Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]

Facility

OP

$1.61

Service Code	NDC 68462-380-01
Hospital Charge Code	ERX110533
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.97
Rate for Payer: Aetna of CA Government/Medicare	$0.97
Rate for Payer: Cash Price	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.21

THEOPHYLLINE ER 400 MG TABLET,EXTENDED RELEASE 24 HR [110533]

Facility

IP

$1.61

Service Code	NDC 68462-380-01
Hospital Charge Code	ERX110533
Hospital Revenue Code	259
Min. Negotiated Rate	$0.89
Max. Negotiated Rate	$1.29
Rate for Payer: Cash Price	$0.72
Rate for Payer: Cigna of CA HMO/PPO	$1.29
Rate for Payer: Health Smart Auto/Commercial	$0.97
Rate for Payer: LLUH Dept of Risk Management WC	$0.89
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.21

THERAPEUTIC MULTIVITAMIN TABLET. [4087857]

Facility

OP

$0.05

Service Code	NDC 904053961
Hospital Charge Code	1711076
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

THERAPEUTIC MULTIVITAMIN TABLET. [4087857]

Facility

IP

$0.05

Service Code	NDC 904053961
Hospital Charge Code	1711076
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

THERAPEUTIC MULTIVITAMIN TABLET. [4087857]

Facility

IP

$0.01

Service Code	NDC 2055502700
Hospital Charge Code	1711076
Hospital Revenue Code	259
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.01
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.01

THERAPEUTIC MULTIVITAMIN TABLET. [4087857]

Facility

OP

$0.01

Service Code	NDC 2055502700
Hospital Charge Code	1711076
Hospital Revenue Code	259
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: 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	$0.01

THERAPEUTIC MULTIVITAMIN TABLET. [4087857]

Facility

IP

$0.04

Service Code	NDC 8068100300
Hospital Charge Code	1711076
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

THERAPEUTIC MULTIVITAMIN TABLET. [4087857]

Facility

OP

$0.04

Service Code	NDC 8068100300
Hospital Charge Code	1711076
Hospital Revenue Code	259
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: 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 Beech St/Commercial/PHCS	$0.03

THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]

Facility

IP

$5.97

Service Code	CPT J3411
Hospital Charge Code	1757658
Hospital Revenue Code	636
Min. Negotiated Rate	$3.28
Max. Negotiated Rate	$4.78
Rate for Payer: Cash Price	$2.69
Rate for Payer: Cash Price	$2.30
Rate for Payer: Cigna of CA HMO/PPO	$4.78
Rate for Payer: Cigna of CA HMO/PPO	$4.10
Rate for Payer: Health Smart Auto/Commercial	$3.58
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: LLUH Dept of Risk Management WC	$3.28
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.84
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.48

THIAMINE HCL (VITAMIN B1) 100 MG/ML INJECTION SOLUTION [7876]

Facility

OP

$5.12

Service Code	CPT J3411
Hospital Charge Code	1757658
Hospital Revenue Code	636
Min. Negotiated Rate	$2.82
Max. Negotiated Rate	$3.84
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.07
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.58
Rate for Payer: Aetna of CA Government/Medicare	$3.58
Rate for Payer: Aetna of CA Government/Medicare	$3.07
Rate for Payer: Cash Price	$2.69
Rate for Payer: Cash Price	$2.30
Rate for Payer: Health Smart Auto/Commercial	$3.07
Rate for Payer: Health Smart Auto/Commercial	$3.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.07
Rate for Payer: LLUH Dept of Risk Management WC	$2.82
Rate for Payer: LLUH Dept of Risk Management WC	$3.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.84

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

OP

$0.03

Service Code	NDC 4098521151
Hospital Charge Code	1711135
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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	$0.01
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 Beech St/Commercial/PHCS	$0.02

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

IP

$0.03

Service Code	NDC 4098521151
Hospital Charge Code	1711135
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

IP

$0.03

Service Code	NDC 8770140729
Hospital Charge Code	1711135
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

OP

$0.04

Service Code	NDC 8068109800
Hospital Charge Code	1711135
Hospital Revenue Code	259
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: 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 Beech St/Commercial/PHCS	$0.03

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

IP

$0.04

Service Code	NDC 8068109800
Hospital Charge Code	1711135
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.03

THIAMINE HCL (VITAMIN B1) 100 MG TABLET [7877]

Facility

OP

$0.03

Service Code	NDC 8770140729
Hospital Charge Code	1711135
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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	$0.01
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 Beech St/Commercial/PHCS	$0.02

THIAMINE HCL (VITAMIN B1) 500 MG TABLET [8650]

Facility

IP

$0.18

Service Code	NDC 1184573105
Hospital Charge Code	ERX8650
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

THIAMINE HCL (VITAMIN B1) 500 MG TABLET [8650]

Facility

OP

$0.18

Service Code	NDC 1184573105
Hospital Charge Code	ERX8650
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

THIAMINE HCL (VITAMIN B1) CRUSHED PARTIAL TABLET [4081453]

Facility

OP

$0.03

Service Code	NDC 8068109700
Hospital Charge Code	ERX4081453
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
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	$0.01
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 Beech St/Commercial/PHCS	$0.02

THIAMINE HCL (VITAMIN B1) CRUSHED PARTIAL TABLET [4081453]

Facility

IP

$0.03

Service Code	NDC 8068109700
Hospital Charge Code	ERX4081453
Hospital Revenue Code	259
Min. Negotiated Rate	$0.02
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.02
Rate for Payer: LLUH Dept of Risk Management WC	$0.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]

Facility

IP

$0.23

Service Code	NDC 5026885111
Hospital Charge Code	1712631
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]

Facility

OP

$0.23

Service Code	NDC 5026885115
Hospital Charge Code	1712631
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]

Facility

IP

$0.23

Service Code	NDC 5026885115
Hospital Charge Code	1712631
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

THIAMINE MONONITRATE (VITAMIN B1) 100 MG TABLET [121375]

Facility

OP

$0.23

Service Code	NDC 5026885111
Hospital Charge Code	1712631
Hospital Revenue Code	259
Min. Negotiated Rate	$0.13
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.14
Rate for Payer: Aetna of CA Government/Medicare	$0.14
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.14
Rate for Payer: LLUH Dept of Risk Management WC	$0.13
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

THIOGUANINE 40 MG TABLET [7886]

Facility

OP

$30.33

Service Code	NDC 76388-880-25
Hospital Charge Code	1711149
Hospital Revenue Code	259
Min. Negotiated Rate	$16.68
Max. Negotiated Rate	$22.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$18.20
Rate for Payer: Aetna of CA Government/Medicare	$18.20
Rate for Payer: Cash Price	$13.65
Rate for Payer: Health Smart Auto/Commercial	$18.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$18.20
Rate for Payer: LLUH Dept of Risk Management WC	$16.68
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$22.75

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