Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SERTRALINE 50 MG TABLET [11351]

Facility

IP

$0.47

Service Code	NDC 60687-242-01
Hospital Charge Code	1711554
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.38
Rate for Payer: Cash Price	$0.21
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$0.35

SERVATOR B ORGAN PRESERVATION SOLUTION [40817911]

Facility

OP

$0.22

Service Code	NDC 9994-0817-91
Hospital Charge Code	NDG40817911
Hospital Revenue Code	272
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.17
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.13
Rate for Payer: Aetna of CA Government/Medicare	$0.13
Rate for Payer: Cash Price	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

SERVATOR B ORGAN PRESERVATION SOLUTION [40817911]

Facility

IP

$0.22

Service Code	NDC 9994-0817-91
Hospital Charge Code	NDG40817911
Hospital Revenue Code	272
Min. Negotiated Rate	$0.12
Max. Negotiated Rate	$0.18
Rate for Payer: Cash Price	$0.10
Rate for Payer: Cigna of CA HMO/PPO	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.13
Rate for Payer: LLUH Dept of Risk Management WC	$0.12
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.17

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

IP

$11.35

Service Code	NDC 43598-478-90
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$5.11
Rate for Payer: Cigna of CA HMO/PPO	$9.08
Rate for Payer: Health Smart Auto/Commercial	$6.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.51

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

OP

$2.27

Service Code	NDC 65862-930-08
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$1.36
Rate for Payer: Cash Price	$1.02
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

OP

$2.27

Service Code	NDC 65862-930-90
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.70
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$1.36
Rate for Payer: Cash Price	$1.02
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

IP

$2.33

Service Code	NDC 0115-1365-30
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna of CA HMO/PPO	$1.86
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.75

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

IP

$2.33

Service Code	NDC 0115-1365-29
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.05
Rate for Payer: Cigna of CA HMO/PPO	$1.86
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.75

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

OP

$11.35

Service Code	NDC 43598-478-01
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$8.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.81
Rate for Payer: Aetna of CA Government/Medicare	$6.81
Rate for Payer: Cash Price	$5.11
Rate for Payer: Health Smart Auto/Commercial	$6.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.51

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

IP

$11.35

Service Code	NDC 43598-478-01
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$5.11
Rate for Payer: Cigna of CA HMO/PPO	$9.08
Rate for Payer: Health Smart Auto/Commercial	$6.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.51

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

IP

$2.27

Service Code	NDC 65862-930-08
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.02
Rate for Payer: Cigna of CA HMO/PPO	$1.82
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

IP

$2.27

Service Code	NDC 65862-930-90
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.02
Rate for Payer: Cigna of CA HMO/PPO	$1.82
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

OP

$11.35

Service Code	NDC 43598-478-90
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$8.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.81
Rate for Payer: Aetna of CA Government/Medicare	$6.81
Rate for Payer: Cash Price	$5.11
Rate for Payer: Health Smart Auto/Commercial	$6.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.51

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

OP

$2.33

Service Code	NDC 0115-1365-29
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.05
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.75

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

OP

$2.33

Service Code	NDC 0115-1365-30
Hospital Charge Code	1712471
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.75
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$1.40
Rate for Payer: Aetna of CA Government/Medicare	$1.40
Rate for Payer: Cash Price	$1.05
Rate for Payer: Health Smart Auto/Commercial	$1.40
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$1.40
Rate for Payer: LLUH Dept of Risk Management WC	$1.28
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.75

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

OP

$11.35

Service Code	NDC 43598-479-01
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$8.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.81
Rate for Payer: Aetna of CA Government/Medicare	$6.81
Rate for Payer: Cash Price	$5.11
Rate for Payer: Health Smart Auto/Commercial	$6.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.51

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

OP

$11.35

Service Code	NDC 43598-479-90
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$8.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.81
Rate for Payer: Aetna of CA Government/Medicare	$6.81
Rate for Payer: Cash Price	$5.11
Rate for Payer: Health Smart Auto/Commercial	$6.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.51

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

OP

$21.42

Service Code	NDC 58468-0131-2
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$11.78
Max. Negotiated Rate	$16.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.85
Rate for Payer: Aetna of CA Government/Medicare	$12.85
Rate for Payer: Cash Price	$9.64
Rate for Payer: Health Smart Auto/Commercial	$12.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.85
Rate for Payer: LLUH Dept of Risk Management WC	$11.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.06

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

IP

$11.35

Service Code	NDC 43598-479-90
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$5.11
Rate for Payer: Cigna of CA HMO/PPO	$9.08
Rate for Payer: Health Smart Auto/Commercial	$6.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.51

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

IP

$11.35

Service Code	NDC 43598-479-01
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$5.11
Rate for Payer: Cigna of CA HMO/PPO	$9.08
Rate for Payer: Health Smart Auto/Commercial	$6.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.51

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

IP

$2.27

Service Code	NDC 65862-931-08
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.02
Rate for Payer: Cigna of CA HMO/PPO	$1.82
Rate for Payer: Health Smart Auto/Commercial	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.70

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

OP

$21.42

Service Code	NDC 58468-0131-1
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$11.78
Max. Negotiated Rate	$16.06
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$12.85
Rate for Payer: Aetna of CA Government/Medicare	$12.85
Rate for Payer: Cash Price	$9.64
Rate for Payer: Health Smart Auto/Commercial	$12.85
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$12.85
Rate for Payer: LLUH Dept of Risk Management WC	$11.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.06

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

IP

$21.42

Service Code	NDC 58468-0131-1
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$11.78
Max. Negotiated Rate	$17.14
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cigna of CA HMO/PPO	$17.14
Rate for Payer: Health Smart Auto/Commercial	$12.85
Rate for Payer: LLUH Dept of Risk Management WC	$11.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.06

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

OP

$11.35

Service Code	NDC 0955-1054-90
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$8.51
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$6.81
Rate for Payer: Aetna of CA Government/Medicare	$6.81
Rate for Payer: Cash Price	$5.11
Rate for Payer: Health Smart Auto/Commercial	$6.81
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$6.81
Rate for Payer: LLUH Dept of Risk Management WC	$6.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$8.51

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

IP

$21.42

Service Code	NDC 58468-0131-2
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$11.78
Max. Negotiated Rate	$17.14
Rate for Payer: Cash Price	$9.64
Rate for Payer: Cigna of CA HMO/PPO	$17.14
Rate for Payer: Health Smart Auto/Commercial	$12.85
Rate for Payer: LLUH Dept of Risk Management WC	$11.78
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$16.06

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