|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$0.43
|
|
|
Service Code
|
NDC 0603-2407-21
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Blue Shield of California Commercial |
$0.31
|
| Rate for Payer: Blue Shield of California EPN |
$0.22
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 29300-344-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$0.80
|
|
|
Service Code
|
NDC 0904-6476-61
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Blue Shield of California Commercial |
$0.57
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$0.28
|
|
|
Service Code
|
NDC 70710-1286-1
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 52817-321-10
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Blue Shield of California Commercial |
$0.09
|
| Rate for Payer: Blue Shield of California EPN |
$0.07
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 29300-344-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Distinction Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Media |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$0.43
|
|
|
Service Code
|
NDC 0603-2407-21
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.10 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.24
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.26
|
| Rate for Payer: Blue Distinction Transplant |
$0.26
|
| Rate for Payer: Blue Shield of California Commercial |
$0.32
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO |
$0.30
|
| Rate for Payer: Cigna of CA PPO |
$0.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Media |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.17
|
| Rate for Payer: Galaxy Health WC |
$0.37
|
| Rate for Payer: Global Benefits Group Commercial |
$0.26
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.32
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.10
|
| Rate for Payer: Multiplan Commercial |
$0.34
|
| Rate for Payer: Networks By Design Commercial |
$0.28
|
| Rate for Payer: Prime Health Services Commercial |
$0.37
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.26
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.26
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.22
|
| Rate for Payer: United Healthcare All Other HMO |
$0.22
|
| Rate for Payer: United Healthcare HMO Rider |
$0.22
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.37
|
| Rate for Payer: Vantage Medical Group Senior |
$0.37
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
NDC 60687-514-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.67
|
| Rate for Payer: Blue Distinction Transplant |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: Dignity Health Media |
$0.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO |
$0.57
|
| Rate for Payer: United Healthcare HMO Rider |
$0.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Vantage Medical Group Senior |
$0.96
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 31722-999-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
NDC 60687-514-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$0.80
|
|
|
Service Code
|
NDC 0904-6476-61
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.19 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.44
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.48
|
| Rate for Payer: Blue Distinction Transplant |
$0.48
|
| Rate for Payer: Blue Shield of California Commercial |
$0.59
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO |
$0.56
|
| Rate for Payer: Cigna of CA PPO |
$0.56
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Media |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.32
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.32
|
| Rate for Payer: Galaxy Health WC |
$0.68
|
| Rate for Payer: Global Benefits Group Commercial |
$0.48
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.64
|
| Rate for Payer: Networks By Design Commercial |
$0.52
|
| Rate for Payer: Prime Health Services Commercial |
$0.68
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.48
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.48
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO |
$0.40
|
| Rate for Payer: United Healthcare HMO Rider |
$0.40
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.68
|
| Rate for Payer: Vantage Medical Group Senior |
$0.68
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$0.28
|
|
|
Service Code
|
NDC 70710-1286-1
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.07 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.17
|
| Rate for Payer: Blue Distinction Transplant |
$0.17
|
| Rate for Payer: Blue Shield of California Commercial |
$0.21
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO |
$0.20
|
| Rate for Payer: Cigna of CA PPO |
$0.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Media |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.24
|
| Rate for Payer: Global Benefits Group Commercial |
$0.17
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.21
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.19
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.11
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.24
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.17
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.17
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: Vantage Medical Group Senior |
$0.24
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 52817-321-10
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.03 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.08
|
| Rate for Payer: Blue Distinction Transplant |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.10
|
| Rate for Payer: Blue Shield of California EPN |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| Rate for Payer: Cigna of CA HMO |
$0.09
|
| Rate for Payer: Cigna of CA PPO |
$0.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Media |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.05
|
| Rate for Payer: Galaxy Health WC |
$0.11
|
| Rate for Payer: Global Benefits Group Commercial |
$0.08
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.10
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: Networks By Design Commercial |
$0.08
|
| Rate for Payer: Prime Health Services Commercial |
$0.11
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.08
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.07
|
| Rate for Payer: United Healthcare All Other HMO |
$0.07
|
| Rate for Payer: United Healthcare HMO Rider |
$0.07
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.07
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.11
|
| Rate for Payer: Vantage Medical Group Senior |
$0.11
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
NDC 68084-868-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
NDC 60687-514-11
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.67
|
| Rate for Payer: Blue Distinction Transplant |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: Dignity Health Media |
$0.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO |
$0.57
|
| Rate for Payer: United Healthcare HMO Rider |
$0.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Vantage Medical Group Senior |
$0.96
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
NDC 60687-514-11
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
NDC 68084-868-11
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.67
|
| Rate for Payer: Blue Distinction Transplant |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: Dignity Health Media |
$0.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO |
$0.57
|
| Rate for Payer: United Healthcare HMO Rider |
$0.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Vantage Medical Group Senior |
$0.96
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 31722-999-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.06
|
| Rate for Payer: Blue Distinction Transplant |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.07
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO |
$0.07
|
| Rate for Payer: Cigna of CA PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Media |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.04
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.04
|
| Rate for Payer: Galaxy Health WC |
$0.09
|
| Rate for Payer: Global Benefits Group Commercial |
$0.06
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.04
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: Networks By Design Commercial |
$0.07
|
| Rate for Payer: Prime Health Services Commercial |
$0.09
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.06
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO |
$0.05
|
| Rate for Payer: United Healthcare HMO Rider |
$0.05
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.09
|
| Rate for Payer: Vantage Medical Group Senior |
$0.09
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$1.13
|
|
|
Service Code
|
NDC 68084-868-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.62
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.67
|
| Rate for Payer: Blue Distinction Transplant |
$0.68
|
| Rate for Payer: Blue Shield of California Commercial |
$0.83
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: Dignity Health Media |
$0.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.85
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.68
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.68
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.57
|
| Rate for Payer: United Healthcare All Other HMO |
$0.57
|
| Rate for Payer: United Healthcare HMO Rider |
$0.57
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.57
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Vantage Medical Group Senior |
$0.96
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$1.13
|
|
|
Service Code
|
NDC 68084-868-11
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.27 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Blue Shield of California Commercial |
$0.80
|
| Rate for Payer: Blue Shield of California EPN |
$0.58
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO |
$0.79
|
| Rate for Payer: Cigna of CA PPO |
$0.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.45
|
| Rate for Payer: Galaxy Health WC |
$0.96
|
| Rate for Payer: Global Benefits Group Commercial |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.75
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.27
|
| Rate for Payer: Multiplan Commercial |
$0.90
|
| Rate for Payer: Networks By Design Commercial |
$0.73
|
| Rate for Payer: Prime Health Services Commercial |
$0.96
|
|
|
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION [21880]
|
Facility
|
IP
|
$39.56
|
|
|
Service Code
|
CPT J0476
|
| Hospital Charge Code |
1757066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.49 |
| Max. Negotiated Rate |
$33.63 |
| Rate for Payer: Blue Shield of California Commercial |
$28.17
|
| Rate for Payer: Blue Shield of California EPN |
$20.25
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cigna of CA HMO |
$27.69
|
| Rate for Payer: Cigna of CA PPO |
$27.69
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.82
|
| Rate for Payer: Galaxy Health WC |
$33.63
|
| Rate for Payer: Global Benefits Group Commercial |
$23.74
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.49
|
| Rate for Payer: Multiplan Commercial |
$31.65
|
| Rate for Payer: Networks By Design Commercial |
$19.78
|
| Rate for Payer: Prime Health Services Commercial |
$33.63
|
| Rate for Payer: United Healthcare All Other Commercial |
$14.94
|
| Rate for Payer: United Healthcare All Other HMO |
$14.59
|
| Rate for Payer: United Healthcare HMO Rider |
$14.27
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$13.05
|
|
|
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION [21880]
|
Facility
|
OP
|
$39.56
|
|
|
Service Code
|
CPT J0476
|
| Hospital Charge Code |
1757066
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$9.49 |
| Max. Negotiated Rate |
$235.51 |
| Rate for Payer: Aetna of CA HMO/PPO |
$235.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.63
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.76
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$21.76
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$154.04
|
| Rate for Payer: Blue Distinction Transplant |
$23.74
|
| Rate for Payer: Blue Shield of California Commercial |
$29.16
|
| Rate for Payer: Blue Shield of California EPN |
$39.56
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cash Price |
$17.80
|
| Rate for Payer: Cigna of CA HMO |
$27.69
|
| Rate for Payer: Cigna of CA PPO |
$27.69
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.63
|
| Rate for Payer: Dignity Health Media |
$33.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.82
|
| Rate for Payer: EPIC Health Plan Transplant |
$15.82
|
| Rate for Payer: Galaxy Health WC |
$33.63
|
| Rate for Payer: Global Benefits Group Commercial |
$23.74
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$29.67
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$26.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.49
|
| Rate for Payer: Multiplan Commercial |
$31.65
|
| Rate for Payer: Networks By Design Commercial |
$19.78
|
| Rate for Payer: Prime Health Services Commercial |
$33.63
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$23.74
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$23.74
|
| Rate for Payer: United Healthcare All Other Commercial |
$19.78
|
| Rate for Payer: United Healthcare All Other HMO |
$19.78
|
| Rate for Payer: United Healthcare HMO Rider |
$19.78
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$19.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.63
|
| Rate for Payer: Vantage Medical Group Senior |
$33.63
|
|
|
BACLOFEN ORAL SUSPENSION COMPOUND 5 MG/ML [4080246]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0802-46
|
| Hospital Charge Code |
1715278
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Blue Shield of California Commercial |
$0.19
|
| Rate for Payer: Blue Shield of California EPN |
$0.14
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
|
|
BACLOFEN ORAL SUSPENSION COMPOUND 5 MG/ML [4080246]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0802-46
|
| Hospital Charge Code |
1715278
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.06 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Aetna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$0.16
|
| Rate for Payer: Blue Distinction Transplant |
$0.16
|
| Rate for Payer: Blue Shield of California Commercial |
$0.20
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.12
|
| Rate for Payer: Cigna of CA HMO |
$0.19
|
| Rate for Payer: Cigna of CA PPO |
$0.19
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Media |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.11
|
| Rate for Payer: EPIC Health Plan Transplant |
$0.11
|
| Rate for Payer: Galaxy Health WC |
$0.23
|
| Rate for Payer: Global Benefits Group Commercial |
$0.16
|
| Rate for Payer: Health Plan of Nevada (Sierra) Other |
$0.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial/Self Funded |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.22
|
| Rate for Payer: Networks By Design Commercial |
$0.18
|
| Rate for Payer: Prime Health Services Commercial |
$0.23
|
| Rate for Payer: Temecula Valley Physicians Medical Group Commercial |
$0.16
|
| Rate for Payer: TriValley Medical Group Commercial/Senior |
$0.16
|
| Rate for Payer: United Healthcare All Other Commercial |
$0.14
|
| Rate for Payer: United Healthcare All Other HMO |
$0.14
|
| Rate for Payer: United Healthcare HMO Rider |
$0.14
|
| Rate for Payer: United Healthcare Select/Navigate/Core |
$0.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.23
|
| Rate for Payer: Vantage Medical Group Senior |
$0.23
|
|
|
BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM
|
Facility
|
IP
|
$54,166.80
|
|
|
Service Code
|
APR-DRG 0494
|
| Min. Negotiated Rate |
$41,551.63 |
| Max. Negotiated Rate |
$54,166.80 |
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$41,551.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54,166.80
|
|
