Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$2.27

Service Code	NDC 65862-930-90
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	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$1.36
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	$1.36
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 Commercial	$1.70

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$2.27

Service Code	NDC 65862-930-08
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	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Commercial	$1.70

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$2.27

Service Code	NDC 65862-930-90
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	$1.36
Rate for Payer: LLUH Dept of Risk Management WC	$1.25
Rate for Payer: Multiplan Commercial	$1.70

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$2.27

Service Code	NDC 65862-930-08
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	$1.36
Rate for Payer: Aetna of CA Government/Medicare	$1.36
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	$1.36
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 Commercial	$1.70

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$11.35

Service Code	NDC 43598-478-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$9.08
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	$6.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.08
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 Commercial	$8.51

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$2.33

Service Code	NDC 0115-1365-29
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.75

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$11.35

Service Code	NDC 43598-478-01
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$6.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$8.51

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$2.33

Service Code	NDC 0115-1365-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.75

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$11.35

Service Code	NDC 43598-478-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$9.08
Rate for Payer: Cash Price	$6.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$8.51

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$11.35

Service Code	NDC 43598-478-90
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$6.24
Max. Negotiated Rate	$9.08
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	$6.24
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$9.08
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 Commercial	$8.51

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$1.60

Service Code	NDC 33342-288-68
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.28
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	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.28
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 Commercial	$1.20

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$2.33

Service Code	NDC 0115-1365-29
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
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	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.86
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 Commercial	$1.75

SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]

Facility

$2.33

Service Code	NDC 0115-1365-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
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	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.86
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 Commercial	$1.75

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

$1.60

Service Code	NDC 33342-289-68
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.28
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	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.28
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 Commercial	$1.20

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

$1.60

Service Code	NDC 33342-289-68
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$0.88
Max. Negotiated Rate	$1.28
Rate for Payer: Cash Price	$0.88
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.20

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

$2.33

Service Code	NDC 0115-1366-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.75

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

$2.33

Service Code	NDC 0115-1366-29
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
Rate for Payer: Cash Price	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO 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 Commercial	$1.75

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

$2.33

Service Code	NDC 0115-1366-29
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
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	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.86
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 Commercial	$1.75

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

$2.33

Service Code	NDC 0115-1366-30
Hospital Charge Code	901700029
Hospital Revenue Code	259
Min. Negotiated Rate	$1.28
Max. Negotiated Rate	$1.86
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	$1.28
Rate for Payer: Evernorth Behavioral Health (Cigna Behavioral Health) - HMO HMO/PPO	$1.86
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 Commercial	$1.75

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$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: Aetna of CA EPO/HMO/POS/PPO	$0.22
Rate for Payer: Aetna of CA Government/Medicare	$0.22
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: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$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

$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

$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

$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

$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: 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

$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

Know your out-of-pocket cost for care.

All Charges