|
HC SOM FHSI 86695
|
Facility
|
IP
|
$37.37
|
|
|
Service Code
|
CPT 86695
|
| Hospital Charge Code |
900914756
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$28.03 |
| Rate for Payer: Adventist Health Commercial |
$7.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.67
|
| Rate for Payer: Cash Price |
$16.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.30
|
| Rate for Payer: Heritage Provider Network Senior |
$25.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$28.03
|
|
|
HC SOM FHSI 86695
|
Facility
|
OP
|
$37.37
|
|
|
Service Code
|
CPT 86695
|
| Hospital Charge Code |
900914756
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$110.39 |
| Rate for Payer: Adventist Health Commercial |
$7.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$38.38
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.78
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.19
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.39
|
| Rate for Payer: Blue Shield of California Commercial |
$103.02
|
| Rate for Payer: Blue Shield of California EPN |
$80.54
|
| Rate for Payer: Cash Price |
$16.82
|
| Rate for Payer: Cash Price |
$16.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.78
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.51
|
| Rate for Payer: Dignity Health Senior |
$13.19
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.29
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.19
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.13
|
| Rate for Payer: Heritage Provider Network Senior |
$23.13
|
| Rate for Payer: Humana Medicare |
$13.19
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.19
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$25.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.56
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.62
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.62
|
| Rate for Payer: Multiplan Commercial |
$28.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.19
|
| Rate for Payer: TriValley Medical Group Senior |
$13.19
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.24
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.24
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.78
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.51
|
| Rate for Payer: Vantage Medical Group Senior |
$13.19
|
|
|
HC SOM FHSII 86696
|
Facility
|
OP
|
$37.37
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
900914757
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$161.90 |
| Rate for Payer: Adventist Health Commercial |
$7.47
|
| Rate for Payer: Aetna of CA Gatekeeper |
$56.31
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$21.28
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$19.35
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.90
|
| Rate for Payer: Blue Shield of California Commercial |
$151.21
|
| Rate for Payer: Blue Shield of California EPN |
$118.21
|
| Rate for Payer: Cash Price |
$16.82
|
| Rate for Payer: Cash Price |
$16.82
|
| Rate for Payer: Cigna of CA HMO/PPO |
$24.29
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$29.02
|
| Rate for Payer: Dignity Health Medi-Cal |
$21.28
|
| Rate for Payer: Dignity Health Senior |
$19.35
|
| Rate for Payer: EPIC Health Plan Commercial |
$24.29
|
| Rate for Payer: EPIC Health Plan Medicare |
$19.35
|
| Rate for Payer: Heritage Provider Network Commercial |
$23.13
|
| Rate for Payer: Heritage Provider Network Senior |
$23.13
|
| Rate for Payer: Humana Medicare |
$19.35
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$19.35
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$36.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.76
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$22.83
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$24.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$24.38
|
| Rate for Payer: Multiplan Commercial |
$28.03
|
| Rate for Payer: TriValley Medical Group Commercial |
$19.35
|
| Rate for Payer: TriValley Medical Group Senior |
$19.35
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$29.02
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$21.28
|
| Rate for Payer: Vantage Medical Group Senior |
$19.35
|
|
|
HC SOM FHSII 86696
|
Facility
|
IP
|
$37.37
|
|
|
Service Code
|
CPT 86696
|
| Hospital Charge Code |
900914757
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$6.76 |
| Max. Negotiated Rate |
$28.03 |
| Rate for Payer: Adventist Health Commercial |
$7.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$25.67
|
| Rate for Payer: Cash Price |
$16.82
|
| Rate for Payer: Heritage Provider Network Commercial |
$25.30
|
| Rate for Payer: Heritage Provider Network Senior |
$25.30
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$6.76
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$9.34
|
| Rate for Payer: Multiplan Commercial |
$28.03
|
|
|
HC SOM FHTL 87798A
|
Facility
|
IP
|
$112.81
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900914745
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.42 |
| Max. Negotiated Rate |
$84.61 |
| Rate for Payer: Adventist Health Commercial |
$22.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.50
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.37
|
| Rate for Payer: Heritage Provider Network Senior |
$76.37
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Multiplan Commercial |
$84.61
|
|
|
HC SOM FHTL 87798A
|
Facility
|
OP
|
$112.81
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900914745
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.42 |
| Max. Negotiated Rate |
$284.23 |
| Rate for Payer: Adventist Health Commercial |
$22.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$102.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.50
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$284.23
|
| Rate for Payer: Blue Shield of California Commercial |
$274.13
|
| Rate for Payer: Blue Shield of California EPN |
$214.30
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cash Price |
$50.76
|
| Rate for Payer: Cigna of CA HMO/PPO |
$73.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Senior |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.33
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.83
|
| Rate for Payer: Heritage Provider Network Senior |
$69.83
|
| Rate for Payer: Humana Medicare |
$35.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$47.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$66.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$41.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$44.21
|
| Rate for Payer: Multiplan Commercial |
$84.61
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.09
|
| Rate for Payer: TriValley Medical Group Senior |
$35.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Vantage Medical Group Senior |
$35.09
|
|
|
HC SOM FHTL 87798B
|
Facility
|
OP
|
$112.82
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900914746
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.42 |
| Max. Negotiated Rate |
$284.23 |
| Rate for Payer: Adventist Health Commercial |
$22.56
|
| Rate for Payer: Aetna of CA Gatekeeper |
$102.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.51
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.64
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$35.09
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$284.23
|
| Rate for Payer: Blue Shield of California Commercial |
$274.13
|
| Rate for Payer: Blue Shield of California EPN |
$214.30
|
| Rate for Payer: Cash Price |
$50.77
|
| Rate for Payer: Cash Price |
$50.77
|
| Rate for Payer: Cigna of CA HMO/PPO |
$73.33
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.64
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Senior |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$73.33
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$69.84
|
| Rate for Payer: Heritage Provider Network Senior |
$69.84
|
| Rate for Payer: Humana Medicare |
$35.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$47.03
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$66.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.42
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$41.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$44.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$44.21
|
| Rate for Payer: Multiplan Commercial |
$84.62
|
| Rate for Payer: TriValley Medical Group Commercial |
$35.09
|
| Rate for Payer: TriValley Medical Group Senior |
$35.09
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$52.64
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Vantage Medical Group Senior |
$35.09
|
|
|
HC SOM FHTL 87798B
|
Facility
|
IP
|
$112.82
|
|
|
Service Code
|
CPT 87798
|
| Hospital Charge Code |
900914746
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$20.42 |
| Max. Negotiated Rate |
$84.62 |
| Rate for Payer: Adventist Health Commercial |
$22.56
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$77.51
|
| Rate for Payer: Cash Price |
$50.77
|
| Rate for Payer: Heritage Provider Network Commercial |
$76.38
|
| Rate for Payer: Heritage Provider Network Senior |
$76.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$28.20
|
| Rate for Payer: Multiplan Commercial |
$84.62
|
|
|
HC SOM FIAIA 82397
|
Facility
|
OP
|
$186.25
|
|
|
Service Code
|
CPT 82397
|
| Hospital Charge Code |
900915258
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$14.12 |
| Max. Negotiated Rate |
$139.69 |
| Rate for Payer: Adventist Health Commercial |
$37.25
|
| Rate for Payer: Aetna of CA Gatekeeper |
$41.11
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$127.95
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$21.18
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$15.53
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$14.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$118.28
|
| Rate for Payer: Blue Shield of California Commercial |
$110.35
|
| Rate for Payer: Blue Shield of California EPN |
$86.26
|
| Rate for Payer: Cash Price |
$83.81
|
| Rate for Payer: Cash Price |
$83.81
|
| Rate for Payer: Cigna of CA HMO/PPO |
$121.06
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$21.18
|
| Rate for Payer: Dignity Health Medi-Cal |
$15.53
|
| Rate for Payer: Dignity Health Senior |
$14.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$121.06
|
| Rate for Payer: EPIC Health Plan Medicare |
$14.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$115.29
|
| Rate for Payer: Heritage Provider Network Senior |
$115.29
|
| Rate for Payer: Humana Medicare |
$14.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$19.58
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$14.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.71
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$16.66
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.56
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$17.79
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$17.79
|
| Rate for Payer: Multiplan Commercial |
$139.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$14.12
|
| Rate for Payer: TriValley Medical Group Senior |
$14.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.25
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$21.18
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$15.53
|
| Rate for Payer: Vantage Medical Group Senior |
$14.12
|
|
|
HC SOM FIAIA 82397
|
Facility
|
IP
|
$186.25
|
|
|
Service Code
|
CPT 82397
|
| Hospital Charge Code |
900915258
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$33.71 |
| Max. Negotiated Rate |
$139.69 |
| Rate for Payer: Adventist Health Commercial |
$37.25
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$127.95
|
| Rate for Payer: Cash Price |
$83.81
|
| Rate for Payer: Heritage Provider Network Commercial |
$126.09
|
| Rate for Payer: Heritage Provider Network Senior |
$126.09
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$33.71
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$46.56
|
| Rate for Payer: Multiplan Commercial |
$139.69
|
|
|
HC SOM FIBRO CULT FOR GENE TEST
|
Facility
|
IP
|
$194.48
|
|
|
Service Code
|
CPT 88233
|
| Hospital Charge Code |
900915284
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$35.20 |
| Max. Negotiated Rate |
$145.86 |
| Rate for Payer: Adventist Health Commercial |
$38.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$133.61
|
| Rate for Payer: Cash Price |
$87.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$131.66
|
| Rate for Payer: Heritage Provider Network Senior |
$131.66
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.62
|
| Rate for Payer: Multiplan Commercial |
$145.86
|
|
|
HC SOM FIBRO CULT FOR GENE TEST
|
Facility
|
OP
|
$194.48
|
|
|
Service Code
|
CPT 88233
|
| Hospital Charge Code |
900915284
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$35.20 |
| Max. Negotiated Rate |
$1,099.16 |
| Rate for Payer: Adventist Health Commercial |
$38.90
|
| Rate for Payer: Aetna of CA Gatekeeper |
$409.43
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$133.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$211.10
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$154.80
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$140.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$999.95
|
| Rate for Payer: Blue Shield of California Commercial |
$1,099.16
|
| Rate for Payer: Blue Shield of California EPN |
$859.27
|
| Rate for Payer: Cash Price |
$87.52
|
| Rate for Payer: Cash Price |
$87.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$126.41
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$211.10
|
| Rate for Payer: Dignity Health Medi-Cal |
$154.80
|
| Rate for Payer: Dignity Health Senior |
$140.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$126.41
|
| Rate for Payer: EPIC Health Plan Medicare |
$140.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$120.38
|
| Rate for Payer: Heritage Provider Network Senior |
$120.38
|
| Rate for Payer: Humana Medicare |
$140.73
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$195.12
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$140.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$267.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$35.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$166.06
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$48.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$177.32
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$177.32
|
| Rate for Payer: Multiplan Commercial |
$145.86
|
| Rate for Payer: TriValley Medical Group Commercial |
$140.73
|
| Rate for Payer: TriValley Medical Group Senior |
$140.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$151.99
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$151.99
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$211.10
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$154.80
|
| Rate for Payer: Vantage Medical Group Senior |
$140.73
|
|
|
HC SOM FIBRO CULT GENE TEST CRYO
|
Facility
|
OP
|
$13.95
|
|
|
Service Code
|
CPT 88240
|
| Hospital Charge Code |
900915290
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$38.21 |
| Rate for Payer: Adventist Health Commercial |
$2.79
|
| Rate for Payer: Aetna of CA Gatekeeper |
$29.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.58
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$13.07
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$38.21
|
| Rate for Payer: Blue Shield of California Commercial |
$35.83
|
| Rate for Payer: Blue Shield of California EPN |
$28.01
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Cigna of CA HMO/PPO |
$9.07
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.38
|
| Rate for Payer: Dignity Health Senior |
$13.07
|
| Rate for Payer: EPIC Health Plan Commercial |
$9.07
|
| Rate for Payer: EPIC Health Plan Medicare |
$13.07
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.64
|
| Rate for Payer: Heritage Provider Network Senior |
$8.64
|
| Rate for Payer: Humana Medicare |
$13.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$12.46
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$13.07
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$24.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.52
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$15.42
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.47
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.47
|
| Rate for Payer: Multiplan Commercial |
$10.46
|
| Rate for Payer: TriValley Medical Group Commercial |
$13.07
|
| Rate for Payer: TriValley Medical Group Senior |
$13.07
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$14.11
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$14.11
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.38
|
| Rate for Payer: Vantage Medical Group Senior |
$13.07
|
|
|
HC SOM FIBRO CULT GENE TEST CRYO
|
Facility
|
IP
|
$13.95
|
|
|
Service Code
|
CPT 88240
|
| Hospital Charge Code |
900915290
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$2.52 |
| Max. Negotiated Rate |
$10.46 |
| Rate for Payer: Adventist Health Commercial |
$2.79
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$9.58
|
| Rate for Payer: Cash Price |
$6.28
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.44
|
| Rate for Payer: Heritage Provider Network Senior |
$9.44
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.52
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.49
|
| Rate for Payer: Multiplan Commercial |
$10.46
|
|
|
HC SOM FIDQL 86331
|
Facility
|
IP
|
$59.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
900914249
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$10.68 |
| Max. Negotiated Rate |
$44.25 |
| Rate for Payer: Adventist Health Commercial |
$11.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.53
|
| Rate for Payer: Cash Price |
$26.55
|
| Rate for Payer: Heritage Provider Network Commercial |
$39.94
|
| Rate for Payer: Heritage Provider Network Senior |
$39.94
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.75
|
| Rate for Payer: Multiplan Commercial |
$44.25
|
|
|
HC SOM FIDQL 86331
|
Facility
|
OP
|
$59.00
|
|
|
Service Code
|
CPT 86331
|
| Hospital Charge Code |
900914249
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$9.20 |
| Max. Negotiated Rate |
$100.30 |
| Rate for Payer: Adventist Health Commercial |
$11.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$34.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$40.53
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.97
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.18
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.98
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$100.30
|
| Rate for Payer: Blue Shield of California Commercial |
$93.63
|
| Rate for Payer: Blue Shield of California EPN |
$73.20
|
| Rate for Payer: Cash Price |
$26.55
|
| Rate for Payer: Cash Price |
$26.55
|
| Rate for Payer: Cigna of CA HMO/PPO |
$38.35
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.97
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.18
|
| Rate for Payer: Dignity Health Senior |
$11.98
|
| Rate for Payer: EPIC Health Plan Commercial |
$38.35
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.98
|
| Rate for Payer: Heritage Provider Network Commercial |
$36.52
|
| Rate for Payer: Heritage Provider Network Senior |
$36.52
|
| Rate for Payer: Humana Medicare |
$11.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$9.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.98
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$22.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$10.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.14
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$14.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.09
|
| Rate for Payer: Multiplan Commercial |
$44.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.98
|
| Rate for Payer: TriValley Medical Group Senior |
$11.98
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.94
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.94
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.97
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.18
|
| Rate for Payer: Vantage Medical Group Senior |
$11.98
|
|
|
HC SOM FINA 86382
|
Facility
|
OP
|
$393.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
900914730
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$16.91 |
| Max. Negotiated Rate |
$294.75 |
| Rate for Payer: Adventist Health Commercial |
$78.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$49.21
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$269.99
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.36
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.60
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$16.91
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$188.33
|
| Rate for Payer: Blue Shield of California Commercial |
$132.04
|
| Rate for Payer: Blue Shield of California EPN |
$103.22
|
| Rate for Payer: Cash Price |
$176.85
|
| Rate for Payer: Cash Price |
$176.85
|
| Rate for Payer: Cigna of CA HMO/PPO |
$255.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.36
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.60
|
| Rate for Payer: Dignity Health Senior |
$16.91
|
| Rate for Payer: EPIC Health Plan Commercial |
$255.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$16.91
|
| Rate for Payer: Heritage Provider Network Commercial |
$243.27
|
| Rate for Payer: Heritage Provider Network Senior |
$243.27
|
| Rate for Payer: Humana Medicare |
$16.91
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$23.45
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$16.91
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$32.13
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$71.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.95
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$98.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.31
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.31
|
| Rate for Payer: Multiplan Commercial |
$294.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$16.91
|
| Rate for Payer: TriValley Medical Group Senior |
$16.91
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.26
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.26
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.36
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.60
|
| Rate for Payer: Vantage Medical Group Senior |
$16.91
|
|
|
HC SOM FINA 86382
|
Facility
|
IP
|
$393.00
|
|
|
Service Code
|
CPT 86382
|
| Hospital Charge Code |
900914730
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$71.13 |
| Max. Negotiated Rate |
$294.75 |
| Rate for Payer: Adventist Health Commercial |
$78.60
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$269.99
|
| Rate for Payer: Cash Price |
$176.85
|
| Rate for Payer: Heritage Provider Network Commercial |
$266.06
|
| Rate for Payer: Heritage Provider Network Senior |
$266.06
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$71.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$98.25
|
| Rate for Payer: Multiplan Commercial |
$294.75
|
|
|
HC SOM FINA 87253
|
Facility
|
OP
|
$469.23
|
|
|
Service Code
|
CPT 87253
|
| Hospital Charge Code |
900914731
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$20.20 |
| Max. Negotiated Rate |
$351.92 |
| Rate for Payer: Adventist Health Commercial |
$93.85
|
| Rate for Payer: Aetna of CA Gatekeeper |
$58.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$322.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.22
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.20
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$71.06
|
| Rate for Payer: Blue Shield of California Commercial |
$71.66
|
| Rate for Payer: Blue Shield of California EPN |
$56.02
|
| Rate for Payer: Cash Price |
$211.15
|
| Rate for Payer: Cash Price |
$211.15
|
| Rate for Payer: Cigna of CA HMO/PPO |
$305.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.22
|
| Rate for Payer: Dignity Health Senior |
$20.20
|
| Rate for Payer: EPIC Health Plan Commercial |
$305.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.20
|
| Rate for Payer: Heritage Provider Network Commercial |
$290.45
|
| Rate for Payer: Heritage Provider Network Senior |
$290.45
|
| Rate for Payer: Humana Medicare |
$20.20
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24.96
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.20
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$38.38
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.93
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.84
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$117.31
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.45
|
| Rate for Payer: Multiplan Commercial |
$351.92
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.20
|
| Rate for Payer: TriValley Medical Group Senior |
$20.20
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.82
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.82
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.22
|
| Rate for Payer: Vantage Medical Group Senior |
$20.20
|
|
|
HC SOM FINA 87253
|
Facility
|
IP
|
$469.23
|
|
|
Service Code
|
CPT 87253
|
| Hospital Charge Code |
900914731
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$84.93 |
| Max. Negotiated Rate |
$351.92 |
| Rate for Payer: Adventist Health Commercial |
$93.85
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$322.36
|
| Rate for Payer: Cash Price |
$211.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$317.67
|
| Rate for Payer: Heritage Provider Network Senior |
$317.67
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$84.93
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$117.31
|
| Rate for Payer: Multiplan Commercial |
$351.92
|
|
|
HC SOM FISH AML LOCUS ANOMALIES
|
Facility
|
IP
|
$350.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900912611
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$63.35 |
| Max. Negotiated Rate |
$262.50 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$240.45
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$236.95
|
| Rate for Payer: Heritage Provider Network Senior |
$236.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$87.50
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
|
|
HC SOM FISH AML LOCUS ANOMALIES
|
Facility
|
OP
|
$350.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900912611
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$297.50 |
| Rate for Payer: Adventist Health Commercial |
$70.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$61.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$240.45
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$297.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$192.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$262.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$156.37
|
| Rate for Payer: Blue Shield of California Commercial |
$217.35
|
| Rate for Payer: Blue Shield of California EPN |
$205.45
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cash Price |
$157.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$227.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$297.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$297.50
|
| Rate for Payer: Dignity Health Senior |
$297.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$227.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$216.65
|
| Rate for Payer: Heritage Provider Network Senior |
$216.65
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$168.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$63.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$87.50
|
| Rate for Payer: Multiplan Commercial |
$262.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$297.50
|
| Rate for Payer: Vantage Medical Group Senior |
$297.50
|
|
|
HC SOM FISH B ALL
|
Facility
|
IP
|
$170.30
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900912609
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$30.82 |
| Max. Negotiated Rate |
$127.72 |
| Rate for Payer: Adventist Health Commercial |
$34.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$117.00
|
| Rate for Payer: Cash Price |
$76.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$115.29
|
| Rate for Payer: Heritage Provider Network Senior |
$115.29
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.58
|
| Rate for Payer: Multiplan Commercial |
$127.72
|
|
|
HC SOM FISH B ALL
|
Facility
|
OP
|
$170.30
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900912609
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$21.25 |
| Max. Negotiated Rate |
$156.37 |
| Rate for Payer: Adventist Health Commercial |
$34.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$61.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$117.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$144.76
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$93.66
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$127.72
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$156.37
|
| Rate for Payer: Blue Shield of California Commercial |
$105.76
|
| Rate for Payer: Blue Shield of California EPN |
$99.97
|
| Rate for Payer: Cash Price |
$76.64
|
| Rate for Payer: Cash Price |
$76.64
|
| Rate for Payer: Cigna of CA HMO/PPO |
$110.70
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$144.76
|
| Rate for Payer: Dignity Health Medi-Cal |
$144.76
|
| Rate for Payer: Dignity Health Senior |
$144.76
|
| Rate for Payer: EPIC Health Plan Commercial |
$110.70
|
| Rate for Payer: Heritage Provider Network Commercial |
$105.42
|
| Rate for Payer: Heritage Provider Network Senior |
$105.42
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$21.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$82.08
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$30.82
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$42.58
|
| Rate for Payer: Multiplan Commercial |
$127.72
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$36.25
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$36.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$144.76
|
| Rate for Payer: Vantage Medical Group Senior |
$144.76
|
|
|
HC SOM FISH DIGEORGE VELO-CARDIO-FACL
|
Facility
|
IP
|
$200.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900910684
|
|
Hospital Revenue Code
|
310
|
| 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
|
|
