|
HC SOM CLONAZEPAM (CLONOPIN)
|
Facility
|
OP
|
$30.00
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911228
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$161.96 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.04
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$20.61
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$16.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$22.50
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.96
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$19.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.50
|
| Rate for Payer: Dignity Health Medi-Cal |
$25.50
|
| Rate for Payer: Dignity Health Senior |
$25.50
|
| Rate for Payer: EPIC Health Plan Commercial |
$19.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$18.57
|
| Rate for Payer: Heritage Provider Network Senior |
$18.57
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$14.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.00
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.00
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$15.00
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$15.00
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.50
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$25.50
|
| Rate for Payer: Vantage Medical Group Senior |
$25.50
|
|
|
HC SOM CLONAZEPAM (CLONOPIN)
|
Facility
|
IP
|
$30.00
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911228
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.43 |
| Max. Negotiated Rate |
$22.50 |
| Rate for Payer: Adventist Health Commercial |
$6.00
|
| Rate for Payer: Cash Price |
$30.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$20.31
|
| Rate for Payer: Heritage Provider Network Senior |
$20.31
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.43
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.50
|
| Rate for Payer: Multiplan Commercial |
$22.50
|
|
|
HC SOM CLOZAPINE LEVEL
|
Facility
|
IP
|
$31.59
|
|
|
Service Code
|
CPT 80159
|
| Hospital Charge Code |
900911438
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$23.69 |
| Rate for Payer: Adventist Health Commercial |
$6.32
|
| Rate for Payer: Cash Price |
$31.59
|
| Rate for Payer: Heritage Provider Network Commercial |
$21.39
|
| Rate for Payer: Heritage Provider Network Senior |
$21.39
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.72
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.90
|
| Rate for Payer: Multiplan Commercial |
$23.69
|
|
|
HC SOM CLOZAPINE LEVEL
|
Facility
|
OP
|
$31.59
|
|
|
Service Code
|
CPT 80159
|
| Hospital Charge Code |
900911438
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$5.72 |
| Max. Negotiated Rate |
$145.32 |
| Rate for Payer: Adventist Health Commercial |
$6.32
|
| Rate for Payer: Aetna of CA Gatekeeper |
$16.88
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$21.70
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$22.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$20.15
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$101.60
|
| Rate for Payer: Blue Shield of California Commercial |
$145.32
|
| Rate for Payer: Blue Shield of California EPN |
$116.56
|
| Rate for Payer: Cash Price |
$31.59
|
| Rate for Payer: Cash Price |
$31.59
|
| Rate for Payer: Cigna of CA HMO/PPO |
$20.53
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$30.23
|
| Rate for Payer: Dignity Health Medi-Cal |
$22.16
|
| Rate for Payer: Dignity Health Senior |
$20.15
|
| Rate for Payer: EPIC Health Plan Commercial |
$20.53
|
| Rate for Payer: EPIC Health Plan Medicare |
$20.15
|
| Rate for Payer: Heritage Provider Network Commercial |
$19.55
|
| Rate for Payer: Heritage Provider Network Senior |
$19.55
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.63
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$20.15
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$15.07
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$23.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$7.90
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$25.39
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$25.39
|
| Rate for Payer: Multiplan Commercial |
$23.69
|
| Rate for Payer: TriValley Medical Group Commercial |
$20.15
|
| Rate for Payer: TriValley Medical Group Senior |
$20.15
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$21.77
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$21.77
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$30.23
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$22.16
|
| Rate for Payer: Vantage Medical Group Senior |
$20.15
|
|
|
HC SOM CMV PCR NON-BLOOD
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 87496
|
| Hospital Charge Code |
900912519
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$41.25 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$37.23
|
| Rate for Payer: Heritage Provider Network Senior |
$37.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.96
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| Rate for Payer: Multiplan Commercial |
$41.25
|
|
|
HC SOM CMV PCR NON-BLOOD
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 87496
|
| Hospital Charge Code |
900912519
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$310.02 |
| Rate for Payer: Adventist Health Commercial |
$11.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$29.40
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$37.78
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$52.63
|
| 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 |
$310.02
|
| Rate for Payer: Blue Shield of California Commercial |
$282.47
|
| Rate for Payer: Blue Shield of California EPN |
$226.56
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cash Price |
$55.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$35.75
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$52.63
|
| Rate for Payer: Dignity Health Medi-Cal |
$38.60
|
| Rate for Payer: Dignity Health Senior |
$35.09
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$35.09
|
| Rate for Payer: Heritage Provider Network Commercial |
$34.05
|
| Rate for Payer: Heritage Provider Network Senior |
$34.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$50.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$35.09
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$26.23
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$9.96
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$40.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| 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 |
$41.25
|
| 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 |
$52.63
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$38.60
|
| Rate for Payer: Vantage Medical Group Senior |
$35.09
|
|
|
HC SOM CMVQU 87497
|
Facility
|
IP
|
$333.90
|
|
|
Service Code
|
CPT 87497
|
| Hospital Charge Code |
900915269
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$60.44 |
| Max. Negotiated Rate |
$250.43 |
| Rate for Payer: Adventist Health Commercial |
$66.78
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$226.05
|
| Rate for Payer: Heritage Provider Network Senior |
$226.05
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.47
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
|
|
HC SOM CMVQU 87497
|
Facility
|
OP
|
$333.90
|
|
|
Service Code
|
CPT 87497
|
| Hospital Charge Code |
900915269
|
|
Hospital Revenue Code
|
306
|
| Min. Negotiated Rate |
$42.84 |
| Max. Negotiated Rate |
$344.74 |
| Rate for Payer: Adventist Health Commercial |
$66.78
|
| Rate for Payer: Aetna of CA Gatekeeper |
$178.47
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$229.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$64.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.12
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$42.84
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$236.20
|
| Rate for Payer: Blue Shield of California Commercial |
$344.74
|
| Rate for Payer: Blue Shield of California EPN |
$276.51
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: Cash Price |
$333.90
|
| Rate for Payer: Cigna of CA HMO/PPO |
$217.03
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$64.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$47.12
|
| Rate for Payer: Dignity Health Senior |
$42.84
|
| Rate for Payer: EPIC Health Plan Commercial |
$217.03
|
| Rate for Payer: EPIC Health Plan Medicare |
$42.84
|
| Rate for Payer: Heritage Provider Network Commercial |
$206.68
|
| Rate for Payer: Heritage Provider Network Senior |
$206.68
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$61.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$42.84
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$159.27
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$60.44
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$49.27
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$83.47
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$53.98
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$53.98
|
| Rate for Payer: Multiplan Commercial |
$250.43
|
| Rate for Payer: TriValley Medical Group Commercial |
$42.84
|
| Rate for Payer: TriValley Medical Group Senior |
$42.84
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$46.27
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$46.27
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$64.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$47.12
|
| Rate for Payer: Vantage Medical Group Senior |
$42.84
|
|
|
HC SOM CNS DEMYELINATING MOG FACS
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915331
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Adventist Health Commercial |
$60.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$160.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$206.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.08
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$195.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$195.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$185.70
|
| Rate for Payer: Heritage Provider Network Senior |
$185.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$143.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.18
|
| Rate for Payer: Multiplan Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM CNS DEMYELINATING MOG FACS
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915331
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Adventist Health Commercial |
$60.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$203.10
|
| Rate for Payer: Heritage Provider Network Senior |
$203.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.00
|
| Rate for Payer: Multiplan Commercial |
$225.00
|
|
|
HC SOM CNS DEMYELINATING NMO/AQP4 FACS
|
Facility
|
IP
|
$300.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915330
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$54.30 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Adventist Health Commercial |
$60.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$203.10
|
| Rate for Payer: Heritage Provider Network Senior |
$203.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.30
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.00
|
| Rate for Payer: Multiplan Commercial |
$225.00
|
|
|
HC SOM CNS DEMYELINATING NMO/AQP4 FACS
|
Facility
|
OP
|
$300.00
|
|
|
Service Code
|
CPT 86255
|
| Hospital Charge Code |
900915330
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$12.05 |
| Max. Negotiated Rate |
$225.00 |
| Rate for Payer: Adventist Health Commercial |
$60.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$160.35
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$206.10
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.05
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$110.08
|
| Rate for Payer: Blue Shield of California Commercial |
$97.00
|
| Rate for Payer: Blue Shield of California EPN |
$77.80
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cash Price |
$300.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$195.00
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$18.07
|
| Rate for Payer: Dignity Health Medi-Cal |
$13.26
|
| Rate for Payer: Dignity Health Senior |
$12.05
|
| Rate for Payer: EPIC Health Plan Commercial |
$195.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.05
|
| Rate for Payer: Heritage Provider Network Commercial |
$185.70
|
| Rate for Payer: Heritage Provider Network Senior |
$185.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$13.98
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.05
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$143.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$54.30
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$75.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$15.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$15.18
|
| Rate for Payer: Multiplan Commercial |
$225.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.05
|
| Rate for Payer: TriValley Medical Group Senior |
$12.05
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.02
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.02
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$18.07
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$13.26
|
| Rate for Payer: Vantage Medical Group Senior |
$12.05
|
|
|
HC SOM COAG FACTOR VIII ASSAY
|
Facility
|
OP
|
$75.32
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
900913969
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$13.63 |
| Max. Negotiated Rate |
$163.49 |
| Rate for Payer: Adventist Health Commercial |
$15.06
|
| Rate for Payer: Aetna of CA Gatekeeper |
$40.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$51.74
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$26.85
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.90
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$163.49
|
| Rate for Payer: Blue Shield of California Commercial |
$144.12
|
| Rate for Payer: Blue Shield of California EPN |
$115.59
|
| Rate for Payer: Cash Price |
$75.32
|
| Rate for Payer: Cash Price |
$75.32
|
| Rate for Payer: Cigna of CA HMO/PPO |
$48.96
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$26.85
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.69
|
| Rate for Payer: Dignity Health Senior |
$17.90
|
| Rate for Payer: EPIC Health Plan Commercial |
$48.96
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.90
|
| Rate for Payer: Heritage Provider Network Commercial |
$46.62
|
| Rate for Payer: Heritage Provider Network Senior |
$46.62
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$25.69
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.90
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$35.93
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.63
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$20.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.83
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$22.55
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$22.55
|
| Rate for Payer: Multiplan Commercial |
$56.49
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.90
|
| Rate for Payer: TriValley Medical Group Senior |
$17.90
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$19.33
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$19.33
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$26.85
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.69
|
| Rate for Payer: Vantage Medical Group Senior |
$17.90
|
|
|
HC SOM COAG FACTOR VIII ASSAY
|
Facility
|
IP
|
$75.32
|
|
|
Service Code
|
CPT 85240
|
| Hospital Charge Code |
900913969
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$13.63 |
| Max. Negotiated Rate |
$56.49 |
| Rate for Payer: Adventist Health Commercial |
$15.06
|
| Rate for Payer: Cash Price |
$75.32
|
| Rate for Payer: Heritage Provider Network Commercial |
$50.99
|
| Rate for Payer: Heritage Provider Network Senior |
$50.99
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$13.63
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$18.83
|
| Rate for Payer: Multiplan Commercial |
$56.49
|
|
|
HC SOM COAG FVIII INHIB SCREEN
|
Facility
|
OP
|
$222.45
|
|
|
Service Code
|
CPT 85335
|
| Hospital Charge Code |
900913971
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$12.87 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: Adventist Health Commercial |
$44.49
|
| Rate for Payer: Aetna of CA Gatekeeper |
$118.90
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$152.82
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$19.30
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$12.87
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$117.52
|
| Rate for Payer: Blue Shield of California Commercial |
$103.62
|
| Rate for Payer: Blue Shield of California EPN |
$83.11
|
| Rate for Payer: Cash Price |
$222.45
|
| Rate for Payer: Cash Price |
$222.45
|
| Rate for Payer: Cigna of CA HMO/PPO |
$144.59
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$19.30
|
| Rate for Payer: Dignity Health Medi-Cal |
$14.16
|
| Rate for Payer: Dignity Health Senior |
$12.87
|
| Rate for Payer: EPIC Health Plan Commercial |
$144.59
|
| Rate for Payer: EPIC Health Plan Medicare |
$12.87
|
| Rate for Payer: Heritage Provider Network Commercial |
$137.70
|
| Rate for Payer: Heritage Provider Network Senior |
$137.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$18.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$12.87
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$106.11
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.26
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$14.80
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.61
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$16.22
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$16.22
|
| Rate for Payer: Multiplan Commercial |
$166.84
|
| Rate for Payer: TriValley Medical Group Commercial |
$12.87
|
| Rate for Payer: TriValley Medical Group Senior |
$12.87
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$13.90
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$13.90
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$19.30
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$14.16
|
| Rate for Payer: Vantage Medical Group Senior |
$12.87
|
|
|
HC SOM COAG FVIII INHIB SCREEN
|
Facility
|
IP
|
$222.45
|
|
|
Service Code
|
CPT 85335
|
| Hospital Charge Code |
900913971
|
|
Hospital Revenue Code
|
305
|
| Min. Negotiated Rate |
$40.26 |
| Max. Negotiated Rate |
$166.84 |
| Rate for Payer: Adventist Health Commercial |
$44.49
|
| Rate for Payer: Cash Price |
$222.45
|
| Rate for Payer: Heritage Provider Network Commercial |
$150.60
|
| Rate for Payer: Heritage Provider Network Senior |
$150.60
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.26
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$55.61
|
| Rate for Payer: Multiplan Commercial |
$166.84
|
|
|
HC SOM COCCI AB IGG CSF BY CF
|
Facility
|
IP
|
$12.00
|
|
|
Service Code
|
CPT 86635
|
| Hospital Charge Code |
900911338
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$9.00 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.12
|
| Rate for Payer: Heritage Provider Network Senior |
$8.12
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
|
|
HC SOM COCCI AB IGG CSF BY CF
|
Facility
|
OP
|
$12.00
|
|
|
Service Code
|
CPT 86635
|
| Hospital Charge Code |
900911338
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.17 |
| Max. Negotiated Rate |
$106.21 |
| Rate for Payer: Adventist Health Commercial |
$2.40
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.41
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.24
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.21
|
| Rate for Payer: Blue Shield of California Commercial |
$92.33
|
| Rate for Payer: Blue Shield of California EPN |
$74.06
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cash Price |
$12.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$7.80
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.62
|
| Rate for Payer: Dignity Health Senior |
$11.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$7.80
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$7.43
|
| Rate for Payer: Heritage Provider Network Senior |
$7.43
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$5.72
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.17
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.00
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.45
|
| Rate for Payer: Multiplan Commercial |
$9.00
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.47
|
| Rate for Payer: TriValley Medical Group Senior |
$11.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.62
|
| Rate for Payer: Vantage Medical Group Senior |
$11.47
|
|
|
HC SOM COCCI AB IGG CSF BY ID
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
CPT 86635
|
| Hospital Charge Code |
900912666
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$9.75 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.80
|
| Rate for Payer: Heritage Provider Network Senior |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
|
|
HC SOM COCCI AB IGG CSF BY ID
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
CPT 86635
|
| Hospital Charge Code |
900912666
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$106.21 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.21
|
| Rate for Payer: Blue Shield of California Commercial |
$92.33
|
| Rate for Payer: Blue Shield of California EPN |
$74.06
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.62
|
| Rate for Payer: Dignity Health Senior |
$11.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.05
|
| Rate for Payer: Heritage Provider Network Senior |
$8.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.45
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.47
|
| Rate for Payer: TriValley Medical Group Senior |
$11.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.62
|
| Rate for Payer: Vantage Medical Group Senior |
$11.47
|
|
|
HC SOM COCCI AB IGM CSF BY ID
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
CPT 86635
|
| Hospital Charge Code |
900912665
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$106.21 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.21
|
| Rate for Payer: Blue Shield of California Commercial |
$92.33
|
| Rate for Payer: Blue Shield of California EPN |
$74.06
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.62
|
| Rate for Payer: Dignity Health Senior |
$11.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.05
|
| Rate for Payer: Heritage Provider Network Senior |
$8.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.45
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.47
|
| Rate for Payer: TriValley Medical Group Senior |
$11.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.62
|
| Rate for Payer: Vantage Medical Group Senior |
$11.47
|
|
|
HC SOM COCCI AB IGM CSF BY ID
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
CPT 86635
|
| Hospital Charge Code |
900912665
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$9.75 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.80
|
| Rate for Payer: Heritage Provider Network Senior |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
|
|
HC SOM COCCIDIOIDES AB IGG BY CF
|
Facility
|
OP
|
$13.00
|
|
|
Service Code
|
CPT 86635
|
| Hospital Charge Code |
900912669
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$106.21 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Aetna of CA Gatekeeper |
$6.95
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$8.93
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$17.20
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$12.62
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$11.47
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$106.21
|
| Rate for Payer: Blue Shield of California Commercial |
$92.33
|
| Rate for Payer: Blue Shield of California EPN |
$74.06
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$8.45
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$17.20
|
| Rate for Payer: Dignity Health Medi-Cal |
$12.62
|
| Rate for Payer: Dignity Health Senior |
$11.47
|
| Rate for Payer: EPIC Health Plan Commercial |
$8.45
|
| Rate for Payer: EPIC Health Plan Medicare |
$11.47
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.05
|
| Rate for Payer: Heritage Provider Network Senior |
$8.05
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16.52
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$11.47
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$6.20
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$13.19
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$14.45
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$14.45
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$11.47
|
| Rate for Payer: TriValley Medical Group Senior |
$11.47
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$12.38
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$12.38
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$17.20
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$12.62
|
| Rate for Payer: Vantage Medical Group Senior |
$11.47
|
|
|
HC SOM COCCIDIOIDES AB IGG BY CF
|
Facility
|
IP
|
$13.00
|
|
|
Service Code
|
CPT 86635
|
| Hospital Charge Code |
900912669
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.35 |
| Max. Negotiated Rate |
$9.75 |
| Rate for Payer: Adventist Health Commercial |
$2.60
|
| Rate for Payer: Cash Price |
$13.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$8.80
|
| Rate for Payer: Heritage Provider Network Senior |
$8.80
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.35
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.25
|
| Rate for Payer: Multiplan Commercial |
$9.75
|
|
|
HC SOM COCCIDIOIDES AB IGG BY ID
|
Facility
|
IP
|
$13.50
|
|
|
Service Code
|
CPT 86635
|
| Hospital Charge Code |
900911752
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$2.44 |
| Max. Negotiated Rate |
$10.12 |
| Rate for Payer: Adventist Health Commercial |
$2.70
|
| Rate for Payer: Cash Price |
$13.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$9.14
|
| Rate for Payer: Heritage Provider Network Senior |
$9.14
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$2.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$3.38
|
| Rate for Payer: Multiplan Commercial |
$10.12
|
|
