Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

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	1740337
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.19
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	$0.11
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 Beech St/Commercial/PHCS	$0.19

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

Facility

OP

$0.53

Service Code	NDC 0065-0419-18
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

$0.25

Service Code	NDC 0065-0416-22
Hospital Charge Code	1740337
Hospital Revenue Code	259
Min. Negotiated Rate	$0.14
Max. Negotiated Rate	$0.20
Rate for Payer: Cash Price	$0.11
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.19

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

Facility

IP

$0.53

Service Code	NDC 0065-0419-18
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

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

IP

$0.33

Service Code	NDC 0065-8063-01
Hospital Charge Code	1740337
Hospital Revenue Code	259
Min. Negotiated Rate	$0.18
Max. Negotiated Rate	$0.26
Rate for Payer: Cash Price	$0.15
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.25

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	1740337
Hospital Revenue Code	259
Min. Negotiated Rate	$0.17
Max. Negotiated Rate	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.18
Rate for Payer: Cash Price	$0.14
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: 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 Beech St/Commercial/PHCS	$0.23

DEXTRANOMER 50MG-HYALURONATE 15MG/ML(1)-0.9%SODCHL GEL IMPLANT SYRINGE [227990]

Facility

IP

$3,466.32

Service Code	CPT L8604
Hospital Charge Code	NDG227990
Hospital Revenue Code	278
Min. Negotiated Rate	$1,906.48
Max. Negotiated Rate	$2,773.06
Rate for Payer: Cash Price	$1,559.84
Rate for Payer: Cigna of CA HMO/PPO	$2,773.06
Rate for Payer: Health Smart Auto/Commercial	$2,079.79
Rate for Payer: LLUH Dept of Risk Management WC	$1,906.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,599.74

DEXTRANOMER 50MG-HYALURONATE 15MG/ML(1)-0.9%SODCHL GEL IMPLANT SYRINGE [227990]

Facility

OP

$3,466.32

Service Code	CPT L8604
Hospital Charge Code	NDG227990
Hospital Revenue Code	278
Min. Negotiated Rate	$1,906.48
Max. Negotiated Rate	$2,599.74
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2,079.79
Rate for Payer: Aetna of CA Government/Medicare	$2,079.79
Rate for Payer: Cash Price	$1,559.84
Rate for Payer: Health Smart Auto/Commercial	$2,079.79
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2,079.79
Rate for Payer: LLUH Dept of Risk Management WC	$1,906.48
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$2,599.74

DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET [111424]

Facility

IP

$0.45

Service Code	NDC 0185-0853-01
Hospital Charge Code	1730113
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of CA HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.34

DEXTROAMPHETAMINE-AMPHETAMINE 20 MG TABLET [111424]

Facility

OP

$0.45

Service Code	NDC 0185-0853-01
Hospital Charge Code	1730113
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.34

DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]

Facility

OP

$0.45

Service Code	NDC 0185-0831-01
Hospital Charge Code	1731013
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.34
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.27
Rate for Payer: Aetna of CA Government/Medicare	$0.27
Rate for Payer: Cash Price	$0.20
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.34

DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]

Facility

IP

$0.45

Service Code	NDC 0185-0831-01
Hospital Charge Code	1731013
Hospital Revenue Code	259
Min. Negotiated Rate	$0.25
Max. Negotiated Rate	$0.36
Rate for Payer: Cash Price	$0.20
Rate for Payer: Cigna of CA HMO/PPO	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.27
Rate for Payer: LLUH Dept of Risk Management WC	$0.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.34

DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]

Facility

OP

$0.61

Service Code	NDC 0406-8891-01
Hospital Charge Code	1731013
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.46
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	$0.27
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 Beech St/Commercial/PHCS	$0.46

DEXTROAMPHETAMINE-AMPHETAMINE 5 MG TABLET [112071]

Facility

IP

$0.61

Service Code	NDC 0406-8891-01
Hospital Charge Code	1731013
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.49
Rate for Payer: Cash Price	$0.27
Rate for Payer: Cigna of CA HMO/PPO	$0.49
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.46

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP. [4089774]

Facility

IP

$0.50

Service Code	NDC 0121-0638-05
Hospital Charge Code	1716018
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP. [4089774]

Facility

OP

$0.50

Service Code	NDC 0121-0638-05
Hospital Charge Code	1716018
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP. [4089774]

Facility

OP

$0.50

Service Code	NDC 0121-0638-00
Hospital Charge Code	1716018
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.30
Rate for Payer: Aetna of CA Government/Medicare	$0.30
Rate for Payer: Cash Price	$0.23
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-100 MG/5 ML SYRUP. [4089774]

Facility

IP

$0.50

Service Code	NDC 0121-0638-00
Hospital Charge Code	1716018
Hospital Revenue Code	259
Min. Negotiated Rate	$0.28
Max. Negotiated Rate	$0.40
Rate for Payer: Cash Price	$0.23
Rate for Payer: Cigna of CA HMO/PPO	$0.40
Rate for Payer: Health Smart Auto/Commercial	$0.30
Rate for Payer: LLUH Dept of Risk Management WC	$0.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.38

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-200 MG/5 ML ORAL LIQUID [15097]

Facility

IP

$0.05

Service Code	NDC 6056906404
Hospital Charge Code	NDG15097
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Cash Price	$0.02
Rate for Payer: Cigna of CA HMO/PPO	$0.04
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

DEXTROMETHORPHAN-GUAIFENESIN 10 MG-200 MG/5 ML ORAL LIQUID [15097]

Facility

OP

$0.05

Service Code	NDC 6056906404
Hospital Charge Code	NDG15097
Hospital Revenue Code	259
Min. Negotiated Rate	$0.03
Max. Negotiated Rate	$0.04
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.03
Rate for Payer: Aetna of CA Government/Medicare	$0.03
Rate for Payer: Cash Price	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.03
Rate for Payer: LLUH Dept of Risk Management WC	$0.03
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.04

DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR [9773]

Facility

OP

$0.12

Service Code	NDC 63824-171-63
Hospital Charge Code	1719206
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.09
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.07
Rate for Payer: Aetna of CA Government/Medicare	$0.07
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

DEXTROMETHORPHAN POLISTIREX ER 30 MG/5 ML ORAL SUSP EXT.RELEASE 12HR [9773]

Facility

IP

$0.12

Service Code	NDC 63824-171-63
Hospital Charge Code	1719206
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.07
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.09

DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9808]

Facility

IP

$0.02

Service Code	NDC 0264-7623-20
Hospital Charge Code	1771305
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Cash Price	$0.01
Rate for Payer: Cigna of CA HMO/PPO	$0.02
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

DEXTROSE 10 % AND 0.2 % SODIUM CHLORIDE INTRAVENOUS SOLUTION [9808]

Facility

OP

$0.02

Service Code	NDC 0264-7623-20
Hospital Charge Code	1771305
Hospital Revenue Code	250
Min. Negotiated Rate	$0.01
Max. Negotiated Rate	$0.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.01
Rate for Payer: Aetna of CA Government/Medicare	$0.01
Rate for Payer: Cash Price	$0.01
Rate for Payer: Health Smart Auto/Commercial	$0.01
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.01
Rate for Payer: LLUH Dept of Risk Management WC	$0.01
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.02

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