Anthem Vivity, Anthem HMO: disclosed hospital rates

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Based on the published hospital price files, Anthem Vivity, Anthem HMO appears in disclosed negotiated rates across 4 hospitals and 603 services. This is public hospital price transparency data, not a guaranteed estimate of your bill.

Actual patient responsibility may vary based on your insurance plan, deductible, coinsurance, network status, diagnosis, setting, bundled services, clinical circumstances, and hospital billing practices.

603 prices shown.

Service	Hospital	Code	List price	Cash price	Negotiated range	Allowed (median)
"Silver Nitrate Applicator 6""" Inpatient	UCLA West Valley Medical Center	12165010001 NDC	$165	$90.75	$34.65 – $165	—
0.9% SODIUM CHLORIDE--CONTROL FOR ATG Outpatient	Ronald Reagan UCLA Medical Center	63323018610 NDC	$40.00	$22.00	$10.00 – $200	—
0.9% SODIUM CHLORIDE--CONTROL FOR ATG Outpatient	UCLA Santa Monica Medical Center	63323018610 NDC	$40.00	$22.00	$1.03 – $200	—
0.9% SODIUM CHLORIDE--CONTROL FOR ATG Outpatient	UCLA Resnick Neuropsychiatric Hospital	63323018610 NDC	$40.00	$22.00	$10.00 – $37.60	—
1 pc ost pou w built-in conv Outpatient	UCLA Santa Monica Medical Center	A5057 HCPCS	—	—	$22.28 – $22.28	—
1 pc ost pouch w filter Outpatient	UCLA Santa Monica Medical Center	A5056 HCPCS	—	—	$10.85 – $10.85	—
12-24hr sealed lead acid Outpatient	Ronald Reagan UCLA Medical Center	K0733 HCPCS	—	—	$6.09 – $28.90	—
12-24hr sealed lead acid Outpatient	UCLA Santa Monica Medical Center	K0733 HCPCS	—	—	$5.25 – $28.90	—
1pc ost pch drain hgh output Outpatient	UCLA Santa Monica Medical Center	A4435 HCPCS	—	—	$13.37 – $13.37	—
1ST PSYC COLLAB CARE MGMT Outpatient	Ronald Reagan UCLA Medical Center	99492 HCPCS	—	—	$111 – $375	—
1ST PSYC COLLAB CARE MGMT Outpatient	UCLA Santa Monica Medical Center	99492 HCPCS	—	—	$118 – $375	—
1ST PSYC COLLAB CARE MGMT Outpatient	UCLA West Valley Medical Center	99492 HCPCS	—	—	$118 – $282	—
2 pc drainable ost pouch Outpatient	UCLA Santa Monica Medical Center	A4413 HCPCS	—	—	$12.79 – $12.79	—
2019-ncov diagnostic p Outpatient	UCLA Santa Monica Medical Center	U0001 HCPCS	—	—	$35.91 – $103	—
22nf nonsealed leadacid Outpatient	Ronald Reagan UCLA Medical Center	E2360 HCPCS	—	—	$24.73 – $107	—
22nf nonsealed leadacid Outpatient	UCLA Santa Monica Medical Center	E2360 HCPCS	—	—	$21.49 – $107	—
22nf sealed leadacid battery Outpatient	Ronald Reagan UCLA Medical Center	E2361 HCPCS	—	—	$26.15 – $128	—
22nf sealed leadacid battery Outpatient	UCLA Santa Monica Medical Center	E2361 HCPCS	—	—	$22.26 – $128	—
2d cephal radio image Outpatient	Ronald Reagan UCLA Medical Center	D0702 HCPCS	—	—	$112 – $321	—
2d cephal radio image Outpatient	UCLA Santa Monica Medical Center	D0702 HCPCS	—	—	$112 – $321	—
2d cephal radio image Outpatient	UCLA West Valley Medical Center	D0702 HCPCS	—	—	$112 – $269	—
2d cephalometric image Outpatient	Ronald Reagan UCLA Medical Center	D0340 HCPCS	—	—	$112 – $321	—
2d cephalometric image Outpatient	UCLA Santa Monica Medical Center	D0340 HCPCS	—	—	$112 – $321	—
2d cephalometric image Outpatient	UCLA West Valley Medical Center	D0340 HCPCS	—	—	$112 – $269	—
2d oral/facial photo image Outpatient	Ronald Reagan UCLA Medical Center	D0703 HCPCS	—	—	$112 – $321	—