|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$0.36
|
|
|
Service Code
|
NDC 69097-967-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-59
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.38
|
| 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 |
$1.71
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.34
|
| Rate for Payer: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$0.91
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Central Health Plan Commercial |
$1.82
|
| 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 Medi-Cal |
$1.94
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.91
|
| Rate for Payer: EPIC Health Plan Senior |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.94
|
| Rate for Payer: Global Benefits Group Commercial |
$1.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.05
|
| Rate for Payer: InnovAge PACE Commercial |
$1.14
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.60
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.60
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
| Rate for Payer: Networks By Design Commercial |
$1.48
|
| Rate for Payer: Prime Health Services Commercial |
$1.94
|
| Rate for Payer: Riverside University Health System MISP |
$0.91
|
| 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 |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| 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: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.42
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| 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
|
$0.36
|
|
|
Service Code
|
NDC 65862-921-27
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.20
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.27
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: InnovAge PACE Commercial |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
| Rate for Payer: Riverside University Health System MISP |
$0.14
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.22
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.22
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.18
|
| Rate for Payer: United Healthcare All Other HMO |
$0.18
|
| Rate for Payer: United Healthcare HMO Rider |
$0.18
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.18
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.31
|
| Rate for Payer: Vantage Medical Group Senior |
$0.31
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-59
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1.76
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Central Health Plan Commercial |
$1.82
|
| 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: EPIC Health Plan Senior |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.94
|
| Rate for Payer: Global Benefits Group Commercial |
$1.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.05
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
| 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
|
$1.39
|
|
|
Service Code
|
NDC 50268-720-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.84
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$1.04
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.82
|
| Rate for Payer: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.55
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Central Health Plan Commercial |
$1.11
|
| Rate for Payer: Cigna of CA HMO |
$0.97
|
| Rate for Payer: Cigna of CA PPO |
$0.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.18
|
| Rate for Payer: Dignity Health Medicare Advantage |
$1.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Senior |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.25
|
| Rate for Payer: InnovAge PACE Commercial |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.97
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
| Rate for Payer: Networks By Design Commercial |
$0.90
|
| Rate for Payer: Prime Health Services Commercial |
$1.18
|
| Rate for Payer: Riverside University Health System MISP |
$0.56
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.83
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.70
|
| Rate for Payer: United Healthcare All Other HMO |
$0.70
|
| Rate for Payer: United Healthcare HMO Rider |
$0.70
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.70
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.18
|
| Rate for Payer: Vantage Medical Group Senior |
$1.18
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 24979-186-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| 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 |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| 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 Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.42
|
| Rate for Payer: InnovAge PACE Commercial |
$0.24
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Riverside University Health System MISP |
$0.19
|
| 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
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.46 |
| Max. Negotiated Rate |
$2.05 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Blue Shield of California Commercial |
$1.76
|
| Rate for Payer: Blue Shield of California EPN |
$1.15
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Central Health Plan Commercial |
$1.82
|
| 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: EPIC Health Plan Senior |
$0.91
|
| Rate for Payer: Galaxy Health WC |
$1.94
|
| Rate for Payer: Global Benefits Group Commercial |
$1.37
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.05
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$1.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.46
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
| 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
|
$1.39
|
|
|
Service Code
|
NDC 50268-720-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Central Health Plan Commercial |
$1.11
|
| Rate for Payer: Cigna of CA HMO |
$0.97
|
| Rate for Payer: Cigna of CA PPO |
$0.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Senior |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
| Rate for Payer: Networks By Design Commercial |
$0.90
|
| Rate for Payer: Prime Health Services Commercial |
$1.18
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 65162-058-27
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| 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 |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| 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 Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.42
|
| Rate for Payer: InnovAge PACE Commercial |
$0.24
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Riverside University Health System MISP |
$0.19
|
| 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
|
$0.36
|
|
|
Service Code
|
NDC 65862-921-27
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Central Health Plan Commercial |
$0.29
|
| Rate for Payer: Cigna of CA HMO |
$0.25
|
| Rate for Payer: Cigna of CA PPO |
$0.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: EPIC Health Plan Senior |
$0.14
|
| Rate for Payer: Galaxy Health WC |
$0.31
|
| Rate for Payer: Global Benefits Group Commercial |
$0.22
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
| Rate for Payer: Networks By Design Commercial |
$0.23
|
| Rate for Payer: Prime Health Services Commercial |
$0.31
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$1.39
|
|
|
Service Code
|
NDC 50268-720-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.28 |
| Max. Negotiated Rate |
$1.25 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$1.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.70
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Central Health Plan Commercial |
$1.11
|
| Rate for Payer: Cigna of CA HMO |
$0.97
|
| Rate for Payer: Cigna of CA PPO |
$0.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.56
|
| Rate for Payer: EPIC Health Plan Senior |
$0.56
|
| Rate for Payer: Galaxy Health WC |
$1.18
|
| Rate for Payer: Global Benefits Group Commercial |
$0.83
|
| Rate for Payer: Health Management Network EPO/PPO |
$1.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$0.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
| Rate for Payer: Networks By Design Commercial |
$0.90
|
| Rate for Payer: Prime Health Services Commercial |
$1.18
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$3.46
|
|
|
Service Code
|
NDC 0904-6707-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.69 |
| Max. Negotiated Rate |
$3.11 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Blue Shield of California Commercial |
$2.67
|
| Rate for Payer: Blue Shield of California EPN |
$1.74
|
| Rate for Payer: Cash Price |
$1.90
|
| Rate for Payer: Central Health Plan Commercial |
$2.77
|
| Rate for Payer: Cigna of CA HMO |
$2.42
|
| Rate for Payer: Cigna of CA PPO |
$2.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.38
|
| Rate for Payer: EPIC Health Plan Senior |
$1.38
|
| Rate for Payer: Galaxy Health WC |
$2.94
|
| Rate for Payer: Global Benefits Group Commercial |
$2.08
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.11
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.32
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.69
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
| Rate for Payer: Networks By Design Commercial |
$2.25
|
| Rate for Payer: Prime Health Services Commercial |
$2.94
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
|
OP
|
$3.33
|
|
|
Service Code
|
NDC 68462-447-18
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA HMO/PPO |
$2.02
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.83
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.83
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.50
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.61
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.96
|
| Rate for Payer: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Central Health Plan Commercial |
$2.66
|
| Rate for Payer: Cigna of CA HMO |
$2.33
|
| Rate for Payer: Cigna of CA PPO |
$2.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.83
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Senior |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.83
|
| Rate for Payer: Global Benefits Group Commercial |
$2.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.00
|
| Rate for Payer: InnovAge PACE Commercial |
$1.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.33
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: Networks By Design Commercial |
$1.67
|
| Rate for Payer: Prime Health Services Commercial |
$2.83
|
| Rate for Payer: Riverside University Health System MISP |
$1.33
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$2.00
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$2.00
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.22
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.09
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.83
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.83
|
| Rate for Payer: Vantage Medical Group Senior |
$2.83
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
|
IP
|
$3.33
|
|
|
Service Code
|
NDC 68462-447-18
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$0.67 |
| Max. Negotiated Rate |
$3.00 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Blue Shield of California Commercial |
$2.57
|
| Rate for Payer: Blue Shield of California EPN |
$1.68
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Central Health Plan Commercial |
$2.66
|
| Rate for Payer: Cigna of CA HMO |
$2.33
|
| Rate for Payer: Cigna of CA PPO |
$2.33
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.33
|
| Rate for Payer: EPIC Health Plan Senior |
$1.33
|
| Rate for Payer: Galaxy Health WC |
$2.83
|
| Rate for Payer: Global Benefits Group Commercial |
$2.00
|
| Rate for Payer: Health Management Network EPO/PPO |
$3.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$2.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.27
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$2.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.67
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: Networks By Design Commercial |
$1.67
|
| Rate for Payer: Prime Health Services Commercial |
$2.83
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.25
|
| Rate for Payer: United Healthcare All Other HMO |
$1.22
|
| Rate for Payer: United Healthcare HMO Rider |
$1.19
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.09
|
|
|
SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 9994-0803-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California Commercial |
$0.36
|
| Rate for Payer: Blue Shield of California EPN |
$0.24
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| 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: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.42
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
|
|
SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]
|
Facility
|
OP
|
$0.47
|
|
|
Service Code
|
NDC 9994-0803-33
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.42 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA HMO/PPO |
$0.29
|
| 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 |
$0.35
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$0.23
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.28
|
| Rate for Payer: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.19
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Central Health Plan Commercial |
$0.38
|
| 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 Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Medicare Advantage |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: EPIC Health Plan Senior |
$0.19
|
| Rate for Payer: Galaxy Health WC |
$0.40
|
| Rate for Payer: Global Benefits Group Commercial |
$0.28
|
| Rate for Payer: Health Management Network EPO/PPO |
$0.42
|
| Rate for Payer: InnovAge PACE Commercial |
$0.24
|
| 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: Kaiser Permanente of CA Medicare Advantage |
$0.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.33
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.33
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
| Rate for Payer: Networks By Design Commercial |
$0.31
|
| Rate for Payer: Prime Health Services Commercial |
$0.40
|
| Rate for Payer: Riverside University Health System MISP |
$0.19
|
| 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
|
|
|
SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]
|
Facility
|
IP
|
$26.07
|
|
|
Service Code
|
NDC 0069-0338-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Blue Shield of California Commercial |
$20.15
|
| Rate for Payer: Blue Shield of California EPN |
$13.14
|
| Rate for Payer: Cash Price |
$14.34
|
| Rate for Payer: Central Health Plan Commercial |
$20.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.43
|
| Rate for Payer: EPIC Health Plan Senior |
$10.43
|
| Rate for Payer: Galaxy Health WC |
$22.16
|
| Rate for Payer: Global Benefits Group Commercial |
$15.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.21
|
| Rate for Payer: Multiplan Commercial |
$19.55
|
| Rate for Payer: Networks By Design Commercial |
$16.95
|
| Rate for Payer: Prime Health Services Commercial |
$22.16
|
|
|
SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]
|
Facility
|
IP
|
$17.76
|
|
|
Service Code
|
NDC 55150-166-13
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$15.98 |
| Rate for Payer: Adventist Health Commercial |
$3.55
|
| Rate for Payer: Blue Shield of California Commercial |
$13.73
|
| Rate for Payer: Blue Shield of California EPN |
$8.95
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Central Health Plan Commercial |
$14.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.10
|
| Rate for Payer: EPIC Health Plan Senior |
$7.10
|
| Rate for Payer: Galaxy Health WC |
$15.10
|
| Rate for Payer: Global Benefits Group Commercial |
$10.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.55
|
| Rate for Payer: Multiplan Commercial |
$13.32
|
| Rate for Payer: Networks By Design Commercial |
$11.54
|
| Rate for Payer: Prime Health Services Commercial |
$15.10
|
|
|
SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]
|
Facility
|
OP
|
$26.07
|
|
|
Service Code
|
NDC 0069-0338-01
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$5.21 |
| Max. Negotiated Rate |
$23.46 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Aetna of CA HMO/PPO |
$15.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.34
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.55
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$12.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$15.31
|
| Rate for Payer: Blue Shield of California Commercial |
$15.93
|
| Rate for Payer: Blue Shield of California EPN |
$10.40
|
| Rate for Payer: Cash Price |
$14.34
|
| Rate for Payer: Central Health Plan Commercial |
$20.86
|
| Rate for Payer: Cigna of CA HMO |
$16.68
|
| Rate for Payer: Cigna of CA PPO |
$19.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.16
|
| Rate for Payer: Dignity Health Medicare Advantage |
$22.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$10.43
|
| Rate for Payer: EPIC Health Plan Senior |
$10.43
|
| Rate for Payer: Galaxy Health WC |
$22.16
|
| Rate for Payer: Global Benefits Group Commercial |
$15.64
|
| Rate for Payer: Health Management Network EPO/PPO |
$23.46
|
| Rate for Payer: InnovAge PACE Commercial |
$13.04
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$17.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.21
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.25
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.25
|
| Rate for Payer: Multiplan Commercial |
$19.55
|
| Rate for Payer: Networks By Design Commercial |
$16.95
|
| Rate for Payer: Prime Health Services Commercial |
$22.16
|
| Rate for Payer: Riverside University Health System MISP |
$10.43
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$15.64
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$15.64
|
| Rate for Payer: United Healthcare All Other Commercial |
$13.04
|
| Rate for Payer: United Healthcare All Other HMO |
$13.04
|
| Rate for Payer: United Healthcare HMO Rider |
$13.04
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.16
|
| Rate for Payer: Vantage Medical Group Senior |
$22.16
|
|
|
SILDENAFIL 10 MG/12.5 ML INTRAVENOUS SOLUTION [100417]
|
Facility
|
OP
|
$17.76
|
|
|
Service Code
|
NDC 55150-166-13
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.55 |
| Max. Negotiated Rate |
$15.98 |
| Rate for Payer: Adventist Health Commercial |
$3.55
|
| Rate for Payer: Aetna of CA HMO/PPO |
$10.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$15.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$9.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.32
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$8.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$10.43
|
| Rate for Payer: Blue Shield of California Commercial |
$10.85
|
| Rate for Payer: Blue Shield of California EPN |
$7.09
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Central Health Plan Commercial |
$14.21
|
| Rate for Payer: Cigna of CA HMO |
$11.37
|
| Rate for Payer: Cigna of CA PPO |
$13.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.10
|
| Rate for Payer: Dignity Health Medicare Advantage |
$15.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.10
|
| Rate for Payer: EPIC Health Plan Senior |
$7.10
|
| Rate for Payer: Galaxy Health WC |
$15.10
|
| Rate for Payer: Global Benefits Group Commercial |
$10.66
|
| Rate for Payer: Health Management Network EPO/PPO |
$15.98
|
| Rate for Payer: InnovAge PACE Commercial |
$8.88
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$11.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.77
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$10.99
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$12.43
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$12.43
|
| Rate for Payer: Multiplan Commercial |
$13.32
|
| Rate for Payer: Networks By Design Commercial |
$11.54
|
| Rate for Payer: Prime Health Services Commercial |
$15.10
|
| Rate for Payer: Riverside University Health System MISP |
$7.10
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$10.66
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$10.66
|
| Rate for Payer: United Healthcare All Other Commercial |
$8.88
|
| Rate for Payer: United Healthcare All Other HMO |
$8.88
|
| Rate for Payer: United Healthcare HMO Rider |
$8.88
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$8.88
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$15.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Vantage Medical Group Senior |
$15.10
|
|
|
SILDENAFIL 25 MG TABLET [22836]
|
Facility
|
IP
|
$104.91
|
|
|
Service Code
|
NDC 0069-4200-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.98 |
| Max. Negotiated Rate |
$94.42 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Blue Shield of California Commercial |
$81.10
|
| Rate for Payer: Blue Shield of California EPN |
$52.87
|
| Rate for Payer: Cash Price |
$57.70
|
| Rate for Payer: Central Health Plan Commercial |
$83.93
|
| Rate for Payer: Cigna of CA HMO |
$73.44
|
| Rate for Payer: Cigna of CA PPO |
$73.44
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.96
|
| Rate for Payer: EPIC Health Plan Senior |
$41.96
|
| Rate for Payer: Galaxy Health WC |
$89.17
|
| Rate for Payer: Global Benefits Group Commercial |
$62.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$94.42
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$69.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$64.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.98
|
| Rate for Payer: Multiplan Commercial |
$78.68
|
| Rate for Payer: Networks By Design Commercial |
$68.19
|
| Rate for Payer: Prime Health Services Commercial |
$89.17
|
|
|
SILDENAFIL 25 MG TABLET [22836]
|
Facility
|
OP
|
$104.91
|
|
|
Service Code
|
NDC 0069-4200-30
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$20.98 |
| Max. Negotiated Rate |
$94.42 |
| Rate for Payer: Adventist Health Commercial |
$20.98
|
| Rate for Payer: Aetna of CA HMO/PPO |
$63.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$89.17
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$57.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$78.68
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$50.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$61.61
|
| Rate for Payer: Blue Shield of California Commercial |
$64.10
|
| Rate for Payer: Blue Shield of California EPN |
$41.86
|
| Rate for Payer: Cash Price |
$57.70
|
| Rate for Payer: Central Health Plan Commercial |
$83.93
|
| Rate for Payer: Cigna of CA HMO |
$73.44
|
| Rate for Payer: Cigna of CA PPO |
$73.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$89.17
|
| Rate for Payer: Dignity Health Medi-Cal |
$89.17
|
| Rate for Payer: Dignity Health Medicare Advantage |
$89.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.96
|
| Rate for Payer: EPIC Health Plan Senior |
$41.96
|
| Rate for Payer: Galaxy Health WC |
$89.17
|
| Rate for Payer: Global Benefits Group Commercial |
$62.95
|
| Rate for Payer: Health Management Network EPO/PPO |
$94.42
|
| Rate for Payer: InnovAge PACE Commercial |
$52.45
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$69.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$39.97
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$64.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$20.98
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$73.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$73.44
|
| Rate for Payer: Multiplan Commercial |
$78.68
|
| Rate for Payer: Networks By Design Commercial |
$68.19
|
| Rate for Payer: Prime Health Services Commercial |
$89.17
|
| Rate for Payer: Riverside University Health System MISP |
$41.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$62.95
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$62.95
|
| Rate for Payer: United Healthcare All Other Commercial |
$52.45
|
| Rate for Payer: United Healthcare All Other HMO |
$52.45
|
| Rate for Payer: United Healthcare HMO Rider |
$52.45
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$52.45
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$89.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$89.17
|
| Rate for Payer: Vantage Medical Group Senior |
$89.17
|
|
|
SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]
|
Facility
|
IP
|
$2.81
|
|
|
Service Code
|
NDC 9994-0803-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Blue Shield of California Commercial |
$2.17
|
| Rate for Payer: Blue Shield of California EPN |
$1.42
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Central Health Plan Commercial |
$2.25
|
| Rate for Payer: Cigna of CA HMO |
$1.97
|
| Rate for Payer: Cigna of CA PPO |
$1.97
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Senior |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.39
|
| Rate for Payer: Global Benefits Group Commercial |
$1.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.53
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: Networks By Design Commercial |
$1.83
|
| Rate for Payer: Prime Health Services Commercial |
$2.39
|
|
|
SILDENAFIL ORAL SUSPENSION COMPOUND 2.5 MG/ML [4080335]
|
Facility
|
OP
|
$2.81
|
|
|
Service Code
|
NDC 9994-0803-35
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.56 |
| Max. Negotiated Rate |
$2.53 |
| Rate for Payer: Adventist Health Commercial |
$0.56
|
| Rate for Payer: Aetna of CA HMO/PPO |
$1.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.11
|
| Rate for Payer: Anthem Blue Cross of CA Exchange |
$1.36
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1.65
|
| Rate for Payer: Blue Shield of California Commercial |
$1.72
|
| Rate for Payer: Blue Shield of California EPN |
$1.12
|
| Rate for Payer: Cash Price |
$1.54
|
| Rate for Payer: Central Health Plan Commercial |
$2.25
|
| Rate for Payer: Cigna of CA HMO |
$1.97
|
| Rate for Payer: Cigna of CA PPO |
$1.97
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.39
|
| Rate for Payer: Dignity Health Medicare Advantage |
$2.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.12
|
| Rate for Payer: EPIC Health Plan Senior |
$1.12
|
| Rate for Payer: Galaxy Health WC |
$2.39
|
| Rate for Payer: Global Benefits Group Commercial |
$1.69
|
| Rate for Payer: Health Management Network EPO/PPO |
$2.53
|
| Rate for Payer: InnovAge PACE Commercial |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$1.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$1.74
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1.97
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1.97
|
| Rate for Payer: Multiplan Commercial |
$2.11
|
| Rate for Payer: Networks By Design Commercial |
$1.83
|
| Rate for Payer: Prime Health Services Commercial |
$2.39
|
| Rate for Payer: Riverside University Health System MISP |
$1.12
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$1.69
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$1.69
|
| Rate for Payer: United Healthcare All Other Commercial |
$1.41
|
| Rate for Payer: United Healthcare All Other HMO |
$1.41
|
| Rate for Payer: United Healthcare HMO Rider |
$1.41
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$1.41
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.39
|
| Rate for Payer: Vantage Medical Group Senior |
$2.39
|
|
