|
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 |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
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 |
$0.41 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.57
|
| 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: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.11
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.94
|
| Rate for Payer: Dignity Health Senior |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| 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: TriValley Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$1.39
|
|
|
Service Code
|
NDC 50268-720-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Senior |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$3.46
|
|
|
Service Code
|
NDC 0904-6707-06
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.63 |
| Max. Negotiated Rate |
$2.94 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.38
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$1.90
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$2.60
|
| Rate for Payer: Blue Shield of California Commercial |
$2.11
|
| Rate for Payer: Blue Shield of California EPN |
$1.69
|
| Rate for Payer: Cash Price |
$1.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.94
|
| Rate for Payer: Dignity Health Senior |
$2.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.21
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.14
|
| Rate for Payer: Heritage Provider Network Senior |
$2.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$2.42
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$2.42
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
| Rate for Payer: TriValley Medical Group Commercial |
$1.38
|
| Rate for Payer: TriValley Medical Group Senior |
$1.38
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.73
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.73
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$2.94
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$2.94
|
| Rate for Payer: Vantage Medical Group Senior |
$2.94
|
|
|
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 |
$0.63 |
| Max. Negotiated Rate |
$2.60 |
| Rate for Payer: Adventist Health Commercial |
$0.69
|
| Rate for Payer: Cash Price |
$1.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Senior |
$2.34
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.87
|
| Rate for Payer: Multiplan Commercial |
$2.60
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
IP
|
$0.47
|
|
|
Service Code
|
NDC 65162-058-27
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$1.39
|
|
|
Service Code
|
NDC 50268-720-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.95
|
| 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: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.18
|
| Rate for Payer: Dignity Health Senior |
$1.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Senior |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| 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: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-59
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
|
|
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 |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| 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: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| 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: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 68094-034-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.71 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| Rate for Payer: Multiplan Commercial |
$1.71
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$0.36
|
|
|
Service Code
|
NDC 69097-967-93
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.31 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.25
|
| 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: Blue Shield of California Commercial |
$0.22
|
| Rate for Payer: Blue Shield of California EPN |
$0.18
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.23
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.31
|
| Rate for Payer: Dignity Health Senior |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.22
|
| Rate for Payer: Heritage Provider Network Senior |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| 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: TriValley Medical Group Commercial |
$0.14
|
| Rate for Payer: TriValley Medical Group Senior |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.18
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
OP
|
$1.39
|
|
|
Service Code
|
NDC 50268-720-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.18 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.95
|
| 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: Blue Shield of California Commercial |
$0.85
|
| Rate for Payer: Blue Shield of California EPN |
$0.68
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.18
|
| Rate for Payer: Dignity Health Senior |
$1.18
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.86
|
| Rate for Payer: Heritage Provider Network Senior |
$0.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| 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: TriValley Medical Group Commercial |
$0.56
|
| Rate for Payer: TriValley Medical Group Senior |
$0.56
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.70
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
IP
|
$1.39
|
|
|
Service Code
|
NDC 50268-720-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.25 |
| Max. Negotiated Rate |
$1.04 |
| Rate for Payer: Adventist Health Commercial |
$0.28
|
| Rate for Payer: Cash Price |
$0.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.94
|
| Rate for Payer: Heritage Provider Network Senior |
$0.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.35
|
| Rate for Payer: Multiplan Commercial |
$1.04
|
|
|
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 |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| 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: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Senior |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| 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: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.47
|
|
|
Service Code
|
NDC 24979-186-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| Max. Negotiated Rate |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
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 |
$0.27 |
| Rate for Payer: Adventist Health Commercial |
$0.07
|
| Rate for Payer: Cash Price |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.24
|
| Rate for Payer: Heritage Provider Network Senior |
$0.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.27
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
|
OP
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-64
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.94 |
| Rate for Payer: Adventist Health Commercial |
$0.46
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.22
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.57
|
| 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: Blue Shield of California Commercial |
$1.39
|
| Rate for Payer: Blue Shield of California EPN |
$1.11
|
| Rate for Payer: Cash Price |
$1.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.94
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.94
|
| Rate for Payer: Dignity Health Senior |
$1.94
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.41
|
| Rate for Payer: Heritage Provider Network Senior |
$1.41
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.57
|
| 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: TriValley Medical Group Commercial |
$0.91
|
| Rate for Payer: TriValley Medical Group Senior |
$0.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 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 |
$0.60 |
| Max. Negotiated Rate |
$2.50 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.53
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| Rate for Payer: Multiplan Commercial |
$2.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.10
|
|
|
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 |
$0.60 |
| Max. Negotiated Rate |
$2.83 |
| Rate for Payer: Adventist Health Commercial |
$0.67
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.29
|
| 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: Blue Shield of California Commercial |
$2.03
|
| Rate for Payer: Blue Shield of California EPN |
$1.63
|
| Rate for Payer: Cash Price |
$1.83
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$2.83
|
| Rate for Payer: Dignity Health Medi-Cal |
$2.83
|
| Rate for Payer: Dignity Health Senior |
$2.83
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.54
|
| Rate for Payer: Heritage Provider Network Senior |
$1.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.83
|
| 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: TriValley Medical Group Commercial |
$1.33
|
| Rate for Payer: TriValley Medical Group Senior |
$1.33
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$1.20
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$1.10
|
| 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 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 |
$0.35 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.32
|
| Rate for Payer: Heritage Provider Network Senior |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| Rate for Payer: Multiplan Commercial |
$0.35
|
|
|
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 |
$0.40 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.32
|
| 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: Blue Shield of California Commercial |
$0.29
|
| Rate for Payer: Blue Shield of California EPN |
$0.23
|
| Rate for Payer: Cash Price |
$0.26
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.31
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.40
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.40
|
| Rate for Payer: Dignity Health Senior |
$0.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.30
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.29
|
| Rate for Payer: Heritage Provider Network Senior |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.12
|
| 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: TriValley Medical Group Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Senior |
$0.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$17.76
|
|
|
Service Code
|
NDC 55150-166-13
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$3.21 |
| Max. Negotiated Rate |
$13.32 |
| Rate for Payer: Adventist Health Commercial |
$3.55
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.02
|
| Rate for Payer: Heritage Provider Network Senior |
$12.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.44
|
| Rate for Payer: Multiplan Commercial |
$13.32
|
|
|
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 |
$4.72 |
| Max. Negotiated Rate |
$22.16 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.93
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.91
|
| 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: Blue Shield of California Commercial |
$15.90
|
| Rate for Payer: Blue Shield of California EPN |
$12.72
|
| Rate for Payer: Cash Price |
$14.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.95
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.16
|
| Rate for Payer: Dignity Health Senior |
$22.16
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.68
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.14
|
| Rate for Payer: Heritage Provider Network Senior |
$16.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.52
|
| 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: TriValley Medical Group Commercial |
$10.43
|
| Rate for Payer: TriValley Medical Group Senior |
$10.43
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 |
$3.21 |
| Max. Negotiated Rate |
$15.10 |
| Rate for Payer: Adventist Health Commercial |
$3.55
|
| Rate for Payer: Aetna of CA Gatekeeper |
$9.49
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$12.20
|
| 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: Blue Shield of California Commercial |
$10.83
|
| Rate for Payer: Blue Shield of California EPN |
$8.67
|
| Rate for Payer: Cash Price |
$9.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$11.54
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$15.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.10
|
| Rate for Payer: Dignity Health Senior |
$15.10
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$10.99
|
| Rate for Payer: Heritage Provider Network Senior |
$10.99
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$8.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.21
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.44
|
| 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: TriValley Medical Group Commercial |
$7.10
|
| Rate for Payer: TriValley Medical Group Senior |
$7.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.88
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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 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 |
$4.72 |
| Max. Negotiated Rate |
$19.55 |
| Rate for Payer: Adventist Health Commercial |
$5.21
|
| Rate for Payer: Cash Price |
$14.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.65
|
| Rate for Payer: Heritage Provider Network Senior |
$17.65
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.52
|
| Rate for Payer: Multiplan Commercial |
$19.55
|
|
