|
HC SOM MCLON PROT ELEC. U
|
Facility
|
IP
|
$17.53
|
|
|
Service Code
|
CPT 84166 90
|
| Hospital Charge Code |
900912767
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.64 |
| Max. Negotiated Rate |
$14.02 |
| Rate for Payer: Cash Price |
$7.89
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.02
|
| Rate for Payer: Health Smart Auto/Commercial |
$10.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.64
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.15
|
|
|
HC SOM MCLON T. PROT U
|
Facility
|
OP
|
$3.61
|
|
|
Service Code
|
CPT 84156 90
|
| Hospital Charge Code |
900912765
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.71
|
|
|
HC SOM MCLON T. PROT U
|
Facility
|
IP
|
$3.61
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
900912765
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.71
|
|
|
HC SOM MCLON T. PROT U
|
Facility
|
IP
|
$3.61
|
|
|
Service Code
|
CPT 84156 90
|
| Hospital Charge Code |
900912765
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.89 |
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Cigna of CA HMO/PPO |
$2.89
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.71
|
|
|
HC SOM MCLON T. PROT U
|
Facility
|
OP
|
$3.61
|
|
|
Service Code
|
CPT 84156
|
| Hospital Charge Code |
900912765
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$1.99 |
| Max. Negotiated Rate |
$2.71 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$2.17
|
| Rate for Payer: Aetna of CA Government/Medicare |
$2.17
|
| Rate for Payer: Cash Price |
$1.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$1.99
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$2.71
|
|
|
HC SOM MEASLES AB CSF IGG
|
Facility
|
OP
|
$22.50
|
|
|
Service Code
|
CPT 86765 90
|
| Hospital Charge Code |
900911355
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.50
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.88
|
|
|
HC SOM MEASLES AB CSF IGG
|
Facility
|
IP
|
$22.50
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
900911355
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.88
|
|
|
HC SOM MEASLES AB CSF IGG
|
Facility
|
IP
|
$22.50
|
|
|
Service Code
|
CPT 86765 90
|
| Hospital Charge Code |
900911355
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.88
|
|
|
HC SOM MEASLES AB CSF IGG
|
Facility
|
OP
|
$22.50
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
900911355
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Health Smart Auto/Commercial |
$13.50
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.88
|
|
|
HC SOM MEASLES AB IGM CSF
|
Facility
|
IP
|
$22.50
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
900912655
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.88
|
|
|
HC SOM MEASLES AB IGM CSF
|
Facility
|
IP
|
$22.50
|
|
|
Service Code
|
CPT 86765 90
|
| Hospital Charge Code |
900912655
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.88
|
|
|
HC SOM MEASLES AB IGM CSF
|
Facility
|
OP
|
$22.50
|
|
|
Service Code
|
CPT 86765 90
|
| Hospital Charge Code |
900912655
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.50
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.88
|
|
|
HC SOM MEASLES AB IGM CSF
|
Facility
|
OP
|
$22.50
|
|
|
Service Code
|
CPT 86765
|
| Hospital Charge Code |
900912655
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.38 |
| Max. Negotiated Rate |
$16.88 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.50
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.50
|
| Rate for Payer: Cash Price |
$10.13
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.38
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.88
|
|
|
HC SOM MECONIUM AMPHETAMINE CONFIRM
|
Facility
|
OP
|
$35.08
|
|
|
Service Code
|
CPT 80324
|
| Hospital Charge Code |
900912830
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$26.31 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.05
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.31
|
|
|
HC SOM MECONIUM AMPHETAMINE CONFIRM
|
Facility
|
IP
|
$35.08
|
|
|
Service Code
|
CPT 80324
|
| Hospital Charge Code |
900912830
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$28.06 |
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.31
|
|
|
HC SOM MECONIUM AMPHETAMINE CONFIRM
|
Facility
|
IP
|
$35.08
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900912830
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$28.06 |
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.31
|
|
|
HC SOM MECONIUM AMPHETAMINE CONFIRM
|
Facility
|
OP
|
$35.08
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900912830
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$26.31 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.05
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.31
|
|
|
HC SOM MECONIUM AMPHETAMINE CONFIRM
|
Facility
|
OP
|
$35.08
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900912830
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$26.31 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$21.05
|
| Rate for Payer: Aetna of CA Government/Medicare |
$21.05
|
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$21.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.31
|
|
|
HC SOM MECONIUM AMPHETAMINE CONFIRM
|
Facility
|
IP
|
$35.08
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900912830
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.29 |
| Max. Negotiated Rate |
$28.06 |
| Rate for Payer: Cash Price |
$15.79
|
| Rate for Payer: Cigna of CA HMO/PPO |
$28.06
|
| Rate for Payer: Health Smart Auto/Commercial |
$21.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.29
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$26.31
|
|
|
HC SOM MECONIUM COCAINE CONFIRM
|
Facility
|
OP
|
$96.01
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900912832
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.81 |
| Max. Negotiated Rate |
$72.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.61
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.01
|
|
|
HC SOM MECONIUM COCAINE CONFIRM
|
Facility
|
IP
|
$96.01
|
|
|
Service Code
|
CPT 80353
|
| Hospital Charge Code |
900912832
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.81 |
| Max. Negotiated Rate |
$76.81 |
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.01
|
|
|
HC SOM MECONIUM COCAINE CONFIRM
|
Facility
|
IP
|
$96.01
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900912832
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.81 |
| Max. Negotiated Rate |
$76.81 |
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.01
|
|
|
HC SOM MECONIUM COCAINE CONFIRM
|
Facility
|
IP
|
$96.01
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900912832
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.81 |
| Max. Negotiated Rate |
$76.81 |
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Cigna of CA HMO/PPO |
$76.81
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.01
|
|
|
HC SOM MECONIUM COCAINE CONFIRM
|
Facility
|
OP
|
$96.01
|
|
|
Service Code
|
CPT 80353
|
| Hospital Charge Code |
900912832
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.81 |
| Max. Negotiated Rate |
$72.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.61
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.01
|
|
|
HC SOM MECONIUM COCAINE CONFIRM
|
Facility
|
OP
|
$96.01
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900912832
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$52.81 |
| Max. Negotiated Rate |
$72.01 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$57.61
|
| Rate for Payer: Aetna of CA Government/Medicare |
$57.61
|
| Rate for Payer: Cash Price |
$43.20
|
| Rate for Payer: Health Smart Auto/Commercial |
$57.61
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$57.61
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$52.81
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$72.01
|
|
