|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$0.10
|
|
|
Service Code
|
NDC 70756-289-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.09 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.08
|
| Rate for Payer: Blue Shield of California Commercial |
$0.06
|
| Rate for Payer: Blue Shield of California EPN |
$0.05
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.09
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.09
|
| Rate for Payer: Dignity Health Senior |
$0.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.78
|
|
|
Service Code
|
NDC 50268-107-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: Dignity Health Senior |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$0.10
|
|
|
Service Code
|
NDC 31722-999-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Senior |
$0.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.08
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$0.13
|
|
|
Service Code
|
NDC 29300-344-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.10 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.09
|
| Rate for Payer: Heritage Provider Network Senior |
$0.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$0.13
|
|
|
Service Code
|
NDC 29300-344-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.11 |
| Rate for Payer: Adventist Health Commercial |
$0.03
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.07
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$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 |
$0.10
|
| Rate for Payer: Blue Shield of California Commercial |
$0.08
|
| Rate for Payer: Blue Shield of California EPN |
$0.06
|
| Rate for Payer: Cash Price |
$0.07
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.08
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.11
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.11
|
| Rate for Payer: Dignity Health Senior |
$0.11
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.08
|
| Rate for Payer: Heritage Provider Network Senior |
$0.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.03
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.09
|
| Rate for Payer: Multiplan Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.05
|
| Rate for Payer: TriValley Medical Group Senior |
$0.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.07
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
$0.43
|
|
|
Service Code
|
NDC 0603-2407-21
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Cash Price |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.23
|
| 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 Medi-Cal |
$0.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.11
|
| Rate for Payer: Multiplan Commercial |
$0.32
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
IP
|
$0.78
|
|
|
Service Code
|
NDC 50268-107-15
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.42
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.53
|
| Rate for Payer: Heritage Provider Network Senior |
$0.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$0.78
|
|
|
Service Code
|
NDC 50268-107-11
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.66 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.42
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.54
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.59
|
| Rate for Payer: Blue Shield of California Commercial |
$0.48
|
| Rate for Payer: Blue Shield of California EPN |
$0.38
|
| Rate for Payer: Cash Price |
$0.43
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.66
|
| Rate for Payer: Dignity Health Senior |
$0.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.48
|
| Rate for Payer: Heritage Provider Network Senior |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.55
|
| Rate for Payer: Multiplan Commercial |
$0.59
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.31
|
| Rate for Payer: TriValley Medical Group Senior |
$0.31
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.39
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.39
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.66
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.66
|
| Rate for Payer: Vantage Medical Group Senior |
$0.66
|
|
|
BACLOFEN 20 MG TABLET [861]
|
Facility
|
OP
|
$0.08
|
|
|
Service Code
|
NDC 59651-395-01
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.01 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.04
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.06
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.04
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.07
|
| Rate for Payer: Dignity Health Senior |
$0.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Senior |
$0.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.01
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.03
|
| Rate for Payer: TriValley Medical Group Senior |
$0.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.04
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.04
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: Vantage Medical Group Senior |
$0.07
|
|
|
BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION [107800]
|
Facility
|
IP
|
$61.81
|
|
|
Service Code
|
NDC 66794-157-02
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$46.36 |
| Rate for Payer: Adventist Health Commercial |
$12.36
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.85
|
| Rate for Payer: Heritage Provider Network Senior |
$41.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.45
|
| Rate for Payer: Multiplan Commercial |
$46.36
|
|
|
BACLOFEN 40,000 MCG/20 ML (2,000 MCG/ML) INTRATHECAL SOLUTION [107800]
|
Facility
|
OP
|
$61.81
|
|
|
Service Code
|
NDC 66794-157-02
|
| Min. Negotiated Rate |
$11.19 |
| Max. Negotiated Rate |
$52.54 |
| Rate for Payer: Adventist Health Commercial |
$12.36
|
| Rate for Payer: Aetna of CA Gatekeeper |
$33.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$42.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.54
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$46.36
|
| Rate for Payer: Blue Shield of California Commercial |
$37.70
|
| Rate for Payer: Blue Shield of California EPN |
$30.16
|
| Rate for Payer: Cash Price |
$34.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$40.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.54
|
| Rate for Payer: Dignity Health Medi-Cal |
$52.54
|
| Rate for Payer: Dignity Health Senior |
$52.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$40.18
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.26
|
| Rate for Payer: Heritage Provider Network Senior |
$38.26
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$29.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$15.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$43.27
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$43.27
|
| Rate for Payer: Multiplan Commercial |
$46.36
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$30.91
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$30.91
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.54
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$52.54
|
| Rate for Payer: Vantage Medical Group Senior |
$52.54
|
|
|
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION [9209]
|
Facility
|
IP
|
$14.18
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$10.63 |
| Rate for Payer: Adventist Health Commercial |
$2.84
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.52
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.57
|
| Rate for Payer: Heritage Provider Network Senior |
$6.57
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Multiplan Commercial |
$10.63
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.69
|
|
|
BACLOFEN 500 MCG/ML INTRATHECAL SOLUTION [9209]
|
Facility
|
OP
|
$14.18
|
|
|
Service Code
|
HCPCS J0475
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$2.57 |
| Max. Negotiated Rate |
$229.21 |
| Rate for Payer: Adventist Health Commercial |
$2.84
|
| Rate for Payer: Aetna of CA Gatekeeper |
$7.58
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$219.77
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$193.40
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$193.40
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$229.21
|
| Rate for Payer: Blue Shield of California Commercial |
$90.27
|
| Rate for Payer: Blue Shield of California EPN |
$90.27
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cash Price |
$7.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$6.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$219.77
|
| Rate for Payer: Dignity Health Medi-Cal |
$193.40
|
| Rate for Payer: Dignity Health Senior |
$193.40
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.08
|
| Rate for Payer: EPIC Health Plan Medicare |
$175.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$6.57
|
| Rate for Payer: Heritage Provider Network Senior |
$6.57
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$174.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$175.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$202.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.54
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$221.53
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$221.53
|
| Rate for Payer: Multiplan Commercial |
$10.63
|
| Rate for Payer: TriValley Medical Group Commercial |
$5.67
|
| Rate for Payer: TriValley Medical Group Senior |
$5.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$5.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$4.69
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$219.77
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$193.40
|
| Rate for Payer: Vantage Medical Group Senior |
$193.40
|
|
|
BACLOFEN 50 MCG/ML INTRATHECAL SOLUTION [21880]
|
Facility
|
OP
|
$39.56
|
|
|
Service Code
|
HCPCS J0476
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$85.38 |
| Rate for Payer: Adventist Health Commercial |
$7.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$21.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.18
|
| 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 |
$29.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$85.38
|
| Rate for Payer: Blue Shield of California Commercial |
$15.36
|
| Rate for Payer: Blue Shield of California EPN |
$15.36
|
| Rate for Payer: Cash Price |
$21.76
|
| Rate for Payer: Cash Price |
$21.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.20
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$33.63
|
| Rate for Payer: Dignity Health Senior |
$33.63
|
| Rate for Payer: EPIC Health Plan Commercial |
$25.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.32
|
| Rate for Payer: Heritage Provider Network Senior |
$18.32
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$53.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$18.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.89
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.69
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.69
|
| Rate for Payer: Multiplan Commercial |
$29.67
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.82
|
| Rate for Payer: TriValley Medical Group Senior |
$15.82
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.10
|
| 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 50 MCG/ML INTRATHECAL SOLUTION [21880]
|
Facility
|
IP
|
$39.56
|
|
|
Service Code
|
HCPCS J0476
|
| Hospital Charge Code |
901700025
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$7.16 |
| Max. Negotiated Rate |
$29.67 |
| Rate for Payer: Adventist Health Commercial |
$7.91
|
| Rate for Payer: Cash Price |
$21.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$21.36
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.32
|
| Rate for Payer: Heritage Provider Network Senior |
$18.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.89
|
| Rate for Payer: Multiplan Commercial |
$29.67
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.29
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.10
|
|
|
BACLOFEN ORAL SUSPENSION COMPOUND 5 MG/ML [4080246]
|
Facility
|
IP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0802-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.20 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.18
|
| Rate for Payer: Heritage Provider Network Senior |
$0.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
|
|
BACLOFEN ORAL SUSPENSION COMPOUND 5 MG/ML [4080246]
|
Facility
|
OP
|
$0.27
|
|
|
Service Code
|
NDC 9994-0802-46
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.23 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| 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 |
$0.20
|
| Rate for Payer: Blue Shield of California Commercial |
$0.16
|
| Rate for Payer: Blue Shield of California EPN |
$0.13
|
| Rate for Payer: Cash Price |
$0.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.23
|
| Rate for Payer: Dignity Health Senior |
$0.23
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.07
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.19
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.19
|
| Rate for Payer: Multiplan Commercial |
$0.20
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.11
|
| Rate for Payer: TriValley Medical Group Senior |
$0.11
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$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
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]
|
Facility
|
OP
|
$0.25
|
|
|
Service Code
|
NDC 0065-0800-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.13
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.17
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.19
|
| Rate for Payer: Blue Shield of California Commercial |
$0.15
|
| Rate for Payer: Blue Shield of California EPN |
$0.12
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.16
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.21
|
| Rate for Payer: Dignity Health Senior |
$0.21
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.16
|
| 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 Commercial |
$0.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.18
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.10
|
| Rate for Payer: TriValley Medical Group Senior |
$0.10
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.13
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.13
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.21
|
| Rate for Payer: Vantage Medical Group Senior |
$0.21
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.1 INTRAOCULAR IRRIGATION [14123]
|
Facility
|
IP
|
$0.25
|
|
|
Service Code
|
NDC 0065-0800-50
|
| Hospital Charge Code |
901700029
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.19 |
| Rate for Payer: Adventist Health Commercial |
$0.05
|
| Rate for Payer: Cash Price |
$0.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.17
|
| Rate for Payer: Heritage Provider Network Senior |
$0.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.19
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0065-1795-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0065-1795-04
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
OP
|
$0.09
|
|
|
Service Code
|
NDC 0065-0795-50
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.06
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.05
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.07
|
| Rate for Payer: Blue Shield of California Commercial |
$0.05
|
| Rate for Payer: Blue Shield of California EPN |
$0.04
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.08
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.08
|
| Rate for Payer: Dignity Health Senior |
$0.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.06
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.04
|
| Rate for Payer: TriValley Medical Group Senior |
$0.04
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.05
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.05
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.08
|
| Rate for Payer: Vantage Medical Group Senior |
$0.08
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
IP
|
$0.09
|
|
|
Service Code
|
NDC 0065-0795-50
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$0.07 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Cash Price |
$0.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.06
|
| Rate for Payer: Heritage Provider Network Senior |
$0.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.02
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.02
|
| Rate for Payer: Multiplan Commercial |
$0.07
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
OP
|
$1.01
|
|
|
Service Code
|
NDC 0065-0795-15
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.86 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.69
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$0.86
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$0.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$0.76
|
| Rate for Payer: Blue Shield of California Commercial |
$0.62
|
| Rate for Payer: Blue Shield of California EPN |
$0.49
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.86
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.86
|
| Rate for Payer: Dignity Health Senior |
$0.86
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.63
|
| Rate for Payer: Heritage Provider Network Senior |
$0.63
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.48
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$0.71
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$0.71
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
| Rate for Payer: TriValley Medical Group Commercial |
$0.40
|
| Rate for Payer: TriValley Medical Group Senior |
$0.40
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$0.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$0.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$0.86
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.86
|
| Rate for Payer: Vantage Medical Group Senior |
$0.86
|
|
|
BALANCED SALT SOLUTION COMBINATION NO.2 INTRAOCULAR IRRIGATION [10781]
|
Facility
|
IP
|
$1.01
|
|
|
Service Code
|
NDC 0065-0795-15
|
| Hospital Charge Code |
901700004
|
|
Hospital Revenue Code
|
250
|
| Min. Negotiated Rate |
$0.18 |
| Max. Negotiated Rate |
$0.76 |
| Rate for Payer: Adventist Health Commercial |
$0.20
|
| Rate for Payer: Cash Price |
$0.56
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.68
|
| Rate for Payer: Heritage Provider Network Senior |
$0.68
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.25
|
| Rate for Payer: Multiplan Commercial |
$0.76
|
|
