|
HC SOM ESTRONE
|
Facility
|
IP
|
$20.00
|
|
|
Service Code
|
CPT 82679
|
| Hospital Charge Code |
900911482
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$15.00 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.54
|
| Rate for Payer: Heritage Provider Network Senior |
$13.54
|
| 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 |
$15.00
|
|
|
HC SOM ESTRONE
|
Facility
|
OP
|
$20.00
|
|
|
Service Code
|
CPT 82679
|
| Hospital Charge Code |
900911482
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$3.62 |
| Max. Negotiated Rate |
$208.89 |
| Rate for Payer: Adventist Health Commercial |
$4.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$72.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$37.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$24.95
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$208.89
|
| Rate for Payer: Blue Shield of California Commercial |
$194.98
|
| Rate for Payer: Blue Shield of California EPN |
$152.43
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cash Price |
$9.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$13.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$37.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$27.44
|
| Rate for Payer: Dignity Health Senior |
$24.95
|
| Rate for Payer: EPIC Health Plan Commercial |
$13.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$24.95
|
| Rate for Payer: Heritage Provider Network Commercial |
$12.38
|
| Rate for Payer: Heritage Provider Network Senior |
$12.38
|
| Rate for Payer: Humana Medicare |
$24.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$34.60
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$24.95
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$47.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$29.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$31.44
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$31.44
|
| Rate for Payer: Multiplan Commercial |
$15.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$24.95
|
| Rate for Payer: TriValley Medical Group Senior |
$24.95
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$26.95
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$26.95
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$37.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$27.44
|
| Rate for Payer: Vantage Medical Group Senior |
$24.95
|
|
|
HC SOM ETHANOL, U
|
Facility
|
OP
|
$49.90
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
900912919
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$0.02 |
| Max. Negotiated Rate |
$86.78 |
| Rate for Payer: Adventist Health Commercial |
$9.98
|
| Rate for Payer: Aetna of CA Gatekeeper |
$0.02
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.28
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$42.42
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$27.44
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$37.42
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$86.78
|
| Rate for Payer: Cash Price |
$22.46
|
| Rate for Payer: Cash Price |
$22.46
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.44
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$42.42
|
| Rate for Payer: Dignity Health Medi-Cal |
$42.42
|
| Rate for Payer: Dignity Health Senior |
$42.42
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.44
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.89
|
| Rate for Payer: Heritage Provider Network Senior |
$30.89
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$37.42
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$42.42
|
| Rate for Payer: Vantage Medical Group Senior |
$42.42
|
|
|
HC SOM ETHANOL, U
|
Facility
|
IP
|
$49.90
|
|
|
Service Code
|
CPT 80320
|
| Hospital Charge Code |
900912919
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.03 |
| Max. Negotiated Rate |
$37.42 |
| Rate for Payer: Adventist Health Commercial |
$9.98
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.28
|
| Rate for Payer: Cash Price |
$22.46
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.78
|
| Rate for Payer: Heritage Provider Network Senior |
$33.78
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.03
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.48
|
| Rate for Payer: Multiplan Commercial |
$37.42
|
|
|
HC SOM ETHCHLORVINYL (PLACIDYL)
|
Facility
|
IP
|
$45.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910427
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$33.75 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.92
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.46
|
| Rate for Payer: Heritage Provider Network Senior |
$30.46
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
|
|
HC SOM ETHCHLORVINYL (PLACIDYL)
|
Facility
|
OP
|
$45.00
|
|
|
Service Code
|
CPT 80307
|
| Hospital Charge Code |
900910427
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$8.14 |
| Max. Negotiated Rate |
$515.78 |
| Rate for Payer: Adventist Health Commercial |
$9.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$165.01
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$30.92
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$62.14
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$515.78
|
| Rate for Payer: Blue Shield of California Commercial |
$446.14
|
| Rate for Payer: Blue Shield of California EPN |
$348.77
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cash Price |
$20.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$29.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$93.21
|
| Rate for Payer: Dignity Health Medi-Cal |
$68.35
|
| Rate for Payer: Dignity Health Senior |
$62.14
|
| Rate for Payer: EPIC Health Plan Commercial |
$29.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$62.14
|
| Rate for Payer: Heritage Provider Network Commercial |
$27.86
|
| Rate for Payer: Heritage Provider Network Senior |
$27.86
|
| Rate for Payer: Humana Medicare |
$62.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$67.86
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$62.14
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$118.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$8.14
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$73.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$11.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$78.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$78.30
|
| Rate for Payer: Multiplan Commercial |
$33.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$62.14
|
| Rate for Payer: TriValley Medical Group Senior |
$62.14
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$67.12
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$67.12
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$93.21
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$68.35
|
| Rate for Payer: Vantage Medical Group Senior |
$62.14
|
|
|
HC SOM ETHOSUXIMIDE (ZARONTIN)
|
Facility
|
OP
|
$35.00
|
|
|
Service Code
|
CPT 80168
|
| Hospital Charge Code |
900910338
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$136.76 |
| Rate for Payer: Adventist Health Commercial |
$7.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$47.55
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.04
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$24.51
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$17.97
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.34
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.76
|
| Rate for Payer: Blue Shield of California Commercial |
$127.62
|
| Rate for Payer: Blue Shield of California EPN |
$99.77
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Cigna of CA HMO/PPO |
$22.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$24.51
|
| Rate for Payer: Dignity Health Medi-Cal |
$17.97
|
| Rate for Payer: Dignity Health Senior |
$16.34
|
| Rate for Payer: EPIC Health Plan Commercial |
$22.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.34
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.66
|
| Rate for Payer: Heritage Provider Network Senior |
$21.66
|
| Rate for Payer: Humana Medicare |
$16.34
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.34
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.34
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.28
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$20.59
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$20.59
|
| Rate for Payer: Multiplan Commercial |
$26.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.34
|
| Rate for Payer: TriValley Medical Group Senior |
$16.34
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$17.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$17.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$24.51
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$17.97
|
| Rate for Payer: Vantage Medical Group Senior |
$16.34
|
|
|
HC SOM ETHOSUXIMIDE (ZARONTIN)
|
Facility
|
IP
|
$35.00
|
|
|
Service Code
|
CPT 80168
|
| Hospital Charge Code |
900910338
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$6.34 |
| Max. Negotiated Rate |
$26.25 |
| Rate for Payer: Adventist Health Commercial |
$7.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$24.04
|
| Rate for Payer: Cash Price |
$15.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.70
|
| Rate for Payer: Heritage Provider Network Senior |
$23.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$8.75
|
| Rate for Payer: Multiplan Commercial |
$26.25
|
|
|
HC SOM EVEROLIMUS B
|
Facility
|
OP
|
$41.42
|
|
|
Service Code
|
CPT 80169
|
| Hospital Charge Code |
900913810
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$104.70 |
| Rate for Payer: Adventist Health Commercial |
$8.28
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.72
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.46
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$20.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$69.09
|
| Rate for Payer: Blue Shield of California Commercial |
$104.70
|
| Rate for Payer: Blue Shield of California EPN |
$81.85
|
| Rate for Payer: Cash Price |
$18.64
|
| Rate for Payer: Cash Price |
$18.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$26.92
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$20.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.10
|
| Rate for Payer: Dignity Health Senior |
$13.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$26.92
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.64
|
| Rate for Payer: Heritage Provider Network Senior |
$25.64
|
| Rate for Payer: Humana Medicare |
$13.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.50
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.36
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.30
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.30
|
| Rate for Payer: Multiplan Commercial |
$31.06
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.73
|
| Rate for Payer: TriValley Medical Group Senior |
$13.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.83
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.83
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$20.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.10
|
| Rate for Payer: Vantage Medical Group Senior |
$13.73
|
|
|
HC SOM EVEROLIMUS B
|
Facility
|
IP
|
$41.42
|
|
|
Service Code
|
CPT 80169
|
| Hospital Charge Code |
900913810
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$7.50 |
| Max. Negotiated Rate |
$31.06 |
| Rate for Payer: Adventist Health Commercial |
$8.28
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$28.46
|
| Rate for Payer: Cash Price |
$18.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$28.04
|
| Rate for Payer: Heritage Provider Network Senior |
$28.04
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$7.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$10.36
|
| Rate for Payer: Multiplan Commercial |
$31.06
|
|
|
HC SOM FANBF 86038
|
Facility
|
IP
|
$75.00
|
|
|
Service Code
|
CPT 86038
|
| Hospital Charge Code |
900914925
|
|
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 FANBF 86038
|
Facility
|
OP
|
$75.00
|
|
|
Service Code
|
CPT 86038
|
| Hospital Charge Code |
900914925
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.09 |
| Max. Negotiated Rate |
$101.15 |
| Rate for Payer: Adventist Health Commercial |
$15.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$35.17
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.14
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.30
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.15
|
| Rate for Payer: Blue Shield of California Commercial |
$94.42
|
| Rate for Payer: Blue Shield of California EPN |
$73.81
|
| 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 |
$18.14
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.30
|
| Rate for Payer: Dignity Health Senior |
$12.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.42
|
| Rate for Payer: Heritage Provider Network Senior |
$46.42
|
| Rate for Payer: Humana Medicare |
$12.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.58
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.23
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.23
|
| Rate for Payer: Multiplan Commercial |
$56.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.09
|
| Rate for Payer: TriValley Medical Group Senior |
$12.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.06
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.06
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.14
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.30
|
| Rate for Payer: Vantage Medical Group Senior |
$12.09
|
|
|
HC SOM FAP KNOWN MUT EXTRACT
|
Facility
|
IP
|
$318.21
|
|
|
Service Code
|
CPT 81202
|
| Hospital Charge Code |
900914620
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$238.66 |
| Rate for Payer: Adventist Health Commercial |
$63.64
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$218.61
|
| Rate for Payer: Cash Price |
$143.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$215.43
|
| Rate for Payer: Heritage Provider Network Senior |
$215.43
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.60
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.55
|
| Rate for Payer: Multiplan Commercial |
$238.66
|
|
|
HC SOM FAP KNOWN MUT EXTRACT
|
Facility
|
OP
|
$318.21
|
|
|
Service Code
|
CPT 81202
|
| Hospital Charge Code |
900914620
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$57.60 |
| Max. Negotiated Rate |
$532.00 |
| Rate for Payer: Adventist Health Commercial |
$63.64
|
| Rate for Payer: Aetna of CA Gatekeeper |
$102.84
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$218.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$420.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$308.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$280.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$109.66
|
| Rate for Payer: Blue Shield of California Commercial |
$197.61
|
| Rate for Payer: Blue Shield of California EPN |
$186.79
|
| Rate for Payer: Cash Price |
$143.19
|
| Rate for Payer: Cash Price |
$143.19
|
| Rate for Payer: Cigna of CA HMO/PPO |
$206.84
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$420.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$308.00
|
| Rate for Payer: Dignity Health Senior |
$280.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$206.84
|
| Rate for Payer: EPIC Health Plan Medicare |
$280.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$196.97
|
| Rate for Payer: Heritage Provider Network Senior |
$196.97
|
| Rate for Payer: Humana Medicare |
$280.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$117.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$280.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$532.00
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$57.60
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$330.40
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$79.55
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$352.80
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$352.80
|
| Rate for Payer: Multiplan Commercial |
$238.66
|
| Rate for Payer: TriValley Medical Group Commercial |
$280.00
|
| Rate for Payer: TriValley Medical Group Senior |
$280.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$302.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$302.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$420.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$308.00
|
| Rate for Payer: Vantage Medical Group Senior |
$280.00
|
|
|
HC SOM FASP 86606
|
Facility
|
OP
|
$77.80
|
|
|
Service Code
|
CPT 86606
|
| Hospital Charge Code |
900914727
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$14.08 |
| Max. Negotiated Rate |
$126.00 |
| Rate for Payer: Adventist Health Commercial |
$15.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$43.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$53.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$22.58
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.56
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$15.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$126.00
|
| Rate for Payer: Blue Shield of California Commercial |
$117.56
|
| Rate for Payer: Blue Shield of California EPN |
$91.90
|
| Rate for Payer: Cash Price |
$35.01
|
| Rate for Payer: Cash Price |
$35.01
|
| Rate for Payer: Cigna of CA HMO/PPO |
$50.57
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$22.58
|
| Rate for Payer: Dignity Health Medi-Cal |
$16.56
|
| Rate for Payer: Dignity Health Senior |
$15.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$50.57
|
| Rate for Payer: EPIC Health Plan Medicare |
$15.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$48.16
|
| Rate for Payer: Heritage Provider Network Senior |
$48.16
|
| Rate for Payer: Humana Medicare |
$15.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$20.87
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$15.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$28.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.08
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$17.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.45
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$18.96
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$18.96
|
| Rate for Payer: Multiplan Commercial |
$58.35
|
| Rate for Payer: TriValley Medical Group Commercial |
$15.05
|
| Rate for Payer: TriValley Medical Group Senior |
$15.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$16.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$16.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$22.58
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$16.56
|
| Rate for Payer: Vantage Medical Group Senior |
$15.05
|
|
|
HC SOM FASP 86606
|
Facility
|
IP
|
$77.80
|
|
|
Service Code
|
CPT 86606
|
| Hospital Charge Code |
900914727
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$14.08 |
| Max. Negotiated Rate |
$58.35 |
| Rate for Payer: Adventist Health Commercial |
$15.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$53.45
|
| Rate for Payer: Cash Price |
$35.01
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.67
|
| Rate for Payer: Heritage Provider Network Senior |
$52.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$14.08
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$19.45
|
| Rate for Payer: Multiplan Commercial |
$58.35
|
|
|
HC SOM FAT FECAL QUANT
|
Facility
|
OP
|
$28.02
|
|
|
Service Code
|
CPT 82710
|
| Hospital Charge Code |
900911139
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$140.65 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$48.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.25
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.80
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$140.65
|
| Rate for Payer: Blue Shield of California Commercial |
$131.20
|
| Rate for Payer: Blue Shield of California EPN |
$102.56
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Cigna of CA HMO/PPO |
$18.21
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.48
|
| Rate for Payer: Dignity Health Senior |
$16.80
|
| Rate for Payer: EPIC Health Plan Commercial |
$18.21
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$17.34
|
| Rate for Payer: Heritage Provider Network Senior |
$17.34
|
| Rate for Payer: Humana Medicare |
$16.80
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.31
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.80
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$31.92
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.07
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.17
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.17
|
| Rate for Payer: Multiplan Commercial |
$21.02
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.80
|
| Rate for Payer: TriValley Medical Group Senior |
$16.80
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.48
|
| Rate for Payer: Vantage Medical Group Senior |
$16.80
|
|
|
HC SOM FAT FECAL QUANT
|
Facility
|
IP
|
$28.02
|
|
|
Service Code
|
CPT 82710
|
| Hospital Charge Code |
900911139
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.07 |
| Max. Negotiated Rate |
$21.02 |
| Rate for Payer: Adventist Health Commercial |
$5.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$19.25
|
| Rate for Payer: Cash Price |
$12.61
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.97
|
| Rate for Payer: Heritage Provider Network Senior |
$18.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.07
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.00
|
| Rate for Payer: Multiplan Commercial |
$21.02
|
|
|
HC SOM FATTY ACIDS FREE
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
900910286
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$36.20 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Adventist Health Commercial |
$40.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$137.40
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$135.40
|
| Rate for Payer: Heritage Provider Network Senior |
$135.40
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.00
|
| Rate for Payer: Multiplan Commercial |
$150.00
|
|
|
HC SOM FATTY ACIDS FREE
|
Facility
|
OP
|
$200.00
|
|
|
Service Code
|
CPT 82725
|
| Hospital Charge Code |
900910286
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.77 |
| Max. Negotiated Rate |
$150.00 |
| Rate for Payer: Adventist Health Commercial |
$40.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.75
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$137.40
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$28.16
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.65
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.77
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$111.46
|
| Rate for Payer: Blue Shield of California Commercial |
$103.97
|
| Rate for Payer: Blue Shield of California EPN |
$81.28
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cash Price |
$90.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$130.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$28.16
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.65
|
| Rate for Payer: Dignity Health Senior |
$18.77
|
| Rate for Payer: EPIC Health Plan Commercial |
$130.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$123.80
|
| Rate for Payer: Heritage Provider Network Senior |
$123.80
|
| Rate for Payer: Humana Medicare |
$18.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.77
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$36.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$50.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.65
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.65
|
| Rate for Payer: Multiplan Commercial |
$150.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.77
|
| Rate for Payer: TriValley Medical Group Senior |
$18.77
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$28.16
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.65
|
| Rate for Payer: Vantage Medical Group Senior |
$18.77
|
|
|
HC SOM FATTY ACIDS PEROXISOMAL
|
Facility
|
IP
|
$150.00
|
|
|
Service Code
|
CPT 82726
|
| Hospital Charge Code |
900911471
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$27.15 |
| Max. Negotiated Rate |
$112.50 |
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.05
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$101.55
|
| Rate for Payer: Heritage Provider Network Senior |
$101.55
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.15
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.50
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
|
|
HC SOM FATTY ACIDS PEROXISOMAL
|
Facility
|
OP
|
$150.00
|
|
|
Service Code
|
CPT 82726
|
| Hospital Charge Code |
900911471
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$19.75 |
| Max. Negotiated Rate |
$150.51 |
| Rate for Payer: Adventist Health Commercial |
$30.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$52.54
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$103.05
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.62
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.72
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.75
|
| 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 |
$67.50
|
| Rate for Payer: Cash Price |
$67.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$97.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.62
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.72
|
| Rate for Payer: Dignity Health Senior |
$19.75
|
| Rate for Payer: EPIC Health Plan Commercial |
$97.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.75
|
| Rate for Payer: Heritage Provider Network Commercial |
$92.85
|
| Rate for Payer: Heritage Provider Network Senior |
$92.85
|
| Rate for Payer: Humana Medicare |
$19.75
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.04
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.75
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$37.52
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$27.15
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$37.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.88
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.88
|
| Rate for Payer: Multiplan Commercial |
$112.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.75
|
| Rate for Payer: TriValley Medical Group Senior |
$19.75
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.34
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.34
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.62
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.72
|
| Rate for Payer: Vantage Medical Group Senior |
$19.75
|
|
|
HC SOM FBIOT 84591
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 84591
|
| Hospital Charge Code |
900914760
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$17.06 |
| Max. Negotiated Rate |
$96.98 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$33.74
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$68.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.59
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.77
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.06
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$96.98
|
| Rate for Payer: Blue Shield of California Commercial |
$90.56
|
| Rate for Payer: Blue Shield of California EPN |
$70.79
|
| 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 |
$25.59
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.77
|
| Rate for Payer: Dignity Health Senior |
$17.06
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.06
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.90
|
| Rate for Payer: Heritage Provider Network Senior |
$61.90
|
| Rate for Payer: Humana Medicare |
$17.06
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$32.41
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$18.10
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$25.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.50
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.06
|
| Rate for Payer: TriValley Medical Group Senior |
$17.06
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.42
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.42
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.59
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.77
|
| Rate for Payer: Vantage Medical Group Senior |
$17.06
|
|
|
HC SOM FBIOT 84591
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 84591
|
| Hospital Charge Code |
900914760
|
|
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 FBP1 88273
|
Facility
|
IP
|
$84.86
|
|
|
Service Code
|
CPT 88273
|
| Hospital Charge Code |
900914874
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$15.36 |
| Max. Negotiated Rate |
$63.64 |
| Rate for Payer: Adventist Health Commercial |
$16.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.30
|
| Rate for Payer: Cash Price |
$38.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.45
|
| Rate for Payer: Heritage Provider Network Senior |
$57.45
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.36
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.22
|
| Rate for Payer: Multiplan Commercial |
$63.64
|
|
