|
HC SBBB PRE TREAT RBC CHEMICAL RE
|
Facility
|
OP
|
$111.00
|
|
|
Service Code
|
CPT 86970
|
| Hospital Charge Code |
900904736
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.09 |
| Max. Negotiated Rate |
$131.47 |
| Rate for Payer: Adventist Health Commercial |
$22.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$59.33
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$76.26
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$113.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$83.02
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$131.47
|
| Rate for Payer: Blue Shield of California Commercial |
$76.75
|
| Rate for Payer: Blue Shield of California EPN |
$61.72
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$72.15
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$113.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$83.02
|
| Rate for Payer: Dignity Health Senior |
$75.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$72.15
|
| Rate for Payer: EPIC Health Plan Medicare |
$75.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.71
|
| Rate for Payer: Heritage Provider Network Senior |
$68.71
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$27.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$75.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$52.95
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.09
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$86.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$95.09
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$95.09
|
| Rate for Payer: Multiplan Commercial |
$83.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$75.47
|
| Rate for Payer: TriValley Medical Group Senior |
$75.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$37.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$37.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$113.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$83.02
|
| Rate for Payer: Vantage Medical Group Senior |
$75.47
|
|
|
HC SBBB PRE TREAT RBC CHEMICAL RE
|
Facility
|
IP
|
$111.00
|
|
|
Service Code
|
CPT 86970
|
| Hospital Charge Code |
900904736
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$20.09 |
| Max. Negotiated Rate |
$83.25 |
| Rate for Payer: Adventist Health Commercial |
$22.20
|
| Rate for Payer: Cash Price |
$111.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$75.15
|
| Rate for Payer: Heritage Provider Network Senior |
$75.15
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$20.09
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.75
|
| Rate for Payer: Multiplan Commercial |
$83.25
|
|
|
HC SBBB RBC FROZEN DEGLYCROLIZED
|
Facility
|
IP
|
$427.25
|
|
|
Service Code
|
CPT P9039
|
| Hospital Charge Code |
900904716
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$77.33 |
| Max. Negotiated Rate |
$320.44 |
| Rate for Payer: Adventist Health Commercial |
$85.45
|
| Rate for Payer: Cash Price |
$427.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$289.25
|
| Rate for Payer: Heritage Provider Network Senior |
$289.25
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$77.33
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.81
|
| Rate for Payer: Multiplan Commercial |
$320.44
|
|
|
HC SBBB RBC FROZEN DEGLYCROLIZED
|
Facility
|
OP
|
$427.25
|
|
|
Service Code
|
CPT P9039
|
| Hospital Charge Code |
900904716
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$77.33 |
| Max. Negotiated Rate |
$1,245.96 |
| Rate for Payer: Adventist Health Commercial |
$85.45
|
| Rate for Payer: Aetna of CA Gatekeeper |
$228.37
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$293.52
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$1,245.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$913.70
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$830.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$242.42
|
| Rate for Payer: Blue Shield of California Commercial |
$260.62
|
| Rate for Payer: Blue Shield of California EPN |
$208.50
|
| Rate for Payer: Cash Price |
$427.25
|
| Rate for Payer: Cash Price |
$427.25
|
| Rate for Payer: Cash Price |
$427.25
|
| Rate for Payer: Cigna of CA HMO/PPO |
$277.71
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$1,245.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$913.70
|
| Rate for Payer: Dignity Health Senior |
$830.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$277.71
|
| Rate for Payer: EPIC Health Plan Medicare |
$830.64
|
| Rate for Payer: Heritage Provider Network Commercial |
$264.47
|
| Rate for Payer: Heritage Provider Network Senior |
$264.47
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$562.51
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$830.64
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$203.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$77.33
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$955.24
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$106.81
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$1,046.61
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$1,046.61
|
| Rate for Payer: Multiplan Commercial |
$320.44
|
| Rate for Payer: TriValley Medical Group Commercial |
$913.70
|
| Rate for Payer: TriValley Medical Group Senior |
$830.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$626.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$526.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$1,245.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$913.70
|
| Rate for Payer: Vantage Medical Group Senior |
$830.64
|
|
|
HC SBBB RBC LEUKOREDUCED
|
Facility
|
IP
|
$345.00
|
|
|
Service Code
|
CPT P9016
|
| Hospital Charge Code |
900904408
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$62.45 |
| Max. Negotiated Rate |
$258.75 |
| Rate for Payer: Adventist Health Commercial |
$69.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$233.56
|
| Rate for Payer: Heritage Provider Network Senior |
$233.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.45
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$86.25
|
| Rate for Payer: Multiplan Commercial |
$258.75
|
|
|
HC SBBB RBC LEUKOREDUCED
|
Facility
|
OP
|
$345.00
|
|
|
Service Code
|
CPT P9016
|
| Hospital Charge Code |
900904408
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$62.45 |
| Max. Negotiated Rate |
$626.00 |
| Rate for Payer: Adventist Health Commercial |
$69.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$184.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$237.01
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$346.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$254.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$231.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$195.75
|
| Rate for Payer: Blue Shield of California Commercial |
$210.45
|
| Rate for Payer: Blue Shield of California EPN |
$168.36
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cash Price |
$345.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$224.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$346.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$254.38
|
| Rate for Payer: Dignity Health Senior |
$231.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$224.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$231.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$213.56
|
| Rate for Payer: Heritage Provider Network Senior |
$213.56
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$299.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$231.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$164.56
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$62.45
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$265.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$86.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$291.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$291.38
|
| Rate for Payer: Multiplan Commercial |
$258.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$254.38
|
| Rate for Payer: TriValley Medical Group Senior |
$231.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$626.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$526.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$346.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$254.38
|
| Rate for Payer: Vantage Medical Group Senior |
$231.25
|
|
|
HC SBBB RBC LEUKOREDU CPDA-1 SPLIT UNIT
|
Facility
|
OP
|
$570.00
|
|
|
Service Code
|
CPT P9011
|
| Hospital Charge Code |
900909509
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$103.17 |
| Max. Negotiated Rate |
$626.00 |
| Rate for Payer: Adventist Health Commercial |
$114.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$304.67
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$391.59
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$270.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$198.19
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$180.17
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$323.42
|
| Rate for Payer: Blue Shield of California Commercial |
$347.70
|
| Rate for Payer: Blue Shield of California EPN |
$278.16
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$370.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$270.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$198.19
|
| Rate for Payer: Dignity Health Senior |
$180.17
|
| Rate for Payer: EPIC Health Plan Commercial |
$370.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$180.17
|
| Rate for Payer: Heritage Provider Network Commercial |
$352.83
|
| Rate for Payer: Heritage Provider Network Senior |
$352.83
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$241.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$180.17
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$271.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$103.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$207.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$227.01
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$227.01
|
| Rate for Payer: Multiplan Commercial |
$427.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$198.19
|
| Rate for Payer: TriValley Medical Group Senior |
$180.17
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$626.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$526.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$270.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$198.19
|
| Rate for Payer: Vantage Medical Group Senior |
$180.17
|
|
|
HC SBBB RBC LEUKOREDU CPDA-1 SPLIT UNIT
|
Facility
|
IP
|
$570.00
|
|
|
Service Code
|
CPT P9011
|
| Hospital Charge Code |
900909509
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$103.17 |
| Max. Negotiated Rate |
$427.50 |
| Rate for Payer: Adventist Health Commercial |
$114.00
|
| Rate for Payer: Cash Price |
$570.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$385.89
|
| Rate for Payer: Heritage Provider Network Senior |
$385.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$103.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$142.50
|
| Rate for Payer: Multiplan Commercial |
$427.50
|
|
|
HC SBBB RBC LEUKOREDU CPDA-1 WHOLE UNIT
|
Facility
|
OP
|
$509.00
|
|
|
Service Code
|
CPT P9016
|
| Hospital Charge Code |
900909508
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$92.13 |
| Max. Negotiated Rate |
$626.00 |
| Rate for Payer: Adventist Health Commercial |
$101.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$272.06
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$349.68
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$346.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$254.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$231.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$288.81
|
| Rate for Payer: Blue Shield of California Commercial |
$310.49
|
| Rate for Payer: Blue Shield of California EPN |
$248.39
|
| Rate for Payer: Cash Price |
$509.00
|
| Rate for Payer: Cash Price |
$509.00
|
| Rate for Payer: Cash Price |
$509.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$330.85
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$346.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$254.38
|
| Rate for Payer: Dignity Health Senior |
$231.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$330.85
|
| Rate for Payer: EPIC Health Plan Medicare |
$231.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$315.07
|
| Rate for Payer: Heritage Provider Network Senior |
$315.07
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$299.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$231.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$242.79
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$92.13
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$265.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$291.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$291.38
|
| Rate for Payer: Multiplan Commercial |
$381.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$254.38
|
| Rate for Payer: TriValley Medical Group Senior |
$231.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$626.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$526.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$346.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$254.38
|
| Rate for Payer: Vantage Medical Group Senior |
$231.25
|
|
|
HC SBBB RBC LEUKOREDU CPDA-1 WHOLE UNIT
|
Facility
|
IP
|
$509.00
|
|
|
Service Code
|
CPT P9016
|
| Hospital Charge Code |
900909508
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$92.13 |
| Max. Negotiated Rate |
$381.75 |
| Rate for Payer: Adventist Health Commercial |
$101.80
|
| Rate for Payer: Cash Price |
$509.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$344.59
|
| Rate for Payer: Heritage Provider Network Senior |
$344.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$92.13
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$127.25
|
| Rate for Payer: Multiplan Commercial |
$381.75
|
|
|
HC SBBB RBC OCTOPED CMV LEUKOREDU
|
Facility
|
IP
|
$164.00
|
|
|
Service Code
|
CPT P9016
|
| Hospital Charge Code |
900904705
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$29.68 |
| Max. Negotiated Rate |
$123.00 |
| Rate for Payer: Adventist Health Commercial |
$32.80
|
| Rate for Payer: Cash Price |
$164.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.03
|
| Rate for Payer: Heritage Provider Network Senior |
$111.03
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.68
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.00
|
| Rate for Payer: Multiplan Commercial |
$123.00
|
|
|
HC SBBB RBC OCTOPED CMV LEUKOREDU
|
Facility
|
OP
|
$164.00
|
|
|
Service Code
|
CPT P9016
|
| Hospital Charge Code |
900904705
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$29.68 |
| Max. Negotiated Rate |
$626.00 |
| Rate for Payer: Adventist Health Commercial |
$32.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$87.66
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$112.67
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$346.88
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$254.38
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$231.25
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$93.05
|
| Rate for Payer: Blue Shield of California Commercial |
$100.04
|
| Rate for Payer: Blue Shield of California EPN |
$80.03
|
| Rate for Payer: Cash Price |
$164.00
|
| Rate for Payer: Cash Price |
$164.00
|
| Rate for Payer: Cash Price |
$164.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$106.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$346.88
|
| Rate for Payer: Dignity Health Medi-Cal |
$254.38
|
| Rate for Payer: Dignity Health Senior |
$231.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$106.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$231.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$101.52
|
| Rate for Payer: Heritage Provider Network Senior |
$101.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$299.94
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$231.25
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$78.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.68
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$265.94
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$291.38
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$291.38
|
| Rate for Payer: Multiplan Commercial |
$123.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$254.38
|
| Rate for Payer: TriValley Medical Group Senior |
$231.25
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$626.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$526.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$346.88
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$254.38
|
| Rate for Payer: Vantage Medical Group Senior |
$231.25
|
|
|
HC SBBB RETIC SEPARATION
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
CPT 86972
|
| Hospital Charge Code |
900904737
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.87
|
| Rate for Payer: Heritage Provider Network Senior |
$56.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
|
|
HC SBBB RETIC SEPARATION
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT 86972
|
| Hospital Charge Code |
900904737
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$326.60 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$44.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$326.60
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$239.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$217.73
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$164.29
|
| Rate for Payer: Blue Shield of California Commercial |
$72.72
|
| Rate for Payer: Blue Shield of California EPN |
$58.48
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$326.60
|
| Rate for Payer: Dignity Health Medi-Cal |
$239.50
|
| Rate for Payer: Dignity Health Senior |
$217.73
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$217.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.00
|
| Rate for Payer: Heritage Provider Network Senior |
$52.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.97
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$217.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$250.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$274.34
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$274.34
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$217.73
|
| Rate for Payer: TriValley Medical Group Senior |
$217.73
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$164.51
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$164.51
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$326.60
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$239.50
|
| Rate for Payer: Vantage Medical Group Senior |
$217.73
|
|
|
HC SBBB RH DISCREP ADD'L TEST
|
Facility
|
OP
|
$86.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
900905005
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$74.81 |
| Rate for Payer: Adventist Health Commercial |
$17.20
|
| Rate for Payer: Aetna of CA Gatekeeper |
$45.97
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$59.08
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$54.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.53
|
| Rate for Payer: Blue Shield of California Commercial |
$24.02
|
| Rate for Payer: Blue Shield of California EPN |
$19.27
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.90
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.86
|
| Rate for Payer: Dignity Health Senior |
$49.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.90
|
| Rate for Payer: EPIC Health Plan Medicare |
$49.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.23
|
| Rate for Payer: Heritage Provider Network Senior |
$53.23
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$41.02
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.57
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$57.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$62.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$62.84
|
| Rate for Payer: Multiplan Commercial |
$64.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$49.87
|
| Rate for Payer: TriValley Medical Group Senior |
$49.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.86
|
| Rate for Payer: Vantage Medical Group Senior |
$49.87
|
|
|
HC SBBB RH DISCREP ADD'L TEST
|
Facility
|
IP
|
$86.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
900905005
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.57 |
| Max. Negotiated Rate |
$64.50 |
| Rate for Payer: Adventist Health Commercial |
$17.20
|
| Rate for Payer: Cash Price |
$86.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$58.22
|
| Rate for Payer: Heritage Provider Network Senior |
$58.22
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.57
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.50
|
| Rate for Payer: Multiplan Commercial |
$64.50
|
|
|
HC SBBB RH D TYPING
|
Facility
|
IP
|
$22.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
900904732
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.98 |
| Max. Negotiated Rate |
$16.50 |
| Rate for Payer: Adventist Health Commercial |
$4.40
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$14.89
|
| Rate for Payer: Heritage Provider Network Senior |
$14.89
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.98
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.50
|
| Rate for Payer: Multiplan Commercial |
$16.50
|
|
|
HC SBBB RH D TYPING
|
Facility
|
OP
|
$22.00
|
|
|
Service Code
|
CPT 86901
|
| Hospital Charge Code |
900904732
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$3.23 |
| Max. Negotiated Rate |
$74.81 |
| Rate for Payer: Adventist Health Commercial |
$4.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$11.76
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$15.11
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$54.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$57.53
|
| Rate for Payer: Blue Shield of California Commercial |
$24.02
|
| Rate for Payer: Blue Shield of California EPN |
$19.27
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Cash Price |
$22.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$14.30
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.86
|
| Rate for Payer: Dignity Health Senior |
$49.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$14.30
|
| Rate for Payer: EPIC Health Plan Medicare |
$49.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$13.62
|
| Rate for Payer: Heritage Provider Network Senior |
$13.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$3.99
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$10.49
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$3.98
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$57.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$5.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$62.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$62.84
|
| Rate for Payer: Multiplan Commercial |
$16.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$49.87
|
| Rate for Payer: TriValley Medical Group Senior |
$49.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$3.23
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$3.23
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.86
|
| Rate for Payer: Vantage Medical Group Senior |
$49.87
|
|
|
HC SBBB RH PHENOTYPING
|
Facility
|
IP
|
$84.00
|
|
|
Service Code
|
CPT 86906
|
| Hospital Charge Code |
900904623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$15.20 |
| Max. Negotiated Rate |
$63.00 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$56.87
|
| Rate for Payer: Heritage Provider Network Senior |
$56.87
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
|
|
HC SBBB RH PHENOTYPING
|
Facility
|
OP
|
$84.00
|
|
|
Service Code
|
CPT 86906
|
| Hospital Charge Code |
900904623
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$8.38 |
| Max. Negotiated Rate |
$74.81 |
| Rate for Payer: Adventist Health Commercial |
$16.80
|
| Rate for Payer: Aetna of CA Gatekeeper |
$44.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$57.71
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$74.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$54.86
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$49.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$70.74
|
| Rate for Payer: Blue Shield of California Commercial |
$62.38
|
| Rate for Payer: Blue Shield of California EPN |
$50.03
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cash Price |
$84.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$54.60
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$74.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$54.86
|
| Rate for Payer: Dignity Health Senior |
$49.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$54.60
|
| Rate for Payer: EPIC Health Plan Medicare |
$49.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$52.00
|
| Rate for Payer: Heritage Provider Network Senior |
$52.00
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$8.44
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$49.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.20
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$57.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$62.84
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$62.84
|
| Rate for Payer: Multiplan Commercial |
$63.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$49.87
|
| Rate for Payer: TriValley Medical Group Senior |
$49.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$74.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$54.86
|
| Rate for Payer: Vantage Medical Group Senior |
$49.87
|
|
|
HC SBBB SEND OUT COORDINATION FEE
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 86999
|
| Hospital Charge Code |
900905001
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$626.00 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$26.73
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$34.35
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$46.68
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$34.23
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$31.12
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$28.37
|
| Rate for Payer: Blue Shield of California Commercial |
$30.50
|
| Rate for Payer: Blue Shield of California EPN |
$24.40
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$32.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$46.68
|
| Rate for Payer: Dignity Health Medi-Cal |
$34.23
|
| Rate for Payer: Dignity Health Senior |
$31.12
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$31.12
|
| Rate for Payer: Heritage Provider Network Commercial |
$30.95
|
| Rate for Payer: Heritage Provider Network Senior |
$30.95
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$31.12
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$23.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$35.79
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$39.21
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$39.21
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$34.23
|
| Rate for Payer: TriValley Medical Group Senior |
$31.12
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$626.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$526.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$46.68
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$34.23
|
| Rate for Payer: Vantage Medical Group Senior |
$31.12
|
|
|
HC SBBB SEND OUT COORDINATION FEE
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 86999
|
| Hospital Charge Code |
900905001
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$37.50 |
| Rate for Payer: Adventist Health Commercial |
$10.00
|
| Rate for Payer: Cash Price |
$50.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$33.85
|
| Rate for Payer: Heritage Provider Network Senior |
$33.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.05
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
|
|
HC SBBB SHIPPING OF BLOOD 1-6 UNI
|
Facility
|
OP
|
$100.00
|
|
|
Service Code
|
CPT 99001
|
| Hospital Charge Code |
900904609
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$13.00 |
| Max. Negotiated Rate |
$626.00 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$13.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$13.00
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$85.00
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$55.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$75.00
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$56.74
|
| Rate for Payer: Blue Shield of California Commercial |
$61.00
|
| Rate for Payer: Blue Shield of California EPN |
$48.80
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cash Price |
$100.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$65.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$85.00
|
| Rate for Payer: Dignity Health Medi-Cal |
$85.00
|
| Rate for Payer: Dignity Health Senior |
$85.00
|
| Rate for Payer: EPIC Health Plan Commercial |
$65.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$61.90
|
| Rate for Payer: Heritage Provider Network Senior |
$61.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$47.70
|
| 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: Molina Healthcare of CA Medi-Cal |
$70.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$70.00
|
| Rate for Payer: Multiplan Commercial |
$75.00
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$626.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$526.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$85.00
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$85.00
|
| Rate for Payer: Vantage Medical Group Senior |
$85.00
|
|
|
HC SBBB SHIPPING OF BLOOD 1-6 UNI
|
Facility
|
IP
|
$100.00
|
|
|
Service Code
|
CPT 99001
|
| Hospital Charge Code |
900904609
|
|
Hospital Revenue Code
|
390
|
| Min. Negotiated Rate |
$18.10 |
| Max. Negotiated Rate |
$75.00 |
| Rate for Payer: Adventist Health Commercial |
$20.00
|
| Rate for Payer: Cash Price |
$100.00
|
| 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 SBBB STAT LABORATORY PROCEDURE
|
Facility
|
IP
|
$106.00
|
|
|
Service Code
|
CPT 86999
|
| Hospital Charge Code |
900904619
|
|
Hospital Revenue Code
|
300
|
| Min. Negotiated Rate |
$19.19 |
| Max. Negotiated Rate |
$79.50 |
| Rate for Payer: Adventist Health Commercial |
$21.20
|
| Rate for Payer: Cash Price |
$106.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$71.76
|
| Rate for Payer: Heritage Provider Network Senior |
$71.76
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$26.50
|
| Rate for Payer: Multiplan Commercial |
$79.50
|
|
