|
SERTRALINE 50 MG TABLET [11351]
|
Facility
IP
|
$0.47
|
|
|
Service Code
|
NDC 60687-242-01
|
| Hospital Charge Code |
1711554
|
|
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: Aetna of CA Non-Gatekeeper |
$0.32
|
| Rate for Payer: Cash Price |
$0.21
|
| 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
|
|
|
SERVATOR B ORGAN PRESERVATION SOLUTION [40817911]
|
Facility
IP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0817-91
|
| Hospital Charge Code |
NDG40817911
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.17 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Senior |
$0.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
|
|
SERVATOR B ORGAN PRESERVATION SOLUTION [40817911]
|
Facility
OP
|
$0.22
|
|
|
Service Code
|
NDC 9994-0817-91
|
| Hospital Charge Code |
NDG40817911
|
|
Hospital Revenue Code
|
272
|
| Min. Negotiated Rate |
$0.04 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.04
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.12
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.14
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.10
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.14
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.19
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.19
|
| Rate for Payer: Dignity Health Senior |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Senior |
$0.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.17
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.19
|
| Rate for Payer: Vantage Medical Group Senior |
$0.19
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
OP
|
$11.35
|
|
|
Service Code
|
NDC 43598-478-01
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.51
|
| Rate for Payer: Blue Shield of California Commercial |
$7.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.66
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.65
|
| Rate for Payer: Dignity Health Senior |
$9.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.03
|
| Rate for Payer: Heritage Provider Network Senior |
$7.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.65
|
| Rate for Payer: Vantage Medical Group Senior |
$9.65
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
OP
|
$2.33
|
|
|
Service Code
|
NDC 0115-1365-30
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.98
|
| Rate for Payer: Dignity Health Senior |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1.98
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
OP
|
$11.35
|
|
|
Service Code
|
NDC 43598-478-90
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.51
|
| Rate for Payer: Blue Shield of California Commercial |
$7.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.66
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.65
|
| Rate for Payer: Dignity Health Senior |
$9.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.03
|
| Rate for Payer: Heritage Provider Network Senior |
$7.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.65
|
| Rate for Payer: Vantage Medical Group Senior |
$9.65
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
IP
|
$2.27
|
|
|
Service Code
|
NDC 65862-930-90
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Cash Price |
$1.02
|
| 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 |
$1.70
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
IP
|
$11.35
|
|
|
Service Code
|
NDC 43598-478-01
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.68
|
| Rate for Payer: Heritage Provider Network Senior |
$7.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
IP
|
$2.27
|
|
|
Service Code
|
NDC 65862-930-08
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Cash Price |
$1.02
|
| 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 |
$1.70
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
OP
|
$2.27
|
|
|
Service Code
|
NDC 65862-930-08
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| 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: Multiplan Commercial |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
OP
|
$2.33
|
|
|
Service Code
|
NDC 0115-1365-29
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.98 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.60
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.98
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.28
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.75
|
| Rate for Payer: Blue Shield of California Commercial |
$1.45
|
| Rate for Payer: Blue Shield of California EPN |
$1.37
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.98
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.98
|
| Rate for Payer: Dignity Health Senior |
$1.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.44
|
| Rate for Payer: Heritage Provider Network Senior |
$1.44
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$1.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.98
|
| Rate for Payer: Vantage Medical Group Senior |
$1.98
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
IP
|
$2.33
|
|
|
Service Code
|
NDC 0115-1365-29
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.60
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
IP
|
$11.35
|
|
|
Service Code
|
NDC 43598-478-90
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.68
|
| Rate for Payer: Heritage Provider Network Senior |
$7.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
OP
|
$2.27
|
|
|
Service Code
|
NDC 65862-930-90
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| 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: Multiplan Commercial |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
SEVELAMER CARBONATE 0.8 GRAM ORAL POWDER PACKET [99694]
|
Facility
IP
|
$2.33
|
|
|
Service Code
|
NDC 0115-1365-30
|
| Hospital Charge Code |
1712471
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.42 |
| Max. Negotiated Rate |
$1.75 |
| Rate for Payer: Adventist Health Commercial |
$0.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.60
|
| Rate for Payer: Cash Price |
$1.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$1.58
|
| Rate for Payer: Heritage Provider Network Senior |
$1.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.58
|
| Rate for Payer: Multiplan Commercial |
$1.75
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
OP
|
$11.35
|
|
|
Service Code
|
NDC 43598-479-90
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.51
|
| Rate for Payer: Blue Shield of California Commercial |
$7.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.66
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.65
|
| Rate for Payer: Dignity Health Senior |
$9.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.03
|
| Rate for Payer: Heritage Provider Network Senior |
$7.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.65
|
| Rate for Payer: Vantage Medical Group Senior |
$9.65
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
IP
|
$11.35
|
|
|
Service Code
|
NDC 0955-1054-90
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.68
|
| Rate for Payer: Heritage Provider Network Senior |
$7.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
IP
|
$2.27
|
|
|
Service Code
|
NDC 65862-931-08
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.70 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: Cash Price |
$1.02
|
| 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 |
$1.70
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
IP
|
$11.35
|
|
|
Service Code
|
NDC 43598-479-90
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.68
|
| Rate for Payer: Heritage Provider Network Senior |
$7.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
OP
|
$2.27
|
|
|
Service Code
|
NDC 65862-931-08
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| Max. Negotiated Rate |
$1.93 |
| Rate for Payer: Adventist Health Commercial |
$0.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$1.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$1.56
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$1.93
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.70
|
| Rate for Payer: Blue Shield of California Commercial |
$1.41
|
| Rate for Payer: Blue Shield of California EPN |
$1.33
|
| Rate for Payer: Cash Price |
$1.02
|
| Rate for Payer: Cigna of CA HMO/PPO |
$1.48
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1.93
|
| Rate for Payer: Dignity Health Medi-Cal |
$1.93
|
| Rate for Payer: Dignity Health Senior |
$1.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$1.45
|
| 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: Multiplan Commercial |
$1.70
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1.93
|
| Rate for Payer: Vantage Medical Group Senior |
$1.93
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
OP
|
$11.35
|
|
|
Service Code
|
NDC 43598-479-01
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.51
|
| Rate for Payer: Blue Shield of California Commercial |
$7.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.66
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.65
|
| Rate for Payer: Dignity Health Senior |
$9.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.03
|
| Rate for Payer: Heritage Provider Network Senior |
$7.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.65
|
| Rate for Payer: Vantage Medical Group Senior |
$9.65
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
OP
|
$11.35
|
|
|
Service Code
|
NDC 0955-1054-90
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.51
|
| Rate for Payer: Blue Shield of California Commercial |
$7.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.66
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.65
|
| Rate for Payer: Dignity Health Senior |
$9.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.03
|
| Rate for Payer: Heritage Provider Network Senior |
$7.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.65
|
| Rate for Payer: Vantage Medical Group Senior |
$9.65
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
OP
|
$11.35
|
|
|
Service Code
|
NDC 0955-1054-01
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$9.65 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$9.65
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$6.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$8.51
|
| Rate for Payer: Blue Shield of California Commercial |
$7.05
|
| Rate for Payer: Blue Shield of California EPN |
$6.66
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.65
|
| Rate for Payer: Dignity Health Medi-Cal |
$9.65
|
| Rate for Payer: Dignity Health Senior |
$9.65
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.26
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.03
|
| Rate for Payer: Heritage Provider Network Senior |
$7.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$9.65
|
| Rate for Payer: Vantage Medical Group Senior |
$9.65
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
OP
|
$21.42
|
|
|
Service Code
|
NDC 58468-0131-1
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$18.21 |
| Rate for Payer: Adventist Health Commercial |
$4.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.72
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$18.21
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$11.78
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$16.06
|
| Rate for Payer: Blue Shield of California Commercial |
$13.30
|
| Rate for Payer: Blue Shield of California EPN |
$12.57
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.21
|
| Rate for Payer: Dignity Health Senior |
$18.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.26
|
| Rate for Payer: Heritage Provider Network Senior |
$13.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.88
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.36
|
| Rate for Payer: Multiplan Commercial |
$16.06
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.21
|
| Rate for Payer: Vantage Medical Group Senior |
$18.21
|
|
|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
IP
|
$11.35
|
|
|
Service Code
|
NDC 0955-1054-01
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$2.05 |
| Max. Negotiated Rate |
$8.51 |
| Rate for Payer: Adventist Health Commercial |
$2.27
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$7.80
|
| Rate for Payer: Cash Price |
$5.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$6.13
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.68
|
| Rate for Payer: Heritage Provider Network Senior |
$7.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.84
|
| Rate for Payer: Multiplan Commercial |
$8.51
|
|
