|
BACLOFEN 10 MG TABLET [860]
|
Facility
IP
|
$0.69
|
|
|
Service Code
|
NDC 68084-855-11
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.52 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.37
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.47
|
| Rate for Payer: Heritage Provider Network Senior |
$0.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
|
|
BACLOFEN 10 MG TABLET [860]
|
Facility
OP
|
$0.69
|
|
|
Service Code
|
NDC 68084-855-01
|
| Hospital Charge Code |
1710453
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.12 |
| Max. Negotiated Rate |
$0.59 |
| Rate for Payer: Adventist Health Commercial |
$0.14
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.47
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.59
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.38
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.52
|
| Rate for Payer: Blue Shield of California Commercial |
$0.43
|
| Rate for Payer: Blue Shield of California EPN |
$0.41
|
| Rate for Payer: Cash Price |
$0.31
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.59
|
| Rate for Payer: Dignity Health Senior |
$0.59
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Senior |
$0.43
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.17
|
| Rate for Payer: Multiplan Commercial |
$0.52
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.59
|
| Rate for Payer: Vantage Medical Group Senior |
$0.59
|
|
|
BACLOFEN 2,000 MCG/ML INTRATHECAL SOLUTION [9208]
|
Facility
OP
|
$56.71
|
|
|
Service Code
|
CPT J0475
|
| Hospital Charge Code |
1726021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$438.13 |
| Rate for Payer: Adventist Health Commercial |
$11.34
|
| Rate for Payer: Aetna of CA Gatekeeper |
$436.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.96
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$222.26
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$195.58
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$195.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$438.13
|
| Rate for Payer: Blue Shield of California Commercial |
$158.80
|
| Rate for Payer: Blue Shield of California EPN |
$158.80
|
| Rate for Payer: Cash Price |
$25.52
|
| Rate for Payer: Cash Price |
$25.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.09
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$266.71
|
| Rate for Payer: Dignity Health Medi-Cal |
$195.58
|
| Rate for Payer: Dignity Health Senior |
$195.58
|
| Rate for Payer: EPIC Health Plan Commercial |
$36.29
|
| Rate for Payer: EPIC Health Plan Medicare |
$177.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$26.26
|
| Rate for Payer: Heritage Provider Network Senior |
$26.26
|
| Rate for Payer: Humana Medicare |
$177.80
|
| Rate for Payer: IEHP Medi-Cal |
$284.33
|
| Rate for Payer: IEHP Medicare Advantage |
$177.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$337.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$209.81
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.18
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$224.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$224.03
|
| Rate for Payer: Multiplan Commercial |
$42.53
|
| Rate for Payer: TriValley Medical Group Commercial |
$195.58
|
| Rate for Payer: TriValley Medical Group Senior |
$177.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$266.71
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$195.58
|
| Rate for Payer: Vantage Medical Group Senior |
$177.80
|
|
|
BACLOFEN 2,000 MCG/ML INTRATHECAL SOLUTION [9208]
|
Facility
IP
|
$56.71
|
|
|
Service Code
|
CPT J0475
|
| Hospital Charge Code |
1726021
|
|
Hospital Revenue Code
|
636
|
| Min. Negotiated Rate |
$10.26 |
| Max. Negotiated Rate |
$42.53 |
| Rate for Payer: Adventist Health Commercial |
$11.34
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$38.96
|
| Rate for Payer: Cash Price |
$25.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$30.62
|
| Rate for Payer: Heritage Provider Network Commercial |
$38.39
|
| Rate for Payer: Heritage Provider Network Senior |
$38.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.18
|
| Rate for Payer: Multiplan Commercial |
$42.53
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.95
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| 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: Multiplan Commercial |
$0.21
|
| 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
|
$0.28
|
|
|
Service Code
|
NDC 29300-344-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.24 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.15
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.15
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.21
|
| Rate for Payer: Blue Shield of California Commercial |
$0.17
|
| Rate for Payer: Blue Shield of California EPN |
$0.16
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.18
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.24
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.24
|
| Rate for Payer: Dignity Health Senior |
$0.24
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.18
|
| 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: Multiplan Commercial |
$0.21
|
| 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
IP
|
$1.13
|
|
|
Service Code
|
NDC 68084-868-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
|
|
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 |
$0.02 |
| 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: AlphaCare Medical Group Commercial/Exchange |
$0.11
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.07
|
| Rate for Payer: AlphaCare 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 |
$0.08
|
| Rate for Payer: Cash Price |
$0.06
|
| 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: Multiplan Commercial |
$0.10
|
| 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 60687-514-11
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.96
|
| Rate for Payer: Dignity Health Senior |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
| 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
|
$1.13
|
|
|
Service Code
|
NDC 68084-868-11
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.96
|
| Rate for Payer: Dignity Health Senior |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
| 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
|
$0.13
|
|
|
Service Code
|
NDC 52817-321-10
|
| Hospital Charge Code |
1712107
|
|
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: Aetna of CA Non-Gatekeeper |
$0.09
|
| Rate for Payer: Cash Price |
$0.06
|
| 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
|
$0.10
|
|
|
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: 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: AlphaCare Medical Group Commercial/Exchange |
$0.09
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.06
|
| Rate for Payer: AlphaCare 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 |
$0.06
|
| 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: Multiplan Commercial |
$0.08
|
| 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
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 |
$0.08 |
| Rate for Payer: Adventist Health Commercial |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.07
|
| 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
|
$1.13
|
|
|
Service Code
|
NDC 68084-868-11
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
|
|
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 |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| 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 |
$0.21
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.96
|
| Rate for Payer: Dignity Health Senior |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
| 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 60687-514-01
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.20 |
| Max. Negotiated Rate |
$0.85 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.77
|
| Rate for Payer: Heritage Provider Network Senior |
$0.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
|
|
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 |
$0.08 |
| Max. Negotiated Rate |
$0.32 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: Cash Price |
$0.19
|
| 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
OP
|
$0.80
|
|
|
Service Code
|
NDC 0904-6476-61
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.14 |
| Max. Negotiated Rate |
$0.68 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.68
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.44
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.60
|
| Rate for Payer: Blue Shield of California Commercial |
$0.50
|
| Rate for Payer: Blue Shield of California EPN |
$0.47
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.52
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.68
|
| Rate for Payer: Dignity Health Senior |
$0.68
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.50
|
| Rate for Payer: Heritage Provider Network Senior |
$0.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.39
|
| 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 |
$0.60
|
| 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
|
$0.43
|
|
|
Service Code
|
NDC 0603-2407-21
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.08 |
| Max. Negotiated Rate |
$0.37 |
| Rate for Payer: Adventist Health Commercial |
$0.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.23
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.30
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.37
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.24
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.32
|
| Rate for Payer: Blue Shield of California Commercial |
$0.27
|
| Rate for Payer: Blue Shield of California EPN |
$0.25
|
| Rate for Payer: Cash Price |
$0.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.28
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.37
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.37
|
| Rate for Payer: Dignity Health Senior |
$0.37
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.27
|
| Rate for Payer: Heritage Provider Network Senior |
$0.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.21
|
| 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
|
| 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
IP
|
$0.28
|
|
|
Service Code
|
NDC 70710-1286-1
|
| Hospital Charge Code |
1712107
|
|
Hospital Revenue Code
|
259
|
| Min. Negotiated Rate |
$0.05 |
| Max. Negotiated Rate |
$0.21 |
| Rate for Payer: Adventist Health Commercial |
$0.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.19
|
| Rate for Payer: Cash Price |
$0.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.19
|
| Rate for Payer: Heritage Provider Network Senior |
$0.19
|
| 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 |
$0.21
|
|
|
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 |
$0.14 |
| Max. Negotiated Rate |
$0.60 |
| Rate for Payer: Adventist Health Commercial |
$0.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.55
|
| Rate for Payer: Cash Price |
$0.36
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.43
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.54
|
| Rate for Payer: Heritage Provider Network Senior |
$0.54
|
| 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 |
$0.60
|
|
|
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 |
$0.20 |
| Max. Negotiated Rate |
$0.96 |
| Rate for Payer: Adventist Health Commercial |
$0.23
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$0.78
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$0.96
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$0.62
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$0.85
|
| Rate for Payer: Blue Shield of California Commercial |
$0.70
|
| Rate for Payer: Blue Shield of California EPN |
$0.66
|
| Rate for Payer: Cash Price |
$0.51
|
| Rate for Payer: Cigna of CA HMO/PPO |
$0.73
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$0.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$0.96
|
| Rate for Payer: Dignity Health Senior |
$0.96
|
| Rate for Payer: EPIC Health Plan Commercial |
$0.72
|
| Rate for Payer: Heritage Provider Network Commercial |
$0.70
|
| Rate for Payer: Heritage Provider Network Senior |
$0.70
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$0.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$0.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$0.28
|
| Rate for Payer: Multiplan Commercial |
$0.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$0.96
|
| Rate for Payer: Vantage Medical Group Senior |
$0.96
|
|
|
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 |
$7.16 |
| Max. Negotiated Rate |
$154.45 |
| Rate for Payer: Adventist Health Commercial |
$7.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$91.99
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$27.18
|
| Rate for Payer: AlphaCare Medical Group Commercial/Exchange |
$33.63
|
| Rate for Payer: AlphaCare Medical Group Medi-Cal |
$21.76
|
| Rate for Payer: AlphaCare Medical Group Medicare Advantage/Dual Product |
$29.67
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$154.45
|
| 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 |
$17.80
|
| Rate for Payer: Cash Price |
$17.80
|
| 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: IEHP Medi-Cal |
$65.36
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$19.07
|
| 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 |
$14.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$33.63
|
| Rate for Payer: Vantage Medical Group Senior |
$33.63
|
|
