Health Smart Auto/Commercial	$12.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.60
Rate for Payer: LLUH Dept of Risk Management WC	$11.55
Rate for Payer: Multiplan Commercial	$15.75

TRETINOIN (VESANOID) ORAL SYRINGE [40820212]

Facility

IP

$33.03

Service Code	NDC 9940-8202-12
Min. Negotiated Rate	$18.17
Max. Negotiated Rate	$26.42
Rate for Payer: Cash Price	$18.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.42
Rate for Payer: Health Smart Auto/Commercial	$19.82
Rate for Payer: LLUH Dept of Risk Management WC	$18.17
Rate for Payer: Multiplan Commercial	$24.77

TRETINOIN (VESANOID) ORAL SYRINGE [40820212]

Facility

OP

$33.03

Service Code	NDC 9940-8202-12
Min. Negotiated Rate	$18.17
Max. Negotiated Rate	$26.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.82
Rate for Payer: Aetna of CA Government/Medicare	$19.82
Rate for Payer: Cash Price	$18.17
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.42
Rate for Payer: Health Smart Auto/Commercial	$19.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.82
Rate for Payer: LLUH Dept of Risk Management WC	$18.17
Rate for Payer: Multiplan Commercial	$24.77

TRIAMCINOLONE 9 MG-MOXIFLOX 0.6 MG/0.6 ML IN WATER(PF)INTRAOCULAR SUSP [221760]

Facility

OP

$30.60

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$24.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.36
Rate for Payer: Aetna of CA Government/Medicare	$18.36
Rate for Payer: Cash Price	$16.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.48
Rate for Payer: Health Smart Auto/Commercial	$18.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.36
Rate for Payer: LLUH Dept of Risk Management WC	$16.83
Rate for Payer: Multiplan Commercial	$22.95

TRIAMCINOLONE 9 MG-MOXIFLOX 0.6 MG/0.6 ML IN WATER(PF)INTRAOCULAR SUSP [221760]

Facility

IP

$30.60

Service Code	HCPCS J3490
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$16.83
Max. Negotiated Rate	$24.48
Rate for Payer: Cash Price	$16.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$24.48
Rate for Payer: Health Smart Auto/Commercial	$18.36
Rate for Payer: LLUH Dept of Risk Management WC	$16.83
Rate for Payer: Multiplan Commercial	$22.95

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]

Facility

OP

$0.09

Service Code	NDC 33342-327-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.05
Rate for Payer: Aetna of CA Government/Medicare	$0.05
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]

Facility

IP

$0.14

Service Code	NDC 0168-0003-80
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

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]

Facility

IP

$0.12

Service Code	NDC 45802-063-36
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

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]

Facility

IP

$0.11

Service Code	NDC 0713-0226-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]

Facility

OP

$0.12

Service Code	NDC 45802-063-36
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]

Facility

OP

$0.11

Service Code	NDC 0713-0226-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]

Facility

IP

$0.09

Service Code	NDC 33342-327-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.05
Max. Negotiated Rate	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.07
Rate for Payer: Health Smart Auto/Commercial	$0.05
Rate for Payer: LLUH Dept of Risk Management WC	$0.05
Rate for Payer: Multiplan Commercial	$0.07

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL CREAM [8112]

Facility

OP

$0.14

Service Code	NDC 0168-0003-80
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

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT [8117]

Facility

OP

$0.25

Service Code	NDC 0713-0229-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT [8117]

Facility

OP

$0.40

Service Code	NDC 45802-054-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.24
Rate for Payer: Aetna of CA Government/Medicare	$0.24
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT [8117]

Facility

IP

$0.12

Service Code	NDC 0713-0229-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
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

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT [8117]

Facility

IP

$0.40

Service Code	NDC 45802-054-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.22
Max. Negotiated Rate	$0.32
Rate for Payer: Cash Price	$0.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.32
Rate for Payer: Health Smart Auto/Commercial	$0.24
Rate for Payer: LLUH Dept of Risk Management WC	$0.22
Rate for Payer: Multiplan Commercial	$0.30

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT [8117]

Facility

IP

$0.25

Service Code	NDC 0713-0229-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

TRIAMCINOLONE ACETONIDE 0.025 % TOPICAL OINTMENT [8117]

Facility

OP

$0.12

Service Code	NDC 0713-0229-80
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.06
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Commercial	$0.09

TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]

Facility

OP

$6.00

Service Code	NDC 64980-320-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]

Facility

IP

$15.47

Service Code	NDC 0713-0655-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.51
Max. Negotiated Rate	$12.38
Rate for Payer: Cash Price	$8.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.38
Rate for Payer: Health Smart Auto/Commercial	$9.28
Rate for Payer: LLUH Dept of Risk Management WC	$8.51
Rate for Payer: Multiplan Commercial	$11.60

TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]

Facility

IP

$15.47

Service Code	NDC 51672-1267-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.51
Max. Negotiated Rate	$12.38
Rate for Payer: Cash Price	$8.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.38
Rate for Payer: Health Smart Auto/Commercial	$9.28
Rate for Payer: LLUH Dept of Risk Management WC	$8.51
Rate for Payer: Multiplan Commercial	$11.60

TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]

Facility

OP

$15.47

Service Code	NDC 0713-0655-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.51
Max. Negotiated Rate	$12.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.28
Rate for Payer: Aetna of CA Government/Medicare	$9.28
Rate for Payer: Cash Price	$8.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.38
Rate for Payer: Health Smart Auto/Commercial	$9.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.28
Rate for Payer: LLUH Dept of Risk Management WC	$8.51
Rate for Payer: Multiplan Commercial	$11.60

TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]

Facility

OP

$15.47

Service Code	NDC 51672-1267-5
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.51
Max. Negotiated Rate	$12.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.28
Rate for Payer: Aetna of CA Government/Medicare	$9.28
Rate for Payer: Cash Price	$8.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.38
Rate for Payer: Health Smart Auto/Commercial	$9.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.28
Rate for Payer: LLUH Dept of Risk Management WC	$8.51
Rate for Payer: Multiplan Commercial	$11.60

TRIAMCINOLONE ACETONIDE 0.1 % DENTAL PASTE [8121]

Facility

IP

$6.00

Service Code	NDC 64980-320-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50

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