|
HC SOM MEPERIDINE
|
Facility
|
IP
|
$98.28
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900910758
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$54.05 |
| Max. Negotiated Rate |
$78.62 |
| Rate for Payer: Cash Price |
$44.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$73.71
|
|
|
HC SOM MEPERIDINE
|
Facility
|
IP
|
$98.28
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900910758
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$54.05 |
| Max. Negotiated Rate |
$78.62 |
| Rate for Payer: Cash Price |
$44.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$73.71
|
|
|
HC SOM MEPERIDINE
|
Facility
|
IP
|
$98.28
|
|
|
Service Code
|
CPT 80362
|
| Hospital Charge Code |
900910758
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$54.05 |
| Max. Negotiated Rate |
$78.62 |
| Rate for Payer: Cash Price |
$44.23
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.62
|
| Rate for Payer: Health Smart Auto/Commercial |
$58.97
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$54.05
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$73.71
|
|
|
HC SOM MERCURY BLOOD
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
900910759
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.10 |
| Max. Negotiated Rate |
$17.60 |
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.50
|
|
|
HC SOM MERCURY BLOOD
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 83825 90
|
| Hospital Charge Code |
900910759
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.10 |
| Max. Negotiated Rate |
$17.60 |
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.50
|
|
|
HC SOM MERCURY BLOOD
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 83825 90
|
| Hospital Charge Code |
900910759
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.10 |
| Max. Negotiated Rate |
$16.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.20
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.50
|
|
|
HC SOM MERCURY BLOOD
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 83825
|
| Hospital Charge Code |
900910759
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.10 |
| Max. Negotiated Rate |
$16.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.20
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.50
|
|
|
HC SOM METANEPHRINES,FRACT,FREE,P
|
Facility
|
IP
|
$24.26
|
|
|
Service Code
|
CPT 83835 90
|
| Hospital Charge Code |
900912922
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.34 |
| Max. Negotiated Rate |
$19.41 |
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$18.20
|
|
|
HC SOM METANEPHRINES,FRACT,FREE,P
|
Facility
|
OP
|
$24.26
|
|
|
Service Code
|
CPT 83835
|
| Hospital Charge Code |
900912922
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.34 |
| Max. Negotiated Rate |
$18.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.56
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$18.20
|
|
|
HC SOM METANEPHRINES,FRACT,FREE,P
|
Facility
|
OP
|
$24.26
|
|
|
Service Code
|
CPT 83835 90
|
| Hospital Charge Code |
900912922
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.34 |
| Max. Negotiated Rate |
$18.20 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$14.56
|
| Rate for Payer: Aetna of CA Government/Medicare |
$14.56
|
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$14.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$18.20
|
|
|
HC SOM METANEPHRINES,FRACT,FREE,P
|
Facility
|
IP
|
$24.26
|
|
|
Service Code
|
CPT 83835
|
| Hospital Charge Code |
900912922
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.34 |
| Max. Negotiated Rate |
$19.41 |
| Rate for Payer: Cash Price |
$10.92
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.41
|
| Rate for Payer: Health Smart Auto/Commercial |
$14.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.34
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$18.20
|
|
|
HC SOM METHADONE CONFIRMATION, U
|
Facility
|
IP
|
$114.08
|
|
|
Service Code
|
CPT 80358
|
| Hospital Charge Code |
900912918
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.74 |
| Max. Negotiated Rate |
$91.26 |
| Rate for Payer: Cash Price |
$51.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$85.56
|
|
|
HC SOM METHADONE CONFIRMATION, U
|
Facility
|
OP
|
$114.08
|
|
|
Service Code
|
CPT 80358
|
| Hospital Charge Code |
900912918
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.74 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$68.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$68.45
|
| Rate for Payer: Cash Price |
$51.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$68.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$85.56
|
|
|
HC SOM METHADONE CONFIRMATION, U
|
Facility
|
OP
|
$114.08
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900912918
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.74 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$68.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$68.45
|
| Rate for Payer: Cash Price |
$51.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$68.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$85.56
|
|
|
HC SOM METHADONE CONFIRMATION, U
|
Facility
|
IP
|
$114.08
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900912918
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.74 |
| Max. Negotiated Rate |
$91.26 |
| Rate for Payer: Cash Price |
$51.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$85.56
|
|
|
HC SOM METHADONE CONFIRMATION, U
|
Facility
|
IP
|
$114.08
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900912918
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.74 |
| Max. Negotiated Rate |
$91.26 |
| Rate for Payer: Cash Price |
$51.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$91.26
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$85.56
|
|
|
HC SOM METHADONE CONFIRMATION, U
|
Facility
|
OP
|
$114.08
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900912918
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$62.74 |
| Max. Negotiated Rate |
$85.56 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$68.45
|
| Rate for Payer: Aetna of CA Government/Medicare |
$68.45
|
| Rate for Payer: Cash Price |
$51.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$68.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$68.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.74
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$85.56
|
|
|
HC SOM METHANPHETAMINE QUANT
|
Facility
|
OP
|
$16.18
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900912822
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$12.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.71
|
| Rate for Payer: Cash Price |
$7.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.14
|
|
|
HC SOM METHANPHETAMINE QUANT
|
Facility
|
OP
|
$16.18
|
|
|
Service Code
|
CPT 80359
|
| Hospital Charge Code |
900912822
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$12.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.71
|
| Rate for Payer: Cash Price |
$7.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.14
|
|
|
HC SOM METHANPHETAMINE QUANT
|
Facility
|
IP
|
$16.18
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900912822
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: Cash Price |
$7.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.14
|
|
|
HC SOM METHANPHETAMINE QUANT
|
Facility
|
IP
|
$16.18
|
|
|
Service Code
|
CPT 80359
|
| Hospital Charge Code |
900912822
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: Cash Price |
$7.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.14
|
|
|
HC SOM METHANPHETAMINE QUANT
|
Facility
|
IP
|
$16.18
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900912822
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$12.94 |
| Rate for Payer: Cash Price |
$7.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.94
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.14
|
|
|
HC SOM METHANPHETAMINE QUANT
|
Facility
|
OP
|
$16.18
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900912822
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.90 |
| Max. Negotiated Rate |
$12.14 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$9.71
|
| Rate for Payer: Aetna of CA Government/Medicare |
$9.71
|
| Rate for Payer: Cash Price |
$7.28
|
| Rate for Payer: Health Smart Auto/Commercial |
$9.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$9.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.90
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$12.14
|
|
|
HC SOM METHYLMALONIC ACID
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 83921 90
|
| Hospital Charge Code |
900911265
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.10 |
| Max. Negotiated Rate |
$17.60 |
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$17.60
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.50
|
|
|
HC SOM METHYLMALONIC ACID
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 83921 90
|
| Hospital Charge Code |
900911265
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.10 |
| Max. Negotiated Rate |
$16.50 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$13.20
|
| Rate for Payer: Aetna of CA Government/Medicare |
$13.20
|
| Rate for Payer: Cash Price |
$9.90
|
| Rate for Payer: Health Smart Auto/Commercial |
$13.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$13.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.10
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$16.50
|
|
