|
HC ADM SARSCOV2 MOD 50MCG/0.5 MLBST
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0094A
|
| Hospital Charge Code |
949001330
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.02
|
| Rate for Payer: Blue Shield of California Commercial |
$68.32
|
| Rate for Payer: Blue Shield of California EPN |
$54.66
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$53.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.40
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 MOD BV BOOSTER 50MCG/0.5ML
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT 0134A
|
| Hospital Charge Code |
949001350
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$90.75 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.92
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.92
|
| Rate for Payer: Heritage Provider Network Senior |
$81.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
|
|
HC ADM SARSCOV2 MOD BV BOOSTER 50MCG/0.5ML
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT 0134A
|
| Hospital Charge Code |
949001350
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$102.85 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.52
|
| Rate for Payer: Blue Shield of California Commercial |
$73.81
|
| Rate for Payer: Blue Shield of California EPN |
$59.05
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$102.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.90
|
| Rate for Payer: Heritage Provider Network Senior |
$74.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$57.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$84.70
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.85
|
| Rate for Payer: Vantage Medical Group Senior |
$102.85
|
|
|
HC ADM SARSCOV2 MOD BV PEDS (6-11YRS) BOOSTER 25MCG/0.25ML
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT 0144A
|
| Hospital Charge Code |
949001352
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$102.85 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.52
|
| Rate for Payer: Blue Shield of California Commercial |
$73.81
|
| Rate for Payer: Blue Shield of California EPN |
$59.05
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$102.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.90
|
| Rate for Payer: Heritage Provider Network Senior |
$74.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$57.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$84.70
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.85
|
| Rate for Payer: Vantage Medical Group Senior |
$102.85
|
|
|
HC ADM SARSCOV2 MOD BV PEDS (6-11YRS) BOOSTER 25MCG/0.25ML
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT 0144A
|
| Hospital Charge Code |
949001352
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$90.75 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.92
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.92
|
| Rate for Payer: Heritage Provider Network Senior |
$81.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
|
|
HC ADM SARSCOV2 MOD BV PEDS (6MS-5YRS) BOOSTER 10MCG/0.2ML
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT 0164A
|
| Hospital Charge Code |
949001353
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$90.75 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.92
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.92
|
| Rate for Payer: Heritage Provider Network Senior |
$81.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
|
|
HC ADM SARSCOV2 MOD BV PEDS (6MS-5YRS) BOOSTER 10MCG/0.2ML
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT 0164A
|
| Hospital Charge Code |
949001353
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$102.85 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.52
|
| Rate for Payer: Blue Shield of California Commercial |
$73.81
|
| Rate for Payer: Blue Shield of California EPN |
$59.05
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$102.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.90
|
| Rate for Payer: Heritage Provider Network Senior |
$74.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$57.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$84.70
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.85
|
| Rate for Payer: Vantage Medical Group Senior |
$102.85
|
|
|
HC ADM SARSCOV2 MOD PEDS (6MS-4YRS) 1ST 50MCG/.5 ML IM
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0091A
|
| Hospital Charge Code |
949001341
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.13
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 MOD PEDS (6MS-4YRS) 1ST 50MCG/.5 ML IM
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0091A
|
| Hospital Charge Code |
949001341
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.02
|
| Rate for Payer: Blue Shield of California Commercial |
$68.32
|
| Rate for Payer: Blue Shield of California EPN |
$54.66
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$53.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.40
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 MOD PEDS (6MS-4YRS) 2ND 50MCG/.5 ML IM
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0092A
|
| Hospital Charge Code |
949001342
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.02
|
| Rate for Payer: Blue Shield of California Commercial |
$68.32
|
| Rate for Payer: Blue Shield of California EPN |
$54.66
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$53.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.40
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 MOD PEDS (6MS-4YRS) 2ND 50MCG/.5 ML IM
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0092A
|
| Hospital Charge Code |
949001342
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.13
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 MOD PEDS (6MS-4YRS) 3RD 50MCG/.5 ML IM
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0093A
|
| Hospital Charge Code |
949001343
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.13
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 MOD PEDS (6MS-4YRS) 3RD 50MCG/.5 ML IM
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0093A
|
| Hospital Charge Code |
949001343
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.02
|
| Rate for Payer: Blue Shield of California Commercial |
$68.32
|
| Rate for Payer: Blue Shield of California EPN |
$54.66
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$53.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.40
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 MOD PEDS (6MS-5YRS) 3RD 25 MCG/0.25ML
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT 0113A
|
| Hospital Charge Code |
949001344
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$102.85 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.52
|
| Rate for Payer: Blue Shield of California Commercial |
$73.81
|
| Rate for Payer: Blue Shield of California EPN |
$59.05
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$102.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.90
|
| Rate for Payer: Heritage Provider Network Senior |
$74.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$57.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$84.70
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.85
|
| Rate for Payer: Vantage Medical Group Senior |
$102.85
|
|
|
HC ADM SARSCOV2 MOD PEDS (6MS-5YRS) 3RD 25 MCG/0.25ML
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT 0113A
|
| Hospital Charge Code |
949001344
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$90.75 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.92
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.92
|
| Rate for Payer: Heritage Provider Network Senior |
$81.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
|
|
HC ADM SARSCOV2 NV 2ND 5MCG/0.5ML IM
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0042A
|
| Hospital Charge Code |
949001340
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.02
|
| Rate for Payer: Blue Shield of California Commercial |
$68.32
|
| Rate for Payer: Blue Shield of California EPN |
$54.66
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$53.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.40
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 NV 2ND 5MCG/0.5ML IM
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0042A
|
| Hospital Charge Code |
949001340
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.13
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 PF BV BOOSTER 30MCG/0.3ML 12YRS OR OLDER
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT 0124A
|
| Hospital Charge Code |
949001346
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$90.75 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.92
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.92
|
| Rate for Payer: Heritage Provider Network Senior |
$81.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
|
|
HC ADM SARSCOV2 PF BV BOOSTER 30MCG/0.3ML 12YRS OR OLDER
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT 0124A
|
| Hospital Charge Code |
949001346
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$102.85 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.52
|
| Rate for Payer: Blue Shield of California Commercial |
$73.81
|
| Rate for Payer: Blue Shield of California EPN |
$59.05
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$102.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.90
|
| Rate for Payer: Heritage Provider Network Senior |
$74.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$57.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$84.70
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.85
|
| Rate for Payer: Vantage Medical Group Senior |
$102.85
|
|
|
HC ADM SARSCOV2 PF BV PEDS (5-11YRS) BOOSTER 10MCG/0.2ML
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT 0154A
|
| Hospital Charge Code |
949001348
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$90.75 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.92
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.92
|
| Rate for Payer: Heritage Provider Network Senior |
$81.92
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
|
|
HC ADM SARSCOV2 PF BV PEDS (5-11YRS) BOOSTER 10MCG/0.2ML
|
Facility
|
OP
|
$121.00
|
|
|
Service Code
|
CPT 0154A
|
| Hospital Charge Code |
949001348
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$21.90 |
| Max. Negotiated Rate |
$102.85 |
| Rate for Payer: Adventist Health Commercial |
$24.20
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$74.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$66.55
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$90.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.52
|
| Rate for Payer: Blue Shield of California Commercial |
$73.81
|
| Rate for Payer: Blue Shield of California EPN |
$59.05
|
| Rate for Payer: Cash Price |
$54.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.65
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$102.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$102.85
|
| Rate for Payer: Dignity Health Medicare Advantage |
$102.85
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.90
|
| Rate for Payer: Heritage Provider Network Senior |
$74.90
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$57.72
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$84.70
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$102.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$102.85
|
| Rate for Payer: Vantage Medical Group Senior |
$102.85
|
|
|
HC ADM SARSCOV2 PF PEDS (6MS -4 YRS) 3MCG TRS-SUCR 1
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0081A
|
| Hospital Charge Code |
949001327
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.02
|
| Rate for Payer: Blue Shield of California Commercial |
$68.32
|
| Rate for Payer: Blue Shield of California EPN |
$54.66
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$53.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.40
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 PF PEDS (6MS -4 YRS) 3MCG TRS-SUCR 1
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0081A
|
| Hospital Charge Code |
949001327
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.13
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
|
HC ADM SARSCOV2 PF PEDS (6MS -4 YRS) 3MCG TRS-SUCR 2
|
Facility
|
OP
|
$112.00
|
|
|
Service Code
|
CPT 0082A
|
| Hospital Charge Code |
949001328
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$95.20 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$69.22
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$61.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$84.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.02
|
| Rate for Payer: Blue Shield of California Commercial |
$68.32
|
| Rate for Payer: Blue Shield of California EPN |
$54.66
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$95.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$95.20
|
| Rate for Payer: Dignity Health Medicare Advantage |
$95.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$66.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.33
|
| Rate for Payer: Heritage Provider Network Senior |
$69.33
|
| Rate for Payer: Kaiser Foundation Hospitals Commercial |
$53.42
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal/Medicare |
$78.40
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$95.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$95.20
|
| Rate for Payer: Vantage Medical Group Senior |
$95.20
|
|
|
HC ADM SARSCOV2 PF PEDS (6MS -4 YRS) 3MCG TRS-SUCR 2
|
Facility
|
IP
|
$112.00
|
|
|
Service Code
|
CPT 0082A
|
| Hospital Charge Code |
949001328
|
|
Hospital Revenue Code
|
771
|
| Min. Negotiated Rate |
$20.27 |
| Max. Negotiated Rate |
$84.00 |
| Rate for Payer: Adventist Health Commercial |
$22.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$72.13
|
| Rate for Payer: Cash Price |
$50.40
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.82
|
| Rate for Payer: Heritage Provider Network Senior |
$75.82
|
| Rate for Payer: Kaiser Foundation Hospitals Medi-Cal |
$20.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.00
|
| Rate for Payer: Multiplan Commercial |
$84.00
|
|
