Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

OP

$2.28

Service Code	NDC 68094-034-64
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.37
Rate for Payer: Aetna of CA Government/Medicare	$1.37
Rate for Payer: Cash Price	$1.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.82
Rate for Payer: Health Smart Auto/Commercial	$1.37
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.37
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Commercial	$1.71

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

IP

$1.39

Service Code	NDC 50268-720-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.11
Rate for Payer: Cash Price	$0.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.11
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Commercial	$1.04

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

IP

$1.39

Service Code	NDC 50268-720-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.11
Rate for Payer: Cash Price	$0.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.11
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Commercial	$1.04

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

IP

$0.36

Service Code	NDC 69097-967-93
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

OP

$1.39

Service Code	NDC 50268-720-15
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.83
Rate for Payer: Aetna of CA Government/Medicare	$0.83
Rate for Payer: Cash Price	$0.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.11
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Commercial	$1.04

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

IP

$2.28

Service Code	NDC 68094-034-64
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.82
Rate for Payer: Health Smart Auto/Commercial	$1.37
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Commercial	$1.71

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

IP

$0.36

Service Code	NDC 65862-921-27
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.20
Max. Negotiated Rate	$0.29
Rate for Payer: Cash Price	$0.20
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.29
Rate for Payer: Health Smart Auto/Commercial	$0.22
Rate for Payer: LLUH Dept of Risk Management WC	$0.20
Rate for Payer: Multiplan Commercial	$0.27

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

IP

$0.47

Service Code	NDC 24979-186-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

IP

$2.28

Service Code	NDC 68094-034-59
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.25
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.82
Rate for Payer: Health Smart Auto/Commercial	$1.37
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Commercial	$1.71

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

OP

$0.47

Service Code	NDC 24979-186-46
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

OP

$1.39

Service Code	NDC 50268-720-11
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.76
Max. Negotiated Rate	$1.11
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.83
Rate for Payer: Aetna of CA Government/Medicare	$0.83
Rate for Payer: Cash Price	$0.76
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.11
Rate for Payer: Health Smart Auto/Commercial	$0.83
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.83
Rate for Payer: LLUH Dept of Risk Management WC	$0.76
Rate for Payer: Multiplan Commercial	$1.04

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

OP

$0.47

Service Code	NDC 65162-058-27
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

SEVELAMER HCL 800 MG TABLET [28715]

Facility

OP

$3.33

Service Code	NDC 68462-447-18
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.00
Rate for Payer: Aetna of CA Government/Medicare	$2.00
Rate for Payer: Cash Price	$1.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.66
Rate for Payer: Health Smart Auto/Commercial	$2.00
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.00
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Commercial	$2.50

SEVELAMER HCL 800 MG TABLET [28715]

Facility

IP

$3.33

Service Code	NDC 68462-447-18
Hospital Charge Code	901700025
Hospital Revenue Code	636
Min. Negotiated Rate	$1.83
Max. Negotiated Rate	$2.66
Rate for Payer: Cash Price	$1.83
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.66
Rate for Payer: Health Smart Auto/Commercial	$2.00
Rate for Payer: LLUH Dept of Risk Management WC	$1.83
Rate for Payer: Multiplan Commercial	$2.50

SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]

Facility

IP

$0.47

Service Code	NDC 9994-0803-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]

Facility

OP

$0.47

Service Code	NDC 9994-0803-33
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.28
Rate for Payer: Aetna of CA Government/Medicare	$0.28
Rate for Payer: Cash Price	$0.26
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.38
Rate for Payer: Health Smart Auto/Commercial	$0.28
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.28
Rate for Payer: LLUH Dept of Risk Management WC	$0.26
Rate for Payer: Multiplan Commercial	$0.35

SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]

Facility

IP

$26.07

Service Code	NDC 0069-0338-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$14.34
Max. Negotiated Rate	$20.86
Rate for Payer: Cash Price	$14.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.86
Rate for Payer: Health Smart Auto/Commercial	$15.64
Rate for Payer: LLUH Dept of Risk Management WC	$14.34
Rate for Payer: Multiplan Commercial	$19.55

SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]

Facility

IP

$17.76

Service Code	NDC 55150-166-13
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$9.77
Max. Negotiated Rate	$14.21
Rate for Payer: Cash Price	$9.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.21
Rate for Payer: Health Smart Auto/Commercial	$10.66
Rate for Payer: LLUH Dept of Risk Management WC	$9.77
Rate for Payer: Multiplan Commercial	$13.32

SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]

Facility

OP

$26.07

Service Code	NDC 0069-0338-01
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$14.34
Max. Negotiated Rate	$20.86
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$15.64
Rate for Payer: Aetna of CA Government/Medicare	$15.64
Rate for Payer: Cash Price	$14.34
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$20.86
Rate for Payer: Health Smart Auto/Commercial	$15.64
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$15.64
Rate for Payer: LLUH Dept of Risk Management WC	$14.34
Rate for Payer: Multiplan Commercial	$19.55

SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]

Facility

OP

$17.76

Service Code	NDC 55150-166-13
Hospital Charge Code	901700004
Hospital Revenue Code	250
Min. Negotiated Rate	$9.77
Max. Negotiated Rate	$14.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$10.66
Rate for Payer: Aetna of CA Government/Medicare	$10.66
Rate for Payer: Cash Price	$9.77
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$14.21
Rate for Payer: Health Smart Auto/Commercial	$10.66
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$10.66
Rate for Payer: LLUH Dept of Risk Management WC	$9.77
Rate for Payer: Multiplan Commercial	$13.32

SILDENAFIL 25 MG TABLET [22836]

Facility

IP

$104.91

Service Code	NDC 0069-4200-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$57.70
Max. Negotiated Rate	$83.93
Rate for Payer: Cash Price	$57.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.93
Rate for Payer: Health Smart Auto/Commercial	$62.95
Rate for Payer: LLUH Dept of Risk Management WC	$57.70
Rate for Payer: Multiplan Commercial	$78.68

SILDENAFIL 25 MG TABLET [22836]

Facility

OP

$104.91

Service Code	NDC 0069-4200-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$57.70
Max. Negotiated Rate	$83.93
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$62.95
Rate for Payer: Aetna of CA Government/Medicare	$62.95
Rate for Payer: Cash Price	$57.70
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$83.93
Rate for Payer: Health Smart Auto/Commercial	$62.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$62.95
Rate for Payer: LLUH Dept of Risk Management WC	$57.70
Rate for Payer: Multiplan Commercial	$78.68

SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]

Facility

IP

$2.81

Service Code	NDC 9994-0803-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.25
Rate for Payer: Cash Price	$1.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.25
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Commercial	$2.11

SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]

Facility

OP

$2.81

Service Code	NDC 9994-0803-35
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.55
Max. Negotiated Rate	$2.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.69
Rate for Payer: Aetna of CA Government/Medicare	$1.69
Rate for Payer: Cash Price	$1.54
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$2.25
Rate for Payer: Health Smart Auto/Commercial	$1.69
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.69
Rate for Payer: LLUH Dept of Risk Management WC	$1.55
Rate for Payer: Multiplan Commercial	$2.11

SILDENAFIL (PULMONARY HYPERTENSION) 20 MG TABLET [41832]

Facility

IP

$1.40

Service Code	HCPCS S0090
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.77
Max. Negotiated Rate	$1.12
Rate for Payer: Cash Price	$0.77
Rate for Payer: Cash Price	$0.49
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$0.71
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.12
Rate for Payer: Health Smart Auto/Commercial	$0.84
Rate for Payer: Health Smart Auto/Commercial	$0.53
Rate for Payer: LLUH Dept of Risk Management WC	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.77
Rate for Payer: Multiplan Commercial	$0.67
Rate for Payer: Multiplan Commercial	$1.05

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