|
HC SOM QUANTIFERON TB GOLD
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 86480
|
| Hospital Charge Code |
900912882
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$24.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$24.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$30.00
|
|
|
HC SOM RIBOSOMAL P AB
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 83516 90
|
| Hospital Charge Code |
900911367
|
|
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 RIBOSOMAL P AB
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
900911367
|
|
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 RIBOSOMAL P AB
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 83516
|
| Hospital Charge Code |
900911367
|
|
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 RIBOSOMAL P AB
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 83516 90
|
| Hospital Charge Code |
900911367
|
|
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 RISTOCETIN-WILLEBRAND FACTOR
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 85245 90
|
| Hospital Charge Code |
900911282
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$24.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$24.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$30.00
|
|
|
HC SOM RISTOCETIN-WILLEBRAND FACTOR
|
Facility
|
OP
|
$40.00
|
|
|
Service Code
|
CPT 85245
|
| Hospital Charge Code |
900911282
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$30.00 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$24.00
|
| Rate for Payer: Aetna of CA Government/Medicare |
$24.00
|
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$30.00
|
|
|
HC SOM RISTOCETIN-WILLEBRAND FACTOR
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 85245 90
|
| Hospital Charge Code |
900911282
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$30.00
|
|
|
HC SOM RISTOCETIN-WILLEBRAND FACTOR
|
Facility
|
IP
|
$40.00
|
|
|
Service Code
|
CPT 85245
|
| Hospital Charge Code |
900911282
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.00 |
| Max. Negotiated Rate |
$32.00 |
| Rate for Payer: Cash Price |
$18.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.00
|
| Rate for Payer: Health Smart Auto/Commercial |
$24.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$22.00
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$30.00
|
|
|
HC SOM SACCHAROMY CEREVI AB, IGA
|
Facility
|
IP
|
$18.54
|
|
|
Service Code
|
CPT 86671 90
|
| Hospital Charge Code |
900913806
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Cash Price |
$8.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.90
|
|
|
HC SOM SACCHAROMY CEREVI AB, IGA
|
Facility
|
OP
|
$18.54
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
900913806
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$13.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.12
|
| Rate for Payer: Cash Price |
$8.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.90
|
|
|
HC SOM SACCHAROMY CEREVI AB, IGA
|
Facility
|
IP
|
$169.30
|
|
|
Service Code
|
CPT 86671 90
|
| Hospital Charge Code |
900913805
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$93.12 |
| Max. Negotiated Rate |
$135.44 |
| Rate for Payer: Cash Price |
$76.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$135.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$101.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$93.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$126.98
|
|
|
HC SOM SACCHAROMY CEREVI AB, IGA
|
Facility
|
IP
|
$169.30
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
900913805
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$93.12 |
| Max. Negotiated Rate |
$135.44 |
| Rate for Payer: Cash Price |
$76.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$135.44
|
| Rate for Payer: Health Smart Auto/Commercial |
$101.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$93.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$126.98
|
|
|
HC SOM SACCHAROMY CEREVI AB, IGA
|
Facility
|
OP
|
$169.30
|
|
|
Service Code
|
CPT 86671 90
|
| Hospital Charge Code |
900913805
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$93.12 |
| Max. Negotiated Rate |
$126.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$101.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$101.58
|
| Rate for Payer: Cash Price |
$76.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$101.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$101.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$93.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$126.98
|
|
|
HC SOM SACCHAROMY CEREVI AB, IGA
|
Facility
|
IP
|
$18.54
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
900913806
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$14.83 |
| Rate for Payer: Cash Price |
$8.34
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.83
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.90
|
|
|
HC SOM SACCHAROMY CEREVI AB, IGA
|
Facility
|
OP
|
$18.54
|
|
|
Service Code
|
CPT 86671 90
|
| Hospital Charge Code |
900913806
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.20 |
| Max. Negotiated Rate |
$13.90 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$11.12
|
| Rate for Payer: Aetna of CA Government/Medicare |
$11.12
|
| Rate for Payer: Cash Price |
$8.34
|
| Rate for Payer: Health Smart Auto/Commercial |
$11.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$11.12
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.20
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$13.90
|
|
|
HC SOM SACCHAROMY CEREVI AB, IGA
|
Facility
|
OP
|
$169.30
|
|
|
Service Code
|
CPT 86671
|
| Hospital Charge Code |
900913805
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$93.12 |
| Max. Negotiated Rate |
$126.98 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$101.58
|
| Rate for Payer: Aetna of CA Government/Medicare |
$101.58
|
| Rate for Payer: Cash Price |
$76.19
|
| Rate for Payer: Health Smart Auto/Commercial |
$101.58
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$101.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$93.12
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$126.98
|
|
|
HC SOM SCHISTOSOMIASIS AB IGG
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 86682 90
|
| Hospital Charge Code |
900911335
|
|
Hospital Revenue Code
|
302
|
| 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 SCHISTOSOMIASIS AB IGG
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
900911335
|
|
Hospital Revenue Code
|
302
|
| 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 SCHISTOSOMIASIS AB IGG
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 86682
|
| Hospital Charge Code |
900911335
|
|
Hospital Revenue Code
|
302
|
| 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 SCHISTOSOMIASIS AB IGG
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 86682 90
|
| Hospital Charge Code |
900911335
|
|
Hospital Revenue Code
|
302
|
| 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 SECOBARBITAL
|
Facility
|
IP
|
$228.60
|
|
|
Service Code
|
CPT 80345
|
| Hospital Charge Code |
900910552
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$125.73 |
| Max. Negotiated Rate |
$182.88 |
| Rate for Payer: Cash Price |
$102.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$182.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$137.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$171.45
|
|
|
HC SOM SECOBARBITAL
|
Facility
|
IP
|
$228.60
|
|
|
Service Code
|
CPT G0480
|
| Hospital Charge Code |
900910552
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$125.73 |
| Max. Negotiated Rate |
$182.88 |
| Rate for Payer: Cash Price |
$102.87
|
| Rate for Payer: Cigna of CA HMO/PPO |
$182.88
|
| Rate for Payer: Health Smart Auto/Commercial |
$137.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$171.45
|
|
|
HC SOM SECOBARBITAL
|
Facility
|
OP
|
$228.60
|
|
|
Service Code
|
CPT G0480 90
|
| Hospital Charge Code |
900910552
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$125.73 |
| Max. Negotiated Rate |
$171.45 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$137.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$137.16
|
| Rate for Payer: Cash Price |
$102.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$137.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$137.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$171.45
|
|
|
HC SOM SECOBARBITAL
|
Facility
|
OP
|
$228.60
|
|
|
Service Code
|
CPT 80345
|
| Hospital Charge Code |
900910552
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$125.73 |
| Max. Negotiated Rate |
$171.45 |
| Rate for Payer: Aetna of CA EPO/HMO/POS/PPO |
$137.16
|
| Rate for Payer: Aetna of CA Government/Medicare |
$137.16
|
| Rate for Payer: Cash Price |
$102.87
|
| Rate for Payer: Health Smart Auto/Commercial |
$137.16
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal/Medicare Advantage |
$137.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.73
|
| Rate for Payer: Multiplan Beech St/Commercial/PHCS |
$171.45
|
|
