Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION [152936]

Facility

IP

$0.15

Service Code	NDC 68094-193-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION [152936]

Facility

OP

$0.33

Service Code	NDC 0121-4675-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION [152936]

Facility

IP

$0.52

Service Code	NDC 0121-4675-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION [152936]

Facility

OP

$0.15

Service Code	NDC 68094-193-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.08
Max. Negotiated Rate	$0.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.09
Rate for Payer: Aetna of CA Government/Medicare	$0.09
Rate for Payer: Cash Price	$0.08
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.12
Rate for Payer: Health Smart Auto/Commercial	$0.09
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.09
Rate for Payer: LLUH Dept of Risk Management WC	$0.08
Rate for Payer: Multiplan Commercial	$0.11

VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION [152936]

Facility

IP

$0.33

Service Code	NDC 0121-4675-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION [152936]

Facility

OP

$0.33

Service Code	NDC 0121-4675-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION [152936]

Facility

IP

$0.33

Service Code	NDC 0121-4675-00
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.18
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.26
Rate for Payer: Health Smart Auto/Commercial	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

VALPROIC ACID (AS SODIUM SALT) 250 MG/5 ML (5 ML) ORAL SOLUTION [152936]

Facility

OP

$0.52

Service Code	NDC 0121-4675-40
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.31
Rate for Payer: Aetna of CA Government/Medicare	$0.31
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.39

VALPROIC ACID (AS SODIUM SALT) 500 MG/10 ML (10 ML) ORAL SOLUTION [188966]

Facility

IP

$0.30

Service Code	NDC 0121-1350-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

VALPROIC ACID (AS SODIUM SALT) 500 MG/10 ML (10 ML) ORAL SOLUTION [188966]

Facility

OP

$0.30

Service Code	NDC 0121-1350-10
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

VALRUBICIN 40 MG/ML INTRAVESICAL SOLUTION [24425]

Facility

OP

$444.06

Service Code	HCPCS J9357
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$244.23
Max. Negotiated Rate	$355.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$266.44
Rate for Payer: Aetna of CA Government/Medicare	$266.44
Rate for Payer: Cash Price	$244.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$355.25
Rate for Payer: Health Smart Auto/Commercial	$266.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$266.44
Rate for Payer: LLUH Dept of Risk Management WC	$244.23
Rate for Payer: Multiplan Commercial	$333.05

VALRUBICIN 40 MG/ML INTRAVESICAL SOLUTION [24425]

Facility

IP

$444.06

Service Code	HCPCS J9357
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$244.23
Max. Negotiated Rate	$355.25
Rate for Payer: Cash Price	$244.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$355.25
Rate for Payer: Health Smart Auto/Commercial	$266.44
Rate for Payer: LLUH Dept of Risk Management WC	$244.23
Rate for Payer: Multiplan Commercial	$333.05

VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]

Facility

OP

$19.08

Service Code	HCPCS J3373
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$10.49
Max. Negotiated Rate	$15.26
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.32
Rate for Payer: Aetna of CA Government/Medicare	$4.32
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$11.45
Rate for Payer: Aetna of CA Government/Medicare	$3.74
Rate for Payer: Cash Price	$10.49
Rate for Payer: Cash Price	$3.96
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$3.43
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: Health Smart Auto/Commercial	$3.74
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$11.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.45
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: LLUH Dept of Risk Management WC	$10.49
Rate for Payer: LLUH Dept of Risk Management WC	$3.43
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$4.68
Rate for Payer: Multiplan Commercial	$5.40
Rate for Payer: Multiplan Commercial	$14.31

VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]

Facility

IP

$3.60

Service Code	HCPCS J3373
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.98
Max. Negotiated Rate	$2.88
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$10.49
Rate for Payer: Cash Price	$3.43
Rate for Payer: Cash Price	$3.96
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.99
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.76
Rate for Payer: Health Smart Auto/Commercial	$4.32
Rate for Payer: Health Smart Auto/Commercial	$3.74
Rate for Payer: Health Smart Auto/Commercial	$11.45
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: LLUH Dept of Risk Management WC	$10.49
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.43
Rate for Payer: LLUH Dept of Risk Management WC	$3.96
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$14.31
Rate for Payer: Multiplan Commercial	$5.40
Rate for Payer: Multiplan Commercial	$4.68

VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]

Facility

OP

$19.25

Service Code	HCPCS J3374
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$10.59
Max. Negotiated Rate	$15.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.55
Rate for Payer: Aetna of CA Government/Medicare	$11.55
Rate for Payer: Cash Price	$10.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.40
Rate for Payer: Health Smart Auto/Commercial	$11.55
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.55
Rate for Payer: LLUH Dept of Risk Management WC	$10.59
Rate for Payer: Multiplan Commercial	$14.44

VANCOMYCIN 1,000 MG INTRAVENOUS INJECTION [8442]

Facility

IP

$19.25

Service Code	HCPCS J3374
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$10.59
Max. Negotiated Rate	$15.40
Rate for Payer: Cash Price	$10.59
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$15.40
Rate for Payer: Health Smart Auto/Commercial	$11.55
Rate for Payer: LLUH Dept of Risk Management WC	$10.59
Rate for Payer: Multiplan Commercial	$14.44

VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]

Facility

IP

$255.00

Service Code	HCPCS J3373
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$140.25
Max. Negotiated Rate	$204.00
Rate for Payer: Cash Price	$140.25
Rate for Payer: Cash Price	$36.30
Rate for Payer: Cash Price	$143.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$204.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$208.54
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: Health Smart Auto/Commercial	$156.41
Rate for Payer: Health Smart Auto/Commercial	$153.00
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: LLUH Dept of Risk Management WC	$140.25
Rate for Payer: LLUH Dept of Risk Management WC	$143.37
Rate for Payer: Multiplan Commercial	$49.50
Rate for Payer: Multiplan Commercial	$195.51
Rate for Payer: Multiplan Commercial	$191.25

VANCOMYCIN 10 GRAM INTRAVENOUS SOLUTION [11627]

Facility

OP

$66.00

Service Code	HCPCS J3373
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$36.30
Max. Negotiated Rate	$52.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$39.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$153.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$156.41
Rate for Payer: Aetna of CA Government/Medicare	$153.00
Rate for Payer: Aetna of CA Government/Medicare	$156.41
Rate for Payer: Aetna of CA Government/Medicare	$39.60
Rate for Payer: Cash Price	$143.37
Rate for Payer: Cash Price	$140.25
Rate for Payer: Cash Price	$36.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$52.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$204.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$208.54
Rate for Payer: Health Smart Auto/Commercial	$39.60
Rate for Payer: Health Smart Auto/Commercial	$156.41
Rate for Payer: Health Smart Auto/Commercial	$153.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$39.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$156.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$153.00
Rate for Payer: LLUH Dept of Risk Management WC	$140.25
Rate for Payer: LLUH Dept of Risk Management WC	$143.37
Rate for Payer: LLUH Dept of Risk Management WC	$36.30
Rate for Payer: Multiplan Commercial	$195.51
Rate for Payer: Multiplan Commercial	$191.25
Rate for Payer: Multiplan Commercial	$49.50

VANCOMYCIN 1 GRAM/200 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [92895]

Facility

OP

$0.16

Service Code	HCPCS J3373
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

VANCOMYCIN 1 GRAM/200 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK [92895]

Facility

IP

$0.16

Service Code	HCPCS J3373
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

VANCOMYCIN 1 GRAM/200 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK PER PHARMACY [40892895]

Facility

OP

$0.16

Service Code	HCPCS J3373
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.10
Rate for Payer: Aetna of CA Government/Medicare	$0.10
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

VANCOMYCIN 1 GRAM/200 ML IN DEXTROSE 5 % INTRAVENOUS PIGGYBACK PER PHARMACY [40892895]

Facility

IP

$0.16

Service Code	HCPCS J3373
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$0.09
Max. Negotiated Rate	$0.13
Rate for Payer: Cash Price	$0.09
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.10
Rate for Payer: LLUH Dept of Risk Management WC	$0.09
Rate for Payer: Multiplan Commercial	$0.12

VANCOMYCIN 500 MG/5 ML MED NEB SOLUTION (IV FORM) [4088443]

Facility

OP

$8.40

Service Code	HCPCS J3373
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$4.62
Max. Negotiated Rate	$6.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.87
Rate for Payer: Aetna of CA Government/Medicare	$5.87
Rate for Payer: Aetna of CA Government/Medicare	$5.04
Rate for Payer: Cash Price	$5.39
Rate for Payer: Cash Price	$4.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.83
Rate for Payer: Health Smart Auto/Commercial	$5.04
Rate for Payer: Health Smart Auto/Commercial	$5.87
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.87
Rate for Payer: LLUH Dept of Risk Management WC	$4.62
Rate for Payer: LLUH Dept of Risk Management WC	$5.38
Rate for Payer: Multiplan Commercial	$7.34
Rate for Payer: Multiplan Commercial	$6.30

VANCOMYCIN 500 MG/5 ML MED NEB SOLUTION (IV FORM) [4088443]

Facility

IP

$9.79

Service Code	HCPCS J3373
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$5.38
Max. Negotiated Rate	$7.83
Rate for Payer: Cash Price	$5.39
Rate for Payer: Cash Price	$4.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.72
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$7.83
Rate for Payer: Health Smart Auto/Commercial	$5.87
Rate for Payer: Health Smart Auto/Commercial	$5.04
Rate for Payer: LLUH Dept of Risk Management WC	$4.62
Rate for Payer: LLUH Dept of Risk Management WC	$5.38
Rate for Payer: Multiplan Commercial	$6.30
Rate for Payer: Multiplan Commercial	$7.34

VANCOMYCIN 500 MG/5 ML MED NEB SOLUTION (IV FORM) [4088443]

Facility

IP

$6.51

Service Code	NDC 0409-6534-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.58
Max. Negotiated Rate	$5.21
Rate for Payer: Cash Price	$3.58
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.21
Rate for Payer: Health Smart Auto/Commercial	$3.91
Rate for Payer: LLUH Dept of Risk Management WC	$3.58
Rate for Payer: Multiplan Commercial	$4.88

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