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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR [221911]

Facility

IP

$2,156.46

Service Code	CPT C9399
Hospital Charge Code	NDG221911
Hospital Revenue Code	636
Min. Negotiated Rate	$1,186.05
Max. Negotiated Rate	$1,725.17
Rate for Payer: Cash Price	$970.41
Rate for Payer: Cigna of CA HMO/PPO	$1,725.17
Rate for Payer: Health Smart Auto/Commercial	$1,293.88
Rate for Payer: LLUH Dept of Risk Management WC	$1,186.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,617.34

SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS PEN INJECTOR [221911]

Facility

OP

$2,156.46

Service Code	CPT C9399
Hospital Charge Code	NDG221911
Hospital Revenue Code	636
Min. Negotiated Rate	$1,186.05
Max. Negotiated Rate	$1,617.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,293.88
Rate for Payer: Aetna of CA Government/Medicare	$1,293.88
Rate for Payer: Cash Price	$970.41
Rate for Payer: Health Smart Auto/Commercial	$1,293.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,293.88
Rate for Payer: LLUH Dept of Risk Management WC	$1,186.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,617.34

SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]

Facility

OP

$2,156.46

Service Code	CPT C9399
Hospital Charge Code	NDG216968
Hospital Revenue Code	636
Min. Negotiated Rate	$1,186.05
Max. Negotiated Rate	$1,617.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1,293.88
Rate for Payer: Aetna of CA Government/Medicare	$1,293.88
Rate for Payer: Cash Price	$970.41
Rate for Payer: Health Smart Auto/Commercial	$1,293.88
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1,293.88
Rate for Payer: LLUH Dept of Risk Management WC	$1,186.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,617.34

SARILUMAB 200 MG/1.14 ML SUBCUTANEOUS SYRINGE [216968]

Facility

IP

$2,156.46

Service Code	CPT C9399
Hospital Charge Code	NDG216968
Hospital Revenue Code	636
Min. Negotiated Rate	$1,186.05
Max. Negotiated Rate	$1,725.17
Rate for Payer: Cash Price	$970.41
Rate for Payer: Cigna of CA HMO/PPO	$1,725.17
Rate for Payer: Health Smart Auto/Commercial	$1,293.88
Rate for Payer: LLUH Dept of Risk Management WC	$1,186.05
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,617.34

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

IP

$19.39

Service Code	NDC 0378-6470-99
Hospital Charge Code	1743445
Hospital Revenue Code	259
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$15.51
Rate for Payer: Cash Price	$8.73
Rate for Payer: Cigna of CA HMO/PPO	$15.51
Rate for Payer: Health Smart Auto/Commercial	$11.63
Rate for Payer: LLUH Dept of Risk Management WC	$10.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.54

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

IP

$22.06

Service Code	NDC 0378-6470-97
Hospital Charge Code	1743445
Hospital Revenue Code	259
Min. Negotiated Rate	$12.13
Max. Negotiated Rate	$17.65
Rate for Payer: Cash Price	$9.93
Rate for Payer: Cigna of CA HMO/PPO	$17.65
Rate for Payer: Health Smart Auto/Commercial	$13.24
Rate for Payer: LLUH Dept of Risk Management WC	$12.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.54

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

OP

$22.06

Service Code	NDC 0378-6470-97
Hospital Charge Code	1743445
Hospital Revenue Code	259
Min. Negotiated Rate	$12.13
Max. Negotiated Rate	$16.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.24
Rate for Payer: Aetna of CA Government/Medicare	$13.24
Rate for Payer: Cash Price	$9.93
Rate for Payer: Health Smart Auto/Commercial	$13.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.24
Rate for Payer: LLUH Dept of Risk Management WC	$12.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.54

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

OP

$19.39

Service Code	NDC 0378-6470-99
Hospital Charge Code	1743445
Hospital Revenue Code	259
Min. Negotiated Rate	$10.66
Max. Negotiated Rate	$14.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.63
Rate for Payer: Aetna of CA Government/Medicare	$11.63
Rate for Payer: Cash Price	$8.73
Rate for Payer: Health Smart Auto/Commercial	$11.63
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.63
Rate for Payer: LLUH Dept of Risk Management WC	$10.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.54

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

OP

$23.00

Service Code	NDC 45802-580-01
Hospital Charge Code	1743445
Hospital Revenue Code	259
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$17.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.80
Rate for Payer: Aetna of CA Government/Medicare	$13.80
Rate for Payer: Cash Price	$10.35
Rate for Payer: Health Smart Auto/Commercial	$13.80
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.80
Rate for Payer: LLUH Dept of Risk Management WC	$12.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.25

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

OP

$22.06

Service Code	NDC 0378-6470-16
Hospital Charge Code	1743445
Hospital Revenue Code	259
Min. Negotiated Rate	$12.13
Max. Negotiated Rate	$16.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.24
Rate for Payer: Aetna of CA Government/Medicare	$13.24
Rate for Payer: Cash Price	$9.93
Rate for Payer: Health Smart Auto/Commercial	$13.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.24
Rate for Payer: LLUH Dept of Risk Management WC	$12.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.54

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

IP

$23.00

Service Code	NDC 45802-580-01
Hospital Charge Code	1743445
Hospital Revenue Code	259
Min. Negotiated Rate	$12.65
Max. Negotiated Rate	$18.40
Rate for Payer: Cash Price	$10.35
Rate for Payer: Cigna of CA HMO/PPO	$18.40
Rate for Payer: Health Smart Auto/Commercial	$13.80
Rate for Payer: LLUH Dept of Risk Management WC	$12.65
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$17.25

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

IP

$22.06

Service Code	NDC 0378-6470-16
Hospital Charge Code	1743445
Hospital Revenue Code	259
Min. Negotiated Rate	$12.13
Max. Negotiated Rate	$17.65
Rate for Payer: Cash Price	$9.93
Rate for Payer: Cigna of CA HMO/PPO	$17.65
Rate for Payer: Health Smart Auto/Commercial	$13.24
Rate for Payer: LLUH Dept of Risk Management WC	$12.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.54

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

IP

$19.26

Service Code	NDC 45802-580-84
Hospital Charge Code	1743445
Hospital Revenue Code	259
Min. Negotiated Rate	$10.59
Max. Negotiated Rate	$15.41
Rate for Payer: Cash Price	$8.67
Rate for Payer: Cigna of CA HMO/PPO	$15.41
Rate for Payer: Health Smart Auto/Commercial	$11.56
Rate for Payer: LLUH Dept of Risk Management WC	$10.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.44

SCOPOLAMINE 1 MG OVER 3 DAYS TRANSDERMAL PATCH [27696]

Facility

OP

$19.26

Service Code	NDC 45802-580-84
Hospital Charge Code	1743445
Hospital Revenue Code	259
Min. Negotiated Rate	$10.59
Max. Negotiated Rate	$14.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$11.56
Rate for Payer: Aetna of CA Government/Medicare	$11.56
Rate for Payer: Cash Price	$8.67
Rate for Payer: Health Smart Auto/Commercial	$11.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$11.56
Rate for Payer: LLUH Dept of Risk Management WC	$10.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$14.44

SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]

Facility

IP

$630.00

Service Code	CPT J2850
Hospital Charge Code	ERX91185
Hospital Revenue Code	636
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$504.00
Rate for Payer: Cash Price	$283.50
Rate for Payer: Cigna of CA HMO/PPO	$504.00
Rate for Payer: Health Smart Auto/Commercial	$378.00
Rate for Payer: LLUH Dept of Risk Management WC	$346.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$472.50

SECRETIN (HUMAN) 16 MCG INTRAVENOUS SOLUTION [91185]

Facility

OP

$630.00

Service Code	CPT J2850
Hospital Charge Code	ERX91185
Hospital Revenue Code	636
Min. Negotiated Rate	$346.50
Max. Negotiated Rate	$472.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$378.00
Rate for Payer: Aetna of CA Government/Medicare	$378.00
Rate for Payer: Cash Price	$283.50
Rate for Payer: Health Smart Auto/Commercial	$378.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$378.00
Rate for Payer: LLUH Dept of Risk Management WC	$346.50
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$472.50

SELEGILINE 5 MG CAPSULE [17280]

Facility

OP

$2.01

Service Code	NDC 60505-0055-1
Hospital Charge Code	1712623
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$0.90
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.51

SELEGILINE 5 MG CAPSULE [17280]

Facility

IP

$2.01

Service Code	NDC 60505-0055-1
Hospital Charge Code	1712623
Hospital Revenue Code	259
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.61
Rate for Payer: Cash Price	$0.90
Rate for Payer: Cigna of CA HMO/PPO	$1.61
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.51

SELENIUM 200 MCG TABLET [7139]

Facility

OP

$0.06

Service Code	NDC 7985401163
Hospital Charge Code	ERX7139
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.04
Rate for Payer: Aetna of CA Government/Medicare	$0.04
Rate for Payer: Cash Price	$0.03
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

SELENIUM 200 MCG TABLET [7139]

Facility

IP

$0.06

Service Code	NDC 7985401163
Hospital Charge Code	ERX7139
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.05
Rate for Payer: Cash Price	$0.03
Rate for Payer: Cigna of CA HMO/PPO	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.04
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.05

SELENIUM 50 MCG TABLET [7140]

Facility

OP

$0.05

Service Code	NDC 26899-721-74
Hospital Charge Code	1710887
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

SELENIUM 50 MCG TABLET [7140]

Facility

IP

$0.05

Service Code	NDC 26899-721-74
Hospital Charge Code	1710887
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]

Facility

IP

$41.16

Service Code	NDC 0517-6560-25
Hospital Charge Code	NDG225026
Hospital Revenue Code	250
Min. Negotiated Rate	$22.64
Max. Negotiated Rate	$32.93
Rate for Payer: Cash Price	$18.52
Rate for Payer: Cigna of CA HMO/PPO	$32.93
Rate for Payer: Health Smart Auto/Commercial	$24.70
Rate for Payer: LLUH Dept of Risk Management WC	$22.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.87

SELENIUM 60 MCG/ML INTRAVENOUS SOLUTION [225026]

Facility

OP

$41.16

Service Code	NDC 0517-6560-25
Hospital Charge Code	NDG225026
Hospital Revenue Code	250
Min. Negotiated Rate	$22.64
Max. Negotiated Rate	$30.87
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$24.70
Rate for Payer: Aetna of CA Government/Medicare	$24.70
Rate for Payer: Cash Price	$18.52
Rate for Payer: Health Smart Auto/Commercial	$24.70
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$24.70
Rate for Payer: LLUH Dept of Risk Management WC	$22.64
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$30.87

SELENIUM SULFIDE 1 % SHAMPOO [38961]

Facility

OP

$0.02

Service Code	NDC 0536-1995-53
Hospital Charge Code	1743730
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
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: 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 Beech St/Commercial/PHCS	$0.02

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