|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-59
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.36
|
| Rate for Payer: Blue Distinction Transplant |
$1.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.68
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cigna of CA HMO |
$1.60
|
| Rate for Payer: Cigna of CA PPO |
$1.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.94
|
| Rate for Payer: Dignity Health Media |
$1.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.94
|
| Rate for Payer: Global Benefits Group Commercial |
$1.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.82
|
| Rate for Payer: Networks By Design Commercial |
$1.48
|
| Rate for Payer: Prime Health Services Commercial |
$1.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.94
|
| Rate for Payer: Vantage Medical Group Senior |
$1.94
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 65862-921-27
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$8.73
|
|
|
Service Code
|
NDC 50268-720-15
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.20
|
| Rate for Payer: Blue Distinction Transplant |
$5.24
|
| Rate for Payer: Blue Shield of California Commercial |
$6.43
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cigna of CA HMO |
$6.11
|
| Rate for Payer: Cigna of CA PPO |
$6.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.42
|
| Rate for Payer: Dignity Health Media |
$7.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.49
|
| Rate for Payer: Galaxy Health WC |
$7.42
|
| Rate for Payer: Global Benefits Group Commercial |
$5.24
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$6.98
|
| Rate for Payer: Networks By Design Commercial |
$5.67
|
| Rate for Payer: Prime Health Services Commercial |
$7.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Other HMO |
$4.36
|
| Rate for Payer: United Healthcare HMO Rider |
$4.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.42
|
| Rate for Payer: Vantage Medical Group Senior |
$7.42
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$8.73
|
|
|
Service Code
|
NDC 50268-720-11
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Blue Shield of California Commercial |
$6.22
|
| Rate for Payer: Blue Shield of California EPN |
$4.47
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cigna of CA HMO |
$6.11
|
| Rate for Payer: Cigna of CA PPO |
$6.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.49
|
| Rate for Payer: Galaxy Health WC |
$7.42
|
| Rate for Payer: Global Benefits Group Commercial |
$5.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$6.98
|
| Rate for Payer: Networks By Design Commercial |
$5.67
|
| Rate for Payer: Prime Health Services Commercial |
$7.42
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 65162-058-27
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Distinction Transplant |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Media |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 24979-186-46
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Distinction Transplant |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Media |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$8.73
|
|
|
Service Code
|
NDC 50268-720-11
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.20
|
| Rate for Payer: Blue Distinction Transplant |
$5.24
|
| Rate for Payer: Blue Shield of California Commercial |
$6.43
|
| Rate for Payer: Blue Shield of California EPN |
$5.10
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cigna of CA HMO |
$6.11
|
| Rate for Payer: Cigna of CA PPO |
$6.11
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.42
|
| Rate for Payer: Dignity Health Media |
$7.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.49
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.49
|
| Rate for Payer: Galaxy Health WC |
$7.42
|
| Rate for Payer: Global Benefits Group Commercial |
$5.24
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.55
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$6.98
|
| Rate for Payer: Networks By Design Commercial |
$5.67
|
| Rate for Payer: Prime Health Services Commercial |
$7.42
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.24
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.24
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.36
|
| Rate for Payer: United Healthcare All Other HMO |
$4.36
|
| Rate for Payer: United Healthcare HMO Rider |
$4.36
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.36
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.42
|
| Rate for Payer: Vantage Medical Group Senior |
$7.42
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-64
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Blue Shield of California Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cigna of CA HMO |
$1.60
|
| Rate for Payer: Cigna of CA PPO |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.94
|
| Rate for Payer: Global Benefits Group Commercial |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.82
|
| Rate for Payer: Networks By Design Commercial |
$1.48
|
| Rate for Payer: Prime Health Services Commercial |
$1.94
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-59
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Blue Shield of California Commercial |
$1.62
|
| Rate for Payer: Blue Shield of California EPN |
$1.17
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cigna of CA HMO |
$1.60
|
| Rate for Payer: Cigna of CA PPO |
$1.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.94
|
| Rate for Payer: Global Benefits Group Commercial |
$1.37
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.82
|
| Rate for Payer: Networks By Design Commercial |
$1.48
|
| Rate for Payer: Prime Health Services Commercial |
$1.94
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-64
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.55 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Aetna of CA HMO/PPO |
$1.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.36
|
| Rate for Payer: Blue Distinction Transplant |
$1.37
|
| Rate for Payer: Blue Shield of California Commercial |
$1.68
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.03
|
| Rate for Payer: Cigna of CA HMO |
$1.60
|
| Rate for Payer: Cigna of CA PPO |
$1.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.94
|
| Rate for Payer: Dignity Health Media |
$1.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.94
|
| Rate for Payer: Global Benefits Group Commercial |
$1.37
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$1.71
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.87
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$1.82
|
| Rate for Payer: Networks By Design Commercial |
$1.48
|
| Rate for Payer: Prime Health Services Commercial |
$1.94
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.37
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.37
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.14
|
| Rate for Payer: United Healthcare All Other HMO |
$1.14
|
| Rate for Payer: United Healthcare HMO Rider |
$1.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.94
|
| Rate for Payer: Vantage Medical Group Senior |
$1.94
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 24979-186-46
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 65862-921-27
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Distinction Transplant |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Media |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$8.73
|
|
|
Service Code
|
NDC 50268-720-15
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.10 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Blue Shield of California Commercial |
$6.22
|
| Rate for Payer: Blue Shield of California EPN |
$4.47
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cigna of CA HMO |
$6.11
|
| Rate for Payer: Cigna of CA PPO |
$6.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.49
|
| Rate for Payer: Galaxy Health WC |
$7.42
|
| Rate for Payer: Global Benefits Group Commercial |
$5.24
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.82
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.10
|
| Rate for Payer: Multiplan Commercial |
$6.98
|
| Rate for Payer: Networks By Design Commercial |
$5.67
|
| Rate for Payer: Prime Health Services Commercial |
$7.42
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
|
IP
|
$8.92
|
|
|
Service Code
|
NDC 58468-0021-1
|
| Hospital Charge Code |
1712253
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$7.58 |
| Rate for Payer: Blue Shield of California Commercial |
$6.35
|
| Rate for Payer: Blue Shield of California EPN |
$4.57
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: Cigna of CA HMO |
$6.24
|
| Rate for Payer: Cigna of CA PPO |
$6.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.57
|
| Rate for Payer: Galaxy Health WC |
$7.58
|
| Rate for Payer: Global Benefits Group Commercial |
$5.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$7.14
|
| Rate for Payer: Networks By Design Commercial |
$5.80
|
| Rate for Payer: Prime Health Services Commercial |
$7.58
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
|
OP
|
$8.92
|
|
|
Service Code
|
NDC 58468-0021-1
|
| Hospital Charge Code |
1712253
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.14 |
| Max. Negotiated Rate |
$7.58 |
| Rate for Payer: Aetna of CA HMO/PPO |
$5.85
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$7.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$4.91
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$4.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$5.31
|
| Rate for Payer: Blue Distinction Transplant |
$5.35
|
| Rate for Payer: Blue Shield of California Commercial |
$6.57
|
| Rate for Payer: Blue Shield of California EPN |
$5.21
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: Cigna of CA HMO |
$6.24
|
| Rate for Payer: Cigna of CA PPO |
$6.24
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.58
|
| Rate for Payer: Dignity Health Media |
$7.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$3.57
|
| Rate for Payer: EPIC Health Plan Transplant |
$3.57
|
| Rate for Payer: Galaxy Health WC |
$7.58
|
| Rate for Payer: Global Benefits Group Commercial |
$5.35
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$6.69
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$5.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.14
|
| Rate for Payer: Multiplan Commercial |
$7.14
|
| Rate for Payer: Networks By Design Commercial |
$5.80
|
| Rate for Payer: Prime Health Services Commercial |
$7.58
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$5.35
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$5.35
|
| Rate for Payer: United Healthcare All Other Commercial |
$4.46
|
| Rate for Payer: United Healthcare All Other HMO |
$4.46
|
| Rate for Payer: United Healthcare HMO Rider |
$4.46
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$4.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$7.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.58
|
| Rate for Payer: Vantage Medical Group Senior |
$7.58
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
|
IP
|
$4.33
|
|
|
Service Code
|
NDC 68462-447-18
|
| Hospital Charge Code |
1712253
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Blue Shield of California Commercial |
$3.08
|
| Rate for Payer: Blue Shield of California EPN |
$2.22
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cigna of CA HMO |
$3.03
|
| Rate for Payer: Cigna of CA PPO |
$3.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$3.68
|
| Rate for Payer: Global Benefits Group Commercial |
$2.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$3.46
|
| Rate for Payer: Networks By Design Commercial |
$2.81
|
| Rate for Payer: Prime Health Services Commercial |
$3.68
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
|
OP
|
$4.33
|
|
|
Service Code
|
NDC 68462-447-18
|
| Hospital Charge Code |
1712253
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.04 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$2.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$3.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.38
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$2.58
|
| Rate for Payer: Blue Distinction Transplant |
$2.60
|
| Rate for Payer: Blue Shield of California Commercial |
$3.19
|
| Rate for Payer: Blue Shield of California EPN |
$2.53
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cigna of CA HMO |
$3.03
|
| Rate for Payer: Cigna of CA PPO |
$3.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.68
|
| Rate for Payer: Dignity Health Media |
$3.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.73
|
| Rate for Payer: EPIC Health Plan Transplant |
$1.73
|
| Rate for Payer: Galaxy Health WC |
$3.68
|
| Rate for Payer: Global Benefits Group Commercial |
$2.60
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$3.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.04
|
| Rate for Payer: Multiplan Commercial |
$3.46
|
| Rate for Payer: Networks By Design Commercial |
$2.81
|
| Rate for Payer: Prime Health Services Commercial |
$3.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.60
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.60
|
| Rate for Payer: United Healthcare All Other Commercial |
$2.16
|
| Rate for Payer: United Healthcare All Other HMO |
$2.16
|
| Rate for Payer: United Healthcare HMO Rider |
$2.16
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$2.16
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$3.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.68
|
| Rate for Payer: Vantage Medical Group Senior |
$3.68
|
|
|
SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 9994-0803-33
|
| Hospital Charge Code |
1715236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.26
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Distinction Transplant |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.35
|
| Rate for Payer: Blue Shield of California EPN |
$0.27
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Media |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.28
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.28
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.24
|
| Rate for Payer: United Healthcare All Other HMO |
$0.24
|
| Rate for Payer: United Healthcare HMO Rider |
$0.24
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 9994-0803-33
|
| Hospital Charge Code |
1715236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.11 |
| Max. Negotiated Rate |
$0.40 |
| Rate for Payer: Blue Shield of California Commercial |
$0.33
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.21
|
| Rate for Payer: Cigna of CA HMO |
$0.33
|
| Rate for Payer: Cigna of CA PPO |
$0.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.38
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
|
|
SHOULDER AND ELBOW JOINT REPLACEMENT
|
Facility
|
IP
|
$31,030.23
|
|
|
Service Code
|
APR-DRG 3222
|
| Min. Negotiated Rate |
$23,803.45 |
| Max. Negotiated Rate |
$31,030.23 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23,803.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$31,030.23
|
|
|
SHOULDER AND ELBOW JOINT REPLACEMENT
|
Facility
|
IP
|
$54,560.50
|
|
|
Service Code
|
APR-DRG 3224
|
| Min. Negotiated Rate |
$41,853.64 |
| Max. Negotiated Rate |
$54,560.50 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$41,853.64
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54,560.50
|
|
|
SHOULDER AND ELBOW JOINT REPLACEMENT
|
Facility
|
IP
|
$28,579.31
|
|
|
Service Code
|
APR-DRG 3221
|
| Min. Negotiated Rate |
$21,923.34 |
| Max. Negotiated Rate |
$28,579.31 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21,923.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$28,579.31
|
|
|
SHOULDER AND ELBOW JOINT REPLACEMENT
|
Facility
|
IP
|
$40,748.79
|
|
|
Service Code
|
APR-DRG 3223
|
| Min. Negotiated Rate |
$31,258.61 |
| Max. Negotiated Rate |
$40,748.79 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$31,258.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40,748.79
|
|
|
SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT
|
Facility
|
IP
|
$58,703.29
|
|
|
Service Code
|
APR-DRG 3154
|
| Min. Negotiated Rate |
$45,031.61 |
| Max. Negotiated Rate |
$58,703.29 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$45,031.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$58,703.29
|
|
|
SHOULDER, UPPER ARM AND FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT
|
Facility
|
IP
|
$24,229.01
|
|
|
Service Code
|
APR-DRG 3152
|
| Min. Negotiated Rate |
$18,586.20 |
| Max. Negotiated Rate |
$24,229.01 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18,586.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$24,229.01
|
|
