|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$279.30
|
|
|
Service Code
|
NDC 00904692561
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$109.76 |
| Max. Negotiated Rate |
$251.37 |
| Rate for Payer: Aetna Commercial |
$237.41
|
| Rate for Payer: Aetna Medicare |
$139.65
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$181.54
|
| Rate for Payer: BCBS Complete |
$111.72
|
| Rate for Payer: Cash Price |
$223.44
|
| Rate for Payer: Cofinity Advantage |
$195.51
|
| Rate for Payer: Cofinity Commercial |
$240.20
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$223.44
|
| Rate for Payer: Healthscope Commercial |
$251.37
|
| Rate for Payer: MI Amish Medical Board Commercial |
$223.44
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$237.41
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$209.47
|
| Rate for Payer: PHP Commercial |
$237.41
|
| Rate for Payer: Priority Health SBD |
$175.96
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$181.54
|
| Rate for Payer: UHC Core |
$145.52
|
| Rate for Payer: UHC Exchange |
$109.76
|
|
|
SERTRALINE 50 MG TABLET
|
Facility
|
OP
|
$225.60
|
|
|
Service Code
|
NDC 59762490003
|
| Hospital Charge Code |
11351
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$88.66 |
| Max. Negotiated Rate |
$203.04 |
| Rate for Payer: Aetna Commercial |
$191.76
|
| Rate for Payer: Aetna Medicare |
$112.80
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$146.64
|
| Rate for Payer: BCBS Complete |
$90.24
|
| Rate for Payer: Cash Price |
$180.48
|
| Rate for Payer: Cofinity Advantage |
$157.92
|
| Rate for Payer: Cofinity Commercial |
$194.02
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$180.48
|
| Rate for Payer: Healthscope Commercial |
$203.04
|
| Rate for Payer: MI Amish Medical Board Commercial |
$180.48
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$191.76
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$169.20
|
| Rate for Payer: PHP Commercial |
$191.76
|
| Rate for Payer: Priority Health SBD |
$142.13
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$146.64
|
| Rate for Payer: UHC Core |
$117.54
|
| Rate for Payer: UHC Exchange |
$88.66
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$2,928.41
|
|
|
Service Code
|
NDC 43598047890
|
| Hospital Charge Code |
99694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,150.87 |
| Max. Negotiated Rate |
$2,635.57 |
| Rate for Payer: Aetna Commercial |
$2,489.15
|
| Rate for Payer: Aetna Medicare |
$1,464.20
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,903.47
|
| Rate for Payer: BCBS Complete |
$1,171.36
|
| Rate for Payer: Cash Price |
$2,342.73
|
| Rate for Payer: Cofinity Advantage |
$2,049.89
|
| Rate for Payer: Cofinity Commercial |
$2,518.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,342.73
|
| Rate for Payer: Healthscope Commercial |
$2,635.57
|
| Rate for Payer: MI Amish Medical Board Commercial |
$2,342.73
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,489.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,196.31
|
| Rate for Payer: PHP Commercial |
$2,489.15
|
| Rate for Payer: Priority Health SBD |
$1,844.90
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,903.47
|
| Rate for Payer: UHC Core |
$1,525.70
|
| Rate for Payer: UHC Exchange |
$1,150.87
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$2,928.41
|
|
|
Service Code
|
NDC 43598047890
|
| Hospital Charge Code |
99694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,844.90 |
| Max. Negotiated Rate |
$2,635.57 |
| Rate for Payer: Aetna Commercial |
$2,489.15
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,903.47
|
| Rate for Payer: Cash Price |
$2,342.73
|
| Rate for Payer: Cofinity Advantage |
$2,049.89
|
| Rate for Payer: Cofinity Commercial |
$2,518.43
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$2,342.73
|
| Rate for Payer: Healthscope Commercial |
$2,635.57
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$2,489.15
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$2,196.31
|
| Rate for Payer: PHP Commercial |
$2,489.15
|
| Rate for Payer: Priority Health SBD |
$1,844.90
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$32.54
|
|
|
Service Code
|
NDC 43598047801
|
| Hospital Charge Code |
99694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$12.79 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Aetna Commercial |
$27.66
|
| Rate for Payer: Aetna Medicare |
$16.27
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.15
|
| Rate for Payer: BCBS Complete |
$13.02
|
| Rate for Payer: Cash Price |
$26.03
|
| Rate for Payer: Cofinity Advantage |
$22.78
|
| Rate for Payer: Cofinity Commercial |
$27.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.03
|
| Rate for Payer: Healthscope Commercial |
$29.29
|
| Rate for Payer: MI Amish Medical Board Commercial |
$26.03
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.41
|
| Rate for Payer: PHP Commercial |
$27.66
|
| Rate for Payer: Priority Health SBD |
$20.50
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$21.15
|
| Rate for Payer: UHC Core |
$16.95
|
| Rate for Payer: UHC Exchange |
$12.79
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$32.54
|
|
|
Service Code
|
NDC 43598047801
|
| Hospital Charge Code |
99694
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$20.50 |
| Max. Negotiated Rate |
$29.29 |
| Rate for Payer: Aetna Commercial |
$27.66
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$21.15
|
| Rate for Payer: Cash Price |
$26.03
|
| Rate for Payer: Cofinity Advantage |
$22.78
|
| Rate for Payer: Cofinity Commercial |
$27.98
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$26.03
|
| Rate for Payer: Healthscope Commercial |
$29.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$27.66
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$24.41
|
| Rate for Payer: PHP Commercial |
$27.66
|
| Rate for Payer: Priority Health SBD |
$20.50
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$759.03
|
|
|
Service Code
|
NDC 64380088180
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$478.19 |
| Max. Negotiated Rate |
$683.13 |
| Rate for Payer: Aetna Commercial |
$645.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.37
|
| Rate for Payer: Cash Price |
$607.22
|
| Rate for Payer: Cofinity Advantage |
$531.32
|
| Rate for Payer: Cofinity Commercial |
$652.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.22
|
| Rate for Payer: Healthscope Commercial |
$683.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$569.27
|
| Rate for Payer: PHP Commercial |
$645.18
|
| Rate for Payer: Priority Health SBD |
$478.19
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$8.44
|
|
|
Service Code
|
NDC 65862093108
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Aetna Commercial |
$7.17
|
| Rate for Payer: Aetna Medicare |
$4.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.49
|
| Rate for Payer: BCBS Complete |
$3.38
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cofinity Advantage |
$5.91
|
| Rate for Payer: Cofinity Commercial |
$7.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.75
|
| Rate for Payer: Healthscope Commercial |
$7.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.33
|
| Rate for Payer: PHP Commercial |
$7.17
|
| Rate for Payer: Priority Health SBD |
$5.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.49
|
| Rate for Payer: UHC Core |
$4.40
|
| Rate for Payer: UHC Exchange |
$3.32
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$8.44
|
|
|
Service Code
|
NDC 64380088100
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.32 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Aetna Commercial |
$7.17
|
| Rate for Payer: Aetna Medicare |
$4.22
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.49
|
| Rate for Payer: BCBS Complete |
$3.38
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cofinity Advantage |
$5.91
|
| Rate for Payer: Cofinity Commercial |
$7.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.75
|
| Rate for Payer: Healthscope Commercial |
$7.60
|
| Rate for Payer: MI Amish Medical Board Commercial |
$6.75
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.33
|
| Rate for Payer: PHP Commercial |
$7.17
|
| Rate for Payer: Priority Health SBD |
$5.32
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$5.49
|
| Rate for Payer: UHC Core |
$4.40
|
| Rate for Payer: UHC Exchange |
$3.32
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$759.03
|
|
|
Service Code
|
NDC 65862093190
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$298.30 |
| Max. Negotiated Rate |
$683.13 |
| Rate for Payer: Aetna Commercial |
$645.18
|
| Rate for Payer: Aetna Medicare |
$379.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.37
|
| Rate for Payer: BCBS Complete |
$303.61
|
| Rate for Payer: Cash Price |
$607.22
|
| Rate for Payer: Cofinity Advantage |
$531.32
|
| Rate for Payer: Cofinity Commercial |
$652.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.22
|
| Rate for Payer: Healthscope Commercial |
$683.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$607.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$569.27
|
| Rate for Payer: PHP Commercial |
$645.18
|
| Rate for Payer: Priority Health SBD |
$478.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$493.37
|
| Rate for Payer: UHC Core |
$395.45
|
| Rate for Payer: UHC Exchange |
$298.30
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
OP
|
$759.03
|
|
|
Service Code
|
NDC 64380088180
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$298.30 |
| Max. Negotiated Rate |
$683.13 |
| Rate for Payer: Aetna Commercial |
$645.18
|
| Rate for Payer: Aetna Medicare |
$379.51
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.37
|
| Rate for Payer: BCBS Complete |
$303.61
|
| Rate for Payer: Cash Price |
$607.22
|
| Rate for Payer: Cofinity Advantage |
$531.32
|
| Rate for Payer: Cofinity Commercial |
$652.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.22
|
| Rate for Payer: Healthscope Commercial |
$683.13
|
| Rate for Payer: MI Amish Medical Board Commercial |
$607.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$569.27
|
| Rate for Payer: PHP Commercial |
$645.18
|
| Rate for Payer: Priority Health SBD |
$478.19
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$493.37
|
| Rate for Payer: UHC Core |
$395.45
|
| Rate for Payer: UHC Exchange |
$298.30
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$8.44
|
|
|
Service Code
|
NDC 64380088100
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.32 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Aetna Commercial |
$7.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.49
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cofinity Advantage |
$5.91
|
| Rate for Payer: Cofinity Commercial |
$7.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.75
|
| Rate for Payer: Healthscope Commercial |
$7.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.33
|
| Rate for Payer: PHP Commercial |
$7.17
|
| Rate for Payer: Priority Health SBD |
$5.32
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$8.44
|
|
|
Service Code
|
NDC 65862093108
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$5.32 |
| Max. Negotiated Rate |
$7.60 |
| Rate for Payer: Aetna Commercial |
$7.17
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$5.49
|
| Rate for Payer: Cash Price |
$6.75
|
| Rate for Payer: Cofinity Advantage |
$5.91
|
| Rate for Payer: Cofinity Commercial |
$7.26
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$6.75
|
| Rate for Payer: Healthscope Commercial |
$7.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$7.17
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$6.33
|
| Rate for Payer: PHP Commercial |
$7.17
|
| Rate for Payer: Priority Health SBD |
$5.32
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET
|
Facility
|
IP
|
$759.03
|
|
|
Service Code
|
NDC 65862093190
|
| Hospital Charge Code |
99695
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$478.19 |
| Max. Negotiated Rate |
$683.13 |
| Rate for Payer: Aetna Commercial |
$645.18
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$493.37
|
| Rate for Payer: Cash Price |
$607.22
|
| Rate for Payer: Cofinity Advantage |
$531.32
|
| Rate for Payer: Cofinity Commercial |
$652.77
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$607.22
|
| Rate for Payer: Healthscope Commercial |
$683.13
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$645.18
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$569.27
|
| Rate for Payer: PHP Commercial |
$645.18
|
| Rate for Payer: Priority Health SBD |
$478.19
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
OP
|
$5,499.50
|
|
|
Service Code
|
NDC 58468013001
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2,161.30 |
| Max. Negotiated Rate |
$4,949.55 |
| Rate for Payer: Aetna Commercial |
$4,674.57
|
| Rate for Payer: Aetna Medicare |
$2,749.75
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3,574.68
|
| Rate for Payer: BCBS Complete |
$2,199.80
|
| Rate for Payer: Cash Price |
$4,399.60
|
| Rate for Payer: Cofinity Advantage |
$3,849.65
|
| Rate for Payer: Cofinity Commercial |
$4,729.57
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4,399.60
|
| Rate for Payer: Healthscope Commercial |
$4,949.55
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4,399.60
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4,674.57
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$4,124.62
|
| Rate for Payer: PHP Commercial |
$4,674.57
|
| Rate for Payer: Priority Health SBD |
$3,464.68
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3,574.68
|
| Rate for Payer: UHC Core |
$2,865.24
|
| Rate for Payer: UHC Exchange |
$2,161.30
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$2,051.57
|
|
|
Service Code
|
NDC 00955105027
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$1,292.49 |
| Max. Negotiated Rate |
$1,846.41 |
| Rate for Payer: Aetna Commercial |
$1,743.83
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,333.52
|
| Rate for Payer: Cash Price |
$1,641.26
|
| Rate for Payer: Cofinity Advantage |
$1,436.10
|
| Rate for Payer: Cofinity Commercial |
$1,764.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,641.26
|
| Rate for Payer: Healthscope Commercial |
$1,846.41
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,743.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,538.68
|
| Rate for Payer: PHP Commercial |
$1,743.83
|
| Rate for Payer: Priority Health SBD |
$1,292.49
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$7.49
|
|
|
Service Code
|
NDC 68094003459
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$4.72 |
| Max. Negotiated Rate |
$6.74 |
| Rate for Payer: Aetna Commercial |
$6.37
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$4.87
|
| Rate for Payer: Cash Price |
$5.99
|
| Rate for Payer: Cofinity Advantage |
$5.24
|
| Rate for Payer: Cofinity Commercial |
$6.44
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$5.99
|
| Rate for Payer: Healthscope Commercial |
$6.74
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$6.37
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$5.62
|
| Rate for Payer: PHP Commercial |
$6.37
|
| Rate for Payer: Priority Health SBD |
$4.72
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
OP
|
$2,051.57
|
|
|
Service Code
|
NDC 00955105027
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$806.27 |
| Max. Negotiated Rate |
$1,846.41 |
| Rate for Payer: Aetna Commercial |
$1,743.83
|
| Rate for Payer: Aetna Medicare |
$1,025.79
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$1,333.52
|
| Rate for Payer: BCBS Complete |
$820.63
|
| Rate for Payer: Cash Price |
$1,641.26
|
| Rate for Payer: Cofinity Advantage |
$1,436.10
|
| Rate for Payer: Cofinity Commercial |
$1,764.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$1,641.26
|
| Rate for Payer: Healthscope Commercial |
$1,846.41
|
| Rate for Payer: MI Amish Medical Board Commercial |
$1,641.26
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$1,743.83
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$1,538.68
|
| Rate for Payer: PHP Commercial |
$1,743.83
|
| Rate for Payer: Priority Health SBD |
$1,292.49
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$1,333.52
|
| Rate for Payer: UHC Core |
$1,068.87
|
| Rate for Payer: UHC Exchange |
$806.27
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$673.66
|
|
|
Service Code
|
NDC 68094003464
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$424.41 |
| Max. Negotiated Rate |
$606.29 |
| Rate for Payer: Aetna Commercial |
$572.61
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$437.88
|
| Rate for Payer: Cash Price |
$538.93
|
| Rate for Payer: Cofinity Advantage |
$471.56
|
| Rate for Payer: Cofinity Commercial |
$579.35
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$538.93
|
| Rate for Payer: Healthscope Commercial |
$606.29
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$572.61
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$505.25
|
| Rate for Payer: PHP Commercial |
$572.61
|
| Rate for Payer: Priority Health SBD |
$424.41
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
OP
|
$258.24
|
|
|
Service Code
|
NDC 50268072015
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$101.49 |
| Max. Negotiated Rate |
$232.42 |
| Rate for Payer: Aetna Commercial |
$219.50
|
| Rate for Payer: Aetna Medicare |
$129.12
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.86
|
| Rate for Payer: BCBS Complete |
$103.30
|
| Rate for Payer: Cash Price |
$206.59
|
| Rate for Payer: Cofinity Advantage |
$180.77
|
| Rate for Payer: Cofinity Commercial |
$222.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.59
|
| Rate for Payer: Healthscope Commercial |
$232.42
|
| Rate for Payer: MI Amish Medical Board Commercial |
$206.59
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$193.68
|
| Rate for Payer: PHP Commercial |
$219.50
|
| Rate for Payer: Priority Health SBD |
$162.69
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$167.86
|
| Rate for Payer: UHC Core |
$134.54
|
| Rate for Payer: UHC Exchange |
$101.49
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$258.24
|
|
|
Service Code
|
NDC 50268072015
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$162.69 |
| Max. Negotiated Rate |
$232.42 |
| Rate for Payer: Aetna Commercial |
$219.50
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$167.86
|
| Rate for Payer: Cash Price |
$206.59
|
| Rate for Payer: Cofinity Advantage |
$180.77
|
| Rate for Payer: Cofinity Commercial |
$222.09
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$206.59
|
| Rate for Payer: Healthscope Commercial |
$232.42
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$219.50
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$193.68
|
| Rate for Payer: PHP Commercial |
$219.50
|
| Rate for Payer: Priority Health SBD |
$162.69
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$951.75
|
|
|
Service Code
|
NDC 69097096793
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$599.60 |
| Max. Negotiated Rate |
$856.58 |
| Rate for Payer: Aetna Commercial |
$808.99
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$618.64
|
| Rate for Payer: Cash Price |
$761.40
|
| Rate for Payer: Cofinity Advantage |
$666.23
|
| Rate for Payer: Cofinity Commercial |
$818.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$761.40
|
| Rate for Payer: Healthscope Commercial |
$856.58
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$808.99
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$713.81
|
| Rate for Payer: PHP Commercial |
$808.99
|
| Rate for Payer: Priority Health SBD |
$599.60
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
IP
|
$493.58
|
|
|
Service Code
|
NDC 60687032865
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$310.96 |
| Max. Negotiated Rate |
$444.22 |
| Rate for Payer: Aetna Commercial |
$419.54
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$320.83
|
| Rate for Payer: Cash Price |
$394.86
|
| Rate for Payer: Cofinity Advantage |
$345.51
|
| Rate for Payer: Cofinity Commercial |
$424.48
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$394.86
|
| Rate for Payer: Healthscope Commercial |
$444.22
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$419.54
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$370.19
|
| Rate for Payer: PHP Commercial |
$419.54
|
| Rate for Payer: Priority Health SBD |
$310.96
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
OP
|
$5.17
|
|
|
Service Code
|
NDC 50268072011
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$2.03 |
| Max. Negotiated Rate |
$4.65 |
| Rate for Payer: Aetna Commercial |
$4.39
|
| Rate for Payer: Aetna Medicare |
$2.58
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$3.36
|
| Rate for Payer: BCBS Complete |
$2.07
|
| Rate for Payer: Cash Price |
$4.14
|
| Rate for Payer: Cofinity Advantage |
$3.62
|
| Rate for Payer: Cofinity Commercial |
$4.45
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$4.14
|
| Rate for Payer: Healthscope Commercial |
$4.65
|
| Rate for Payer: MI Amish Medical Board Commercial |
$4.14
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$4.39
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$3.88
|
| Rate for Payer: PHP Commercial |
$4.39
|
| Rate for Payer: Priority Health SBD |
$3.26
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$3.36
|
| Rate for Payer: UHC Core |
$2.69
|
| Rate for Payer: UHC Exchange |
$2.03
|
|
|
SEVELAMER CARBONATE 800 MG TABLET
|
Facility
|
OP
|
$9.88
|
|
|
Service Code
|
NDC 60687032811
|
| Hospital Charge Code |
89201
|
|
Hospital Revenue Code
|
637
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$8.89 |
| Rate for Payer: Aetna Commercial |
$8.40
|
| Rate for Payer: Aetna Medicare |
$4.94
|
| Rate for Payer: Aetna New Business (MI Preferred) |
$6.42
|
| Rate for Payer: BCBS Complete |
$3.95
|
| Rate for Payer: Cash Price |
$7.90
|
| Rate for Payer: Cofinity Advantage |
$6.92
|
| Rate for Payer: Cofinity Commercial |
$8.50
|
| Rate for Payer: Encore Health Key Benefits Commercial |
$7.90
|
| Rate for Payer: Healthscope Commercial |
$8.89
|
| Rate for Payer: MI Amish Medical Board Commercial |
$7.90
|
| Rate for Payer: Multiplan/Beech St/PHCS Commercial |
$8.40
|
| Rate for Payer: Opus (Opus Packaging Group) HMA |
$7.41
|
| Rate for Payer: PHP Commercial |
$8.40
|
| Rate for Payer: Priority Health SBD |
$6.22
|
| Rate for Payer: UHC All Payor (Choice/PPO) |
$6.42
|
| Rate for Payer: UHC Core |
$5.15
|
| Rate for Payer: UHC Exchange |
$3.88
|
|
