Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]

Facility

$11.35

Service Code	NDC 0955-1054-90
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

$11.35

Service Code	NDC 0955-1054-01
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

$11.35

Service Code	NDC 0955-1054-01
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

$2.27

Service Code	NDC 65862-931-08
Hospital Charge Code	1712470
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.70
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 800 MG TABLET [89201]

Facility

$0.47

Service Code	NDC 65862-921-27
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
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	$0.21
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 Beech St/Commercial/PHCS	$0.35

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$0.47

Service Code	NDC 24979-186-46
Hospital Charge Code	1712469
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

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$8.73

Service Code	NDC 50268-720-11
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$6.98
Rate for Payer: Cash Price	$3.93
Rate for Payer: Cigna of CA HMO/PPO	$6.98
Rate for Payer: Health Smart Auto/Commercial	$5.24
Rate for Payer: LLUH Dept of Risk Management WC	$4.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.55

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$2.28

Service Code	NDC 68094-034-64
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.71
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	$1.03
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 Beech St/Commercial/PHCS	$1.71

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$0.47

Service Code	NDC 65862-921-27
Hospital Charge Code	1712469
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

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$8.73

Service Code	NDC 50268-720-11
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$6.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.24
Rate for Payer: Aetna of CA Government/Medicare	$5.24
Rate for Payer: Cash Price	$3.93
Rate for Payer: Health Smart Auto/Commercial	$5.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.24
Rate for Payer: LLUH Dept of Risk Management WC	$4.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.55

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$2.28

Service Code	NDC 68094-034-59
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.71
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	$1.03
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 Beech St/Commercial/PHCS	$1.71

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$2.28

Service Code	NDC 68094-034-64
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.03
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.71

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$0.47

Service Code	NDC 65162-058-27
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
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	$0.21
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 Beech St/Commercial/PHCS	$0.35

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$0.47

Service Code	NDC 65162-058-27
Hospital Charge Code	1712469
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

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$8.73

Service Code	NDC 50268-720-15
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$6.98
Rate for Payer: Cash Price	$3.93
Rate for Payer: Cigna of CA HMO/PPO	$6.98
Rate for Payer: Health Smart Auto/Commercial	$5.24
Rate for Payer: LLUH Dept of Risk Management WC	$4.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.55

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$8.73

Service Code	NDC 50268-720-15
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$4.80
Max. Negotiated Rate	$6.55
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.24
Rate for Payer: Aetna of CA Government/Medicare	$5.24
Rate for Payer: Cash Price	$3.93
Rate for Payer: Health Smart Auto/Commercial	$5.24
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.24
Rate for Payer: LLUH Dept of Risk Management WC	$4.80
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.55

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$0.47

Service Code	NDC 24979-186-46
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
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	$0.21
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 Beech St/Commercial/PHCS	$0.35

SEVELAMER CARBONATE 800 MG TABLET [89201]

Facility

$2.28

Service Code	NDC 68094-034-59
Hospital Charge Code	1712469
Hospital Revenue Code	259
Min. Negotiated Rate	$1.25
Max. Negotiated Rate	$1.82
Rate for Payer: Cash Price	$1.03
Rate for Payer: Cigna of CA 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 Beech St/Commercial/PHCS	$1.71

SEVELAMER HCL 800 MG TABLET [28715]

Facility

$8.92

Service Code	NDC 58468-0021-1
Hospital Charge Code	1712253
Hospital Revenue Code	259
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$7.14
Rate for Payer: Cash Price	$4.01
Rate for Payer: Cigna of CA HMO/PPO	$7.14
Rate for Payer: Health Smart Auto/Commercial	$5.35
Rate for Payer: LLUH Dept of Risk Management WC	$4.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.69

SEVELAMER HCL 800 MG TABLET [28715]

Facility

$4.33

Service Code	NDC 68462-447-18
Hospital Charge Code	1712253
Hospital Revenue Code	259
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.25
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$2.60
Rate for Payer: Aetna of CA Government/Medicare	$2.60
Rate for Payer: Cash Price	$1.95
Rate for Payer: Health Smart Auto/Commercial	$2.60
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$2.60
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.25

SEVELAMER HCL 800 MG TABLET [28715]

Facility

$8.92

Service Code	NDC 58468-0021-1
Hospital Charge Code	1712253
Hospital Revenue Code	259
Min. Negotiated Rate	$4.91
Max. Negotiated Rate	$6.69
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$5.35
Rate for Payer: Aetna of CA Government/Medicare	$5.35
Rate for Payer: Cash Price	$4.01
Rate for Payer: Health Smart Auto/Commercial	$5.35
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$5.35
Rate for Payer: LLUH Dept of Risk Management WC	$4.91
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$6.69

SEVELAMER HCL 800 MG TABLET [28715]

Facility

$4.33

Service Code	NDC 68462-447-18
Hospital Charge Code	1712253
Hospital Revenue Code	259
Min. Negotiated Rate	$2.38
Max. Negotiated Rate	$3.46
Rate for Payer: Cash Price	$1.95
Rate for Payer: Cigna of CA HMO/PPO	$3.46
Rate for Payer: Health Smart Auto/Commercial	$2.60
Rate for Payer: LLUH Dept of Risk Management WC	$2.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$3.25

SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]

Facility

$0.47

Service Code	NDC 9994-0803-33
Hospital Charge Code	1715236
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

SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]

Facility

$0.47

Service Code	NDC 9994-0803-33
Hospital Charge Code	1715236
Hospital Revenue Code	259
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$0.35
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	$0.21
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 Beech St/Commercial/PHCS	$0.35

SILDENAFIL 25 MG TABLET [22836]

Facility

$99.92

Service Code	NDC 0069-4200-30
Hospital Charge Code	1710917
Hospital Revenue Code	259
Min. Negotiated Rate	$54.96
Max. Negotiated Rate	$74.94
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$59.95
Rate for Payer: Aetna of CA Government/Medicare	$59.95
Rate for Payer: Cash Price	$44.96
Rate for Payer: Health Smart Auto/Commercial	$59.95
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$59.95
Rate for Payer: LLUH Dept of Risk Management WC	$54.96
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$74.94

Know your out-of-pocket cost for care.

All Charges