Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

DEXAMETHASONE SODIUM PHOSPHATE (PF) 10 MG/ML INJECTION SYRINGE [225593]

Facility

IP

$6.94

Service Code	CPT J1100
Hospital Charge Code	NDG225593
Hospital Revenue Code	636
Min. Negotiated Rate	$3.82
Max. Negotiated Rate	$5.55
Rate for Payer: Cash Price	$3.12
Rate for Payer: Cigna of CA HMO/PPO	$5.55
Rate for Payer: Health Smart Auto/Commercial	$4.16
Rate for Payer: LLUH Dept of Risk Management WC	$3.82
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.20

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$7.80

Service Code	NDC 0143-9532-25
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$6.24
Rate for Payer: Cash Price	$3.51
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$5.85

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$3.25

Service Code	NDC 70860-605-03
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.60
Rate for Payer: Cash Price	$1.46
Rate for Payer: Cigna of CA HMO/PPO	$2.60
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$3.24

Service Code	NDC 71288-505-03
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Cash Price	$1.46
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.43

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$7.80

Service Code	NDC 0143-9532-01
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$6.24
Rate for Payer: Cash Price	$3.51
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$5.85

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$3.25

Service Code	NDC 42023-146-25
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.60
Rate for Payer: Cash Price	$1.46
Rate for Payer: Cigna of CA HMO/PPO	$2.60
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$4.32

Service Code	NDC 55150-209-02
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.46
Rate for Payer: Cash Price	$1.94
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$3.24

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$3.24

Service Code	NDC 71288-505-02
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.59
Rate for Payer: Cash Price	$1.46
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$2.43

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$7.80

Service Code	NDC 0143-9532-01
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$5.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.68
Rate for Payer: Aetna of CA Government/Medicare	$4.68
Rate for Payer: Cash Price	$3.51
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.68
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.85

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$4.32

Service Code	NDC 55150-209-02
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.24
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	$1.94
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 Beech St/Commercial/PHCS	$3.24

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$3.25

Service Code	NDC 70860-605-41
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.95
Rate for Payer: Aetna of CA Government/Medicare	$1.95
Rate for Payer: Cash Price	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$3.25

Service Code	NDC 70860-605-03
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.95
Rate for Payer: Aetna of CA Government/Medicare	$1.95
Rate for Payer: Cash Price	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$3.24

Service Code	NDC 71288-505-03
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.43
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	$1.46
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 Beech St/Commercial/PHCS	$2.43

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$7.80

Service Code	NDC 0143-9532-25
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$4.29
Max. Negotiated Rate	$5.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.68
Rate for Payer: Aetna of CA Government/Medicare	$4.68
Rate for Payer: Cash Price	$3.51
Rate for Payer: Health Smart Auto/Commercial	$4.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.68
Rate for Payer: LLUH Dept of Risk Management WC	$4.29
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.85

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

IP

$3.25

Service Code	NDC 70860-605-41
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.60
Rate for Payer: Cash Price	$1.46
Rate for Payer: Cigna of CA HMO/PPO	$2.60
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$3.24

Service Code	NDC 71288-505-02
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.78
Max. Negotiated Rate	$2.43
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	$1.46
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 Beech St/Commercial/PHCS	$2.43

DEXMEDETOMIDINE 100 MCG/ML INTRAVENOUS SOLUTION [27103]

Facility

OP

$3.25

Service Code	NDC 42023-146-25
Hospital Charge Code	1759932
Hospital Revenue Code	250
Min. Negotiated Rate	$1.79
Max. Negotiated Rate	$2.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.95
Rate for Payer: Aetna of CA Government/Medicare	$1.95
Rate for Payer: Cash Price	$1.46
Rate for Payer: Health Smart Auto/Commercial	$1.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.95
Rate for Payer: LLUH Dept of Risk Management WC	$1.79
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2.44

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

Facility

IP

$0.72

Service Code	NDC 71225-132-02
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.58
Rate for Payer: Cash Price	$0.32
Rate for Payer: Cigna of CA HMO/PPO	$0.58
Rate for Payer: Health Smart Auto/Commercial	$0.43
Rate for Payer: LLUH Dept of Risk Management WC	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

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

Facility

IP

$0.41

Service Code	NDC 0143-9526-10
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.31

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

Facility

OP

$0.72

Service Code	NDC 0781-3494-91
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
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	$0.32
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	$0.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.54

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

Facility

IP

$0.41

Service Code	NDC 0143-9526-01
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.31

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

Facility

IP

$0.67

Service Code	NDC 0409-1660-50
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.54
Rate for Payer: Cash Price	$0.30
Rate for Payer: Cigna of CA HMO/PPO	$0.54
Rate for Payer: Health Smart Auto/Commercial	$0.40
Rate for Payer: LLUH Dept of Risk Management WC	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

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

Facility

IP

$1.03

Service Code	NDC 55150-296-10
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.82
Rate for Payer: Cash Price	$0.46
Rate for Payer: Cigna of CA HMO/PPO	$0.82
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

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

Facility

OP

$0.41

Service Code	NDC 0143-9526-10
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.31
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	$0.18
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 Beech St/Commercial/PHCS	$0.31

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

Facility

OP

$0.67

Service Code	NDC 0409-1660-55
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.37
Max. Negotiated Rate	$0.50
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	$0.30
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	$0.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.50

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