Price Transparency

Know your out-of-pocket cost for care.

All Charges

Charge

Type

Setting

Price

SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]

Facility

IP

$0.19

Service Code	NDC 121119030
Hospital Charge Code	1716053
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]

Facility

IP

$0.19

Service Code	NDC 121119000
Hospital Charge Code	1716053
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.15
Rate for Payer: Cash Price	$0.09
Rate for Payer: Cigna of CA HMO/PPO	$0.15
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]

Facility

OP

$0.19

Service Code	NDC 121119030
Hospital Charge Code	1716053
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]

Facility

OP

$0.18

Service Code	NDC 5723731903
Hospital Charge Code	1716053
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

SODIUM CITRATE-CITRIC ACID 500 MG-334 MG/5 ML ORAL SOLUTION [15706]

Facility

OP

$0.19

Service Code	NDC 121119000
Hospital Charge Code	1716053
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.11
Rate for Payer: Aetna of CA Government/Medicare	$0.11
Rate for Payer: Cash Price	$0.09
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

IP

$1.60

Service Code	NDC 6808476495
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.28
Rate for Payer: Cash Price	$0.72
Rate for Payer: Cigna of CA HMO/PPO	$1.28
Rate for Payer: Health Smart Auto/Commercial	$0.96
Rate for Payer: LLUH Dept of Risk Management WC	$0.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.20

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

OP

$0.41

Service Code	NDC 6498010401
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

OP

$0.41

Service Code	NDC 6954326810
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.31
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.25
Rate for Payer: Aetna of CA Government/Medicare	$0.25
Rate for Payer: Cash Price	$0.18
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

IP

$0.77

Service Code	NDC 486112505
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.62
Rate for Payer: Cash Price	$0.35
Rate for Payer: Cigna of CA HMO/PPO	$0.62
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.58

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

IP

$0.41

Service Code	NDC 6954326810
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

IP

$0.41

Service Code	NDC 6498010401
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.23
Max. Negotiated Rate	$0.33
Rate for Payer: Cash Price	$0.18
Rate for Payer: Cigna of CA HMO/PPO	$0.33
Rate for Payer: Health Smart Auto/Commercial	$0.25
Rate for Payer: LLUH Dept of Risk Management WC	$0.23
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.31

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

OP

$0.77

Service Code	NDC 486112505
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.42
Max. Negotiated Rate	$0.58
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.46
Rate for Payer: Aetna of CA Government/Medicare	$0.46
Rate for Payer: Cash Price	$0.35
Rate for Payer: Health Smart Auto/Commercial	$0.46
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.46
Rate for Payer: LLUH Dept of Risk Management WC	$0.42
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.58

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

OP

$0.81

Service Code	NDC 486112501
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.61
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.49
Rate for Payer: Aetna of CA Government/Medicare	$0.49
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

IP

$0.81

Service Code	NDC 486112501
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.45
Max. Negotiated Rate	$0.65
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.65
Rate for Payer: Health Smart Auto/Commercial	$0.49
Rate for Payer: LLUH Dept of Risk Management WC	$0.45
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.61

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

OP

$1.60

Service Code	NDC 6808476495
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.20
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.96
Rate for Payer: Aetna of CA Government/Medicare	$0.96
Rate for Payer: Cash Price	$0.72
Rate for Payer: Health Smart Auto/Commercial	$0.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.96
Rate for Payer: LLUH Dept of Risk Management WC	$0.88
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$1.20

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

IP

$0.49

Service Code	NDC 3932810710
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.39
Rate for Payer: Cash Price	$0.22
Rate for Payer: Cigna of CA HMO/PPO	$0.39
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.37

SODIUM DI- AND MONOPHOSPHATE-POTASSIUM PHOS MONOBASIC 250 MG TABLET [11067]

Facility

OP

$0.49

Service Code	NDC 3932810710
Hospital Charge Code	1711548
Hospital Revenue Code	259
Min. Negotiated Rate	$0.27
Max. Negotiated Rate	$0.37
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.29
Rate for Payer: Aetna of CA Government/Medicare	$0.29
Rate for Payer: Cash Price	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.29
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.29
Rate for Payer: LLUH Dept of Risk Management WC	$0.27
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.37

SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]

Facility

IP

$7.63

Service Code	CPT J2916
Hospital Charge Code	1720934
Hospital Revenue Code	636
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$6.10
Rate for Payer: Cash Price	$3.43
Rate for Payer: Cigna of CA HMO/PPO	$6.10
Rate for Payer: Health Smart Auto/Commercial	$4.58
Rate for Payer: LLUH Dept of Risk Management WC	$4.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.72

SODIUM FERRIC GLUCONATE COMPLEX IN SUCROSE 62.5 MG/5 ML INTRAVENOUS [24932]

Facility

OP

$7.63

Service Code	CPT J2916
Hospital Charge Code	1720934
Hospital Revenue Code	636
Min. Negotiated Rate	$4.20
Max. Negotiated Rate	$5.72
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$4.58
Rate for Payer: Aetna of CA Government/Medicare	$4.58
Rate for Payer: Cash Price	$3.43
Rate for Payer: Health Smart Auto/Commercial	$4.58
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$4.58
Rate for Payer: LLUH Dept of Risk Management WC	$4.20
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$5.72

SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]

Facility

OP

$84.59

Service Code	NDC 8544-5085-81
Hospital Charge Code	1795220
Hospital Revenue Code	272
Min. Negotiated Rate	$46.52
Max. Negotiated Rate	$63.44
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$50.75
Rate for Payer: Aetna of CA Government/Medicare	$50.75
Rate for Payer: Cash Price	$38.07
Rate for Payer: Health Smart Auto/Commercial	$50.75
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$50.75
Rate for Payer: LLUH Dept of Risk Management WC	$46.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.44

SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]

Facility

OP

$369.93

Service Code	NDC 8065183055
Hospital Charge Code	1795220
Hospital Revenue Code	272
Min. Negotiated Rate	$203.46
Max. Negotiated Rate	$277.45
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$221.96
Rate for Payer: Aetna of CA Government/Medicare	$221.96
Rate for Payer: Cash Price	$166.47
Rate for Payer: Health Smart Auto/Commercial	$221.96
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$221.96
Rate for Payer: LLUH Dept of Risk Management WC	$203.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$277.45

SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]

Facility

IP

$84.59

Service Code	NDC 8544-5085-81
Hospital Charge Code	1795220
Hospital Revenue Code	272
Min. Negotiated Rate	$46.52
Max. Negotiated Rate	$67.67
Rate for Payer: Cash Price	$38.07
Rate for Payer: Cigna of CA HMO/PPO	$67.67
Rate for Payer: Health Smart Auto/Commercial	$50.75
Rate for Payer: LLUH Dept of Risk Management WC	$46.52
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$63.44

SODIUM HYALURONATE 10 MG/ML INTRAOCULAR SYRINGE [28913]

Facility

IP

$369.93

Service Code	NDC 8065183055
Hospital Charge Code	1795220
Hospital Revenue Code	272
Min. Negotiated Rate	$203.46
Max. Negotiated Rate	$295.94
Rate for Payer: Cash Price	$166.47
Rate for Payer: Cigna of CA HMO/PPO	$295.94
Rate for Payer: Health Smart Auto/Commercial	$221.96
Rate for Payer: LLUH Dept of Risk Management WC	$203.46
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$277.45

SODIUM HYALURONATE 14 MG/ML INTRAOCULAR SYRINGE [4080907]

Facility

OP

$261.36

Service Code	CPT J3590
Hospital Charge Code	1796112
Hospital Revenue Code	636
Min. Negotiated Rate	$143.75
Max. Negotiated Rate	$196.02
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$156.82
Rate for Payer: Aetna of CA Government/Medicare	$156.82
Rate for Payer: Cash Price	$117.61
Rate for Payer: Health Smart Auto/Commercial	$156.82
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$156.82
Rate for Payer: LLUH Dept of Risk Management WC	$143.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$196.02

SODIUM HYALURONATE 14 MG/ML INTRAOCULAR SYRINGE [4080907]

Facility

IP

$261.36

Service Code	CPT J3590
Hospital Charge Code	1796112
Hospital Revenue Code	636
Min. Negotiated Rate	$143.75
Max. Negotiated Rate	$209.09
Rate for Payer: Cash Price	$117.61
Rate for Payer: Cigna of CA HMO/PPO	$209.09
Rate for Payer: Health Smart Auto/Commercial	$156.82
Rate for Payer: LLUH Dept of Risk Management WC	$143.75
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$196.02

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