Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]

Facility

IP

$13.40

Service Code	CPT A9573
Hospital Charge Code	NDG236211C
Hospital Revenue Code	254
Min. Negotiated Rate	$7.37
Max. Negotiated Rate	$10.72
Rate for Payer: Cash Price	$6.03
Rate for Payer: Cigna of CA HMO/PPO	$10.72
Rate for Payer: Health Smart Auto/Commercial	$8.04
Rate for Payer: LLUH Dept of Risk Management WC	$7.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.05

GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]

Facility

IP

$13.46

Service Code	CPT A9573
Hospital Charge Code	NDG236211B
Hospital Revenue Code	254
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$10.77
Rate for Payer: Health Smart Auto/Commercial	$8.08
Rate for Payer: Cash Price	$6.06
Rate for Payer: Cigna of CA HMO/PPO	$10.77
Rate for Payer: LLUH Dept of Risk Management WC	$7.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.10

GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]

Facility

IP

$13.56

Service Code	CPT A9573
Hospital Charge Code	NDG236211A
Hospital Revenue Code	254
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$10.85
Rate for Payer: Cash Price	$6.10
Rate for Payer: Cigna of CA HMO/PPO	$10.85
Rate for Payer: Health Smart Auto/Commercial	$8.14
Rate for Payer: LLUH Dept of Risk Management WC	$7.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.17

GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]

Facility

OP

$13.56

Service Code	CPT A9573
Hospital Charge Code	NDG236211A
Hospital Revenue Code	254
Min. Negotiated Rate	$7.46
Max. Negotiated Rate	$10.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.14
Rate for Payer: Aetna of CA Government/Medicare	$8.14
Rate for Payer: Cash Price	$6.10
Rate for Payer: Health Smart Auto/Commercial	$8.14
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.14
Rate for Payer: LLUH Dept of Risk Management WC	$7.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.17

GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]

Facility

OP

$13.46

Service Code	CPT A9573
Hospital Charge Code	NDG236211B
Hospital Revenue Code	254
Min. Negotiated Rate	$7.40
Max. Negotiated Rate	$10.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.08
Rate for Payer: Aetna of CA Government/Medicare	$8.08
Rate for Payer: Cash Price	$6.06
Rate for Payer: Health Smart Auto/Commercial	$8.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.08
Rate for Payer: LLUH Dept of Risk Management WC	$7.40
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.10

GADOPICLENOL 0.5 MMOL/ML INTRAVENOUS SOLUTION [236211]

Facility

OP

$13.40

Service Code	CPT A9573
Hospital Charge Code	NDG236211C
Hospital Revenue Code	254
Min. Negotiated Rate	$7.37
Max. Negotiated Rate	$10.05
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$8.04
Rate for Payer: Aetna of CA Government/Medicare	$8.04
Rate for Payer: Cash Price	$6.03
Rate for Payer: Health Smart Auto/Commercial	$8.04
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$8.04
Rate for Payer: LLUH Dept of Risk Management WC	$7.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$10.05

GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]

Facility

IP

$6.04

Service Code	CPT A9575
Hospital Charge Code	NDG201457
Hospital Revenue Code	255
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.83
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: Cash Price	$2.72
Rate for Payer: Cigna of CA HMO/PPO	$4.83
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.53

GADOTERATE MEGLUMINE 0.5 MMOL/ML (376.9 MG/ML) INTRAVENOUS SOLUTION [201457]

Facility

OP

$6.04

Service Code	CPT A9575
Hospital Charge Code	NDG201457
Hospital Revenue Code	255
Min. Negotiated Rate	$3.32
Max. Negotiated Rate	$4.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.62
Rate for Payer: Aetna of CA Government/Medicare	$3.62
Rate for Payer: Cash Price	$2.72
Rate for Payer: Health Smart Auto/Commercial	$3.62
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.62
Rate for Payer: LLUH Dept of Risk Management WC	$3.32
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.53

GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]

Facility

OP

$6.52

Service Code	CPT A9575
Hospital Charge Code	NDG203433
Hospital Revenue Code	255
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$4.89
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.91
Rate for Payer: Aetna of CA Government/Medicare	$3.91
Rate for Payer: Cash Price	$2.93
Rate for Payer: Health Smart Auto/Commercial	$3.91
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.91
Rate for Payer: LLUH Dept of Risk Management WC	$3.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.89

GADOTERATE MEGLUMINE 0.5 MMOL/ML INTRAVENOUS SYRINGE [203433]

Facility

IP

$6.52

Service Code	CPT A9575
Hospital Charge Code	NDG203433
Hospital Revenue Code	255
Min. Negotiated Rate	$3.59
Max. Negotiated Rate	$5.22
Rate for Payer: Cash Price	$2.93
Rate for Payer: Cigna of CA HMO/PPO	$5.22
Rate for Payer: Health Smart Auto/Commercial	$3.91
Rate for Payer: LLUH Dept of Risk Management WC	$3.59
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.89

GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]

Facility

OP

$17.04

Service Code	CPT A9581
Hospital Charge Code	NDG93574
Hospital Revenue Code	255
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$12.78
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.22
Rate for Payer: Aetna of CA Government/Medicare	$10.22
Rate for Payer: Cash Price	$7.67
Rate for Payer: Health Smart Auto/Commercial	$10.22
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.22
Rate for Payer: LLUH Dept of Risk Management WC	$9.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.78

GADOXETATE 0.25 MMOL/ML (181.43 MG/ML) INTRAVENOUS SOLUTION [93574]

Facility

IP

$17.04

Service Code	CPT A9581
Hospital Charge Code	NDG93574
Hospital Revenue Code	255
Min. Negotiated Rate	$9.37
Max. Negotiated Rate	$13.63
Rate for Payer: Cash Price	$7.67
Rate for Payer: Cigna of CA HMO/PPO	$13.63
Rate for Payer: Health Smart Auto/Commercial	$10.22
Rate for Payer: LLUH Dept of Risk Management WC	$9.37
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$12.78

GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]

Facility

OP

$5.50

Service Code	NDC 0378-8106-93
Hospital Charge Code	1711941
Hospital Revenue Code	259
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$4.12
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$3.30
Rate for Payer: Aetna of CA Government/Medicare	$3.30
Rate for Payer: Cash Price	$2.48
Rate for Payer: Health Smart Auto/Commercial	$3.30
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.12

GALANTAMINE ER 16 MG 24 HR CAPSULE,EXTENDED RELEASE [41139]

Facility

IP

$5.50

Service Code	NDC 0378-8106-93
Hospital Charge Code	1711941
Hospital Revenue Code	259
Min. Negotiated Rate	$3.02
Max. Negotiated Rate	$4.40
Rate for Payer: Cash Price	$2.48
Rate for Payer: Cigna of CA HMO/PPO	$4.40
Rate for Payer: Health Smart Auto/Commercial	$3.30
Rate for Payer: LLUH Dept of Risk Management WC	$3.02
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$4.12

GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]

Facility

IP

$537.12

Service Code	CPT J1458
Hospital Charge Code	1759999
Hospital Revenue Code	636
Min. Negotiated Rate	$295.42
Max. Negotiated Rate	$429.70
Rate for Payer: Cash Price	$241.70
Rate for Payer: Cigna of CA HMO/PPO	$429.70
Rate for Payer: Health Smart Auto/Commercial	$322.27
Rate for Payer: LLUH Dept of Risk Management WC	$295.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$402.84

GALSULFASE 5 MG/5 ML INTRAVENOUS SOLUTION [41550]

Facility

OP

$537.12

Service Code	CPT J1458
Hospital Charge Code	1759999
Hospital Revenue Code	636
Min. Negotiated Rate	$295.42
Max. Negotiated Rate	$402.84
Rate for Payer: Cash Price	$241.70
Rate for Payer: Health Smart Auto/Commercial	$322.27
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$322.27
Rate for Payer: Aetna of CA Government/Medicare	$322.27
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$322.27
Rate for Payer: LLUH Dept of Risk Management WC	$295.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$402.84

GANCICLOVIR 0.15 % EYE GEL [104575]

Facility

IP

$106.43

Service Code	NDC 24208-535-35
Hospital Charge Code	1740429
Hospital Revenue Code	259
Min. Negotiated Rate	$58.54
Max. Negotiated Rate	$85.14
Rate for Payer: Cash Price	$47.89
Rate for Payer: Cigna of CA HMO/PPO	$85.14
Rate for Payer: Health Smart Auto/Commercial	$63.86
Rate for Payer: LLUH Dept of Risk Management WC	$58.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$79.82

GANCICLOVIR 0.15 % EYE GEL [104575]

Facility

OP

$106.43

Service Code	NDC 24208-535-35
Hospital Charge Code	1740429
Hospital Revenue Code	259
Min. Negotiated Rate	$58.54
Max. Negotiated Rate	$79.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$63.86
Rate for Payer: Aetna of CA Government/Medicare	$63.86
Rate for Payer: Cash Price	$47.89
Rate for Payer: Health Smart Auto/Commercial	$63.86
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$63.86
Rate for Payer: LLUH Dept of Risk Management WC	$58.54
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$79.82

GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]

Facility

OP

$82.08

Service Code	NDC 0143-9299-01
Hospital Charge Code	1753151
Hospital Revenue Code	636
Min. Negotiated Rate	$45.14
Max. Negotiated Rate	$61.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.25
Rate for Payer: Aetna of CA Government/Medicare	$49.25
Rate for Payer: Cash Price	$36.94
Rate for Payer: Health Smart Auto/Commercial	$49.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.25
Rate for Payer: LLUH Dept of Risk Management WC	$45.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.56

GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]

Facility

OP

$82.08

Service Code	NDC 0143-9299-10
Hospital Charge Code	1753151
Hospital Revenue Code	636
Min. Negotiated Rate	$45.14
Max. Negotiated Rate	$61.56
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$49.25
Rate for Payer: Aetna of CA Government/Medicare	$49.25
Rate for Payer: Cash Price	$36.94
Rate for Payer: Health Smart Auto/Commercial	$49.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$49.25
Rate for Payer: LLUH Dept of Risk Management WC	$45.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.56

GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]

Facility

IP

$82.08

Service Code	NDC 0143-9299-01
Hospital Charge Code	1753151
Hospital Revenue Code	636
Min. Negotiated Rate	$45.14
Max. Negotiated Rate	$65.66
Rate for Payer: Cash Price	$36.94
Rate for Payer: Cigna of CA HMO/PPO	$65.66
Rate for Payer: Health Smart Auto/Commercial	$49.25
Rate for Payer: LLUH Dept of Risk Management WC	$45.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.56

GANCICLOVIR SODIUM 500 MG INTRAVENOUS SOLUTION [10101]

Facility

IP

$82.08

Service Code	NDC 0143-9299-10
Hospital Charge Code	1753151
Hospital Revenue Code	636
Min. Negotiated Rate	$45.14
Max. Negotiated Rate	$65.66
Rate for Payer: Cash Price	$36.94
Rate for Payer: Cigna of CA HMO/PPO	$65.66
Rate for Payer: Health Smart Auto/Commercial	$49.25
Rate for Payer: LLUH Dept of Risk Management WC	$45.14
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$61.56

GELATIN ABSORBABLE EYE FILM [28028]

Facility

IP

$268.54

Service Code	NDC 0009-0297-01
Hospital Charge Code	ERX28028
Hospital Revenue Code	250
Min. Negotiated Rate	$147.70
Max. Negotiated Rate	$214.83
Rate for Payer: Cash Price	$120.84
Rate for Payer: Cigna of CA HMO/PPO	$214.83
Rate for Payer: Health Smart Auto/Commercial	$161.12
Rate for Payer: LLUH Dept of Risk Management WC	$147.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$201.40

GELATIN ABSORBABLE EYE FILM [28028]

Facility

OP

$268.54

Service Code	NDC 0009-0297-01
Hospital Charge Code	ERX28028
Hospital Revenue Code	250
Min. Negotiated Rate	$147.70
Max. Negotiated Rate	$201.40
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$161.12
Rate for Payer: Aetna of CA Government/Medicare	$161.12
Rate for Payer: Cash Price	$120.84
Rate for Payer: Health Smart Auto/Commercial	$161.12
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$161.12
Rate for Payer: LLUH Dept of Risk Management WC	$147.70
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$201.40

GELATIN ABSORBABLE IMPLANT FILM [111340]

Facility

IP

$2,441.98

Service Code	NDC 0009-0283-01
Hospital Charge Code	1780004
Hospital Revenue Code	250
Min. Negotiated Rate	$1,343.09
Max. Negotiated Rate	$1,953.58
Rate for Payer: Cash Price	$1,098.89
Rate for Payer: Cigna of CA HMO/PPO	$1,953.58
Rate for Payer: Health Smart Auto/Commercial	$1,465.19
Rate for Payer: LLUH Dept of Risk Management WC	$1,343.09
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1,831.48

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