|
SEVELAMER CARBONATE 2.4 GRAM ORAL POWDER PACKET [99695]
|
Facility
IP
|
$21.42
|
|
|
Service Code
|
NDC 58468-0131-1
|
| Hospital Charge Code |
1712470
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$3.88 |
| Max. Negotiated Rate |
$16.06 |
| Rate for Payer: Adventist Health Commercial |
$4.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.72
|
| Rate for Payer: Cash Price |
$9.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$11.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.50
|
| Rate for Payer: Heritage Provider Network Senior |
$14.50
|
| 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
|
|
|
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
OP
|
$21.42
|
|
|
Service Code
|
NDC 58468-0131-2
|
| 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
|
$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 800 MG TABLET [89201]
|
Facility
OP
|
$0.47
|
|
|
Service Code
|
NDC 24979-186-46
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare 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 |
$0.28
|
| Rate for Payer: Cash Price |
$0.21
|
| 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 |
$0.23
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
IP
|
$8.73
|
|
|
Service Code
|
NDC 50268-720-11
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.00
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.91
|
| Rate for Payer: Heritage Provider Network Senior |
$5.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$6.55
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
OP
|
$8.73
|
|
|
Service Code
|
NDC 50268-720-15
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.55
|
| Rate for Payer: Blue Shield of California Commercial |
$5.42
|
| Rate for Payer: Blue Shield of California EPN |
$5.12
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.42
|
| Rate for Payer: Dignity Health Senior |
$7.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.40
|
| Rate for Payer: Heritage Provider Network Senior |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$6.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.42
|
| Rate for Payer: Vantage Medical Group Senior |
$7.42
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
IP
|
$8.73
|
|
|
Service Code
|
NDC 50268-720-15
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$6.55 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.00
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.91
|
| Rate for Payer: Heritage Provider Network Senior |
$5.91
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$6.55
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
IP
|
$0.47
|
|
|
Service Code
|
NDC 24979-186-46
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| 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
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
OP
|
$8.73
|
|
|
Service Code
|
NDC 50268-720-11
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.58 |
| Max. Negotiated Rate |
$7.42 |
| Rate for Payer: Adventist Health Commercial |
$1.75
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.42
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.80
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.55
|
| Rate for Payer: Blue Shield of California Commercial |
$5.42
|
| Rate for Payer: Blue Shield of California EPN |
$5.12
|
| Rate for Payer: Cash Price |
$3.93
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.67
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.42
|
| Rate for Payer: Dignity Health Senior |
$7.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.40
|
| Rate for Payer: Heritage Provider Network Senior |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.18
|
| Rate for Payer: Multiplan Commercial |
$6.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.42
|
| Rate for Payer: Vantage Medical Group Senior |
$7.42
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
OP
|
$0.47
|
|
|
Service Code
|
NDC 65162-058-27
|
| Hospital Charge Code |
1712469
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare 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 |
$0.28
|
| Rate for Payer: Cash Price |
$0.21
|
| 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 |
$0.23
|
| 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
|
| 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 65862-921-27
|
| Hospital Charge Code |
1712469
|
|
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
|
|
|
SEVELAMER CARBONATE 800 MG TABLET [89201]
|
Facility
OP
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-64
|
| Hospital Charge Code |
1712469
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.41 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$1.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.71
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.03
|
| 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 |
$1.10
|
| 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
|
| 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
OP
|
$0.47
|
|
|
Service Code
|
NDC 65862-921-27
|
| Hospital Charge Code |
1712469
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare 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 |
$0.28
|
| Rate for Payer: Cash Price |
$0.21
|
| 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 |
$0.23
|
| 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
|
| 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 |
1712469
|
|
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: Aetna of CA Non-Gatekeeper |
$1.57
|
| Rate for Payer: Cash Price |
$1.03
|
| 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
IP
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-59
|
| Hospital Charge Code |
1712469
|
|
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: Aetna of CA Non-Gatekeeper |
$1.57
|
| Rate for Payer: Cash Price |
$1.03
|
| 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
|
$2.28
|
|
|
Service Code
|
NDC 68094-034-59
|
| Hospital Charge Code |
1712469
|
|
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: AlphaCare Medical Group Commercial/Exchange |
$1.94
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$1.25
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$1.71
|
| Rate for Payer: Blue Shield of California Commercial |
$1.42
|
| Rate for Payer: Blue Shield of California EPN |
$1.34
|
| Rate for Payer: Cash Price |
$1.03
|
| 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 |
$1.10
|
| 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
|
| 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 65162-058-27
|
| Hospital Charge Code |
1712469
|
|
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
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
IP
|
$4.33
|
|
|
Service Code
|
NDC 68462-447-18
|
| Hospital Charge Code |
1712253
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.25 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.93
|
| Rate for Payer: Heritage Provider Network Senior |
$2.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.25
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
OP
|
$4.33
|
|
|
Service Code
|
NDC 68462-447-18
|
| Hospital Charge Code |
1712253
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.78 |
| Max. Negotiated Rate |
$3.68 |
| Rate for Payer: Adventist Health Commercial |
$0.87
|
| Rate for Payer: Aetna of CA Gatekeeper |
$2.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$2.97
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$3.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$2.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$3.25
|
| Rate for Payer: Blue Shield of California Commercial |
$2.69
|
| Rate for Payer: Blue Shield of California EPN |
$2.54
|
| Rate for Payer: Cash Price |
$1.95
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.81
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$3.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$3.68
|
| Rate for Payer: Dignity Health Senior |
$3.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$2.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$2.68
|
| Rate for Payer: Heritage Provider Network Senior |
$2.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$2.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.78
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.08
|
| Rate for Payer: Multiplan Commercial |
$3.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3.68
|
| Rate for Payer: Vantage Medical Group Senior |
$3.68
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
OP
|
$8.92
|
|
|
Service Code
|
NDC 58468-0021-1
|
| Hospital Charge Code |
1712253
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$7.58 |
| Rate for Payer: Adventist Health Commercial |
$1.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$4.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.13
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$7.58
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$4.91
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$6.69
|
| Rate for Payer: Blue Shield of California Commercial |
$5.54
|
| Rate for Payer: Blue Shield of California EPN |
$5.24
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$7.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.58
|
| Rate for Payer: Dignity Health Senior |
$7.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$5.71
|
| Rate for Payer: Heritage Provider Network Commercial |
$5.52
|
| Rate for Payer: Heritage Provider Network Senior |
$5.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$4.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$6.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.58
|
| Rate for Payer: Vantage Medical Group Senior |
$7.58
|
|
|
SEVELAMER HCL 800 MG TABLET [28715]
|
Facility
IP
|
$8.92
|
|
|
Service Code
|
NDC 58468-0021-1
|
| Hospital Charge Code |
1712253
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$1.61 |
| Max. Negotiated Rate |
$6.69 |
| Rate for Payer: Adventist Health Commercial |
$1.78
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$6.13
|
| Rate for Payer: Cash Price |
$4.01
|
| Rate for Payer: EPIC Health Plan Commercial |
$4.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.04
|
| Rate for Payer: Heritage Provider Network Senior |
$6.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$1.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$2.23
|
| Rate for Payer: Multiplan Commercial |
$6.69
|
|
|
SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]
|
Facility
IP
|
$0.47
|
|
|
Service Code
|
NDC 9994-0803-33
|
| Hospital Charge Code |
1715236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| 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
|
|
|
SEVELAMER ORAL SUSPENSION COMPOUND 50 MG/ML [4080333]
|
Facility
OP
|
$0.47
|
|
|
Service Code
|
NDC 9994-0803-33
|
| Hospital Charge Code |
1715236
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.09 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$0.40
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.26
|
| Rate for Payer: AlphaCare 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 |
$0.28
|
| Rate for Payer: Cash Price |
$0.21
|
| 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 |
$0.23
|
| 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
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.40
|
| Rate for Payer: Vantage Medical Group Senior |
$0.40
|
|
|
Severing adhesions of anterior segment of eye, incisional technique (with or without injection of air or liquid) (separate procedure); posterior synechiae
|
Facility
OP
|
$7,436.00
|
|
|
Service Code
|
CPT 65875
|
| Min. Negotiated Rate |
$118.48 |
| Max. Negotiated Rate |
$7,436.00 |
| Rate for Payer: Aetna of CA Gatekeeper |
$4,857.00
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$4,367.44
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$3,202.79
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$2,911.63
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$7,436.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$4,367.44
|
| Rate for Payer: Dignity Health Medi-Cal |
$3,202.79
|
| Rate for Payer: Dignity Health Senior |
$2,911.63
|
| Rate for Payer: EPIC Health Plan Medicare |
$2,911.63
|
| Rate for Payer: Humana Medicare |
$2,911.63
|
| Rate for Payer: IEHP Medi-Cal |
$118.48
|
| Rate for Payer: IEHP Medicare Advantage |
$2,911.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5,532.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$3,435.72
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$3,668.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$3,668.65
|
| Rate for Payer: TriValley Medical Group Commercial |
$3,202.79
|
| Rate for Payer: TriValley Medical Group Senior |
$2,911.63
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$4,367.44
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$3,202.79
|
| Rate for Payer: Vantage Medical Group Senior |
$2,911.63
|
|
