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All Charges

Charge

Type

Setting

Price

CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION [9347]

Facility

IP

$480.00

Service Code	HCPCS J0630
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$264.00
Max. Negotiated Rate	$384.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$330.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$384.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$480.00
Rate for Payer: Health Smart Auto/Commercial	$288.00
Rate for Payer: Health Smart Auto/Commercial	$360.00
Rate for Payer: LLUH Dept of Risk Management WC	$330.00
Rate for Payer: LLUH Dept of Risk Management WC	$264.00
Rate for Payer: Multiplan Commercial	$360.00
Rate for Payer: Multiplan Commercial	$450.00

CALCITONIN (SALMON) 200 UNIT/ML INJECTION SOLUTION [9347]

Facility

OP

$480.00

Service Code	HCPCS J0630
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$264.00
Max. Negotiated Rate	$384.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$288.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$360.00
Rate for Payer: Aetna of CA Government/Medicare	$288.00
Rate for Payer: Aetna of CA Government/Medicare	$360.00
Rate for Payer: Cash Price	$264.00
Rate for Payer: Cash Price	$330.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$384.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$480.00
Rate for Payer: Health Smart Auto/Commercial	$288.00
Rate for Payer: Health Smart Auto/Commercial	$360.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$288.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$360.00
Rate for Payer: LLUH Dept of Risk Management WC	$330.00
Rate for Payer: LLUH Dept of Risk Management WC	$264.00
Rate for Payer: Multiplan Commercial	$360.00
Rate for Payer: Multiplan Commercial	$450.00

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

IP

$0.32

Service Code	NDC 64380-723-06
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	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

IP

$0.32

Service Code	NDC 64380-723-04
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	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

OP

$0.32

Service Code	NDC 69452-207-13
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	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
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	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

IP

$0.32

Service Code	NDC 62756-967-88
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	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

OP

$1.14

Service Code	NDC 0054-0007-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.91
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Cash Price	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.91
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Commercial	$0.86

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

IP

$0.32

Service Code	NDC 69452-207-20
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	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

OP

$0.32

Service Code	NDC 64380-723-06
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	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
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	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

IP

$0.96

Service Code	NDC 60687-345-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

OP

$0.96

Service Code	NDC 60687-345-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

IP

$0.96

Service Code	NDC 60687-345-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

IP

$0.32

Service Code	NDC 69452-207-13
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	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

OP

$0.32

Service Code	NDC 69452-207-20
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	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
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	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

IP

$1.14

Service Code	NDC 0054-0007-25
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.63
Max. Negotiated Rate	$0.91
Rate for Payer: Cash Price	$0.62
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.91
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.63
Rate for Payer: Multiplan Commercial	$0.86

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

OP

$0.32

Service Code	NDC 64380-723-04
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	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
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	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

OP

$0.32

Service Code	NDC 62756-967-88
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	$0.19
Rate for Payer: Aetna of CA Government/Medicare	$0.19
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	$0.19
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.19
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.24

CALCITRIOL 0.25 MCG CAPSULE [9350]

Facility

OP

$0.96

Service Code	NDC 60687-345-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.53
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.58
Rate for Payer: Aetna of CA Government/Medicare	$0.58
Rate for Payer: Cash Price	$0.53
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.77
Rate for Payer: Health Smart Auto/Commercial	$0.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.58
Rate for Payer: LLUH Dept of Risk Management WC	$0.53
Rate for Payer: Multiplan Commercial	$0.72

CALCITRIOL 0.5 MCG CAPSULE [9351]

Facility

OP

$0.51

Service Code	NDC 69452-208-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
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	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
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	$0.28
Rate for Payer: Multiplan Commercial	$0.38

CALCITRIOL 0.5 MCG CAPSULE [9351]

Facility

IP

$1.83

Service Code	NDC 63304-240-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.46
Rate for Payer: Cash Price	$1.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.01
Rate for Payer: Multiplan Commercial	$1.37

CALCITRIOL 0.5 MCG CAPSULE [9351]

Facility

OP

$0.51

Service Code	NDC 64380-724-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
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	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
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	$0.28
Rate for Payer: Multiplan Commercial	$0.38

CALCITRIOL 0.5 MCG CAPSULE [9351]

Facility

IP

$0.51

Service Code	NDC 69452-208-20
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

CALCITRIOL 0.5 MCG CAPSULE [9351]

Facility

IP

$0.51

Service Code	NDC 64380-724-06
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.41
Rate for Payer: Cash Price	$0.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.41
Rate for Payer: Health Smart Auto/Commercial	$0.31
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Commercial	$0.38

CALCITRIOL 0.5 MCG CAPSULE [9351]

Facility

IP

$0.55

Service Code	NDC 0093-7353-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.44
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.44
Rate for Payer: Health Smart Auto/Commercial	$0.33
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

CALCITRIOL 0.5 MCG CAPSULE [9351]

Facility

OP

$1.83

Service Code	NDC 63304-240-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.01
Max. Negotiated Rate	$1.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.10
Rate for Payer: Aetna of CA Government/Medicare	$1.10
Rate for Payer: Cash Price	$1.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.10
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.10
Rate for Payer: LLUH Dept of Risk Management WC	$1.01
Rate for Payer: Multiplan Commercial	$1.37

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