Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

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

OP

$0.72

Service Code	NDC 71225-132-02
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.40
Max. Negotiated Rate	$0.54
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

OP

$1.03

Service Code	NDC 55150-296-01
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

IP

$0.72

Service Code	NDC 0781-3494-95
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

$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

IP

$1.03

Service Code	NDC 55150-296-01
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

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

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

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

$0.72

Service Code	NDC 71225-132-01
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

$0.72

Service Code	NDC 0781-3494-91
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

OP

$1.03

Service Code	NDC 55150-296-10
Hospital Charge Code	NDG201902
Hospital Revenue Code	250
Min. Negotiated Rate	$0.57
Max. Negotiated Rate	$0.77
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.62
Rate for Payer: Aetna of CA Government/Medicare	$0.62
Rate for Payer: Cash Price	$0.46
Rate for Payer: Health Smart Auto/Commercial	$0.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.62
Rate for Payer: LLUH Dept of Risk Management WC	$0.57
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.77

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

Facility

OP

$0.60

Service Code	NDC 0409-1660-35
Hospital Charge Code	NDG201904
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
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	$0.27
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 Beech St/Commercial/PHCS	$0.45

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

Facility

IP

$0.60

Service Code	NDC 0409-1660-10
Hospital Charge Code	NDG201904
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.45

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

Facility

IP

$0.60

Service Code	NDC 0409-1660-35
Hospital Charge Code	NDG201904
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.48
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.45

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

Facility

OP

$0.60

Service Code	NDC 0409-1660-10
Hospital Charge Code	NDG201904
Hospital Revenue Code	250
Min. Negotiated Rate	$0.33
Max. Negotiated Rate	$0.45
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	$0.27
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 Beech St/Commercial/PHCS	$0.45

DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]

Facility

IP

$455.94

Service Code	CPT J1190
Hospital Charge Code	ERX40815157
Hospital Revenue Code	636
Min. Negotiated Rate	$250.77
Max. Negotiated Rate	$364.75
Rate for Payer: Cash Price	$205.17
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$341.96

DEXRAZOXANE (CARDIOXANE) HCL 500 MG INTRAVENOUS [40815157]

Facility

OP

$455.94

Service Code	CPT J1190
Hospital Charge Code	ERX40815157
Hospital Revenue Code	636
Min. Negotiated Rate	$250.77
Max. Negotiated Rate	$341.96
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	$205.17
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 Beech St/Commercial/PHCS	$341.96

DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]

Facility

IP

$329.11

Service Code	CPT J1190
Hospital Charge Code	ERX15156
Hospital Revenue Code	636
Min. Negotiated Rate	$181.01
Max. Negotiated Rate	$263.29
Rate for Payer: Cash Price	$148.10
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$246.83

DEXRAZOXANE HCL 250 MG INTRAVENOUS SOLUTION [15156]

Facility

OP

$329.11

Service Code	CPT J1190
Hospital Charge Code	ERX15156
Hospital Revenue Code	636
Min. Negotiated Rate	$181.01
Max. Negotiated Rate	$246.83
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	$148.10
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 Beech St/Commercial/PHCS	$246.83

DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION [15157]

Facility

OP

$478.80

Service Code	CPT J1190
Hospital Charge Code	ERX15157
Hospital Revenue Code	636
Min. Negotiated Rate	$263.34
Max. Negotiated Rate	$359.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$287.28
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$394.93
Rate for Payer: Aetna of CA Government/Medicare	$287.28
Rate for Payer: Aetna of CA Government/Medicare	$394.93
Rate for Payer: Cash Price	$296.19
Rate for Payer: Cash Price	$215.46
Rate for Payer: Health Smart Auto/Commercial	$394.93
Rate for Payer: Health Smart Auto/Commercial	$287.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$394.93
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$287.28
Rate for Payer: LLUH Dept of Risk Management WC	$263.34
Rate for Payer: LLUH Dept of Risk Management WC	$362.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$359.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$493.66

DEXRAZOXANE HCL 500 MG INTRAVENOUS SOLUTION [15157]

Facility

IP

$658.21

Service Code	CPT J1190
Hospital Charge Code	ERX15157
Hospital Revenue Code	636
Min. Negotiated Rate	$362.02
Max. Negotiated Rate	$526.57
Rate for Payer: Cash Price	$296.19
Rate for Payer: Cash Price	$215.46
Rate for Payer: Cigna of CA HMO/PPO	$383.04
Rate for Payer: Cigna of CA HMO/PPO	$526.57
Rate for Payer: Health Smart Auto/Commercial	$287.28
Rate for Payer: Health Smart Auto/Commercial	$394.93
Rate for Payer: LLUH Dept of Risk Management WC	$362.02
Rate for Payer: LLUH Dept of Risk Management WC	$263.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$493.66
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$359.10

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

Facility

OP

$0.53

Service Code	NDC 0065-0419-28
Hospital Charge Code	1740337
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.40
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	$0.24
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 Beech St/Commercial/PHCS	$0.40

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

Facility

IP

$0.53

Service Code	NDC 0065-0419-28
Hospital Charge Code	1740337
Hospital Revenue Code	259
Min. Negotiated Rate	$0.29
Max. Negotiated Rate	$0.42
Rate for Payer: Cash Price	$0.24
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.40

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	1740337
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.25
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	$0.15
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 Beech St/Commercial/PHCS	$0.25

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