|
HC SOFT PALATE
|
Facility
|
IP
|
$1,397.00
|
|
|
Service Code
|
CPT 76499
|
| Hospital Charge Code |
909001202
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$252.86 |
| Max. Negotiated Rate |
$1,047.75 |
| Rate for Payer: Adventist Health Commercial |
$279.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$959.74
|
| Rate for Payer: Cash Price |
$628.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$945.77
|
| Rate for Payer: Heritage Provider Network Senior |
$945.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$252.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$349.25
|
| Rate for Payer: Multiplan Commercial |
$1,047.75
|
|
|
HC SOFT PALATE
|
Facility
|
OP
|
$1,397.00
|
|
|
Service Code
|
CPT 76499
|
| Hospital Charge Code |
909001202
|
|
Hospital Revenue Code
|
320
|
| Min. Negotiated Rate |
$71.68 |
| Max. Negotiated Rate |
$1,047.75 |
| Rate for Payer: Adventist Health Commercial |
$279.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$100.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$959.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$113.54
|
| Rate for Payer: Blue Shield of California Commercial |
$867.54
|
| Rate for Payer: Blue Shield of California EPN |
$820.04
|
| Rate for Payer: Cash Price |
$628.65
|
| Rate for Payer: Cash Price |
$628.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$908.05
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$170.31
|
| Rate for Payer: Dignity Health Medi-Cal |
$124.89
|
| Rate for Payer: Dignity Health Senior |
$113.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$908.05
|
| Rate for Payer: EPIC Health Plan Medicare |
$113.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$864.74
|
| Rate for Payer: Heritage Provider Network Senior |
$864.74
|
| Rate for Payer: Humana Medicare |
$113.54
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$113.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$215.73
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$252.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$133.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$349.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$143.06
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$143.06
|
| Rate for Payer: Multiplan Commercial |
$1,047.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$113.54
|
| Rate for Payer: TriValley Medical Group Senior |
$113.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$71.68
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$71.68
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$170.31
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$124.89
|
| Rate for Payer: Vantage Medical Group Senior |
$113.54
|
|
|
HC SOGDX 230 GCH1 81479
|
Facility
|
IP
|
$925.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900914803
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$167.42 |
| Max. Negotiated Rate |
$693.75 |
| Rate for Payer: Adventist Health Commercial |
$185.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$635.48
|
| Rate for Payer: Cash Price |
$416.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$626.22
|
| Rate for Payer: Heritage Provider Network Senior |
$626.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$167.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$231.25
|
| Rate for Payer: Multiplan Commercial |
$693.75
|
|
|
HC SOGDX 230 GCH1 81479
|
Facility
|
OP
|
$925.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900914803
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$109.45 |
| Max. Negotiated Rate |
$786.25 |
| Rate for Payer: Adventist Health Commercial |
$185.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$109.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$635.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$786.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$508.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$693.75
|
| Rate for Payer: Blue Shield of California Commercial |
$574.42
|
| Rate for Payer: Blue Shield of California EPN |
$542.98
|
| Rate for Payer: Cash Price |
$416.25
|
| Rate for Payer: Cash Price |
$416.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$601.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$786.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$786.25
|
| Rate for Payer: Dignity Health Senior |
$786.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$601.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$572.58
|
| Rate for Payer: Heritage Provider Network Senior |
$572.58
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$445.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$167.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$231.25
|
| Rate for Payer: Multiplan Commercial |
$693.75
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$786.25
|
| Rate for Payer: Vantage Medical Group Senior |
$786.25
|
|
|
HC SOGDX 317 SIX1 81479
|
Facility
|
OP
|
$675.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900914808
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$109.45 |
| Max. Negotiated Rate |
$573.75 |
| Rate for Payer: Adventist Health Commercial |
$135.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$109.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$463.72
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$573.75
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$371.25
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$506.25
|
| Rate for Payer: Blue Shield of California Commercial |
$419.18
|
| Rate for Payer: Blue Shield of California EPN |
$396.22
|
| Rate for Payer: Cash Price |
$303.75
|
| Rate for Payer: Cash Price |
$303.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$438.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$573.75
|
| Rate for Payer: Dignity Health Medi-Cal |
$573.75
|
| Rate for Payer: Dignity Health Senior |
$573.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$438.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$417.82
|
| Rate for Payer: Heritage Provider Network Senior |
$417.82
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$325.35
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$122.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.75
|
| Rate for Payer: Multiplan Commercial |
$506.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$573.75
|
| Rate for Payer: Vantage Medical Group Senior |
$573.75
|
|
|
HC SOGDX 317 SIX1 81479
|
Facility
|
IP
|
$675.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900914808
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$122.18 |
| Max. Negotiated Rate |
$506.25 |
| Rate for Payer: Adventist Health Commercial |
$135.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$463.72
|
| Rate for Payer: Cash Price |
$303.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$456.98
|
| Rate for Payer: Heritage Provider Network Senior |
$456.98
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$122.18
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$168.75
|
| Rate for Payer: Multiplan Commercial |
$506.25
|
|
|
HC SOGDX 559 TP53 GENE 81405
|
Facility
|
IP
|
$1,395.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
900914849
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$252.50 |
| Max. Negotiated Rate |
$1,046.25 |
| Rate for Payer: Adventist Health Commercial |
$279.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$958.36
|
| Rate for Payer: Cash Price |
$627.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$944.42
|
| Rate for Payer: Heritage Provider Network Senior |
$944.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$252.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$348.75
|
| Rate for Payer: Multiplan Commercial |
$1,046.25
|
|
|
HC SOGDX 559 TP53 GENE 81405
|
Facility
|
OP
|
$1,395.00
|
|
|
Service Code
|
CPT 81405
|
| Hospital Charge Code |
900914849
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$252.50 |
| Max. Negotiated Rate |
$1,972.62 |
| Rate for Payer: Adventist Health Commercial |
$279.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$255.39
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$958.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$452.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$331.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$301.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$1,972.62
|
| Rate for Payer: Blue Shield of California Commercial |
$866.30
|
| Rate for Payer: Blue Shield of California EPN |
$818.86
|
| Rate for Payer: Cash Price |
$627.75
|
| Rate for Payer: Cash Price |
$627.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$906.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$452.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$331.48
|
| Rate for Payer: Dignity Health Senior |
$301.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$906.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$301.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$863.50
|
| Rate for Payer: Heritage Provider Network Senior |
$863.50
|
| Rate for Payer: Humana Medicare |
$301.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$470.11
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$301.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$572.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$252.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$355.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$348.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$379.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$379.70
|
| Rate for Payer: Multiplan Commercial |
$1,046.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$301.35
|
| Rate for Payer: TriValley Medical Group Senior |
$301.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$325.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$325.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$452.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$331.48
|
| Rate for Payer: Vantage Medical Group Senior |
$301.35
|
|
|
HC SOHAR HERED PARAGANG PHEO A
|
Facility
|
OP
|
$1,200.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900914679
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$109.45 |
| Max. Negotiated Rate |
$1,020.00 |
| Rate for Payer: Adventist Health Commercial |
$240.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$109.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$824.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,020.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$660.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$900.00
|
| Rate for Payer: Blue Shield of California Commercial |
$745.20
|
| Rate for Payer: Blue Shield of California EPN |
$704.40
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$780.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,020.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$1,020.00
|
| Rate for Payer: Dignity Health Senior |
$1,020.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$780.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$742.80
|
| Rate for Payer: Heritage Provider Network Senior |
$742.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$578.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.00
|
| Rate for Payer: Multiplan Commercial |
$900.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$1,020.00
|
| Rate for Payer: Vantage Medical Group Senior |
$1,020.00
|
|
|
HC SOHAR HERED PARAGANG PHEO A
|
Facility
|
IP
|
$1,200.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900914679
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$217.20 |
| Max. Negotiated Rate |
$900.00 |
| Rate for Payer: Adventist Health Commercial |
$240.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$824.40
|
| Rate for Payer: Cash Price |
$540.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$812.40
|
| Rate for Payer: Heritage Provider Network Senior |
$812.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$217.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$300.00
|
| Rate for Payer: Multiplan Commercial |
$900.00
|
|
|
HC SOHAR HERED PARAGANG PHEO B
|
Facility
|
OP
|
$500.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900914680
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$90.50 |
| Max. Negotiated Rate |
$425.00 |
| Rate for Payer: Adventist Health Commercial |
$100.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$109.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$343.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$425.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$275.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$375.00
|
| Rate for Payer: Blue Shield of California Commercial |
$310.50
|
| Rate for Payer: Blue Shield of California EPN |
$293.50
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$325.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$425.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$425.00
|
| Rate for Payer: Dignity Health Senior |
$425.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$325.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$309.50
|
| Rate for Payer: Heritage Provider Network Senior |
$309.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$241.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.00
|
| Rate for Payer: Multiplan Commercial |
$375.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$425.00
|
| Rate for Payer: Vantage Medical Group Senior |
$425.00
|
|
|
HC SOHAR HERED PARAGANG PHEO B
|
Facility
|
IP
|
$500.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900914680
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$90.50 |
| Max. Negotiated Rate |
$375.00 |
| Rate for Payer: Adventist Health Commercial |
$100.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$343.50
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$338.50
|
| Rate for Payer: Heritage Provider Network Senior |
$338.50
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$90.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$125.00
|
| Rate for Payer: Multiplan Commercial |
$375.00
|
|
|
HC SOHAR HERED PARAGANG PHEO C
|
Facility
|
OP
|
$850.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900914681
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$109.45 |
| Max. Negotiated Rate |
$722.50 |
| Rate for Payer: Adventist Health Commercial |
$170.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$109.45
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$583.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$722.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$467.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$637.50
|
| Rate for Payer: Blue Shield of California Commercial |
$527.85
|
| Rate for Payer: Blue Shield of California EPN |
$498.95
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$552.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$722.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$722.50
|
| Rate for Payer: Dignity Health Senior |
$722.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$552.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$526.15
|
| Rate for Payer: Heritage Provider Network Senior |
$526.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$409.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$153.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.50
|
| Rate for Payer: Multiplan Commercial |
$637.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$722.50
|
| Rate for Payer: Vantage Medical Group Senior |
$722.50
|
|
|
HC SOHAR HERED PARAGANG PHEO C
|
Facility
|
IP
|
$850.00
|
|
|
Service Code
|
CPT 81479
|
| Hospital Charge Code |
900914681
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$153.85 |
| Max. Negotiated Rate |
$637.50 |
| Rate for Payer: Adventist Health Commercial |
$170.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$583.95
|
| Rate for Payer: Cash Price |
$382.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$575.45
|
| Rate for Payer: Heritage Provider Network Senior |
$575.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$153.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$212.50
|
| Rate for Payer: Multiplan Commercial |
$637.50
|
|
|
HC SOLUBLE FIBRIN
|
Facility
|
OP
|
$85.00
|
|
|
Service Code
|
CPT 85366
|
| Hospital Charge Code |
900910118
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$13.37 |
| Max. Negotiated Rate |
$152.87 |
| Rate for Payer: Adventist Health Commercial |
$17.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$23.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$120.69
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$88.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$80.46
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$72.02
|
| Rate for Payer: Blue Shield of California Commercial |
$67.25
|
| Rate for Payer: Blue Shield of California EPN |
$52.57
|
| Rate for Payer: Cash Price |
$38.25
|
| Rate for Payer: Cash Price |
$38.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$120.69
|
| Rate for Payer: Dignity Health Medi-Cal |
$88.51
|
| Rate for Payer: Dignity Health Senior |
$80.46
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$80.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.62
|
| Rate for Payer: Heritage Provider Network Senior |
$52.62
|
| Rate for Payer: Humana Medicare |
$80.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.37
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$80.46
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$152.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.38
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$94.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$101.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$101.38
|
| Rate for Payer: Multiplan Commercial |
$63.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$80.46
|
| Rate for Payer: TriValley Medical Group Senior |
$80.46
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$86.89
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$86.89
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$120.69
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$88.51
|
| Rate for Payer: Vantage Medical Group Senior |
$80.46
|
|
|
HC SOLUBLE FIBRIN
|
Facility
|
IP
|
$121.00
|
|
|
Service Code
|
CPT 85366
|
| Hospital Charge Code |
900910118
|
|
Hospital Revenue Code
|
305
|
| 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 |
$83.13
|
| 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 Permanente of CA Medi-Cal |
$21.90
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.25
|
| Rate for Payer: Multiplan Commercial |
$90.75
|
|
|
HC SOM 11-DEOXYCORTISOL (COMPOUNDS)
|
Facility
|
IP
|
$120.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
900911027
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.72 |
| Max. Negotiated Rate |
$90.00 |
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$81.24
|
| Rate for Payer: Heritage Provider Network Senior |
$81.24
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
|
|
HC SOM 11-DEOXYCORTISOL (COMPOUNDS)
|
Facility
|
OP
|
$120.00
|
|
|
Service Code
|
CPT 82633
|
| Hospital Charge Code |
900911027
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$21.72 |
| Max. Negotiated Rate |
$250.87 |
| Rate for Payer: Adventist Health Commercial |
$24.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$90.12
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$82.44
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$46.47
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.08
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$30.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$250.87
|
| Rate for Payer: Blue Shield of California Commercial |
$241.94
|
| Rate for Payer: Blue Shield of California EPN |
$189.13
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cash Price |
$54.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$78.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.47
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.08
|
| Rate for Payer: Dignity Health Senior |
$30.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$78.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$30.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.28
|
| Rate for Payer: Heritage Provider Network Senior |
$74.28
|
| Rate for Payer: Humana Medicare |
$30.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$42.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$30.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$58.86
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$21.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$36.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$30.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.03
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.03
|
| Rate for Payer: Multiplan Commercial |
$90.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$30.98
|
| Rate for Payer: TriValley Medical Group Senior |
$30.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$33.46
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.46
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$46.47
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.08
|
| Rate for Payer: Vantage Medical Group Senior |
$30.98
|
|
|
HC SOM 17-OH-PROGESTERONE
|
Facility
|
IP
|
$64.00
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
900911017
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.58 |
| Max. Negotiated Rate |
$48.00 |
| Rate for Payer: Adventist Health Commercial |
$12.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.97
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.33
|
| Rate for Payer: Heritage Provider Network Senior |
$43.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.00
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
|
|
HC SOM 17-OH-PROGESTERONE
|
Facility
|
OP
|
$64.00
|
|
|
Service Code
|
CPT 83498
|
| Hospital Charge Code |
900911017
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.58 |
| Max. Negotiated Rate |
$227.38 |
| Rate for Payer: Adventist Health Commercial |
$12.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$79.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$43.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$29.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$27.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$227.38
|
| Rate for Payer: Blue Shield of California Commercial |
$212.14
|
| Rate for Payer: Blue Shield of California EPN |
$165.84
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cash Price |
$28.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$41.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$40.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.89
|
| Rate for Payer: Dignity Health Senior |
$27.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$41.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$27.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.62
|
| Rate for Payer: Heritage Provider Network Senior |
$39.62
|
| Rate for Payer: Humana Medicare |
$27.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$37.33
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$27.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$51.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$32.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$34.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$34.23
|
| Rate for Payer: Multiplan Commercial |
$48.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$27.17
|
| Rate for Payer: TriValley Medical Group Senior |
$27.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$29.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$29.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$40.76
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.89
|
| Rate for Payer: Vantage Medical Group Senior |
$27.17
|
|
|
HC SOM 18-OH CORTICOSTERONE
|
Facility
|
OP
|
$169.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900910709
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$23.95 |
| Max. Negotiated Rate |
$150.51 |
| Rate for Payer: Adventist Health Commercial |
$33.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$116.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$36.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$150.51
|
| Rate for Payer: Blue Shield of California Commercial |
$141.04
|
| Rate for Payer: Blue Shield of California EPN |
$110.26
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Cigna of CA HMO/PPO |
$109.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$36.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$26.50
|
| Rate for Payer: Dignity Health Senior |
$24.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$109.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$104.61
|
| Rate for Payer: Heritage Provider Network Senior |
$104.61
|
| Rate for Payer: Humana Medicare |
$24.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$45.77
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.59
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$28.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$30.35
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$30.35
|
| Rate for Payer: Multiplan Commercial |
$126.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.09
|
| Rate for Payer: TriValley Medical Group Senior |
$24.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$36.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$26.50
|
| Rate for Payer: Vantage Medical Group Senior |
$24.09
|
|
|
HC SOM 18-OH CORTICOSTERONE
|
Facility
|
IP
|
$169.00
|
|
|
Service Code
|
CPT 82542
|
| Hospital Charge Code |
900910709
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$30.59 |
| Max. Negotiated Rate |
$126.75 |
| Rate for Payer: Adventist Health Commercial |
$33.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$116.10
|
| Rate for Payer: Cash Price |
$76.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$114.41
|
| Rate for Payer: Heritage Provider Network Senior |
$114.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.25
|
| Rate for Payer: Multiplan Commercial |
$126.75
|
|
|
HC SOM 199PC 86301
|
Facility
|
OP
|
$29.81
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
900914879
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$174.07 |
| Rate for Payer: Adventist Health Commercial |
$5.96
|
| Rate for Payer: Aetna of CA Gatekeeper |
$60.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.48
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$31.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.81
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$174.07
|
| Rate for Payer: Blue Shield of California Commercial |
$162.50
|
| Rate for Payer: Blue Shield of California EPN |
$127.04
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.38
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$31.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.89
|
| Rate for Payer: Dignity Health Senior |
$20.81
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.38
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.45
|
| Rate for Payer: Heritage Provider Network Senior |
$18.45
|
| Rate for Payer: Humana Medicare |
$20.81
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$28.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.81
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$39.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.40
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$24.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$26.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$26.22
|
| Rate for Payer: Multiplan Commercial |
$22.36
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.81
|
| Rate for Payer: TriValley Medical Group Senior |
$20.81
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$22.48
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$22.48
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$31.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.89
|
| Rate for Payer: Vantage Medical Group Senior |
$20.81
|
|
|
HC SOM 199PC 86301
|
Facility
|
IP
|
$29.81
|
|
|
Service Code
|
CPT 86301
|
| Hospital Charge Code |
900914879
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.40 |
| Max. Negotiated Rate |
$22.36 |
| Rate for Payer: Adventist Health Commercial |
$5.96
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.48
|
| Rate for Payer: Cash Price |
$13.41
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.18
|
| Rate for Payer: Heritage Provider Network Senior |
$20.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.45
|
| Rate for Payer: Multiplan Commercial |
$22.36
|
|
|
HC SOM 22FP 88271 MULTIPLE
|
Facility
|
IP
|
$19.22
|
|
|
Service Code
|
CPT 88271
|
| Hospital Charge Code |
900914753
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$3.48 |
| Max. Negotiated Rate |
$14.42 |
| Rate for Payer: Adventist Health Commercial |
$3.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.20
|
| Rate for Payer: Cash Price |
$8.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.01
|
| Rate for Payer: Heritage Provider Network Senior |
$13.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.48
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$4.80
|
| Rate for Payer: Multiplan Commercial |
$14.42
|
|
