Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

ETHYL CHLORIDE 100 % TOPICAL SPRAY [2951]

Facility

OP

$0.36

Service Code	NDC 9999-9929-51
Hospital Charge Code	901700016
Hospital Revenue Code	271
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]

Facility

OP

$0.68

Service Code	NDC 0409-6695-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]

Facility

IP

$0.68

Service Code	NDC 0409-6695-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Commercial	$0.51

ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]

Facility

IP

$0.90

Service Code	NDC 0517-0780-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

ETOMIDATE 20 MG/10 ML INTRAVENOUS SOLUTION - CODE [40820472]

Facility

OP

$0.90

Service Code	NDC 0517-0780-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.50
Max. Negotiated Rate	$0.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.54
Rate for Payer: Aetna of CA Government/Medicare	$0.54
Rate for Payer: Cash Price	$0.50
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.54
Rate for Payer: LLUH Dept of Risk Management WC	$0.50
Rate for Payer: Multiplan Commercial	$0.68

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

IP

$0.75

Service Code	NDC 0143-9506-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

IP

$0.66

Service Code	NDC 55150-221-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.53
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.50

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

IP

$0.54

Service Code	NDC 72485-508-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

OP

$0.66

Service Code	NDC 55150-221-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.36
Max. Negotiated Rate	$0.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.40
Rate for Payer: Aetna of CA Government/Medicare	$0.40
Rate for Payer: Cash Price	$0.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.53
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.36
Rate for Payer: Multiplan Commercial	$0.50

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

OP

$0.53

Service Code	NDC 72266-146-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

OP

$0.53

Service Code	NDC 72266-146-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

IP

$0.54

Service Code	NDC 72485-508-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

IP

$0.53

Service Code	NDC 72266-146-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

IP

$0.75

Service Code	NDC 0143-9506-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

OP

$0.54

Service Code	NDC 72485-508-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

IP

$0.53

Service Code	NDC 72266-146-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.42
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.29
Rate for Payer: Multiplan Commercial	$0.40

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

OP

$0.75

Service Code	NDC 0143-9506-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.45
Rate for Payer: Aetna of CA Government/Medicare	$0.45
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

OP

$0.54

Service Code	NDC 72485-508-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.30
Max. Negotiated Rate	$0.43
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.32
Rate for Payer: Aetna of CA Government/Medicare	$0.32
Rate for Payer: Cash Price	$0.30
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.43
Rate for Payer: Health Smart Auto/Commercial	$0.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.32
Rate for Payer: LLUH Dept of Risk Management WC	$0.30
Rate for Payer: Multiplan Commercial	$0.41

ETOMIDATE 2 MG/ML INTRAVENOUS SOLUTION [20472]

Facility

OP

$0.75

Service Code	NDC 0143-9506-10
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.41
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.45
Rate for Payer: Aetna of CA Government/Medicare	$0.45
Rate for Payer: Cash Price	$0.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.60
Rate for Payer: Health Smart Auto/Commercial	$0.45
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.45
Rate for Payer: LLUH Dept of Risk Management WC	$0.41
Rate for Payer: Multiplan Commercial	$0.56

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]

Facility

IP

$2.25

Service Code	HCPCS J9181
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.24
Max. Negotiated Rate	$1.80
Rate for Payer: Cash Price	$1.24
Rate for Payer: Cash Price	$1.64
Rate for Payer: Cash Price	$1.36
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.98
Rate for Payer: Health Smart Auto/Commercial	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.35
Rate for Payer: LLUH Dept of Risk Management WC	$1.64
Rate for Payer: LLUH Dept of Risk Management WC	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.36
Rate for Payer: Multiplan Commercial	$2.24
Rate for Payer: Multiplan Commercial	$1.85
Rate for Payer: Multiplan Commercial	$1.69

ETOPOSIDE 20 MG/ML INTRAVENOUS SOLUTION [10000]

Facility

OP

$2.99

Service Code	HCPCS J9181
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.64
Max. Negotiated Rate	$2.39
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.79
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.35
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.48
Rate for Payer: Aetna of CA Government/Medicare	$1.35
Rate for Payer: Aetna of CA Government/Medicare	$1.48
Rate for Payer: Aetna of CA Government/Medicare	$1.79
Rate for Payer: Cash Price	$1.36
Rate for Payer: Cash Price	$1.24
Rate for Payer: Cash Price	$1.64
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.80
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.98
Rate for Payer: Health Smart Auto/Commercial	$1.79
Rate for Payer: Health Smart Auto/Commercial	$1.48
Rate for Payer: Health Smart Auto/Commercial	$1.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.35
Rate for Payer: LLUH Dept of Risk Management WC	$1.24
Rate for Payer: LLUH Dept of Risk Management WC	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.64
Rate for Payer: Multiplan Commercial	$1.85
Rate for Payer: Multiplan Commercial	$1.69
Rate for Payer: Multiplan Commercial	$2.24

ETOPOSIDE 50 MG CAPSULE [10001]

Facility

OP

$103.86

Service Code	HCPCS J8560
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$57.12
Max. Negotiated Rate	$83.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$62.32
Rate for Payer: Aetna of CA Government/Medicare	$62.32
Rate for Payer: Cash Price	$57.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.09
Rate for Payer: Health Smart Auto/Commercial	$62.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$62.32
Rate for Payer: LLUH Dept of Risk Management WC	$57.12
Rate for Payer: Multiplan Commercial	$77.89

ETOPOSIDE 50 MG CAPSULE [10001]

Facility

IP

$103.86

Service Code	HCPCS J8560
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$57.12
Max. Negotiated Rate	$83.09
Rate for Payer: Cash Price	$57.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.09
Rate for Payer: Health Smart Auto/Commercial	$62.32
Rate for Payer: LLUH Dept of Risk Management WC	$57.12
Rate for Payer: Multiplan Commercial	$77.89

ETOPOSIDE ORAL SOLUTION COMPOUND 10 MG/ML [4080272]

Facility

OP

$1.00

Service Code	NDC 9994-0802-72
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.60
Rate for Payer: Aetna of CA Government/Medicare	$0.60
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

ETOPOSIDE ORAL SOLUTION COMPOUND 10 MG/ML [4080272]

Facility

IP

$1.00

Service Code	NDC 9994-0802-72
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.55
Max. Negotiated Rate	$0.80
Rate for Payer: Cash Price	$0.55
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.80
Rate for Payer: Health Smart Auto/Commercial	$0.60
Rate for Payer: LLUH Dept of Risk Management WC	$0.55
Rate for Payer: Multiplan Commercial	$0.75

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