|
HC SOM CATECHOLAMINE FRACT FREE UR
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 82384 90
|
| Hospital Charge Code |
900914081
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.00
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.50
|
|
|
HC SOM CATECHOLAMINES PL
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 82384 90
|
| Hospital Charge Code |
900910483
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.00
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.50
|
|
|
HC SOM CATECHOLAMINES PL
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 82384
|
| Hospital Charge Code |
900910483
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.50
|
|
|
HC SOM CATECHOLAMINES PL
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 82384
|
| Hospital Charge Code |
900910483
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$18.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$18.00
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.50
|
|
|
HC SOM CATECHOLAMINES PL
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 82384 90
|
| Hospital Charge Code |
900910483
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.50 |
| Max. Negotiated Rate |
$24.00 |
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$18.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.50
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$22.50
|
|
|
HC SOM C DIFF PCR STOOL
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 87493
|
| Hospital Charge Code |
900914042
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$36.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$36.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$45.00
|
|
|
HC SOM C DIFF PCR STOOL
|
Facility
|
OP
|
$60.00
|
|
|
Service Code
|
CPT 87493 90
|
| Hospital Charge Code |
900914042
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$45.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$36.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$36.00
|
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$36.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$45.00
|
|
|
HC SOM C DIFF PCR STOOL
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 87493
|
| Hospital Charge Code |
900914042
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$45.00
|
|
|
HC SOM C DIFF PCR STOOL
|
Facility
|
IP
|
$60.00
|
|
|
Service Code
|
CPT 87493 90
|
| Hospital Charge Code |
900914042
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$33.00 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Cash Price |
$27.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$36.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$33.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$45.00
|
|
|
HC SOM CEA PANCREATIC CYST
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 82378 90
|
| Hospital Charge Code |
900912997
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$33.75
|
|
|
HC SOM CEA PANCREATIC CYST
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 82378
|
| Hospital Charge Code |
900912997
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$36.00 |
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$36.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$33.75
|
|
|
HC SOM CEA PANCREATIC CYST
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 82378
|
| Hospital Charge Code |
900912997
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$27.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$27.00
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$27.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$33.75
|
|
|
HC SOM CEA PANCREATIC CYST
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 82378 90
|
| Hospital Charge Code |
900912997
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$24.75 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$27.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$27.00
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Health Smart Auto/Commercial |
$27.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$27.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$24.75
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$33.75
|
|
|
HC SOM CELIAC COMP IGA
|
Facility
|
IP
|
$6.48
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
900914382
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$5.18 |
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.86
|
|
|
HC SOM CELIAC COMP IGA
|
Facility
|
OP
|
$6.48
|
|
|
Service Code
|
CPT 82784 90
|
| Hospital Charge Code |
900914382
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.89
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.89
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.86
|
|
|
HC SOM CELIAC COMP IGA
|
Facility
|
IP
|
$6.48
|
|
|
Service Code
|
CPT 82784 90
|
| Hospital Charge Code |
900914382
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$5.18 |
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$5.18
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.86
|
|
|
HC SOM CELIAC COMP IGA
|
Facility
|
OP
|
$6.48
|
|
|
Service Code
|
CPT 82784
|
| Hospital Charge Code |
900914382
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$3.56 |
| Max. Negotiated Rate |
$4.86 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$3.89
|
| Rate for Payer: Aetna of CA Government/Medicare |
$3.89
|
| Rate for Payer: Cash Price |
$2.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$3.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$3.89
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.56
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$4.86
|
|
|
HC SOM CHLORDIAZEPOXIDE (LIBRIUM)
|
Facility
|
OP
|
$280.10
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900911081
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$154.06 |
| Max. Negotiated Rate |
$210.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$168.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$168.06
|
| Rate for Payer: Cash Price |
$126.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$168.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.08
|
|
|
HC SOM CHLORDIAZEPOXIDE (LIBRIUM)
|
Facility
|
OP
|
$280.10
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900911081
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$154.06 |
| Max. Negotiated Rate |
$210.08 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$168.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$168.06
|
| Rate for Payer: Cash Price |
$126.05
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$168.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.08
|
|
|
HC SOM CHLORDIAZEPOXIDE (LIBRIUM)
|
Facility
|
IP
|
$280.10
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900911081
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$154.06 |
| Max. Negotiated Rate |
$224.08 |
| Rate for Payer: Cash Price |
$126.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.08
|
|
|
HC SOM CHLORDIAZEPOXIDE (LIBRIUM)
|
Facility
|
IP
|
$280.10
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911081
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$154.06 |
| Max. Negotiated Rate |
$224.08 |
| Rate for Payer: Cash Price |
$126.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.08
|
|
|
HC SOM CHLORDIAZEPOXIDE (LIBRIUM)
|
Facility
|
IP
|
$280.10
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900911081
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$154.06 |
| Max. Negotiated Rate |
$224.08 |
| Rate for Payer: Cash Price |
$126.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.08
|
| Rate for Payer: Health Smart Auto/Commercial |
$168.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.08
|
|
|
HC SOM CHLORDIAZEPOXIDE (LIBRIUM)
|
Facility
|
OP
|
$280.10
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911081
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$154.06 |
| Max. Negotiated Rate |
$210.08 |
| Rate for Payer: Health Smart Auto/Commercial |
$168.06
|
| Rate for Payer: Cash Price |
$126.05
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$168.06
|
| Rate for Payer: Aetna of CA Government/Medicare |
$168.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$168.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$154.06
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$210.08
|
|
|
HC SOM CHOLINESTERASE PSEUDO
|
Facility
|
OP
|
$107.03
|
|
|
Service Code
|
CPT 82480
|
| Hospital Charge Code |
900911160
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.87 |
| Max. Negotiated Rate |
$80.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$64.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$64.22
|
| Rate for Payer: Cash Price |
$48.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$64.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$64.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.87
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$80.27
|
|
|
HC SOM CHOLINESTERASE PSEUDO
|
Facility
|
OP
|
$107.03
|
|
|
Service Code
|
CPT 82480 90
|
| Hospital Charge Code |
900911160
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$58.87 |
| Max. Negotiated Rate |
$80.27 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$64.22
|
| Rate for Payer: Aetna of CA Government/Medicare |
$64.22
|
| Rate for Payer: Cash Price |
$48.16
|
| Rate for Payer: Health Smart Auto/Commercial |
$64.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$64.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$58.87
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$80.27
|
|
