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Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$3.24

Service Code	NDC 71288-505-03
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$7.80

Service Code	NDC 0143-9532-25
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$6.24
Rate for Payer: Cash Price	$4.29
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$6.24
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: Multiplan Commercial	$5.85

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$4.32

Service Code	NDC 55150-209-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.46
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.59
Rate for Payer: Aetna of CA Government/Medicare	$2.59
Rate for Payer: Cash Price	$2.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.46
Rate for Payer: Health Smart Auto/Commercial	$2.59
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.59
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Commercial	$3.24

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$2.02

Service Code	NDC 70860-605-41
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.62
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.62
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$4.32

Service Code	NDC 55150-209-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.46
Rate for Payer: Cash Price	$2.38
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$3.46
Rate for Payer: Health Smart Auto/Commercial	$2.59
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Commercial	$3.24

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$3.24

Service Code	NDC 71288-505-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$2.02

Service Code	NDC 70860-605-41
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.11
Max. Negotiated Rate	$1.62
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.21
Rate for Payer: Aetna of CA Government/Medicare	$1.21
Rate for Payer: Cash Price	$1.11
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.62
Rate for Payer: Health Smart Auto/Commercial	$1.21
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.21
Rate for Payer: LLUH Dept of Risk Management WC	$1.11
Rate for Payer: Multiplan Commercial	$1.51

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$3.15

Service Code	NDC 66794-230-42
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.73
Max. Negotiated Rate	$2.52
Rate for Payer: Cash Price	$1.73
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.52
Rate for Payer: Health Smart Auto/Commercial	$1.89
Rate for Payer: LLUH Dept of Risk Management WC	$1.73
Rate for Payer: Multiplan Commercial	$2.36

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$3.24

Service Code	NDC 71288-505-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.94
Rate for Payer: Aetna of CA Government/Medicare	$1.94
Rate for Payer: Cash Price	$1.78
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.59
Rate for Payer: Health Smart Auto/Commercial	$1.94
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.94
Rate for Payer: LLUH Dept of Risk Management WC	$1.78
Rate for Payer: Multiplan Commercial	$2.43

DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]

Facility

OP

$0.62

Service Code	NDC 66794-234-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]

Facility

IP

$0.62

Service Code	NDC 66794-234-44
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]

Facility

IP

$0.62

Service Code	NDC 66794-234-02
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

DEXMEDETOMIDINE 200 MCG/50 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201902]

Facility

OP

$0.62

Service Code	NDC 66794-234-44
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.37
Rate for Payer: Aetna of CA Government/Medicare	$0.37
Rate for Payer: Cash Price	$0.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Commercial	$0.47

DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]

Facility

OP

$0.41

Service Code	NDC 9940-8202-59
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
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	$0.33
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	$0.31

DEXMEDETOMIDINE 400 MCG/100 ML (4 MCG/ML) IN 0.9 % SODIUM CHLORIDE IV [201904]

Facility

IP

$0.41

Service Code	NDC 9940-8202-59
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Cash Price	$0.23
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.33
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	$0.31

DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]

Facility

IP

$455.94

Service Code	HCPCS J1190
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$250.77
Max. Negotiated Rate	$364.75
Rate for Payer: Cash Price	$250.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$364.75
Rate for Payer: Health Smart Auto/Commercial	$273.56
Rate for Payer: LLUH Dept of Risk Management WC	$250.77
Rate for Payer: Multiplan Commercial	$341.95

DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]

Facility

OP

$455.94

Service Code	HCPCS J1190
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$250.77
Max. Negotiated Rate	$364.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$273.56
Rate for Payer: Aetna of CA Government/Medicare	$273.56
Rate for Payer: Cash Price	$250.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$364.75
Rate for Payer: Health Smart Auto/Commercial	$273.56
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$273.56
Rate for Payer: LLUH Dept of Risk Management WC	$250.77
Rate for Payer: Multiplan Commercial	$341.95

DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]

Facility

IP

$329.11

Service Code	HCPCS J1190
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$181.01
Max. Negotiated Rate	$263.29
Rate for Payer: Cash Price	$181.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$263.29
Rate for Payer: Health Smart Auto/Commercial	$197.47
Rate for Payer: LLUH Dept of Risk Management WC	$181.01
Rate for Payer: Multiplan Commercial	$246.83

DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]

Facility

OP

$329.11

Service Code	HCPCS J1190
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$181.01
Max. Negotiated Rate	$263.29
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$197.47
Rate for Payer: Aetna of CA Government/Medicare	$197.47
Rate for Payer: Cash Price	$181.01
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$263.29
Rate for Payer: Health Smart Auto/Commercial	$197.47
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$197.47
Rate for Payer: LLUH Dept of Risk Management WC	$181.01
Rate for Payer: Multiplan Commercial	$246.83

DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]

Facility

OP

$0.30

Service Code	NDC 0065-0416-63
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.18
Rate for Payer: Aetna of CA Government/Medicare	$0.18
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]

Facility

OP

$0.33

Service Code	NDC 0065-8063-01
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	$0.20
Rate for Payer: Aetna of CA Government/Medicare	$0.20
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	$0.20
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]

Facility

IP

$0.25

Service Code	NDC 0065-0416-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]

Facility

IP

$0.30

Service Code	NDC 0065-0416-63
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.24
Rate for Payer: Cash Price	$0.16
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.24
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: LLUH Dept of Risk Management WC	$0.17
Rate for Payer: Multiplan Commercial	$0.23

DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]

Facility

OP

$0.25

Service Code	NDC 0065-0416-22
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.15
Rate for Payer: Aetna of CA Government/Medicare	$0.15
Rate for Payer: Cash Price	$0.14
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.15
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.15
Rate for Payer: LLUH Dept of Risk Management WC	$0.14
Rate for Payer: Multiplan Commercial	$0.19

DEXTRAN 70-HYPROMELLOSE (PF) 0.1 %-0.3 % EYE DROPS IN A DROPPERETTE [120696]

Facility

IP

$0.33

Service Code	NDC 0065-8063-01
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	$0.20
Rate for Payer: LLUH Dept of Risk Management WC	$0.18
Rate for Payer: Multiplan Commercial	$0.25

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