|
HC SOM FISH PRENATAL ANEUPLOIDY DETEC
|
Facility
|
OP
|
$225.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900910689
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$22.06 |
| Max. Negotiated Rate |
$191.25 |
| Rate for Payer: Adventist Health Commercial |
$45.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$120.26
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$154.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$191.25
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$123.75
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$168.75
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$170.56
|
| Rate for Payer: Blue Shield of California Commercial |
$37.25
|
| Rate for Payer: Blue Shield of California EPN |
$29.95
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$146.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$191.25
|
| Rate for Payer: Dignity Health Medi-Cal |
$191.25
|
| Rate for Payer: Dignity Health Senior |
$191.25
|
| Rate for Payer: EPIC Health Plan Commercial |
$146.25
|
| Rate for Payer: Heritage Provider Network Commercial |
$139.28
|
| Rate for Payer: Heritage Provider Network Senior |
$139.28
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$22.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$107.33
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$157.50
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$157.50
|
| Rate for Payer: Multiplan Commercial |
$168.75
|
| 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 Commercial/Exchange |
$191.25
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$191.25
|
| Rate for Payer: Vantage Medical Group Senior |
$191.25
|
|
|
HC SOM FISH PRENATAL ANEUPLOIDY DETEC
|
Facility
|
IP
|
$225.00
|
|
|
Service Code
|
CPT 88291
|
| Hospital Charge Code |
900910689
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$40.73 |
| Max. Negotiated Rate |
$168.75 |
| Rate for Payer: Adventist Health Commercial |
$45.00
|
| Rate for Payer: Cash Price |
$225.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$152.32
|
| Rate for Payer: Heritage Provider Network Senior |
$152.32
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$40.73
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$56.25
|
| Rate for Payer: Multiplan Commercial |
$168.75
|
|
|
HC SOM FISH UROTHELIAL CANCER
|
Facility
|
IP
|
$440.00
|
|
|
Service Code
|
CPT 88120
|
| Hospital Charge Code |
900910694
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$79.64 |
| Max. Negotiated Rate |
$330.00 |
| Rate for Payer: Adventist Health Commercial |
$88.00
|
| Rate for Payer: Cash Price |
$440.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$297.88
|
| Rate for Payer: Heritage Provider Network Senior |
$297.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.64
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.00
|
| Rate for Payer: Multiplan Commercial |
$330.00
|
|
|
HC SOM FISH UROTHELIAL CANCER
|
Facility
|
OP
|
$440.00
|
|
|
Service Code
|
CPT 88120
|
| Hospital Charge Code |
900910694
|
|
Hospital Revenue Code
|
310
|
| Min. Negotiated Rate |
$79.64 |
| Max. Negotiated Rate |
$2,646.47 |
| Rate for Payer: Adventist Health Commercial |
$88.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$235.18
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$302.28
|
| 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 |
$2,646.47
|
| Rate for Payer: Blue Shield of California Commercial |
$2,399.95
|
| Rate for Payer: Blue Shield of California EPN |
$1,929.96
|
| Rate for Payer: Cash Price |
$440.00
|
| Rate for Payer: Cash Price |
$440.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$286.00
|
| 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 |
$286.00
|
| Rate for Payer: EPIC Health Plan Medicare |
$217.73
|
| Rate for Payer: Heritage Provider Network Commercial |
$272.36
|
| Rate for Payer: Heritage Provider Network Senior |
$272.36
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$588.72
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$217.73
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$209.88
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$79.64
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$250.39
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$110.00
|
| 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 |
$330.00
|
| 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 SOM FLECAINIDE ACETATE
|
Facility
|
IP
|
$50.00
|
|
|
Service Code
|
CPT 80181
|
| Hospital Charge Code |
900910551
|
|
Hospital Revenue Code
|
301
|
| 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 SOM FLECAINIDE ACETATE
|
Facility
|
OP
|
$50.00
|
|
|
Service Code
|
CPT 80181
|
| Hospital Charge Code |
900910551
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.05 |
| Max. Negotiated Rate |
$107.37 |
| 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 |
$27.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$60.23
|
| Rate for Payer: Blue Shield of California Commercial |
$107.37
|
| Rate for Payer: Blue Shield of California EPN |
$86.12
|
| 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 |
$27.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.50
|
| Rate for Payer: Dignity Health Senior |
$18.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$32.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.64
|
| 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) Medi-Cal |
$24.15
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.64
|
| 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 |
$21.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$12.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.49
|
| Rate for Payer: Multiplan Commercial |
$37.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.64
|
| Rate for Payer: TriValley Medical Group Senior |
$18.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.50
|
| Rate for Payer: Vantage Medical Group Senior |
$18.64
|
|
|
HC SOM FLEXERIL
|
Facility
|
OP
|
$69.57
|
|
|
Service Code
|
CPT 80369
|
| Hospital Charge Code |
900911448
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.59 |
| Max. Negotiated Rate |
$154.33 |
| Rate for Payer: Adventist Health Commercial |
$13.91
|
| Rate for Payer: Aetna of CA Gatekeeper |
$37.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$47.79
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$59.13
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$38.26
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$52.18
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$154.33
|
| Rate for Payer: Cash Price |
$69.57
|
| Rate for Payer: Cash Price |
$69.57
|
| Rate for Payer: Cigna of CA HMO/PPO |
$45.22
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$59.13
|
| Rate for Payer: Dignity Health Medi-Cal |
$59.13
|
| Rate for Payer: Dignity Health Senior |
$59.13
|
| Rate for Payer: EPIC Health Plan Commercial |
$45.22
|
| Rate for Payer: Heritage Provider Network Commercial |
$43.06
|
| Rate for Payer: Heritage Provider Network Senior |
$43.06
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$33.18
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.39
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$48.70
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$48.70
|
| Rate for Payer: Multiplan Commercial |
$52.18
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$34.78
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$34.78
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$59.13
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$59.13
|
| Rate for Payer: Vantage Medical Group Senior |
$59.13
|
|
|
HC SOM FLEXERIL
|
Facility
|
IP
|
$69.57
|
|
|
Service Code
|
CPT 80369
|
| Hospital Charge Code |
900911448
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.59 |
| Max. Negotiated Rate |
$52.18 |
| Rate for Payer: Adventist Health Commercial |
$13.91
|
| Rate for Payer: Cash Price |
$69.57
|
| Rate for Payer: Heritage Provider Network Commercial |
$47.10
|
| Rate for Payer: Heritage Provider Network Senior |
$47.10
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.59
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$17.39
|
| Rate for Payer: Multiplan Commercial |
$52.18
|
|
|
HC SOM FLT3 D835 INTERP
|
Facility
|
OP
|
$162.50
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900914513
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$8.08 |
| Max. Negotiated Rate |
$121.88 |
| Rate for Payer: Adventist Health Commercial |
$32.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$86.86
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$111.64
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$8.08
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$73.69
|
| Rate for Payer: Blue Shield of California Commercial |
$65.03
|
| Rate for Payer: Blue Shield of California EPN |
$52.16
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Cigna of CA HMO/PPO |
$105.62
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$12.12
|
| Rate for Payer: Dignity Health Medi-Cal |
$8.89
|
| Rate for Payer: Dignity Health Senior |
$8.08
|
| Rate for Payer: EPIC Health Plan Commercial |
$105.62
|
| Rate for Payer: EPIC Health Plan Medicare |
$8.08
|
| Rate for Payer: Heritage Provider Network Commercial |
$100.59
|
| Rate for Payer: Heritage Provider Network Senior |
$100.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$10.77
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$8.08
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$77.51
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.41
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$9.29
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.62
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$10.18
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$10.18
|
| Rate for Payer: Multiplan Commercial |
$121.88
|
| Rate for Payer: TriValley Medical Group Commercial |
$8.08
|
| Rate for Payer: TriValley Medical Group Senior |
$8.08
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$8.72
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$8.72
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$12.12
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$8.89
|
| Rate for Payer: Vantage Medical Group Senior |
$8.08
|
|
|
HC SOM FLT3 D835 INTERP
|
Facility
|
IP
|
$162.50
|
|
|
Service Code
|
CPT 87077
|
| Hospital Charge Code |
900914513
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$29.41 |
| Max. Negotiated Rate |
$121.88 |
| Rate for Payer: Adventist Health Commercial |
$32.50
|
| Rate for Payer: Cash Price |
$162.50
|
| Rate for Payer: Heritage Provider Network Commercial |
$110.01
|
| Rate for Payer: Heritage Provider Network Senior |
$110.01
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.41
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$40.62
|
| Rate for Payer: Multiplan Commercial |
$121.88
|
|
|
HC SOM FLT 3 & D835 VARIANT DET
|
Facility
|
OP
|
$165.00
|
|
|
Service Code
|
CPT 81245
|
| Hospital Charge Code |
900912984
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$29.86 |
| Max. Negotiated Rate |
$572.04 |
| Rate for Payer: Adventist Health Commercial |
$33.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$88.19
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$113.36
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$248.26
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$182.06
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$165.51
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$572.04
|
| Rate for Payer: Blue Shield of California Commercial |
$100.65
|
| Rate for Payer: Blue Shield of California EPN |
$80.52
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$107.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$248.26
|
| Rate for Payer: Dignity Health Medi-Cal |
$182.06
|
| Rate for Payer: Dignity Health Senior |
$165.51
|
| Rate for Payer: EPIC Health Plan Commercial |
$107.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$165.51
|
| Rate for Payer: Heritage Provider Network Commercial |
$102.14
|
| Rate for Payer: Heritage Provider Network Senior |
$102.14
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$214.49
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$165.51
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$78.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.86
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$190.34
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$208.54
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$208.54
|
| Rate for Payer: Multiplan Commercial |
$123.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$165.51
|
| Rate for Payer: TriValley Medical Group Senior |
$165.51
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$178.75
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$178.75
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$248.26
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$182.06
|
| Rate for Payer: Vantage Medical Group Senior |
$165.51
|
|
|
HC SOM FLT 3 & D835 VARIANT DET
|
Facility
|
IP
|
$165.00
|
|
|
Service Code
|
CPT 81245
|
| Hospital Charge Code |
900912984
|
|
Hospital Revenue Code
|
309
|
| Min. Negotiated Rate |
$29.86 |
| Max. Negotiated Rate |
$123.75 |
| Rate for Payer: Adventist Health Commercial |
$33.00
|
| Rate for Payer: Cash Price |
$165.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$111.70
|
| Rate for Payer: Heritage Provider Network Senior |
$111.70
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$29.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$41.25
|
| Rate for Payer: Multiplan Commercial |
$123.75
|
|
|
HC SOM FLUORIDE BLOOD
|
Facility
|
IP
|
$263.80
|
|
|
Service Code
|
CPT 82735
|
| Hospital Charge Code |
900911276
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$47.75 |
| Max. Negotiated Rate |
$197.85 |
| Rate for Payer: Adventist Health Commercial |
$52.76
|
| Rate for Payer: Cash Price |
$263.80
|
| Rate for Payer: Heritage Provider Network Commercial |
$178.59
|
| Rate for Payer: Heritage Provider Network Senior |
$178.59
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.75
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.95
|
| Rate for Payer: Multiplan Commercial |
$197.85
|
|
|
HC SOM FLUORIDE BLOOD
|
Facility
|
OP
|
$263.80
|
|
|
Service Code
|
CPT 82735
|
| Hospital Charge Code |
900911276
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$18.54 |
| Max. Negotiated Rate |
$197.85 |
| Rate for Payer: Adventist Health Commercial |
$52.76
|
| Rate for Payer: Aetna of CA Gatekeeper |
$141.00
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$181.23
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$27.81
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.39
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.54
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$169.27
|
| Rate for Payer: Blue Shield of California Commercial |
$149.24
|
| Rate for Payer: Blue Shield of California EPN |
$119.70
|
| Rate for Payer: Cash Price |
$263.80
|
| Rate for Payer: Cash Price |
$263.80
|
| Rate for Payer: Cigna of CA HMO/PPO |
$171.47
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$27.81
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.39
|
| Rate for Payer: Dignity Health Senior |
$18.54
|
| Rate for Payer: EPIC Health Plan Commercial |
$171.47
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.54
|
| Rate for Payer: Heritage Provider Network Commercial |
$163.29
|
| Rate for Payer: Heritage Provider Network Senior |
$163.29
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$26.70
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.54
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$125.83
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$47.75
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$21.32
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$65.95
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.36
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.36
|
| Rate for Payer: Multiplan Commercial |
$197.85
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.54
|
| Rate for Payer: TriValley Medical Group Senior |
$18.54
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.03
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.03
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.81
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.39
|
| Rate for Payer: Vantage Medical Group Senior |
$18.54
|
|
|
HC SOM FLUOXETINE
|
Facility
|
IP
|
$55.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
900911433
|
|
Hospital Revenue Code
|
301
|
| 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 FLUOXETINE
|
Facility
|
OP
|
$55.00
|
|
|
Service Code
|
CPT 80299
|
| Hospital Charge Code |
900911433
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$9.96 |
| Max. Negotiated Rate |
$132.94 |
| 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 |
$27.96
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$20.50
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$18.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$132.94
|
| Rate for Payer: Blue Shield of California Commercial |
$110.19
|
| Rate for Payer: Blue Shield of California EPN |
$88.38
|
| 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 |
$27.96
|
| Rate for Payer: Dignity Health Medi-Cal |
$20.50
|
| Rate for Payer: Dignity Health Senior |
$18.64
|
| Rate for Payer: EPIC Health Plan Commercial |
$35.75
|
| Rate for Payer: EPIC Health Plan Medicare |
$18.64
|
| 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 |
$20.40
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$18.64
|
| 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 |
$21.44
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$13.75
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$23.49
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$23.49
|
| Rate for Payer: Multiplan Commercial |
$41.25
|
| Rate for Payer: TriValley Medical Group Commercial |
$18.64
|
| Rate for Payer: TriValley Medical Group Senior |
$18.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$20.14
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$20.14
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$27.96
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$20.50
|
| Rate for Payer: Vantage Medical Group Senior |
$18.64
|
|
|
HC SOM FLUPHENAZINE
|
Facility
|
IP
|
$85.63
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
900911432
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$64.22 |
| Rate for Payer: Adventist Health Commercial |
$17.13
|
| Rate for Payer: Cash Price |
$85.63
|
| Rate for Payer: Heritage Provider Network Commercial |
$57.97
|
| Rate for Payer: Heritage Provider Network Senior |
$57.97
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.41
|
| Rate for Payer: Multiplan Commercial |
$64.22
|
|
|
HC SOM FLUPHENAZINE
|
Facility
|
OP
|
$85.63
|
|
|
Service Code
|
CPT 80342
|
| Hospital Charge Code |
900911432
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$15.50 |
| Max. Negotiated Rate |
$136.39 |
| Rate for Payer: Adventist Health Commercial |
$17.13
|
| Rate for Payer: Aetna of CA Gatekeeper |
$45.77
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$58.83
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$72.79
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$47.10
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$64.22
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$136.39
|
| Rate for Payer: Cash Price |
$85.63
|
| Rate for Payer: Cash Price |
$85.63
|
| Rate for Payer: Cigna of CA HMO/PPO |
$55.66
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$72.79
|
| Rate for Payer: Dignity Health Medi-Cal |
$72.79
|
| Rate for Payer: Dignity Health Senior |
$72.79
|
| Rate for Payer: EPIC Health Plan Commercial |
$55.66
|
| Rate for Payer: Heritage Provider Network Commercial |
$53.00
|
| Rate for Payer: Heritage Provider Network Senior |
$53.00
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$40.85
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$15.50
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$21.41
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$59.94
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$59.94
|
| Rate for Payer: Multiplan Commercial |
$64.22
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$42.81
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$42.81
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$72.79
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$72.79
|
| Rate for Payer: Vantage Medical Group Senior |
$72.79
|
|
|
HC SOM FLURAZEPAM (DALMANE) LEVEL
|
Facility
|
OP
|
$67.52
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911084
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.22 |
| Max. Negotiated Rate |
$161.96 |
| Rate for Payer: Adventist Health Commercial |
$13.50
|
| Rate for Payer: Aetna of CA Gatekeeper |
$36.09
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$46.39
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$57.39
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$37.14
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$50.64
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$161.96
|
| Rate for Payer: Cash Price |
$67.52
|
| Rate for Payer: Cash Price |
$67.52
|
| Rate for Payer: Cigna of CA HMO/PPO |
$43.89
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$57.39
|
| Rate for Payer: Dignity Health Medi-Cal |
$57.39
|
| Rate for Payer: Dignity Health Senior |
$57.39
|
| Rate for Payer: EPIC Health Plan Commercial |
$43.89
|
| Rate for Payer: Heritage Provider Network Commercial |
$41.79
|
| Rate for Payer: Heritage Provider Network Senior |
$41.79
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$32.21
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.88
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$47.26
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$47.26
|
| Rate for Payer: Multiplan Commercial |
$50.64
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$33.76
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$33.76
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$57.39
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$57.39
|
| Rate for Payer: Vantage Medical Group Senior |
$57.39
|
|
|
HC SOM FLURAZEPAM (DALMANE) LEVEL
|
Facility
|
IP
|
$67.52
|
|
|
Service Code
|
CPT 80346
|
| Hospital Charge Code |
900911084
|
|
Hospital Revenue Code
|
301
|
| Min. Negotiated Rate |
$12.22 |
| Max. Negotiated Rate |
$50.64 |
| Rate for Payer: Adventist Health Commercial |
$13.50
|
| Rate for Payer: Cash Price |
$67.52
|
| Rate for Payer: Heritage Provider Network Commercial |
$45.71
|
| Rate for Payer: Heritage Provider Network Senior |
$45.71
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$12.22
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$16.88
|
| Rate for Payer: Multiplan Commercial |
$50.64
|
|
|
HC SOM FMGA 84181
|
Facility
|
OP
|
$125.00
|
|
|
Service Code
|
CPT 84181
|
| Hospital Charge Code |
900914770
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$17.03 |
| Max. Negotiated Rate |
$155.50 |
| Rate for Payer: Adventist Health Commercial |
$25.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$66.81
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$85.88
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.55
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$18.73
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.03
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$155.50
|
| Rate for Payer: Blue Shield of California Commercial |
$137.09
|
| Rate for Payer: Blue Shield of California EPN |
$109.96
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$81.25
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.55
|
| Rate for Payer: Dignity Health Medi-Cal |
$18.73
|
| Rate for Payer: Dignity Health Senior |
$17.03
|
| Rate for Payer: EPIC Health Plan Commercial |
$81.25
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.03
|
| Rate for Payer: Heritage Provider Network Commercial |
$77.38
|
| Rate for Payer: Heritage Provider Network Senior |
$77.38
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$24.53
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.03
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$59.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.62
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.58
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.25
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.46
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.46
|
| Rate for Payer: Multiplan Commercial |
$93.75
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.03
|
| Rate for Payer: TriValley Medical Group Senior |
$17.03
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.40
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.40
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.55
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$18.73
|
| Rate for Payer: Vantage Medical Group Senior |
$17.03
|
|
|
HC SOM FMGA 84181
|
Facility
|
IP
|
$125.00
|
|
|
Service Code
|
CPT 84181
|
| Hospital Charge Code |
900914770
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$22.62 |
| Max. Negotiated Rate |
$93.75 |
| Rate for Payer: Adventist Health Commercial |
$25.00
|
| Rate for Payer: Cash Price |
$125.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$84.62
|
| Rate for Payer: Heritage Provider Network Senior |
$84.62
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$22.62
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$31.25
|
| Rate for Payer: Multiplan Commercial |
$93.75
|
|
|
HC SOM FMGS 83520A
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914771
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.91 |
| Max. Negotiated Rate |
$82.50 |
| Rate for Payer: Adventist Health Commercial |
$22.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.47
|
| Rate for Payer: Heritage Provider Network Senior |
$74.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.50
|
| Rate for Payer: Multiplan Commercial |
$82.50
|
|
|
HC SOM FMGS 83520A
|
Facility
|
OP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914771
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$16.59 |
| Max. Negotiated Rate |
$118.19 |
| Rate for Payer: Adventist Health Commercial |
$22.00
|
| Rate for Payer: Aetna of CA Gatekeeper |
$58.80
|
| Rate for Payer: Aetna of CA Non-Gatekeeper |
$75.57
|
| Rate for Payer: Alpha Care Medical Group Commercial/Exchange |
$25.91
|
| Rate for Payer: Alpha Care Medical Group Medi-Cal |
$19.00
|
| Rate for Payer: Alpha Care Medical Group Medicare Advantage/Dual Product |
$17.27
|
| Rate for Payer: Anthem Blue Cross of CA HMO/PPO |
$118.19
|
| Rate for Payer: Blue Shield of California Commercial |
$104.20
|
| Rate for Payer: Blue Shield of California EPN |
$83.58
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Cigna of CA HMO/PPO |
$71.50
|
| Rate for Payer: Dignity Health Commercial/Exchange |
$25.91
|
| Rate for Payer: Dignity Health Medi-Cal |
$19.00
|
| Rate for Payer: Dignity Health Senior |
$17.27
|
| Rate for Payer: EPIC Health Plan Commercial |
$71.50
|
| Rate for Payer: EPIC Health Plan Medicare |
$17.27
|
| Rate for Payer: Heritage Provider Network Commercial |
$68.09
|
| Rate for Payer: Heritage Provider Network Senior |
$68.09
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medi-Cal |
$16.59
|
| Rate for Payer: Inland Empire Health Plan (IEHP) Medicare Advantage |
$17.27
|
| Rate for Payer: Kaiser Permanente of CA Commercial |
$52.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.91
|
| Rate for Payer: Kaiser Permanente of CA Medicare Advantage |
$19.86
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.50
|
| Rate for Payer: Molina Healthcare of CA Medi-Cal |
$21.76
|
| Rate for Payer: Molina Healthcare of CA Medicare |
$21.76
|
| Rate for Payer: Multiplan Commercial |
$82.50
|
| Rate for Payer: TriValley Medical Group Commercial |
$17.27
|
| Rate for Payer: TriValley Medical Group Senior |
$17.27
|
| Rate for Payer: United Healthcare All Other HMO/non HMO |
$18.65
|
| Rate for Payer: United Healthcare Navigate/Select/Select+ |
$18.65
|
| Rate for Payer: Vantage Medical Group Commercial/Exchange |
$25.91
|
| Rate for Payer: Vantage Medical Group Medi-Cal |
$19.00
|
| Rate for Payer: Vantage Medical Group Senior |
$17.27
|
|
|
HC SOM FMGS 83520B
|
Facility
|
IP
|
$110.00
|
|
|
Service Code
|
CPT 83520
|
| Hospital Charge Code |
900914772
|
|
Hospital Revenue Code
|
302
|
| Min. Negotiated Rate |
$19.91 |
| Max. Negotiated Rate |
$82.50 |
| Rate for Payer: Adventist Health Commercial |
$22.00
|
| Rate for Payer: Cash Price |
$110.00
|
| Rate for Payer: Heritage Provider Network Commercial |
$74.47
|
| Rate for Payer: Heritage Provider Network Senior |
$74.47
|
| Rate for Payer: Kaiser Permanente of CA Medi-Cal |
$19.91
|
| Rate for Payer: LLUH Dept of Risk Management WC |
$27.50
|
| Rate for Payer: Multiplan Commercial |
$82.50
|
|
