Loma Linda University Behavioral Medicine Center (BMC)

All Charges

Charge

Type

Setting

Price

BACLOFEN 10 MG TABLET [860]

Facility

$0.69

Service Code	NDC 68084-855-01
Hospital Charge Code	1710453
Hospital Revenue Code	259
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$0.52
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.41
Rate for Payer: Aetna of CA Government/Medicare	$0.41
Rate for Payer: Cash Price	$0.31
Rate for Payer: Health Smart Auto/Commercial	$0.41
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.41
Rate for Payer: LLUH Dept of Risk Management WC	$0.38
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.52

BACLOFEN 10 MG TABLET [860]

Facility

$0.62

Service Code	NDC 50268-106-11
Hospital Charge Code	1710453
Hospital Revenue Code	259
Min. Negotiated Rate	$0.34
Max. Negotiated Rate	$0.50
Rate for Payer: Cash Price	$0.28
Rate for Payer: Cigna of CA HMO/PPO	$0.50
Rate for Payer: Health Smart Auto/Commercial	$0.37
Rate for Payer: LLUH Dept of Risk Management WC	$0.34
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.47

BACLOFEN 10 MG TABLET [860]

Facility

$0.18

Service Code	NDC 29300-343-01
Hospital Charge Code	1710453
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

BACLOFEN 10 MG TABLET [860]

Facility

$0.18

Service Code	NDC 70710-1285-1
Hospital Charge Code	1710453
Hospital Revenue Code	259
Min. Negotiated Rate	$0.10
Max. Negotiated Rate	$0.14
Rate for Payer: Cash Price	$0.08
Rate for Payer: Cigna of CA HMO/PPO	$0.14
Rate for Payer: Health Smart Auto/Commercial	$0.11
Rate for Payer: LLUH Dept of Risk Management WC	$0.10
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.14

BACLOFEN 2,000 MCG/ML INTRATHECAL SOLUTION [9208]

Facility

$56.71

Service Code	CPT J0475
Hospital Charge Code	1726021
Hospital Revenue Code	636
Min. Negotiated Rate	$31.19
Max. Negotiated Rate	$45.37
Rate for Payer: Cash Price	$25.52
Rate for Payer: Cigna of CA HMO/PPO	$45.37
Rate for Payer: Health Smart Auto/Commercial	$34.03
Rate for Payer: LLUH Dept of Risk Management WC	$31.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.53

BACLOFEN 2,000 MCG/ML INTRATHECAL SOLUTION [9208]

Facility

$56.71

Service Code	CPT J0475
Hospital Charge Code	1726021
Hospital Revenue Code	636
Min. Negotiated Rate	$31.19
Max. Negotiated Rate	$42.53
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$34.03
Rate for Payer: Aetna of CA Government/Medicare	$34.03
Rate for Payer: Cash Price	$25.52
Rate for Payer: Health Smart Auto/Commercial	$34.03
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$34.03
Rate for Payer: LLUH Dept of Risk Management WC	$31.19
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$42.53

BACLOFEN 20 MG TABLET [861]

Facility

$0.10

Service Code	NDC 31722-999-01
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Cash Price	$0.05
Rate for Payer: Cigna of CA HMO/PPO	$0.08
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

BACLOFEN 20 MG TABLET [861]

Facility

$0.28

Service Code	NDC 70710-1286-1
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.21
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.17
Rate for Payer: Aetna of CA Government/Medicare	$0.17
Rate for Payer: Cash Price	$0.13
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

BACLOFEN 20 MG TABLET [861]

Facility

$0.13

Service Code	NDC 52817-321-10
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Cash Price	$0.06
Rate for Payer: Cigna of CA HMO/PPO	$0.10
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

BACLOFEN 20 MG TABLET [861]

Facility

$0.80

Service Code	NDC 0904-6476-61
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.60
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.48
Rate for Payer: Aetna of CA Government/Medicare	$0.48
Rate for Payer: Cash Price	$0.36
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

BACLOFEN 20 MG TABLET [861]

Facility

$0.43

Service Code	NDC 0603-2407-21
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.32
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.26
Rate for Payer: Aetna of CA Government/Medicare	$0.26
Rate for Payer: Cash Price	$0.19
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

BACLOFEN 20 MG TABLET [861]

Facility

$0.43

Service Code	NDC 0603-2407-21
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.24
Max. Negotiated Rate	$0.34
Rate for Payer: Cash Price	$0.19
Rate for Payer: Cigna of CA HMO/PPO	$0.34
Rate for Payer: Health Smart Auto/Commercial	$0.26
Rate for Payer: LLUH Dept of Risk Management WC	$0.24
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.32

BACLOFEN 20 MG TABLET [861]

Facility

$1.13

Service Code	NDC 60687-514-01
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Cash Price	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.85

BACLOFEN 20 MG TABLET [861]

Facility

$1.13

Service Code	NDC 60687-514-11
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Cash Price	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.85

BACLOFEN 20 MG TABLET [861]

Facility

$1.13

Service Code	NDC 60687-514-11
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cigna of CA HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.85

BACLOFEN 20 MG TABLET [861]

Facility

$1.13

Service Code	NDC 68084-868-01
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Cash Price	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.85

BACLOFEN 20 MG TABLET [861]

Facility

$0.10

Service Code	NDC 31722-999-01
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.06
Max. Negotiated Rate	$0.08
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.06
Rate for Payer: Aetna of CA Government/Medicare	$0.06
Rate for Payer: Cash Price	$0.05
Rate for Payer: Health Smart Auto/Commercial	$0.06
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.06
Rate for Payer: LLUH Dept of Risk Management WC	$0.06
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.08

BACLOFEN 20 MG TABLET [861]

Facility

$1.13

Service Code	NDC 68084-868-11
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cigna of CA HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.85

BACLOFEN 20 MG TABLET [861]

Facility

$1.13

Service Code	NDC 60687-514-01
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cigna of CA HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.85

BACLOFEN 20 MG TABLET [861]

Facility

$1.13

Service Code	NDC 68084-868-11
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.85
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.68
Rate for Payer: Aetna of CA Government/Medicare	$0.68
Rate for Payer: Cash Price	$0.51
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.85

BACLOFEN 20 MG TABLET [861]

Facility

$0.28

Service Code	NDC 29300-344-01
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

BACLOFEN 20 MG TABLET [861]

Facility

$0.13

Service Code	NDC 52817-321-10
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.07
Max. Negotiated Rate	$0.10
Rate for Payer: Aetna of CA EPO/HMO/POS/PPO	$0.08
Rate for Payer: Aetna of CA Government/Medicare	$0.08
Rate for Payer: Cash Price	$0.06
Rate for Payer: Health Smart Auto/Commercial	$0.08
Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage	$0.08
Rate for Payer: LLUH Dept of Risk Management WC	$0.07
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.10

BACLOFEN 20 MG TABLET [861]

Facility

$1.13

Service Code	NDC 68084-868-01
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.62
Max. Negotiated Rate	$0.90
Rate for Payer: Cash Price	$0.51
Rate for Payer: Cigna of CA HMO/PPO	$0.90
Rate for Payer: Health Smart Auto/Commercial	$0.68
Rate for Payer: LLUH Dept of Risk Management WC	$0.62
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.85

BACLOFEN 20 MG TABLET [861]

Facility

$0.80

Service Code	NDC 0904-6476-61
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.44
Max. Negotiated Rate	$0.64
Rate for Payer: Cash Price	$0.36
Rate for Payer: Cigna of CA HMO/PPO	$0.64
Rate for Payer: Health Smart Auto/Commercial	$0.48
Rate for Payer: LLUH Dept of Risk Management WC	$0.44
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.60

BACLOFEN 20 MG TABLET [861]

Facility

$0.28

Service Code	NDC 70710-1286-1
Hospital Charge Code	1712107
Hospital Revenue Code	259
Min. Negotiated Rate	$0.15
Max. Negotiated Rate	$0.22
Rate for Payer: Cash Price	$0.13
Rate for Payer: Cigna of CA HMO/PPO	$0.22
Rate for Payer: Health Smart Auto/Commercial	$0.17
Rate for Payer: LLUH Dept of Risk Management WC	$0.15
Rate for Payer: Multiplan Beech St/Commercial/PHCS	$0.21

Know your out-of-pocket cost for care.

All Charges