Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

METYRAPONE 250 MG CAPSULE [21867]

Facility

IP

$70.27

Service Code	NDC 76336-455-18
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$38.65
Max. Negotiated Rate	$56.22
Rate for Payer: Cash Price	$38.65
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$56.22
Rate for Payer: Health Smart Auto/Commercial	$42.16
Rate for Payer: LLUH Dept of Risk Management WC	$38.65
Rate for Payer: Multiplan Commercial	$52.70

MEXILETINE 150 MG CAPSULE [10595]

Facility

IP

$2.57

Service Code	NDC 60687-778-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.06
Rate for Payer: Cash Price	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.06
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Commercial	$1.93

MEXILETINE 150 MG CAPSULE [10595]

Facility

OP

$2.57

Service Code	NDC 60687-778-21
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.54
Rate for Payer: Aetna of CA Government/Medicare	$1.54
Rate for Payer: Cash Price	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.06
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Commercial	$1.93

MEXILETINE 150 MG CAPSULE [10595]

Facility

OP

$0.42

Service Code	NDC 50742-239-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

MEXILETINE 150 MG CAPSULE [10595]

Facility

OP

$1.55

Service Code	NDC 0093-8739-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.93
Rate for Payer: Aetna of CA Government/Medicare	$0.93
Rate for Payer: Cash Price	$0.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.24
Rate for Payer: Health Smart Auto/Commercial	$0.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.93
Rate for Payer: LLUH Dept of Risk Management WC	$0.85
Rate for Payer: Multiplan Commercial	$1.16

MEXILETINE 150 MG CAPSULE [10595]

Facility

IP

$0.42

Service Code	NDC 50742-239-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Commercial	$0.32

MEXILETINE 150 MG CAPSULE [10595]

Facility

IP

$1.55

Service Code	NDC 0093-8739-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$1.24
Rate for Payer: Cash Price	$0.85
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.24
Rate for Payer: Health Smart Auto/Commercial	$0.93
Rate for Payer: LLUH Dept of Risk Management WC	$0.85
Rate for Payer: Multiplan Commercial	$1.16

MEXILETINE 150 MG CAPSULE [10595]

Facility

IP

$0.93

Service Code	NDC 0527-4107-37
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Commercial	$0.70

MEXILETINE 150 MG CAPSULE [10595]

Facility

OP

$0.93

Service Code	NDC 0527-4107-37
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.51
Max. Negotiated Rate	$0.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.56
Rate for Payer: Aetna of CA Government/Medicare	$0.56
Rate for Payer: Cash Price	$0.51
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.74
Rate for Payer: Health Smart Auto/Commercial	$0.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.56
Rate for Payer: LLUH Dept of Risk Management WC	$0.51
Rate for Payer: Multiplan Commercial	$0.70

MEXILETINE 150 MG CAPSULE [10595]

Facility

IP

$0.58

Service Code	NDC 62756-955-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

MEXILETINE 150 MG CAPSULE [10595]

Facility

IP

$2.57

Service Code	NDC 60687-778-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.06
Rate for Payer: Cash Price	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.06
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Commercial	$1.93

MEXILETINE 150 MG CAPSULE [10595]

Facility

OP

$0.58

Service Code	NDC 62756-955-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.32
Max. Negotiated Rate	$0.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.35
Rate for Payer: Aetna of CA Government/Medicare	$0.35
Rate for Payer: Cash Price	$0.32
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.35
Rate for Payer: LLUH Dept of Risk Management WC	$0.32
Rate for Payer: Multiplan Commercial	$0.44

MEXILETINE 150 MG CAPSULE [10595]

Facility

OP

$2.57

Service Code	NDC 60687-778-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.41
Max. Negotiated Rate	$2.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.54
Rate for Payer: Aetna of CA Government/Medicare	$1.54
Rate for Payer: Cash Price	$1.41
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.06
Rate for Payer: Health Smart Auto/Commercial	$1.54
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.54
Rate for Payer: LLUH Dept of Risk Management WC	$1.41
Rate for Payer: Multiplan Commercial	$1.93

MEXILETINE 200 MG CAPSULE [10596]

Facility

IP

$0.71

Service Code	NDC 62756-956-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

MEXILETINE 200 MG CAPSULE [10596]

Facility

OP

$1.89

Service Code	NDC 0093-8740-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.13
Rate for Payer: Aetna of CA Government/Medicare	$1.13
Rate for Payer: Cash Price	$1.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.51
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.04
Rate for Payer: Multiplan Commercial	$1.42

MEXILETINE 200 MG CAPSULE [10596]

Facility

IP

$0.60

Service Code	NDC 50742-240-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

MEXILETINE 200 MG CAPSULE [10596]

Facility

OP

$0.71

Service Code	NDC 62756-956-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.39
Max. Negotiated Rate	$0.57
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.43
Rate for Payer: Aetna of CA Government/Medicare	$0.43
Rate for Payer: Cash Price	$0.39
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.57
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.39
Rate for Payer: Multiplan Commercial	$0.53

MEXILETINE 200 MG CAPSULE [10596]

Facility

IP

$1.89

Service Code	NDC 0093-8740-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.04
Max. Negotiated Rate	$1.51
Rate for Payer: Cash Price	$1.04
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.51
Rate for Payer: Health Smart Auto/Commercial	$1.13
Rate for Payer: LLUH Dept of Risk Management WC	$1.04
Rate for Payer: Multiplan Commercial	$1.42

MEXILETINE 200 MG CAPSULE [10596]

Facility

OP

$0.60

Service Code	NDC 50742-240-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.36
Rate for Payer: Aetna of CA Government/Medicare	$0.36
Rate for Payer: Cash Price	$0.33
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.48
Rate for Payer: Health Smart Auto/Commercial	$0.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.36
Rate for Payer: LLUH Dept of Risk Management WC	$0.33
Rate for Payer: Multiplan Commercial	$0.45

MEXILETINE ORAL SUSPENSION COMPOUND 10 MG/ML [4081649]

Facility

OP

$0.10

Service Code	NDC 9994-0816-49
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

MEXILETINE ORAL SUSPENSION COMPOUND 10 MG/ML [4081649]

Facility

IP

$0.10

Service Code	NDC 9994-0816-49
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Commercial	$0.08

MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]

Facility

OP

$89.76

Service Code	HCPCS J2247
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$49.37
Max. Negotiated Rate	$71.81
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.86
Rate for Payer: Aetna of CA Government/Medicare	$53.86
Rate for Payer: Cash Price	$49.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.81
Rate for Payer: Health Smart Auto/Commercial	$53.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.86
Rate for Payer: LLUH Dept of Risk Management WC	$49.37
Rate for Payer: Multiplan Commercial	$67.32

MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]

Facility

OP

$112.20

Service Code	HCPCS J2248
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$61.71
Max. Negotiated Rate	$89.76
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$67.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$28.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$19.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$53.86
Rate for Payer: Aetna of CA Government/Medicare	$28.08
Rate for Payer: Aetna of CA Government/Medicare	$67.32
Rate for Payer: Aetna of CA Government/Medicare	$19.60
Rate for Payer: Aetna of CA Government/Medicare	$53.86
Rate for Payer: Cash Price	$25.74
Rate for Payer: Cash Price	$49.37
Rate for Payer: Cash Price	$61.71
Rate for Payer: Cash Price	$17.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$89.76
Rate for Payer: Health Smart Auto/Commercial	$67.32
Rate for Payer: Health Smart Auto/Commercial	$28.08
Rate for Payer: Health Smart Auto/Commercial	$19.60
Rate for Payer: Health Smart Auto/Commercial	$53.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$67.32
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$19.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$28.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$53.86
Rate for Payer: LLUH Dept of Risk Management WC	$25.74
Rate for Payer: LLUH Dept of Risk Management WC	$17.96
Rate for Payer: LLUH Dept of Risk Management WC	$49.37
Rate for Payer: LLUH Dept of Risk Management WC	$61.71
Rate for Payer: Multiplan Commercial	$35.10
Rate for Payer: Multiplan Commercial	$67.32
Rate for Payer: Multiplan Commercial	$24.50
Rate for Payer: Multiplan Commercial	$84.15

MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]

Facility

IP

$89.76

Service Code	HCPCS J2247
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$49.37
Max. Negotiated Rate	$71.81
Rate for Payer: Cash Price	$49.37
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.81
Rate for Payer: Health Smart Auto/Commercial	$53.86
Rate for Payer: LLUH Dept of Risk Management WC	$49.37
Rate for Payer: Multiplan Commercial	$67.32

MICAFUNGIN 50 MG INTRAVENOUS SOLUTION [41144]

Facility

IP

$89.76

Service Code	HCPCS J2248
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$49.37
Max. Negotiated Rate	$71.81
Rate for Payer: Cash Price	$49.37
Rate for Payer: Cash Price	$25.74
Rate for Payer: Cash Price	$61.71
Rate for Payer: Cash Price	$17.97
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$37.44
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$71.81
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$26.13
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$89.76
Rate for Payer: Health Smart Auto/Commercial	$67.32
Rate for Payer: Health Smart Auto/Commercial	$28.08
Rate for Payer: Health Smart Auto/Commercial	$19.60
Rate for Payer: Health Smart Auto/Commercial	$53.86
Rate for Payer: LLUH Dept of Risk Management WC	$17.96
Rate for Payer: LLUH Dept of Risk Management WC	$61.71
Rate for Payer: LLUH Dept of Risk Management WC	$25.74
Rate for Payer: LLUH Dept of Risk Management WC	$49.37
Rate for Payer: Multiplan Commercial	$24.50
Rate for Payer: Multiplan Commercial	$67.32
Rate for Payer: Multiplan Commercial	$84.15
Rate for Payer: Multiplan Commercial	$35.10

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