Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

OP

$2.24

Service Code	NDC 61314-396-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Cash Price	$1.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.68

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

IP

$15.29

Service Code	NDC 0065-0396-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.41
Max. Negotiated Rate	$12.23
Rate for Payer: Cash Price	$8.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.23
Rate for Payer: Health Smart Auto/Commercial	$9.17
Rate for Payer: LLUH Dept of Risk Management WC	$8.41
Rate for Payer: Multiplan Commercial	$11.47

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

IP

$2.24

Service Code	NDC 61314-396-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Cash Price	$1.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.68

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

OP

$7.17

Service Code	NDC 61314-396-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$5.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.30
Rate for Payer: Aetna of CA Government/Medicare	$4.30
Rate for Payer: Cash Price	$3.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.74
Rate for Payer: Health Smart Auto/Commercial	$4.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.94
Rate for Payer: Multiplan Commercial	$5.38

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

IP

$7.17

Service Code	NDC 61314-396-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$3.94
Max. Negotiated Rate	$5.74
Rate for Payer: Cash Price	$3.94
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$5.74
Rate for Payer: Health Smart Auto/Commercial	$4.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.94
Rate for Payer: Multiplan Commercial	$5.38

CYCLOPENTOLATE 1 % EYE DROPS [2025]

Facility

OP

$15.29

Service Code	NDC 0065-0396-05
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$8.41
Max. Negotiated Rate	$12.23
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$9.17
Rate for Payer: Aetna of CA Government/Medicare	$9.17
Rate for Payer: Cash Price	$8.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$12.23
Rate for Payer: Health Smart Auto/Commercial	$9.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$9.17
Rate for Payer: LLUH Dept of Risk Management WC	$8.41
Rate for Payer: Multiplan Commercial	$11.47

CYCLOPENTOLATE 1 % EYE DROPS >2 ML [4082025]

Facility

IP

$2.24

Service Code	NDC 61314-396-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Cash Price	$1.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.68

CYCLOPENTOLATE 1 % EYE DROPS >2 ML [4082025]

Facility

OP

$2.24

Service Code	NDC 61314-396-03
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$1.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.34
Rate for Payer: Aetna of CA Government/Medicare	$1.34
Rate for Payer: Cash Price	$1.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.34
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.34
Rate for Payer: LLUH Dept of Risk Management WC	$1.23
Rate for Payer: Multiplan Commercial	$1.68

CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]

Facility

OP

$22.21

Service Code	NDC 0065-0359-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$12.22
Max. Negotiated Rate	$17.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$13.33
Rate for Payer: Aetna of CA Government/Medicare	$13.33
Rate for Payer: Cash Price	$12.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.77
Rate for Payer: Health Smart Auto/Commercial	$13.33
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$13.33
Rate for Payer: LLUH Dept of Risk Management WC	$12.22
Rate for Payer: Multiplan Commercial	$16.66

CYCLOPENTOLATE-PHENYLEPHRINE 0.2 %-1 % EYE DROPS [9701]

Facility

IP

$22.21

Service Code	NDC 0065-0359-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$12.22
Max. Negotiated Rate	$17.77
Rate for Payer: Cash Price	$12.22
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$17.77
Rate for Payer: Health Smart Auto/Commercial	$13.33
Rate for Payer: LLUH Dept of Risk Management WC	$12.22
Rate for Payer: Multiplan Commercial	$16.66

CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]

Facility

IP

$672.43

Service Code	HCPCS J9074
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$369.84
Max. Negotiated Rate	$537.94
Rate for Payer: Cash Price	$369.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$537.94
Rate for Payer: Health Smart Auto/Commercial	$403.46
Rate for Payer: LLUH Dept of Risk Management WC	$369.84
Rate for Payer: Multiplan Commercial	$504.32

CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]

Facility

OP

$672.43

Service Code	HCPCS J9074
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$369.84
Max. Negotiated Rate	$537.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$403.46
Rate for Payer: Aetna of CA Government/Medicare	$403.46
Rate for Payer: Cash Price	$369.84
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$537.94
Rate for Payer: Health Smart Auto/Commercial	$403.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$403.46
Rate for Payer: LLUH Dept of Risk Management WC	$369.84
Rate for Payer: Multiplan Commercial	$504.32

CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]

Facility

IP

$432.00

Service Code	HCPCS J9075
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$237.60
Max. Negotiated Rate	$345.60
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cash Price	$155.76
Rate for Payer: Cash Price	$166.98
Rate for Payer: Cash Price	$115.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$345.60
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$168.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$242.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$226.56
Rate for Payer: Health Smart Auto/Commercial	$259.20
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: Health Smart Auto/Commercial	$182.16
Rate for Payer: Health Smart Auto/Commercial	$169.92
Rate for Payer: LLUH Dept of Risk Management WC	$155.76
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: LLUH Dept of Risk Management WC	$166.98
Rate for Payer: LLUH Dept of Risk Management WC	$237.60
Rate for Payer: Multiplan Commercial	$212.40
Rate for Payer: Multiplan Commercial	$157.50
Rate for Payer: Multiplan Commercial	$324.00
Rate for Payer: Multiplan Commercial	$227.70

CYCLOPHOSPHAMIDE 1 GRAM INTRAVENOUS POWDER FOR SOLUTION [38270]

Facility

OP

$210.00

Service Code	HCPCS J9075
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$115.50
Max. Negotiated Rate	$168.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$126.00
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$169.92
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$182.16
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$259.20
Rate for Payer: Aetna of CA Government/Medicare	$259.20
Rate for Payer: Aetna of CA Government/Medicare	$169.92
Rate for Payer: Aetna of CA Government/Medicare	$126.00
Rate for Payer: Aetna of CA Government/Medicare	$182.16
Rate for Payer: Cash Price	$115.50
Rate for Payer: Cash Price	$237.60
Rate for Payer: Cash Price	$155.76
Rate for Payer: Cash Price	$166.98
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$168.00
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$226.56
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$242.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$345.60
Rate for Payer: Health Smart Auto/Commercial	$259.20
Rate for Payer: Health Smart Auto/Commercial	$182.16
Rate for Payer: Health Smart Auto/Commercial	$169.92
Rate for Payer: Health Smart Auto/Commercial	$126.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$259.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$182.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$169.92
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$126.00
Rate for Payer: LLUH Dept of Risk Management WC	$237.60
Rate for Payer: LLUH Dept of Risk Management WC	$115.50
Rate for Payer: LLUH Dept of Risk Management WC	$166.98
Rate for Payer: LLUH Dept of Risk Management WC	$155.76
Rate for Payer: Multiplan Commercial	$212.40
Rate for Payer: Multiplan Commercial	$227.70
Rate for Payer: Multiplan Commercial	$324.00
Rate for Payer: Multiplan Commercial	$157.50

CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [228986]

Facility

IP

$175.80

Service Code	HCPCS J9075
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$96.69
Max. Negotiated Rate	$140.64
Rate for Payer: Cash Price	$96.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.64
Rate for Payer: Health Smart Auto/Commercial	$105.48
Rate for Payer: LLUH Dept of Risk Management WC	$96.69
Rate for Payer: Multiplan Commercial	$131.85

CYCLOPHOSPHAMIDE 200 MG/ML INTRAVENOUS SOLUTION [228986]

Facility

OP

$175.80

Service Code	HCPCS J9075
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$96.69
Max. Negotiated Rate	$140.64
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$105.48
Rate for Payer: Aetna of CA Government/Medicare	$105.48
Rate for Payer: Cash Price	$96.69
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$140.64
Rate for Payer: Health Smart Auto/Commercial	$105.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$105.48
Rate for Payer: LLUH Dept of Risk Management WC	$96.69
Rate for Payer: Multiplan Commercial	$131.85

CYCLOPHOSPHAMIDE 25 MG CAPSULE [206105]

Facility

IP

$3.60

Service Code	HCPCS J8530
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	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$2.70
Rate for Payer: Multiplan Commercial	$4.50

CYCLOPHOSPHAMIDE 25 MG CAPSULE [206105]

Facility

OP

$6.00

Service Code	HCPCS J8530
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$3.30
Max. Negotiated Rate	$4.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$2.16
Rate for Payer: Aetna of CA Government/Medicare	$3.60
Rate for Payer: Cash Price	$1.98
Rate for Payer: Cash Price	$3.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.88
Rate for Payer: Health Smart Auto/Commercial	$3.60
Rate for Payer: Health Smart Auto/Commercial	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.16
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.60
Rate for Payer: LLUH Dept of Risk Management WC	$1.98
Rate for Payer: LLUH Dept of Risk Management WC	$3.30
Rate for Payer: Multiplan Commercial	$4.50
Rate for Payer: Multiplan Commercial	$2.70

CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION [28922]

Facility

IP

$864.00

Service Code	HCPCS J9075
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$475.20
Max. Negotiated Rate	$691.20
Rate for Payer: Cash Price	$475.20
Rate for Payer: Cash Price	$244.20
Rate for Payer: Cash Price	$298.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$433.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$691.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$355.20
Rate for Payer: Health Smart Auto/Commercial	$266.40
Rate for Payer: Health Smart Auto/Commercial	$325.44
Rate for Payer: Health Smart Auto/Commercial	$518.40
Rate for Payer: LLUH Dept of Risk Management WC	$475.20
Rate for Payer: LLUH Dept of Risk Management WC	$244.20
Rate for Payer: LLUH Dept of Risk Management WC	$298.32
Rate for Payer: Multiplan Commercial	$333.00
Rate for Payer: Multiplan Commercial	$406.80
Rate for Payer: Multiplan Commercial	$648.00

CYCLOPHOSPHAMIDE 2 GRAM INTRAVENOUS POWDER FOR SOLUTION [28922]

Facility

OP

$864.00

Service Code	HCPCS J9075
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$475.20
Max. Negotiated Rate	$691.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$518.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$266.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$325.44
Rate for Payer: Aetna of CA Government/Medicare	$266.40
Rate for Payer: Aetna of CA Government/Medicare	$518.40
Rate for Payer: Aetna of CA Government/Medicare	$325.44
Rate for Payer: Cash Price	$244.20
Rate for Payer: Cash Price	$475.20
Rate for Payer: Cash Price	$298.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$691.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$355.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$433.92
Rate for Payer: Health Smart Auto/Commercial	$266.40
Rate for Payer: Health Smart Auto/Commercial	$325.44
Rate for Payer: Health Smart Auto/Commercial	$518.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$325.44
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$266.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$518.40
Rate for Payer: LLUH Dept of Risk Management WC	$298.32
Rate for Payer: LLUH Dept of Risk Management WC	$244.20
Rate for Payer: LLUH Dept of Risk Management WC	$475.20
Rate for Payer: Multiplan Commercial	$333.00
Rate for Payer: Multiplan Commercial	$406.80
Rate for Payer: Multiplan Commercial	$648.00

CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]

Facility

OP

$216.00

Service Code	HCPCS J9075
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$118.80
Max. Negotiated Rate	$172.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$129.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$84.96
Rate for Payer: Aetna of CA Government/Medicare	$84.96
Rate for Payer: Aetna of CA Government/Medicare	$129.60
Rate for Payer: Cash Price	$77.88
Rate for Payer: Cash Price	$118.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$172.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$113.28
Rate for Payer: Health Smart Auto/Commercial	$129.60
Rate for Payer: Health Smart Auto/Commercial	$84.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$84.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$129.60
Rate for Payer: LLUH Dept of Risk Management WC	$77.88
Rate for Payer: LLUH Dept of Risk Management WC	$118.80
Rate for Payer: Multiplan Commercial	$162.00
Rate for Payer: Multiplan Commercial	$106.20

CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]

Facility

IP

$141.60

Service Code	HCPCS J9075
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$77.88
Max. Negotiated Rate	$113.28
Rate for Payer: Cash Price	$77.88
Rate for Payer: Cash Price	$118.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$172.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$113.28
Rate for Payer: Health Smart Auto/Commercial	$84.96
Rate for Payer: Health Smart Auto/Commercial	$129.60
Rate for Payer: LLUH Dept of Risk Management WC	$77.88
Rate for Payer: LLUH Dept of Risk Management WC	$118.80
Rate for Payer: Multiplan Commercial	$106.20
Rate for Payer: Multiplan Commercial	$162.00

CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]

Facility

IP

$336.23

Service Code	HCPCS J9074
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$184.93
Max. Negotiated Rate	$268.98
Rate for Payer: Cash Price	$184.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$268.98
Rate for Payer: Health Smart Auto/Commercial	$201.74
Rate for Payer: LLUH Dept of Risk Management WC	$184.93
Rate for Payer: Multiplan Commercial	$252.17

CYCLOPHOSPHAMIDE 500 MG INTRAVENOUS POWDER FOR SOLUTION [38271]

Facility

OP

$336.23

Service Code	HCPCS J9074
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$184.93
Max. Negotiated Rate	$268.98
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$201.74
Rate for Payer: Aetna of CA Government/Medicare	$201.74
Rate for Payer: Cash Price	$184.93
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$268.98
Rate for Payer: Health Smart Auto/Commercial	$201.74
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$201.74
Rate for Payer: LLUH Dept of Risk Management WC	$184.93
Rate for Payer: Multiplan Commercial	$252.17

CYCLOPHOSPHAMIDE ORAL SUSPENSION COMPOUND 10 MG/ML [4080261]

Facility

IP

$5.30

Service Code	NDC 9994-0802-61
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$2.92
Max. Negotiated Rate	$4.24
Rate for Payer: Cash Price	$2.92
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$4.24
Rate for Payer: Health Smart Auto/Commercial	$3.18
Rate for Payer: LLUH Dept of Risk Management WC	$2.92
Rate for Payer: Multiplan Commercial	$3.98

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