|
HC SOM ALPHA GALACTOSIDASE
|
Facility
|
IP
|
$250.00
|
|
|
Service Code
|
CPT 82657
|
| Hospital Charge Code |
900910718
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$45.25 |
| Max. Negotiated Rate |
$187.50 |
| Rate for Payer: Adventist Health Commercial |
$50.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$171.75
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$169.25
|
| Rate for Payer: Heritage Provider Network Senior |
$169.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.25
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.50
|
| Rate for Payer: Multiplan Commercial |
$187.50
|
|
|
HC SOM ALPHA GALACTOSIDASE
|
Facility
|
OP
|
$250.00
|
|
|
Service Code
|
CPT 82657
|
| Hospital Charge Code |
900910718
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$22.17 |
| Max. Negotiated Rate |
$187.50 |
| Rate for Payer: Adventist Health Commercial |
$50.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$171.75
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$33.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$24.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.17
|
| 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 |
$112.50
|
| Rate for Payer: Cash Price |
$112.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$162.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$33.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$24.39
|
| Rate for Payer: Dignity Health Senior |
$22.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$162.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$22.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$154.75
|
| Rate for Payer: Heritage Provider Network Senior |
$154.75
|
| Rate for Payer: Humana Medicare |
$22.17
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27.67
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$22.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$42.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$45.25
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$26.16
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$62.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$27.93
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$27.93
|
| Rate for Payer: Multiplan Commercial |
$187.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$22.17
|
| Rate for Payer: TriValley Medical Group Senior |
$22.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$23.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$23.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$33.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$24.39
|
| Rate for Payer: Vantage Medical Group Senior |
$22.17
|
|
|
HC SOM ALUMINUM
|
Facility
|
IP
|
$19.99
|
|
|
Service Code
|
CPT 82108
|
| Hospital Charge Code |
900911262
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$14.99 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.73
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.53
|
| Rate for Payer: Heritage Provider Network Senior |
$13.53
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Multiplan Commercial |
$14.99
|
|
|
HC SOM ALUMINUM
|
Facility
|
OP
|
$19.99
|
|
|
Service Code
|
CPT 82108
|
| Hospital Charge Code |
900911262
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$213.29 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$74.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.73
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$38.22
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$28.03
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$25.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$213.29
|
| Rate for Payer: Blue Shield of California Commercial |
$199.00
|
| Rate for Payer: Blue Shield of California EPN |
$155.57
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$12.99
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$38.22
|
| Rate for Payer: Dignity Health Medi-Cal |
$28.03
|
| Rate for Payer: Dignity Health Senior |
$25.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$12.99
|
| Rate for Payer: EPIC Health Plan Medicare |
$25.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.37
|
| Rate for Payer: Heritage Provider Network Senior |
$12.37
|
| Rate for Payer: Humana Medicare |
$25.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$30.76
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$25.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$48.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$30.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$32.10
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$32.10
|
| Rate for Payer: Multiplan Commercial |
$14.99
|
| Rate for Payer: TriValley Medical Group Commercial |
$25.48
|
| Rate for Payer: TriValley Medical Group Senior |
$25.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$27.52
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$27.52
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$38.22
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$28.03
|
| Rate for Payer: Vantage Medical Group Senior |
$25.48
|
|
|
HC SOM AMEBIASIS AB TITER
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
900911754
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.31
|
| Rate for Payer: Heritage Provider Network Senior |
$20.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
HC SOM AMEBIASIS AB TITER
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 86753
|
| Hospital Charge Code |
900911754
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$102.67 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.05
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.63
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.39
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$102.67
|
| Rate for Payer: Blue Shield of California Commercial |
$96.82
|
| Rate for Payer: Blue Shield of California EPN |
$75.69
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.63
|
| Rate for Payer: Dignity Health Senior |
$12.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.39
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.57
|
| Rate for Payer: Heritage Provider Network Senior |
$18.57
|
| Rate for Payer: Humana Medicare |
$12.39
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$17.18
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.39
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.61
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.39
|
| Rate for Payer: TriValley Medical Group Senior |
$12.39
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.63
|
| Rate for Payer: Vantage Medical Group Senior |
$12.39
|
|
|
HC SOM AMINO ACID QUANT UR RANDOM
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 82139
|
| Hospital Charge Code |
900911210
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$16.87 |
| Max. Negotiated Rate |
$140.54 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$49.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$140.54
|
| Rate for Payer: Blue Shield of California Commercial |
$131.76
|
| Rate for Payer: Blue Shield of California EPN |
$103.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.56
|
| Rate for Payer: Dignity Health Senior |
$16.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.90
|
| Rate for Payer: Heritage Provider Network Senior |
$61.90
|
| Rate for Payer: Humana Medicare |
$16.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$32.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.26
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.87
|
| Rate for Payer: TriValley Medical Group Senior |
$16.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.56
|
| Rate for Payer: Vantage Medical Group Senior |
$16.87
|
|
|
HC SOM AMINO ACID QUANT UR RANDOM
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 82139
|
| Hospital Charge Code |
900911210
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.70
|
| Rate for Payer: Cash Price |
$45.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$67.70
|
| Rate for Payer: Heritage Provider Network Senior |
$67.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.10
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
|
|
HC SOM AMINO ACIDS PLASMA
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT 82139
|
| Hospital Charge Code |
900910486
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.58 |
| Max. Negotiated Rate |
$140.54 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$49.08
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$140.54
|
| Rate for Payer: Blue Shield of California Commercial |
$131.76
|
| Rate for Payer: Blue Shield of California EPN |
$103.00
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.56
|
| Rate for Payer: Dignity Health Senior |
$16.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.42
|
| Rate for Payer: Heritage Provider Network Senior |
$46.42
|
| Rate for Payer: Humana Medicare |
$16.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$32.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.26
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.87
|
| Rate for Payer: TriValley Medical Group Senior |
$16.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.22
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.22
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.56
|
| Rate for Payer: Vantage Medical Group Senior |
$16.87
|
|
|
HC SOM AMINO ACIDS PLASMA
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT 82139
|
| Hospital Charge Code |
900910486
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$13.58 |
| Max. Negotiated Rate |
$56.25 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.52
|
| Rate for Payer: Cash Price |
$33.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.78
|
| Rate for Payer: Heritage Provider Network Senior |
$50.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
|
|
HC SOM AMIODARONE
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 80151
|
| Hospital Charge Code |
900911286
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$104.20 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.53
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$55.22
|
| Rate for Payer: Blue Shield of California Commercial |
$104.20
|
| Rate for Payer: Blue Shield of California EPN |
$81.46
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.50
|
| Rate for Payer: Dignity Health Senior |
$18.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.57
|
| Rate for Payer: Heritage Provider Network Senior |
$18.57
|
| Rate for Payer: Humana Medicare |
$18.64
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.26
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.42
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.00
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.49
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.64
|
| Rate for Payer: TriValley Medical Group Senior |
$18.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.50
|
| Rate for Payer: Vantage Medical Group Senior |
$18.64
|
|
|
HC SOM AMIODARONE
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 80151
|
| Hospital Charge Code |
900911286
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.31
|
| Rate for Payer: Heritage Provider Network Senior |
$20.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
HC SOM AMITRIPTYLINE LEVEL
|
Facility
|
IP
|
$34.77
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
900912504
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.29 |
| Max. Negotiated Rate |
$26.08 |
| Rate for Payer: Adventist Health Commercial |
$6.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.89
|
| Rate for Payer: Cash Price |
$15.65
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.54
|
| Rate for Payer: Heritage Provider Network Senior |
$23.54
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.69
|
| Rate for Payer: Multiplan Commercial |
$26.08
|
|
|
HC SOM AMITRIPTYLINE LEVEL
|
Facility
|
OP
|
$34.77
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
900912504
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$143.70 |
| Rate for Payer: Adventist Health Commercial |
$6.95
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$23.89
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$26.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$143.70
|
| Rate for Payer: Cash Price |
$15.65
|
| Rate for Payer: Cash Price |
$15.65
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$29.55
|
| Rate for Payer: Dignity Health Senior |
$29.55
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.52
|
| Rate for Payer: Heritage Provider Network Senior |
$21.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$16.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.69
|
| Rate for Payer: Multiplan Commercial |
$26.08
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$29.55
|
| Rate for Payer: Vantage Medical Group Senior |
$29.55
|
|
|
HC SOM AMOBARBITAL
|
Facility
|
IP
|
$272.21
|
|
|
Service Code
|
CPT 80345
|
| Hospital Charge Code |
900910550
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$49.27 |
| Max. Negotiated Rate |
$204.16 |
| Rate for Payer: Adventist Health Commercial |
$54.44
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$187.01
|
| Rate for Payer: Cash Price |
$122.49
|
| Rate for Payer: Heritage Provider Network Commercial |
$184.29
|
| Rate for Payer: Heritage Provider Network Senior |
$184.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.05
|
| Rate for Payer: Multiplan Commercial |
$204.16
|
|
|
HC SOM AMOBARBITAL
|
Facility
|
OP
|
$272.21
|
|
|
Service Code
|
CPT 80345
|
| Hospital Charge Code |
900910550
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$231.38 |
| Rate for Payer: Adventist Health Commercial |
$54.44
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$187.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$231.38
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$149.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$204.16
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$91.96
|
| Rate for Payer: Cash Price |
$122.49
|
| Rate for Payer: Cash Price |
$122.49
|
| Rate for Payer: Cigna of CA HMO/PPO |
$176.94
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$231.38
|
| Rate for Payer: Dignity Health Medi-Cal |
$231.38
|
| Rate for Payer: Dignity Health Senior |
$231.38
|
| Rate for Payer: EPIC Health Plan Commercial |
$176.94
|
| Rate for Payer: Heritage Provider Network Commercial |
$168.50
|
| Rate for Payer: Heritage Provider Network Senior |
$168.50
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$131.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$49.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$68.05
|
| Rate for Payer: Multiplan Commercial |
$204.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$231.38
|
| Rate for Payer: Vantage Medical Group Senior |
$231.38
|
|
|
HC SOM AMOXAPINE
|
Facility
|
IP
|
$65.46
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
900911071
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$11.85 |
| Max. Negotiated Rate |
$49.10 |
| Rate for Payer: Adventist Health Commercial |
$13.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$44.97
|
| Rate for Payer: Cash Price |
$29.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$44.32
|
| Rate for Payer: Heritage Provider Network Senior |
$44.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.36
|
| Rate for Payer: Multiplan Commercial |
$49.10
|
|
|
HC SOM AMOXAPINE
|
Facility
|
OP
|
$65.46
|
|
|
Service Code
|
CPT 80335
|
| Hospital Charge Code |
900911071
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$143.70 |
| Rate for Payer: Adventist Health Commercial |
$13.09
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$44.97
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$55.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$36.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.10
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$143.70
|
| Rate for Payer: Cash Price |
$29.46
|
| Rate for Payer: Cash Price |
$29.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$42.55
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$55.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$55.64
|
| Rate for Payer: Dignity Health Senior |
$55.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$42.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$40.52
|
| Rate for Payer: Heritage Provider Network Senior |
$40.52
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$11.85
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.36
|
| Rate for Payer: Multiplan Commercial |
$49.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$55.64
|
| Rate for Payer: Vantage Medical Group Senior |
$55.64
|
|
|
HC SOM AMPHETAMINE QUANT
|
Facility
|
OP
|
$20.78
|
|
|
Service Code
|
CPT 80325
|
| Hospital Charge Code |
900910720
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$137.27 |
| Rate for Payer: Adventist Health Commercial |
$4.16
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.66
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$11.43
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.58
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$137.27
|
| Rate for Payer: Cash Price |
$9.35
|
| Rate for Payer: Cash Price |
$9.35
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.51
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.66
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.66
|
| Rate for Payer: Dignity Health Senior |
$17.66
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.86
|
| Rate for Payer: Heritage Provider Network Senior |
$12.86
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.20
|
| Rate for Payer: Multiplan Commercial |
$15.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.66
|
| Rate for Payer: Vantage Medical Group Senior |
$17.66
|
|
|
HC SOM AMPHETAMINE QUANT
|
Facility
|
IP
|
$20.78
|
|
|
Service Code
|
CPT 80325
|
| Hospital Charge Code |
900910720
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.76 |
| Max. Negotiated Rate |
$15.58 |
| Rate for Payer: Adventist Health Commercial |
$4.16
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$14.28
|
| Rate for Payer: Cash Price |
$9.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.07
|
| Rate for Payer: Heritage Provider Network Senior |
$14.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.20
|
| Rate for Payer: Multiplan Commercial |
$15.58
|
|
|
HC SOM AMYLASE ISOENZYMES
|
Facility
|
OP
|
$25.00
|
|
|
Service Code
|
CPT 82150
|
| Hospital Charge Code |
900910241
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$54.32 |
| Rate for Payer: Adventist Health Commercial |
$5.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$18.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.18
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$9.72
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$7.13
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$6.48
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$54.32
|
| Rate for Payer: Blue Shield of California Commercial |
$50.65
|
| Rate for Payer: Blue Shield of California EPN |
$39.59
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$16.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$9.72
|
| Rate for Payer: Dignity Health Medi-Cal |
$7.13
|
| Rate for Payer: Dignity Health Senior |
$6.48
|
| Rate for Payer: EPIC Health Plan Commercial |
$16.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$6.48
|
| Rate for Payer: Heritage Provider Network Commercial |
$15.48
|
| Rate for Payer: Heritage Provider Network Senior |
$15.48
|
| Rate for Payer: Humana Medicare |
$6.48
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$6.48
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$12.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$7.65
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$8.16
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$8.16
|
| Rate for Payer: Multiplan Commercial |
$18.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$6.48
|
| Rate for Payer: TriValley Medical Group Senior |
$6.48
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$7.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$7.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$9.72
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$7.13
|
| Rate for Payer: Vantage Medical Group Senior |
$6.48
|
|
|
HC SOM AMYLASE ISOENZYMES
|
Facility
|
IP
|
$25.00
|
|
|
Service Code
|
CPT 82150
|
| Hospital Charge Code |
900910241
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.52 |
| Max. Negotiated Rate |
$18.75 |
| Rate for Payer: Adventist Health Commercial |
$5.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$17.18
|
| Rate for Payer: Cash Price |
$11.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.92
|
| Rate for Payer: Heritage Provider Network Senior |
$16.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.25
|
| Rate for Payer: Multiplan Commercial |
$18.75
|
|
|
HC SOM ANDROSTENEDIONE
|
Facility
|
IP
|
$24.00
|
|
|
Service Code
|
CPT 82157
|
| Hospital Charge Code |
900911011
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$18.00 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.49
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$16.25
|
| Rate for Payer: Heritage Provider Network Senior |
$16.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
|
|
HC SOM ANDROSTENEDIONE
|
Facility
|
OP
|
$24.00
|
|
|
Service Code
|
CPT 82157
|
| Hospital Charge Code |
900911011
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$4.34 |
| Max. Negotiated Rate |
$244.96 |
| Rate for Payer: Adventist Health Commercial |
$4.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$85.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$16.49
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$43.92
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$32.21
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$29.28
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$244.96
|
| Rate for Payer: Blue Shield of California Commercial |
$228.63
|
| Rate for Payer: Blue Shield of California EPN |
$178.73
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cash Price |
$10.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$15.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$43.92
|
| Rate for Payer: Dignity Health Medi-Cal |
$32.21
|
| Rate for Payer: Dignity Health Senior |
$29.28
|
| Rate for Payer: EPIC Health Plan Commercial |
$15.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$29.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.86
|
| Rate for Payer: Heritage Provider Network Senior |
$14.86
|
| Rate for Payer: Humana Medicare |
$29.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$40.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$29.28
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$55.63
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$4.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$34.55
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$6.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$36.89
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$36.89
|
| Rate for Payer: Multiplan Commercial |
$18.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$29.28
|
| Rate for Payer: TriValley Medical Group Senior |
$29.28
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$31.62
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$31.62
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$43.92
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$32.21
|
| Rate for Payer: Vantage Medical Group Senior |
$29.28
|
|
|
HC SOM ANGIOTENSIN 1 CONVERTING ENZYM
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT 82164
|
| Hospital Charge Code |
900911119
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$122.17 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$42.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.90
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.60
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$122.17
|
| Rate for Payer: Blue Shield of California Commercial |
$113.98
|
| Rate for Payer: Blue Shield of California EPN |
$89.10
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cash Price |
$5.40
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.90
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.06
|
| Rate for Payer: Dignity Health Senior |
$14.60
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.60
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.43
|
| Rate for Payer: Humana Medicare |
$14.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20.25
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.60
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$27.74
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.23
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.40
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.40
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.60
|
| Rate for Payer: TriValley Medical Group Senior |
$14.60
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.90
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.06
|
| Rate for Payer: Vantage Medical Group Senior |
$14.60
|
|
